ACOs may elect Track 2 without completing a prior agreement period under a one-sided model

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1 Financial and Regulatory Parameters for MSSP Risk Tracks in ACO Learning Network Comments and the blue box indicates LN different from ; red text indicates change from and/or LN on Transition to Two-Sided Model Allow ACOs to remain in a one-sided risk model for an additional performance period (not to exceed a total of 6 years in one-sided risk) before being required to transition into a twosided risk model and LN Comment ACOs may elect Track 2 without completing a under a one-sided model ACOs cannot switch into Track 1 for subsequent agreement periods rule ACOs may elect Track 3 without completing a under a one-sided model ACOs cannot switch into Track 1 for subsequent agreement periods Shard Savings Rate Up to 50% based on quality performance in the first performance period No change from current regulation; ACOs remain at 50% in second performance period Up to 60%, but may be reduced based on quality performance Up to 75%, but may be reduced based on quality performance Reduced by 10 percent (40%) in second performance period, if ACO remains in Track 1 In addition to our s on Tracks 1, 2, and 3, the ACO Learning Network also proposed the creation of a Track 4 option for ACOs that were willing to assume even greater financial risk than that allowed in Track 3. Unfortunately, CMS did not adopt our proposal, which we feel would have allowed ACOs to gain greater experience with financial risk, including capitated payments, without having to move into a fully capitated Medicare Advantage (MA) model. Our proposed Track 4 would have included a number of the features included in Track 3, but with the option of having upwards of 50% of the ACO s historical Part A and B spending included in a population-based payment, similar to what has been offered to Pioneer ACOs, as well as the proposed Next Generation ACO model. The model would have also included incentives for ACOs to move to this new financial model, including up to 70% of shared savings; a fixed MSR of 1 percent; a prospective attribution model; a readjusted benchmark that better accounts for regional variation; the option of patient attestation model to help organizations better understand their target population; waivers on FFS requirements, such as SNF 3-day rule, teleheath billing restrictions, and referrals to post-acute care settings; and an improved risk adjustment methodology to better account for patient health status changes over time.

2 Financial and Regulatory Parameters for MSSP Risk Tracks in ACO Learning Network Comments and the blue box indicates LN different from ; red text indicates change from and/or LN on Minimum Savings Rate (MSR) 2.0% to 3.9% depending on number of assigned beneficiaries. Explore extending the lower bound to one percent for organizations with over 80,000 beneficiaries, if there is evidence that these organizations are statistically less significant to reach the MSR Instead of fixed 2% MSR, Explore extending the lower bound to one percent for organizations with over 80,000 beneficiaries, if there is evidence that these organizations are statistically less significant to reach the MSR Instead of fixed 2% MSR, Minimum Loss Rate (MLR) 2.0% to 3.9% depending on number of assigned beneficiaries. Instead of fixed 2% MLR, Instead of fixed 2% MLR, Shared Loss Rate One minus final sharing rate applied to first dollar losses once MLR is met or exceeded; Shared loss rate not to exceed 60% regulation and proposed rule; does not include sliding scale in ACO LN One minus final sharing rate applied to first dollar losses once MLR is met or exceeded; Shared loss rate not to be less than 40% or exceed 75% regulation and proposed rule; does not include sliding scale in ACO LN

3 Financial and Regulatory Parameters for MSSP Risk Tracks in ACO Learning Network Comments and the blue box indicates LN different from ; red text indicates change from and/or LN on Consider creating a sliding scale for the shared loss rate (15 percent to 60 percent) that changes over time to allow ACOs to assume increasing levels of downside risk as they gain more experience Consider creating a sliding scale for the shared loss rate (15 percent to 75 percent) that changes over time to allow ACOs to assume increasing levels of downside risk as they gain more experience Performance Payment Limit 10% rule 15% rule and ACO LN 20% Loss Sharing Limit Limit on the amount of losses increases annually over 3 years (5% in year 1, 7.5% in year 2, 10% in year 3 and subsequent years) regulation 15% Losses in excess of annual limit would not be shared Beneficiary Assignment Preliminary prospective beneficiary assignment, followed by retrospective reconciliation at the end of each based on whether the patient received a Prospective patient assignment for reports and financial reconciliation at the beginning of each Limited reconciliation at the end of each to remove ineligible regulation and proposed rule; preliminary prospective beneficiary assignment, followed by retrospective reconciliation at the end of each performance year Prospective assignment for reports, quality reporting and financial reconciliation

4 Financial and Regulatory Parameters for MSSP Risk Tracks in ACO Learning Network Comments and the blue box indicates LN different from ; red text indicates change from and/or LN on plurality of services from ACO providers beneficiaries, including those that joined MA plans or moved outside of the ACO provider network region Patient Choice in Assignment Allow patients to opt-in or opt-out of assignment to an ACO as a supplement to the existing patient assignment process, which occurs simultaneously with beneficiary decision about data sharing optout Opt-in or opt-out may occur during a 3-month period at beginning of each ACOs must inform patients of the option to attest ACO via signage in patient waiting areas CMS administers the process and collects all patient choices Patients opting into the ACO are eligible regulation and proposed rule Allow patients to opt-in Similar to ACO LN or opt-out of assignment ; beginning in to an ACO as a 2017, beneficiaries may supplement to the attest that their main existing patient doctor is participating in assignment process, a performance-based which occurs risk track ACO and be simultaneously with assigned to that ACO beneficiary decision about data sharing optout Opt-in or opt-out may occur during a 3-month period at beginning of each ACOs must inform patients of the option to attest ACO via signage in patient waiting areas CMS administers the process and collects all patient choices Patients opting into the ACO are eligible

5 Financial and Regulatory Parameters for MSSP Risk Tracks in ACO Learning Network Comments and the blue box indicates LN different from ; red text indicates change from and/or LN on for eliminated or reduced copays for primary care services furnished by providers in the ACO provider network for eliminated or reduced copays for primary care services furnished by providers in the ACO provider network Benchmark Continue to use existing historical methodology Modifications to rebasing methodology for years two and beyond; equally weighting benchmark years, and including per capita amount reflecting savings generated in Intend to commence rulemaking later this year to implement a methodology that better accounts for regional cost trends Continue to use existing historical methodology in first agreement period Beginning in second agreement period, transition the benchmark to a blended historical-regional methodology Second contract: gradual transition to 40 percent historical benchmark/60 percent regional benchmark Third contract: transition from 20 percent historical/80 percent regional to 100 percent regional benchmark after the first year Fourth and any subsequent periods: 100 percent regional Modifications to rebasing methodology for years two and beyond; equally weighting benchmark years, and including per capita amount reflecting savings generated in Intend to commence rulemaking later this year to implement a methodology that better accounts for regional cost trends Continue to use existing historical methodology in first agreement period Beginning in second agreement period, transition the benchmark to a blended historical-regional methodology Second contract: gradual transition to 40 percent historical benchmark/60 percent regional benchmark Third contract: transition from 20 percent historical/80 percent regional to 100 percent regional benchmark after the first year Fourth and any subsequent periods: 100 percent regional Modifications to rebasing methodology for years two and beyond; equally weighting benchmark years, and including per capita amount reflecting savings generated in Intend to commence rulemaking later this year to implement a methodology that better accounts for regional cost trends

6 Financial and Regulatory Parameters for MSSP Risk Tracks in ACO Learning Network Comments and the blue box indicates LN different from ; red text indicates change from and/or LN on Adjustments for health status and demographic changes ACO Learning Network Comment For All Tracks In conjunction with revised benchmark methodology transition, use CMS- HCC risk adjustment model on an annual basis to account for the risk profile and health status of the patient population. Newly assigned beneficiaries adjusted using CMS-HCC model; continuously assigned beneficiaries adjusted on an annual basis using demographic and health status factors, which can result in both a decreased and increased risk score For All Tracks regulation: Historical benchmark expenditures adjusted based on CMS-HCC model. Updated historical benchmark adjusted relative to the risk profile of the assigned beneficiary population for the. Performance year: newly assigned beneficiaries adjusted using CMS-HCC model; continuously assigned beneficiaries adjusted using demographic factors (not heath status) unless CMS-HCC risk scores result in a lower risk score. Waivers for Existing FFS Payment Requirements ACO Learning Network Comment for Tracks 2,3 Allow the use of waivers (SNF 3-day Rule, Billing and Payment for Telehealth Services, Homebound Requirement, and Referrals to Post-Acute Care Settings), with greater flexibility from traditional FFS restrictions for ACOs bearing more risk Consider use of waivers for co-pays of beneficiaries of the CCM code, and to allow ACOs to cover additional costs that deemed necessary for chronic care management for Tracks 2,3 Similar to proposed rule, not ACO LN ; applies only to Track 3 As early as 2017 begin to phase-in a waiver of certain billing and payment requirements for telehealth services after it is tested in the Innovation Center Beginning in 2017, ACOs may elect to apply for a waiver of the SNF 3-Day Rule Quality Measures ACO Learning Network Comment For All Tracks Continue to shift toward more outcome oriented quality measures, particularly those that are patient reported Require more sophisticated quality measures for larger ACOs and those taking on higher risk Consider providing payment bonuses for reporting on more advanced measures and for better performance on quality measures, as in the Medicare Advantage program

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