Accountable Care Organization (ACO) Investment Model

Transcription

1 FINAL EXPECTED RELEASE: June 25, 2015 General Questions MEDIA EXTERNAL FAQS Accountable Care Organization (ACO) Investment Model Q: What is the ACO Investment Model? A: The ACO Investment Model is a new model of pre-paid shared savings that builds on the experience with the Advance Payment Model. Please visit our website at for more information. Q: What is the purpose of the ACO Investment Model? A: The ACO Investment Model was developed in response to stakeholder concerns and research suggesting that some Medicare Shared Savings Program ACOs lack adequate access to the capital needed to invest in infrastructure necessary to implement population care management successfully. This model aims to encourage ACO formation in areas of low ACO penetration in order to produce better care and lower costs for Medicare fee-for-service (FFS) beneficiaries. CMS also believes that encouraging existing Medicare Shared Savings ACOs to transition to higher risk arrangements will increase the degree and speed at which ACOs can improve care for FFS beneficiaries and generate Medicare savings. Q: When does the ACO Investment Model start? A: The application period for Medicare Shared Savings Program ACOs with start dates in 2014, 2015 or 2016 will open July 1 st, 2015 and will close July 31 st, Q: Whom do we contact if we have questions? A: Any questions about the program can be directed to AIM@cms.hhs.gov. If you have technical questions directly related to the online application tool, please contact CMMIForceSupport@cms.hhs.gov or call Q: When can I review the application? A: A preview of the application was made available in PDF format on June 2nd 2015 for download and review. Q: How do we apply? A: The application will be available via our online tool on July 1 st. A log in ID and password will be created during your initial log in. The application website is Q: When can we apply? A: The ACO Investment Model application will be available beginning July 1 st for Medicare Shared Savings Program ACOs with start dates in 2014, 2015, or Page 1 of 6

2 Q: How will the ACO Investment Model benefit my Medicare Shared Savings Program ACO? A: Access to upfront capital and ongoing per member per month payments will assist an ACO in growing or sustaining investments in the infrastructure, staff and processes necessary to successfully transform care consistent with your goals as an Accountable Care Organization. Eligibility Q: Who is eligible for this program? A: For the initial round, the ACO Investment Model was only available to ACOs who began participating in the Medicare Shared Savings Program on April 1, 2012, July 1, 2012, or January 1, The upcoming round of the ACO Investment Model will be available to ACOs who began participating in the Medicare Shared Savings Program on January 1, 2014, January 1, 2015, or will begin on January 1, Other Eligibility Criteria: 1) The ACO must be accepted into and participate in the Medicare Shared Savings Program. The ACO s first performance year in the Medicare Shared Savings Program must have started in 2012, 2013, 2014, or 2015, or will start in ) The ACO has completely and accurately reported quality measures to the Medicare Shared Savings Program in the most recent performance year, excluding ACOs starting in 2015 or ) The ACO has a preliminary prospective beneficiary assignment of 10,000 or fewer beneficiaries for the most recent quarter, as determined in accordance with the Medicare Shared Savings Program regulations. However, ACOs that started the Medicare Shared Savings Program in 2015 or will start in 2016, and are determined to be from a rural area using the application selection criteria, are permitted to exceed the 10,000 beneficiary assignment limit. 4) The ACO does not include a hospital as an ACO participant or an ACO provider/supplier (as defined by the Medicare Shared Savings Program regulations), unless the hospital is a critical access hospital (CAH) or inpatient prospective payment system (IPPS) hospital with 100 or fewer beds. 5) The ACO is not owned or operated in whole or in part by a health plan. 6) The ACO did not participate in the Advance Payment Model. Q: My ACO participated in the Advance Payment Model, are we eligible for this program? A: No, participants in the Advance Payment Model are not eligible for this model. Q: My ACO will begin participating in the Medicare Shared Savings Program in Are we eligible for this program?

3 A: Yes, eligibility for the ACO Investment Model has been extended to include 2015 starters. Q: With respect to the eligibility criteria regarding ownership or partnership with an IPPS hospital with 100 or fewer beds, how is a hospital bed defined? A: "Hospital beds" refers to acute care beds. For further information, please see the following link: Payment/AcuteInpatientPPS/index.html?redirect=/acuteinpatientpps/ Selection Criteria and Process Q: How will you select ACOs to participate among applicants? A: Existing ACOs (April 1, 2012, July 1, 2012, January 1, 2013, or January 1, 2014 starters) Once determined eligible for the ACO Investment Model, applicants will be scored and selected based on: Spend Plan Quality Quality performance in the most recent performance year. Financial performance in the most recent performance year. The commitment of the ACO to renewing its agreement under a two-sided risk track in its upcoming ACO agreement. ACOs starting in 2012 or 2013 would have to commit to renewing their agreement under a two-sided risk track starting in ACOs starting in 2014 would have to commit to renewing their agreement under a two-sided risk track starting in ACO s application demonstrated exceptional need for pre-paid shared savings New ACOs with a start date of January 1, 2015 or January 1, 2016 Once determined eligible, applicants for this test under the ACO Investment Model will be scored and selected based on: Spend Plan Quality ACO serves a rural area ACO serves an area with low access to coordinated care (i.e. low ACO penetration) ACO elects a two-sided risk track ACO s application demonstrated exceptional need for pre-paid shared savings Applications will be scored via an independent panel. Please refer to the Request for Applications for more information how applications will be scored. Spend Plan Q: What is a spend plan? A: The spend plan is the ACO s proposed financial plan for how it will spend the funds awarded in the ACO Investment Model. It is a key program document that CMS will use to score applications and to monitor the management of funds during the ACO s participation in the Model.

4 Q: What is covered in the spend plan? A: The application tool provides applicants with a required template to use in submitting their spend plan. The spend plan written by the ACO must include: A description of the types of staffing and infrastructure the ACO will acquire/expand using the ACO Investment Model funding and how it supports population care management, financial management or other essential ACO functions. The expected unit prices for ACO investments, if applicable. The ACO s timing of procurement and hiring activities. The ACO s plan to build on staff and infrastructure currently in place (or plans to acquire using their own funds). A request for justification to use the funds for any item on the unacceptable use of advance payment list. Q: What are the restrictions for using money provided in this program? A: Unacceptable uses of advance payment include but are not limited to: Augmenting provider salaries or providing bonuses to executives or administrators. Purchasing imaging equipment (use of funds for other equipment will be scrutinized carefully as well, but not necessarily prohibited) An ACO may request justification to use Model funds for these unacceptable uses in the spend plan it submits as a component of its application. A determination will be made about whether the restriction will be lifted. If you have questions about whether a particular type of investment is allowable under the ACO Investment Model, please contact program staff at AIM@cms.hhs.gov. Payment Q: What are the payment amounts? A: ACOs that began participation in the Medicare Shared Savings Program on April 1, 2012, July 1, 2012, January 1, 2013 or January 1, 2014 will receive an upfront variable payment and an ongoing monthly payment. An upfront, variable payment: $36 per assigned beneficiary (based on preliminarily prospectively-assigned beneficiaries) (capped at 10,000 beneficiaries) A monthly payment of varying amount depending on the size of the ACO: $6 per beneficiary per month (based on preliminarily prospectively-assigned beneficiaries.) (capped at 10,000 beneficiaries) ACOs that began participation in the Medicare Shared Savings Program on January 1, 2015 or are set to begin on January 1, 2016 will receive an upfront fixed payment, an upfront variable payment, and an ongoing monthly payment.

5 An upfront, fixed payment: $250,000. An upfront, variable payment: $36 per assigned beneficiary (based on preliminarily prospectively-assigned beneficiaries) (capped at 10,000 beneficiaries) A monthly payment of varying amount depending on the size of the ACO: $8 per beneficiary per month (based on preliminarily prospectively-assigned beneficiaries.) (capped at 10,000 beneficiaries) For rural ACOs that exceed 10,000 beneficiaries under the amended program requirements, upfront variable payments and monthly payments will still be capped at the 10,000 beneficiary level. Q: What if my ACO only needs a portion of those funds? A: The program will not make partial payments. However, the ACO may reserve any unspent funds to apply against future recoveries. Q: When do we get the ACO Investment Model payments? A: The initial payment for the first round of applications will begin early in the second quarter of calendar year 2015 and would continue for up to two years, as long as your ACO continues to participate in the Medicare Shared Savings Program. The initial payment for new ACOs entering the Shared Savings Program in 2015 or 2016 will begin in the first quarter of Recovery Q: Do we have to repay the money? A: Existing ACOs (April 1, 2012, July 1, 2012, January 1, 2013, or January 1, 2014 starters) Repayment is required for the ACO Investment Model ACOs that began participation in the Medicare Shared Saving Program on April 1, 2012, July 1, 2012, January 1, 2013, or January 1, CMS will recover payments from earned shared savings for as long as the ACO remains in the Medicare Shared Savings Program. If the ACO ceases participation in the ACO Investment Model or Medicare Shared Savings Program before repaying the full amount, the outstanding balance will be due at that time. Applicants will be required to obtain a financial guarantee to cover at least 50% of the total anticipated payments. New ACOs (January 1, 2015 or January 1, 2016 starters) CMS will recover payments from earned shared savings for as long as the participant remains the Medicare Shared Savings Program. CMS will recover all pre-payments up to the total shared savings earned by the ACO, but will not pursue amounts in excess of the earned shared savings. CMS will pursue full recovery of pre-paid shared savings from any ACO that does not complete its initial Medicare Shared Savings Program agreement period or the full term of the ACO Investment Model agreement. CMS may terminate an ACO s Medicare Shared Savings Program agreement and the ACO Investment Model agreement should the ACO fail to comply with regulations and terms of the Medicare Shared Savings Program agreement. CMS may terminate the ACO Investment

6 Model agreement and recover all pre-paid shared savings payments from any ACOs that expend funds in a manner inconsistent with the approved spend plan. Q: Will we have to pay interest on the money we receive under this program? A: We will recover prepaid shared savings made under the ACO Investment Model from the shared savings earned by the ACO under the Medicare Shared Savings Program; interest will not accrue during this period. If the ACO does not fully repay the prepaid shared savings by the end of its second agreement period in the Medicare Shared Savings Program, or if the ACO is terminated from either the Shared Savings Program or the ACO Investment Model, CMS will issue a demand for repayment of any outstanding ACO Investment Model payments. If the ACO does not repay owed funds in full within 30 days of the date of the demand letter, interest may accrue on the remaining balance from the date of the demand letter at the applicable federal rate. Q: How do we repay the money? A: Money will be deducted from your earned shared savings each year until the full amount has been paid. For ACOs that began participation in the Medicare Shared Saving Program on April 1, 2012, July 1, 2012, January 1, 2013, or January 1, 2014, applicants will be required to obtain a financial guarantee to cover at least 50% of the total anticipated payments in the event that the ACO leaves or is terminated from the ACO Investment Model or Medicare Shared Savings Program. If your ACO began participation in the Medicare Shared Saving Program on April 1, 2012, July 1, 2012, January 1, 2013, or January 1, 2014, you will be required to obtain a financial guarantee against which money can be recouped. Q: If I choose to leave the Medicare Shared Savings Program will I have to repay the money? A: If your ACO began participation in the Medicare Shared Savings Program on April 1, 2012, July 1, 2012, January 1, 2013 or January 1, 2014 and subsequently ceases participation in ACO Investment Model or the Medicare Shared Savings Program before repaying the full amount, the outstanding balance will be due at that time. If your ACO began participation in the Medicare Shared Savings Program on January 1, 2015 or begins January 1, 2016 and subsequently does not complete the full 2016 agreement period, the outstanding balance will be due. Q: Will there be an evaluation of the ACO Investment Model? And are participants required to participate in the evaluation? A: Yes, like with other CMS Innovation Center Models, there will be an evaluation of the ACO Investment Model. Model participants will be required to submit data and information to the CMS evaluation contactor. The evaluation of this model will determine whether these payments: 1) increase Medicare Shared Savings Program participation by ACOs that meet the eligibility criteria; 2) sustain ACO participation; and 3) move ACOs to greater levels of risk. In addition, this model will be evaluated to determine how each of these changes increase the level and/or speed at which ACOs improve the quality of care for Medicare beneficiaries, lower the cost of care and improve the health of Medicare beneficiaries.