Title 42

PART 425

Part 425 - Medicare Shared Savings Program

PART 425 - MEDICARE SHARED SAVINGS PROGRAM Authority:42 U.S.C. 1302, 1306, 1395hh, and 1395jjj. Source:76 FR 67973, Nov. 2, 2011, unless otherwise noted.

42:3.0.1.1.12.1SUBPART A
Subpart A - General Provisions
42:3.0.1.1.12.1.9.1SECTION 425.10
   425.10 Basis and scope.
42:3.0.1.1.12.1.9.2SECTION 425.20
   425.20 Definitions.
42:3.0.1.1.12.2SUBPART B
Subpart B - Shared Savings Program Eligibility Requirements
42:3.0.1.1.12.2.9.1SECTION 425.100
   425.100 General.
42:3.0.1.1.12.2.9.2SECTION 425.102
   425.102 Eligible providers and suppliers.
42:3.0.1.1.12.2.9.3SECTION 425.104
   425.104 Legal entity.
42:3.0.1.1.12.2.9.4SECTION 425.106
   425.106 Shared governance.
42:3.0.1.1.12.2.9.5SECTION 425.108
   425.108 Leadership and management.
42:3.0.1.1.12.2.9.6SECTION 425.110
   425.110 Number of ACO professionals and beneficiaries.
42:3.0.1.1.12.2.9.7SECTION 425.112
   425.112 Required processes and patient-centeredness criteria.
42:3.0.1.1.12.2.9.8SECTION 425.114
   425.114 Participation in other shared savings initiatives.
42:3.0.1.1.12.2.9.9SECTION 425.116
   425.116 Agreements with ACO participants and ACO providers/suppliers.
42:3.0.1.1.12.2.9.10SECTION 425.118
   425.118 Required reporting of ACO participants and ACO providers/suppliers.
42:3.0.1.1.12.3SUBPART C
Subpart C - Application Procedures and Participation Agreement
42:3.0.1.1.12.3.9.1SECTION 425.200
   425.200 Participation agreement with CMS.
42:3.0.1.1.12.3.9.2SECTION 425.202
   425.202 Application procedures.
42:3.0.1.1.12.3.9.3SECTION 425.204
   425.204 Content of the application.
42:3.0.1.1.12.3.9.4SECTION 425.206
   425.206 Evaluation procedures for applications.
42:3.0.1.1.12.3.9.5SECTION 425.208
   425.208 Provisions of participation agreement.
42:3.0.1.1.12.3.9.6SECTION 425.210
   425.210 Application of agreement to ACO participants, ACO providers/suppliers, and others.
42:3.0.1.1.12.3.9.7SECTION 425.212
   425.212 Changes to program requirements during the agreement period.
42:3.0.1.1.12.3.9.8SECTION 425.214
   425.214 Managing changes to the ACO during the agreement period.
42:3.0.1.1.12.3.9.9SECTION 425.216
   425.216 Actions prior to termination.
42:3.0.1.1.12.3.9.10SECTION 425.218
   425.218 Termination of the participation agreement by CMS.
42:3.0.1.1.12.3.9.11SECTION 425.220
   425.220 Termination of the participation agreement by the ACO.
42:3.0.1.1.12.3.9.12SECTION 425.221
   425.221 Close-out procedures and payment consequences of early termination.
42:3.0.1.1.12.3.9.13SECTION 425.222
   425.222 Eligibility to re-enter the program for agreement periods beginning before July 1, 2019.
42:3.0.1.1.12.3.9.14SECTION 425.224
   425.224 Application procedures for renewing ACOs and re-entering ACOs.
42:3.0.1.1.12.3.9.15SECTION 425.226
   425.226 Annual participation elections.
42:3.0.1.1.12.4SUBPART D
Subpart D - Program Requirements and Beneficiary Protections
42:3.0.1.1.12.4.9.1SECTION 425.300
   425.300 Compliance plan.
42:3.0.1.1.12.4.9.2SECTION 425.302
   425.302 Program requirements for data submission and certifications.
42:3.0.1.1.12.4.9.3SECTION 425.304
   425.304 Beneficiary incentives.
42:3.0.1.1.12.4.9.4SECTION 425.305
   425.305 Other program safeguards.
42:3.0.1.1.12.4.9.5SECTION 425.306
   425.306 Participant agreement and exclusivity of ACO participants.
42:3.0.1.1.12.4.9.6SECTION 425.308
   425.308 Public reporting and transparency.
42:3.0.1.1.12.4.9.7SECTION 425.310
   425.310 Marketing requirements.
42:3.0.1.1.12.4.9.8SECTION 425.312
   425.312 Beneficiary notifications.
42:3.0.1.1.12.4.9.9SECTION 425.314
   425.314 Audits and record retention.
42:3.0.1.1.12.4.9.10SECTION 425.315
   425.315 Reopening determinations of ACO shared savings or shared losses to correct financial reconciliation calculations.
42:3.0.1.1.12.4.9.11SECTION 425.316
   425.316 Monitoring of ACOs.
42:3.0.1.1.12.5SUBPART E
Subpart E - Assignment of Beneficiaries
42:3.0.1.1.12.5.9.1SECTION 425.400
   425.400 General.
42:3.0.1.1.12.5.9.2SECTION 425.401
   425.401 Criteria for a beneficiary to be assigned to an ACO.
42:3.0.1.1.12.5.9.3SECTION 425.402
   425.402 Basic assignment methodology.
42:3.0.1.1.12.5.9.4SECTION 425.404
   425.404 Special assignment conditions for ACOs including FQHCs and RHCs.
42:3.0.1.1.12.6SUBPART F
Subpart F - Quality Performance Standards and Reporting
42:3.0.1.1.12.6.9.1SECTION 425.500
   425.500 Measures to assess the quality of care furnished by an ACO.
42:3.0.1.1.12.6.9.2SECTION 425.502
   425.502 Calculating the ACO quality performance score.
42:3.0.1.1.12.6.9.3SECTION 425.504
   425.504 Incorporating reporting requirements related to the Physician Quality Reporting System Incentive and Payment Adjustment.
42:3.0.1.1.12.6.9.4SECTION 425.506
   425.506 Incorporating reporting requirements related to adoption of certified electronic health record technology.
42:3.0.1.1.12.6.9.5SECTION 425.508
   425.508 Incorporating quality reporting requirements related to the Quality Payment Program.
42:3.0.1.1.12.7SUBPART G
Subpart G - Shared Savings and Losses
42:3.0.1.1.12.7.9.1SECTION 425.600
   425.600 Selection of risk model.
42:3.0.1.1.12.7.9.2SECTION 425.601
   425.601 Establishing, adjusting, and updating the benchmark for agreement periods beginning on July 1, 2019, and in subsequent years.
42:3.0.1.1.12.7.9.3SECTION 425.602
   425.602 Establishing, adjusting, and updating the benchmark for an ACO's first agreement period beginning on or before January 1, 2018.
42:3.0.1.1.12.7.9.4SECTION 425.603
   425.603 Resetting, adjusting, and updating the benchmark for a subsequent agreement period beginning on or before January 1, 2019.
42:3.0.1.1.12.7.9.5SECTION 425.604
   425.604 Calculation of savings under the one-sided model.
42:3.0.1.1.12.7.9.6SECTION 425.605
   425.605 Calculation of shared savings and losses under the BASIC track.
42:3.0.1.1.12.7.9.7SECTION 425.606
   425.606 Calculation of shared savings and losses under Track 2.
42:3.0.1.1.12.7.9.8SECTION 425.608
   425.608 Determining first year performance for ACOs beginning April 1 or July 1, 2012.
42:3.0.1.1.12.7.9.9SECTION 425.609
   425.609 Determining performance for 6-month performance years during CY 2019.
42:3.0.1.1.12.7.9.10SECTION 425.610
   425.610 Calculation of shared savings and losses under the ENHANCED track.
42:3.0.1.1.12.7.9.11SECTION 425.611
   425.611 Adjustments to Shared Savings Program calculations to address the COVID-19 pandemic.
42:3.0.1.1.12.7.9.12SECTION 425.612
   425.612 Waivers of payment rules or other Medicare requirements.
42:3.0.1.1.12.7.9.13SECTION 425.613
   425.613 Telehealth services.
42:3.0.1.1.12.8SUBPART H
Subpart H - Data Sharing With ACOs
42:3.0.1.1.12.8.9.1SECTION 425.700
   425.700 General rules.
42:3.0.1.1.12.8.9.2SECTION 425.702
   425.702 Aggregate reports.
42:3.0.1.1.12.8.9.3SECTION 425.704
   425.704 Beneficiary-identifiable claims data.
42:3.0.1.1.12.8.9.4SECTION 425.706
   425.706 Minimum necessary data.
42:3.0.1.1.12.8.9.5SECTION 425.708
   425.708 Beneficiaries may decline claims data sharing.
42:3.0.1.1.12.8.9.6SECTION 425.710
   425.710 Data use agreement.
42:3.0.1.1.12.9SUBPART I
Subpart I - Reconsideration Review Process
42:3.0.1.1.12.9.9.1SECTION 425.800
   425.800 Preclusion of administrative and judicial review.
42:3.0.1.1.12.9.9.2SECTION 425.802
   425.802 Request for review.
42:3.0.1.1.12.9.9.3SECTION 425.804
   425.804 Reconsideration review process.
42:3.0.1.1.12.9.9.4SECTION 425.806
   425.806 On-the-record review of reconsideration official's recommendation by independent CMS official.
42:3.0.1.1.12.9.9.5SECTION 425.808
   425.808 Effect of independent CMS official's decision.
42:3.0.1.1.12.9.9.6SECTION 425.810
   425.810 Effective date of decision.