42 CFR Part 425
PART 425—MEDICARE SHARED SAVINGS PROGRAM
- PART 425—MEDICARE SHARED SAVINGS PROGRAM
- Chapter IV—Centers for Medicare & Medicaid Services, Department of Health and Human Services › Subchapter B—Medicare Program
- Subpart A—General Provisions
- § 425.10 Basis and scope.
- § 425.20 Definitions.
- Subpart B—Shared Savings Program Eligibility Requirements
- § 425.100 General.
- § 425.102 Eligible providers and suppliers.
- § 425.104 Legal entity.
- § 425.106 Shared governance.
- § 425.108 Leadership and management.
- § 425.110 Number of ACO professionals and beneficiaries.
- § 425.112 Required processes and patient-centeredness criteria.
- § 425.114 Participation in other shared savings initiatives.
- § 425.116 Agreements with ACO participants and ACO providers/suppliers.
- § 425.118 Required reporting of ACO participants and ACO providers/suppliers.
- Subpart C—Application Procedures and Participation Agreement
- § 425.200 Participation agreement with CMS.
- § 425.202 Application procedures.
- § 425.204 Content of the application.
- § 425.206 Evaluation procedures for applications.
- § 425.208 Provisions of participation agreement.
- § 425.210 Application of agreement to ACO participants, ACO providers/suppliers, and others.
- § 425.212 Changes to program requirements during the agreement period.
- § 425.214 Managing changes to the ACO during the agreement period.
- § 425.216 Actions prior to termination.
- § 425.218 Termination of the participation agreement by CMS.
- § 425.220 Termination of the participation agreement by the ACO.
- § 425.221 Close-out procedures and payment consequences of early termination.
- § 425.222 Eligibility to re-enter the program for agreement periods beginning before July 1, 2019.
- § 425.224 Application procedures for renewing ACOs and re-entering ACOs.
- § 425.226 Annual participation elections.
- Subpart D—Program Requirements and Beneficiary Protections
- § 425.300 Compliance plan.
- § 425.302 Program requirements for data submission and certifications.
- § 425.304 Beneficiary incentives.
- § 425.305 Other program safeguards.
- § 425.306 Participant agreement and exclusivity of ACO participants.
- § 425.308 Public reporting and transparency.
- § 425.310 Marketing requirements.
- § 425.312 Beneficiary notifications.
- § 425.314 Audits and record retention.
- § 425.315 Reopening determinations of ACO shared savings or shared losses to correct financial reconciliation calculations.
- § 425.316 Monitoring of ACOs.
- Subpart E—Assignment of Beneficiaries
- § 425.400 General.
- § 425.401 Criteria for a beneficiary to be assigned to an ACO.
- § 425.402 Basic assignment methodology.
- § 425.404 Special assignment conditions for ACOs including FQHCs and RHCs.
- Subpart F—Quality Performance Standards and Reporting
- § 425.500 Measures to assess the quality of care furnished by an ACO for performance years (or a performance period) beginning on or before January 1, 2020.
- § 425.502 Calculating the ACO quality performance score for performance years (or a performance period) beginning on or before January 1, 2020.
- § 425.504 Incorporating reporting requirements related to the Physician Quality Reporting System Incentive and Payment Adjustment.
- § 425.506 Incorporating reporting requirements related to adoption of certified electronic health record technology.
- § 425.507 Incorporating Promoting Interoperability requirements related to the Quality Payment Program for performance years beginning on or after January 1, 2025.
- § 425.508 Incorporating quality reporting requirements related to the Quality Payment Program.
- § 425.510 Application of the APM Performance Pathway (APP) quality measure set or the APP Plus quality measure set (as applicable) to Shared Savings Program ACOs for performance years beginning on or after January 1, 2021.
- § 425.512 Determining the ACO quality performance standard for performance years beginning on or after January 1, 2021.
- Subpart G—Shared Savings and Losses
- § 425.600 Selection of risk model.
- § 425.601 Establishing, adjusting, and updating the benchmark for agreement periods beginning on or after July 1, 2019, and before January 1, 2024.
- § 425.602 Establishing, adjusting, and updating the benchmark for an ACO's first agreement period beginning on or before January 1, 2018.
- § 425.603 Resetting, adjusting, and updating the benchmark for a subsequent agreement period beginning on or before January 1, 2019.
- § 425.604 Calculation of savings under the one-sided model.
- § 425.605 Calculation of shared savings and losses under the BASIC track.
- § 425.606 Calculation of shared savings and losses under Track 2.
- § 425.608 Determining first year performance for ACOs beginning April 1 or July 1, 2012.
- § 425.609 Determining performance for 6-month performance years during CY 2019.
- § 425.610 Calculation of shared savings and losses under the ENHANCED track.
- § 425.611 Adjustments to Shared Savings Program calculations to address the COVID-19 pandemic.
- § 425.612 Waivers of payment rules or other Medicare requirements.
- § 425.613 Telehealth services.
- §§ 425.614-425.629 [Reserved]
- § 425.630 Option to receive advance investment payments.
- §§ 425.631-425.639 [Reserved]
- § 425.640 Option to receive prepaid shared savings.
- §§ 425.641-425.649 [Reserved]
- § 425.650 Benchmarking methodology.
- § 425.652 Establishing, adjusting, and updating the benchmark for agreement periods beginning on January 1, 2024, and in subsequent years.
- § 425.654 Calculating county expenditures and regional expenditures.
- § 425.655 Calculating the regional risk score growth cap adjustment factor.
- § 425.656 Calculating the regional adjustment to the historical benchmark.
- § 425.658 Calculating the prior savings adjustment to the historical benchmark.
- § 425.659 Calculating risk scores used in Shared Savings Program benchmark calculations.
- § 425.660 Accountable Care Prospective Trend (ACPT).
- § 425.661 [Reserved]
- § 425.662 Calculating the population adjustment to the historical benchmark.
- § 425.663-425.669 [Reserved]
- § 425.670 Adjustments to mitigate the impact of significant, anomalous, and highly suspect billing activity on Shared Savings Program financial calculations involving calendar year 2023.
- § 425.672 Adjustments to mitigate the impact of significant, anomalous, and highly suspect billing activity on Shared Savings Program financial calculations involving calendar year 2024 or subsequent calendar years.
- § 425.674 Accounting for the impact of improper payments on Shared Savings Program financial calculations.
- Subpart H—Data Sharing With ACOs
- § 425.700 General rules.
- § 425.702 Aggregate reports.
- § 425.704 Beneficiary-identifiable claims data.
- § 425.706 Minimum necessary data.
- § 425.708 Beneficiaries may decline claims data sharing.
- § 425.710 Data use agreement.
- Subpart I—Reconsideration Review Process
- § 425.800 Preclusion of administrative and judicial review.
- § 425.802 Request for review.
- § 425.804 Reconsideration review process.
- § 425.806 On-the-record review of reconsideration official's recommendation by independent CMS official.
- § 425.808 Effect of independent CMS official's decision.
- § 425.810 Effective date of decision.
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