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Frequently Asked Questions

Contents

ACO General Questions

ACO Participant List

ACO Participant TIN Exclusivity and Other Entities

Assignment

Dually Eligible Beneficiary Assignment

Form CMS-588 Electronic Funds Transfer (EFT)

Governing Body

ACO General Questions

  1.  What is the definition of an ACO participant and why is this concept important to understand?

    An ACO participant is defined at §425.20 as an individual or group of ACO providers/suppliers that is identified by a Medicare-enrolled tax ID number (TIN), that alone or together with one or more other ACO participants comprises the ACO, and that is included on the list of ACO participants required to be submitted as part of the application and updated at the start of each performance year and at other times as specified by CMS. An ACO participant bills Medicare for services through its Medicare-enrolled TIN, or CMS Certification Number (CCN). ACO participant billing TINs (or CCNs) are the basis for establishing eligibility, assignment of beneficiaries, computation of the benchmark, and quality assessment.

    As part of its application, the ACO will be required to submit a list of ACO participants. Examples of ACO participants are: a group practice, an acute care hospital, a pharmacy, a solo practice, a Federally Qualified Health Center, a Critical Access Hospital, a Rural Health Center, and other entities that are Medicare-enrolled and bill Medicare for services though a Medicare-enrolled TIN.
  2. What is the definition of an ACO provider/supplier?

    An ACO provider/supplier means an individual or entity that is a Medicare provider or supplier enrolled in Medicare and bills for services under an ACO participant TIN. For example, a large group practice may qualify as an ACO participant. A Medicare enrolled physician billing under the practice TIN would be an ACO provider/supplier.
  3. We are a large group practice that meets the definition of an ACO participant. We have many ACO providers/suppliers that bill under our practice TIN. May we form an ACO using only a subset of our ACO providers/suppliers?

    No. When an ACO participant agrees to participate in the Shared Savings Program, it does so on behalf of all the ACO providers/suppliers that bill under its Medicare-enrolled TIN. All contracts or arrangements between or among the ACO, ACO participants, ACO providers/suppliers, and other individuals or entities performing functions or services related to ACO activities must require compliance with the requirements and conditions of the Shared Savings Program.
  4. I (we) meet the definition of an ACO participant, however, I (we) do not bill for primary care services. May I (we) form or participate in a Shared Savings Program ACO?

    Any Medicare-enrolled provider or supplier that bills Medicare directly for services may be an ACO participant, however, a Medicare-enrolled provider that bills Medicare directly but does not bill for primary care services (as defined in 42 CFR Part 425.20) is not eligible to form an ACO unless joined by Medicare-enrolled providers or suppliers that bill Medicare directly for primary care services since primary care services are the basis for assigning patients to the ACO for purposes of measuring quality and financial performance.
  5. When an ACO applies for participation in the Medicare Shared Savings Program, must the ACO have agreements with all ACO participants at that time?

    Yes. As part of its application, the ACO must certify that the ACO, its ACO participants, and its ACO providers/suppliers have agreed to become accountable for the quality, cost, and overall care of the Medicare fee-for-service beneficiaries assigned to the ACO (42 CFR 425.204(a)). We note that, as part of the application, the ACO must submit to CMS documents (for example, participation agreements, employment contracts, and operating policies) sufficient to describe, among other things, the ACO participants’ and the ACO providers’/suppliers’ rights and obligations in and representation by the ACO (42 CFR 425.204(c)). The ACO is responsible for ensuring each ACO participant, ACO providers/supplier billing through each ACO participant, and other individuals or entities performing functions or services related to ACO activities agree to and are in compliance with the requirements of the program (42 CFR 425.210).
  6. I (we) meet the definition of an ACO participant. Do I (we) bill for primary care services?

    A6: For purposes of the Medicare Shared Savings Program, primary care services mean the set of services identified by the following HCPCS codes: 99201-99215, 99304-99340, 99341 through 99350, G0402, G0438, G0439. Primary care services are also defined as revenue center codes 0521, 0522, 0524, 0525 when submitted by FQHCs (for services furnished prior to January 1, 2011) or by RHCs Any Medicare provider that bills using these codes will be used to determine an ACOs assigned patient population.
  7. I (we) meet the definition of an ACO participant. Must I (we) be exclusive to a single Medicare Shared Savings Program ACO?

    ACO participants that bill for primary care services must be exclusive to a single Medicare Shared Savings Program ACO.
  8. I (we) want to participate in an ACO. How do I find out about ACOs forming in my region?

    We recommend that you contact other potential ACO participants in your region or the relevant state or national professional association to see whether others are developing or considering developing a Medicare Shared Savings Program ACO.
  9. I am an individual practitioner and have a solo practice. May I form an ACO by myself?

    No. The Shared Savings Program is designed to provide an incentive for individuals and groups of practitioners to come together to form an ACO. Solo practitioners whose practices have a Medicare-enrolled TIN and bill Medicare for services may wish to become an ACO participant by joining with other ACO participants to form an ACO. Talking with other Medicare-enrolled providers and suppliers in your region may be good way to determine who may be interested in forming an ACO.
  10. We are a small group practice. May we form an ACO?

    We believe it would be difficult for a small group practice to meet the requirements for participation (one example is the requirement to have at least 5,000 fee-for-service beneficiaries assigned to the ACO participants) in the Shared Savings Program, which is designed to provide an incentive for individuals and groups of providers and suppliers to come together to form an ACO. Small group practices that have a Medicare-enrolled TIN and bill Medicare for services may wish to become an ACO participant by connecting with other ACO participants to form an ACO. Talking with other Medicare-enrolled providers and suppliers in your region may be a good way to determine who may be interested in forming an ACO.
  11. We are a non-Medicare-enrolled entity. Can we form or participate in a Shared Savings Program ACO?

    The Shared Savings Program is designed to provide an incentive to Medicare-enrolled providers and suppliers that come together to form an ACO. Therefore, non-Medicare-enrolled entities are not eligible to form a Medicare Shared Savings Program ACO. However, it was our intent in the final rule to provide flexibility for Medicare-enrolled providers and suppliers to join with others, including non-Medicare-enrolled entities, and to include them in the ACO’s governing body structure, at the discretion of the ACO, provided that at least 75% control of the ACO’s governing body is held by ACO participants.
  12. I am a physician who just graduated from residency. I just started a primary care practice, have become Medicare-enrolled and have a brand new billing TIN. Can I form or participate in a Shared Savings Program ACO?

    As a newly enrolled Medicare physician practice that bills Medicare directly for services, you are eligible to be an ACO participant. However, because your billing TIN does not have a history, you must come together with other ACO participants that furnish primary care services in order for CMS to set a benchmark based on expenditures for beneficiaries that would have been assigned to the ACO in any of the 3 most recent years prior to the start of the agreement period.
  13. How are beneficiaries assigned to an ACO?
    Beneficiaries will be assigned to an ACO, in a two-step process, if they receive at least one primary care service from a physician within the ACO:

    1) The first step assigns a beneficiary to an ACO if the beneficiary receives the plurality of his or her primary care services from primary care physicians within the ACO. Primary care physicians are defined as those with one of four specialty designations: internal medicine, general practice, family practice, and geriatric medicine or for services furnished in a federally qualified health center (FQHC) or rural health clinic (RHC), a physician included in the attestation provided by the ACO as part of its application.

    2) The second step only considers beneficiaries who have not had a primary care service furnished by any primary care physician either inside or outside the ACO. Under this second step, a beneficiary is assigned to an ACO if the beneficiary receives a plurality of his or her primary care services from specialist physicians and certain non-physician practitioners (nurse practitioners, clinical nurse specialists, and physician assistants) within the ACO.

    A plurality means the ACO participants provided a greater proportion of primary care services, measured in terms of allowed charges, than the ACO participants in any other ACO or Medicare-enrolled provider TIN, but can be less than a majority of services.
  14. How is a benchmark determined for the ACO?

    The benchmark for the ACO is calculated based on the per capita Medicare costs of beneficiaries that would have been assigned to ACO participants in each of the three years before the start of the agreement. For example, for ACOs starting in 2012, benchmarking years will be 2009, 2010, and 2011. The assignment algorithm described in the final rule will be applied to each of these years. The ACO’s benchmark is not set for individual ACO participants, rather, the benchmark is set for the ACO as a whole based on the per capita Part A and B expenditures for all beneficiaries who would have been assigned to the ACO in any of the 3 most recent years prior to the start of the agreement period. The benchmark is trended using national Medicare expenditure growth factors and risk adjusted to reflect the most recent benchmark year, which is also weighted the most in establishing the 3 year historical benchmark. The benchmark is updated annually by the projected absolute amount of growth in national Part A and B fee-for-service expenditures.
  15. I (we) are billing under a brand new Medicare-enrolled billing TIN. How will my benchmark be calculated and how will beneficiaries be assigned?

    Benchmarks are not set for individual ACO participants, rather, the benchmark is set for the ACO as a whole based on the per capita Parts A and B fee-for-service expenditures for beneficiaries that would have been assigned to the ACO in any of the 3 most recent years prior to the start of the agreement period. When you come together with other ACO participants to form a Shared Savings Program ACO, the ACO’s benchmark will be based on the Part A and B fee-for-service expenditures for beneficiaries that would have been assigned to the ACO on the basis of services furnished by your fellow ACO participants. During the course of the year, your patients that receive a plurality of their primary care services from you and the other ACO participants in the ACO will start to show up in the preliminary assignment lists that are provided on a quarterly basis, and also in the final assignment report at the end of the year.
  16. Once an ACO has signed an agreement with CMS, may ACO participants be added or subtracted during the course of the agreement period?

    Although each ACO participant TIN is required to agree to commit to a 3-year agreement with CMS to participate in the Shared Savings Program, we recognize there may be reasons why an ACO participant may leave or be added to an ACO during the course of the agreement period. When such changes occur, the ACO must notify CMS within 30 days of the change. Additionally, the ACO must provide an updated ACO participant list at the beginning of each performance year and at such other times as specified by CMS. The ACO’s eligibility to participate may be affected by such changes. Additionally, such changes may necessitate adjustments to the ACO’s benchmark or cause changes to risk scores or preliminary prospective assignment.
  17. Our group practice is applying for participation in the Medicare Shared Savings Program. We recently purchased two small primary care practices. The primary care providers from those small 5 practices are now employees of our group practice and have reassigned their billing to our group practice TIN. Is there a way to take into account the information from the small group practices on my application for the Medicare Shared Savings Program for purposes of benchmarking and preliminary prospective assignment?

    Yes. Under certain circumstances, CMS may take TINs acquired through purchase or merger into account:

    • The ACO participant must have subsumed the acquired TIN in its entirety, including all the ACO providers/suppliers that billed under that TIN.
    • All the ACO providers/suppliers that billed through the acquired TIN must reassign their billing to the ACO participant TIN.
    • The acquired TIN must no longer be used.

    In order to assess the impact of these acquired TINs on the ACO’s application, the ACO applicant must:
    • Submit acquired TINs on the ACO participant list, along with an attestation stating that all ACO providers/suppliers that previously billed under the acquired TIN have reassigned their billings to the current ACO participant TIN.
    • Flag acquired TINs and which ACO participant acquired them for the CMS application reviewer.
    • Submit supporting documentation demonstrating that the TIN was acquired by an ACO participant through a sale or merger and submit a letter attesting that the TIN will no longer be used.

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ACO Participant List  

  1. What is an ACO Participant?

    An ACO participant is defined at 42 CFR §425.20 as an individual or group of ACO providers/suppliers that is identified by a Medicare-enrolled tax ID number (TIN), that alone or together with one or more other ACO participants comprises the ACO, and that is included on the list of ACO participants required to be submitted as part of the application. This list of ACO participants is also to be updated at the start of each performance year and at other times as specified by CMS.

    The Medicare Shared Savings Program uses ACO participant billing TINs (in addition to CCNs in the case of FQHCs, RHCs, and Method II critical access hospitals) as the basis for establishing eligibility, assignment of beneficiaries, computation of the benchmark, and quality assessment.

    As part of its application, the ACO will be required to submit a list of ACO participants. Examples of ACO participants are: a group practice, an acute care hospital, a pharmacy, a solo practice, a federally qualified health center, a critical access hospital, a rural health center, and other entities that are Medicare-enrolled and bill Medicare for services though a Medicare-enrolled TIN.
  2. Who is an ACO provider/supplier?

    An ACO provider/supplier is an individual or entity that is a provider or supplier enrolled in Medicare, bills for items and services under an ACO participant tax ID number (TIN), and is included on the list of ACO participants required to be submitted as part of the application and updated as required by CMS. For example, a large group practice may qualify as an ACO participant. A Medicare enrolled physician billing under the practice’s TIN would be an ACO provider/supplier.
  3. When should I include CCN information on the ACO Participant List, and why is this important?

    You must include the CMS Certification Number (CCN) information if the ACO participant is a federally qualified health center (FQHC), rural health center (RHC) or Method II Critical Access Hospital (Method II CAH). We use the CCN to identify primary care service claims submitted by those types of providers when assigning beneficiaries to your ACO (for all other types of providers, we use the tax ID number (TIN) to identify those claims.)
  4. Will I have to identify the NPIs of ACO providers/suppliers billing under my ACO participants?

    You must include the National Provider Identifier (NPI) information for physicians who directly provide patient primary care services in an FQHC or RHC on the ACO Participant List submitted as part of your application. By including the NPI information for these physicians, you attest that the individual NPIs are physicians who directly provide patient primary care services in the FQHC or RHC as required under 42 CFR §425.404. We use this information to identify the pool of eligible beneficiaries for assignment, although all NPIs under the FQHC or RHC CMS Certification Number (CCN) are part of the ACO as ACO providers/suppliers.

    In the application, you will not have to identify any NPIs on the ACO Participant List for physicians who do not provide primary care services under an FQHC or RHC. However, if we accept your application to the Medicare Shared Savings Program we will identify all the Medicare enrolled providers and suppliers associated with your ACO participants using the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). All ACO providers/suppliers billing under an ACO participant tax ID number (TIN) are a part of the ACO. Once we identify the providers and suppliers associated with your ACO participants, we will send you a list of those NPIs for your review. You should note any corrections to the list, certify the accuracy of the list (as corrected, if necessary), and return the certified list to CMS.

    It is important that all your ACO participants and ACO providers/suppliers verify that their PECOS enrollment is up to date. Your ACO participants, and the ACO providers/suppliers billing under those TINs must update their own enrollment information in PECOS. You can learn more about Medicare enrollment at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedEnroll_PECOS_PhysNonPhys_FactSheet_ICN903764.pdf. Instructions are available through the CMS Web site at https://pecos.cms.hhs.gov/pecos/login.do
  5. What is the purpose of the ACO Participant List?

    The Participant List is the official list of the ACO participants in your ACO. We use this list: (1) to identify and screen the ACO participants, (2) to identify and screen all ACO providers/suppliers associated with the ACO participants’ tax ID numbers (TINs) submitted (and CCNs, as appropriate), and (3) as a way for applicants that include FQHC/RHC participants to meet the attestation requirement under 42 CFR §425.404. Such applicants are required to attest that the individual NPIs included in Column I of the Participant List template are physicians who directly provide patient primary care services in the FQHC or RHC.

    We also use this information to identify the beneficiaries for preliminary prospective and final retrospective assignment. (For more information about beneficiary assignment, see this CMS factsheet.)
  6. How do I add/remove ACO participants to/from my ACO Participant List?

    During the application period, you will have limited opportunities to add or remove ACO participants to or from this list. Once the ACO agreement period begins, pursuant to 42 C.F.R. §425.304(d), the ACO must maintain, update, and annually furnish the list to CMS at the beginning of each performance year and at other such times as specified by CMS. Consistent with this requirement, you must notify CMS of any changes to the ACO Participant List within 30 days of such a change. 
  7. According to guidance issued by CMS, under certain circumstances merged TINs can be included on the ACO Participant List in order to help create an accurate benchmark for our ACO. What constitutes “supporting documentation” demonstrating that TINs were acquired by an ACO participant?

    “Supporting documentation” is any documentation that demonstrates to us that the TIN is newly acquired (e.g. merger agreement, bill of sale, etc.) and meets the other requirements outlined in the guidance.

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ACO Participant TIN Exclusivity and Other Entities

  1. What is the rule on provider exclusivity under the Medicare Shared Savings Program?

    The Medicare Shared Savings Program requires that each Accountable Care Organization (ACO) participant TIN upon which beneficiary assignment is dependent must be exclusive to one Medicare Shared Savings Program ACO (This requirement appears in the Medicare Shared Savings Program regulations at §425.306(b)). This means that a taxpayer identification number (TIN) or CMS Certification Number (CCN) billing Medicare for primary care services (as defined in the Medicare Shared Savings Program regulations at §425.20) must be exclusive to one ACO’s certified list of ACO participants. A TIN or CCN may appear on the certified list of ACO participants for multiple ACOs only if it doesn’t bill Medicare for primary care services.

    Under the Medicare Shared Savings Program rules, ACOs submit a certified list of ACO participants at the beginning of each performance year and at such other times as specified by CMS.  CMS uses this list for assignment, benchmarking, developing the sample for quality reporting, and other important program operations.   Any ACO participant that bills for primary care services must be exclusive to a single Medicare Shared Savings Program ACO to make sure each ACO has a unique list of assigned beneficiaries.  

    Note:  This exclusivity rule applies to the Medicare-enrolled billing TIN that is an ACO participant in the ACO, not to individual practitioners.  Individual practitioners are free to participate in multiple ACOs if they bill under several different TINs.   Also, the exclusivity rule applies only for Medicare Shared Savings Program operational purposes.  In no way does it establish or otherwise imply a lock in of beneficiaries or a limitation of provider practice or referrals.
  2. Why does Medicare have an exclusivity rule under the Medicare Shared Savings Program?

    We require each ACO to have a unique patient population so we can perform important program operations such as beneficiary assignment, benchmarking, sampling for quality reporting, and performance evaluation.  Therefore, we require that ACO participants billing for “primary care services” on which we base assignment are exclusive to a single ACO. If we were to allow ACO participants to be associated with two or more ACOs, then it would be unclear to which ACO beneficiaries that get primary care services billed by the ACO participant would be assigned, and consequently, which ACO would get any shared savings arising from the ACO participant’s efforts.
  3. I’m a medical specialist in solo practice and I bill for office evaluation and management services that are included in the definition of primary care services.  Is it true that I must keep my TIN exclusive to only one ACO?

    Yes, an ACO participant TIN that bills for primary care services must be exclusive to a single Medicare Shared Savings Program ACO. Exclusivity under the Medicare Shared Savings Program is governed by the types of services that are furnished by the ACO providers/suppliers that bill under the ACO participant TIN, not by whether the TIN bills for services furnished by primary care physicians, specialists, or a mix of providers. 
  4. I heard that only primary care physicians are required to be exclusive to only 1 ACO under the Medicare Shared Savings program. Is that true?

    No.  You may have heard about the one-step assignment methodology discussed under the proposed rule, but that’s not the policy that was adopted in the final rule.  In response to comments submitted to CMS by specialists and other practitioners, we expanded the assignment methodology in the final rule to provide for consideration of the primary care services provided by specialist physicians, physician assistants (PAs), nurse practitioners (NPs), and clinical nurse specialists (CNSs) in the assignment process. Therefore, we also extended our exclusivity policy to include ACO participant TINs made up of practitioners with physician specialty designations, NPs, PAs, and CNSs if they bill for primary care services.
  5. I’m a specialist and bill for office evaluation and management services (which CMS defines as being “primary care”) under a single TIN.  Can my TIN be a participant in more than one ACO if I make sure all my patients see a primary care physician who’s not participating in my ACO?  By doing this I’d make sure that no patients are assigned to my ACO based on my services.

    No.  An ACO participant TIN that bills for primary care services must be exclusive to a single Medicare Shared Savings Program ACO.  TIN exclusivity under the Medicare Shared Savings Program is not affected by whether or not non-ACO physicians also treat beneficiaries that receive primary care services billed by the ACO participant TIN.
  6. How does the Medicare Shared Savings Program define primary care services?

    The regulations at §425.20 define primary care services for the Medicare Shared Savings Program as the set of services identified by the following healthcare common procedure coding system (HCPCS) codes:(1) 99201 through 99215;
    (2) 99304 through 99340, and 99341 through 99350, G0402 (the code for the “Welcome
    To Medicare” visit), G0438 and G0439 (codes for the annual wellness visits);
    (3) Revenue center codes 0521, 0522, 0524, 0525 submitted by federally qualified health centers (FQHCs) (for services furnished before January 1, 2011), or by rural health centers (RHCs).
  7. How do I know if my ACO participant TIN is billing Medicare for primary care services, that is, how do I know if my ACO participant TIN must be exclusive to one ACO’s list of ACO participants?

    As an ACO participant, you should be able to determine this based on your own Medicare billings.  Also, CMS checks for this as part of its pre-screening process for each ACO application and reports the list of ACO participant TINs that furnish primary care services to the ACO during the course of the application period.
  8. Our practice TIN would like to affiliate with an ACO, however, we don’t wish to be exclusive to that ACO.  May we affiliate with an ACO as an “other entity” instead of as an ACO participant, even though our practice TIN is Medicare enrolled?

    Regulations governing the Shared Savings Program don’t require “other individuals or entities performing functions or services related to ACO activities” to be non-Medicare enrolled individuals or entities.  Therefore, a Medicare-enrolled entity may enter into an agreement with an ACO as an “other entity”. 
  9. If our practice signs an agreement with an ACO as an “other entity”, must our practice be exclusive to a single Medicare Shared Savings Program ACO?

    No.  “Other entities” don’t appear on the certified list of ACO participants and they wouldn’t be used for program operations such as assignment.  Therefore, they aren’t required to be exclusive to a single Medicare Shared Savings Program ACO.
  10. If our practice signs an agreement with an ACO as an “other entity”, will our claims be used to assign beneficiaries?

    No.  Only those ACO participants that appear on the certified list submitted by the ACO will be used for program operations such as benchmarking, assignment, or quality reporting sampling.  Thus, claims submitted by an “other entity” that performs functions or services on behalf of an ACO will not be used for such program operations.   Please review our guidance regarding changes in ACO participants and ACO providers/suppliers during the assignment period (found HERE) to read about which program operations are dependent on the certified list of ACO participants. 
  11. If our practice signs an agreement with an ACO as an “other entity”, will we qualify for a Physician Quality Reporting System (PQRS) incentive payment through ACO quality reporting?

    No.  Only ACO participants can qualify for a PQRS incentive or avoid the PQRS adjustment through ACO quality reporting.
  12. What must the agreement between the ACO and an “other entity” contain?  

    Agreements between an ACO and an “other entity” must contain an explicit requirement that the “other entity” agrees to comply with the Medicare Shared Savings Program rules (42 CFR 425.210).  Also, CMS recommends that the agreement include authority for the ACO to terminate the agreement unilaterally if the “other entity” fails to comply with program rules.
  13. If our practice signs an agreement with the ACO as an “other entity”, will we qualify for shared savings?

    Maybe.  The ACO decides how to use or share savings resulting from an ACO’s participation in the Medicare Shared Savings Program.  Carefully review the “other entity” agreement you make with the ACO to make sure you understand how the ACO plans to share savings.

 

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Assignment

  1. Are primary care services performed by physicians in Electing Teaching Amendment (“ETA”) hospitals included in the assignment of beneficiaries to ACOs?  

    Yes.  Electing Teaching Amendment” (“ETA”) hospitals are hospitals that, under § 1861(b)(7) of the Medicare Act and 42 C.F.R. § 415.160, have voluntarily elected to receive payment on a reasonable cost basis for the direct medical and surgical services of their physicians in lieu of Medicare fee schedule payments that might otherwise be made for these services. As a result of this election, CMS does not receive separate claims for physician and other professional services furnished in ETA hospitals.  However, ETA hospitals do bill separately for their outpatient hospital facility services, and these bills include the information needed to assign beneficiaries to an ACO.  Note that while these bills do not include physician allowed charges (used to determine where a beneficiary received the plurality of primary care services as part of the assignment process), as a proxy we use the amount payable under the physician fee schedule for the applicable HCPCS/CPT code and geographic area.  

Dually Eligible Beneficiary Assignment

  1. My state has entered into a partnership with the Centers for Medicare & Medicaid Services (CMS) in the Financial Alignment Demonstration (Demonstration) designed to give dually-eligible beneficiaries a more coordinated and person-centered care experience. Does CMS consider this Demonstration to be an overlapping Medicare initiative involving shared savings?
    CMS does not consider this Demonstration to be an overlapping shared savings initiative under 42 CFR 425.114(a) because under the Demonstration, CMS is entering into a partnership with the state, not the provider.
  2. Can my ACO participant TIN participate in both the Financial Alignment Demonstration (Demonstration) and the Medicare Shared Savings Program?
    Yes, providers can generally participate in the Medicare Shared Savings Program while also working with their state through the Demonstration.
  3. Does my state’s participation in the Financial Alignment Demonstration (Demonstration) have implications for my ACO’s assigned population?
    Yes. States participating in the Financial Alignment Demonstration may choose to use either a capitated model or a managed fee-for-service care model. The two models have different implications for your ACO’s assigned population.
    1. Capitated Model: Under the Medicare Shared Savings Program rules, dually-eligible beneficiaries participating in a state’s capitated model will no longer meet the Shared Savings Program definition of a Medicare fee-for-service beneficiary (42 CFR 425.20) and therefore these beneficiaries become ineligible for assignment to an ACO participating in the Shared Savings Program (42 CFR 425.400(a)).
    2. Managed Fee-For-Service Model: The Medicare Shared Savings Program final rule stated that CMS would determine an appropriate method to avoid duplicate payments for beneficiaries assigned to other shared savings programs or initiatives. This includes initiatives involving dually-eligible beneficiaries, when such other shared savings programs have an assignment methodology that’s different from the Shared Savings Program (42 CFR 425.114(c)). Dually-eligible beneficiaries from states participating in the managed fee for-service model continue to meet the Shared Savings Program definition of a Medicare fee-for-service beneficiary, so they’re still eligible for assignment to an ACO on that basis. However, to promote continuity of care and ensure that individuals are assigned to the most integrated care models possible, beneficiaries in states participating in the Demonstration will be assigned to the Financial Alignment Demonstration if the Demonstration has a start date that’s the same or earlier than the ACO’s start date in the Shared Savings Program. If a beneficiary has appeared on a preliminary prospective or quarterly updated assignment list of an ACO that’s participating in the Shared Savings Program, the beneficiary will remain assigned to the ACO as long as the beneficiary continuously gets most of his or her primary care services from ACO providers/suppliers participating in the ACO.
  4. Which states participate in the Financial Alignment Demonstration (Demonstration)?
    As of October 2012, Massachusetts and Washington have approved Memoranda of Understanding (MOU) to participate in the Financial Alignment Demonstration beginning in 2013. Massachusetts has elected to use a capitated model. Washington has chosen to implement a managed fee-for-service model in 2013, and is seeking approval to implement a capitated model in some areas in 2014. More states are expected to participate in the Demonstration over time. You can learn more about the Demonstration and see proposals submitted by other states by visiting our Financial Alignment Initiative Web page.
  5. My ACO’s assigned population is very near the required 5,000 beneficiaries. What happens if my state’s decision to participate in the Financial Alignment Demonstration (Demonstration) causes my ACO’s assigned population to fall below 5,000 beneficiaries?
    If your ACO’s number of assigned beneficiaries falls below 5,000, your ACO will be placed on a corrective action plan (42 CFR 425.110(b)). ACOs will be assessed at the end of each performance year to determine whether they continue to meet the requirement that they have at least 5,000 fee-for-service beneficiaries assigned to it (42 CFR 425.110(a)). If you’re concerned that your state’s decision to participate in the Demonstration may cause your assigned beneficiary population to fall below 5,000, we recommend you consider inviting additional ACO participants that bill for primary care services to join your ACO. Adding ACO participant TINs to your ACO may lead to the assignment of enough additional fee-for-service beneficiaries to keep your assigned population above 5,000 beneficiaries.

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Form CMS-588 Electronic Funds Transfer (EFT)

  1. We already receive Electronic Funds Transfer (EFT) payments from Medicare. Do we need to submit a new Form CMS-588 Electronic Funds Transfer (EFT) Authorization Agreement or can we use our existing Form CMS-588?

    You must submit a new Form CMS-588 and cover sheet to participate in the Shared Savings Program, even if you already receive EFT payments from Medicare.
  2. Will the Form CMS-588 jeopardize or cause issues with our current method for receiving Medicare reimbursement?

    No. Payments for the Shared Savings Program will be made through a different payment system than that used for other Medicare payments and will have no effect on EFTs set up for other Medicare payments.
  3. If we already have a Form CMS-588 on file with Medicare, should we check the “New EFT” box at the top or leave it blank?

    This will be a ‘New EFT’ payment used only for purposes of Shared Savings Program payments.
  4. We are approved to participate in both the Shared Savings Program and the Advance Payment ACO model. If we change the Form CMS-588 for the Shared Savings Program do we need to change the form for the Advance Payment ACO model?

    No. Any changes to an ACO’s Form CMS-588 for the purposes of the Shared Savings Program will also apply to the Advance Payment ACO model.
  5. Does the bank account have to be set up under the ACO TIN and ACO legal name? Can it be a bank account set up under the TIN and legal name of an ACO participant TIN?

    The banking information must be associated with the ACO’s Legal Entity TIN/EIN and DBA, not one of the ACO participant’s TINs or the TIN of a parent/chain organization.
  6. The Form CMS-588 has a line for a National Provider Identifier (NPI.) We are an ACO. Do we need an NPI for this form to be complete?

    No, you do not need an NPI to complete the Form CMS-588 for the Shared Savings Program.  You should leave the NPI line blank.
  7. When filling out the Form CMS-588, it says that the signer must be one of the 'designated persons' from the Form CMS-855. Should our ACO complete a Form CMS-855?

    No. You do not need to complete a Form CMS-855. This form is used in the provider enrollment process, and it does not apply to ACOs participating in the Shared Savings Program.
  8. Who is an acceptable person to sign as the Authorized Official?

    The instructions state that the person must be the same person listed as the Authorized Official on the Form 855 (provider Medicare enrollment file). Would the CFO or CEO of our ACO be ok? They are identified in our ACO application. Any authorized official of the ACO may sign the form as long as he/she has the authority to legally bind the ACO and are identified by their title in the Form CMS-588.   
  9. Can we change the banking institution and account information at a later time?

    Yes, you may make changes at a later time. Please contact us immediately and submit a new Form CMS-588 and cover sheet with the updated information.
  10. Can we submit a bank letter in lieu of a cancelled check?

    Yes, you may submit a bank letter in lieu of a cancelled check. In fact, using a bank letter for account verification is encouraged. The bank letter needs to contain the ACO legal name, the account number and the routing number, all of which need to match the information entered in the Form CMS-588. The bank letter should be on the bank’s letterhead and must be signed by a bank official.
  11. Should the Form CMS-588 be mailed to the Medicare contractor in our area? No. The Form CMS-588 must be signed and sent to CMS Central Office in Baltimore. You should send the form via tracked mail, Federal Express or United Parcel Service to:
  12. Centers for Medicare & Medicaid Services
    Attention:  Jonnice McQuay
    7500 Security Boulevard
    Mail Stop: C5-15-02
    Location: C4-02-02
    Baltimore, MD 21244-1850

  13. When should I update my Form 588? You must update your banking form when any of the following changes are made to your ACO:
    1. Legal Name
    2. TIN
    3. Financial Institutions.
    4 Authorized/Delegated Financial Officer
    5. Contact Person. 

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Governing Body

  1. What positions do we need to name for committees (e.g. chair, secretary, etc.)? Are there any guidelines concerning the number of members on a committee?

    Provided the requirements of 42 CFR 425.106 are met, the ACO has the flexibility to set up the governing body that best suits its needs. We have no requirements regarding specific board positions or the number of committee members.
  2. How should we complete the governing body template?  

    Use the template provided to submit the following information for all members of the ACO’s governing body. This template is not for any other committees the ACO has in its organization.

    1. Name – First & Last
    2. Member Position/Title – the title the member has on the governing body (e.g., Chair, President, Secretary, Treasurer, etc.)
    3. Member’s Voting Power – the number of votes the member has. Example: 1, 2, 3. Enter a 0 for nonvoting members.
    4. Membership Type – whom the governing body member represents (e.g. ACO Participant Representative, Medicare Beneficiary Representative, Community Stakeholder Representative or Other (describe.) (“Other” may refer to any community organization members you choose to include on your Governing Body.)
    5. ACO Participant TIN Legal Name – complete this section for members that are ACO participant representatives.  Use the legal name that appears on your “ACO Participant List” that was submitted pursuant to 42 CFR 425.204(c)(5), and updated in accordance with 42 CFR 425.304(d) . (Enter N/A when the member is a Medicare Beneficiary or represents an “Other” entity.)

  3. Do I need to submit all the names for each committee member at the time of application or can I simply list a description of the types of individuals who will make up each committee?

    As part of your application, you must submit an organizational chart showing the committees in relationship to the governing body, and the first and last names and titles of key leadership members for each committee within your organization. For example, a key member of a committee could be the chairman of the committee.
  4. Would we meet the requirement for having a Medicare beneficiary on the governing body by including a beneficiary on the Advisory Board of the ACO?

    If the Advisory Board satisfies the requirements for the ACO governing body, then having a beneficiary on the Advisory Board would meet the requirement to include a Medicare beneficiary on the governing board.
    If the Advisory Board does not meet the requirements of the ACO governing body, then you should check “NO” and explain how you are providing for meaningful representation of beneficiaries in ACO governance by including beneficiaries on the Advisory Board.
  5. Are non-board members of the ACO prohibited from serving as committee members or committee chairpersons? For example, the chairperson of the Finance Committee is not an ACO Governing Board member.

    The Shared Savings Program rule does not prohibit non-governing board members from serving as committee members and/or chairs.  However, in accordance with 42 CFR 425.106(b), the governing body must retain responsibility for the oversight and strategic direction of the ACO.
  6. Can the compliance officer and quality control person be the same person?

    We believe the compliance officer and healthcare professional responsible for the ACO’s quality assurance and improvement program have different roles and responsibilities.   Thus, although the regulations do not require these roles to be filled by two different people, we believe it may be difficult to find a single person who is qualified to fill both positions.
  7. I know that an ACO must have a “qualified healthcare professional” responsible for the ACO’s quality assurance and improvement program.” Must that person be a physician?

    There is no requirement that the healthcare professional responsible for the ACO’s quality assurance and improvement program be a physician.  However, the ACO must have a qualified healthcare professional filling this role.

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