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Frequently Asked Questions

Contents

ACO General Questions

ACO Participant List

ACO Participant TIN Exclusivity and Other Entities

Dually Eligible Beneficiary Assignment

Form CMS-588 Electronic Funds Transfer (EFT)

Governing Body

ACO General Questions

  1.  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.
     
  2. 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).
     
  3. 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.
     
  4. 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.
     
  5. 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.
     
  6. 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.
     
  7. 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.
     
  8. 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.
     
  9. 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 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.
     
  2. 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. 

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ACO Participant TIN Exclusivity and Other Entities

  1. 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.

 

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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)?

    Currently 12 States participate in the Financial Alignment Initiative (FAI). California, Illinois, Massachusetts, Michigan, New York, Ohio, Rhode Island, South Carolina, Texas and Virginia are in the Capitated Model. Colorado and Washington are in the Managed Fee for Service Model. 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. My Accountable Care Organization needs to complete the Form CMS-588, where can I get the form?

    You can find the Form CMS-588 on the Center for Medicare & Medicaid Services website.
     
  2. 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.
     
  3. Will 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 used for other Medicare payments and will have no effect on EFTs set up for other Medicare payments.
     
  4. We are approved to participate in both the Shared Savings Program and the ACO Investment Model (AIM). If we change the Form CMS-588 for the Shared Savings Program do we need to change the form for the ACO Investment Model?

    Yes. The accounting for the Shared Saving Program and ACO Investment Model are completed separately. If an ACO makes any changes to its Form CMS-588 for the purposes of the Shared Savings Program, it must also make those changes to the ACO’s Form CMS-588 for the purposes of the ACO Investment 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/ Employer Identification Number (EIN) established by the Internal Revenue Service (IRS), not one of the ACO participant’s TINs or the TIN of a parent/chain organization Model.
     
  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?

    It depends upon whether your ACO TIN is Medicare enrolled.   
    1. If your ACO TIN is not Medicare enrolled: 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.
       
    2. If your ACO TIN is Medicare enrolled: Yes, you must enter your Medicare Identification Number, Health Plan Identifier (HPID) or Other Entity Identifier (OEID), and NPI. Spaces for NPI's are limited. You can list any additional names on a separate page and add it to the package with your other documentation.
       
  7. When filling out the Form CMS-588, the instructions says the EFT authorization form must be signed and dated by the same Authorized Representative or a Delegated Official named on the CMS-855 Medicare enrollment application which the Medicare contractor has on file. What is a CMS-855?

    The CMS-855 is the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) Medicare enrollment application.
     
  8. Do we have to complete a CMS-855 before we submit our Form CMS-588?

    No, you  do not need to complete a Form CMS-855 for purposes of being elgible to receive an incentive payment from the Shared Savings Program.
     
  9. Who us 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 From 855 (provider Medicare enrollment file). Would the CFO or CEO of our ACO be ok? They are identified in our ACO application?

    For the Shared Savings Program the authorized official of the ACO may sign the form as long as he/she has the authority to legally bind the ACO, is listed in the Health Plan Management System (HPMS) and are identified by their title in the Form CMS-588.
     
  10. 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.

                 

      

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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. 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.
  3. 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.
     
  4. 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.
     
  5. 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.
     
  6. 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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