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Financial and Beneficiary Assignment

Beneficiary assignment is the basis for many key program operations, including the development of quarterly program reports, calculation of the ACO’s historical benchmark, determining the ACO’s financial performance after each performance year, and developing the ACO’s sample of beneficiaries for reporting on quality measures.

There are important differences between the program’s financial models: Track 1 (one-sided shared savings model), and Track 2 and Track 3 (two-sided shared savings / losses models). Although, many of the same program requirements apply to ACOs regardless of Track.

Financial & Beneficiary Assignment Specifications

Medicare Shared Savings Program: Shared Savings and Losses and Assignment Methodology Specifications, Version 5 [PDF, 577KB] - This document describes the current methodology for assigning beneficiaries to an ACO, and determining ACO financial performance including: establishing the ACO’s historical benchmark and updated benchmark, and calculating shared savings and losses under the program’s three financial models (Track 1:  one-sided shared savings model and Track 2 and 3:  two-sided shared savings and losses models).  This document incorporates the changes outlined in the Shared Savings Program 2016 Final Rule that are applicable for Performance Year 2017 and onward.

Medicare Shared Savings Program: Shared Savings and Losses and Assignment Methodology Specifications, Version 4 [PDF, 725KB] - This document describes the methodology for assigning beneficiaries to an ACO, and determining ACO financial performance including: establishing the ACO’s historical benchmark and updated benchmark, and calculating shared savings and losses under the program’s three financial models (Track 1:  one-sided shared savings model and Track 2 and 3:  two-sided shared savings and losses models).  This document incorporates the changes outlined in the Shared Savings Program 2015 Final Rule that are applicable for Performance Year 2016.

Assignment, Expenditure & Utilization Data

Reports provided to ACOs – As explained in the Specifications document (see above), we provide ACOs with information on their assigned population and financial performance at the start of the agreement period and routinely during the course of the performance year. We provide:

  • Assignment List Report – contains beneficiary identifiable information on the ACO’s assigned population and identifies select ACO participants (TINs) and ACO providers/suppliers (NPIs, CCNs) who treat assigned beneficiaries.
    • Tracks 1 and 2: ACOs receive an initial preliminary prospective assignment list close to the start of each performance year, quarterly reports on the ACO’s preliminary prospectively assigned population throughout each performance year, and a year-end report on retrospectively assigned beneficiaries used for financial reconciliation.
    • Track 3: ACOs receive a prospective assignment list close to the start of each performance year, quarterly report indicating which beneficiaries have been removed from the ACO’s assignment list as a result of meeting select assignment exclusion criteria, and a year-end report on assigned beneficiaries used for financial reconciliation updated to identify beneficiaries no longer eligible for assignment at the end of the performance year.
  • Assignment Summary Reports – provides aggregate information on the ACO’s assigned beneficiaries and the primary care services they received.
    • Tracks 1 and 2: ACOs receive a report based on preliminarily prospectively assigned population for each benchmark year, quarterly reports based on preliminarily prospectively assigned population throughout each performance year, and a year-end report on beneficiaries retrospectively assigned for financial reconciliation.
    • Track 3: ACOs receive a report based on its prospective assignment list close to the start of each performance year, reports based on prospectively assigned beneficiaries for each benchmark year, quarterly reports based on the ACO’s currently assigned beneficiaries for the performance year updated to identify exclusions made in the year to date period, and a year-end report on prospectively assigned beneficiaries for the performance year updated to identify beneficiaries no longer eligible for assignment at the end of the performance year.
  • Aggregate Expenditure and Utilization Report – provides aggregate information on the ACO’s assigned beneficiaries provided each quarter during the agreement period, and provided for each benchmark year and annually for each performance period.
  • Historical Benchmark Report – specifies the calculation of the ACO’s 3-year average per capita benchmark value. Preliminary historical benchmark report provided within several months following the ACO’s agreement start date. Final historical benchmark provided with each financial reconciliation, and typically provided in advance for informational purposes. To account for changes in the ACO’s certified ACO Participant List effective for the performance year, an adjusted historical benchmark is provided annually several months after the start of the performance year. Benchmarks are adjusted as needed to account for program-wide regulatory changes.
  • Reconciliation package – contains financial and quality performance reports and informational reports on the ACO’s performance year assigned population.
    • Financial reconciliation reports specify the calculation of the ACO’s historical benchmark, updated historical benchmark and determination of shared savings/losses.
    • Quality performance reports specify the ACO’s quality performance results for the performance year: overall report on quality performance, and a detailed CAHPS for ACOs report.

Report Templates - CMS revises the format of the reports annually to account for changes in the program’s regulations, and to incorporate ACOs’ feedback on the reports including requests for additional data elements. 

Performance Year 2017 Shared Savings Program Report Templates [ZIP, 475KB] - This zip file contains the report templates finalized for Performance Year 2017. Report templates are finalized close-in-time to when the reports are initially produced for a specific performance year. Please check this file periodically for updates.

Monthly Claim and Claim Line Feed files – ACOs may also request to receive monthly data files from CMS on Medicare fee-for-service beneficiaries receiving primary care services from ACO providers and suppliers, who have not declined to share their data with ACOs. To receive these data, ACOs must follow the program’s requirements for notifying beneficiaries about the opportunity to decline sharing their data with ACOs, and meet the requirements for requesting and receiving data.

Prior Year's Documentation

Medicare Shared Savings Program: Shared Savings and Losses and Assignment Methodology Specifications, Version 3 [PDF, 470KB]