Find guidance and specifications pertaining to Accountable Care Organizations (ACOs) applying to and/or participating in the Medicare Shared Savings Program (Shared Savings Program).

• Application Guidance
• ACO Participant List and Participant Agreement Guidance
• SNF 3-Day Rule Waiver Guidance
• Beneficiary Incentive Program Guidance
• ACO Banking Form Instructions
• Repayment Mechanism Arrangements Guidance
• ACO Compliance Plan Guidance
• Data and Report Sharing
• Financial and Beneficiary Assignment Specifications
• Quality Resources and Information
• Primary Service Area Calculation
• Requesting Technical Assistance and Reconsideration Review Guidance

Application Guidance

The Application Toolkit provides quick access to guidance relevant to all application types. For more information about applying to the Shared Savings Program, refer to the Application Toolkit.

ACO Participant List and Participant Agreement Guidance

Participating ACOs may modify their ACO Participant List and associated agreements for the upcoming performance year during established timeframes. 

• ACO Participant List and Participant Agreement Guidance (Updated 5/1/2020) (PDF)
• Frequently asked questions about affiliating with an ACO as an “Other Entity (PDF),” instead of as an ACO participant

SNF 3-Day Rule Waiver Guidance

Participating ACOs approved for a Skilled Nursing Facility (SNF) 3-Day Rule Waiver may modify their SNF Affiliate List and associated agreements for the upcoming performance year during established timeframes. 

• Skilled Nursing Facility 3-Day Rule Waiver Guidance (Updated 5/1/2020) (PDF)

Beneficiary Incentive Program Guidance

Participating ACOs approved to establish and operate a Beneficiary Incentive Program (BIP) may provide an incentive payment with a value of up to $20 to each assigned beneficiary for each qualifying primary care service received.

• Beneficiary Incentive Program Guidance (Updated 5/1/2020) (PDF)

ACO Banking Form Instructions

Participating ACOs must maintain a current Electronic Funds Transfer Authorization Agreement (Form CMS-588) to receive shared savings.

• ACO Banking Form Instructions (Updated 4/30/2021) (PDF)

Repayment Mechanism Arrangements Guidance

ACOs electing to participate in two-sided risk must have the ability to pay all shared losses for which they may be liable. The Centers for Medicare & Medicaid Services (CMS) strongly encourages applicants to submit preliminary repayment mechanism documentation in Microsoft Word format for feedback. 

• Repayment Mechanism Arrangements Guidance (Updated 6/18/2020) (PDF)
  • Appendix A: Escrow Agreement Template (DOCX)
  • Appendix B: Escrow Agreement Amendment Sample (DOCX)
  • Appendix C: Letter of Credit Sample (DOCX)
  • Appendix D: Surety Bond Sample (DOCX)
  • Appendix E: Repayment Mechanism Documentation Cover Sheet (DOCX)

ACO Compliance Plan Guidance

To participate in the Shared Savings Program, each ACO must have a compliance plan in accordance with 42 CFR § 425.300.

• Compliance Plan Tip Sheet (PDF)

Data and Report Sharing

CMS provides ACOs with information on their assigned population and financial performance at the start of the agreement period and routinely during the performance year. ACOs must request to receive monthly Claim and Claim Line Feed (CCLF) files on Medicare fee-for-service (FFS) beneficiaries who have not declined to share their data.

• PY 2021 Shared Savings Program Report Templates (ZIP): 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. Please check this file periodically for updates.

Financial and Beneficiary Assignment Specifications

Participating ACOs are encouraged to reference the program’s financial and beneficiary assignment specifications for detailed information on how the Shared Savings Program assigns beneficiaries to each ACO and calculates a historical financial benchmark from which to assess annual financial performance, and ultimately, eligibility for an earned shared savings payment.

Table: Shared Savings and Losses and Assignment Methodology Specifications, Crosswalk between Methodology & Resources

• Shared Savings and Losses and Assignment Methodology, Specifications of Policies to Address the Public Health Emergency for COVID-19 (PDF): describes the changes and clarifications to Shared Savings Program policies, addressing the impact of the COVID-19 pandemic and the resulting PHE, that were finalized in the Calendar Year (CY) 2021 Physician Fee Schedule Final Rule (85 FR 84472).
• Shared Savings and Losses and Assignment Methodology Specifications Version 9 (PDF): incorporates changes to Shared Savings Program policies outlined in the CY 2021 Physician Fee Schedule Final Rule (85 FR 84472), including the beneficiary assignment methodology and the quality performance standard applicable for performance years (PYs) beginning on or after January 1, 2021.  Note: Version 9 of the Specifications is relevant to ACOs with agreement periods starting on or after July 1, 2019, except as otherwise noted. ACOs with agreement periods beginning before July 1, 2019, should reference earlier versions of the Specifications for the applicable benchmarking methodology.
• Shared Savings and Losses and Assignment Methodology Specifications Version 8 (PDF): incorporates the changes outlined in the Pathways to Success Final Rule (83 FR 67816) that are applicable for agreement periods beginning on July 1, 2019, and for subsequent performance years.
• Shared Savings and Losses and Assignment Methodology Specifications Version 7 (PDF): incorporates the changes outlined in the CY 2019 Physician Fee Schedule Final Rule (83 FR 59452) that are applicable for PY 2019 for ACOs participating as of January 1, 2019. 

Shared Savings and Losses and Assignment Methodology Specifications Version 6

Shared Savings and Losses and Assignment Methodology Specifications Version 6 (PDF): incorporates the changes outlined in the CY 2018 Physician Fee Schedule Final Rule (82 FR 52976) and the Shared Savings Program Interim Final Rule for Extreme and Uncontrollable Circumstances (82 FR 60912) that are applicable for PY 2018.

Shared Savings and Losses and Assignment Methodology Specifications Version 5

Shared Savings and Losses and Assignment Methodology Specifications Version 5 (PDF): incorporates the changes outlined in the Shared Savings Program June 2016 Final Rule (81 FR 37949) that are applicable for PY 2017.

Shared Savings and Losses and Assignment Methodology Specifications Version 4

Shared Savings and Losses and Assignment Methodology Specifications Version 4 (PDF): incorporates the changes outlined in the Shared Savings Program June 2015 Final Rule (80 FR 32691) that are applicable for PY 2016.

Shared Savings and Losses and Assignment Methodology Specifications Version 3

Shared Savings and Losses and Assignment Methodology Specifications Version 3 (PDF): documentation supporting prior years in the Shared Savings Program, applicable through PY 2015, as related to the Shared Savings Program November 2011 Final Rule (76 FR 67991).

Quality Resources and Information

Quality Measurement

Participating ACOs must report quality data to CMS after the close of every performance year to be eligible to share in any earned shared savings and to avoid sharing losses at the maximum level. CMS measures every ACO’s quality performance using standard methods. Quality measures span four domains: patient/caregiver experience, care coordination/patient safety, preventive health, and at-risk populations.

To learn more about the Shared Savings Program quality measurement for PY 2020, refer to: 

• Shared Savings Program Quality Measure Benchmark for PY 2020 (PDF): This document is updated to reflect quality performance benchmarks for the 2020 quality performance year only and the removal of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for ACOs benchmarks due to waiving the requirement for ACOs to field a CAHPS for ACOs Survey for performance year 2020 only.
• 2020 Measure Information Forms (ZIP): These documents describe in detail each of the three administrative and claims based measure in the Shared Savings Program Measure for PY 2020. 
• 2020 Quality Measurement Methodology and Resources (PDF): This document reviews the quality performance standard and scoring methodology for ACOs participating in the Shared Savings Program and describes the Shared Savings Program’s quality measurement and reporting methodology.
• CAHPS for ACOs Survey website

To learn more about the Shared Savings Program quality measurement for PY 2019, refer to: 

• The Shared Savings Program Quality Measure Benchmarks for PY 2019 (Updated 05/27/2020) (PDF) is updated to indicate that ACO-14, Preventative Care and Screening: Influenza Immunization is pay-for-reporting for PY 2019. 
• 2019 Measure Information Forms (ZIP): These documents describe in detail each of the three administrative and claims-based measure in the Shared Savings Program measure set for PY 2019. 
• 2019 Quality Measurement Methodology and Resources (PDF): This document reviews the quality performance standard and scoring methodology for ACOs participating in the Shared Savings Program and describes the Shared Savings Program’s quality measurement and reporting methodology.
• CMS Web Interface Measure Documentation Reference Guide for Performance Year 2019 (PDF): This document outlines the documentation requirements for each of the 2019 CMS Web Interface quality measures. It is intended to be used as a supplemental resource in conjunction with the 2019 Web Interface measure specifications posted in the online Quality Payment Program Library.
• CAHPS for ACOs Survey website

Prior Years Quality Documentation

• 2018 ACO Quality Reporting Documentation (ZIP) 
• 2017 ACO Quality Reporting Documentation (ZIP)
• 2016 ACO Quality Reporting Documentation (ZIP)
• 2015 ACO Quality Reporting Documentation (ZIP)
• 2014 ACO Quality Reporting Documentation (ZIP)
• 2013 ACO Quality Reporting Documentation (ZIP)
• 2012 ACO Quality Reporting Documentation (ZIP)

Quality Measurement Performance Program Interactions Resources 

For more information on interactions between the Shared Savings Program and other CMS initiatives, please reference:

• Medicare Shared Savings Program and Quality Payment Program Interactions for Performance Year 2020 (PDF): Provides an overview of the interaction between Quality Payment Program and Shared Savings Program for PY 2020. 
• Medicare Shared Savings Program & Quality Payment Program Interactions for Performance Years during 2019: Provides an overview of the interactions between the Quality Payment Program and the Shared Savings Program for performance years during 2019.
• Interaction with Other Medicare Initiatives: Provides an overview of how the Quality Payment Program and other CMS Innovation Center initiatives intersect with the Shared Savings Program.
• Quality Payment Program Resource Library: Presents Quality Payment Program resources, including fact sheets describing the interaction between the Shared Savings Program and the Quality Payment Program.

Primary Service Area Calculation

CMS makes data available to applicants to allow them to calculate their share of services in each applicable primary service area as described by the Antitrust Enforcement Policy.

• Calculating Your Primary Service Areas Guidance (PDF)

Requesting Technical Assistance and Reconsideration Review Guidance

ACOs may request an appeal of an initial determination by CMS in limited circumstances.

• Requesting Technical Assistance and Reconsideration Review Guidance (Updated 09/14/2020) (PDF)

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