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Program Statutes & Regulations

Find statutes and regulatory documents describing the establishment and further modifications to the Shared Savings Program through stand-alone rules and sections within the annual Physician Fee Schedule (PFS) rules. For the complete and up-to-date Shared Savings Program regulations, refer to the eCFR.

Statutory Basis

Congress enacted the Patient Protection and Affordable Care Act (Pub.L. 111-148) on March 23, 2010. Section 3022 of the Affordable Care Act amended Section 1899 of the Social Security Act and established the Shared Savings Program. To learn more, refer to the Affordable Care Act and Social Security Act.

 

Physician Fee Schedule Final Rule November 1, 2018

The PFS final rule displayed in November 2018 addresses a subset of changes to the Medicare Shared Savings Program for Accountable Care Organizations (ACOs) proposed in the August 2018 proposed rule “Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations Pathways to Success” and addresses various other revisions designed to update program policies under the Shared Savings Program. In order to ensure continuity of participation, finalize time-sensitive program policy changes for currently participating ACOs, and streamline the ACO core quality measure set to reduce burden and encourage better outcomes, CMS is finalizing the following policies:

  • A voluntary 6-month extension for existing ACOs whose participation agreements expire on December 31, 2018, and the methodology for determining financial and quality performance for this 6-month performance year from January 1, 2019, through June 30, 2019.
  • Reducing the Shared Savings Program core quality measure set by eight measures; and promoting interoperability among ACO providers and suppliers by adding a new Certified EHR Technology (CEHRT) threshold criterion to determine ACOs’ eligibility for program participation and retiring the current Shared Savings Program quality measure on the percentage of eligible clinicians using CEHRT. 
  • Allowing beneficiaries who voluntarily align to a Nurse Practitioner, Physician Assistant, Certified Nurse Specialist, or a physician with a specialty not used in assignment to be prospectively assigned to an ACO if the clinician they align with is participating in an ACO, as provided for in the Bipartisan Budget Act of 2018.
  • Providing relief for ACOs and their clinicians impacted by extreme and uncontrollable circumstances in 2018 and subsequent years.
  • Revising the definition of primary care services used in beneficiary assignment.

To learn more, refer to Details for Calendar Year (CY) 2019 Physician Fee Schedule Final Rule.

Proposed Rule July 12, 2018

To learn more, refer to CY 2019 PFS.

Shared Savings Program Proposed Rule August 9, 2018

CMS issued a proposed rule that would provide a new direction for the Shared Savings Program by establishing pathways to success through redesigning the participation options available under the program to encourage Accountable Care Organizations (ACOs) to transition to two-sided models (in which they may share in savings and are accountable for repaying shared losses). These proposed policies are designed to increase savings for the Trust Funds and mitigate losses, reduce gaming opportunities, and promote regulatory flexibility and free-market principles. The proposed rule also would provide new tools to support coordination of care across settings and strengthen beneficiary engagement; ensure rigorous benchmarking; promote interoperable electronic health record technology among ACO providers/suppliers; and improve information sharing on opioid use to combat opioid addiction.

    To learn more, refer to the Federal Register August 2018 Notice of Proposed Rule Making (NPRM).

    NOTE: The 60-day comment period closed on October 16, 2018.

    Shared Savings Program Interim Final Rule for Extreme and Uncontrollable Circumstances December 26, 2017

    CMS published an interim final rule with comment period (IFC) that established policies for assessing the quality and financial performance of Shared Savings Program ACOs affected by extreme and uncontrollable circumstances, such as Hurricanes Harvey, Irma, Maria, and the California wildfires, during Performance Year (PY) 2017. The IFC includes the following:

    • CMS will use the same determination of an extreme and uncontrollable circumstance as determined under the Quality Payment Program, including the identification of affected geographic areas.
    • ACOs with 20 percent or more of their assigned beneficiaries who reside in impacted counties, or an ACO legal entity located in impacted counties, will receive the higher of their ACO reported quality score or the mean Shared Savings Program ACO quality score.
    • Performance-based risk ACOs will have any owed losses adjusted for the percent of the ACO’s assigned beneficiaries residing in impacted counties and the length of the emergency declaration.

    To learn more, refer to Federal Register December 2017 IFC.

    Physician Fee Schedule Final Rule November 15, 2017

    The PFS final rule published in November 2017 includes the following:

    • Modifications to the Shared Savings Program beneficiary assignment methodology for performance year 2019 and subsequent years.
    • Revisions to ACO quality reporting.
    • Skilled Nursing Facility (SNF) 3-Day Rule Waiver Application requirement that ACOs report their financial relationships and modifications to the Shared Savings Program Initial Application.
    • Addressing compliance with ACO participant taxpayer identification number (TIN) exclusivity requirement.
    • Treatment of individually beneficiary-identifiable payments made under a demonstration, pilot, or time limited program.

    To learn more, refer to Details for CY 2018 Physician Fee Schedule Final Rule.

    Proposed Rule July 21, 2017

    To learn more, refer to Details for Proposed CY 2018 Revisions to Payment Policies Under PFS.

    Physician Fee Schedule Final Rule November 15, 2016

    The PFS final rule published in November 2016 included the following:

    • Revisions permitting eligible professionals in ACOs to report quality apart from the ACO including during the 2016 Physician Quality Reporting System (PQRS) special reporting period for eligible professionals.
    • Modifications to the assignment algorithm to align beneficiaries to an ACO when a beneficiary has designated an ACO professional as responsible for their overall care.

    To learn more, refer to Details for CY 2017 Revisions to Payment Policies Under PFS.

    Proposed Rule July 15, 2016

    To learn more, refer to Details for Proposed CY 2017 Revisions to Payment Policies Under PFS.

    Shared Savings Program Final Rule June 10, 2016

    The new final rule published in June 2016 included the following:

    • Revisions to the approach for resetting (or rebasing) an ACO's benchmark for a second or subsequent agreement period beginning on or after January 1, 2017 to take into account regional fee-for-service (FFS) expenditures.
    • Revisions to the methodology for national FFS calculations to use assignable Medicare FFS beneficiaries (a subset of the broader FFS population) instead of all FFS beneficiaries.
    • Addition of an option for ACOs participating under Track 1 to apply to renew for a second agreement period under a two-sided model (Track 2 or Track 3). If the ACO’s renewal request is approved, the ACO may request that its initial participation agreement under Track 1 be extended for an additional year (that is, the ACO would enter a fourth performance year under Track 1).

    To learn more, refer to:

    Proposed Rule February 3, 2016

    To learn more, refer to:

    Physician Fee Schedule Final Rule November 16, 2015

    The PFS final rule published in November 2015 included the following:

    • Clarifying how PQRS-eligible professionals participating within an ACO meet their PQRS reporting requirements when their ACO satisfactorily reports quality.
    • Amending the definition of primary care services to include claims submitted by Electing Teaching Amendment (ETA) hospitals and exclude claims submitted by SNFs when the claim contains the place-of-service 31 modifier.

    To learn more, refer to Details for CY 2016 Revisions to Payment Policies Under PFS.

    Proposed Rule July 15, 2015

    To learn more, refer to Details for Proposed CY 2016 Revisions to Payment Policies Under PFS.

    Shared Savings Program Final Rule June 9, 2015

    The final rule improves several program areas including:

    • Creates a new performance-based risk option (Track 3) that includes prospective beneficiary assignment, a higher sharing rate, and the opportunity to use new care coordination tools.
    • Permits ACOs to participate in one additional 3-year agreement period under Track 1 and maintain the same maximum sharing rate applicable in their first agreement period.
    • Establishes a waiver of the 3-day stay SNF rule for beneficiaries that are prospectively assigned to ACOs under Track 3.
    • Streamlines the process for ACOs to access Medicare beneficiary claims data necessary for health care operations, while retaining the opportunity for beneficiaries to decline to have their claims data shared with the ACO.
    • Refines the policies for resetting ACO benchmarks to help ensure that the program continues to provide strong incentives for ACOs to improve patient care and generate cost savings, and announces CMS’ intent to propose further improvements to the benchmarking methodology later this year.
    • Revises the assignment methodology to remove certain specialty types whose services are not likely to indicate the provision of primary care services. Includes primary care services furnished by nurse practitioners, physician assistants, and clinical nurse specialists.

    To learn more, refer to:

    Proposed Rule December 8, 2014

    To learn more, refer to Federal Register December 2014 Proposed Rule.

    Shared Savings Program Final Rule November 2, 2011

    To learn more, refer to Federal Register November 2011 Final Rule.

    Proposed Rule April 7, 2011

    To learn more, refer to Federal Register April 2011 Proposed Rule.

     

    Other Regulations

    To learn more about other applicable regulations, refer to the resources below:

     

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