CMS Announces Program to Fund ACO Growth, Extends Fraud and Abuse Waivers

Posted by Chris Raphaely on October 16, 2014
Accountable Care Organizations, CMS, OIG

The Centers for Medicare & Medicaid Services (“CMS”) announced a new initiative, the ACO Investment Model, on October 15, 2014.  Under the model, ACOs which are made up of “providers [who] lack adequate access to … capital” may receive additional funding from the CMS “to invest in infrastructure necessary to successfully implement population care management.” The eligibility criteria are as follows:

  • The ACO must be accepted into and participate in the Medicare Shared Savings Program. The ACO’s first performance period in the Medicare Shared Savings Program must have started in either 2012, 2013 or 2014 or will start in 2016.
  • The ACO has completely and accurately reported quality measures to the Medicare Shared Savings Program in the most recent performance year, if the ACO started in the Medicare Shared Savings Program in 2012, 2013 or 2014, excluding ACOs that will start in 2016.  The ACO has a preliminary prospective beneficiary assignment of 10,000 or fewer beneficiaries for the most recent quarter, as determined in accordance with the Shared Savings Program regulations.
  • The ACO does not include a hospital as an ACO participant or an ACO provider/supplier (as defined by the Shared Savings Program regulations), unless the hospital is a critical access hospital (CAH) or inpatient prospective payment system (IPPS) hospital with 100 or fewer beds.
  •  The ACO is not owned or operated in whole or in part by a health plan.
  •  The ACO did not participate in the Advance Payment Model.

The CMS also said the program“will target new ACOs serving rural areas and areas of low ACO penetration and existing ACOs committed to moving to higher risk tracks.” Applications for eligible ACOs that began to participate in the Medicare Shared Savings Program in 2012 or 2013 will be accepted until December 1, 2014, and applications for eligible ACOs that began to participate in the Medicare Shared Savings Program in 2014 or will begin to participate in 2016 will be accepted in the summer of 2015.

On October 16, 2014 the CMS and the Office of Inspector General, U.S. Department of Health and Human Services (“OIG”), announced that the waivers (“Waivers”’) to the federal Stark Law, Anti-Kickback Statute and Civil Monetary Penalties Law for ACOs participating in the Medicare  Shared Savings Program would remain in effect until at least November 2, 2015.  The Waivers were promulgated as interim final rules and, pursuant to the Social Security Act, would have expired on November 2, 2014 unless either a final rule or a notice of the extension was published before such date.

In extending the Waivers the CMS and the OIG cited the need to issue “final waiver regulations that align with” the modification to the Medicare Shared Savings Program regulations that the CMS is developing and additional input on the Waivers from stakeholders.  CMS sent the proposed  modifications to the  Medicare Shared Savings Program regulations to the Office of Management and Budget in late June 2014, but they have yet to be published.

To read the Waiver in its entirety, please click here.

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