Recent Changes to the Medicare Shared Savings (ACO) Program Aimed to Encourage Beneficiaries to be Proactive with Their Health Care

March 2018 – Recent additions to the Medicare Shared Savings Program (“MSSP”), include several changes aimed to encourage Medicare beneficiaries to take a more proactive approach with their health care.

By way of background, on March 23, 2010, Section 3022 of the Affordable Care Act added section 1899 (42 U.S.C. § 1395jjj) to the Social Security Act, requiring that the U.S. Department of Health & Human Services (“DHHS”) establish the MSSP. The program provides for a new type of health care entity, an Accountable Care Organization (“ACO”), that is held accountable for the quality and experience of care for a population of assigned Medicare beneficiaries while reducing the rate of growth in health care spending for that population. Under the MSSP, an ACO’s quality and financial performance is assessed annually by the Center for Medicare and Medicaid Services (“CMS”) based on its assigned beneficiaries to determine whether the ACO has met the quality performance standards and reduced growth in expenditures compared to a historical financial benchmark. ACOs that meet or exceed a minimum savings rate and satisfy minimum quality performance standards are eligible to receive a portion of the shared savings generated which incentivizes ACOs to improve the coordination and quality of care. There are different tracks or programs, depending on the amount of risk an ACO wishes to assume.

On February 9, 2018, President Trump signed H.R. 1892, entitled the Bipartisan Budget Act of 2018, into law which, among other things, inserts 42 U.S.C. § 1395jjj(m) providing that certain ACOs (limited to ACOs in risk-bearing tracks) may apply to establish an ACO Beneficiary Incentive Program to provide incentive payments to beneficiaries who are furnished certain qualifying services by an ACO.

Under an ACO Beneficiary Incentive Program, an ACO is permitted to pay a Medicare beneficiary up to twenty dollars (updated annually based on the consumer price index for all urban consumers) for each qualifying service furnished to a beneficiary. A qualifying service is defined as certain primary care services (as defined in 42 C.F.R. 425.20) to which Part B coinsurance applies, furnished by certain ACO primary care providers. DHHS will implement this program between January 1, 2019 and January 1, 2020.

H.R. 1982 also inserted 42 U.S.C. § 1395jjj(c)(2)(B) which permits beneficiaries to assign a physician in an ACO as their primary-care provider.

Experts say these changes are aimed to encourage beneficiaries to take a more proactive approach with their health care.

Click here to access H.R. 1892.

Click here to access 42 U.S.C. § 1395jjj.

 

For more information on this topic, please contact Adrienne Dresevic, Esq. or Clinton Mikel, Esq. at (248) 996-8510 or by email at adresevic@thehlp.com or cmikel@thehlp.com.