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FEDERAL · 42 CFR

Part 425 — Medicare Shared Savings Program

94 sections · Title 42: Public Health

§ 425.10Basis and scope.
§ 425.20Definitions.
§ 425.100General.
§ 425.102Eligible providers and suppliers.
§ 425.104Legal entity.
§ 425.106Shared governance.
§ 425.108Leadership and management.
§ 425.110Number of ACO professionals and beneficiaries.
§ 425.112Required processes and patient-centeredness criteria.
§ 425.114Participation in other shared savings initiatives.
§ 425.116Agreements with ACO participants and ACO providers/suppliers.
§ 425.118Required reporting of ACO participants and ACO providers/suppliers.
§ 425.200Participation agreement with CMS.
§ 425.202Application procedures.
§ 425.204Content of the application.
§ 425.206Evaluation procedures for applications.
§ 425.208Provisions of participation agreement.
§ 425.210Application of agreement to ACO participants, ACO providers/suppliers, and others.
§ 425.212Changes to program requirements during the agreement period.
§ 425.214Managing changes to the ACO during the agreement period.
§ 425.216Actions prior to termination.
§ 425.218Termination of the participation agreement by CMS.
§ 425.220Termination of the participation agreement by the ACO.
§ 425.221Close-out procedures and payment consequences of early termination.
§ 425.222Eligibility to re-enter the program for agreement periods beginning before July 1, 2019.
§ 425.224Application procedures for renewing ACOs and re-entering ACOs.
§ 425.226Annual participation elections.
§ 425.300Compliance plan.
§ 425.302Program requirements for data submission and certifications.
§ 425.304Beneficiary incentives.
§ 425.305Other program safeguards.
§ 425.306Participant agreement and exclusivity of ACO participants.
§ 425.308Public reporting and transparency.
§ 425.310Marketing requirements.
§ 425.312Beneficiary notifications.
§ 425.314Audits and record retention.
§ 425.315Reopening determinations of ACO shared savings or shared losses to correct financial reconciliation calculations.
§ 425.316Monitoring of ACOs.
§ 425.400General.
§ 425.401Criteria for a beneficiary to be assigned to an ACO.
§ 425.402Basic assignment methodology.
§ 425.404Special assignment conditions for ACOs including FQHCs and RHCs.
§ 425.500Measures to assess the quality of care furnished by an ACO for performance years (or a performance period) beginning on or before January 1, 2020.
§ 425.502Calculating the ACO quality performance score for performance years (or a performance period) beginning on or before January 1, 2020.
§ 425.504Incorporating reporting requirements related to the Physician Quality Reporting System Incentive and Payment Adjustment.
§ 425.506Incorporating reporting requirements related to adoption of certified electronic health record technology.
§ 425.507Incorporating Promoting Interoperability requirements related to the Quality Payment Program for performance years beginning on or after January 1, 2025.
§ 425.508Incorporating quality reporting requirements related to the Quality Payment Program.
§ 425.510Application of the APM Performance Pathway (APP) quality measure set or the APP Plus quality measure set (as applicable) to Shared Savings Program ACOs for performance years beginning on or after January 1, 2021.
§ 425.512Determining the ACO quality performance standard for performance years beginning on or after January 1, 2021.
§ 425.600Selection of risk model.
§ 425.601Establishing, adjusting, and updating the benchmark for agreement periods beginning on or after July 1, 2019, and before January 1, 2024.
§ 425.602Establishing, adjusting, and updating the benchmark for an ACO's first agreement period beginning on or before January 1, 2018.
§ 425.603Resetting, adjusting, and updating the benchmark for a subsequent agreement period beginning on or before January 1, 2019.
§ 425.604Calculation of savings under the one-sided model.
§ 425.605Calculation of shared savings and losses under the BASIC track.
§ 425.606Calculation of shared savings and losses under Track 2.
§ 425.608Determining first year performance for ACOs beginning April 1 or July 1, 2012.
§ 425.609Determining performance for 6-month performance years during CY 2019.
§ 425.610Calculation of shared savings and losses under the ENHANCED track.
§ 425.611Adjustments to Shared Savings Program calculations to address the COVID-19 pandemic.
§ 425.612Waivers of payment rules or other Medicare requirements.
§ 425.613Telehealth services.
§ 425.614-425.629§§ 425.614-425.629 [Reserved]
§ 425.630Option to receive advance investment payments.
§ 425.631-425.639§§ 425.631-425.639 [Reserved]
§ 425.640Option to receive prepaid shared savings.
§ 425.641-425.649§§ 425.641-425.649 [Reserved]
§ 425.650Benchmarking methodology.
§ 425.652Establishing, adjusting, and updating the benchmark for agreement periods beginning on January 1, 2024, and in subsequent years.
§ 425.654Calculating county expenditures and regional expenditures.
§ 425.655Calculating the regional risk score growth cap adjustment factor.
§ 425.656Calculating the regional adjustment to the historical benchmark.
§ 425.658Calculating the prior savings adjustment to the historical benchmark.
§ 425.659Calculating risk scores used in Shared Savings Program benchmark calculations.
§ 425.660Accountable Care Prospective Trend (ACPT).
§ 425.661§ 425.661 [Reserved]
§ 425.662Calculating the population adjustment to the historical benchmark.
§ 425.663-425.669§ 425.663-425.669 [Reserved]
§ 425.670Adjustments to mitigate the impact of significant, anomalous, and highly suspect billing activity on Shared Savings Program financial calculations involving calendar year 2023.
§ 425.672Adjustments to mitigate the impact of significant, anomalous, and highly suspect billing activity on Shared Savings Program financial calculations involving calendar year 2024 or subsequent calendar years.
§ 425.674Accounting for the impact of improper payments on Shared Savings Program financial calculations.
§ 425.700General rules.
§ 425.702Aggregate reports.
§ 425.704Beneficiary-identifiable claims data.
§ 425.706Minimum necessary data.
§ 425.708Beneficiaries may decline claims data sharing.
§ 425.710Data use agreement.
§ 425.800Preclusion of administrative and judicial review.
§ 425.802Request for review.
§ 425.804Reconsideration review process.
§ 425.806On-the-record review of reconsideration official's recommendation by independent CMS official.
§ 425.808Effect of independent CMS official's decision.
§ 425.810Effective date of decision.