United States: MSSP Final Rule Adopts All Proposed Additional Program Requirements And Beneficiary Protections Provisions

This is the sixth post in Health Care Law Today's series on the final rule. This post addresses additional program requirements and beneficiary protections.

The Medicare Shared Savings Program ("MSSP") final rule published on June 4, 2015 finalized all proposed additional program requirements and beneficiary protections outlined in the December 2014 proposed rule. The specific additional public reporting obligations that ACOs must fulfill to participate in the MSSP that CMS finalized include:

  • Maintain a dedicated webpage through which the ACO publicly reports information uniformly on the CMS-specified template;
  • Identify key clinical and administrative leaders within the ACO;
  • Identify types of ACO participants or combinations of ACO participants that form the ACO;
  • Publicly report ACO performance on all quality measures; and
  • Publicly report use of any waivers under 42 C.F.R. § 425.612.

Additionally, CMS finalized the requirement that ACOs must report the webpage address to CMS and apprise CMS of any changes to the website address. The final rule also makes an exception for information reported on a public reporting webpage in standardized format from the otherwise required CMS review and approval of marketing materials.

With the finalization of these proposed changes to the MSSP requirements, CMS is allowed to publicly report ACO-specific information, including any of the information outlined above that the ACO is required to publicly report as necessary to support program goals and transparency. This additional transparency should provide better information to the public concerning an ACO and its effectiveness.

Terminating Program Participation

CMS also adopted the proposals related to how program participation may be terminated. In addition to existing grounds on which CMS may terminate ACO program participation, CMS added the following two grounds:

  • Failure to comply with requests for information and documentation by the due date CMS specifies; and
  • Submission of false or fraudulent data.

Close-Out Procedures

Under the final rule, an ACO whose participation agreement is terminated prior to its expiration, either voluntarily or by CMS, must implement the following close-out procedures in a form, manner and deadline specified by CMS:

  • Notice to ACO participants of termination
  • Record retention
  • Data sharing
  • Quality reporting
  • Beneficiary continuity of care

CMS has also adopted the proposed qualifications for when an ACO may still qualify for shared savings for the performance year during which a voluntary termination becomes effective. These conditions include:

  1. The effective date of termination is December 31;
  2. By a date specified by CMS, the ACO completes the close out process for the performance year in which the termination becomes effective; and
  3. The ACO has satisfied the criteria for sharing in savings for the performance year.

With respect to voluntary terminations, CMS finalized the requirement that in order to be eligible for shared savings for the prior performance year, the ACO must provide notice termination to CMS that specifies that its termination effective date is December 31 and obtain approval from CMS.

Reconsideration Review Process

CMS also finalized its proposal to permit only on-the-record reviews of reconsideration requests to achieve its goal of greater transparency. As proposed and finalized, the reconsideration review process allows the ACO and CMS to submit one brief each in support of its position, and based on comments received, CMS had added a provision for the submission of additional briefs or evidence at the sole discretion of the reconsideration official.

Quality Performance Standards

All proposed requirements in relation to quality performance standards were adopted with some minor modification. The changes involved only technical changes to ensure that the ACO report quality measures accurately, completely and timely and in a manner consistent with other standards in the rule.

The final version of additional program requirements and beneficiary protections have been adopted exactly as they were proposed. Other than the additional briefs or evidence that may be submitted at the sole discretion of a reconsideration official with respect to the reconsideration review process, the proposed version of the additional program requirements and beneficiary protections sections has been adopted as is. ACOs should take these final requirements into consideration when forming or voluntarily terminating an ACO.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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