An ACO refers to a group of physicians, hospitals and other suppliers of services that will work together to provide coordinated care to Medicare beneficiaries. The statute lists the following groups of providers of services and suppliers as eligible to participate as an ACO: • ACO professionals in group practice arrangements.
What is a Medicare-Medicaid Accountable Care Organization (ACO)?
Through the Medicare-Medicaid Accountable Care Organization (ACO) Model, the Centers for Medicare & Medicaid Services (CMS) intends to partner with interested states to offer ACOs in those states the opportunity to take on accountability for both Medicare and Medicaid costs and quality for their beneficiaries.
Do ACO patients keep Original Medicare benefits?
Patients of ACOs maintain all of their Original Medicare benefits and are able to see any Medicare provider. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it can share in the savings it achieves for the Medicare program.
Can I be assigned to an ACO?
Only people with Original Medicare can be assigned to an ACO. You can’t be assigned to an ACO if you have a Medicare Advantage Plan (Part C), like an HMO or a PPO. An ACO can't tell you which health care providers to see and can't change your Medicare Benefits.
What is provider participation in an ACO?
Provider participation in an ACO is purely voluntary. In developing this final rule, CMS worked closely with agencies across the Federal government to ensure a coordinated and aligned inter- and intra-agency effort to facilitate implementation of the Shared Savings Program.
Who are ACO participants?
An ACO is composed of groups of doctors, hospitals, and other health care providers that come together voluntarily to give coordinated, high-quality care to their Medicare FFS beneficiaries.
How does Medicare determine which patients will be assigned to the ACO?
Under the Medicare Shared Savings Program Accountable Care Organization (MSSP ACO), beneficiaries will be automatically assigned based on where they receive their primary care.
What are the four major categories for pursuing ACOs?
ACOs in the first year of performance contracts are commonly focusing on four areas: first, transforming primary care through increased access and team-based care; second, reducing avoidable emergency department use; third, strengthening practice-based care management; and fourth, developing new boundary spanner roles ...
How are ACO beneficiaries assigned?
Beneficiaries will be assigned to an ACO, in a two step process, if they receive at least one primary care service from a physician within the ACO: The first step assigns a beneficiary to an ACO if the beneficiary receives the plurality of his or her primary care services from primary care physicians within the ACO.
What part of a patient's care is an ACO financially accountable for?
ACOs take value-based reimbursement to a new level by not only tying payments to quality, but also holding providers financially accountable for the care costs of their patient population.
What does ACO mean to patient?
What is an ACO? ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients.
What are the three types of Medicare accountable care organizations?
Medicare offers three main participation options, including the Medicare Shared Savings Program (MSSP), the Pioneer ACO Model, and the Next Generation ACO Model.
What are the different ACO models?
Medicare offers several different types of ACO programs:Medicare Shared Savings Program - works to achieve better health for individuals, better population health, and lowering growth in expenditures.ACO Investment Model - tests prepayment approaches to support MSSP ACOs.More items...
How is ACO different from HMO?
An HMO is a medical insurance organization that provides health care to anyone who is a member for a certain annual fee. On the other hand, an ACO is a group of networked healthcare professionals who are supposed to make sure that quality health care is provided to a set number of members.
What is an ACO beneficiary?
Accountable Care Organizations The Shared Savings Program is a voluntary program that encourages groups of doctors, hospitals, and other health care providers to come together as an ACO to give coordinated, high quality care to their Medicare beneficiaries.
Can providers participate in multiple ACOs?
However, individual practitioners, identified by individual National Provider Identifiers (NPIs), are free to participate in multiple ACOs if they bill under several different TINs.
Do Medicare beneficiaries need to be notified that their physician is participating in a Medicare Shared Savings Program ACO?
Individuals enrolled in Medicare Advantage plans under Part C, an eligible HMO organization under section 1876, or a PACE program cannot be assigned to an ACO. Medicare ACOs must notify patients that they are participating in an ACO.
What is Medicare ACO model?
The Medicare-Medicaid ACO Model is open to all states and the District of Columbia that have a sufficient number of Medicare-Medicaid enrollees in fee-for-service Medicare and Medicaid. CMS will enter into Participation Agreements with up to six states, with preference given to states with low Medicare ACO saturation. Additional eligibility requirements and details about the application process are provided in the Request for Letters of Intent found at the Medicare-Medicaid ACO Model web page. States must follow all rules, including those related to Medicaid coverage, payment and fiscal administration that apply under the approach they are approved to offer. CMS will work with states to determine the appropriate Medicaid authority needed for their desired approach. State participation in the Model is contingent upon obtaining any necessary approvals and/or waivers from CMS.
What is an ACO?
On December 15, 2016, the Department of Health and Human Services (HHS) announced a new model focused on improving care and reducing costs for beneficiaries who are dually eligible for Medicare and Medicaid (“Medicare-Medicaid enrollees”). Through the Medicare-Medicaid Accountable Care Organization (ACO) Model, the Centers for Medicare & Medicaid Services (CMS) intends to partner with interested states to offer ACOs in those states the opportunity to take on accountability for both Medicare and Medicaid costs and quality for their beneficiaries. This is in accordance with the Department of Health and Human Services’ “Better, Smarter, Healthier” approach to improving our nation’s health care and the Administration setting clear, measurable goals and a timeline to move the Medicare program -- and the health care system at large -- toward paying providers based on the quality rather than the quantity of care they provide to patients. CMS is adding the Medicare-Medicaid ACO Model to its existing portfolio of ACO initiatives, which include: 1 Medicare Shared Savings Program (Shared Savings Program) 2 Pioneer ACO Model 3 Next Generation ACO Model 4 ACO Investment Model (AIM) 5 Comprehensive ESRD Care (CEC) Model
What is a letter of intent for ACO?
The Request for Letters of Intent includes some ACO eligibility criteria, but states and CMS may agree to additional criteria during the state-specific development process. A state-specific Request for Applications will be released to ACOs at a later date. In addition to applying to participate in the Medicare-Medicaid ACO Model, ACOs will be required to apply to participate in (or apply to renew their Participation Agreement for) the Shared Savings Program and ultimately sign a Participation Agreement to participate in the Shared Savings Program in order to participate in the Medicare-Medicaid ACO Model. Providers, whether currently participating in an ACO or potentially interested in joining or forming an ACO, are encouraged to participate in the state-specific development process and to submit letters of interest with their state’s Letter of Intent.
When will the ACO model start?
States may choose from three options for when to begin the first 12-month performance period for the Model ACOs in the state: January 1 , 2018; January 1, 2019; or January 1, 2020. The Medicare-Medicaid ACO Model includes strong patient protections to ensure that patients have access to and receive high-quality care.
Can ACOs see Medicare?
Patients of ACOs maintain all of their Original Medicare benefits and are able to see any Medicare provider. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it can share in the savings it achieves for the Medicare program.
Is Medicare ACO accountable for Medicaid?
Current Medicare ACOs, however, often do not have financial accountability for the Medicaid expenditures for those beneficiaries. Summary of the Medicare-Medicaid ACO Model.
When does ACO start?
Beginning July 1, 2019, an ACO or ACO participant provides each beneficiary with a standardized written notice before or at the first primary care visit of the performance year in the form and manner specified by CMS.
When are ACOs rewarded?
ACOs are rewarded when they lower growth in Medicare Parts A and B expenditures (relative to their benchmark) while meeting quality performance standards at the same time. Performance year financial reconciliation occurs annually after CMS assesses quality performance.
What is Beneficiary Assignment?
Beneficiary assignment contributes to key program operations, such as calculating the ACO’s financial benchmark, assessing the ACO’ s financial performance after the close of each performance year, and determining the ACO’s sample of beneficiaries for quality reporting.
What is Medicare ACO?
20, 2011, the Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), finalized new rules under the Affordable Care Act to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs). ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities. The Medicare Shared Savings Program (Shared Savings Program) will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first. Provider participation in an ACO is purely voluntary.
What is an ACO in CMS?
Accountable Care Organizations (ACOs) are one way CMS is working to meet the three-part aim of better health care, better health, and lower growth in expenditures through continuous improvement.
What is ACO model?
The Advance Payment ACO Model is an initiative developed by the Centers for Medicare and Medicaid (CMS) Innovation Center designed for organizations participating as Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (Shared Savings Program).
How does CMS recoup advance payments?
CMS will recoup Advance Payments through an ACO’s earned shared savings. ACOs selected to receive advance payments will enter into an agreement with CMS that details the obligation to repay advance payments.
How much revenue does an ACO have?
ACOs that do not include any inpatient facilities AND have less than $50 million in total annual revenue. ACOs in which the only inpatient facilities are critical access hospitals and/or Medicare low-volume rural hospitals AND have less than $80 million in total annual revenue.
What is ACO in healthcare?
ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities.
Does CMS recoup ACO?
CMS will not pursue recoupment on any remaining balance of advance payments after the ACO completes the first agreement period. CMS will pursue full recoupment of advance payments from any ACO that does not complete the full, initial agreement period of the Shared Savings Program. Eligibility/Selection:
What is an accountable care organization?
An ACO is a self-selected group of healthcare providers who work together to give high-quality, coordinated care to patients, while also finding ways to lessen the cost of that care.
What is the purpose of accountable care organizations?
Providers in an ACO set out to deliver patient care more efficiently and effectively. That’s why each ACO provider shares patient health records with all others in their ACO and with Medicare. (If you don’t want your medical information shared in this way, you can request that by calling Medicare at 1-800-633-4227 .)
What is the Medicare Shared Savings Program?
The Medicare Shared Savings Program (MSSP) is the predominant model of ACO in the U.S. Providers coordinate care by sharing patient records and cost information. Through teamwork, they streamline processes, reducing duplicate tests and appointments and cutting unnecessary fees.
What are the pros and cons of accountable care organizations?
Better incentives for doctors: Healthcare providers in ACOs get rewards for providing you with high-quality care and improving your health. The result: They're incentivized to give you preventative screenings, coordinate treatment, and reduce extra fees.
Do accountable care organizations save you money?
It appears from the data that ACOs save Medicare money. In 2020, the Centers for Medicare & Medicaid Services (CMS) reported MSSP ACOs saved Medicare nearly $2 billion with consecutive years of savings. Another study found ACOs reduce Medicare costs by 1% to 2% .
How to find accountable care organizations
Ask your doctor if they are part of an ACO. You can also see if there is an ACO near you by checking the map on this CMS page .
The bottom line
The mission of ACOs is to provide more affordable care to Medicare beneficiaries without sacrificing quality. In recent years, they have saved Medicare billions of dollars, but there’s little evidence that the out-of-pocket costs for patients are declining.
What should physicians understand about ACO?
According to the guide, “physicians should understand the contents, frequency, and quality of data that they will receive through the ACO. At minimum, the ACO should provide participating physicians with claims data regarding their patients who are attributed to the ACO.”
What are the three important topics physicians should consider when evaluating an ACO?
Three important topics physicians should consider when evaluating an ACO include risk, data access and physician obligations under the agreement.
How long does an ACO have to take on risk?
Under the Pathways to Success Rule, Medicare Shared Savings Program ACOs are now required to taking on risk within five years or less, depending on the ACO’s revenue.
What is an ACO?
Accountable care organizations (ACOs) can be an attractive option for physicians looking to retain their independence while benefiting from collaboration with others delivering patient care. Finding success in ACOs requires careful planning and substantial knowledge about current realities of ACOs, which have rapidly matured since their debut less than 10 years ago.
Can ACOs require periodic capital contributions?
As stated in the guide, “The ACO also may require periodic capital contributions from its Participants, including the physician practice, in order to fund ongoing operations.
Preparing For The Performance Year
What to Expect During The Performance Year
- Beneficiary Notification and Marketing
Beginning July 1, 2019, an ACO or ACO participant provides each beneficiary with a standardized written notice before or at the first primary care visit of the performance year in the form and manner specified by CMS. In addition, an ACO participant posts signs in its facilities and in setti… - Beneficiary Assignment
Beneficiary assignment contributes to key program operations, such as calculating the ACO’s financial benchmark, assessing the ACO’s financial performance after the close of each performance year, and determining the ACO’s sample of beneficiaries for quality reporting. For …
Post-Performance Year Activities
- Quality Reporting and Measurement
Shared Savings Program ACOs must demonstrate that they meet the quality performance standards for each performance year before they can share in any earned savings. For more information on quality, refer to Program Guidance & Specifications. - Financial Reconciliation
ACOs are rewarded when they lower growth in Medicare Parts A and B expenditures (relative to their benchmark) while meeting quality performance standards at the same time. Performance year financial reconciliation occurs annually after CMS assesses quality performance. CMS adju…