Title 42
SECTION 425.512
425.512 Determining the ACO quality performance standard for performance years beginning on or after January 1, 2021.
§ 425.512 Determining the ACO quality performance standard for performance years beginning on or after January 1, 2021.(a) Establishing a quality performance standard - (1) Overall standard. The quality performance standard is the overall standard the ACO must meet in order to be eligible to receive shared savings for a performance year. An ACO will not qualify to share in savings in any year it fails to meet the quality performance standard.
(2) For performance year 2022 and subsequent performance years. For the first performance year of an ACO's first agreement period under the Shared Savings Program, if the ACO meets the data completeness requirement at § 414.1340 of this chapter and case minimum requirement at § 414.1380 of this chapter on the three measures it is actively required to report and fields a CAHPS for MIPS survey via the APP, the ACO will meet the quality performance standard.
(3) For performance years 2021 and 2022 - (i) Designation of quality performance standard. For all ACOs, except as specified in paragraph (a)(2) of this section, CMS designates the quality performance standard as the ACO reporting quality data via the APP established under § 414.1367 of this chapter, according to the method of submission established by CMS and achieving a quality performance score that is equivalent to or higher than the 30th percentile across all MIPS Quality performance category scores, excluding entities/providers eligible for facility-based scoring.
(ii) For performance year 2021. If an ACO does not report any of the ten CMS Web Interface measures or any of the three measures it is actively required to report and does not field a CAHPS for MIPS survey via the APP, the ACO will not meet the quality performance standard.
(iii) For performance year 2022. If an ACO does not report any of the three measures it is actively required to report and does not field a CAHPS for MIPS survey via the APP, the ACO will not meet the quality performance standard.
(4) For performance years 2023 and subsequent performance years. (i) For all ACOs, except as specified in paragraph (a)(2) of this section, CMS designates the quality performance standard as the ACO reporting quality data via the APP established under § 414.1367 of this chapter, according to the method of submission established by CMS and achieving a quality performance score that is equivalent to or higher than the 40th percentile across all MIPS Quality performance category scores, excluding entities/providers eligible for facility-based scoring.
(ii) If an ACO does not report any of the three measures it is actively required to report and does not field a CAHPS for MIPS survey via the APP, the ACO will not meet the quality performance standard.
(b) Extreme and uncontrollable circumstances. For performance year 2021 and subsequent performance years, including the applicable quality data reporting period for the performance year, CMS uses an alternative approach to calculating the quality score for ACOs affected by extreme and uncontrollable circumstances instead of the methodology specified in paragraph (a) of this section as follows:
(1) CMS determines the ACO was affected by an extreme and uncontrollable circumstance based on either of the following:
(i) Twenty percent or more of the ACO's assigned beneficiaries reside in an area identified under the Quality Payment Program as being affected by an extreme and uncontrollable circumstance.
(A) Assignment is determined under subpart E of this part.
(B) In making this determination, CMS uses the quarter four list of assigned beneficiaries.
(ii) The ACO's legal entity is located in an area identified under the Quality Payment Program as being affected by an extreme and uncontrollable circumstance. An ACO's legal entity location is based on the address on file for the ACO in CMS' ACO application and management system.
(2) If CMS determines the ACO meets the requirements of paragraph (b)(1) of this section, CMS calculates the ACO's quality score as follows:
(i) For performance years 2021 and 2022, the ACO's minimum quality performance score is set to the equivalent of the 30th percentile MIPS Quality performance category score for the relevant performance year as determined under paragraph (a)(3) of this section.
(ii) For performance year 2023 and subsequent performance years, the ACO's minimum quality performance score is set to the equivalent of the 40th percentile MIPS Quality performance category score for the relevant performance year as determined under paragraph (a)(4) of this section.
(3) If the ACO reports quality data via the APP and meets data completeness and case minimum requirements:
(i) For performance years 2021 and 2022, CMS will use the higher of the ACO's quality performance score or the equivalent of the 30th percentile MIPS Quality performance category score for the relevant performance year.
(ii) For performance year 2023 and subsequent performance years, CMS will use the higher of the ACO's quality performance score or the equivalent of the 40th percentile MIPS Quality performance category score for the relevant performance year.
(4) CMS applies determinations made under the Quality Payment Program with respect to -
(i) Whether an extreme and uncontrollable circumstance has occurred; and
(ii) The affected areas.
(5) CMS has sole discretion to determine the time period during which an extreme and uncontrollable circumstance occurred, the percentage of the ACO's assigned beneficiaries residing in the affected areas, and the location of the ACO legal entity.
[85 FR 85041, Dec. 28, 2020]