As used in this part, unless otherwise indicated--
Accountable care organization (ACO) means a legal entity that is recognized and authorized under applicable State, Federal, or Tribal law, is identified by a Taxpayer Identification Number (TIN), and is formed by one or more ACO participants(s) that is(are) defined at Sec. 425.102(a) and may also include any other ACO participants described at Sec. 425.102(b).
ACO participant means an entity identified by a Medicare-enrolled billing TIN through which one or more ACO providers/suppliers bill Medicare, that alone or together with one or more other ACO participants compose an ACO, and that is included on the list of ACO participants that is required under Sec. 425.118.
ACO participant agreement means the written agreement (as required at Sec. 425.116) between the ACO and ACO participant in which the ACO participant agrees to participate in, and comply with, the requirements of the Shared Savings Program.
ACO professional means an individual who is Medicare-enrolled and bills for items and services furnished to Medicare fee-for-service beneficiaries under a Medicare billing number assigned to the TIN of an ACO participant in accordance with applicable Medicare regulations and who is either of the following:
(1) A physician legally authorized to practice medicine and surgery by the State in which he or she performs such function or action.
(2) A practitioner who is one of the following:
(i) A physician assistant (as defined at Sec. 410.74(a)(2) of this chapter).
(ii) A nurse practitioner (as defined at Sec. 410.75(b) of this chapter).
(iii) A clinical nurse specialist (as defined at Sec. 410.76(b) of this chapter).
ACO provider/supplier means an individual or entity that meets all of the following:
(1) Is a--
(i) Provider (as defined at Sec. 400.202 of this chapter); or
(ii) Supplier (as defined at Sec. 400.202 of this chapter).
(2) Is enrolled in Medicare.
(3) Bills for items and services furnished to Medicare fee-for-service beneficiaries during the agreement period under a Medicare billing number assigned to the TIN of an ACO participant in accordance with applicable Medicare regulations.
(4) Is included on the list of ACO providers/suppliers that is required under Sec. 425.118.
Agreement period means the term of the participation agreement, which is 3 performance years unless otherwise specified in the participation agreement.
Antitrust Agency means the Department of Justice or Federal Trade Commission.
Assignment means the operational process by which CMS determines whether a beneficiary has chosen to receive a sufficient level of the requisite primary care services from ACO professionals so that the ACO may be appropriately designated as exercising basic responsibility for that beneficiary's care during a given benchmark or performance year.
Assignment window means the 12-month period used to assign beneficiaries to an ACO.
At-risk beneficiary means, but is not limited to, a beneficiary who--
(1) Has a high risk score on the CMS-HCC risk adjustment model;
(2) Is considered high cost due to having two or more hospitalizations or emergency room visits each year;
(3) Is dually eligible for Medicare and Medicaid;
(4) Has a high utilization pattern;
(5) Has one or more chronic conditions.
(6) Has had a recent diagnosis that is expected to result in increased cost.
(7) Is entitled to Medicaid because of disability; or
(8) Is diagnosed with a mental health or substance abuse disorder.
Continuously assigned beneficiary means a beneficiary assigned to the ACO in the current performance year who was either assigned to or received a primary care service from any of the ACO participants during the assignment window for the most recent prior benchmark or performance year.
Covered professional services has the same meaning given these terms under section 1848(k)(3)(A) of the Act.
Critical access hospital (CAH) has the same meaning given this term under Sec. 400.202 of this chapter.
Eligible professional has the meanings given this term under section 1848(k)(3)(B) of the Act.
Federally qualified health center (FQHC) has the same meaning given to this term under Sec. 405.2401(b) of this chapter.
Hospital means a hospital as defined in section 1886(d)(1)(B) of the Act.
Marketing materials and activities include, but are not limited to, general audience materials such as brochures, advertisements, outreach events, letters to beneficiaries, Web pages, data sharing opt out letters, mailings, social media, or other activities conducted by or on behalf of the ACO, or by ACO participants, or ACO providers/suppliers participating in the ACO, when used to educate, solicit, notify, or contact Medicare beneficiaries or providers and suppliers regarding the Shared Savings Program. The following beneficiary communications are not marketing materials and activities: Certain informational materials customized or limited to a subset of beneficiaries; materials that do not include information about the ACO, its ACO participants, or its ACO providers/suppliers; materials that cover beneficiary-specific billing and claims issues or other specific individual health related issues; educational information on specific medical conditions (for example, flu shot reminders), written referrals for health care items and services, and materials or activities that do not constitute ``marketing'' under 45 CFR 164.501 and 164.508(a)(3)(i).
Medicare fee-for-service beneficiary means an individual who is--
(1) Enrolled in the original Medicare fee-for-service program under both parts A and B; and
(2) Not enrolled in any of the following:
(i) A MA plan under part C.
(ii) An eligible organization under section 1876 of the Act.
(iii) A PACE program under section 1894 of the Act.
Medicare Shared Savings Program (Shared Savings Program) means the program, established under section 1899 of the Act and implemented in this part.
Newly assigned beneficiary means a beneficiary that is assigned to the ACO in the current performance year who was neither assigned to nor received a primary care service from any of the ACO participants during the assignment window for the most recent prior benchmark or performance year.
One-sided model means a model under which the ACO may share savings with the Medicare program, if it meets the requirements for doing so, but is not liable for sharing any losses incurred under subpart G of this part.
Participation agreement means the written agreement required under Sec. 425.208(a) between the ACO and CMS that, along with the regulations in this part, govern the ACO's participation in the Shared Savings Program.
Performance year means the 12-month period beginning on January 1 of each year during the agreement period, unless otherwise noted in the participation agreement. For an ACO with a start date of April 1, 2012 or July 1, 2012, the ACO's first performance year is defined as 21 months and 18 months, respectively.
Physician means a doctor of medicine or osteopathy (as defined in section 1861(r)(1) of the Act).
Physician Quality Reporting System (PQRS) means the quality reporting system established under section 1848(k) of the Act.
Primary care physician means a physician included in an attestation by the ACO as provided under Sec. 425.404 for services furnished in an FQHC or RHC, or a physician who has a primary care specialty designation of--
(1) For performance years 2012 through 2015, internal medicine, general practice, family practice, or geriatric medicine; and
(2) For performance year 2016 and subsequent years, internal medicine, general practice, family practice, geriatric medicine, or pediatric medicine.
Primary care services means the set of services identified by the following HCPCS codes:
(1) For performance years 2012 through 2015 as follows:
(i) 99201 through 99215.
(ii)(A) 99304 through 99340 and 99341 through 99350.
(A) 99304 through 99340 and 99341 through 99350.
(B) G0402 (the code for the Welcome to Medicare visit).
(C) G0438 and G0439 (codes for the annual wellness visits).
(iii) Revenue center codes 0521, 0522, 0524, and 0525 submitted by FQHCs (for services furnished prior to January 1, 2011), or by RHCs.
(2) For performance years 2016 and subsequent years as follows:
(i) 99201 through 99215.
(ii)(A) 99304 through 99340 and 99341 through 99350.
(A) 99304 through 99340 and 99341 through 99350.
(B) G0402 (the code for the Welcome to Medicare visit).
(C) G0438 and G0439 (codes for the annual wellness visits).
(iii) Revenue center codes 0521, 0522, 0524, and 0525 submitted by FQHCs (for services furnished prior to January 1, 2011), or by RHCs.
(iv) 99495, 99496, and 99490.
(3) Additional codes designated by CMS as primary care services for purposes of the Shared Savings Program, including new HCPCS/CPT and revenue center codes and any subsequently modified or replacement codes for the HCPCS/CPT and revenue center codes identified in paragraphs (1) through (2) of this definition.
Quality measures means the measures defined by the Secretary, under section 1899 of the Act, to assess the quality of care furnished by an ACO, such as measures of clinical processes and outcomes, patient and, where practicable, caregiver experience of care and utilization.
Reporting period, for purposes of subpart F of this part, means the calendar year from January 1 to December 31.
Rural health center (RHC) has the same meaning given to this term under Sec. 405.2401(b).
Shared losses means a portion of the ACO's performance year Medicare fee-for-service Parts A and B expenditures, above the applicable benchmark, it must repay to CMS. An ACO's eligibility for shared losses will be determined for each performance year. For an ACO requesting interim payment, shared losses may result from the interim payment calculation.
Shared savings means a portion of the ACO's performance year Medicare fee-for-service Parts A and B expenditures, below the applicable benchmark, it is eligible to receive payment for from CMS. An ACO's eligibility for shared savings will be determined for each performance year. For an ACO requesting interim payment, shared savings may result from the interim payment system calculation.
Taxpayer Identification Number (TIN) means a Federal taxpayer identification number or employer identification number as defined by the IRS in 26 CFR 301.6109-1.
Two-sided model means a model under which the ACO may share savings with the Medicare program, if it meets the requirements for doing so, and is also liable for sharing any losses incurred under subpart G of this part. [76 FR 67973, Nov. 2, 2011, as amended at 80 FR 32833, June 9, 2015]