(a) The value-based payment modifier is applicable:
(1) For the CY 2015 payment adjustment period, to physicians in groups with 100 or more eligible professionals based on the performance period described at Sec. 414.1215(a).
(2) For the CY 2016 payment adjustment period, to physicians in groups with 10 or more eligible professionals based on the performance period described at Sec. 414.1215(b).
(3) For the CY 2017 payment adjustment period and each subsequent calendar year payment adjustment period, to physicians in groups with 2 or more eligible professionals and to physicians who are solo practitioners based on the performance period for the payment adjustment period as described at Sec. 414.1215.
(4) For the CY 2018 payment adjustment period and each subsequent calendar year payment adjustment period, to nonphysician eligible professionals in groups with 2 or more eligible professionals and to nonphysician eligible professionals who are solo practitioners based on the performance period for the payment adjustment period as described at Sec. 414.1215.
(b) Exceptions. (1) Groups of physicians that are participating in the Medicare Shared Savings Program, the testing of the Pioneer ACO model, or other similar Innovation Center or CMS initiatives shall not be subject to any adjustments under the value-based payment modifier for CY 2015 and CY 2016.
(1) Groups of physicians that are participating in the Medicare Shared Savings Program, the testing of the Pioneer ACO model, or other similar Innovation Center or CMS initiatives shall not be subject to any adjustments under the value-based payment modifier for CY 2015 and CY 2016.
(2) Application of the value-based payment modifier to participants in the Shared Savings Program.
(i) For the CY 2017 payment adjustment period and each subsequent calendar year payment adjustment period, the value-based payment modifier is applicable to physicians in groups with 2 or more eligible professionals and to physicians who are solo practitioners that participate in an ACO under the Shared Savings Program during the performance period for the payment adjustment period as described at Sec. 414.1215. The value-based payment modifier for a group or solo practitioner that participates in an ACO under the Shared Savings Program during the performance period is determined based on paragraphs (b)(2)(i)(A) through (D) of this section.
(A) The cost composite is classified as ``average'' under Sec. 414.1275(b).
(B) The quality composite score is calculated under Sec. 414.1260(a) using quality data reported by the ACO for the performance period through the ACO GPRO Web interface as required under Sec. 425.504(a)(1) or another mechanism specified by CMS and the ACO all-cause readmission measure.
(C) For the CY 2017 payment adjustment period, the value-based payment modifier adjustment will be equal to the amount determined under Sec. 414.1275 for the payment adjustment period, except that if the ACO does not successfully report quality data as described in paragraph (b)(2)(i)(B) of this section for the performance period, such adjustment will be equal to -4% for groups with 10 or more eligible professionals and equal to -2% for groups with two to nine eligible professionals and for solo practitioners.
(D) The same value-based payment modifier adjustment will be applied in the payment adjustment period to all groups based on size as specified under Sec. 414.1275 and solo practitioners that participated in the ACO during the performance period.
(ii) For the CY 2018 payment adjustment period and each subsequent calendar year payment adjustment period, the value-based payment modifier is applicable to nonphysician eligible professionals in groups with 2 or more eligible professionals and to nonphysician eligible professionals who are solo practitioners that participate in an ACO under the Shared Savings Program during the performance period for the payment adjustment period as described at Sec. 414.1215. The value-based payment modifier for nonphysician eligible professionals is determined in the same manner as for physicians as described under paragraphs (b)(2)(i)(A) through (D) of this section.
(3) Application of the value-based payment modifier to participants in the Pioneer ACO Model and the Comprehensive Primary Care Initiative.
(i) For the CY 2017 payment adjustment period, the value-based payment modifier is applicable to physicians in groups with 2 or more eligible professionals and to physicians who are solo practitioners that participate in the Pioneer ACO Model or the Comprehensive Primary Care (CPC) Initiative during the performance period for the payment adjustment period as described at Sec. 414.1215. For purposes of the value-based payment modifier, a group or solo practitioner is considered to be participating in the Pioneer ACO Model or CPC Initiative if at least one eligible professional billing under the TIN in the performance period is participating in the Pioneer ACO Model or CPC Initiative in the performance period. The value-based payment modifier for groups and solo practitioners that participate in the Pioneer ACO Model or the CPC Initiative during the performance period is determined based on paragraphs (b)(3)(i)(A) through (C) of this section.
(A) The cost composite is classified as ``average'' under Sec. 414.1275(b).
(B) The quality composite is classified as ``average'' under Sec. 414.1275(b).
(C) The same value-based payment modifier adjustment will be applied in the payment adjustment period to all groups based on size as specified under Sec. 414.1275 and solo practitioners that participated in the Pioneer ACO or CPC site during the performance period.
(4) Application of the value-based payment modifier to participants in other similar Innovation Center models or CMS initiatives.
(i) For the CY 2017 payment adjustment period and each subsequent calendar year payment adjustment period, the value-based payment modifier is applicable to physicians in groups with 2 or more eligible professionals and to physicians who are solo practitioners that participate in other similar Innovation Center models or CMS initiatives during the performance period for the payment adjustment period as described at Sec. 414.1215. For purposes of the value-based payment modifier, a group or solo practitioner is considered to be participating in a similar Innovation Center model or CMS initiative if at least one eligible professional billing under the TIN in the performance period is participating in the model or initiative in the performance period. The value-based payment modifier for groups and solo practitioners that participate in a similar Innovation Center model or CMS initiative is determined based on paragraphs (b)(3)(i)(A) through (C) of this section.
(ii) [Reserved]
(c) Group size determination. The list of groups of physicians subject to the value-based payment modifier for the CY 2015 payment adjustment period is based on a query of PECOS on October 15, 2013. For each subsequent calendar year payment adjustment period, the list of groups and solo practitioners subject to the value-based payment modifier is based on a query of PECOS that occurs within 10 days of the close of the Physician Quality Reporting System group registration process during the applicable performance period described at Sec. 414.1215. Groups are removed from the PECOS-generated list if, based on a claims analysis, the group did not have the required number of eligible professionals, as defined in Sec. 414.1210(a), that submitted claims during the performance period for the applicable calendar year payment adjustment period. Solo practitioners are removed from the PECOS-generated list if, based on a claims analysis, the solo practitioner did not submit claims during the performance period for the applicable calendar year payment adjustment period. [77 FR 69368, Nov. 16, 2012, as amended at 78 FR 74820, Dec. 10, 2013; 79 FR 68005, Nov. 13, 2014]