(a)(1) General. CMS employs the assignment methodology described in Sec. 425.402 and Sec. 425.404 for purposes of benchmarking, preliminary prospective assignment (including quarterly updates), retrospective reconciliation, and prospective assignment.
(1) General. CMS employs the assignment methodology described in Sec. 425.402 and Sec. 425.404 for purposes of benchmarking, preliminary prospective assignment (including quarterly updates), retrospective reconciliation, and prospective assignment.
(i) A Medicare fee-for-service beneficiary is assigned to an ACO if the--
(A) Beneficiary meets the eligibility criteria under Sec. 425.401(a); and
(B) Beneficiary's utilization of primary care services meets the criteria established under the assignment methodology described in Sec. 425.402 and Sec. 425.404.
(ii) CMS applies a step-wise process based on the beneficiary's utilization of primary care services provided under Title XVIII by a physician who is an ACO professional during each performance year for which shared savings are to be determined.
(2) Assignment under Tracks 1 and 2. (i) Medicare assigns beneficiaries in a preliminary manner at the beginning of a performance year based on most recent data available.
(i) Medicare assigns beneficiaries in a preliminary manner at the beginning of a performance year based on most recent data available.
(ii) Assignment will be updated quarterly based on the most recent 12 months of data.
(iii) Final assignment is determined after the end of each performance year, based on data from the performance year.
(3) Prospective assignment under Track 3. (i) Medicare fee-for-service beneficiaries are prospectively assigned to an ACO under Track 3 at the beginning of each benchmark or performance year based on the beneficiary's use of primary care services in the most recent 12 months for which data are available, using the assignment methodology described in Secs. 425.402 and 425.404.
(i) Medicare fee-for-service beneficiaries are prospectively assigned to an ACO under Track 3 at the beginning of each benchmark or performance year based on the beneficiary's use of primary care services in the most recent 12 months for which data are available, using the assignment methodology described in Secs. 425.402 and 425.404.
(ii) Beneficiaries that are prospectively assigned to an ACO under paragraph (a)(3)(i) of this section will remain assigned to the ACO at the end of the benchmark or performance year unless they meet any of the exclusion criteria under Sec. 425.401(b).
(b) Beneficiary assignment to an ACO is for purposes of determining the population of Medicare fee-for-service beneficiaries for whose care the ACO is accountable under subpart F of this part, and for determining whether an ACO has achieved savings under subpart G of this part, and in no way diminishes or restricts the rights of beneficiaries assigned to an ACO to exercise free choice in determining where to receive health care services.
(c) Primary care services for purposes of assigning beneficiaries are identified by selected HCPCS codes, G codes, or revenue center codes as indicated in the definition of primary care services under Sec. 425.20. [76 FR 67973, Nov. 2, 2011, as amended at 80 FR 32840, June 9, 2015]