(a) General. CMS may waive certain payment rules or other Medicare requirements as determined necessary to carry out the Shared Savings Program under this part.
(1) SNF 3-day rule. For performance year 2017 and subsequent performance years, CMS waives the requirement in section 1861(i) of the Act for a 3-day inpatient hospital stay prior to a Medicare-covered post-hospital extended care service for eligible beneficiaries prospectively assigned to ACOs participating in Track 3 that receive otherwise covered post-hospital extended care services furnished by an eligible SNF that has entered into a written agreement to partner with the ACO for purposes of this waiver. All other provisions of the statute and regulations regarding Medicare Part A post-hospital extended care services continue to apply.
(i) ACOs must submit to CMS supplemental application information sufficient to demonstrate the ACO has the capacity to identify and manage beneficiaries who would be either directly admitted to a SNF or admitted to a SNF after an inpatient hospitalization of fewer than 3-days in the form and manner specified by CMS. Application materials include but are not limited to, the following:
(A) Narratives describing how the ACO plans to implement the waiver. Narratives must include the following:
(1) The communication plan between the ACO and its SNF affiliates.
(2) A care management plan for beneficiaries admitted to a SNF affiliate.
(3) A beneficiary evaluation and admission plan approved by the ACO medical director and the healthcare professional responsible for the ACO's quality improvement and assurance processes under Sec. 425.112.
(4) Any financial relationships between the ACO, SNF, and acute care hospitals.
(B) A list of SNFs with whom the ACO will partner along with executed written SNF affiliate agreements between the ACO and each listed SNF.
(C) Documentation demonstrating that each SNF included on the list provided under paragraph (a)(1)(i)(B) of this section has an overall rating of 3 or higher under the CMS 5-star Quality Rating System.
(ii) In order to be eligible to receive covered SNF services under the waiver, a beneficiary must meet the following requirements:
(A) Is prospectively assigned to the ACO for the performance year in which they are admitted to the eligible SNF.
(B) Does not reside in a SNF or other long-term care setting.
(C) Is medically stable.
(D) Does not require inpatient or further inpatient hospital evaluation or treatment.
(E) Have certain and confirmed diagnoses.
(F) Have an identified skilled nursing or rehabilitation need that cannot be provided as an outpatient.
(G) Have been evaluated and approved for admission to the SNF within 3 days prior to the SNF admission by an ACO provider/supplier who is a physician, consistent with the ACO's beneficiary evaluation and admission plan.
(iii) SNFs eligible to partner and enter into written agreements with ACOs for purposes of this waiver must do the following:
(A) Have and maintain an overall rating of 3 or higher under the CMS 5-star Quality Rating System.
(B) Sign a SNF affiliate agreement with the ACO that includes elements determined by CMS including but not limited to the following:
(1) Agreement to comply with the requirements and conditions of this part, including but not limited to those specified in the participation agreement with CMS.
(2) Effective dates of the SNF affiliate agreement.
(3) Agreement to implement and comply with the ACO's beneficiary evaluation and admission plan and the care management plan.
(4) Agreement to validate the eligibility of a beneficiary to receive covered SNF services in accordance with the waiver prior to admission.
(5) Remedial processes and penalties that will apply for non-compliance.
(2) [Reserved]
(b) Review and determination of request to use waivers. (1) In order to obtain a determination regarding whether the ACO may use waivers under this section, an ACO must submit a waiver request to CMS in the form and manner and by a deadline specified by CMS.
(1) In order to obtain a determination regarding whether the ACO may use waivers under this section, an ACO must submit a waiver request to CMS in the form and manner and by a deadline specified by CMS.
(2) An ACO executive who has the authority to legally bind the ACO must certify to the best of his or her knowledge, information, and belief that the information contained in the waiver request submitted under paragraph (b)(1) of this section is accurate, complete, and truthful.
(3) CMS evaluates an ACO's waiver request to determine whether it satisfies the requirements of this part and approves or denies waiver requests accordingly. Waiver requests are approved or denied on the basis of the following:
(i) Information contained in and submitted with the waiver request by a deadline specified by CMS.
(ii) Supplemental information submitted by a deadline specified by CMS in response to a CMS request for information.
(iii) Screening of the ACO, ACO participants, ACO providers/suppliers, and other individuals or entities providing services to Medicare beneficiaries in accordance with the terms of the waiver.
(iv) Other information available to CMS.
(4) CMS may deny a waiver request if an ACO fails to submit requested information by the deadlines established by CMS.
(c) Effective and termination date of waivers. (1) Waivers are effective upon CMS notification of approval for the waiver or the start date of the participation agreement, whichever is later.
(1) Waivers are effective upon CMS notification of approval for the waiver or the start date of the participation agreement, whichever is later.
(2) Waivers do not extend beyond the end of the participation agreement.
(3) If CMS terminates the participation agreement under Sec. 425.218, the waiver ends on the date specified by CMS in the termination notice.
(4) If the ACO terminates the participation agreement, the waiver ends on the effective date of termination as specified in the written notification required under Sec. 425.220.
(d) Monitoring and termination of waivers. (1) ACOs with approved waivers are required to post their use of the waiver as part of public reporting under Sec. 425.308.
(1) ACOs with approved waivers are required to post their use of the waiver as part of public reporting under Sec. 425.308.
(2) CMS monitors and audits the use of such waivers in accordance with Sec. 425.316.
(3) CMS reserves the right to deny or revoke a waiver if an ACO, its ACO participants, ACO providers/suppliers or other individuals or entities providing services to Medicare beneficiaries are not in compliance with the requirements of this part or if any of the following occur:
(i) The waiver is not used as described in the ACO's waiver request under paragraph (b)(1) of this section.
(ii) The ACO does not successfully meet the quality reporting standard under subpart F of this part.
(iii) CMS identifies a program integrity issue affecting the ACO's use of the waiver.
(e) Other rules governing use of waivers. (1) Waivers under this section do not protect financial or other arrangements between or among ACOs, ACO participants, ACO providers/suppliers, or other individual or entities providing services to Medicare beneficiaries from liability under the fraud and abuse laws or any other applicable laws.
(1) Waivers under this section do not protect financial or other arrangements between or among ACOs, ACO participants, ACO providers/suppliers, or other individual or entities providing services to Medicare beneficiaries from liability under the fraud and abuse laws or any other applicable laws.
(2) Waivers under this section do not protect any person or entity from liability for any violation of law or regulation for any conduct other than the conduct permitted by a waiver under paragraph (a) of this section.
(3) ACOs must ensure compliance with all claims submission requirements, except those expressly waived under paragraph (a) of this section. [80 FR 32843, June 9, 2015]