Finalized Changes to the Medicare Shared Savings Program
Background:
On June 4, 2015, the Centers for Medicare and Medicaid (CMS) issued a final rule that updates implementing regulations for
the Medicare Shared Savings Program (MSSP). Final implementation regulations for the MSSP program were issued in
November 2011. In December 2014, CMS published a proposed rule updating MSSP implementing regulations to “advance the
ACO models, codify existing guidance, reduce administrative burden and improve program function and transparency in a
number of program areas.” Most provisions of the final rule go into effect on August 3, 2015.
This memo provides a summary of key provisions included in the MSSP final rule. It also provides a chart that compares the
final rule to comments submitted by the consumer Coalition for Better Care (CBC) Coalition on the proposed MSSP rule.
The MSSP program now includes 400 Accountable Care Organizations (ACOs) across 49 states. More than 7.3 million
beneficiaries are receiving care through the program.1
Summary of Major Provisions in the MSSP Final Rule:

CMS added a new performance-based risk model (“Track 3”) for ACOs. Track 3 offers a higher sharing rate than Tracks 1
and 2. Beneficiaries will be prospectively assigned to Track 3 ACOs; there will be no retrospective reconciliation.

Current Track 1 (one-sided risk) MSSP ACOs are permitted to participate in one additional three-year agreement under
Track 1 and maintain the same maximum sharing rate applicable in their first agreement period. Extended participation in
an addition Track 1 three-year agreement cycle is only available to current Track 1 MSSP ACOs that have met the quality
performance standards in at least one of the first two years of their agreement.
1
http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-06-04.html
1

A waiver of the three-day inpatient stay rule for SNFs services will be made available to Track 3 MSSP ACOs. (This waives
the requirement of a three-day inpatient hospital stay prior to the provision of Medicare covered post-hospital extended
care services for beneficiaries that are prospectively assigned to Track 3 MSSP ACOs.) This waiver will be effective no
earlier than January 1, 2017.
The other waivers proposed in the proposed rule (Billing and Payment for Telehealth Services; Homebound Requirement
Under the Home Health Benefit; Referrals to Post-acute Care Settings; Waiver of Other Payment Rules) were not included
in the final rule. CMS plans to conduct further development and testing of other selected waivers through the CMS
Innovation Center prior to deciding whether it is appropriate to incorporate such waivers into MSSP. CMS anticipates a
telehealth waiver being available to ACOs no earlier than January 1, 2017, after notice and comment and rulemaking.

CMS finalized data-sharing proposals that would discontinue individual beneficiary notifications of data-sharing and the
opportunity to opt out. Under the final rule, MSSP ACOs must provide written notification at the point of care through
signs posted in facilities. These signs must provide information about data sharing and beneficiary ability to decline data
sharing by calling 1-800-Medicare. Beneficiaries will now directly notify CMS, rather than the ACO, of their decision to opt
out of data sharing.

CMS will now also include primary care services provided by nurse practitioners, physician assistants, and clinical nurse
specialists for purposes of assigning beneficiaries to an MSSP ACO based on utilization of primary care services provided
by primary care providers. However, CMS states that beneficiaries will not be assigned to ACOs based solely on the
services provided by non-physician providers. CMS will continue to first identify patients who have received a primary care
service from a physician participating in the ACO before counting the primary care services provided by non-physician
ACO providers.
Comparison Chart: Final Rule on Medicare Shared Savings Program
Category
Program
Evolution
Sub-Issue
Quality Measures
CBC Comment/Recommendation
Strongly urge CMS to prioritize
outcomes measures, with a focus on
coordination of care, including
transitions of care, hospital
admissions and readmissions, use of
emergency departments, and
2
MSSP Final Rule
Not addressed in the final rule. (As
expected. MSSP ACO quality measures
are determined in/by the Physician Fee
Schedule.)
medication management.
Governance
Consumer/Beneficiary Urge CMS to strengthen
Representation in
requirements for meaningful
ACO Governance
involvement of consumer/beneficiary
representatives and to exercise
greater oversight to ensure the
success of engagement efforts
CMS should encourage ACOs to
pursue additional approaches, such
as involving patient/family
representatives on ACO quality and
safety improvement bodies.
Encourage CMS to offer guidance and
assistance to ACOs with respect to
developing onboarding and
orientation processes for
consumer/beneficiary representatives
In the preamble, HHS states that a
focus on the beneficiary in all facets of
ACO governance is critical for ACOs to
achieve the three-part aim and that
beneficiary representation is important.
HHS encourages ACOs to consider
seriously how to provide opportunities
for beneficiaries and others to be
involved in ACO governance through
both governing body representation and
other appropriate mechanisms.
However, HHS states that they believe
their current regulations balance the
overall objectives for the program while
permitting ACOs flexibility to structure
their governing bodies appropriately
and are not incorporating suggestions to
increase the beneficiary representation
requirement.
HHS finalized the proposed revision to
explicitly prohibit an ACO
provider/supplier from being the
beneficiary representative on the
governing body (§ 425.106(c)(2))
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Beneficiary
Assignment
Definition of Primary
Care Services
Strongly support including
transitional care management codes
(CPT codes 99495 and 99496) and
chronic care management codes
(HCPCS code GXXXI) as primary
care services.
HHS finalized the proposal to update
the definition of primary care services to
include both TCM codes (CPT codes
99495 and 99496), the CCM code (CPT
code 99490), and to include these codes
in the beneficiary assignment
methodology (§ 425.20 and § 425.402)
Definition of Primary
Care Providers
Strongly support inclusion of Nurse
Practitioners, Physician Assistants,
and Clinical Nurse Specialists as
primary care providers for the
purposes of beneficiary assignment.
HHS finalized the proposal to include
claims for primary care services
furnished by NPs, PAs, and CNSs under
step 1 of the assignment process, after
having identified beneficiaries who
received at least one primary care
service by a physician participating in
the ACO. (§ 425.402(a))
Voluntary Beneficiary
Alignment, Education
and Outreach
Support enhanced beneficiary choice
with respect to their alignment with
an ACO.
HHS agreed with commenters who
recommended implementing a policy to
revise the beneficiary assignment
methodology to permit beneficiaries to
indicate who they believe is the "main
doctor" responsible for their care
coordination.
Before beneficiaries can be expected
to elect into their primary care
provider’s ACO, however, they must
have access to materials that help
them understand what an ACO is,
how this new model of care functions,
what alignment means to them, and
what their rights are with respect to
accessing care inside and outside of
the ACO.
4
HHS expects to propose to implement
beneficiary attestation for purposes of
beneficiary assignment under the
Shared Savings Program beginning
January 1, 2017, in the 2017 Physician
Fee Schedule (PFS) rulemaking. This
timeline will allow for further
Beneficiary education on Medicare
ACO programs must accompany
dissemination of any voluntary
alignment materials.
Other key issues that CMS should
address:
 How and when beneficiaries are
informed of the opportunity to
align
 Ensuring that written materials
and verbal communications
resonate and effectively reach
beneficiaries and their families
 Ensuring that beneficiaries are
contacted by appropriate, trusted
messengers
 Ensuring that beneficiaries are
able to contact assistors with
questions and know whom to
contact if they have questions
 Ensuring maintenance and
enforcement of necessary and
appropriate consumer protections,
particularly with respect to direct
outreach and communication with
Medicare beneficiaries
Prohibition on
Financial
Inducements To
Incentivize Voluntary
Alignment
Strongly support the prohibition of
the use of gifts or other financial
inducements to beneficiaries or use of
penalties as part of a voluntary
alignment process
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development and testing of this
approach through the Pioneer ACO
Model and the Next Generation ACO
Model and development of appropriate
safeguards against abusive or coercive
marketing associated with beneficiary
attestation. Initially, until CMS can
gain additional operational experience,
they anticipate limiting the beneficiary
attestation process to ACOs
participating under Tracks 2 or 3.
HHS did not create a specific
prohibition on the use of gifts but stated
in the preamble that they did not
believe ACOs or others should be
permitted to offer gifts or other
inducements to beneficiaries, nor should
they be allowed to withhold or threaten
to withhold services, for the purposes of
coercing or influencing their alignment
decisions.
Assignment to ACOs
that include FQHCs,
RHCs, CAHs, and/or
ETA Hospitals
Support including FQHCs, RHCs,
CAHs, and ETA hospitals in ACOs;
the beneficiaries who rely on these
providers, many who reside in rural
and underserved populations, could
benefit from the improved care
coordination ACOs may provide.
HHS finalized the proposal to use
FQHC/RHC physician attestation
information only for purposes of
determining whether a beneficiary is
eligible to be assigned to an ACO. If a
beneficiary is identified as "assignable"
then CMS will use claims for primary
care services furnished by all ACO
professionals submitted by the FQHC or
RHC to determine whether the
beneficiary received a plurality of his or
her primary care services from the ACO
under Step 1. (§ 425.404)
HHS will continue including claims for
primary care services billed by method
II CAHs in the beneficiary assignment
process under established procedures. (§
425.402)
Beneficiary
Notification
and Data
Sharing
Support the goals of improving
beneficiary notification of data
sharing and the opportunity to opt
out. Expressed concerned about the
changes proposed, however. Proposal
was to replace individual notice to
beneficiaries with non-specific/group
notice provided via the Medicare &
You handbook and signs posted in
practice sites.
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HHS finalized the proposed
modifications to a “streamlined” process
by which beneficiaries may decline
claims data sharing.
HHS finalized requiring ACO
participants to use CMS-approved
template language to notify
beneficiaries regarding participation in
an ACO and the opportunity to decline
data at the point of care. ACOs are no
Urged CMS to maintain individual
notice of data sharing and the ability
to opt out; support communications to
beneficiaries and their doctors (or
practice staff) about ACOs and data
sharing; utilize community resources;
and consider offering patients realtime, electronic access to their health
information which may bolster trust
and better equip beneficiaries to
make more informed decisions
regarding data sharing
longer required to send individualized
notification. (§ 425.708 and §
425.312(a))
HHS finalized their proposal to honor
any beneficiary request to decline
claims data sharing until such time as
the beneficiary may reverse his or her
claims data sharing preference to allow
data sharing. These changes are
effective November 1, 2015. (§
425.708(c))
Urged CMS to require ACOs to work
with beneficiaries and consumers to
ensure language clearly describes
why and how their health
information will be stored,
exchanged, used and protected, the
opportunity to opt-out, and other
beneficiary rights
Eligibility
Requirements
for MSSP
ACOs
Care Planning and
Coordination,
Patient-Centeredness
Criteria
Support requiring ACOs, as part of
the application process, to have a
mechanism in place for coordinating
patient care and to detail the kinds of
processes that will be used
Strongly support maintaining the
existing requirements in this section
and continuing to require
documentation of specific plans and
processes for implementing these
criteria as part of the ACO
application process
7
Applicants to MSSP must provide a
description, or provide documents
sufficient to describe, how the ACO will
implement the required processes and
patient-centeredness criteria. An ACO
must establish processes to accomplish
the following: promote evidence-based
medicine; promote patient engagement;
develop an infrastructure to internally
report on quality and cost metrics
required for monitoring and feedback;
and coordinate care across and among
primary care physicians, specialists and
Commend HHS’ continued support
for shared decision-making in ACOs
and urge HHS to include even more
support for shared decision making
through strong program
requirements and quality measures
Emphasize that true beneficiary
engagement goes beyond an
occasional focus group or an annual
patient experience to encompass
mutually beneficial partnerships at
every level of care. Patients and
family caregivers must be
systematically and meaningfully
involved in all decisions concerning
their care, and at every level – in care
design and redesign, in policy and
governance, and at the community
level.
acute and postacute providers and
suppliers. (§ 425.204(c)(1)(ii), § 425.112,
§ 425.112(b))
Additionally, HHS states that
beneficiary engagement is an important
element in the ACO's ability to meet its
goal of improving quality and reducing
costs. For this reason, the rules require
ACOs to develop a process to promote
patient engagement. CMS believes that
patient engagement works best at the
point of care and the development of the
patient-doctor relationship. CMS
highlights that several ACOs that
achieved first year success in the
program have observed that patient
engagement improves when engaged
providers improve patient care.
Encourage HHS to work with ACOs
to support “hard-wiring” patient and
family-centered care and
partnerships by incorporating patient
and family centered care criteria and
principles into hiring practices, job
descriptions, etc.; supporting strong
leadership commitment to patient
and family centered care
Requirement to
Demonstrate Intent
to Promote
Strongly support the proposal to
require MSSP ACO applicants to
describe how it will promote use of
8
HHS finalized the proposal to add a new
requirement to the eligibility
requirements to require an ACO to
Acceleration of
Health IT
health IT to improve care
coordination, including plans to
partner with long-term and postacute care providers, and to identify
performance targets for assessing
progress
Encourage HHS to consider requiring
ACOs to delineate their plans for
partnering with patients and families
to make health information
electronically available and useful to
patients and families
Encourage HHS to regard beneficiary
electronic access to and sharing of
health information as core elements
that will advance interoperability
efforts
describe in its application how it will
encourage and promote the use of
enabling technologies for improving care
coordination for beneficiaries.
Specifically, such enabling technologies
and services may include electronic
health records and other health IT tools
(such as population health management
and data aggregation and analytic
tools), telehealth services, remote
patient monitoring, health information
exchange services, or other electronic
tools to engage patients in their care. (§
425.112(b)(4)(ii)(C))
HHS states that enabling technologies
should be adopted thoughtfully with the
goal of improving care, and not just
adoption for its own sake. However,
HHS did not finalize additional specific
requirements because they believe
ACOs should have flexibility to define
their care coordination processes and
use of enabling technologies. HHS
believes this flexibility can encourage
innovative methods of engaging both
beneficiaries and providers in the
coordination of a patient's care.
In addition, HHS will assess general
progress through ACO performance on
measures related to HIT adoption and
use, for instance, the current MSSP
quality measure around participation in
the EHR Incentives program, or a
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future measure which would reflect
ACO providers' ability to electronically
exchange data to support care
transitions.
HHS encourages providers to monitor
the degree of interoperability and
exchange across providers in their ACO,
which could include evaluating
performance on the transition of care or
health information exchange measures
in the EHR Incentives Program.
Regulatory
Waivers
Waiver of 3-Day
Inpatient Rule for
SNF Services
Support proposal to waive the 3-day
inpatient requirement for SNF care.
However, strong beneficiary
protections and quality standards
must be in place to prevent abuse and
ensure ACOs are providing high
quality, patient- and family- centered
discharge planning
Any proposal to waive the SNF
requirement must include strong
beneficiary protections, including:
 Assurances that beneficiaries
would not be liable for the cost of
SNF care
 Significant education efforts to
explain the waiver and its
limitations
 Network adequacy protections
 Patient choice protections
Urge CMS to clearly require ACOs to
10
HHS finalized the proposal to waive the
3-day SNF rule for eligible beneficiaries
that are prospectively assigned to ACOs
that participate in Track 3.
An ACO's use of the 3-day SNF rule
waiver will be associated with a distinct
and easily identified event (admission of
a prospectively assigned beneficiary to a
SNF without prior hospitalization or
after an inpatient hospitalization of
fewer than 3 days).
CMS is limiting the waiver to ACOs in
Track 3 because under the prospective
assignment methodology used in Track
3. This waiver under will be effective for
services provided on or after January 1,
2017.
All ACOs electing to participate in
Track 3 will be offered the opportunity
Referrals to PostAcute Care Settings
elicit and accommodate patient and
family preferences when it comes to
discharge planning and transitions of
care, including referrals to SNFs.
to apply for a waiver of the SNF 3-day
rule for their prospectively assigned
beneficiaries at the time of their initial
application to the program. In their
request to use the waiver, ACOs must
demonstrate that they have the capacity
to identify and manage patients who
would be either directly admitted to a
SNF or admitted to a SNF after an
inpatient hospitalization of fewer than
three days. Specific criteria will be set
forth in the materials for both initial
applications and renewals under Track
3.
If ACOs are permitted to affiliate
themselves more closely with certain
providers, strong quality measures
must be in place to ensure
recommended entities deliver the
highest standards of care. ACOs must
be transparent about these
affiliations and continue to make
beneficiaries aware of the full range
of providers available to them,
beyond the recommended few.
Proposal was not included in the final
rule.
Waiver must be accompanied by
strong oversight, monitoring, and
enforcement mechanisms.
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Billing and Payment
for Telehealth
Services
Homebound
Requirement for
Home Health
Services
HHS should carefully consider
appropriate use of telehealth
services, and how it impacts more
vulnerable beneficiaries, especially
dually eligible beneficiaries.
Support the opportunity to waive the
Medicare homebound requirement for
home health services for Track 3
ACOs. However, need to ensure
beneficiaries retain choice of home
health providers to the greatest
extent possible.
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Proposal was not included in the final
rule.
HHS expects to focus on further
development of a waiver of certain
billing and payment requirements for
telehealth services. HHS intends to
offer such a waiver starting as early as
in 2017, with specific requirements to be
determined based on HHS’ experience
implementing such a waiver in the Next
Generation ACO Model. HHS
anticipates a telehealth waiver being
available to ACOs no earlier than
January 1, 2017, after notice and
comment and rulemaking.
Proposal was not included in the final
rule.
Additional
Program
Requirements
and
Beneficiary
Protections
Transparency of
Information:
Participating ACO
Providers
We support CMS’s efforts to improve
the integrity and timeliness of
information about ACO participants,
providers, and suppliers and to
improve the process for reporting
changes in a timelier manner.
CMS will require that each ACO
maintain a dedicated Web page on
which the ACO must publicly report
designated information via a template
specified by CMS (§ 425.308 (b)).
ACO must report, for example:
We support requiring each ACO to
create and maintain a dedicated
webpage on which it must report
information in a standardized way.
To be successful, the webpage must
be easy to find, contain easy-to-read
information about the providers, and
be updated regularly. Further, the
webpage should not just include the
names of the participating providers
but also information about the
physical accessibility of the office as
well as information about languages
spoken.
We also encourage requiring ACOs to
provide non-online sources of
information for beneficiaries, such as
mailing this information to
beneficiaries once per year. Finally,
we encourage standardized reporting
of complaints and problems into a
centralized unified tracking system
(like the complaint tracking module).
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(1) Name and location.
(2) Primary contact.
(3) Organizational information,
including all of the following:
 Identification of ACO participants.
 Identification of participants in joint
ventures between ACO professionals
and hospitals.
 Identification of the members of its
governing body.
 Identification of key clinical and
administrative leadership.
 Identification of associated
committees and committee
leadership.
 Identification of the types of ACO
participants or combinations of ACO
participants (as listed in §
425.102(a)) that formed the ACO.
(4) Shared savings and losses
information, including the following:
 Amount of any payment of shared
savings received by the ACO or
shared losses owed to CMS.
 Total proportion of shared savings
invested in infrastructure,
redesigned care processes and other
resources required to support the
three-part aim goals of better health
for populations, better care for
individuals and lower growth in
expenditures, including the
proportion distributed among ACO
participants.
(5) The ACO's performance on all
quality measures.
Transparency of
Information: Quality
Performance
Additional
Priorities
Grievance and
Appeals Processes
Urge HHS to require ACOs to
publicly report cost information in a
consumer-friendly manner. ACOs
should publicly report Medicare total
costs for beneficiaries assigned to the
ACO and total costs for the
commercially insured receiving care
in the ACO. ACOs also should
publicly disclose their prices for
routine procedures for Medicare and
an average price (blended fee
schedules) for commercial payers.
Urge HHS to require ACOs to report
quality and cost information at the
provider level, as well as at the ACO
level.
HHS should ensure appropriate
grievance and appeals processes for
beneficiaries in ACOs and clearly
communicate these rights to
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(6) Use of payment rule waivers under §
425.612, if applicable.
CMS finalized the proposal to require
ACOs to report all quality measure data
on their public websites (see above for
full list of reporting requirements).
HHS states in the preamble that
beneficiaries maintain the ability to
dispute charges or file an appeal for a
claim under the fee-for-service (FFS)
beneficiaries. Processes should be
standardized across plans, with
regular reporting to a HHS official
with oversight authority.
ACOs should:
 Require providers to state all
treatment options available to a
beneficiary
 Communicate to beneficiaries
that they have the option to seek
a second opinion by a non-ACO
provider; and
 Assist beneficiaries in submitting
complaints or grievances.
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program and the Shared Savings
Program does not change any FFS
beneficiary choices or benefits.