June 12, 2025
To comply with President Trump’s Executive Order, “Unleashing Prosperity Through Deregulation,” which states the Administration’s policy to significantly reduce the private expenditures required to comply with federal regulations, CMS included a Request for Information (RFI) in the CY 2026 IPPS proposed rule seeking input on approaches and opportunities to streamline regulations and reduce burdens on those participating in the Medicare program. The RFI is available here; responses must be submitted through this weblink.
RFI questions and A4H responses are listed below.
Streamline Regulatory Requirements
Are there existing regulatory requirements (including those issued through regulations but also rules, memoranda, administrative orders, guidance documents, or policy statements), that could be waived, modified, or streamlined to reduce administrative burdens without compromising patient safety or the integrity of the Medicare program?
– In the CY 2025 Physician Fee Schedule, CMS finalized a policy establishing a new “prepaid shared savings” option for eligible ACOs with a history of earning shared savings. Eligible ACOs include those participating in Levels C-E of the BASIC track or the ENHANCED track with consistent prior success in earning shared savings in the Shared Savings Program. At least 50% of prepaid shared savings must be spent on direct beneficiary services not otherwise payable by Medicare (e.g., meals, transportation, dental, vision, hearing, and Part B cost-sharing reductions). Up to 50% of the prepaid shared savings can be spent on staffing and health care infrastructure.
CMS should remove conditions regarding receipt of the prepaid shared savings option in the Medicare Shared Savings Program (MSSP). These savings represent revenue that an ACO has earned through its efforts to improve care and reduce costs for patients. ACOs must be granted flexibility to build specific care management programs that meet the needs of patients. Restrictions around how dollars can be spent and requiring ACOs to submit spend plans not only imposes unnecessary burden but discourages innovation and flexibility in accountable care.
– In the CY 2025 Physician Fee Schedule, CMS created a new, tiered coding bundle for advanced primary care management (APCM). APCM codes can be billed by the provider who serves as the “focal point” of the patient’s care. If a provider chooses to bill ACPM, they may not bill a number of other codes as standalone services, including chronic care management, transitional care management, and other communications-based technology services codes. Providers billing these codes must offer and document an expansive set of required APCM service level elements and practice-level capabilities, including expanded access to care through 24/7 access for urgent care needs; care delivery in alternate settings; comprehensive care management, including a systematic needs assessment, systems-based approaches to ensure receipt of preventive services, and medication reconciliation; and practitioner, home-, and community-based care coordination. There is also a performance measurement component of the code set that requires providers billing the code to report through the MIPS Value in Primary Care MVP or to participate in one of the Innovation Center models (e.g., ACO REACH).
CMS should waive requirements to bill the Advanced Primary Care Management (APCM) for all providers in accountable care arrangements including MSSP participants. A4H also recommends CMS streamline criteria for participation, focusing this code set on advanced primary care services that require provider behavior change rather than simply scalability (e.g., focusing on coordinated referrals rather than 24/7 access to care or care delivered in alternate care settings).
– One administratively burdensome and frustrating experience among traditional Medicare primary care providers is the imposition of a 365 day +1 limitation on Medicare-covered Annual Wellness Visits (AWVs). The statute governing the occurrence of AWVs (section 1861(hhh)(4)(G) of the Social Security Act; implemented under 42 CFR 410.15) imposes these restrictions. While statutory changes require Congressional action, CMS may still have the authority to waive the requirement for certain programs such as the Medicare Shared Savings Program and CMMI’s ACO programs.
AWVs are a central benefit for Medicare beneficiaries to ensure they receive at least annual care and can be assessed for current and/or future health risks. Primary care providers in total cost of care risk arrangements with Medicare, should have the autonomy to schedule those visits when it is best for the patient and the practice, often in the first few months of a new year. This allows the practice to pace and triage their visits appropriately, determine each patient’s care needs including prevention and chronic disease management, and spend the balance of the year focusing on the highest risk patients who may need several visits to better manage their health. However, the statute’s scheduling restrictions introduce barriers to that autonomy and sometimes result in denied AWV claims and uncompensated care.
Instead, it would be less burdensome and more supportive of primary care providers in two-sided risk models if providers were able to schedule AWVs based on a calendar year schedule, which resets January 1st of each year. The cost of annual AWVs would not change, as only one AWV would be reimbursable per calendar year, but the requirement for the AWVs to be more than 12 months apart year over year would be waived for those participating in the Medicare Shared Savings Program, CMMI’s ACO programs and any others deemed necessary by CMS.
This release from Medicare statutory requirements would align at-risk traditional Medicare models with the flexibility available to patients and providers in Medicare Advantage.
Which specific Medicare administrative processes or quality and data reporting requirements create the most significant burdens for providers?
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) included important incentives to accelerate the adoption of and participation in accountable care. Through MACRA, Congress laid out two clear paths: the Merit-Based Incentive Payment System (MIPS) and Advanced APMs. MIPS was intended to create a pay-for-performance system in traditional Medicare, while Advanced APMs rewarded clinicians for assuming clinical and financial risk through an incentive payment and MIPS exemption.
MIPS has proved to be significantly burdensome, but financially lucrative, for providers with limited return in terms of actual care improvements and financial accountability for patient populations. Reporting is extremely costly, with annual reporting associated with an estimated $12,800 and more than 200 hours per physician. Worse more, research has shown that the MIPS program does not adequately capture high-quality care and has instead become a check-the-box activity for providers.
Despite the above, CMS has finalized policies in recent years that have significantly increased burden for MSSP ACOs reporting through MIPs. Beginning in 2025, all MSSP ACOs must also report either eCQMs or CQMs for all patients, across all payers, and in all practices. Further, in the CY 2025 Physician Fee Schedule, CMS finalized additional quality reporting requirements with the Alternative Payment Model (APM) Performance Pathway (APP) Plus Quality Measure Set. Finally, CMS also implemented a new policy requiring MSSP participants to report the MIPS Promoting Interoperability performance category measures.
We recommend that CMS reduce administrative burden by zeroing out MIPS performance bonus payment and penalties. This will have the dual benefit of eliminating the current financial incentive for FFS reimbursement and eliminating the administrative burden associated with today’s complicated and non-impactful MIPS reporting structures. If CMS chooses not to pursue this path, CMS should instead eliminate and/or streamline MIPS requirements for accountable care entities.
Identification of Duplicative Requirements
Which specific Medicare requirements or processes do you consider duplicative, either within the program itself, or with other healthcare programs (including Medicaid, private insurance, and state or local requirements)?
Since the 2021 performance period, many MSSP ACOs have been required to field two Consumer Assessment of Healthcare Provider & Systems (CAHPS) surveys each year for two different purposes – one to satisfy MSSP requirements and one to satisfy MIPS requirements. Accountable care providers should not be required to field two identical CAHPS patient experience surveys to the same patients in the same years. These surveys are frequently redundant and impose unnecessary burden on accountable care providers.
June 12, 2025
To comply with President Trump’s Executive Order, “Unleashing Prosperity Through Deregulation,” which states the Administration’s policy to significantly reduce the private expenditures required to comply with federal regulations, CMS included a Request for Information (RFI) in the CY 2026 IPPS proposed rule seeking input on approaches and opportunities to streamline regulations and reduce burdens on those participating in the Medicare program. The RFI is available here; responses must be submitted through this weblink.
RFI questions and A4H responses are listed below.
Streamline Regulatory Requirements
Are there existing regulatory requirements (including those issued through regulations but also rules, memoranda, administrative orders, guidance documents, or policy statements), that could be waived, modified, or streamlined to reduce administrative burdens without compromising patient safety or the integrity of the Medicare program?
– In the CY 2025 Physician Fee Schedule, CMS finalized a policy establishing a new “prepaid shared savings” option for eligible ACOs with a history of earning shared savings. Eligible ACOs include those participating in Levels C-E of the BASIC track or the ENHANCED track with consistent prior success in earning shared savings in the Shared Savings Program. At least 50% of prepaid shared savings must be spent on direct beneficiary services not otherwise payable by Medicare (e.g., meals, transportation, dental, vision, hearing, and Part B cost-sharing reductions). Up to 50% of the prepaid shared savings can be spent on staffing and health care infrastructure.
CMS should remove conditions regarding receipt of the prepaid shared savings option in the Medicare Shared Savings Program (MSSP). These savings represent revenue that an ACO has earned through its efforts to improve care and reduce costs for patients. ACOs must be granted flexibility to build specific care management programs that meet the needs of patients. Restrictions around how dollars can be spent and requiring ACOs to submit spend plans not only imposes unnecessary burden but discourages innovation and flexibility in accountable care.
– In the CY 2025 Physician Fee Schedule, CMS created a new, tiered coding bundle for advanced primary care management (APCM). APCM codes can be billed by the provider who serves as the “focal point” of the patient’s care. If a provider chooses to bill ACPM, they may not bill a number of other codes as standalone services, including chronic care management, transitional care management, and other communications-based technology services codes. Providers billing these codes must offer and document an expansive set of required APCM service level elements and practice-level capabilities, including expanded access to care through 24/7 access for urgent care needs; care delivery in alternate settings; comprehensive care management, including a systematic needs assessment, systems-based approaches to ensure receipt of preventive services, and medication reconciliation; and practitioner, home-, and community-based care coordination. There is also a performance measurement component of the code set that requires providers billing the code to report through the MIPS Value in Primary Care MVP or to participate in one of the Innovation Center models (e.g., ACO REACH).
CMS should waive requirements to bill the Advanced Primary Care Management (APCM) for all providers in accountable care arrangements including MSSP participants. A4H also recommends CMS streamline criteria for participation, focusing this code set on advanced primary care services that require provider behavior change rather than simply scalability (e.g., focusing on coordinated referrals rather than 24/7 access to care or care delivered in alternate care settings).
– One administratively burdensome and frustrating experience among traditional Medicare primary care providers is the imposition of a 365 day +1 limitation on Medicare-covered Annual Wellness Visits (AWVs). The statute governing the occurrence of AWVs (section 1861(hhh)(4)(G) of the Social Security Act; implemented under 42 CFR 410.15) imposes these restrictions. While statutory changes require Congressional action, CMS may still have the authority to waive the requirement for certain programs such as the Medicare Shared Savings Program and CMMI’s ACO programs.
AWVs are a central benefit for Medicare beneficiaries to ensure they receive at least annual care and can be assessed for current and/or future health risks. Primary care providers in total cost of care risk arrangements with Medicare, should have the autonomy to schedule those visits when it is best for the patient and the practice, often in the first few months of a new year. This allows the practice to pace and triage their visits appropriately, determine each patient’s care needs including prevention and chronic disease management, and spend the balance of the year focusing on the highest risk patients who may need several visits to better manage their health. However, the statute’s scheduling restrictions introduce barriers to that autonomy and sometimes result in denied AWV claims and uncompensated care.
Instead, it would be less burdensome and more supportive of primary care providers in two-sided risk models if providers were able to schedule AWVs based on a calendar year schedule, which resets January 1st of each year. The cost of annual AWVs would not change, as only one AWV would be reimbursable per calendar year, but the requirement for the AWVs to be more than 12 months apart year over year would be waived for those participating in the Medicare Shared Savings Program, CMMI’s ACO programs and any others deemed necessary by CMS.
This release from Medicare statutory requirements would align at-risk traditional Medicare models with the flexibility available to patients and providers in Medicare Advantage.
Which specific Medicare administrative processes or quality and data reporting requirements create the most significant burdens for providers?
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) included important incentives to accelerate the adoption of and participation in accountable care. Through MACRA, Congress laid out two clear paths: the Merit-Based Incentive Payment System (MIPS) and Advanced APMs. MIPS was intended to create a pay-for-performance system in traditional Medicare, while Advanced APMs rewarded clinicians for assuming clinical and financial risk through an incentive payment and MIPS exemption.
MIPS has proved to be significantly burdensome, but financially lucrative, for providers with limited return in terms of actual care improvements and financial accountability for patient populations. Reporting is extremely costly, with annual reporting associated with an estimated $12,800 and more than 200 hours per physician. Worse more, research has shown that the MIPS program does not adequately capture high-quality care and has instead become a check-the-box activity for providers.
Despite the above, CMS has finalized policies in recent years that have significantly increased burden for MSSP ACOs reporting through MIPs. Beginning in 2025, all MSSP ACOs must also report either eCQMs or CQMs for all patients, across all payers, and in all practices. Further, in the CY 2025 Physician Fee Schedule, CMS finalized additional quality reporting requirements with the Alternative Payment Model (APM) Performance Pathway (APP) Plus Quality Measure Set. Finally, CMS also implemented a new policy requiring MSSP participants to report the MIPS Promoting Interoperability performance category measures.
We recommend that CMS reduce administrative burden by zeroing out MIPS performance bonus payment and penalties. This will have the dual benefit of eliminating the current financial incentive for FFS reimbursement and eliminating the administrative burden associated with today’s complicated and non-impactful MIPS reporting structures. If CMS chooses not to pursue this path, CMS should instead eliminate and/or streamline MIPS requirements for accountable care entities.
Identification of Duplicative Requirements
Which specific Medicare requirements or processes do you consider duplicative, either within the program itself, or with other healthcare programs (including Medicaid, private insurance, and state or local requirements)?
Since the 2021 performance period, many MSSP ACOs have been required to field two Consumer Assessment of Healthcare Provider & Systems (CAHPS) surveys each year for two different purposes – one to satisfy MSSP requirements and one to satisfy MIPS requirements. Accountable care providers should not be required to field two identical CAHPS patient experience surveys to the same patients in the same years. These surveys are frequently redundant and impose unnecessary burden on accountable care providers.
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