On November 2, CMS released a final rule on CY 2024 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Continued Implementation of Requirements for Manufacturers of Certain Single-dose Container or Single-use Package Drugs to Provide Refunds with Respect to Discarded Amounts; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program.

Links to CMS Materials:

Below, we provide brief summaries of several provisions of note.

Finalized Proposals
Medicare Shared Savings Program
Proposal to Cap Regional Service Area Risk Score Growth for Symmetry with ACO Risk Score Cap: CMS finalized modifications the calculation of the regional component of the three-way blended benchmark update factor (weighted one-third accountable care prospective trend (ACPT), and two-thirds national-regional blend), for agreement periods beginning on January 1, 2024, and in subsequent years. The approach will cap prospective HCC risk score growth in an ACO’s regional service area between benchmark year three and the performance year using a similar methodology as the one adopted in the CY 2023 PFS final rule for capping ACO risk score growth, while additionally accounting for an ACO’s aggregate market share. CMS also proposes to modify the policies adopted in the CY 2023 PFS final rule so as to prevent any ACO from receiving an adjustment that would cause its benchmark to be lower than it would have been in the absence of a regional adjustment.
Proposal to Update How Benchmarks Are Risk Adjusted: Currently, when the CMS-HCC risk adjustment model changes, Shared Savings Program performance year and benchmark year comparisons are calculated using different CMS-HCC risk adjustment models. CMS is finalizing a proposal to apply the same CMS-HCC risk adjustment model used in the performance year for all benchmark years when calculating prospective HCC risk scores for agreement periods beginning on January 1, 2024, and in subsequent years. This would be the same three-year phase-in as Medicare Advantage to the revised 2024 CMS-HCC model, which will mean the underlying model will be 67 percent of the current 2020 CMS-HCC risk adjustment model and 33 percent of the CMS-HCC risk adjustment model for PY 2024.
Advance Incentive Payments: Beginning with ACOs entering agreement periods on January 1, 2024, CMS finalized a series of technical modifications to refine advance incentive payments (AIPs) policies to better prepare for initial implementation of AIP:

  • Modify AIP eligibility requirements to allow an ACO to elect to advance to a two-sided model level of the BASIC track’s glide path beginning with the third performance year of the five-year agreement period in which the ACO receives advance investment payments.
  • Modify AIP recoupment and recovery polices to forgo immediate collection of advance investment payments from an ACO that terminates its participation agreement early in order to early renew under a new participation agreement to continue their participation in the Shared Savings Program.
  • Modify termination policies to specify that CMS would immediately terminate advance investment payments to an ACO for future quarters if the ACO voluntarily terminates from the Shared Savings Program.
  • Modify ACO reporting requirements to require ACOs to submit spend plan updates to CMS in addition to publicly reporting spend plan updates.
  • Modify AIP requirements to permit ACOs to seek reconsideration review of all quarterly payment calculations.
Beneficiary Assignment: CMS finalized modifications to the assignment methodology, and the definition of an assignable beneficiary, to better account for beneficiaries who receive primary care from nurse practitioners, physician assistants and clinical nurse specialists during the 12-month assignment window and who received at least one primary care service from a physician in the preceding 12 months.

CMS finalized revisions the definition of primary care services used for assignment in the Shared Savings Program regulations to include Smoking and Tobacco-use Cessation Counseling; Remote Physiologic Monitoring; Cervical or Vaginal Cancer Screening; Office-Based Opioid Use Disorder Services; Complex Evaluation and Management Services; Community Health Integration services; Principal Illness Navigation (PIN) services; SDOH Risk Assessment; Caregiver Behavior Management Training; and Caregiver Training Services.

Shared Savings Program Eligibility Requirements: CMS finalized updates the Shared Savings Program eligibility requirements to:

  • Remove the option for ACOs to request an exception to the shared governance requirement that 75 percent control of an ACO’s governing body must be held by ACO participants; and
  • Codify the existing Shared Savings Program operational approach to specify that CMS determines that an ACO participant TIN participated in a performance-based risk Medicare ACO initiative if it was included on a participant list used in financial reconciliation for a performance year under performance-based risk during the five most recent performance years.
Proposal for Shared Savings Program ACOs to Report Medicare CQMs: For performance year 2024 and subsequent performance years, CMS finalized establishing the Medicare CQMs for ACOs participating in the Medicare Shared Savings Program (Medicare CQMs) as a new collection type for Shared Saving Program ACOs under the APM Performance Pathway (APP). Medicare CQMs would serve as a transition collection type to help ACOs build the infrastructure, skills, knowledge, and expertise necessary to report the all payer/all patient MIPS CQMs and eCQMs by focusing on Medicare patients with claims encounters with ACO professionals with specialty designations used in the Shared Savings Program assignment methodology. ACOs that report Medicare CQMs would be eligible for the health equity adjustment to their quality performance category score when calculating shared savings payments.
Aligning CEHRT Requirements for Shared Savings Program ACOs with MIPS: CMS finalized, with a one-year delay, with a one-year delay, removing the Shared Savings Program certified electronic health record technology (CEHRT) threshold requirements beginning performance year 2024, and add a new requirement, for performance years beginning on or after January 1, 2024, that all MIPS eligible clinicians, QPs, and Partial QPs participating in the ACO, regardless of track, are to report the MIPS Promoting Interoperability (PI) performance category measures and requirements to MIPS. CMS stated that this delay is intended to give ACOs time to work with their participants to meet this new requirement. Beginning on or after January 1, 2025, unless otherwise excluded, an ACO participant, ACO provider/supplier, and ACO professional that is a MIPS eligible clinician, QP, or Partial QP, regardless of track, would be required to report the MIPS PI performance category measures and requirements to MIPS and earn a performance category score for the MIPS PI performance category at the individual, group, virtual group, or APM Entity level.
Proposals to Modify the Health Equity Adjustment Underserved Multiplier: CMS finalized modifications to the calculation of the proportion of assigned beneficiaries dually eligible for Medicare and Medicaid, and the calculation of the proportion of assigned beneficiaries enrolled in the Medicare Part D low-income subsidy (LIS), to use the number of beneficiaries, rather than person years, for calculating the proportion of the ACO’s assigned beneficiaries who are enrolled in LIS or who are dually eligible for Medicare and Medicaid, starting in performance year 2024.
MIPS Quality Performance Category Score: CMS finalized using historical submission-level MIPS Quality performance category scores to calculate the 40th percentile MIPS Quality performance category score. CMS proposes to use a rolling three-performance year average with a lag of one performance year.
Apply a Shared Savings Program Scoring Policy for Excluded APP Measures: CMS finalized alleviating the potential adverse impacts to shared savings determinations that may arise in the event that one or more of the quality measures required under the APP is excluded by using the higher of the ACO’s health equity adjusted quality performance score or the equivalent of the 40th percentile MIPS Quality performance category score across all MIPS Quality performance category scores. CMS also finalized a modification to add the determination of quality performance score for an ACO affected by this Shared Savings Program Scoring Policy to the list of uses of the ACO’s health equity adjusted quality performance score.
Revise the Requirement to Meet the Case Minimum Requirement for Quality Performance Standard Determinations: CMS finalized replacing the references to meeting the case minimum requirement with the requirement that the ACO must receive a MIPS Quality performance category score in order to meet the quality performance standard.
Quality Payment Program
MIPS Value Pathways Development and Maintenance: CMS finalized five new MVPs around the topics of: Women’s Health; Infectious Disease, Including Hepatitis C and HIV; Mental Health and Substance Use Disorder; Quality Care for Ear, Nose, and Throat (ENT); and Rehabilitative Support for Musculoskeletal Care. CMS also proposes MVP maintenance updates to the MVP inventory that are in alignment with the MVP development criteria, and in consideration of the feedback from interested parties received through the maintenance process.
Subgroup Reporting: CMS finalized codifying previously finalized subgroup policies in the preamble to regulation text, update the subgroup policy for reweighting of MVP performance categories, update the facility-based scoring as well as the complex patient bonus for subgroups under final score calculation, and add subgroups to the targeted review regulation text. In order to operationalize previously established policy, CMS proposes to implement a manual process for reviewing subgroup reweighting applications for the CY 2023 performance period/2025 MIPS payment year.
CMS finalized some proposed modifications to the quality performance category:

  • CMS finalized expanding the definition of the collection type to include Medicare Clinical Quality Measures for Accountable Care Organizations Participating in the Medicare Shared Savings Program (Medicare CQMs).
  • CMS finalized establishing the quality performance category data submission criteria for electronic clinical quality measures (eCQMs) that requires the utilization of certified electronic health record (EHR) technology (CEHRT).
  • CMS finalized establishing the data submission criteria for Medicare CQMs.
  • CMS finalized requiring the administration of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey in the Spanish translation.
  • CMS finalized maintaining the data completeness criteria threshold to at least 75 percent for the CY 2026 performance period/2028 MIPS payment year, but did not finalize an increase in the data completeness criteria threshold to at least 80 percent for the CY 2027 performance period/2029 MIPS payment year.
  • CMS finalized, with modification, establishing the data completeness criteria for Medicare CQMs to at least 75 percent for the CY 2024, CY 2025, and CY 2026 performance periods/2026, 2027, and 2028 MIPS payment years, but did not finalize an increase the data completeness criteria threshold for Medicare CQMs to at least 80 percent for the CY 2027 performance period/2029 MIPS payment year.
  • CMS finalized, with modification, establishing a measure set inventory of 198 MIPS quality measures.
Cost Performance Category: CMS finalized adding five new episode-based measures to the cost performance category beginning with the CY 2024 performance period/2026 MIPS payment year: Depression, Emergency Medicine, Heart Failure, Low Back Pain, and Psychoses and Related conditions.
MIPS Final Scoring Methodology:

  • Performance Category Scores: CMS finalized updates the criteria by which it assesses the scoring impacts of coding changes and applies scoring flexibilities.
  • Cost improvement scoring: CMS finalized two modifications to the cost improvement scoring method that was established in the CY 2018 Quality Payment Program final rule:
    • CMS finalized changing the improvement scoring from a measure-level to a category-level method and to remove the statistical significance requirement.
    • CMS finalized that the maximum cost improvement score is zero percentage points for the 2020 through 2024 MIPS payment years, and one percentage point beginning with the CY 2023 performance period/2025 MIPS payment year.
MIPS Payment Adjustments: CMS did not finalize revising its policy for identifying the “prior period” by which it establishes the performance threshold as three performance periods, instead of a single prior performance period beginning with the CY 2024 performance period/2026 MIPS payment year. To determine the performance threshold for the CY 2024 performance period/2026 MIPS payment year, CMS will use the CY 2017 performance period/2019 MIPS payment year.

CMS did not finalize using the CY 2017 through CY 2019 performance periods/2019 through 2021 MIPS payment years (mean of 82 points, rounded down from 82.06 points) as the prior period for the purpose of establishing the performance threshold for the CY 2024 performance period/2026 MIPS payment year. CMS will instead establish that the performance threshold for the CY 2024 performance period/2026 MIPS payment year is 75 points, using the mean of the final scores for all MIPS eligible clinicians using CY 2017.

MIPS Targeted Review: CMS finalized adding virtual groups and subgroups as being eligible to submit a request for targeted review. Specifically, CMS proposes to permit submission of a request for targeted review beginning on the day the MIPS final score is available and ending 30 days after publication of the MIPS payment adjustment factors for the MIPS payment year.
Third Party Intermediaries: CMS finalized codifying previously finalized policies and make technical updates for clarity, including adding requirements for third party intermediaries to obtain documentation of their authority to submit on behalf of a MIPS eligible clinician; add requirements for Qualified Clinical Data Registries to provide measure numbers and identifiers for performance categories; and specify the criteria for audits.
Public Reporting on Compare Tools: CMS finalized modifying the existing policy for public reporting on individual clinician and group profile pages, including telehealth indicators and utilization data.

  • CMS finalized using the most recent CMS coding policies at the time the information is updated to identify the telehealth services provided on clinician profile pages instead of only using specific Place of Service (POS) and claims modifier codes.
  • CMS finalized revising utilization data to have additional procedure code grouping flexibility; address procedure volume limitations and provide a more complete scope of a clinician’s experience by adding Medicare Advantage data to procedure counts; and align the data in the Provider Data Catalog (PDC) with the procedural groupings shown on profile pages.
Increasing Alignment Across Value-Based Care Programs: CMS finalized consolidating the previously finalized Promoting Wellness and Optimizing Chronic Disease Management MVPs into a single consolidated primary care MVP that aligns with the adult Universal Core set of quality measures.
Major APM Initiatives:

  • APM Performance Pathway: CMS finalized to include the Medicare Clinical Quality Measure (Medicare CQM) for Accountable Care Organizations Participating in the Medicare Shared Savings Program collection type in the APM Performance Pathway (APP) measure set.
  • APM Incentive: CMS notes that note that the CAA, 2023, did not extend the APM Incentive Payment beyond payment year 2025. Beginning for the 2026 payment year, which relates to the 2024 QP Performance Period, there will be two separate PFS conversion factors, one for items and services furnished by a QP of 0.75 percent, known as “qualifying APM conversion factor” (versus non-QPs, who receive 0.25 percent). CMS finalized adjusting the Targeted Review period to address operational challenges that have arisen ahead of the required transition beginning for payment year 2026 (performance year 2024) from the APM Incentive Payment to the higher PFS payment rate for QPs.
    • CMS did not finalize ending the use of APM Entity-level QP determinations and instead make all QP determinations at the individual eligible clinician level. CMS also proposes to modify the “sixth criterion” under the definition of “attribution-eligible beneficiary” to include any beneficiary who has received a covered professional service furnished by the NPI for the purpose of making QP determinations.
    • CMS finalized amending § 414.1430 to reflect the statutory QP and Partial QP threshold percentages for both the payment amount and patient count methods under the Medicare Option and the All-Payer Option with respect to payment year 2025 (performance year 2023) in accordance with amendments made by the CAA, 2023.
  • Advanced APMs: CMS finalized, as proposed, as proposed modifying the certified electronic health record (EHR) technology (CEHRT) use criterion for Advanced APMs to provide greater flexibility for APMs to tailor CEHRT use requirements to the APM and its participants.
Requests for Information
Future of the Shared Savings Program
CMS sought comment on potential future developments to Shared Savings Program Policies:

  • Incorporating a Higher Risk Track than the ENHANCED Track: CMS sought comment on (1) policies/model design elements that could be implemented so that a higher risk track could be offered without increasing program expenditures; (2) ways to protect ACOs serving high-risk beneficiaries from expenditure outliers and reduce incentives for ACOs to avoid high-risk beneficiaries; and (3) the impact that higher sharing rates could have on care delivery redesign, specialty integration, and ACO investment in health care providers and practices. CMS appreciates the feedback received in response to this comment solicitation and will consider this information to inform future rulemaking.
  • Increasing the Amount of the Prior Savings Adjustment: CMS sought comment on potential changes to the 50 percent scaling factor used in determining the prior savings adjustment. CMS appreciates the feedback received in response to this comment solicitation and will consider this information to inform future rulemaking.
  • Expanding the ACPT Over Time and Addressing Overall Market-wide Ratchet Effects: CMS sought comment on the following: (1) replacing the national component of the two-way blend with the ACPT; and (2) scaling the weight given to the ACPT in a two-way blend for each ACO based on the collective market share of multiple ACOs within the ACO’s regional service area. CMS appreciates the feedback received in response to this comment solicitation and will consider this information to inform future rulemaking.
  • Promoting ACO and Community Based Organization (CBO) Collaboration: CMS sought comment on comment on approaches, generally, for encouraging or incentivizing increased collaboration between ACOs and CBOs, including any policies specifically designed to encourage ACOs to partner with CBOs and address unmet health-related social needs. CMS appreciates the feedback received in response to this comment solicitation and will consider this information to inform future rulemaking.
Transforming the QPP: CMS sought comment on how the Quality Payment Program can facilitate continuous improvement of Medicare beneficiaries’ health care and best build on existing CMS Innovation Center model policies and Medicare programs, such as the MSSP. CMS appreciates the feedback received in response to this comment solicitation and will consider this information to inform future rulemaking.
MIPS Reporting for Specialists in Shared Savings Program ACOs: CMS sought comments on potential future scoring incentives that could be applied to an ACO’s health equity adjusted quality performance score, beginning in performance year 2025 when specialists who participate in the ACO report quality MVPs. CMS appreciates the feedback received in response to this comment solicitation and will consider this information to inform future rulemaking.
Public Reporting on Compare Tools: CMS sought feedback on ways to publicly report data submitted on measures under the MIPS cost performance category on the Compare tool. CMS seeks comment on potential approaches to best establish publicly reporting cost measures; specific considerations for benchmarking and possible comparators to provide frames of reference; and ways to meaningfully present cost measures to patients and caregivers. In future rulemaking, CMS intends to propose to publicly report MIPS cost measures beginning with data from the CY 2024 performance period/2026 MIPS payment year in CY 2026 on Compare tool clinician and group profile pages and in the PDC in 2026.
CMS appreciates the feedback received in response to this comment solicitation and will consider this information to inform future rulemaking.

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