An Internship at the Centers for Medicare and Medicaid

CBMP AT CMS 2015/2016 1
An Internship at the Centers for Medicare and Medicaid: Region III, Consortium for Financial
Management & Fee for Service Operations
Toni S.J. Williams
Drexel University

CBMP AT CMS 2015/2016 2
Contents
Abstract ............................................................................................................................... 3
An Internship at the Centers for Medicare and Medicaid: Region III, Consortium for
Financial Management & Fee for Service Operations.................................................................... 4
Research.............................................................................................................................. 8
Hospital Accreditation..................................................................................................... 8
MACRA........................................................................................................................ 10
References..........................................................................................................................11
APPENDICES .................................................................................................................. 12
Comments by clinicians and hospital administrators left on MACRA (names and
organizations have been withheld due to privacy).....................Error! Bookmark not defined.
ACO Models Comparison across Key Design Elements............................................. 16

CBMP AT CMS 2015/2016 3
Abstract
The Dornsife School of Public Health at Drexel University provides their 2nd year master’s
students the unique opportunity to participate in a Community Based Master’s Project (CBMP).
The purpose of CBMP is to give students the opportunity to apply the knowledge gained from
courses at Dornsife in real world situations that result in the student using the core competences.
My time spent at the Centers for Medicare and Medicaid (CMS) was a highly integral part of my
time in the program; I was provided the opportunity to take theoretical knowledge and apply it to
real world situations. The experience left me feeling as I would succeed in any endeavor I
elected to undertake in my public health career.

CBMP AT CMS 2015/2016 4
An Internship at the Centers for Medicare and Medicaid: Region III, Consortium for Financial
Management & Fee for Service Operations
For my CMBP project, the option of an internship where I could apply theoretical
knowledge into real life scenarios was appealing to me; deciding to intern at the CMS was a
quick decision. My advisor at Drexel University was Professor Dennis Gallagher and my
preceptor at CMS was Martie Ann Polaski.
CMS is an organization under the parent company of the Department of Health and
Human Services. With 9 regional offices (RO), located in nine different regions across the
United States, and 1 central office, located in Maryland, CMS holds the great responsibility of
interpreting the legislation related to the Affordable Care Act. While at the Philadelphia RO, I
interned under the Consortium for Financial Management & Fee for Service Operations
(CFMFFSO) in the financial management branch (FMB). It was here, in the FMB, where I was
able to apply various MPH competencies allowing my experience to be further enhanced. The
MPH competencies are listed below with the relating projects:
 Discuss how social, organizational, and individual factors on the use of
information technology by end users
o I was fully integrated into the Workers Compensation Medicare Set Aside
(WCMSA) team during my tenure. The WCMSA is a financial agreement
setting aside a portion of a workers’ compensation settlement to pay for
future medical services related to the workers’ compensation injury,
illness, or disease (Workers' Compensation Medicare Set Aside
Arrangements, 2016). My main responsibilities were as follows:
interpreting the Benefits Coordination and Recovery Center ruling on the

CBMP AT CMS 2015/2016 5
beneficiaries account and approving or rejection disposition letters,
returning phone calls to beneficiaries who may have questions on the
interpretation of the law, and learning the importance a re-review has in
determining the outcome of potential worker’s compensation benefits for
the beneficiary. A large portion of WCMSA is done via the internet with
decision letters and notes uploaded to the beneficiary’s account. During
various branch meetings and instructional time spent with Jermaine, I
learned that a good number of individuals do not have access to a
computer to view their electronic decision. If there was access, the next
issue was understanding the decision letter issued by CMS. Often there
was a communication gap between the lawyer and the beneficiary in terms
of explaining the letter, providing the next steps, and providing counsel on
the management of the funds. The calls I returned all dealt with the issues
stemming from the communication gap. When I left, Jermaine was
working with various other employees in other ROs on creating a type of
frequently asked question sheet to include in the hardcopy of the decision
letter.
 Apply legal and ethical principles to the use of information technology and
resources in public health settings
o Martie Ann was fantastic at assigning me projects that were challenging
and allowed me to build fundamental skills. One such project was working
with Joanne on a quality assurance surveillance plan (QASP). The
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) “sets

CBMP AT CMS 2015/2016 6
for a provision in Section 509 that requires contractor performance
transparency to the extent possible without compromising the process for
entering into and renewing contracts with Medicare Administrative
Contractors (MAC)” (MAC Performance Compliance, 2015). The purpose
of the QASP is to measure the MAC’s compliance with the Statement of
Work (SOW). My role in the QASP was to review the correspondence
between the MAC and beneficiaries to ensure the replies were done in the
time frame that complied with the contract requirement. The legal
principles applied were related to the legislation on MACs and the ethical
principles were how we decided to interpret the legislation. For example,
if the MAC replied in 61 days and not the required 60 an exception would
be made if the MAC provided an interim response.
 Describe alternative strategies for collaboration and partnership among
organizations, focused on public health goals
o Martie Ann was also thoughtful in inviting me to every meeting taking
place with the branch, the consortium, regional meetings, and agency wide
meetings. In these gatherings, I was able to see the collaboration taking
place behind the scenes. CMS allows for their employees to apply to
details where the individual experiences working in a different branch
allowing for partnership and engagement in the organization. At the
agency wide meeting on February 25th, 2016 the acting administrator,
Andrew Slavitt stated he had a goal for removing the silo culture that
tends to take place in the agency and open more opprotunities for

CBMP AT CMS 2015/2016 7
teamwork amongst the staff. I was able to see this taking place in FMB
where members of different teams had the understanding and ability to
assist their colleagues on various projects due to rotating through different
roles.
 Engage in dialogue and learning from others to advance public health goals
o My first assignment at CMS was working with Luiza on an Accountable
Care Organization comparison chart detailing the specifics of each ACO.
Reflecting on this project, it was the perfect experience to learn more
about the interworking’s of CMS, an occasion to meet others in the office,
and an introduction to the wealth of knowledge contained in a fraction of
the department.
 Analyze the effects of political, social, and economic policies on public health
systems at the local, state, national, and international levels
o My last project was working with Ken in audits and reimbursement. Ken,
as with everyone else I interacted with, was incredibly patient and took the
time to explain the complexities of the legislative code surrounding CMS
and how it related to real life. An example was a visual lesson on the
definition of hospital property and the distance that separated an “on-
campus” location from an “off-campus” location, we walked the 250 yards
to apply the definition into real life. While working with Ken, I assisted
with approving or denying provider based status applications based on 42
CFR 413.65, the legislation for the requirements for a determination that a
facility or an organization has provider-based status (42 CFR 413.65 -

CBMP AT CMS 2015/2016 8
Requirements for a determination that a facility or an organization has
provider-based status., 2009).
My time at CMS was well spent. I’m grateful for the experience and the chance to
develop my skill set in public health. The internship opened my eyes to what I would like to do
and not to do regarding my career. I’m also thankful for the ability to have such a phenomenal
advisor and preceptor who both pushed me to deepen my skill set in healthcare finance and
health economics through real world application.
Research
In my learning agreement created at the start of the experience, Professor Gallagher,
Martie Ann, and I agreed to a research component in addition to completing various projects
given during the internship tenure. The following includes details of the two research ventures I
undertook.
Hospital Accreditation
The idea to research hospital accreditation came about from a conversation with Martie
Ann. Due to CMS expanding the agencies appointed with the role of deeming authority1 status
from sole approval agency of the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) in 2009, there has been an increase of agencies in the marketplace
hospitals are able to decide among for their accreditation needs. Martie Ann was concerned with
if the new agencies used by organizations having deeming authority from CMS because there
was an influx of hospitals receiving accreditation from agencies other than JCAHO.
1 A hospital deeming authority is defined as “the power of a regulative body to certify or accredit hospitals
as meeting eligibility for state licensure or for federal Medicaid or Medicare reimbursement” (Hospital Deeming
Authority, 2009).

CBMP AT CMS 2015/2016 9
When a hospital is accredited, it represents a credible and reputable organization
dedicated to ongoing and continuous compliance with the highest standard of quality. The
Institute of Medicine has six domains for healthcare quality which are “safe, effective, patient-
centered, timely, efficient, and equitable” (Medicine, 2001). Safe refers to avoiding causing harm
to patients from care that is intended for them, effective refers to avoiding underuse and misuse,
patient-centered refers to care that is responsive to individual patient preference, timely refers to
reducing waits and potentially harmful delays, efficient means avoiding waste, and lastly
equitable refers to providing care that is equal for everyone. Due to variations in healthcare
quality the likelihood is greater for an increase in complications, poorer outcomes due to the
variations, and the medical expenditures associated with how care may vary amongst the
population. Accreditation seeks to remove the variations and discrepancies by having criteria that
all hospital organizations much reach to be approved.
When an organization is accredited, they are showing a commitment to being a provider
of choice while ensuring patients are receiving the best care possible (Mayberry, 2006). The seal
of approval from an agency also provides a competitive edge in the health marketplace via the
organization voluntarily deciding to pursue accreditation. Due to the evolution in transparency in
healthcare moving in the direction of patients having equal access to information regarding
quality of care provided, having accreditation demonstrates the organizations ability to maintain
compliance with national standards (Benefits of Joint Commission Accreditation, 2015). Lastly,
when a system is accredited by an agency with deeming authority, there is the benefit of
qualifying for CMS certification without undergoing a separate quality inspection.

CBMP AT CMS 2015/2016 10
From my research, I was able to location 5 agencies with deeming authority: JCAHO,
Healthcare Facilities Accreditation Program, Det Norske Vertias, Accreditation Association for
Ambulatory HealthCare, and the National Committee for Quality Assurance.
JCAHO is has 17 accreditation services, the largest of the 5 agencies named.
Each agency specializes in certain aspects of healthcare such as healthcare staffing
services, integrated care, patient blood management certification, critical access hospital,
behavioral health, clinical laboratory, and acute care. JCAHO offers the largest range of
accreditation services with 17 different areas, the agency is also the most widely used due to the
duration of time it was the only deeming authority available to use. Other agencies are rising in
popularity due to the ability to compare for cost effectiveness.
There is consistent evidence showing that accreditation programs improve the process of
care provided and also improve clinical outcomes of a wide spectrum through standardized
metrics. Verifying an organization’s accreditation status can be done through the agency’s
website.
MACRA
As previously mentioned, MACRA is an acronym for the Medicare Access & CHIP
Reauthorization Act of 2015. Signed into law on April 16, 2015, the legislation averted a 21%
cut to Medicare physician rates and permanently repealed the Sustainable Growth Rate (SGR)
formula (Franco, 2015). Developed

CBMP AT CMS 2015/2016 11
References
42 CFR 413.65 - Requirements for a determination that a facility or an organization has
provider-based status. (2009, August 27). Retrieved from Cornell University Law
School: https://www.law.cornell.edu/cfr/text/42/413.65
Benefits of Joint Commission Accreditation. (2015, August 28). Retrieved from The Joint
Commission:
https://www.jointcommission.org/benefits_of_joint_commission_accreditation/
Hospital Deeming Authority. (2009). Retrieved from The Free Dictionary: http://medical-
dictionary.thefreedictionary.com/hospital+deeming+authority
MAC Performance Compliance. (2015, September 1). Retrieved from Centers for Medicare and
Medicaid: https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-
Administrative-Contractors/MACPerformanceCompliance.html
Mayberry, R. N. (2006). Improving quality and reducing inequities: a challenge in achieving best
care. Proceedings (Baylor University. Medical Center), 103-118.
Medicine, I. o. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century.
Washington, D.C.: National Academy Press.
Workers' Compensation Medicare Set Aside Arrangements. (2016, April 18). Retrieved from
Centers for Medicaid Services: https://www.cms.gov/Medicare/Coordination-of-Benefits-
and-Recovery/Workers-Compensation-Medicare-Set-Aside-Arrangements/WCMSA-
Overview.html

CBMP AT CMS 2015/2016 12
APPENDICES

CBMP AT CMS 2015/2016 13
Master’s Project-Learning Agreement
Student: Toni Williams
Advisor: Dennis Gallagher
Preceptor: Martie Ann Polaski, Medicare Operations Branch Manager, (DFMFFSO)
Preceptor Contact Information:
Medicare Operations Branch Manager:
Martie Ann Polaski: 215-861-4318, martieann.polaski@cms.hhs.gov
Project: Internship with CMS, Philadelphia Regional Office (Region III)
Sponsoring Organization: Centers for Medicare & Medicaid Services, Region III,
HHS
Suite 216, The Public Ledger Building
150 S. Independence Mall West
615 Chestnut St
Philadelphia, PA 19106
Project Description: My Master’s Project will be completing an internship working with
the Centers for Medicare and Medicaid Services (CMS), a federal agency that operates under the
Department of Health and Human Services, in Philadelphia’s Regional Office. The duration of
this internship will last from the Fall Quarter 2015 through the Spring Quarter 2016. CMS
Central Office and the Regional Offices share a common vision and mission as well as a shared
commitment to the five key objectives outlined in the CMS Strategic Plan:
1. Skilled, Committed, and Highly Motivated Workforce
2. Affordable Health Care System
3. High-Value Health Care
4. Confident, Informed Consumers
5. Collaborative Partnerships
CMS provides health coverage to nearly 100 million people through Medicare, Medicaid,
CHIP, and now through the Health Insurance Marketplace as prescribed by the Affordable Care
Act. CMS’s main responsibilities include providing coverage and processing insurance
enrollment for eligible individuals and families. However, the services provided through CMS
vary from contractor oversight, customer service and responding to beneficiary inquiries,
outreach and strategic planning, marketing, as well as financial processing and management.
Last year, the Health Insurance Marketplace was implemented. During the first enrollment
period, over eight million people purchased coverage through the Marketplace. With the second
enrollment period underway, CMS faces challenges of addressing issues from the first
enrollment year, assisting previous customers with re-enrollment and providing customers with
adequate information, assisting healthcare providers to understand and apply new regulations,
while maintaining timeliness with its usual functions.

CBMP AT CMS 2015/2016 14
For this Master’s Project, I will become fully integrated with the teams under Management and
Fee for Service Operations (DFMFFSO). In DFMFFSO the current branch manager is Martie
Ann Polaski. Under DFMFFSO I will be working with the Financial Management Branch (FMB)
and will provide assistance on various projects, data analysis, any requested research as well as
special assignments that arise based on my interests.
This Master’s Project will allow me to gain a deeper understanding of the daily processes
of an essential federal agency and how Medicare Secondary Payer (MSP) laws and Workers’
Compensation Medicare Set-Aside Agreement (WCMSA) financial agreement are interpreted
and implemented. As an intern at CMS, I will spend approximately 16 hours per week onsite
and will be expected to attend meetings, trainings, and provide timely output as directed.
Learning Goals:
 Understand CMS’s role in providing federally funded and subsidized insurance to
millions of eligible individuals.
 Acquire an in depth understanding of the inner workings of the WCMSA including
challenges, goals, opportunities, benefits achieved.
 Learn the relationships between the different HHS agencies and what role CMS plays in
various context.
Public Health Core Competencies:
1. Identify the main components and issues of the organization, financing and delivery of
health services and public health systems in the US.
2. Apply principles of strategic planning and marketing to public health.
3. Communicate health policy and management issues using appropriate channels and
technologies.
4. Demonstrate effective written and oral skills for communicating with different audiences
in the context of professional public health activities.
5. Identify unintended consequences produced by changes made to a public health system.
6. Discuss the policy process for improving the health status of populations.
7. Demonstrate team building, negotiation, and conflict management skills.
8. Describe how societal, organizational, and individual factors influence and are influenced
by public health communications.
9. Engage in dialogue and learning from others to advance public health goals.
10. Appreciate the importance of working collaboratively with diverse communities and
constituencies (e.g. researchers, practitioners, agencies and organizations).
11. Analyze the effects of political, social, and economic policies on public health systems at
the local, state, national and international levels.
Student Responsibilities:
 Support team members of DFMFFSO
 Complete all research and writing requested by managers
 Comply with all federal regulations in guarding sensitive information
 Attend FMB branch meetings when possible and provide appropriate input
 Attend and participate in other relevant employee meetings and trainings

CBMP AT CMS 2015/2016 15
 Identify MPH Core Competencies achieved during project, and provide report at
conclusion of internship.
 Provide biweekly report to faculty advisor and organization.
 Prepare and present a research paper about a particular aspect of interest to the
sponsoring organization, in a format to be determined in concert with the faculty advisor.
 Target dates for deliverables:
o Learning agreement – November 2015
o Establishment of research topic – January 2016 (date TBD)
o Brief, preliminary outline of final report - February 2016 (date TBD)
o Detailed outline - March 2016 (date TBD)
o Preliminary draft of final report – April 2016 (date TBD)
o Preview presentation of internship experience – April 2016 (date TBD)
o Second draft - May 2016 (date TBD)
o Oral presentation of internship experience - May 2016 (date TBD)
o Final report (includes research paper, core competency assessment) - June 2016
Advisor Responsibilities:
 Provide guidance and insight throughout the internship experience.
 Provide feedback, when requested, on written reports and deliverables.
Preceptor/Site Responsibilities:
 Workspace, computer/internet access.
 Provide access to training materials, relevant software, and standard operating procedures
 Provide meaningful projects/assignments/research
 Participation in periodic evaluation of intern performance.
Student Signature Date
12/14/15
Faculty Advisor Signature Date
Preceptor Signature Date

CBMP AT CMS 2015/2016 16
ACO Models
Comparison across Key Design Elements

CBMP AT CMS 2015/2016 17
17
Shared Savings
Program
Pioneer ACOModel ACO Investment
Model
Comprehensive ESRD
Care Initiative
Next Generation ACO Model
Purpose
The purpose of
Shared Savings Program
is to facilitate
coordination among
providers to improve the
quality and reduce costs
of care for traditional
Medicare fee-for-service
beneficiaries. The Shared
Savings Program
is intended to improve
beneficiary outcomes
and increase value of
care by
(1) promoting
accountability for the
care of Medicare fee-for-
service beneficiaries,
(2) encouraging
coordinated care
for all services provided
under Medicare fee-for-
service, (3) encouraging
investment in
infrastructure and
redesigned care
processes
The purpose of Pioneer
ACO Model is
1) to show how particular
ACO payment arrangements
can best improve care and
generating savings for
Medicare; and
2) to test alternative program
designs to inform future
rulemaking for the Medicare
Shared Savings Program.
Designed for organizations
with experience operating as
ACOs or in similar
arrangements,the Pioneer
Model will provide ACOs
successfulin achieving
shared savings in the first
two years the opportunity to
move into a population-
based payment in year three.
The Pioneer Model will also
require participating ACOs
to engage in similar
arrangements with
commercial and other
payers.
The ACO Investment
Model is an initiative
designed for ACOs in
the Medicare Shared
Savings Program. The
ACO Investment
Model is a model of
pre-paid shared
savings that builds on
the experience with the
Advance Payment
Model. This model
will test the use of pre-
paid shared savings to
encourage new ACOs
to form in rural and
underserved areas and
to encourage current
Medicare Shared
Savings Program
ACOs to transition to
arrangements with
greater financial risk.
Through this new
initiative, CMS will
partner with groups of
health care providers and
suppliers – ESRD
Seamless Care
Organizations (ESCOs) –
to test and evaluate a new
model of payment and
care delivery specific to
Medicare beneficiaries
with ESRD. The goals of
the model are to improve
beneficiary health
outcomes and reduce per
capita Medicare
expenditures
The purpose of the Next Generation ACO
is to test whether strong financial
incentives for ACOs can improve health
outcomes and reduce expenditures for
MFFS beneficiaries. The Model offers
financial arrangements with higher levels
of risk and reward than current Medicare
ACO initiatives, using refined
benchmarking methods that:
(1) reward quality performance;
(2) reward both attainment of and
improvement in cost containment; and
(3) transition away from reference to ACO
historical expenditures.
The Model additionally offers a selection
of alternative payment mechanisms to
enable a graduation from FFS
reimbursements to capitation.
Also central to the Next Generation Model
are severaltools to help ACOs improve
engagement with beneficiaries, such as:
(1) enhanced access to home visits,
telehealth services,and skilled nursing
facilities;
(2) a reward payment for receiving care
from the ACO;
(3) a process that gives beneficiaries a
decision in their alignment with ACOs;
(4) collaboration between CMS and ACOs
to clearly communicate to beneficiaries
the characteristics and potential benefits of
ACOs in relation to their care.

CBMP AT CMS 2015/2016 18
18
Shared Savings
Program
Pioneer ACO Model ACO Investment
Model
Comprehensive ESRD Care
Initiative
Next Generation ACO
Model
Shared Savings Program Pioneer ACOModel ACO Investment Model Comprehensive ESRD
Care Initiative
Next Generation ACO
Model
Timeline
Accepted applications with start
dates on April 1, 2012 (3-year
and 9-month agreement period)
and July 1, 2012 (3-year and 6-
month agreement period). For
all subsequent years, the
agreement period start date is
January 1, and the term of the
agreement is 3 calendar years.
Initial three-year contract
period (2012-2014).
Pioneer ACOs currently in
performance year (PY)4,
the first of two options
years. PY5of the Model is
in 2016.
The application for:
- Existing ACOs was
December 1, 2014;
- NewACOs opened in
July 1, 2015 and closed
July 31, 2015.
Two application cycles:
- LDO (Large Dialysis
Org.) due June 23, 2014
- Non-LDO September
15, 2014
The model started on
October 1, 2015 with the
initial agreement period
lasting for 3 years. CMS
and ESCO (ESRD
Seamless Care
Organization) will have
the option to extend for an
additional 2 years based on
the ESRD performance.
Two application cycles,
the first Next
Generation ACOs will
begin in 2016 and have
initial three-year
agreement period. Next
Generation ACOs that
beginin 2017 have
initial two-year
agreement period. Two
option PYs (2019, 2020)
following the initial
agreementperiod.
Letter of Intent (for 2016
start) due May 1, 2015.
Application (for 2016
start)due June 1, 2015.

CBMP AT CMS 2015/2016 19
19
Shared Savings Program Pioneer ACOModel ACO Investment Model Comprehensive ESRD Care
Initiative
Next Generation ACO
Model
ACOComposition
Existing or newly
formed organizations may
form an ACO:ACO
professionals in group
practice arrangements;
Networks of individual
practices of ACO
professionals; Joint
ventures/partnerships of
hospitals and ACO
professionals; Hospitals
employing ACO
professionals; Federal
Qualified Health Centers
(FQHC) and Rural Health
Clinics (RHC); Critical
Access Hospitals (CAHs)
that bill under method II.
Secretarialdiscretion
for other providers and
suppliers of services.
Participants have to
have a minimum 5,000
MFFS beneficiaries.
Participants are
required to be providers or
suppliers of services structured
as:
ACO professionals in
group practice arrangements;
1. Networks of individual
practices of ACO
professionals;
2. Partnerships or joint
venture arrangements
between hospitals and
ACO professionals;
3. Hospitals employing ACO
professionals; or
4. Federally Qualified Health
Centers (FQHC).
Generally, participants
must have a minimum of
15,000 aligned beneficiaries; if
in a rural area, they must have
a minimum of 5,000
beneficiaries*.
Participation is limited to
existing ACOs that joined the
Shared Savings Program in, 2012,
2013, 2014, 2015 or new ACO`s
will start in 2016:
- ACOs started in 2015 or will start
in 2016 from a rural area
- ACOs completed accurately and
reported quality measures to SSP
in the most recent performance
year
- ACOs have preliminary
prospective beneficiary assignment
of 10,000 or fewer for the most
recent quarter
*ACOs don`t include a
hospital or provider/supplier,
unless is a critical access hospital
(CAH) or inpatient prospective
payment system (IPPS) hospital
with 100 or fewer beds.
*ACOs is not owned or
operated in whole or in part by a
health plan
*ACOs did not participate
in the Advance Payment Model
*ACOs that started the
MSSP in 2015 or will start in 2016,
and are from a rural area using the
application selection criteria, are
permitted to exceed the 10,000
beneficiary assignment limit
- Together, the following
providers are eligible to form
an ESCO that may apply to
participate in the Model:
- Medicare Certified dialysis
facilities, including facilities
owned by LDOs,non-LDOs,
hospital- based facilities, and
independently-owned dialysis
facilities
- Nephrologists and/or
nephrology practices;
- Other Medicare enrolled
providers and suppliers
(exception apply)
An ESCO is required
to have a minimum of 350
matched beneficiaries based
on a defined look-back period
prior to the start of the Model
and must maintain at least 350
matched beneficiaries
throughout the life of the
Model to continue with
participation. If at any point
during a performance year an
ESCO drops below the
minimum threshold, the ESCO
will be placed on a CAP until
the minimum threshold is met.
Core ACO
composition is identical to
the Pioneer Model of split
TIN Providers/Suppliers.
Participants must
have a minimum of
10,000 beneficiaries.
Participants that are Rural
ACOs will be permitted to
have a minimum of 7,500
beneficiaries*.

CBMP AT CMS 2015/2016 20
20
BeneficiaryAlignment
Beneficiaries are
preliminary prospective with
retrospective reconciliation
and are claims-based.
Beneficiaries
prospectively aligned through
claims.
Began testing voluntary
alignment (allowing
beneficiaries to elect alignment
to an ACO even if not aligned
through claims) for PY4 (2015).
Beneficiaries are
preliminary prospective with
retrospective reconciliation and
are claims-based.
Beneficiaries aligned
prospectively, claims-
based.
Beneficiaries aligned
prospectively through claims.
Claims-based alignment
augmented with voluntary
alignment beginning in PY2
(2017) (i.e., in PY1 (2016)
beneficiaries will have the option
to voluntarily align for PY2
(2017)).
Care Initiative

CBMP AT CMS 2015/2016 21
21
FinancialRisk
ACOs may share in savings if actual
assigned patient population
expenditures are below the
established benchmark AND the
performance year expenditures meet
or exceed the minimum savings rate
(MSR). The MSR takes into account
normal variations in expenditures.
Track 1 max share ofsavings of
50% based on quality performance
with a cap of 10% on shared savings.
Track 1 has NO share losses
Track 2 max share ofsavings of
60% based on quality performance
with a cap on shared savings of 15%.
Track 2 shared loss rate may not be
less than 40% or exceed 60%. Limit
of losses to be shared in phases in
over 3-years starting at 5% in year 1;
7.5% in year 2; and 10% in year 3 and
any subsequent year. Losses in
excess of the annual limit would not
be shared.
Track 3 (NEW June/2015) max
share ofsavings of 75% based on
quality performance with a cap on
shared savings of 20%.
Track 3 share loss rate may not be
less than 40% or exceed 75%. Limit
of losses to be shared is 15%. Losses
in excess of the annual limit would
not be shared
Offers the option of five
payment arrangements
(see last page), which
share savings and losses
of up to 60-75%; savings
and losses sharing rate
varies based on quality
score.
ACO savings must exceed
the minimum savings rate
(MSR) in order to share in
savings or the minimum
loss rate (MLR) to be
accountable for losses.
The ACO Investment Model is
a model of pre-paid shared
savings that builds on the
experience with the Advance
Payment Model. This model
will test the use of pre-paid
shared savings to encourage
new ACOs to form in rural
and underserved areas and to
encourage current Medicare
ACOs to transition to
arrangements with greater
financial risk
CMS will recover payments
from earned shared savings for
as long as the participant
remains the Medicare Shared
Savings Program. If the ACO
ceases participation in the
ACO Investment Model or
Medicare Shared Savings
Program before repaying the
full amount, the outstanding
balance will be due at that
time. Applicants will be
required to obtain a financial
guarantee to cover at least
50% of the total anticipated
payments. Interest may accrue.
Track 1 Non-LDO
(non- Large Dialysis
Org.) are eligible for
shared savings but will
not be liable for shared
losses
Track 2 LDO (200 or
more dialysis facilities)
are eligible for shared
savings payments and
will be liable for shared
losses.
Offers the option of two risk
arrangements:
1. Risk Arrangement A
(Increased Shared Risk)
Parts A and B Shared Risk
- 80% sharing rate (PY1-3)
- 85% sharing rate (PY4-5)
- 15% savings/losses cap
- Discount
2. Risk Arrangement B
(Full Performance Risk )
- 100% Risk for Part A and B
- 15% savings/losses cap
- Discount
First dollar shared savings for
spending below the benchmark
(which includes a discount)
and accountable for first dollar
shared losses for spending
above the benchmark.

22
Care Initiative
Benchmark
Calculated as the sum of
risk-adjusted historical benchmark
expenditures plus the flat dollar
amount equal to the projected
absolute amount of growth in
national per capita expenditures for
Parts A and B services under the
original FFS program from the
benchmark to the performance year.
Historical benchmark =
60% x (most recent historical year
expenditures) + 30% x
(trended and risk-adjusted
middle historical year expenditures)
+ 10% x (trended and
risk-adjusted earliest
historical year expenditures)
Updated benchmark =
(historical benchmark) x (risk
adjustment factor) + (national
expenditure growth
increment)
Risk adjustment factor =
(estimated risk of beneficiaries
assigned in performance
year)/(estimated risk of
beneficiaries assigned in the most
recent historical benchmark
year)
Benchmark (PY4-5)*
calculated using a three-year
historic baseline trended by
50/50 blend of national
percentage and national flat
dollar growth. IME and DSH
are included in expenditure
calculations, with an
adjustment for DSH made in
baseline.
Regional prices
accounted for through a
locality adjustment.
Risks adjustment
using the CMS-HCC model to
compare average risk between
the baseline and performance
year. Option for change in
PY5.
Retrospective:
Benchmark finalized at the
end of the performance year
to incorporate actual,
observed trend.
*The Pioneer Model
adopted a new benchmarking
methodology beginning in
PY4. PY 1-3 methodology is
available on the Pioneer
Model webpage.
Spend Plan
Quality is the ACO`s
proposed financial plan for
how it will spend the funds
awarded in the ACO
Investment Model. CMS
will use to score
applications and to monitor
the management of the
funds during ACO`s
participation in the Model.
Benchmark calculated using a
Three-year historic
baseline)and is expressed on
a Per-Beneficiary-Per-Year
(PBPY) basis,for the ESCO.
For each performance year,
the historical expenditure
baseline will be risk-
adjusted, trended, price-
adjusted, and bundle-
adjusted.
Unlike the MSSP and the
Pioneer ACO Model, in which a
final updated benchmark is
determined at the end of each
performance year,CMS will
establish the Next Generation
Model benchmark prior to the
start of each performance year.
The benchmark will be set using
the most accurate expenditure,
quality, and risk score data
available at the time of
benchmark setting.
In the first three years of
the Model (calendar years 2016-
2018), for each Next Generation
ACO,this prospective
benchmark will be established
through the following steps:
(1) determine the ACO’s
historic baseline expenditures;
(2) apply the regional
projected trend;
(3) risk adjust using the
CMS Hierarchical Condition
Category (HCC) model; and
(4) apply the discount,
which is derived from one quality
adjustment and two efficiency
adjustments.
CMS intends to develop
an alternative benchmark
methodology for implementation
in PY4.

23
Shared Savings
Program
Pioneer ACOModel ACO Investment Model Comprehensive ESRD
Care Initiative
Next Generation ACO
Model
PaymentMechanism
Most claims paid
under traditional FFS.
CMS will calculate
the payment amounts
included in Parts A and B
FFS claims using a 3-
month claims run-out with
a completion factor
provided by the CMS
Office of the Actuary
(OACT)
Offers options of
payment:
1. Normal FFS
claims(most frequent)
2. Population-based
payments (PBP),participating
Pioneer Providers/Suppliers have
FFS claims reduced and the
ACO receives a monthly per-
beneficiary per-month (PBPM)
payment equal to the FFS
reduction percentage.
NewACOs will receive 3
types of payments:
1. An upfront, fixed payment:
$250,00
2. An upfront, variable
payment: $36 per assigned
beneficiary (based on
preliminarily prospectively-
assigned beneficiaries) (capped
at 10,000 beneficiaries)
3. A monthly payment of varying
amount depending on the size
of the ACO: $8 per beneficiary
per month (based on
Existing ACOs will
receive 2 types of payments
1. An upfront, variable
payment: $36 per assigned
beneficiary (based on
2. A monthly payment
depending on the size ofthe
ACO:$6 per beneficiary per
month (based on preliminarily
prospectively-assigned
beneficiaries) (capped at 10,000
beneficiaries)
The Model test a
newsystem ofpayment.
Offers options of payment
tied to the organization size:
1. Non-LDO
- 4.75% MSR for first-
dollar shared savings at
350 beneficiaries, 4%
MSR at 500 beneficiaries,
2% MSR < 2,000
- No guaranteed discount
- Shared Savings 50% in
years 1-3, 3+
- Cap in Shared Savings
5% in years 1-3, 3+
2. LDO
- +/-1% threshold for first-
dollar shared savings or
losses (option for higher
threshold if desired)
- Guaranteed discount
applied only to non-
dialysis FFS Part A and B
per capita benchmark.
Year 1: 0% ;Year 2: 1%
;Year 3: 2%; Year 4+: 3%
- Shared Savings up to
70% of first-dollar
- Shared Losses in year 1,
75% in years 2+
- Caps on Shared
savings/Shared Losses
10% years 1&2, 15% years 3+
Offers the option of four
payment mechanisms:
1. Normal FFS claims.
2. Normal FFS plus an
additional PBPM
infrastructure payment that is
recouped against shared
savings or in addition to
losses (at a rate of no more
than $6 PBPM).
3. PBP (same as Pioneer).
4. Capitation, in which the
ACO receives monthly
PBPM capitation payments
and is responsible for paying
claims for ACO providers
(not available until PY2).

24
Shared Savings Program Pioneer ACOModel ACO Investment
Model
Comprehensive ESRD
Care Initiative
BenefitEnhancements
(throughwaiversofspecificpaymentrules)
Waiver of 3 day
hospitalization rule for Skilled
Nursing Facility (SNF) for Track 3
*As early as 2017 begin to
phase-in a waiver of certain billing
and payment requirements for
telehealth services after it is tested
in the Innovation Center
Waiver of 3 day
hospitalization rule for
Skilled Nursing Facility
(SNF)
None None Next Generation ACOs may
elect to participate in some, none, or
all of the following benefit
enhancements:
- Waiver of 3 day hospitalization
rule for Skilled Nursing Facility
(SNF)
- Telehealth originating site
expansion
- Post-Discharge Home Visits (once
in first 10 days post-discharge and
once in the subsequent 20 days)
- Monetarycare-coordination
rewards for beneficiaries who
receive a threshold percentage of
their services from preferred
providers

CBMP AT CMS 2015/2016 25
Shared Savings Program Pioneer ACO
Model
ACO Investment Model Comprehensive ESRD
Care Initiative
Next Generation ACO
Model
Quality
Before an ACO can share in any
savings generated,it must
demonstrate that it met the quality
performance standard for that year.
There are also interactions between
ACO quality reporting and other
CMS initiatives, particularly the
Physician Quality Reporting
System (PQRS) Physician Value-
Based Payment Modifier, and the
Electronic Health Record (EHR)
Incentive Program.
33 quality measures:
1.Patient / Caregiver Experience (8
measures)
2. Care Coordination / Patient
Safety (10 measures)
3.At-Risk Population (6 measures,
including a 2-component diabetes
composite measure)
4. Preventive Care (8 measurers)
Same as
Medicare Shared Savings
Program measure set.
Quality score
determines savings/losses
sharing rate.
Evaluation of the
model will determine whether
these payments:
1) increase Medicare
participation by ACOs that meet
the eligibility criteria;
2) sustain ACO
participation;
3) move ACOs to
greater levels of risk.
Also, the evaluation will
determine how each of these
changes increase the level and/or
speed at which ACOs
a. improve the quality of care
for Medicare beneficiaries,
b. lower the cost of care
c. improve the health of
Medicare beneficiaries
CMS will calculate
the End Stage Renal Disease
(ESRD) Seamless Care
Organization’s (ESCO) Total
Quality Score (TQS) for the
Comprehensive ESRD Care
Initiative (CEC Initiative)
using a set of
26 quality measures.
1. Patient Safety (4 measures)
2. Person-and Caregiver-
Centered Experience and
Outcomes (8 measures)
3. Communication and Care
Coordination (3 measures)
4. Clinical Quality of Care (7
measures)
5. Population Health (4
measures)
Quality performance
will be reviewed annually
and updated as necessary for
each performance year
within the agreement period
Same as Medicare
measure set,except removing
the EHR measure. Next
Generation ACOs will be
expected to already meet EHR
criteria and demonstrate such in
their applications.
Quality score
determines quality component
of the benchmark discount.

26
Shared Savings Program Pioneer ACOModel ACO Investment Model Comprehensive ESRD Care
Initiative
Next Generation ACO
Model
Reports
The 33 quality measures
will be reported via a combination
of :
- CAHPS survey (8 measures of
patient / caregiver experience)
- Claims ( 7 measures on care
coordination/patient safety)
- Group Practice Reporting
Option Web Interface (GPRO
WI) (17 measures on care
coordination/patient safety,at
risk-population, and preventive
Health)
- Medicare and Medicaid EHR
Incentive Program data ( 1
measure on care
coordination/patient safety)
Quarterly financial
reports and monthly
expenditure reports and
Claims and Claim Line Feeds
(CCLFs).
Model participants
will be required to submit
data and information to the
CMS evaluation
contractor.
CMS will monitor
the Spend Plan on:
1. Staffing and infrastructure
the ACO will
acquire/expand using the
ACO IM funding
2. The expected unit price for
investments
3. Timing of procurement
and hiring activities
4. Plan to build on staff and
infrastructure currently in
place ( or plans to acquire
using their one funds)
5. Requests to use fund for
any items on the
“unacceptable use of
advancement payment list”
The 26 measures will
be reported via:
- Claims and CMS administrative
data ( 3 measures)
- Medicare claims and medical
records (Hybrid) (10 measures)
- ESRD* QIP results (12
measures)
- Kidney Disease Quality of Life
(KDQOL) patient Surveys (1
measure)
* End Stage Renal
Disease
Same as Pioneer.

27
Pioneer ACO Model five payment arrangements
Yr. Pioneer Core Option A Option B Alternative 1 Alternative 2
1 60% 2-sided
10% sharing cap
10% loss cap
1% MSR
50% 2-sided
5% sharing cap
5% loss cap
1% MSR
70% 2-sided
15% sharing cap
15% loss cap
1% MSR
50% 1-sided
5% sharing cap
2% to 2.7% MSR
(depending on number of
aligned beneficiaries)
60% 2-sided,
10% sharing cap
10% loss cap
1% MSR
2 70% 2-sided
15% sharing cap
15% loss cap
1% MSR
60% 2-sided,
10% sharing cap
10% loss cap
1% MSR
75% 2-sided,
15% sharing cap
15% loss cap
1% MSR
70% 2-sided,
15% sharing cap
15% loss cap
1% MSR
70% 2-sided,
15% sharing cap
15% loss cap
1% MSR
3 Payment:
Population-based
payment of up to
50% of ACO’s
expected part A & B
revenue
Risk: 70% 2-sided,
15% sharing cap
15% loss cap
1% MSR
Payment:
Population-based
payment of up to
50% of ACO’s
expected part A & B
revenue
Risk: 70% 2-sided,
15% sharing cap
15% loss cap
1% MSR
Payment:
Population-based
payment of up to
50% of ACO’s
expected part A &
B revenue
Risk: 75% 2-
sided,
15% sharing cap
15% loss cap
1% MSR
Payment: Population
based payment of up to
100% of ACO’s own
expected part B revenue,
less 3% discount.
Risk: Full risk for all part
B with a discount of 3% to
6% (depending on quality
scores) and shared risk for
Part A (70% sharing rate,
15% sharing and loss cap)
Payment: Population
based payment of up
to 100% of ACO’s
own expected part A
& B revenue,less 3%
discount.
Risk: Full risk for all
part A & B revenue
with a discount of
3% to 6% (depending
on quality scores)
4 Same as above.
Rebase using 2011,
2012, 2013
Same as above.
Rebase using 2011,
2012, 2013
Same as above.
Rebase using
2011, 2012, 2013
Same as above.
Rebase using 2011, 2012,
2013
Same as above.
Rebase using 2011,
2012, 2013
5 Same as above. Same as above. Same as above. Same as above. Same as above.

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