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Electronic Code of Federal Regulations

e-CFR data is current as of November 12, 2019

Title 42Chapter IVSubchapter BPart 425


TITLE 42—Public Health

CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED)

SUBCHAPTER B—MEDICARE PROGRAM (CONTINUED)

PART 425—MEDICARE SHARED SAVINGS PROGRAM

rule

Subpart A—GENERAL PROVISIONS

§425.10
Basis and scope.
§425.20
Definitions.
rule

Subpart B—SHARED SAVINGS PROGRAM ELIGIBILITY REQUIREMENTS

§425.100
General.
§425.102
Eligible providers and suppliers.
§425.104
Legal entity.
§425.106
Shared governance.
§425.108
Leadership and management.
§425.110
Number of ACO professionals and beneficiaries.
§425.112
Required processes and patient-centeredness criteria.
§425.114
Participation in other shared savings initiatives.
§425.116
Agreements with ACO participants and ACO providers/suppliers.
§425.118
Required reporting of ACO participants and ACO providers/suppliers.
rule

Subpart C—APPLICATION PROCEDURES AND PARTICIPATION AGREEMENT

§425.200
Participation agreement with CMS.
§425.202
Application procedures.
§425.204
Content of the application.
§425.206
Evaluation procedures for applications.
§425.208
Provisions of participation agreement.
§425.210
Application of agreement to ACO participants, ACO providers/suppliers, and others.
§425.212
Changes to program requirements during the agreement period.
§425.214
Managing changes to the ACO during the agreement period.
§425.216
Actions prior to termination.
§425.218
Termination of the participation agreement by CMS.
§425.220
Termination of the participation agreement by the ACO.
§425.221
Close-out procedures and payment consequences of early termination.
§425.222
Eligibility to re-enter the program for agreement periods beginning before July 1, 2019.
§425.224
Application procedures for renewing ACOs and re-entering ACOs.
§425.226
Annual participation elections.
rule

Subpart D—PROGRAM REQUIREMENTS AND BENEFICIARY PROTECTIONS

§425.300
Compliance plan.
§425.302
Program requirements for data submission and certifications.
§425.304
Beneficiary incentives.
§425.305
Other program safeguards.
§425.306
Participant agreement and exclusivity of ACO participants.
§425.308
Public reporting and transparency.
§425.310
Marketing requirements.
§425.312
Beneficiary notifications.
§425.314
Audits and record retention.
§425.315
Reopening determinations of ACO shared savings or shared losses to correct financial reconciliation calculations.
§425.316
Monitoring of ACOs.
rule

Subpart E—ASSIGNMENT OF BENEFICIARIES

§425.400
General.
§425.401
Criteria for a beneficiary to be assigned to an ACO.
§425.402
Basic assignment methodology.
§425.404
Special assignment conditions for ACOs including FQHCs and RHCs.
rule

Subpart F—QUALITY PERFORMANCE STANDARDS AND REPORTING

§425.500
Measures to assess the quality of care furnished by an ACO.
§425.502
Calculating the ACO quality performance score.
§425.504
Incorporating reporting requirements related to the Physician Quality Reporting System Incentive and Payment Adjustment.
§425.506
Incorporating reporting requirements related to adoption of certified electronic health record technology.
§425.508
Incorporating quality reporting requirements related to the Quality Payment Program.
rule

Subpart G—SHARED SAVINGS AND LOSSES

§425.600
Selection of risk model.
§425.601
Establishing, adjusting, and updating the benchmark for agreement periods beginning on July 1, 2019, and in subsequent years.
§425.602
Establishing, adjusting, and updating the benchmark for an ACO's first agreement period beginning on or before January 1, 2018.
§425.603
Resetting, adjusting, and updating the benchmark for a subsequent agreement period beginning on or before January 1, 2019.
§425.604
Calculation of savings under the one-sided model.
§425.605
Calculation of shared savings and losses under the BASIC track.
§425.606
Calculation of shared savings and losses under Track 2.
§425.608
Determining first year performance for ACOs beginning April 1 or July 1, 2012.
§425.609
Determining performance for 6-month performance years during CY 2019.
§425.610
Calculation of shared savings and losses under the ENHANCED track.
§425.612
Waivers of payment rules or other Medicare requirements.
§425.613
Telehealth services.
rule

Subpart H—DATA SHARING WITH ACOS

§425.700
General rules.
§425.702
Aggregate reports.
§425.704
Beneficiary-identifiable claims data.
§425.706
Minimum necessary data.
§425.708
Beneficiaries may decline claims data sharing.
§425.710
Data use agreement.
rule

Subpart I—RECONSIDERATION REVIEW PROCESS

§425.800
Preclusion of administrative and judicial review.
§425.802
Request for review.
§425.804
Reconsideration review process.
§425.806
On-the-record review of reconsideration official's recommendation by independent CMS official.
§425.808
Effect of independent CMS official's decision.
§425.810
Effective date of decision.

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