Sec. 501. Eliminating barriers to care coordination under accountable care organizations
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Section 1899 of the Social Security Act ( 42 U.S.C. 1395jjj ), as amended by section 304(a), is amended— in subsection (b)(2), by adding at the end the following new subparagraph: An ACO that seeks to operate an ACO Beneficiary Incentive Program pursuant to subsection
(m)shall apply to the Secretary at such time, in such manner, and with such information as the Secretary may require. ; by adding at the end the following new subsection: In order to encourage Medicare fee-for-service beneficiaries to obtain medically necessary primary care services, an ACO participating under this section under a payment model described in clause
(i)or
(ii)of paragraph (2)(B) may apply to establish an ACO Beneficiary Incentive Program to provide incentive payments to such beneficiaries who are furnished qualifying services in accordance with this subsection. The Secretary shall permit such an ACO to establish such a program at the Secretary’s discretion and subject to such requirements, including program integrity requirements, as the Secretary determines necessary. The Secretary shall implement this subsection on a date determined appropriate by the Secretary. Such date shall be no earlier than January 1, 2019, and no later than January 1, 2020. Subject to subparagraph (H), an ACO Beneficiary Incentive Program established under this subsection shall be conducted for such period (of not less than 1 year) as the Secretary may approve. An ACO Beneficiary Incentive Program established under this subsection shall provide incentive payments to all of the following Medicare fee-for-service beneficiaries who are furnished qualifying services by the ACO: With respect to the Track 2 and Track 3 payment models described in section 425.600(a) of title 42, Code of Federal Regulations (or in any successor regulation), Medicare fee-for-service beneficiaries who are preliminarily prospectively or prospectively assigned (or otherwise assigned, as determined by the Secretary) to the ACO. With respect to any future payment models involving two-sided risk, Medicare fee-for-service beneficiaries who are assigned to the ACO, as determined by the Secretary. For purposes of this subsection, a qualifying service is a primary care service, as defined in section 425.20 of title 42, Code of Federal Regulations (or in any successor regulation), with respect to which coinsurance applies under part B, furnished through an ACO by— an ACO professional described in subsection (h)(1)(A) who has a primary care specialty designation included in the definition of primary care physician under section 425.20 of title 42, Code of Federal Regulations (or any successor regulation); an ACO professional described in subsection (h)(1)(B); or a Federally qualified health center or rural health clinic (as such terms are defined in section 1861(aa)). An incentive payment made by an ACO pursuant to an ACO Beneficiary Incentive Program established under this subsection shall be— in an amount up to $20, with such maximum amount updated annually by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the previous year; in the same amount for each Medicare fee-for-service beneficiary described in clause
(i)or
(ii)of subparagraph
(B)without regard to enrollment of such a beneficiary in a medicare supplemental policy (described in section 1882(g)(1)), in a State Medicaid plan under title XIX or a waiver of such a plan, or in any other health insurance policy or health benefit plan; made for each qualifying service furnished to such a beneficiary described in clause
(i)or
(ii)of subparagraph
(B)during a period specified by the Secretary; and made no later than 30 days after a qualifying service is furnished to such a beneficiary described in clause
(i)or
(ii)of subparagraph (B). The Secretary shall not make any separate payment to an ACO for the costs, including incentive payments, of carrying out an ACO Beneficiary Incentive Program established under this subsection. Nothing in this subparagraph shall be construed as prohibiting an ACO from using shared savings received under this section to carry out an ACO Beneficiary Incentive Program. Incentive payments made by an ACO under this subsection shall be disregarded for purposes of calculating benchmarks, estimated average per capita Medicare expenditures, and shared savings under this section. An ACO conducting an ACO Beneficiary Incentive Program under this subsection shall, at such times and in such format as the Secretary may require, report to the Secretary such information and retain such documentation as the Secretary may require, including the amount and frequency of incentive payments made and the number of Medicare fee-for-service beneficiaries receiving such payments. The Secretary may terminate an ACO Beneficiary Incentive Program established under this subsection at any time for reasons determined appropriate by the Secretary. Any payment made under an ACO Beneficiary Incentive Program established under this subsection shall not be considered income or resources or otherwise taken into account for purposes of— determining eligibility for benefits or assistance (or the amount or extent of benefits or assistance) under any Federal program or under any State or local program financed in whole or in part with Federal funds; or any Federal or State laws relating to taxation. ; in subsection (e), by inserting , including an ACO Beneficiary Incentive Program under subsections (b)(2)(I) and
(m)after the program ; and in subsection (g)(6), by inserting or of an ACO Beneficiary Incentive Program under subsections (b)(2)(I) and
(m)after under subsection (d)(4) . Section 1128B(b)(3) of the Social Security Act (42 U.S.C. 1320a–7b(b)(3)) is amended— by striking and at the end of subparagraph (I); by striking the period at the end of subparagraph
(J)and inserting ; and ; and by adding at the end the following new subparagraph: an incentive payment made to a Medicare fee-for-service beneficiary by an ACO under an ACO Beneficiary Incentive Program established under subsection
(m)of section 1899, if the payment is made in accordance with the requirements of such subsection and meets such other conditions as the Secretary may establish. . The Secretary of Health and Human Services (in this subsection referred to as the Secretary ) shall conduct an evaluation of the ACO Beneficiary Incentive Program established under subsections (b)(2)(I) and
(m)of section 1899 of the Social Security Act ( 42 U.S.C. 1395jjj ), as added by subsection (a). The evaluation shall include an analysis of the impact of the implementation of the Program on expenditures and beneficiary health outcomes under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq.). Not later than October 1, 2023, the Secretary shall submit to Congress a report containing the results of the evaluation under paragraph (1), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.
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- 42 USC 1320a–7b(b)(3)
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Sec. 501
Eliminating barriers to care coordination under accountable care organizations
Cite42 USC 1320a–7b(b)(3)
Cites 3Cited by 0 across 0 sources