Recently, the Centers for Medicare & Medicaid (CMS) released another interim rule providing updated support and guidance on their COVID-19 response and the public health emergency (PHE) measures. With the COVID-19 pandemic creating unpredictability for many ACOs with expenditure and utilization changes to benchmarks and performance year totals, some ACOs face the potential liability of shared losses. To ensure that no details are missed in these significant updates issued by CMS, I have compiled a question and answer style overview based on the CMS documentation to address any immediate concerns.
Will the application cycle remain the same in light of these changes?
No, CMS decided to forgo the previous application cycle scheduled to begin on January 1, 2021. With this change, eligible ACOs will be able to stay under their existing historical benchmark for an additional year, which will increase their stability and predictability. 160 ACOs have agreements that will end on December 31, 2020; these ACOs are eligible to renew. ACOs that began theirs on January 1, 2018, may elect to extend their agreement period for an optional fourth performance year. By forgoing the 2021 application cycle, it will provide CMS additional time to determine how to remove 2020 from benchmark calculations moving forward.
Do ACOs on the Basic track’s glide path have the option to maintain their current level of participation for performance year 2021 and not assume higher levels of risk?
Yes, ACOs can elect to stay at the same level in the glide path for 2021. For performance year 2022, an ACO that elects this advancement deferral option will automatically advance to the level of the Basic track’s glide path, which they would have been participating in during performance year 2020. For example, if an ACO is in a Basic B contract for performance year 2020 and elects to freeze and remain Basic B for 2021, they will advance to Basic D in performance year 2022.
Is the Extreme and Uncontrollable Circumstances Policy due to the pandemic applicable for this performance year?
Yes, the defined period began in January 2020 and will continue through the end of the public health emergency period. Catastrophic events outside of an ACO’s control can increase the difficulty of coordinating care for patient populations. Due to the unpredictable changes in utilization and the cost of services furnished to beneficiaries, there may be a significant impact on costs for the applicable performance year and their benchmark in the subsequent agreement period.
If the COVID-19 public health emergency extends throughout 2020, all shared losses for the performance year will be mitigated for ACOs participating in a performance-based risk track, including Track 2, the Enhanced track, Levels C, D, and E of the Basic track, and the Track 1+ model. At this time, the COVID-19 public health emergency already covers four months (January to April 2020), meaning that any shared losses that ACOs incur for performance year 2020 will reduce by at least one-third.
How will CMS adjust MSSP calculations to mitigate the impact of COVID-19 on ACOs?
CMS will remove the payment amounts for episodes of care (as identified by inpatient care for treatment of COVID-19) from the Medicare Shared Savings Program (MSSP) performance year expenditures. They will make updates to the historical benchmarks and revenue calculations to determine loss sharing limits for certain ACOs. CMS anticipates that the localized nature of infections (such as rapid outbreaks in individual skilled nursing facilities (SNFs) and unanticipated increases in expenditures) will affect the costs of Medicare Parts A and B during 2020. The hope is that the increased flexibilities will allow health care providers to better identify and treat COVID-19 patients. These factors of acute care for performance year 2020 is not reflected in the ACOs’ historical benchmarks.
The prospective CMS hierarchical condition category (HCC) risk score is not expected to adjust for the variability because they are prospective and use 2019 diagnoses. Increased expenditures related to the treatment of COVID-19 in an ACO’s benchmark calculations for 2020 could lead to higher future historical benchmarks that may advantage some ACOs once COVID-19 cases decline.
CMS is revising its policies under the MSSP to exclude Parts A and B fee-for-service payment amounts for an episode of care for the treatment of COVID-19. If an inpatient service triggers an episode, as specified, Parts A and B claims with dates of service during that episode will be grouped for exclusion due to COVID provisions.
- B97.29: (Other coronaviruses as the cause of diseases classified elsewhere)
- U07.1 (COVID-19): Discharges occurring on or after April 1, 2019
Where can I find resources on the expansion of codes used for services provided virtually? Telehealth, virtual-check-ins, e-visits, or telephone services, etc.
We have made these expansions the focus of several recent thought leadership blogs and webinars since CMS announced them. I encourage you to read our Director of Clinical Transformation Jessica Scruton’s blog post on the downstream impact of COVID-19 for an overview of the policy expansions and methods to refocus strategies for remote chronic care management. Our Director of Advisory Services, Maha Salah-Ud-Din, also wrote a blog post detailing the process of performing an annual wellness visit (AWV) via telehealth. I encourage you to visit Lightbeam’s COVID-19 Resources page on our site for up-to-date information for providers during the COVID-19 pandemic.
What are the waivers for video requirements of certain evaluation and management services delivered via telehealth (99441, 99442, 99443)?
The 1135 Telehealth Waiver and Interim Final Rule (IFR) is retroactive to March 1, 2020, and will remain in place throughout the PHE. It allows for audio-only telehealth services E/M codes for 99441, 99442, and 99443.
The 1135 waiver also allows for additional services to be provided telephonically. However, unless the service is listed as an audio-only covered service, all other telehealth services provided to Medicare beneficiaries must incorporate audio and video communications that permit two-way, real-time communication between the patient and their provider. Here is the full list of telehealth service codes.
For more documentation on the second wave of changes released by CMS, visit the Medicare Learning Network (MLN) page.
Josh Patten is the Vice President of Operations at Lightbeam.