Pathways to Success
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ACO Options
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Glide Path ACO TypeExperienced with RiskHigh/Low Revenue ACOStart/Renewal DateOption to Renew Early under PathwaysBasic TrackBasic E TrackOption to Advance to Higher Glide Path Level
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New ACO*NoHigh7/1/2019 and afterN/AYes (A-E)YesYes
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Low7/1/2019 and afterN/AYes (A-E) - Can elect for 3rd year under Basic B, but would require automatic advancement to Basic E in Year 4 and 5.YesYes
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New Legal Entity ACO (40% of composition with ACO participants with prior risk experience)*YesHigh7/1/2019 and afterN/ANoNoNo
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Low7/1/2019 and afterN/ANoYesNo
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Track 1 Existing Renewal (2013 New/2016 New/Renewal)(that have extended for 6 months 1/1/2019 to 6/1/30)*NoHigh7/1/2019N/AYes (Max of 1.5 Years under Basic B and Min of 2 years under Basic E)YesYes
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Low7/1/2019N/AYes (Max of 1.5 Years under Basic B and Min of 2 years under Basic E)YesYes
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Track 1 Existing Renewal (2014 New/2017 New/Renewal)NoHigh1/1/2020YesYes (Max of 1 Year under Basic B and Min of 2 years under Basic E)YesYes
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Low1/1/2020YesYes (Max of 1 Year under Basic B and Min of 2 years under Basic E)YesYes
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Track 1 Existing Renewal (2015 New/2018 New/Renewal)NoHigh1/1/2021YesYes (Max of 1 Year under Basic B and Min of 2 years under Basic E)YesYes
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Low1/1/2021YesYes (Max of 1 Year under Basic B and Min of 2 years under Basic E)YesYes
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Track 1+ Existing Renewal (2018 New)YesHigh1/1/2021 Must start Enhanced Pathways TrackYesNoYes - If ACO is to renew under Pathways 2020 or before.No
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Low1/1/2021 Must start Enhanced Pathways TrackYesNoYes - If ACO is to renew under Pathways 2020 or before.No
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Track 2 Existing Renewal (ALL)YesHighAll Renewal DatesYesNoNoNo
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LowAll Renewal DatesYesNoYesNo
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Track 3 Exisiting Renewal (ALL)YesHighAll Renewal DatesYesNoNoNo
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LowAll Renewal DatesYesNoYesNo
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NextGENNextGEN ACO Model expected to continue until 2020 and will release and updated model soon based on future options. No changes to model at this time.
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*Renewal ACOs starting on 7-1-19 would have a 1 time agreement period of 5 Years and 6 mo. The first 6 month period would be under the Basic B model and the new ACO would be allowed a maximum of 1.5-3.5 years with no risk.
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*ACOs starting on 7-1-19 would have a 1 time agreement period of 5 Years and 6 mo. The first 6 month period would be under the Basic A model and the new ACO would be allowed a maximum of 2.5-3.5 years with no risk depending on revenue model.
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Notes
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ACOs currently participating in Tracks 1, 1+, 2, or 3 will be allowed to complete their current three-year agreements, or may elect to terminate their existing contracts early and switch to either the BASIC or ENHANCED track at or after July 1, 2019.
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High/Low Revenue Calculation35%Part A + Part B Expenditures (All Spend)ACO Revenue for Participants35%
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High RevenueIf the ACO’s assigned beneficiary Part A + Part B for ACO Participants revenue is greater than 35% of the expenditures, the ACO would be considered “High Revenue”.$93,411,313$34,562,186$32,693,960
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Low RevenueIf the ACO’s assigned beneficiary Part A + Part B revenue is less than 35% of the expenditures, the ACO would be considered “Low Revenue”.$93,411,313$13,630,983$32,693,960
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Savings and Losses
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Shared Savings (once MSR met or exceeded)Shared Losses (once MLR met or exceeded)Advanced APM 5% or MIPS Upward Adjustment Part B
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Level A & B1st dollar savings at a rate up to 40% based on quality performance; not to exceed 10% of updated benchmarkN/AMIPS Upward Adjustment
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Level C1st dollar savings at a rate of up to 50% based on quality performance, not to exceed 10% of updated benchmark1st dollar losses at a rate of 30%, not to exceed 2% of ACO participant revenue capped at 1% of updated benchmarkMIPS Upward Adjustment
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Level D1st dollar savings at a rate of up to 50% based on quality performance, not to exceed 10% of updated benchmark1st dollar losses at a rate of 30%, not to exceed 4% of ACO participant revenue capped at 2% of updated benchmarkMIPS Upward Adjustment
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Level E1st dollar savings at a rate of up to 50% based on quality performance, not to exceed 10% of updated benchmark1st dollar losses at a rate of 30%, not to exceed the percentage of revenue specified in the revenue-based nominal amount standard under the Quality Payment Program (for example, 8% of ACO participant revenue in 2019 – 2020), capped at a percentage of updated benchmark that is 1 percentage point higher than the expenditure-based nominal amount standard (for example, 4% of updated benchmark).Advanced APM 5%
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ENHANCED No change. 1st dollar savings at a rate of up to 75% based on quality performance, not to exceed 20% of updated benchmarkNo change. 1st dollar losses at a rate of 1 minus final sharing rate, with minimum shared loss rate of 40% and maximum of 75%, not to exceed 15% of updated benchmarkAdvanced APM 5%
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Hypothetical Loss Calculation
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ACO TrackPart A + Part B Benchmark ExpendituresACO Revenue (Parts A and B)% of ACO Revenue at RiskRisk Revenue %CAP - % of Updated Benchmark ExpendituresCAP - Updated Benchmark Expenditure %Advanced APM 5% of Part BMIPS Upward Adjustment
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Basic C$93,411,313$13,630,983$272,6202%$934,113.131%N/AYes
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Basic D$93,411,313$13,630,983$545,2394%$1,868,2262%N/AYes
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Basic E$93,411,313$13,630,983$1,090,4798%$3,736,4534%$250,000.00N/A
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Enhanced$93,411,313$13,630,983N/AN/A$14,011,69715%$250,000.00N/A
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Hypothetical Gain Calculation Shared Savings PercentageMSR/MLRShared Savings AmountACO Shared Savings
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Basic C, D and E50%Satisfied$5,000,000.00$2,500,000.00
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Enhanced75%Satisfied$5,000,000.00$3,750,000.00
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Hypothetical Cooridor Gain Example MSR/MLR PercentagePart A + Part B Benchmark ExpendituresMinimum Savings AmountAmount Saved 2.3%
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Basic C, D and E3.00%$93,411,313$2,802,339.39$2,148,460.20No Payment/Repayment
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Enhanced3.00%$93,411,313$2,802,339.39$2,148,460.20No Payment/Repayment
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Hypothetical Cooridor Gain Example MSR/MLR PercentagePart A + Part B Benchmark ExpendituresMinimum Savings Amount 3%Losses Amount 2.3%
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Basic C, D and E3.00%$93,411,313$2,802,339.39-$2,148,460.20No Payment/Repayment
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Enhanced3.00%$93,411,313$2,802,339.39-$2,148,460.20No Payment/Repayment
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Hypothetical Loss Calculation
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ACO TrackPart A + Part B Benchmark ExpendituresACO Revenue (Parts A and B)% of ACO Revenue at RiskRisk Revenue %CAP - % of Updated Benchmark ExpendituresCAP - Updated Benchmark Expenditure %Advanced APM 5% of Part BMIPS Upward Adjustment
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Basic C$193,411,313$93,411,313$1,868,2262%$1,934,113.131%N/AYes
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Basic D$193,411,313$93,411,313$3,736,4534%$3,868,2262%N/AYes
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Basic E$193,411,313$93,411,313$7,472,9058%$7,736,4534%$1,250,000.00N/A
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Enhanced$193,411,313$93,411,313N/AN/A$14,011,69715%$1,250,000.00N/A
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Program Flexibility
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Choice of Beneficiary Assignment?Annual election to enter higher risk?Beneficiary Incentive ProgramExpanded Telehealth Services3-Day SNF Rule Waiver
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Level A & BYesYesNoNoNo
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Level CYesYesYes, ACOs may establish an approved program starting July 1, 2019, or in subsequent yearsYes, in 2020 for ACOs electing prospective assignmentYes, ACOs may apply to start on July 1, 2019, and in subsequent years
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Level DYesNo; ACO will automatically transition to Level E at the start of the next performance year.Yes, ACOs may establish an approved program starting July 1, 2019, or in subsequent yearsYes, in 2020 for ACOs electing prospective assignmentYes, ACOs may apply to start on July 1, 2019, and in subsequent years
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Level EYesNo; maximum level of risk/reward under the BASIC trackYes, ACOs may establish an approved program starting July 1, 2019, or in subsequent yearsYes, in 2020 for ACOs electing prospective assignmentYes, ACOs may apply to start on July 1, 2019, and in subsequent years
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ENHANCEDYesNo; maximum level of risk/rewardYes, ACOs may establish an approved program starting July 1, 2019, or in subsequent yearsYes, in 2020 for ACOs electing prospective assignmentYes, ACOs may apply to start on July 1, 2019, and in subsequent years
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