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Final rule implementing the Advancing Care Coordination through Episode Payment Models mandatory bundled payment program.

On December 20, 2016, the Centers for Medicare & Medicaid Services (CMS) issued the final rule implementing the Advancing Care Coordination through Episode Payment Models mandatory bundled payment program. (The CMS Fact Sheet on the rule can be found online here.  View the final rule in the Federal Register here.)

The final rule includes the following modifications to the EPMs from the proposed rule based on stakeholder comments. The rule:

  • Implements downside risk for the AMI, CABG, and SHFFT Models in performance year 3 (January 1, 2019), but provides the option of downside risk beginning in performance year 2 (January 1, 2018), for hospitals wishing to offer collaborating suppliers participation in an Advanced Alternative Payment Model as part of the Quality Payment Program;
  • Revises the proposed transfer policy. For AMI episodes, the episode will be canceled at the original transferring hospital and a new one established upon admission to the hospital accepting the transfer if the discharging DRG for that hospital falls under applicable cardiac episode payment model MS-DRGs and the hospital accepting the transfer is a participant in the cardiac episode payment model;
  • Adopts a voluntary quality measure for the CABG Model;
  • Creates greater protections for low-volume hospitals;
  • Expands flexibility to offer additional beneficiary engagement incentives beyond transportation for CR Incentive Payment Model; and
  • Establishes an Alternative Payment Models Beneficiary Ombudsman to monitor the models and field inquiries from beneficiaries, if needed.

In addition to establishing the three new EPMs, the rule also does the following:

  • Establishes a Cardiac Incentive Rehabilitation incentive program for hospitals in 48 markets;
  • Establishes a new “Track 1+” to the Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs);
  • Makes modifications to the Comprehensive Care for Joint Replacement (CJR) demonstration to allow providers to qualify for the Alternative Payment Model (APM) designation under the Quality Payment Program; and
  • Modifies the policies governing the use of the SNF 3-day waiver in the CJR demonstration.