H.R. 8129: To amend title XVIII of the Social Security Act to establish a full risk ACO program.

Full Risk ACO Program

This bill proposes the introduction of a Full Risk Accountable Care Organization (ACO) program, which would amend Title XVIII of the Social Security Act. The primary objective is to establish a permanent framework for healthcare providers to engage in full risk models for managing care for Medicare beneficiaries.

Findings

The bill outlines several findings:

• Successful pilot programs in recent years have shown that full risk ACOs can improve healthcare outcomes while reducing costs for traditional Medicare.
• Currently, there is no permanent program that allows providers the flexibility to operate under full risk models outside of pilot projects.
• A range of providers serving traditional Medicare beneficiaries would benefit from permanent options for full risk accountable care.
• Full risk models could transform care delivery and coordination, especially for beneficiaries with complex health needs.

Establishment of the Program

The Secretary of Health and Human Services is required to establish the full risk ACO program by June 30, 2026. The program will incentivize healthcare providers to manage care effectively for Medicare fee-for-service beneficiaries. Healthcare professionals will work together in either standard or complex care ACOs, which will receive payments designed to encourage high-quality care and cost reduction.

Standard and Complex Care Tracks

Under this program:

• A standard full risk ACO must have at least 2,500 beneficiaries.
• A complex care full risk ACO requires a minimum of 250 beneficiaries in the first year, increasing to at least 1,000 in the third year and beyond.

ACOs must provide flexible care tailored to individual needs, emphasizing care coordination and access to various services.

Payment Arrangements

ACOs participating in the program will be eligible for several payment options, including:

• Capitated payments (fixed amount per patient per month) for primary care and total care.
• Reduction of fee-for-service claims payments in favor of these capitated arrangements.

Quality and Reporting Standards

The Secretary will develop quality performance standards specifically for full risk ACOs, focusing on patient experience and health outcomes. Additionally, participants will be exempt from the Merit-Based Incentive Payment System (MIPS).

Beneficiary Assignment and Communication

The program participants will follow established Medicare alignment and assignment methodologies, with patients having the option to opt out of the full risk ACO program. The Secretary will also set requirements for effectively communicating with Medicare beneficiaries about their care options.

Waivers and Data Provision

The Secretary may waive certain provisions necessary to implement the program and will provide regular data reports to the ACOs based on claims and payments for their beneficiaries.

Definitions and Risk Adjustment

The bill outlines definitions for key terms relating to ACOs and introduces both prospective and concurrent risk adjustment methods for determining care costs.

Relevant Companies

None found.