(ACO) regulations - American Society of Anesthesiologists

CMS-1345-P 242
To meet the statutory requirement to adjust the benchmark for "beneficiary
characteristics" we would adjust the annual per capita expenditures to account for
changes in health status.
For beneficiaries without 3 full years of immediately-prior Medicare eligibility
(such as beneficiaries who were not 68 in their first year assigned to the ACO), a further
adjustment would be necessary under this option.
• For those beneficiaries with less than one full year of prior Medicare
experience, we would either—
++ Use a substitute for their own expenditures in the update amount within the
benchmark, that is, substitute the average per capita FFS expenditures for all Medicare
beneficiaries during the year they are first assigned to the ACO, adjusted for health status
(as described later in the document in section 3); or
++ Exclude their experience from the shared savings computations.
• For those assigned beneficiaries with more than 12 months prior Medicare
experience but less than 36 months we also have two choices:
++ Compute a weighted-average (using number of months as the weight) that
blends
-- Their prior expenditure experience and
-- The average per capita Parts A and B FFS expenditures for all Medicare
beneficiaries during the year before the first year they are assigned to the ACO, adjusted
for health status; or
++ Use only their prior expenditure experience.