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ACOs Have New Options for Beneficiary Incentive Programs

By Robert Shaw
01.17.2019

With CMS’s continued “regulatory sprint to coordinated care,” the new Medicare Shared Savings Program regulations expand the playing field for ACOs to offer beneficiary incentive programs to encourage healthy outcomes. Termed “Pathways to Success,” the final rules promulgated on December 21, 2018, expand beneficiary incentives program options for ACOs. In addition to the noncash incentives that are currently allowed for beneficiary incentive programs, Pathways to Success allows ACOs accepting two-sided risk to offer cash equivalents of up to $20 per year to patients as incentives to obtain medically necessary primary care services.

In introducing the new beneficiary incentive program options, CMS noted that “patient engagement is an important part of motivating and encouraging more active participation by beneficiaries in their health care[.]” Although the expanded beneficiary incentive program options remain limited, they are a clear step by CMS towards encouraging greater ACO engagement with patients’ health care choices. Rewarding patients for seeing their primary care provider for services such as annual visits and follow-up appointments are key objectives of the new rules. ACOs implementing successful beneficiary incentive programs can be optimistic that their investments in such programs will put them on the leading edge of innovation in the Medicare system.

In order to offer a beneficiary incentive program under the new rules starting on July 1, 2019, an ACO must submit a Notice of Intent to Apply by January 18, 2019, and must participate in a two-sided risk track (i.e., the ENHANCED track or BASIC track levels C, D, or E). Beneficiary incentive programs under the new rules must also be disclosed to CMS and to the public on the ACO’s website, as well as to beneficiaries directly.

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Jamie Greene
jgreene@smithlaw.com
T: 919.838.2045

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