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waivers offered under the ACO REACH Model starting in Performance Year 2021 (PY2021).Consistent with the authority under section 1115A(d)(1), the Secretary issued a waiver of 1877(a) of theAct (relating to the Federal physician self-referral law) and sections 1128B(b)(1) and (2) of the Act (relatingto the Federal anti-kickback statute) with respect to any startup arrangement between a DCE and one ormore DC Participant Providers or Preferred Providers or both (as such terms were defined in theParticipation Agreements for the first and second Implementation Periods of the model). 2 For startuparrangements entered into for any future Implementation Period, CMS is considering whether to seek anamendment to the current fraud and abuse waiver (e.g., to reflect the revised terminology of the ACOREACH Model) or, in lieu of a fraud and abuse waiver, to determine that the anti-kickback statute safeharbor for CMS-sponsored model arrangements (42 CFR § 1001.952(ii)(1)) is available. No fraud or abusewaivers are being issued in this document. A new or revised fraud and abuse waiver, if any, would be setforth in separately issued documentation. Any such waiver would apply solely to the ACO REACH Modeland could differ in scope or design from waivers granted for other programs or models.In addition to the fraud and abuse waiver issued for certain startup arrangements, CMS determined that,beginning April 1, 2021, the anti-kickback statute safe harbor for CMS-sponsored model arrangements (42CFR § 1001.952(ii)(1)) is available to protect certain DCE financial arrangements between or among theDCE, one or more DC Participant Providers, one or more Preferred Providers, or a combination thereof,provided that such arrangements comply with the applicable requirements set forth in the ParticipationAgreement for the Model Performance Period (“MPP Participation Agreement”). Further, CMSdetermined that, beginning April 1, 2021, the anti-kickback statute safe harbor for CMS-sponsored modelpatient incentives (42 CFR § 1001.952(ii)(2)) is available to protect certain in-kind patient incentives andBeneficiary Engagement Incentives furnished to a DC Beneficiary by a DCE, a DC Participant Provider, or aPreferred Provider, as applicable , provided that such incentives (as defined in the MPP ParticipationAgreement) are furnished in a manner that complies with the relevant requirements set forth in the MPPParticipation Agreement. For future performance years under the ACO REACH Model, CMS intends thatACOs, Participant Providers, and Preferred Providers will receive the same scope of protection currentlyavailable for this model under the CMS-sponsored model safe harbor at 42 CFR 1001.952(ii).Notwithstanding any provision of this RFA, individuals and entities must comply with all applicable lawsand regulations, except as explicitly provided for the ACO REACH Model in a separately documentedwaiver issued pursuant to section 1115A(d)(1). We note that the applicable law includes the CMSsponsored model safe harbor to the extent CMS has determined that it is applicable for this model.III.Scope and General ApproachA. Model Performance PeriodThe model will be implemented over six performance years, from PY2021-PY2026 (collectively, the ModelPerformance Period or MPP). PY2021 occurred from April 2021 through December 2021, and PY2022,PY2023, PY2024, PY2025 and PY2026 will occur in calendar years 2022, 2023, 2024, 2025, and 2026The waiver document can be found at rofessional-options-direct.pdf.26

respectively 3. This RFA is for applications to begin participation in PY2023. Throughout this RFA and allother ACO REACH Model materials, CMS has chosen to use performance year-specific terminology(PY2021 – PY2026) rather than participant-specific terminology (e.g., a given participant’s firstperformance year (PY1), second performance year (PY2), etc.) because all model policies apply equallyto all model participants within a given year, regardless of when each participant began participation(unless otherwise specified 4). As such, all tables and other descriptions of policies that vary throughoutthe life of the model will be described in performance year-specific terms. While the policies for PY2021and PY2022 may be shown for completeness and as a reference, organizations that submit applicationsin response to this RFA and that are selected to begin participation in PY2023 would be subject to onlythose policies described for PY2023 and subsequent Performance Years.The risk sharing options available under the ACO REACH Model aim to reduce expenditures whilepreserving or enhancing quality of care for beneficiaries. By aligning financial incentives, providing aprospectively determined and predictable revenue stream for participants, and putting a greateremphasis on beneficiary choice, the ACO REACH Model aims to: Transform risk sharing options in Medicare FFS by offering both capitated and partially capitatedpopulation-based payments that move away from traditional FFS; Broaden participation in CMS Innovation Center models by allowing model participation byorganizations new to Medicare FFS, such as physician managed organizations currently operatingexclusively in the MA program and organizations too small to meet the beneficiary minimumrequirements of prior ACO initiatives; Empower beneficiaries to engage in their care delivery through voluntary alignment and potentialBenefit Enhancements; Reduce health care provider burden to meet health care needs effectively through, for example, asmaller set of core quality measures (than used in the Pioneer ACO Model, NGACO Model, and SharedSavings Program), and waivers to facilitate care delivery; and Improve the quality of care for all aligned Medicare beneficiaries through financial mechanisms andhealth equity plans that encourage and support model participants and providers in addressing healthinequities beginning in PY2023.The risk sharing options available under the ACO REACH Model are expected to increase beneficiaries’access to innovative, affordable care while maintaining all original Medicare benefits. While an ACO thathas selected either of the risk sharing options available under the ACO REACH Model may offer BenefitEnhancements to eligible beneficiaries, these beneficiaries may still choose whether to receive enhancedbenefits. Relative to other CMS initiatives, the ACO REACH Model places an emphasis on voluntaryalignment, empowering beneficiaries to choose the health care providers with whom they want to havea care relationship. The ACO REACH Model also aims to improve beneficiaries’ experience of care byreducing administrative burden on practitioners, so that they can focus on what is most important: caringfor patients.CMS is committed to improving care for beneficiaries and thereby may modify or terminate the ACOREACH Model if the model is not achieving its established goals and aims or as may be required underPlease note that the shortened PY2021 (9 months) and the addition of PY2026 is a policy change from the PY2021RFA due to the challenges posed by coronavirus disease 2019.34For example, the participation retention policy described in Section XVIII.7

section 1115A.B. Implementation PeriodIn line with the opportunities made available to ACOs that began participation in PY2021 and PY2022, theInnovation Center will allow all applicants accepted under this RFA to participate in an ImplementationPeriod leading up to PY2023 (herein referred to as ‘IP3,’ since it will be the third such ImplementationPeriod over the life of the ACO REACH Model). The IP3 will begin August 1, 2022 and run throughDecember 31, 2022 and is intended to provide ACOs joining the model beginning in PY2023 an opportunityto conduct voluntary alignment activities (described in Section VI.B) in preparation for meeting theapplicable beneficiary alignment minimum at the start of PY2023 (also described in Section VI.B). Whilelists of Participant Providers (described in Section V.A) will be established for IP3 for purposes ofdocumenting which providers and suppliers will be conducting voluntary alignment activities during theIP3, no beneficiaries will be aligned to the ACO for the IP3 itself, either through claims-based alignmentor voluntary alignment (described in section VI.B); all beneficiaries aligned to the ACO via voluntaryalignment activities conducted during the IP3 will have an effective date of alignment at the beginning ofPY2023. Moreover, ACOs participating in the ACO REACH Model during IP3 do not take financial risk fortheir performance during IP3 and no beneficiary-identifiable data will be shared with these ACOs forpurposes of participation in IP3 (described in Section XI).All accepted applicants under this RFA will have the opportunity, but not the obligation, to participate inthe IP3. Accepted applicants choosing to participate in the IP3 must sign an IP3-specific ParticipationAgreement governing their participation in the IP3. Signing the IP3 Participation Agreement does notobligate an accepted applicant to participate in the model performance period beginning in PY2023 andchoosing not to sign the IP3 Participation Agreement does not prevent an accepted applicant fromparticipating in the model performance period beginning in PY2023. Regardless of whether theyparticipate in the IP3, all accepted applicants must sign an MPP Participation Agreement in order toparticipate in the model performance period beginning in PY2023.IV.Application ProcessAll entities that want to participate in the ACO REACH Model are required to submit an application.A. ApplicationThe application portal will be available beginning on March 7, 2022 and will close at 11:59 PM EasternTime (E.T.) on April 22, 2022. Applications are due by 11:59 PM E.T. on April 22, 2022. CMS is not solicitingLetters of Intent (LOIs) for PY2023 starters, therefore submitting an LOI is not required to submit anapplication in response to this RFA. All ACOs accepted under this RFA for participation beginning in PY2023will also have the opportunity (but not the obligation) to participate in the IP3. Please continue to checkthe website for updated timelines: each.Any questions that arise during the application process may be directed to the ACO REACH Modelmailbox: [email protected] with the subject “Application Question.”B. Withdrawal of ApplicationApplicants seeking to withdraw a completed application must submit an electronic withdrawal request toCMS via email to the ACO REACH Model mailbox: [email protected], prior to signing either the8

participation agreement for IP3 (if applicable) or the MPP Participation Agreement. The request must besubmitted as a PDF on the organization’s letterhead and signed by an official authorized to act on behalfof the organization. It should include the applicant organization’s legal name; the organization’s primarypoint of contact; the full address of the organization; and a description of the reason for the withdrawal.V.Applicant Eligibility and Participation RequirementsThe following sections describe the requirements an entity must meet to be eligible to participate in theACO REACH Model. The ACO REACH Model is designed to attract a range of providers and suppliersoperating under a common legal structure, with attention given to advancing primary care as a means tobetter managing health care overall. We believe this model is well-suited to various types of provider-ledorganizations, including those with prior experience participating in the NGACO Model or the SharedSavings Program that are interested in continuing and deepening their participation in Medicare sharedrisk arrangements.In addition to attracting participants from the NGACO Model, one of the goals of the ACO REACH Modelis to add innovative organizations to CMS risk sharing arrangements that have not been eligible for theShared Savings Program and/or the NGACO Model due to an insufficient number of aligned Medicare FFSbeneficiaries or other reasons. These innovative organizations may include provider-led organizationsthat have strong track records in taking on risk and improving quality of care for seniors and othervulnerable populations outside of FFS Medicare. Enhanced opportunities for voluntary alignment, alongwith an alignment “glide path,” provide opportunities for organizations new to Medicare FFS and/orInnovation Center models to build an aligned Medicare FFS population through means other than claimsbased alignment.Depending on the volume of applications received, CMS may choose to limit the total number of acceptedapplications. Please note that this RFA is intended only for applicants that serve a general, heterogenouspopulation of FFS Medicare beneficiaries or that serve a sub-population of FFS Medicare beneficiaries forwhich a targeted total cost of care initiative does not exist. For example, the Kidney Care Choices (KCC)Model is a total cost of care initiative focused on Medicare beneficiaries with renal disease. Accordingly,organizations (or their Participant Providers, as appropriate) that serve primarily beneficiaries withChronic Kidney Disease (CKD) and End-Stage Renal Disease (ESRD) should not submit an application forthe ACO REACH Model and are instead encouraged to apply for KCC. To help ensure that ACO REACHparticipants are not focused primarily on sub-populations of Medicare beneficiaries for which CMS alreadyhas a total cost of care initiative, to be selected for participation in the ACO REACH Model beginning inPY2023, an applicant must demonstrate an appropriate focus and / or diversity, as determined by CMS,among the individuals and entities the Applicant ACO expects will be Participant Providers. Specifically,an applicant comprised primarily of renal disease providers would not be selected to participate in theACO REACH Model beginning in PY2023. In addition, beginning in PY2023, no greater than 50% of eachREACH ACO’s aligned population may have a given medical condition or belong to a specialized subpopulation for which a targeted total cost of care initiative exists; ACOs that fail to satisfy this requirementwill be subject to remedial action, potentially including termination. This requirement will apply to bothexisting ACOs and those organizations accepted under this RFA.Organizations that serve a sub-population of FFS Medicare beneficiaries for which a targeted total cost ofcare initiative does not exist should further consider whether it is appropriate to apply to the ACO REACHModel as a High Needs Population ACO. Please refer to Section VI.F.3 for additional details o

ACO Realizing Equity, Access, and Community Health (REACH) Mo d el 1 Request for Applications 02/ 24 /2022 1 The Global and Professional Direct Contracting (GPDC) Model has been redesigned and renamed the ACO REACH