ACO Realizing Equity, Access, and CommunityHealth (REACH) Model1Request for Applications02/24/2022The Global and Professional Direct Contracting (GPDC) Model has been redesigned and renamed the ACO REACHModel.1

Table of ContentsI.Background and Introduction. 4II.Statutory Authority . 4A.General Authority to Test Model. 4B.Financial and Payment Model Authorities . 4C.Waiver and Safe Harbor Authority. 5III.Scope and General Approach . 6A.Model Performance Period . 6B.Implementation Period . 8IV.Application Process . 8A.Application . 8B.Withdrawal of Application . 8V.Applicant Eligibility and Participation Requirements . 9A.Eligible Providers and Suppliers . 10B.Screening . 11C.ACO Organization Types, Legal Entity Status, Governance Structure, and Leadership . 12D.Participant Providers and Preferred Providers. 15E.ACO Service Area . 15F.State Licensure . 15G.Use of Certified EHR Technology . 16H.Program Overlap. 16I.Advanced APM Determination . 18J.MIPS APM Scoring . 18K.Focus on Health Equity . 18L.Additional updates from prior Request for Applications . 21VI.Model Design Elements. 23A.Beneficiary Eligibility . 23B.Beneficiary Alignment . 23C.Beneficiary Engagement and Marketing . 28D.Financial Methodology: Risk Sharing Options, Risk Mitigation, and Financial Settlement . 32E.Financial Methodology: ACO REACH Model Payment Mechanisms . 382

F.Financial Methodology: Beneficiary Alignment and the Performance Year Benchmark forEach of the Three ACO Types . 46G.Medicare Part D . 70H.Benefit Enhancements . 70I.Health Equity Plan . 77VII.Quality and Performance . 78A.Quality Monitoring . 78B.Quality in Calculating the Performance Year Benchmark . 78C.Demographic Data Collection and Reporting . 79VIII.ACO Monitoring and Oversight . 80IX.CMS Monitoring. 81X.Remedial Actions . 81XI.Data Sharing and Reports . 83A.Data Sharing . 83B.Data Suppression and Beneficiary Data Sharing Opt Out . 84XII.Evaluation . 85XIII.Information Resources for Beneficiaries and Providers . 85XIV.Application Scoring and Selection . 85XV.Duration of the ACO REACH Model . 86XVI.Learning and Diffusion Resources . 86XVII.Public Reporting . 86XVIII. Termination . 87XIX.Amendment . 87Appendices . 89Appendix A: Glossary of Key Definitions . 89Appendix B: Summary Table of ACO Types by Design Elements . 94Appendix C: Global and Professional Quality Measures for PY2023 . 99Appendix D: Application Template . 1003

I.Background and IntroductionNOTE: This Request for Applications (RFA) is for the ACO Realizing Equity, Access, and Community Health(REACH) Model, which is the redesigned and renamed Global and Professional Direct Contracting(GPDC) Model. Per the Center for Medicare and Medicaid Innovation (Innovation Center) announcementdated 2/24/22 (see the ACO REACH Model website: ach), all Model-related documents (including this RFA) specific to 2023 and beyond willuse the revised Model name. Model participants, formerly referred to as Direct Contracting Entities(DCEs), will be referred to as Accountable Care Organizations.The ACO Realizing Equity, Access, and Community Health (REACH) Model provides an opportunity for theCenters for Medicare & Medicaid Services (CMS) to test an array of financial risk sharing options,leveraging lessons learned from other Medicare Accountable Care Organization (ACO) initiatives, such asthe Medicare Shared Savings Program (Shared Savings Program) and the Next Generation ACO (NGACO)Model, as well as innovative approaches from Medicare Advantage (MA) and private sector risk sharingarrangements. The ACO REACH Model seeks to improve quality of care and health outcomes for Medicarebeneficiaries through the alignment of financial incentives, emphasis on patient choice, strong monitoringto ensure that beneficiaries maintain access to care, and an emphasis on care delivery. This model is partof a strategy by the CMS Center for Medicare and Medicaid Innovation (Innovation Center) to use theredesign of primary care as a platform to drive broader health care delivery system reform. The ACOREACH Model creates a variety of pathways for taking on financial risk supported by enhanced flexibilities.Because the model reduces administrative burden, supports a focus on complex, chronically ill patients,and aims to encourage organizations to participate that have not typically participated in Medicare feefor-service (FFS), Innovation Center models, or both (for example, provider-led organizations with a strongtrack record of taking risk in Medicare Advantage or Managed Medicaid), we anticipate that this modelwill appeal to a broad range of provider-led organizations. The ACO REACH Model provides an opportunityfor health care providers that have not previously been eligible for the Shared Savings Program, theNGACO Model, or both due to an insufficient number of aligned Medicare FFS beneficiaries.Under the ACO REACH Model, CMS is testing two voluntary risk sharing options, which are described inthis Request for Applications (RFA): (1) Professional Option (hereinafter referred to as Professional), alower-risk option with 50 percent Shared Savings/Shared Losses and Primary Care Capitation generallyequal to seven percent of the Performance Year Benchmark for enhanced primary care services; and (2)Global Option (hereinafter referred to as Global), a full risk option with 100 percent Shared Savings/SharedLosses and either Primary Care Capitation or Total Care Capitation.II.Statutory AuthorityA. General Authority to Test ModelSection 1115A of the Social Security Act (the Act) (added by Section 3021 of the Affordable Care Act) (42U.S.C. 1315a) establishes the Innovation Center to test innovative payment and service delivery modelsthat have the potential to lower Medicare, Medicaid, and Children’s Health Insurance Program (CHIP)spending while maintaining or improving the quality of beneficiaries’ care.B. Financial and Payment Model AuthoritiesSection 1115A(b)(2) of the Act requires the Secretary to select models to be tested where the Secretary4

determines that there is evidence that the model addresses a defined population for which there aredeficits in care leading to poor clinical outcomes or potentially avoidable expenditures. The statute alsoprovides a non-exhaustive list of examples of models that the Secretary may select to test.The ACO REACH Model seeks to improve quality of care and health outcomes for Medicare beneficiariesthrough alignment of financial incentives to promote effective and appropriate care, the promotion ofhealth equity among all Model participants, emphasis on patient choice, strong monitoring to ensure thatbeneficiaries maintain access to care, and emphasis on care delivery for the complex, chronically andseriously ill population. The two risk sharing options available under the ACO REACH Model, combinedwith other Model flexibilities, like the ability to offer Benefit Enhancements which broaden the set ofcovered services available to aligned beneficiaries, are expected to increase beneficiaries’ access toinnovative, affordable care while maintaining all original Medicare benefits. The ACO REACH Model alsoplaces a greater emphasis on voluntary alignment, empowering beneficiaries to choose the health careproviders with whom they want to have a care relationship, and enabling stability through strongerpatient and provider relationships.The ACO REACH Model advances risk sharing options and builds upon lessons from CMS’ ACO portfolio. Itaddresses stakeholders’ concerns that there is no common approach to benchmarking, that the financialmethodology in other CMS risk-based initiatives offered under Medicare FFS, such as the Shared SavingsProgram and NGACO Model, has not borrowed sufficiently from private sector approaches, and that theylack access to a true population-based payment structure to drive broad transformation. Further, we aredesigning financial incentives to attract organizations that responsibly manage complex, chronically andseriously ill patients, through refinements in our benchmarking methodology and risk adjustment.Through accountability for the total cost of care and the option for population-based payments,participating providers and suppliers will shift from FFS billing and gain the flexibility to adapt clinicaldelivery to meet beneficiaries’ needs, such as longer visits for high-risk patients or continued care beyonda standard office visit. ACOs may also benefit from risk stratification of patients and tailoring caremanagement strategies to match their patient population.Building on the lessons learned from and experiences of the previous initiatives, the ACO REACH Model isexpected to reduce administrative burdens and empower primary care providers to spend more timecaring for patients while reducing overall health care costs. For many patients, the primary care clinicianis the first point of contact with the health care delivery system. Empirical evidence shows thatstrengthening primary care is associated with high quality of care, better outcomes, and lower costs withinand across major population subgroups. Despite this evidence, primary care spending accounts for a smallportion of the total cost of care, and is even lower for patients with complex, chronic conditions. CMS’experience with innovative models, programs and demonstrations to date has shown that whenincentives for primary care clinicians are aligned to reward the provision of high-value care, the qualityand cost effectiveness of patient care improves.C. Waiver and Safe Harbor AuthorityThe authority for the ACO REACH Model is section 1115A of the Act. Under section 1115A(d)(1) of the Act,the Secretary of Health and Human Services may waive such requirements of Titles XI and XVIII and ofsections 1902(a)(1), 1902(a)(13), 1903(m)(2)(A)(iii), and certain provisions of section 1934 of the Act asmay be necessary solely for purposes of carrying out section 1115A with respect to testing modelsdescribed in section 1115A(b). Please refer to the Benefit Enhancements section for a list of programmatic5

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