§ 512.210 - RO participants and geographic areas.

§ 512.210 RO participants and geographic areas.

Cross Reference

Link to an amendment published at 86 FR 63994, Nov. 16, 2021.

(a) RO participants. Unless otherwise specified in paragraph (b) or (c) of this section, any RO participant Medicare-enrolled PGP, freestanding radiation therapy center, or HOPD that furnishes included RT services in a 5-digit ZIP Code linked to a CBSA selected for participation to an RO beneficiary for an RO episode that begins on or after July 1, 2021, and ends on or before December 31, 2025, and ends during the model performance period must participate in the RO Model.

(b) Participant exclusions. A PGP, freestanding radiation therapy center, or HOPD is excluded from participation in the RO Model if it:

(1) Furnishes RT services only in Maryland;

(2) Furnishes RT services only in Vermont;

(3) Furnishes RT services only in U.S. Territories;

(4) Is classified as an ambulatory surgery center (ASC), critical access hospital (CAH), or Prospective Payment System (PPS)-exempt cancer hospital; or

(5) Participates in or is identified by CMS as eligible to participate in the Pennsylvania Rural Health Model; or

(6) Participates in the Community Transformation Track of the Community Health Access and Rural Transformation (CHART) Model as a participating hospital.

(c) Low volume opt-out. A PGP, freestanding radiation therapy center, or HOPD , which that would otherwise be required to participate in the RO Model may choose to opt-out of the RO Model for a given PY if it has as follows:

(1) If the PGP, freestanding radiation therapy center, or HOPD furnished fewer than 20 episodes

of RT services

in the calendar year that is two years prior to the start of PY1 across all CBSAs selected for participation

in the most recent year with claims data available prior to the applicable PY.

, it may opt out of the RO Model for PY1.

(2) If the PGP, freestanding radiation therapy center, or HOPD furnished fewer than 20 episodes in the calendar year that is two years prior to the start of PY2 across all CBSAs selected for participation, it may opt out of the RO Model for PY2.

(3) If the PGP, freestanding radiation therapy center, or HOPD furnished fewer than 20 RO episodes in PY1 across all CBSAs selected for participation, and PY1 begins on January 1, it may choose to opt out of the RO Model for PY3. In the event that PY1 begins on a date other than January 1, the PGP, freestanding radiation therapy center, or HOPD may opt-out of the RO Model for PY3 if the total number of furnished episodes of the calendar year in which PY1 began and RO episodes in PY1 is fewer than 20 across all CBSAs selected for participation.

(4) If the PGP, freestanding radiation therapy center, or HOPD furnished fewer than 20 RO episodes in PY2 across all CBSAs selected for participation, it may opt out of the RO Model for PY4.

(5) If the PGP, freestanding radiation therapy center, or HOPD furnished fewer than 20 RO episodes in PY3 across all CBSAs selected for participation, it may opt out of the RO Model for PY5.

(6) At least 30 days prior to the start of each PY, CMS

notifies

provides notice to RO participants eligible for the low volume opt-out for the upcoming PY of such eligibility. The RO participant must attest

to its intention of opting

that it intends to opt out of the RO Model prior to the start of the upcoming PY.

Low volume opt-out eligibility is determined as follows: (1) PY1. Episodes from January 1, 2019 through December 31, 2019 determine eligibility

(7) An entity is not eligible for the low

volume opt

-

out for PY1. (2) PY2. Episodes from January 1, 2020 through December 31, 2020 determine eligibility for the low

volume opt

-out for PY2.

(3) PY3. Episodes from January 1, 2021 through June 30, 2021 and RO episodes from July 1, 2021 through December 31, 2021 determine eligibility for the low volume opt-out for PY3.

(4) PY4. RO episodes from January 1, 2022 through December 31, 2022 determine low volume opt-out eligibility for PY4.

(5) PY5. RO episodes from January 1, 2023 through December 31, 2023 determine low volume opt-out eligibility for PY5

out if its current TIN or CCN, or its legacy TIN or legacy CCN, or both were used to bill Medicare for 20 or more episodes or RO episodes, as applicable, of RT services in the two years prior to the applicable PY across all CBSAs selected for participation.

(d) Selected CBSAs. CMS randomly selects CBSAs to identify RT providers and RT suppliers to participate in the RO Model through a stratified sample design, allowing for participant and comparison groups to contain approximately 30 percent of all episodes in eligible geographic areas (CBSAs).

(e) Notice of change in TIN or CCN. An RO participant must furnish written notice to CMS in a form and manner specified by CMS at least 90 days before the effective date of any change in TIN or CCN that is used to bill Medicare.

[85 FR 61362, Sept. 29, 2020, as amended at 85 FR 86304, Dec. 29, 2020; 86 FR 63994, Nov. 16, 2021]

Editorial Note

Editorial Note:

At 85 FR 86304, Dec. 29, 2020, this section was amended, effective Dec. 4, 2020; however, due to a publication error, the amendments were codified at 86 FR 33902, June 28, 2021.