§ 512.710 - Determination of CR incentive payments.

§ 512.710 Determination of CR incentive payments.

(a) General. CMS provides a CR incentive payment for each CR performance year to each EPM-CR participant and FFS-CR participant based on CR/ICR services paid by Medicare under the OPPS or to any supplier reporting place of service code 11 on the PFS claim for beneficiaries in AMI and CABG model episodes or AMI and CABG care periods, respectively. CMS makes CR incentive payments from the Medicare Part B Trust Fund to CR participants, and also submits beneficiary-specific CR amounts to the CMS Master Database Management System. The initial level of the per-service CR incentive amount is $25 per CR/ICR service for each of up to 11 CR/ICR services paid for by Medicare. For those CR/ICR services in an AMI or CABG model episode or AMI care period or CABG care period that exceed 11, the per-service CR incentive amount increases to $175 per CR/ICR service for each additional CR/ICR service paid for by Medicare.

(b) Determination of CR incentive payment. At the same time that CMS carries out the determination of NPRA and reconciliation process for an EPM performance year as specified in § 512.305 for EPM participants, CMS also determines each CR participant's CR incentive payment for the CR performance year according to the following:

(1) CR amount when the CR service count is less than 12. CMS determines the CR amount for a beneficiary in an AMI or CABG model episode or AMI care period or CABG care period with a CR service count less than 12 by multiplying the CR service count by $25.

(2) CR amount when the CR service count is 12 or more. CMS determines the CR amount for a beneficiary in an AMI or CABG model episode or AMI care period or CABG care period with a CR service count of 12 or more as the sum of $275 ($25 multiplied by 11 for the first 11 CR/ICR services paid for by Medicare) and $175 multiplied by the difference between the CR service count and 11.

(3) CR incentive payment. CMS sums the CR amounts determined in paragraphs (b)(1) and (2) of this section across the CR participant's beneficiaries in AMI and CABG model episodes or AMI care periods and CABG care periods for a given CR performance year to determine the CR incentive payment for the CR performance year.

(c) Relation of CR incentive payments to reconciliation and Medicare repayments under EPMs. CR incentive payments to EPM-CR participants determined under § 512.710(b) are exclusive of reconciliation payments and Medicare repayment amounts determined under § 512.305(d).

(d) Relation of CR incentive payments to sharing arrangements for EPM-CR participants. CR incentive payments under § 512.710(b) are not eligible for and may not be distributed under sharing arrangements specified in § 512.500.

(e) Exclusion of CR incentive payments when updating quality-adjusted target prices for EPM-CR participants. CR incentive payments under § 512.710(b) are excluded when updating quality-adjusted target prices for EPM performance years 3 through 5.

(f) CR incentive payment report. At the same time CMS issues the reconciliation report as specified in § 512.305(f) to EPM participants, CMS issues each EPM-CR participant and each FFS-CR participant a CR incentive payment report for the CR performance year. Each report contains the following:

(1) The number of AMI and CABG model episodes or AMI care periods and CABG care periods attributed to the CR participant in which Medicare paid for 11 or fewer CR/ICR services for a beneficiary during the CR performance year, if any.

(2) The total number of CR/ICR services Medicare paid for during AMI and CABG model episodes or AMI care periods and CABG care periods identified in paragraph (f)(1) of this section.

(3) The amount of the CR incentive payment attributable to the AMI and CABG model episodes or AMI care periods and CABG care periods identified in paragraph (f)(1) of this section.

(4) The number of AMI and CABG model episodes or AMI care periods and CABG care periods attributed to the CR participant in which Medicare paid for 12 or more CR/ICR services for a beneficiary during the CR performance year, if any.

(5) The total number of CR/ICR services Medicare paid for during AMI and CABG model episodes or AMI care periods and CABG care periods identified in paragraph (f)(4) of this section.

(6) The amount of the CR incentive payment attributable to the AMI and CABG model episodes or AMI care periods and CABG care periods identified in paragraph (f)(4) of this section.

(7) The total amount of the CR incentive payment.

(g) Timing of CR incentive payments. CMS makes CR incentive payments on a retrospective basis subject to the following:

(1) For EPM-CR participants, CMS makes the CR incentive payment, if any, concurrently with EPM reconciliation payments or repayment amounts assessed for a specific EPM and CR performance year, subject to the appeals process for EPM participants in § 512.310.

(2) For FFS-CR participants, CMS makes the CR incentive payments, if any, at the same time as for EPM-CR participants, subject to the provisions in § 512.720.