CMS Alternative Payment Model Overlap
Alternative Payment Model (APM) overlap is complex and is a concern for many ACOs that have patients and providers participating in multiple models. The Centers for Medicare & Medicaid Services (CMS) has not developed a consistent overlap policy that applies across APMs. There are a number of challenges associated with overlap, such as duplication of resources, patient and provider confusion and challenges financially reconciling patients who are assigned to an ACO and trigger a bundled payment episode. The easiest and most effective solution, advocated for by NAACOS, is to adopt a standard policy to exclude ACO patients from other initiatives while allowing ACO providers to participate in multiple models. While CMS has taken this approach with the Direct Contracting Model, they have generally chosen alternate approaches for the Medicare Shared Savings Program.
ACOs are responsible for all of patients’ spending for a given year. They are in the driver’s seat in coordinating their patients’ care and should therefore be financially responsible for the cost and quality of care provided to their patients. NAACOS opposes overlap polices that disadvantage value-based entities focused on total-cost-of-care, penalizing ACOs who have proven to slow Medicare spending by tens of billions of dollars over the last several years, more than any other federal value-based model. The chart below reviews CMS’s current overlap polices. Please note that this information is current at the time of publication (October 2021)
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Medicare Shared Savings Program (MSSP) |
Direct Contracting Model (DC) |
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Providers |
Beneficiaries |
Providers |
Beneficiaries |
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BPCI-A Bundled Payments for Care Initiative – Advanced |
Providers may participate in both MSSP and BPCI-A. |
(for Model Year 3/4, beginning 1/1/2020) |
Providers may participate in both DC and BPCI-A |
DC beneficiaries cannot participate in BPCI-A (beneficiaries cannot trigger an episode) |
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CJR Comprehensive Joint Replacement |
MSSP participants may be either CJR collaborators or collaborator agents. |
MSSP Track 3 beneficiaries are excluded from CJR (beneficiaries cannot trigger an episode); |
DC participants may be either CJR collaborators or collaborator agents. |
DC beneficiaries cannot participate in CJR (beneficiaries cannot trigger an episode). |
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OCM Oncology Care Model |
Providers may participate in both MSSP and OCM. |
OCM beneficiaries are not excluded from participation in MSSP. |
Providers may participate in both DC and OCM. |
OCM beneficiaries are not excluded from participation in DC. |
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CEC Comprehensive ESRD Care Model |
Providers (full TIN) cannot participate in both CEC and MSSP. |
CEC beneficiaries are excluded from participation in MSSP. |
DC Professionals cannot participate in both CEC and DC. DC Participants who are not primary care specialists and DC Preferred Providers may participate in both CEC and DC. |
CEC beneficiaries are excluded from participation in DC. |
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KCF Kidney Care First |
KCF Practices may also participate in MSSP. However, nephrologists and KCF practices participating in KCF that are also participating in MSSP will be required to have a letter signed by the ACO acknowledging that the nephrologist or practice is simultaneously participating in KCF and that payments under KCF for beneficiaries assigned to the ACO will be included in the ACO’s expenditure calculations under MSSP. |
MSSP beneficiaries are excluded from KCC. A beneficiary will only be aligned to a KCF practice if the beneficiary has not already been aligned to an ACO. |
KCF practices will not be able to participate in the DC Model. |
DC beneficiaries are excluded from KCC. A beneficiary will only be aligned to a KCF practice if the beneficiary has not already been aligned to a DCE. |
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CKCC Comprehensive Kidney Care Contracting |
Kidney Contracting Entity (KCE) participants are precluded from participating in MSSP. |
MSSP beneficiaries are excluded from KCC. A beneficiary will only be aligned to a KCF practice if the beneficiary has not already been aligned to an ACO. |
KCE participants are precluded from participating in DC. |
DC beneficiaries are excluded from KCC. A beneficiary will only be aligned to a KCF practice if the beneficiary has not already been aligned to a DCE. |
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CPC+ Comprehensive Primary Care + |
Providers can participate in both CPC+ and MSSP. |
MSSP beneficiaries may participate in CPC+ regardless of MSSP track. |
Providers cannot participate in both DC and CPC+. |
DC beneficiaries may not participate in CPC+. (DC has alignment preference over CPC+). |
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PCF Primary Care First |
Providers can participate in both PCF and MSSP (any track). |
MSSP beneficiaries may participate in PCF regardless of MSSP track. |
Providers cannot participate in both DC and PCF. |
DC beneficiaries may not participate in PCF. (DC has alignment preference over PCF). |