May 30, 2024

CMS Releases ACO Primary Care Flex (PC Flex) Model Details in Request for Applications (RFA)

Today the Centers for Medicare and Medicaid Services (CMS) published the request for applications (RFA) for the PC Flex Model, which will test primary care hybrid payments within MSSP beginning January 1, 2025.

ACOs must submit an MSSP application (as an initial, re-entering, or renewing/early renewing applicant) and a supplemental PC Flex application questionnaire. The MSSP application is open now through June 17 at 12:00pm (noon) ET. The PC Flex supplemental application must be submitted by August 1, 2024.

CMS will host a model applications webinar on June 6 at 2-3:30pm ET. NAACOS hosted a MSSP 2025 Application Insights webinar yesterday, the slides and recording will be available on-demand shortly. Stay tuned for additional NAACOS resources on the PC Flex model.

Key model details:

  • The model will run January 1, 2025 – December 31, 2029.
  • Eligible participants are low revenue ACOs using prospective assignment that begin a new MSSP agreement starting Jan. 1, 2025; ACOs cannot simultaneously participate in Advance Investment Payments (AIP).
  • Participation is at the ACO level and all ACO participants and their primary care providers will be required to participate; fee reductions will be applied at the TIN/NPI level.
  • In addition to the MSSP application and PC Flex questionnaire, applicants must submit a spend plan, roster of non-physician practitioner data, and assurance of ability to repay; applicants may withdraw the PC Flex application at any time prior to signing the Participation Agreement (December 6 – 12, 2024), and may withdraw the PC Flex application without impacting the MSSP application.
  • Participants will be required to submit a health equity plan, collect and report health equity data, and secure a repayment mechanism (separate from MSSP repayment mechanism for 2-sided tracks).
  • ACOs will distribute the PPCP to their participant primary care providers, FQHCs and RHCs. CMS will require ACOs to publicly report information on the distribution of the PPCP.

Payment structure:

  • Advance shared savings payment of $250,000 will be provided as a one-time payment to each PC Flex ACO after the start of the first performance year and will be recouped through future shared savings earned by the ACO.
  • Prospective Primary Care Payment (PPCP): ACOs will receive a monthly prospective payment that replaces fee-for-service primary care services for all primary care providers, FQHCs, and RHCs in the ACO. ACOs will distribute the PPCP to their participant primary care providers, FQHCs and RHCs. CMS will require ACOs to publicly report information on the distribution of the PPCP. The PPCP will include several components:
    • Risk-standardized County Base Rate for primary care
    • Beneficiary-level add-on for beneficiaries who receive the plurality of primary care services from FQHCs and RHCs
    • Enhanced amount:
      • County Enhancement applied at the county-level in counties designated as low spending relative to standardized national spending
      • Flex Enhancement
    • PPCP Adjustments:
      • Operational: Payment Precision Withhold
      • Payment: Risk Adjustment
      • Payment: Adjustment for Primary Care Delivered Outside of ACO
    • Health equity adjustment (PBPM) based on the mix of beneficiaries living in underserved communities
    • Primary Care Prospective Administrative Trend (PCPAT)

Model overlap:

  • Participants in PC Flex are prohibited from simultaneously participating in:
    • ACO REACH (both Participant Providers and Preferred Providers cannot overlap)
    • Vermont All-Payer ACO Model
    • Making Care Primary (MCP) Model
    • All-Payer Health Equity Advancement and Development (AHEAD) Model
    • Primary Care First Model
    • Independence at Home Demonstration
    • Maryland Primary Care Program
    • Kidney Care Choices Model (KCC)
  • PC Flex ACOs may participate in CMS Innovation Center models that do not include shared savings, including:
    • Bundled Payments for Care Improvement (BPCI) Advanced Model
    • Enhancing Oncology Model (EOM)
    • End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model
    • Financial Alignment Initiative for Medicare-Medicaid Enrollees
    • Guiding an Improved Dementia Experiences (GUIDE) Model

Additional Information: