The Affordable Care Act (ACA) recognizes NPs as professionals eligible to participate in MSSP ACOs. However, the statute prevents Medicare beneficiaries who receive their primary care services solely from NPs from being assigned based on their claims data to ACOs in the program.
Section 3022 of the ACA established the MSSP based on concepts developed by existing ACOs. ACOs create incentives for health care providers to work together to treat an individual patient across care settings. MSSP participants agree to lower the cost of health care while meeting identified performance standards by sharing resources and care in a coordinated manner. ACOs that are able to accomplish these goals will be eligible for financial benefits (shared savings). The health reform law recognizes NPs as authorized “ACO professionals.” In order to count towards the shared savings, a patient must be assigned to an ACO based on their claims information (claims-based assignment) or by selecting an ACO provider as their primary care provider (voluntary alignment).
Effective in 2019, CMS amended the voluntary alignment pathway so that a patient can select an NP as their primary care provider in an MSSP ACO and be assigned to the ACO without requiring that the patient receive one primary care visit from a primary care physician. This change will provide greater opportunity for NPs and their patients to join and establish MSSP ACOs.
However, the claims-based assignment pathway still requires a patient to receive at least one primary care service provided by a primary care physician each year for the patient to be assigned to an ACO. While this restriction does not prevent individual NPs from joining an ACO, it prevents their patients from being assigned to a Medicare Shared Saving ACO through claims-based assignment and any benefits that result from such participation, unless the NP sends their patient to receive a primary care service from a primary care physician.
H.R. 900 will amend Section 1899(c) of the Social Security Act, which bases the claims-based assignment of beneficiaries on the utilization of primary care services provided by primary care physicians. This language currently excludes the patients of NPs from assignment to MSSP ACOs without the patient receiving an unnecessary physician visit. The MSSP has demonstrated cost-savings for the Medicare program while maintaining high-quality care, and it is imperative to fully include NPs and their patients in the MSSP in order to continue to improve patient access, quality and cost effectiveness.
AANP calls on Members of Congress to cosponsor H.R. 900 to improve the way beneficiaries are assigned under the MSSP.
For additional information, please contact the AANP Government Affairs Office at 703-740-2529 or firstname.lastname@example.org.