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Centers for Medicare & Medicaid Services

*ACO Primary Care Flex (ACO PC Flex) Model:*

*Preliminary ACO PC Flex FQHC & RHC Add-Ons Posted** *

 

The Preliminary PY 2025 ACO PC Flex FQHC & RHC Add-Ons [ https://www.cms.gov/priorities/innovation/files/aco-pc-flex-py25-prelim-ratebook.xlsx ] have been posted to the ACO PC Flex website. For the ACO PC Flex Model, there will be two rate books for PY 2025 used in payment calculation affecting County Base Rates, federally qualified health centers (FQHC)/rural health clinics (RHC) add-ons, and the County Enhancement: the Preliminary Rate Book and the Updated Rate Book. The Preliminary Rate Book, published August 16, 2024, uses base years 2021-2023 and will be used for the prospective primary care payments (PPCP) paid between January and June 2025. The Preliminary PY 2025 ACO PC Flex Rate Book published in August did not include the FQHC/RHC add-ons. A version including the FQHC/RHC add-ons is now available on the ACO PC Flex website. *The FQHC/RHC add-ons are now populated in the parameters tab of the Preliminary Rate Book but the County Base Rates and County Enhancement amounts have not changed compared to the version published on August 16, 2024.*

Beneficiaries with FQHC or RHC Focused care are excluded from the PC Flex Rate Book reference population used to calculate the PPCP County Base Rates and the County Enhancement. These beneficiaries are excluded because FQHCs and RHCs are paid under different payment systems (the FQHC prospective payment system and RHC all-inclusive rates (AIR), respectively) and because these providers receive all-inclusive per-visit payments, the historical claims for FQHCs and RHCs do not lend themselves to standardization and inclusion in the calculation of the County Base Rates.

As a result, CMS includes an add-on payment to the PPCP for beneficiaries with FQHC- or RHC- Focused care.  These add-ons are model-level variables: one for beneficiaries who receive the plurality of primary care services at FQHCs and separately, one for RHCs.

The add-ons are fixed dollar amounts added to the PPCP for these beneficiaries based on the average difference in national historical spending for beneficiaries who receive the plurality of primary care services at FQHCs or RHCs and the average County Base Rates that exclude these beneficiaries. The add-ons are not geographically adjusted.

The Updated PY 2025 Rate Book, expected to be published toward the end of the second quarter of 2025, will use base years 2022-2024 and will be used for PPCP paid between July 2025 and December 2025, with payment rates retroactively applied back to January 2025. Because claims reductions and payment of County Base Rate and FQHC/RHC add-ons will not start until July of 2025, this retroactivity will only apply to the County Enhancement. Other methodological changes may be implemented with the Updated Rate Book to improve payment accuracy and will be detailed in the forthcoming ACO PC Flex Rate Book technical document.

For PY 2025 only, once the Updated Rate Book is implemented, CMS will pay the greater of the two rate books by comparing the sum of the County Base Rate, the FQHC/RHC add-on (where eligible), and the County Enhancement (where eligible) at the beneficiary-month level.

 

This determination of payable rates for PY 2025 will be calculated prior to adjustments for clinical risk, Primary Care Outside of ACO (PCOA), and the Primary Care Prospective Administrative Trend (PCPAT).

If you are interested in receiving additional information, updates, or have questions about the ACO Primary Care Flex Model, please contact the model team at ACOPCFlex@cms.hhs.gov.

To stay updated on upcoming model announcements and events, join our ACO PC Flex listserv by registering your email [ https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_13195%3eClick ]. The ACO PC Flex Model webpage [ https://www.cms.gov/priorities/innovation/innovation-models/aco-primary-care-flex-model ] has additional resources, such as the Model Overview Webinar [ https://www.cms.gov/aco-pc-flex-overview-webinar ], Factsheet [ https://www.cms.gov/files/document/aco-pc-flex-fs.pdf ], and FAQs [ https://www.cms.gov/priorities/innovation/innovation-models/aco-primary-care-flex-model/faqs ].

Centers for Medicare & Medicaid Services (CMS) has sent this update. To contact Centers for Medicare & Medicaid Services (CMS) go to our contact us [ https://secure-web.cisco.com/1Wm5LuslbEdfAe7EA7DY2ayJZWgtMfqTSqVGch4C0r2ixdxlR1FMGgzxfqaUX04eP0JGYZAoSXotcflqLJWiVOyaKYkR1yDA68xM1auevfddKdtMVUkTGKylc8ZXI8TPjNkPBpqogxAaQuX0XkdPNiiPMdt7KBGg4MdNDSPTvGtY3Odlxr7szBNTXmtBnOR9N-clkdhiyD00X3IMAMbeTI7k_KHMLZby-PoHeaspq3Y2ZKIahx_IRxw5plCCC_zSRPk5rjdX2Be-wJhadhl4vqviJJ4xlmY-Nn4rBRFVHQi79Gi98-uShELH7ZBYRJLuU9PbAYyhdBLcve9PQJv49CGUvNST7juboq0o8ZwIiuYSimTL-Rf3xlIVJThiwSf-APW8BuAmVy8wtirn0L4j1Wk8qlwwI-J_r4ElM-sZFDW2nlmNTbpfEvW9Ht_PKCMJtg7xFDhcm07x9IT7ytB0srI6MsvlgHKRXPUyEX4CdOOJ5uP_V7K27yrFEARdrnrZvF93gBz-iD8JCukcmUdxFHdl7ULwxZLGt-ZCuiW7OSTc/https%3A%2F%2Flnks.gd%2Fl%2FeyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDcsInVyaSI6ImJwMjpjbGljayIsInVybCI6Imh0dHA6Ly93d3cuY21zLmdvdi9BYm91dC1DTVMvQWdlbmN5LUluZm9ybWF0aW9uL0NvbnRhY3RDTVMvaW5kZXguaHRtbCIsImJ1bGxldGluX2lkIjoiMjAyNDAyMjIuOTA2NjYyMjEifQ.i0vH3tedpZo0tEgQau_Rsa5zf4Mza079MM2aCPX1p1Y%2Fs%2F2905793976%2Fbr%2F237579287421-l ] page.    

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