On the surface, voluntary alignment sounds like a straightforward way to increase the number of beneficiaries aligned (i.e., assigned) to your accountable care organization (ACO). Traditional claims-based alignment requires that a beneficiary receive a plurality of primary care claims within the ACO, but under voluntary alignment the beneficiary simply selects a “primary clinician” from your ACO on Medicare.gov or, if your ACO opts to participate in paper-based voluntary alignment, complete a paper-based “Voluntary Alignment Form.” However, there are additional requirements for voluntary alignment that are significantly more complicated and may not lead to the results your ACO expects. In this article, we explore the voluntary alignment requirements that apply to Global/Professional Direct Contracting (GPDC) and ACO Realizing Equity, Access, and Community Health (REACH) along with strategic considerations for beneficiary engagement. While voluntary alignment in the Medicare Shared Savings Program (MSSP) is somewhat different, much of the information presented applies to MSSP as well.
In general, the voluntary alignment requirements presented in this article are copied directly from the Direct Contracting Financial Operations Guide and the ACO REACH request for application (RFA). For the full language of the voluntary alignment requirements, please refer to the GPDC Financial Operating Guide and the ACO REACH RFA as listed in the Sources section below.
Benefits and limitations of voluntary alignment
Outlined in Figure 1 are the key reasons why an ACO may pursue voluntary alignment as part of their beneficiary engagement strategy.
Figure 1: Reasons for voluntary assignment
| Benefit of voluntary alignment | Limitations and considerations |
|---|---|
| Increases the aligned population: Voluntary alignment provides a mechanism for ACOs to increase the number of beneficiaries assigned to the ACO. | Voluntary alignment requirements are significant. As explained in this white paper, there are a number of requirements that an ACO must meet in order to voluntarily align a beneficiary—including providing at least one service to each voluntarily aligned beneficiary in the performance year. |
| Enables alignment during the performance year: If the ACO elected the Prospective Plus alignment methodology, then beneficiaries are voluntarily aligned at the beginning of the quarter following the submission of the voluntary alignment information. |
• Requires selecting the Prospective Plus alignment methodology. • Beneficiary may become claims-based aligned in the second year of alignment. This is discussed further below. |
| GPDC/REACH rate book funding, not historical experience: The funding for voluntarily aligned beneficiaries is the risk-adjusted rate book, i.e., the beneficiary’s risk score times the GPDC county rate book amount. The beneficiary’s historical experience (e.g., 2017-2019) is not blended with the rate book. |
• Risk scores are based on the prior year’s diagnoses. • This is anticipated to change for performance years (PYs) 2025 and 2026, when voluntarily aligned beneficiaries’ recent experience is blended with the rate book to develop a benchmark. |
| No risk score cap: Voluntarily aligned beneficiaries are not part of the pool of beneficiaries whose risk score change is capped at 3%, and the Coding Intensity Factor (CIF) does not apply to voluntarily aligned beneficiaries. | |
| Potential for more favorable selection: Because voluntarily aligned beneficiaries are not aligned based on healthcare utilization (i.e., they are not claims-based aligned), their costs may be lower on a risk-adjusted basis. | While it is too early to prove this out for the GPDC and ACO REACH programs, ACOs may see that voluntarily aligned beneficiaries have fewer healthcare needs on a risk-adjusted basis than claims-based aligned beneficiaries. |
In practice, the voluntary alignment eligibility requirements present a significant hurdle for ACOs and lead to many voluntarily aligned beneficiaries becoming claims-based aligned in the performance year after voluntary alignment. These dynamics are explored further below.
Measuring the benefits of voluntary alignment
In developing an ACO’s voluntary alignment strategy, both the costs and benefits of voluntary alignment should be considered. The costs will include infrastructure and operational costs associated with beneficiary outreach and engagement and submitting the voluntary alignment attestations.
The benefits will include increased beneficiary alignment and the associated direct financial benefits, and other benefits related to increased beneficiary engagement (e.g., fewer care gaps).
Risk adjustment for voluntarily aligned beneficiaries
Risk scores in GPDC are assigned using a prospective risk adjuster for Standard and New Entrant ACOs, and a concurrent risk adjuster for High Needs Population ACOs. Therefore, for Standard and New Entrant ACOs the diagnoses that drive each beneficiary’s risk score are based on the calendar year prior to the calendar year to which the risk score applies, as shown in Figure 2.
Figure 2: Diagnosis collection period for prospective risk scores
This means that, for Standard and New Entrant ACOs that voluntarily align beneficiaries, the risk score and risk-adjusted rate book amount will depend on the prior year diagnoses—not diagnoses captured by the ACO during the current performance year.
Voluntary alignment requirements
For a beneficiary to be voluntarily aligned to a Direct Contracting Entity (DCE) or REACH ACO, the criteria listed below must be met:
- Beneficiary is alignment-eligible: The beneficiary must meet the applicable alignment eligibility criteria (consistent with the requirements for a claims-aligned beneficiary), including:1
- Is enrolled in both Medicare Parts A and B
- Is not enrolled in a Medicare Advantage (MA) plan
- Has Medicare as their primary payer
- Resides in the United States and in a county in the ACO’s service area
- Beneficiary is not aligned through another Centers for Medicare and Medicaid Services (CMS) program that takes alignment precedence over the ACO REACH Model:
- For PY2022, the following programs and initiatives will take precedence over GPDC for beneficiary alignment: the Independence at Home Demonstration, the Maryland Primary Care Program, the Kidney Care Choices Model, the Medicare Shared Savings Program (Prospective Alignment only), and the Vermont All-Payer ACO Model.
- We expect that the list of initiatives in PY2023 that take precedence over ACO REACH voluntary alignment will be similar—with MSSP under prospective (but not retrospective) attribution having a significant impact for some REACH ACOs.
- Recent voluntary alignment attestation or PQEM visit with a designated provider:
- Voluntary alignment attestation was made no earlier than two years prior to the performance year (e.g., for a January 1, 2023, start in PY2023, the attestation was made no earlier than January 1, 2021)
- The Participant Provider designated by the beneficiary has submitted a claim for a Primary Care Qualified Evaluation and Management (PQEM) service furnished to the beneficiary in the 24-month period ending one month before the start of that performance year.
Additionally, the most recent valid voluntary alignment attestation takes precedence over any prior or invalid attestations, and voluntary alignment takes precedence over claims-based alignment to an alternative provider.
Finally, if at Final Financial Settlement CMS determines that a beneficiary did not have a single claim (of any type) during the performance year submitted by a Participant Provider or Preferred Provider in the ACO, the beneficiary was preliminarily aligned via voluntary alignment, and the beneficiary had at least one claim for PQEM services during the performance year in the ACO’s service area with a provider or supplier not in the ACO, then the beneficiary will be retroactively removed from alignment to the ACO.
In summary, in order for voluntary alignment to result in actual alignment to your ACO, you will need to ensure that the beneficiary is alignment-eligible, the most recent voluntary alignment attestation for the beneficiary designates an ACO provider (preferred or participating), and the beneficiary receives PQEM services annually from the designated ACO provider (e.g., has an office visit each year). Even if your ACO ensures these requirements are met, the beneficiary can still be prospectively assigned to an MSSP ACO. ACOs may be surprised how few beneficiaries who complete the voluntary alignment attestation are voluntarily aligned.
ACO reporting
CMS treats beneficiaries aligned to a single ACO via both voluntary and claims-based alignment as having claims-based alignment for ACO reporting and benchmarking purposes. Therefore, even with substantial investment in voluntary alignment, you may not see a significant impact from voluntary alignment in your ACO’s reports from CMS if many of those same beneficiaries are also claims-aligned.
When voluntary alignment takes effect
Voluntary alignment takes effect for the calendar year following the submission of the electronic or paper-based voluntary alignment information.
Under Prospective Plus Alignment (available in the GPDC and ACO REACH programs), beneficiaries are voluntarily aligned at the beginning of the quarter following the submission of the voluntary alignment information. Beneficiaries who are already aligned to another ACO or an organization participating in another value-based initiative for which beneficiary overlap is prohibited for the performance year are excluded from midyear alignment under Prospective Plus Alignment. These excluded beneficiaries can be aligned for the next calendar year, assuming all criteria are met (see above discussion).
Conclusion
ACOs developing their beneficiary engagement strategies should consider the potential benefits and operational hurdles of voluntary alignment. Voluntary alignment starts with the beneficiary selecting a Participant Provider or Preferred Provider in your ACO, but the requirements do not stop there. ACOs that maintain annual contact with their voluntarily aligned beneficiaries are the most likely to see a meaningful volume of voluntary alignment at the time of financial reconciliation. On the other hand, ACOs that do not maintain annual contact with their aligned beneficiaries are likely to see limited return on investments in voluntary alignment. Additionally, many ACOs will see a large proportion of the beneficiaries electing voluntary alignment also aligned via claims-based alignment, and thus the count of voluntarily aligned beneficiaries may not be a meaningful proportion of the ACO’s total aligned beneficiaries.
1 Please see Section IV.A (Model Design Elements – Beneficiary Eligibility) of the ACO REACH Model, Request for Applications, February 24, 2022.
Sources
CMS. Global and Professional Direct Contracting Model. Financial Operating Guide: Overview. Retrieved November 8, 2022, from https://innovation.cms.gov/media/document/dc-financial-op-guide-overview.
CMS (February 24, 2022). ACO Realizing Equity, Access, and Community Health (REACH) Model: Request for Applications. Center for Medicare and Medicaid Innovation. Retrieved November 8, 2022, from https://innovation.cms.gov/media/document/aco-reach-rfa.