Crosswalk

All-Payer Payer Initiated Submission Form

2019 Finalized vs 2020 Finalized

Page	Line	Final Rule 2019	Final Rule 2020	Reason for Change
1	18	2018 for the 2019	2020 for the 2021	Alignment with current year.
1	24	2019 for the 2020	2020 for the 2021	Alignment with current year.
1	29	2019 for the 2020	2020 for the 2021	Alignment with current year.
8	28	For performance year 2020, is the total amount an APM Entity potentially owes or foregoes under the payment arrangement at least 4 percent of the average estimated total revenue of the participating providers or other entities under the payer? [Y/N]	Is the total amount an APM Entity potentially owes or foregoes under the payment arrangement at least 5 percent of the average estimated total revenue of the participating providers or other entities under the payer? [Y/N]	Alignment with current year.
8	35	For performance year 2021 and later, is the total amount an APM Entity potentially owes or foregoes under the payment arrangement at least 5 percent of the average estimated total revenue of the participating providers or other entities under the payer? If yes, please describe how the amount that an APM entity owes or foregoes is calculated. [Text Box]		Removed to update requirement for current timeframe.
13	1	[Optional] In 2017, did you offer through Medicare Advantage any plans with requirements similar to those described in this submission? [Y/N] If so, what proportion of the clinicians who saw your enrollees were participating in these types of arrangements? [TEXT BOX] This information in response to this question will only be used to support the independent Federal evaluation of the MAQI demonstration.		Removed to update with current requirements.
13	15		Information for Aligned Other Payer Medical Home Model Determination Aligned Other Payer Medical Home Model means an other payer payment arrangement (not including Medicaid) that is formally aligned with a CMS Multi-Payer Model that is a Medical Home Model and that CMS determines by the following characteristics. Does the payer request that CMS make a determination regarding whether this payment arrangement is an Aligned Other Payer Medical Home Model as defined in 42 CFR 414.1305? [Y/N] If no, skip to section E. [If yes] List the attached document(s) and page numbers that provide evidence of the information required in this section. [TEXT BOX] For which eligible clinicians with a primary care focus does the payment arrangement include specific design elements? Select all Physician Specialty Codes that apply: 01 General Practice; 08 Family Medicine; 11 Internal Medicine; 16 Obstetrics and Gynecology; 37 Pediatric Medicine; 38 Geriatric Medicine; 50 Nurse Practitioner; 89 Clinical Nurse Specialist; and 97 Physician Assistant. [CHECK BOX] Does the payment arrangement require empanelment (assigning individual patients to individual providers) of each patient to a primary clinician? [Y/N] Select all elements from the following list that are required by the payment arrangement. Planned coordination of chronic and preventive care. [Y/N] If yes, cite supporting documentation and page numbers. [TEXT BOX] Patient access and continuity of care. [Y/N] If yes, [TEXT BOX] Risk-stratified care management. [Y/N] If yes, [TEXT BOX] Coordination of care across the medical neighborhood. [Y/N] If yes, [TEXT BOX] Patient and caregiver engagement. [Y/N] If yes, [TEXT BOX] Shared decision-making. [Y/N] If yes, [TEXT BOX] Payment arrangements in addition to, or substituting for, fee-for-service payments (e.g. shared savings or population-based payments). [Y/N] If yes, [TEXT BOX] Aligned Other Payer Medical Home Model Financial Risk Standard Does the Aligned Other Payer Medical Home Model require that, based on the APM Entity's failure to meet or exceed one or more specified performance standards, at least one of the following occurs: Payer withholds payment of services to the APM Entity and/or the APM Entity’s eligible clinicians Payer requires direct payments by the APM Entity to the payer Payer reduces payment rates to APM Entity and/or the APM Entity’s eligible clinicians Payer requires the APM Entity to lose the right to all or part of an otherwise guaranteed payment or payments [Yes/No] Which of the following actions does the payer take in cases where the APM Entity's fails to meet or exceed one or more specified performance standards? [CHECK BOX] Payer withholds payment of services to the APM Entity and/or the APM Entity’s eligible clinicians. Payer reduces payment rates to APM Entity and/or the APM Entity’s eligible clinicians. Payer requires direct payments by the APM Entity to the payer. Payer requires the APM Entity to lose the right to all or part of an otherwise guaranteed payment or payments. Please describe the action(s) checked above that are taken by the payer in cases where the APM Entity fails to meet or exceed one or more specified performance standards. [TEXT BOX] Please describe how the amount that an APM entity owes or forgoes is calculated. [text box] List the attached document(s) and page numbers that provide evidence of the information required in this section. [Text Box] Aligned Other Payer Medical Home Model Nominal Amount Standard Is the total amount an APM Entity potentially owes or foregoes under the payment arrangement at least 5 percent of the average estimated total revenue of the participating providers or other entities under the payer? [Y/N] If yes, please describe how the amount that an APM entity owes or foregoes is calculated. [Text Box] List the attached document(s) and page numbers that provide evidence of the information required in this section. [Text box]	Edited to align with new requirements.
		D	E	Edited for clarity.
19	15		Information for Aligned Other Payer Medical Home Model Determination Aligned Other Payer Medical Home Model means an other payer payment arrangement (not including Medicaid) that is formally aligned with a CMS Multi-Payer Model that is a Medical Home Model and that CMS determines by the following characteristics. Does the payer request that CMS make a determination regarding whether this payment arrangement is an Aligned Other Payer Medical Home Model as defined in 42 CFR 414.1305? [Y/N] If no, skip to section E. [If yes] List the attached document(s) and page numbers that provide evidence of the information required in this section. [TEXT BOX] For which eligible clinicians with a primary care focus does the payment arrangement include specific design elements? Select all Physician Specialty Codes that apply: 01 General Practice; 08 Family Medicine; 11 Internal Medicine; 16 Obstetrics and Gynecology; 37 Pediatric Medicine; 38 Geriatric Medicine; 50 Nurse Practitioner; 89 Clinical Nurse Specialist; and 97 Physician Assistant. [CHECK BOX] Does the payment arrangement require empanelment (assigning individual patients to individual providers) of each patient to a primary clinician? [Y/N] Select all elements from the following list that are required by the payment arrangement. Planned coordination of chronic and preventive care. [Y/N] If yes, cite supporting documentation and page numbers. [TEXT BOX] Patient access and continuity of care. [Y/N] If yes, [TEXT BOX] Risk-stratified care management. [Y/N] If yes, [TEXT BOX] Coordination of care across the medical neighborhood. [Y/N] If yes, [TEXT BOX] Patient and caregiver engagement. [Y/N] If yes, [TEXT BOX] Shared decision-making. [Y/N] If yes, [TEXT BOX] Payment arrangements in addition to, or substituting for, fee-for-service payments (e.g. shared savings or population-based payments). [Y/N] If yes, [TEXT BOX] Aligned Other Payer Medical Home Model Financial Risk Standard Does the Aligned Other Payer Medical Home Model require that, based on the APM Entity's failure to meet or exceed one or more specified performance standards, at least one of the following occurs: Payer withholds payment of services to the APM Entity and/or the APM Entity’s eligible clinicians Payer requires direct payments by the APM Entity to the payer Payer reduces payment rates to APM Entity and/or the APM Entity’s eligible clinicians Payer requires the APM Entity to lose the right to all or part of an otherwise guaranteed payment or payments [Yes/No] Which of the following actions does the payer take in cases where the APM Entity's fails to meet or exceed one or more specified performance standards? [CHECK BOX] Payer withholds payment of services to the APM Entity and/or the APM Entity’s eligible clinicians. Payer reduces payment rates to APM Entity and/or the APM Entity’s eligible clinicians. Payer requires direct payments by the APM Entity to the payer. Payer requires the APM Entity to lose the right to all or part of an otherwise guaranteed payment or payments. Please describe the action(s) checked above that are taken by the payer in cases where the APM Entity fails to meet or exceed one or more specified performance standards. [TEXT BOX] Please describe how the amount that an APM entity owes or forgoes is calculated. [text box] List the attached document(s) and page numbers that provide evidence of the information required in this section. [Text Box] Aligned Other Payer Medical Home Model Nominal Amount Standard Is the total amount an APM Entity potentially owes or foregoes under the payment arrangement at least 5 percent of the average estimated total revenue of the participating providers or other entities under the payer? [Y/N] If yes, please describe how the amount that an APM entity owes or foregoes is calculated. [Text Box] List the attached document(s) and page numbers that provide evidence of the information required in this section. [Text box]	Edited to align with new requirements.
19	23	D	E	Edited for clarity.
22	29	I have read the contents of this submission. By submitting this Form, I certify that I am legally authorized to bind the payer. I further certify that the information contained herein is true, accurate, and complete, and I authorize the Centers for Medicare & Medicaid Services (CMS) to verify this information. If I become aware that any information in this Form is not true, accurate, or complete, I will notify CMS of this fact immediately. I understand that the knowing omission, misrepresentation, or falsification of any information contained in this document or in any communication supplying information to CMS may be punished by criminal, civil, or administrative penalties, including fines, civil damages and/or imprisonment.	I have read the contents of this submission. By submitting this Form, I certify that I am legally authorized to bind the APM Entity submitting this Form. I further certify that the information contained herein is true, accurate, and complete, and I authorize the Centers for Medicare & Medicaid Services (CMS) to verify this information. If I become aware that any information in this Form is not true, accurate, or complete, I will notify CMS of this fact immediately. I understand that any person who knowingly files a statement of claim containing any false, incomplete, or misleading information, may be guilty of a criminal act punishable under Federal and state law and may be subject to civil penalties	Edited for clarity.