(a) General. (1) CMS assesses the home dialysis rate and transplant rate for each ETC Participant against the applicable benchmarks to calculate an—
(i) Achievement score, as described in paragraph (b) of this section; and
(ii) Improvement score, as described in paragraph (c) of this section.
(2)(i) CMS calculates the ETC Participant's MPS as the weighted sum of the higher of the achievement score or the improvement score for the ETC Participant's home dialysis rate and transplant rate, as described in paragraph (d) of this section.
(ii) The ETC Participant's MPS determines the ETC Participant's PPA, as described in § 512.380.
(b) Achievement Scoring. CMS assesses ETC Participant performance at the aggregation group level on the home dialysis rate and transplant rate against achievement benchmarks constructed based on the home dialysis rate and transplant rate among aggregation groups of ESRD facilities and Managing Clinicians located in Comparison Geographic Areas during the Benchmark Year. Achievement benchmarks are calculated as described in paragraph (b)(1) of this section and, for MY3 through MY10, are stratified as described in paragraph (b)(2) of this section. For MY5 through MY10, the ETC Participant's achievement score is subject to the restriction described in paragraph (b)(3) of this section.
(1) Achievement benchmarks. CMS uses the following scoring methodology to assess an ETC Participant's achievement score.
Table 1 to § 512.370(b)(1)—ETC Model Schedule of PPA Achievment Benchmarks by Measurement Year
| MY1 and MY2
| MY3 and MY4
| MY5 and MY6
| MY7 and MY8
| MY9 and MY10
| Points
|
|---|
| 90th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year | 1.1 * (90th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 1.2 * (90th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 1.3 * (90th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 1.4 * (90th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 2
|
| 75th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year | 1.1 * (75th+ Percentile of benchmark rates for Comparison Geographic Areas during the
Benchmark Year) | 1.2 * (75th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 1.3 * (75th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 1.4 * (75th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 1.5
|
| 50th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year | 1.1 * (50th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 1.2 * (50th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 1.3 * (50th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 1.4 * (50th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 1
|
| 30th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year | 1.1 * (30th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 1.2 * (30th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 1.3 * (30th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 1.4 * (30th+ Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 0.5
|
| <30th Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year | 1.1 * (<30th Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 1.2 * (<30th Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 1.3 * (<30th Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 1.4 * (<30th Percentile of benchmark rates for Comparison Geographic Areas during the Benchmark Year) | 0 |
(2) Stratifying achievement benchmarks. For MY3 through MY10, CMS stratifies achievement benchmarks based on the proportion of beneficiary years attributed to the aggregation group for which attributed beneficiaries are dual eligible or LIS recipients during the MY. An ESRD Beneficiary or Pre-emptive LDT Beneficiary is considered to be dual eligible or a LIS recipient for a given month if at any point during the month the beneficiary was dual eligible or an LIS recipient based on Medicare administrative data. CMS stratifies the achievement benchmarks into the following two strata:
(i) Stratum 1: 50 percent or more of attributed beneficiary years during the MY are for beneficiaries who are dual eligible or LIS recipients.
(ii) Stratum 2: Less than 50 percent of attributed beneficiary years during the MY are for beneficiaries who are dual eligible or LIS recipients.
(3) For MY5 through MY10, CMS will assign an achievement score to an ETC Participant for the home dialysis rate or the transplant rate only if the ETC Participant's aggregation group has a home dialysis rate or a transplant rate greater than zero for the MY.
(c) Improvement scoring. CMS assesses ETC Participant improvement on the home dialysis rate and transplant rate against benchmarks constructed based on the ETC Participant's aggregation group's historical performance on the home dialysis rate and transplant rate during the Benchmark Year to calculate the ETC Participant's improvement score, as specified in paragraph (c)(1) of this section. For MY3 through MY10, CMS assesses ETC Participant improvement on the home dialysis rate and transplant rate for ESRD Beneficiaries and, if applicable, Pre-emptive LDT Beneficiaries, who are dual eligible or LIS recipients to determine whether to add the Health Equity Incentive to the ETC Participant's improvement score, as specified in paragraph (c)(2) of this section.
(1) Improvement score calculation. CMS uses the following scoring methodology to assess an ETC Participant's improvement score.
(i) Greater than 10 percent improvement relative to the Benchmark Year rate: 1.5 points
(ii) Greater than 5 percent improvement relative to the Benchmark Year rate: 1 point
(iii) Greater than 0 percent improvement relative to the Benchmark Year rate: 0.5 points
(iv) Less than or equal to the Benchmark Year rate: 0 points
(v) For MY3 through MY10, when calculating improvement benchmarks constructed based on the ETC Participant's aggregation group's historical performance on the home dialysis rate and transplant rate during the Benchmark Year, CMS adds one beneficiary month to the numerator of the home dialysis rate and adds one beneficiary month to the numerator of the transplant rate, such that the Benchmark Year rates cannot be equal to zero.
(2) Health Equity Incentive. CMS calculates the ETC Participant's aggregation group's home dialysis rate and transplant rate as specified in §§ 512.365(b) and 512.365(c), respectively, using only attributed beneficiary years comprised of months during the MY in which ESRD Beneficiaries and, if applicable, Pre-emptive LDT Beneficiaries, are dual eligible or LIS recipients. CMS also calculates the threshold for earning the Health Equity Incentive based on the ETC Participant's aggregation group's historical performance on the home dialysis rate and transplant rate during the Benchmark Year, using only attributed beneficiary years comprised of months during the Benchmark Year in which ESRD Beneficiaries and, if applicable, Pre-emptive LDT Beneficiaries, are dual eligible or LIS recipients. An ESRD Beneficiary or Pre-emptive LDT Beneficiary is considered to be dual eligible or a LIS recipient for a given month if at any point during the month the beneficiary was dual eligible or a LIS recipient. CMS determines whether a beneficiary was dual eligible or a LIS recipient based on Medicare administrative data.
(i) The ETC Participant earns the Health Equity Incentive for the home dialysis rate improvement score if the home dialysis rate for the MY, calculated as specified in this paragraph (c)(2), is at least 2.5-percentage points higher than the home dialysis rate for the Benchmark Year, calculated as specified in this paragraph (c)(2). If the ETC Participant earns the Health Equity Incentive for the home dialysis rate improvement score, CMS adds 0.5 points to the ETC Participant's home dialysis rate improvement score, calculated as specified in paragraph (c)(1) of this section, unless the ETC Participant is ineligible to receive the Home Equity Incentive as specified in paragraph (c)(2)(iii) of this section.
(ii) The ETC Participant earns the Health Equity Incentive for the transplant rate improvement score if the home dialysis rate for the MY, calculated as specified in this paragraph (c)(2), is at least 2.5-percentage points higher than the transplant rate for the Benchmark Year, calculated as specified in this paragraph (c)(2). If the ETC Participant earns the Health Equity Incentive for the transplant rate improvement score, CMS adds 0.5 points to the ETC Participant's transplant rate improvement score, calculated as specified in paragraph (c)(1) of this section, unless the ETC Participant is ineligible to receive the Home Equity Incentive as specified in paragraph (c)(2)(iii) of this section.
(iii) An ETC Participant in an aggregation group with fewer than 11-attributed beneficiary years comprised of months in which ESRD Beneficiaries and, if applicable, Pre-emptive LDT Beneficiaries, are dual eligible or LIS recipients, during either the Benchmark Year or the MY is ineligible to earn the Health Equity Incentive.
(d) Modality Performance Score. (1) For MY1 and MY2, CMS calculates the ETC Participant's MPS as the higher of ETC Participant's achievement score or improvement score for the home dialysis rate, together with the higher of the ETC Participant's achievement score or improvement score for the transplant rate, weighted such that the ETC Participant's score for the home dialysis rate constitutes
2/3 of the MPS and the ETC Participant's score for the transplant rate constitutes
1/3 of the MPS. CMS uses the following formula to calculate the ETC Participant's MPS for MY1 and MY2:
Modality Performance Score = 2 × (Higher of the home dialysis achievement or improvement score) + (Higher of the transplant achievement or improvement score)
(2) For MY3 through MY10, CMS calculates the ETC Participant's MPS as the higher of the ETC Participant's achievement score for the home dialysis rate or the sum of the ETC Participant's improvement score for the home dialysis rate calculated as specified in paragraph (c)(1) of this section and, if applicable, the Health Equity Incentive, calculated as described in paragraph (c)(2)(i) of this section, together with the higher of the ETC Participant's achievement score for the transplant rate or the sum of the ETC Participant's improvement score for the transplant rate calculated as specified in paragraph (c)(1) of this section and, if applicable, the Heath Equity Incentive, calculated as described in paragraph (c)(2)(ii) of this section, weighted such that the ETC Participant's score for the home dialysis rate constitutes
2/3 of the MPS and the ETC Participant's score for the transplant rate constitutes
1/3 of the MPS. CMS uses the following formula to calculate the ETC Participant's MPS for MY3 through MY10:
Modality Performance Score = 2 × (Higher of the home dialysis achievement or (home dialysis improvement score + Health Equity Bonus †)) + (Higher of the transplant achievement or (transplant improvement score + Health Equity Bonus†))
† The Health Equity Incentive is applied to the home dialysis improvement score or transplant improvement score only if earned by the ETC Participant.
[85 FR 61362, Sept. 29, 2020, as amended at 86 FR 62023, Nov. 8, 2021; 87 FR 67302, Nov. 7, 2022]