LEAD (Long-Term Enhanced ACO Design) Model

LEAD@cms.hhs.gov

Long-Term Enhanced ACO Design (LEAD) is a reimbursement model for healthcare providers and Accountable Care Organizations (ACOs). LEAD builds upon the CMS Innovation Center's earlier accountable care work and uses improved benchmarking to appeal to a broader mix of healthcare providers, including those with specialized patient populations and those new to ACOs such as smaller, independent or rural-based practices.

Goals:

• Attract healthcare providers that have had limited participation in ACOs previously
• Encourage healthcare providers to deliver preventive care
• Empower beneficiaries to be more actively involved in their care
• Support healthcare providers who serve high needs and dually eligible beneficiaries to improve care and reduce costs

Program fact sheet

Eligibility requirements:

• Legal entity identified by a federal taxpayer identification number (TIN) formed under applicable state, federal, or tribal law, and authorized to conduct business in each state in which it operates
• Have at least 5,000 original Medicare beneficiaries aligned to the ACO in each performance year to be eligible for participation in LEAD. In addition, ACOs must have 3,000 claims-based aligned beneficiaries in at least one base year to be able to participate in LEAD. Under certain circumstances, ACOs may be able to participate at lower beneficiary alignment minimums. Lowered alignment minimums will be available to ACOs with a high proportion of beneficiaries that meet the high needs eligibility criteria and for newly entering ACOs.
• Does not have active participation in another Medicare initiative that involves shared savings or any other Innovation Center model where simultaneous participation is prohibited
• Have the ability to repay shared losses and any other monies owed for which it may be liable under LEAD, as demonstrated through the establishment of a financial guarantee for the model

Medicare-enrolled providers and suppliers may participate in LEAD as part of a participant TIN. To participate in LEAD, Participant TINs must form or join an ACO, and the ACO must apply and be accepted to LEAD.

Eligible healthcare providers that may participate as part of a participant TIN include, but are not limited to:

• Physicians or other practitioners in group practice arrangements
• Networks of individual practices of physicians or other practitioners
• Hospitals employing physicians or other practitioners
• Federally Qualified Health Centers (FQHCs)
• Rural Health Clinics (RHCs)
• Critical Access Hospitals (CAHs)

Benefits of participation:

• Innovative Benchmarks and Performance Targets: ACOs are measured based on their unique patient populations, with tailored financial benchmarks that meet ACOs where they are on their journey to value-based care
• Upfront Monthly Payments for Care Improvement: Get monthly upfront payments to invest in team care, prevention, and community partnership, keeping people healthy and connected
• Simple, Meaningful Quality Measures: Focus on fewer hospitalizations, faster follow-ups, patient satisfaction, and managing diabetes and blood pressure
• Flexible Risk Options: ACOs can choose the risk level that fits their organization, starting with shared risk or taking on full risk for greater rewards

Links to additional guidance, application instructions, and the online application portal are available on the program website.

Application assistance:

• Checklist
• ACO REACH Model
• Applicant webinar slides