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Code of Federal Regulations Title 42. Public Health § 42.510.205 Beneficiary inclusion criteria

Current as of January 02, 2025 | Updated by Findlaw Staff

(a) Episodes tested in the CJR model include only those in which care is furnished to beneficiaries who meet all of the following criteria upon admission to the anchor hospitalization:

(1) Are enrolled in Medicare Parts A and Part B.

(2) Eligibility for Medicare is not on the basis of end stage renal disease, as described in § 406.13 of this chapter.

(3) Are not enrolled in any managed care plan (for example, Medicare Advantage, health care prepayment plans, or cost-based health maintenance organizations).

(4) Are not covered under a United Mine Workers of America health care plan.

(5) Have Medicare as their primary payer.

(6) For episodes beginning on or after July 1, 2017, are not prospectively assigned to—

(i) An ACO in the Next Generation ACO model;

(ii) An ACO in a track of the Comprehensive ESRD Care Model incorporating downside risk for financial losses;  or

(iii) A Shared Savings Program ACO in the ENHANCED track (formerly Track 3).

(b) If at any time during the episode a beneficiary no longer meets all of the criteria in this section, the episode is canceled in accordance with § 510.210(b).

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Cite this article: FindLaw.com - Code of Federal Regulations Title 42. Public Health § 42.510.205 Beneficiary inclusion criteria - last updated January 02, 2025 | https://codes.findlaw.com/cfr/title-42-public-health/cfr-sect-42-510-205-nr2/

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