Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals (IPPS) and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year (FY) 2026 Rates; Changes to the FY 2025 IPPS Rates Due to Court Decision; Requirements for Quality Programs; and Other Policy Changes; Health Data, Technology, and Interoperability: Electronic Prescribing, Real-Time Prescription Benefit and Electronic Prior Authorization

1. Background a. Purpose

TEAM is a 5-year mandatory alternative payment model tested by the CMS Innovation Center that will begin on January 1, 2026, and end on December 31, 2030. TEAM will test whether an episode-based pricing methodology linked with quality measure performance for select acute care hospitals reduces Medicare program expenditures while preserving or improving the quality of care for Medicare beneficiaries who initiate certain episode categories. Specifically, TEAM will test five surgical episode categories: Coronary Artery Bypass Graft Surgery (CABG), Lower Extremity Joint Replacement (LEJR), Major Bowel Procedure, Surgical Hip/Femur Fracture Treatment (SHFFT), and Spinal Fusion.

As discussed in greater detail in section XI.A.1.b. of the preamble of this final rule, TEAM was established through notice and comment rulemaking. While the model performance period has not yet begun, we noted in the FY 2025 IPPS/LTCH

PPS final rule (89 FR 68986) that a few policies that were proposed were not finalized due to public comment concerns and other policies were not finalized because they needed further consideration, such as how to construct target prices when there are coding changes, which is addressed in section XI.A.2.c.(2) of the preamble of this final rule. Further, we indicated that for certain policies, such as the policy to address TEAM participants that have a low volume of episodes, we would go through rulemaking in the future to promulgate new policies that could be finalized before the model start date. Therefore, in the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18002) we proposed updates to TEAM that included the following modifications:

A limited deferment period for certain hospitals.

Linking Track 2 participation eligibility for hospitals with a Medicare Dependent Hospital (MDH) designation to the expiration of the MDH program.

Adding the Information Transfer Patient Reported Outcome- based Performance Measure (Information Transfer PRO-PM).

Applying a neutral quality measure score for TEAM participants with insufficient quality data.

A methodology to construct target prices when there are coding changes.

Reconstructing the normalization factor and prospective trend factor.

Replacing the Area Deprivation Index (ADI) with the Community Deprivation Index (CDI).

Using a 180-day lookback period and Hierarchical Condition Categories (HCC) version 28 for beneficiary risk adjustment.

Aligning the date range used for episode attribution.

Removing health equity plans.

Broadening the Skilled Nursing Facility (SNF) 3-Day Rule Waiver.

Removing the Decarbonization and Resilience Initiative.

We also solicited comment, but did not propose updates, in the following policy areas:

Indian Health Service (IHS) hospital outpatient episodes.

Low volume hospitals.

Standardized prices and reconciliation amounts.

Primary care services referral requirement.

The policies in the proposed rule, and this final rule reflect our commitment to ensuring TEAM's incentives help to drive beneficiary quality of care improvements and reductions in Medicare spending.

We continue to believe that this model will test ways to further our goals of reducing Medicare expenditures while preserving or enhancing the quality of care furnished to beneficiaries. We received meaningful public comment on our proposed policies and policy considerations and will be finalizing several provisions in this final rule. We note that some of the public comments were outside of the scope of the proposed rule. These out-of-scope public comments, including but not limited to comments about voluntary participation, episode categories and episode length, quality measures not proposed or considered, and target price components not proposed or considered are not addressed in this final rule. However, we will take into consideration these public comments as we implement the model and monitor TEAM participant performance, and if warranted, we would propose new policies or policy modifications in subsequent notice and comment rulemaking, as appropriate. We have summarized the public comments that are within the scope of the proposed rule and our responses to those public comments. b. Statutory Authority and Background

Under the authority of section 1115A of the Act, through notice- and-comment rulemaking, the CMS Innovation Center established TEAM in the FY 2025 IPPS/LTCH PPS final rule that appeared in the August 28, 2024, Federal Register (89 FR 69626 through 69879). The intent of TEAM is to improve beneficiary care through financial accountability for episodes categories that begin with one of the following procedures: CABG, LEJR, major bowel procedure, SHFFT, and spinal fusion. TEAM will test whether financial accountability for these episode categories reduces Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries.

Under Traditional Medicare, Medicare makes separate payments to providers and suppliers for the items and services furnished to a beneficiary over the course of an episode of care. Because providers and suppliers are paid for each individual item or service delivered, providers may not be incentivized to invest in quality improvement and care coordination activities. As a result, care may be fragmented, unnecessary, or duplicative. By holding hospitals accountable for all items and services provided during an episode, providers would be better incentivized to coordinate patient care, avoid duplicative or unnecessary services, and improve the beneficiary care experience during care transitions.

Under TEAM, all acute care hospitals, with limited exceptions, located within the Core Based Statistical Areas (CBSAs) that CMS selected for model implementation will be required to participate in TEAM. CMS allowed a one-time opportunity for hospitals that participate until the last day of the last performance period in the Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model or the last day of the last performance year of the Comprehensive Care for Joint Replacement (CJR) Model, that are not located in a mandatory CBSA selected for TEAM participation, to voluntarily opt into TEAM. TEAM will have a 1-year glide path opportunity that will allow TEAM participants to ease into full financial risk as well as three different participation tracks to accommodate different levels of financial risk and reward. Track 1 is an upside only risk track available for all TEAM participants in the first performance year and available to safety net hospitals for the first 3 performance years. Track 2 is a two-sided risk track that has lower financial risk and reward, relative to Track 3, and will be available to select TEAM participants in performance years 2 through 5.\403\ Track 3 is a two- sided risk track that has higher financial risk and reward, relative to Track 2, and will be available to all TEAM participants in performance years 1 through 5.

\403\ TEAM participants eligible for Track 2 include safety net hospitals, rural hospitals, Medicare dependent hospitals, Sole Community Hospitals, and Essential Access Community Hospitals, all defined at Sec. 512.505.

Episodes will include non-excluded Medicare Parts A and B items and services and will begin with an anchor hospitalization or anchor procedure and would end 30 days after hospital discharge. TEAM participants will continue to bill Medicare FFS as usual for items and services delivered to beneficiaries in an episode but will receive preliminary target prices for episodes prior to each performance year. Target prices will be based on 3 years of baseline data, prospectively trended forward to the relevant performance year, and calculated at the level of Medicare Severity Diagnosis Related Group/Healthcare Common Procedure Coding System (MS-DRG/HCPCS) episode type and region. Target prices will also include a discount factor and risk-adjustment. Participants will receive reconciliation (final) target prices that will incorporate a capped retrospective trend factor adjustment and a capped normalization factor.

Performance in the model will be assessed by comparing TEAM

participants' actual Medicare FFS spending during a performance year to their reconciliation target price as well as by assessing performance on selected quality measures. TEAM participants may earn a payment from CMS, subject to a quality performance adjustment, if their spending is below the reconciliation target price. TEAM participants may owe CMS a repayment amount, subject to a quality performance adjustment, if their spending was above the reconciliation target price. 2. TEAM Provisions of This Final Rule a. Participation (1) Background

In the FY 2025 IPPS/LTCH PPS final rule (89 FR 69642) we indicated that testing TEAM will help us understand the impact of a mandatory episode-based payment model in selected geographic areas for acute care hospitals that initiate the episode categories included in the model. We stated that implementing TEAM among acute care hospitals in select geographic areas will allow CMS and TEAM participants to gain experience testing and evaluating an episode-based payment approach for certain episodes furnished by hospitals with a variety of historic utilization patterns; roles within their local markets, including with regard to accountable care organization participation or affiliation; volume of services provided; access to financial, community, or other resources; and population and health care provider density. Further, Medicare beneficiaries and providers in certain areas, such as rural areas, can be underrepresented in voluntary models, whereas under a mandatory model we have the ability to include these entities, with safeguards as appropriate, for participation so that all beneficiaries have access to care redesign approaches intended to improve the quality care, and such providers gain experience in value-based care. Lastly, we noted that participation of hospitals in selected geographic areas will allow CMS to test episode-based payments without introducing participant attrition or selection bias such as the selection bias inherent in the BPCI Advanced model due to self-selected participation in the model and self-selection of episode categories. (2) Mandatory Participation

In the FY 2025 IPPS/LTCH PPS final rule (89 FR 69642), we defined two ways that an acute care hospital could be designated as a TEAM participant. First, a hospital is a TEAM participant if it initiates episodes and is paid under the IPPS with a CMS Certification Number (CCN) primary address located in one of the mandatory CBSAs selected for participation in TEAM. Second, a hospital that participates in either the Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model or the Comprehensive Care for Joint Replacement (CJR) Model until the last day of the last performance period (or last performance year) of the respective model may voluntarily opt into TEAM participation.

As stated in the proposed rule, these criteria for TEAM participants did not include any temporal restrictions, leading to potential uncertainty regarding the TEAM participant status of hospitals that open before or during the model performance period, which is defined at Sec. 512.505 as the 60-month period from January 1, 2026, to December 31, 2030, during which TEAM is being tested and the TEAM participant is held accountable for spending and quality. Additionally, there was also uncertainty regarding TEAM participant status in circumstances where a hospital that previously did not satisfy the definition of TEAM participant later meets the definition criteria in the months before or during the model performance period. For example, this scenario would apply to a hospital that was previously not paid under the IPPS but then underwent a status change such that the hospital is no longer classified as a critical access hospital (CAH), as defined in section 1861(mm)(1) of the Act, or a hospital that terminated their participation in the Rural Community Health Demonstration (RCHD).\404\ Further, we recognize that there may be instances where a hospital no longer satisfies the definition of TEAM participant during the model performance period, such as a hospital joining the RCHD or a hospital converting to a CAH.

\404\ https://www.cms.gov/priorities/innovation/innovation-models/rural-community-hospital.

We also noted in the proposed rule that our existing policy at Sec. 512.550(b)(2) provides for separate TEAM reconciliation calculations for TEAM participants that experience a reorganization event, as defined at Sec. 512.505, including any new TEAM participant that results from a reorganization event. However, this policy does not address new hospitals that open in TEAM mandatory CBSAs independently of a reorganization event.

We recognized that new hospitals that open shortly before or during the model performance period, as well as hospitals that begin to satisfy the definition of TEAM participant shortly before or during the model performance period, and that would otherwise be required to participate in TEAM based on their receipt of payment under IPPS and their geographic location, may experience multiple disadvantages relative to other TEAM participants.

First, because the list of mandatory CBSAs was published as part of the FY 2025 IPPS/LTCH PPS final rule on August 1, 2024 (89 FR 69706), and a preliminary TEAM participant list was published to the TEAM public web page on September 5, 2024, the TEAM participants in existence at that time have been afforded an opportunity to prepare for TEAM prior to the beginning of the model performance period on January 1, 2026. Based on previous and current episode-based payment models like BPCI Advanced and CJR models, we recognized that hospitals may engage in a number of care redesign activities and processes in order to achieve successful model outcomes, and that new hospitals that open shortly before or during the model performance period, as well as hospitals that begin to satisfy the definition of a TEAM participant shortly before or during the model performance period, may be at a relative disadvantage by not having comparable advance notice to engage in preparatory care redesign activities or otherwise prepare for the model.

Second, to accommodate the varying levels of readiness among TEAM participants at the beginning of the model performance period, we have provided participation track options which allow TEAM participants to phase in financial risk based on performance year (PY). Eligibility for Track 1, which has no downside risk, is available to all TEAM participants in PY 1 and to safety net hospitals in PYs 1 through 3. As a result, if new hospitals were to become TEAM participants during or after PY 1, they would not be afforded the same opportunity to participate in a track with no downside risk for at least 1 year prior to assuming greater levels of financial risk.

In the proposed rule, we proposed to establish a cutoff date after which new hospitals and hospitals that begin to meet the definition of a TEAM participant and that are located in a mandatory CBSAs, excepting any new hospitals resulting from a reorganization event, would not be required to participate immediately in the model and would have a limited deferment period before beginning their participation in TEAM. Therefore, we proposed that any new hospital, as identified by Medicare ID (CMS

Certification Number--CCN) with an initial effective date after December 31, 2024, within the Medicare Provider Enrollment, Chain, and Ownership System (PECOS), excepting any new hospital that is created as part of a reorganization event as defined at Sec. 512.505, would not be required to participate in TEAM immediately and would have at least one full performance year of participation deferment before being required to participate in the model. We also proposed that any hospital that begins to satisfy the definition of TEAM participant after December 31, 2024, would not be required to participate in TEAM immediately and would have at least one full performance year of participation deferment before being required to participate in the model. Specifically, we proposed that any new hospital located in a mandatory CBSA, and any hospital located in a mandatory CBSA that begins to meet the definition of TEAM participant after December 31, 2024, would not be required to participate in TEAM in the performance year when their Medicare ID initially became effective or when they began to meet the definition of TEAM participant, or the performance year thereafter. Rather, these hospitals would be required to participate in TEAM starting on January 1st of the subsequent performance year. For example, if a hospital opened in a mandatory CBSA with a Medicare ID initial effective date on June 1, 2026, then that hospital would not be required to begin participation in TEAM until January 1, 2028 (PY 3). Likewise, if a hospital located in a mandatory CBSA terminated their participation in the RCHD effective on August 1, 2027, then they would not be required to begin participation in TEAM until January 1, 2029 (PY 4). As noted in the proposed rule, we believed this proposed policy would allow new hospitals and hospitals that begin to meet the definition of TEAM participant sufficient time to focus on establishing their care processes and ensuring their ability to comply with TEAM policies and requirements before being required to participate in TEAM. Specifically, the proposed cutoff date of December 31, 2024, would provide all new or newly qualifying hospitals with at least 1 year and not more than 2 years to prepare for the model, thereby establishing a level playing field with hospitals that have had the opportunity to prepare for model implementation since the publication of the preliminary TEAM participant list on the TEAM public web page on September 5, 2024.

As noted in the proposed rule, this proposal would not affect the existing policy at Sec. 512.550(b)(2) to conduct separate reconciliations for each hospital entity that results from a reorganization event as defined at Sec. 512.505.

We also proposed that a hospital that no longer satisfies the definition of TEAM participant would end TEAM participation effective the date they no longer satisfy the definition. As noted in the proposed rule, we believed it was important to only allow hospitals that satisfy the definition of TEAM participant to participate in TEAM, otherwise it may introduce issues with pricing fairness and episode attribution. For example, since Medicare payments to CAHs and to hospitals participating in the RCHD are based on reasonable costs rather than traditional FFS, TEAM's pricing methodology may not afford these hospitals the same opportunity for savings compared to hospitals paid under FFS. Additionally, since TEAM's sampling and pricing methodologies were devised based on acute care hospitals paid under the IPPS, allowing additional hospitals that do not meet these criteria to participate in TEAM could result in changes to the TEAM sample in terms of geographic location and expected episode volume. We also proposed that CMS would notify the hospital that no longer met the definition of TEAM participant within 30 days of the hospital no longer meeting the TEAM participant definition or as soon as is reasonably practicable. For example, if a TEAM participant was classified as a CAH on April 1, 2026, then their last day participating in TEAM would be March 31, 2026, and CMS would notify the hospital that they are no longer a TEAM participant by April 30, 2026, or as soon as is reasonably practicable. We recognized in the proposed rule that this proposed policy may present an opportunity for hospitals to avoid mandatory participation in TEAM. However, we indicated in the proposed rule that we did not believe this policy would affect many hospitals given the stringent requirements to convert to a non-IPPS hospital type, such as a CAH, or to participate in the RCHD. Irrespective of the potentially small impact, we would monitor for concerns of participation gaming.

In the proposed rule, we considered proposing that new hospitals, as identified by a Medicare ID initial effective date after December 31, 2024, within the Medicare PECOS, excepting any new hospital that is created as part of a reorganization event as defined at Sec. 512.505, and hospitals that begin to satisfy the definition of TEAM participant after December 31, 2024, would not be required to participate in TEAM. However, we believed it would be important that new hospitals are exposed to value-based care early on to promote adoption of standard care practices and efficient processes.

We also considered in the proposed rule proposing that new hospitals, as identified by a Medicare ID initial effective date after December 31, 2024, within the Medicare PECOS, excepting any new hospital that is created as part of a reorganization event as defined at Sec. 512.505, and hospitals that begin to satisfy the definition of TEAM participant after December 31, 2024, would be required to participate in the first full performance year following their Medicare ID initial effective date or the date when they began to satisfy the TEAM participant definition. We considered allowing those hospitals to participate with no downside risk for that first performance year and then requiring them to participate in the subsequent performance year in one of the participation tracks, as applicable depending on their eligibility under the participation track requirements. However, as noted in the proposed rule, we believed requiring the hospitals to participate in the first full performance year, even with no downside financial risk, would not provide sufficient opportunity for them to prepare for the participation requirements. That is because, while the hospitals would not have downside financial risk during the first year, they would still need to comply with other model requirements which could be challenging to meet in addition to all the Medicare conditions of participation.

We recognized in the proposed rule that a deferred participation policy or a policy that excludes new hospitals within mandatory CBSAs could provide an opportunity for patient shifting. For example, a TEAM participant or affiliated provider could refer patients who are anticipated to need costly treatments or require extensive and potentially expensive follow-up care to a non-participating hospital. We believed that such patient shifting would run counter to the goals of the model as discussed at 89 FR 69631. We anticipated this practice would be unlikely to occur given our belief that TEAM participants would make medically appropriate decisions for beneficiaries and that the frequency of new hospitals opening during the performance period would be low. However, we recognized in the proposed rule that the introduction of deferred participation for new hospitals

in TEAM mandatory CBSAs could present an opportunity for such patient shifting. As a result, we proposed to monitor specifically for the potential shifting of patients with high anticipated episode spending from TEAM participants to non-participant hospitals. We also noted in the proposed rule that, based on experience with prior models, we anticipated the opening of new hospitals within selected mandatory CBSAs during the TEAM performance period to be a relatively rare occurrence. As a result, we anticipated that the proposed policy would not affect a large number of hospitals.

We considered, but did not propose, including as TEAM participants and requiring immediate participation from any new hospitals in TEAM mandatory CBSAs, as identified by a Medicare ID (CMS Certification Number) with an initial effective date after December 31, 2024, within PECOS and hospitals that begin to satisfy the definition of TEAM participant after December 31, 2024. As discussed previously in the proposed rule, we believed that such hospitals would be placed at a disadvantage in terms of their performance in TEAM if they were not afforded the same opportunities to prepare for the model and phase in financial risk. We also considered, but did not propose, alternative cutoff dates for the inclusion of hospitals as TEAM participants without a deferment period, including June 30, 2025, December 31, 2025, and December 31, 2026. While a cutoff date of June 30, 2025, would provide new or newly qualifying hospitals with at least 6 months to prepare for model implementation in 2025, including receipt and analysis of baseline claims and preliminary target price data from CMS, we recognized in the proposed rule that these hospitals, especially those that open shortly before the cutoff date, could be disadvantaged relative to hospitals that have had at least 1 year to prepare for model implementation. We also recognized that a cutoff date at the end of 2025 could result in the same disadvantage from a lack of preparation time, and that a cutoff date at the end of 2026 could result in this same disadvantage, as well as the disadvantage of missing the opportunity to participate without downside risk in PY 1.

Lastly, we considered but did not propose requiring new hospitals in mandatory CBSAs, as identified by Medicare ID (CMS Certification Number) with an initial effective date after December 31, 2024, within PECOS and hospitals that begin to satisfy the definition of TEAM participant after December 31, 2024, to participate in TEAM either 1 year or 2 years after their Medicare ID initial effective date or from the date they begin to satisfy the definition of TEAM participant. However, TEAM's performance years run on a calendar year basis, and a new hospital Medicare ID effective date or the date when a hospital begins to satisfy the definition of TEAM participant would not generally fall on January 1st of a calendar year, which could have made including them as a TEAM participant after the performance year has started challenging. Many model requirements, like participation track decisions and submission of certain deliverables, occur prior to the beginning of each performance year and apply to the entire performance year, which may have disadvantaged hospitals if they started after the performance year begins.

We sought comment on our proposal at Sec. 512.508 to require new hospitals that open in a mandatory CBSA as indicated by a Medicare ID initial effective date after December 31, 2024, and hospitals located in a mandatory CBSA that begin to satisfy the definition of TEAM participant after December 31, 2024, to participate in TEAM after one full performance year has passed from their Medicare ID initial effective date or the date when they begin to satisfy the definition of TEAM participant, respectively. We also sought comment on our proposal to monitor specifically for the potential shifting of patients with high anticipated episode spending from TEAM participants to non- participant hospitals. We also sought comment on whether or how this policy could affect the business decision of opening a new hospital even when there is patient need in the service area where the new hospital would be opened. Finally, we sought comment on our proposal that a hospital that no longer satisfies the definition of TEAM participant would end TEAM participation effective the date they no longer satisfy the definition.

The following is a summary of the public comments received on the proposed policy for a limited deferment period for hospitals that open in a mandatory CBSA or for hospitals located in a mandatory CBSA that begin to satisfy the definition of TEAM participant after December 31, 2024, and our responses to these comments:

Comment: Many commenters expressed support for the proposed limited deferment period for hospitals that open in a mandatory CBSA or for hospitals located in a mandatory CBSA that begin to satisfy the definition of a TEAM participant after December 31, 2024, indicating that the deferment period would allow new hospitals to prepare for the model. A few commenters stated that the deferment period would help hospitals maintain patient safety and access to care. A couple commenters noted that the deferment period would help to minimize financial risk for new hospitals under the model.

Response: We thank the commenters for their support. We agree that this limited deferment period will benefit hospitals by allowing time to prepare for model participation and permit a smooth transition of care redesign to support and improve patient care.

Comment: A couple commenters stated that the proposed limited deferment period is inadequate and recommended that hospitals that open or that begin to satisfy the definition of TEAM participant after December 31, 2024, be excluded from the model. These commenters indicated that new hospitals already face substantial challenges in recruiting staff, establishing workflows, and developing systems, along with inconsistent patient volume and revenue. The commenters stated that the financial risks to these hospitals would outweigh the benefits of participating for only part of the model's duration and could disincentivize the opening of new hospitals in areas that need them. A commenter stated that the proposed limited deferment period is inadequate and suggested that CMS extend the deferment period from 1 full performance year to 2 full performance years.

Response: We thank the commenters for their suggestions and recognize the challenges involved in establishing a new hospital. However, we disagree that the proposed limited deferment period of at least 1 full performance year is inadequate. We believe that new hospitals will be able to integrate TEAM preparation into their general preparatory activities and could benefit from establishing care processes with TEAM's focus on care coordination and efficiency in mind. We also note that many integral TEAM processes, including quality reporting, deliverables, and reconciliation, are designed to be simpler for participants compared to the requirements of voluntary models like BPCI Advanced. We recognize commenters' concerns that requiring new hospitals to participate in TEAM could disincentivize the opening of new hospitals in areas of need. However, we also note that the potential for financial gains, the receipt of claims data from CMS, and the incentive and support to

develop efficient care delivery processes under the model are potential benefits of TEAM participation for new hospitals. Therefore, we believe that it is unlikely that requiring new hospitals in TEAM mandatory CBSAs to participate in TEAM will have a strong and systematically negative effect on the opening of new hospitals. However, we emphasize the importance of beneficiary quality and access to care in TEAM, and we may monitor for anomalies in the rates of new hospital openings in TEAM mandatory CBSAs as well as any reports that TEAM is affecting the decision to open a particular hospital.

Comment: Some commenters recommended that newly established hospitals be allowed to participate in TEAM with no downside financial risk in their first performance year, which would mirror the Track 1 eligibility granted to all TEAM participants in PY1. These commenters stated that allowing new participants to participate with no downside financial risk in their first performance year would allow them to learn, adjust to the model, and optimize care without risking financial losses. The commenters also indicated that allowing new hospitals to participate with no downside financial risk in their first performance year would reduce the impact of the model on decisions of whether and when to open new hospitals.

Response: We thank the commenters for their recommendations and acknowledge that new hospitals and hospitals that newly satisfy the definition of TEAM participant after December 31, 2024, would not have the opportunity to participate in TEAM with no downside financial risk in their first performance year. However, we disagree that it is necessary to provide new hospitals and hospitals that newly satisfy the definition of TEAM participant after December 31, 2024, with the option to participate with no downside financial risk in their first performance year. As stated in the proposed rule and in comments summarized previously, the proposed limited deferment period provides an opportunity for new hospitals to prepare for the model and thus minimize financial risk. Additionally, hospitals that open or that begin to satisfy the definition of TEAM participant after December 31, 2024, will have a larger set of CMS-created model resources at their disposal compared to those available to participants at the time of publication of the initial TEAM participant list on September 5, 2024. We also note that hospitals newly joining the model in PY 2 or later would experience the financial incentives of the model for a shorter duration than hospitals that begin participation in PY 1. As a result, we believe that further limiting these participants' financial incentives by allowing them to participate without downside risk in their first performance year could dilute the intended impact of the model. However, we note that these new TEAM participants are not precluded from participating in Track 2, the participation track with lower financial risk and reward, if they meet the Track 2 eligibility parameters, as outlined in Sec. 512. 520. Further, the model includes policies that help to protect TEAM participants from significant financial risk, including a high-cost outlier cap that limits high episode spending, as described in Sec. 512.540(b)(4), in addition to a stop-loss policy that prevents extreme loss from a repayment amount, as described in Sec. 512.550(e)(1).

As stated previously, we recognize commenters' concerns that requiring new hospitals to participate in TEAM could disincentivize the opening of new hospitals. However, we also note that the potential for financial gains, the receipt of claims data from CMS, and the incentive and support to develop efficient care delivery processes under the model are potential benefits of TEAM participation for new hospitals. Therefore, we believe that it is unlikely that requiring new hospitals in TEAM mandatory CBSAs to participate in TEAM will have a strong and systematically negative effect on the opening of new hospitals. However, we emphasize the importance of beneficiary quality and access to care in TEAM, and we may monitor for anomalies in the rates of new hospital openings in TEAM mandatory CBSAs as well as any reports that TEAM is affecting the decision to open a particular hospital.

Comment: Some commenters suggested that all TEAM participants be eligible for Track 1 throughout the model, indicating that hospitals would undergo learning and improvement activities throughout the duration of the model, not just in their first year. A commenter requested that all TEAM participants be eligible for Track 1 for 2 years in order to provide adequate time for hospitals to undergo practice transformation, assess risk management strategies, understand performance, and ensure all providers can participate in the model.

Response: We thank the commenters for their suggestions. However, we believe that extending Track 1 eligibility beyond PY 1 would not be sustainable for the model. The introduction of required downside financial risk in PY2 for hospitals that do not meet the definition of a safety net hospital is a critical incentive for efficiency in care delivery under the model and is necessary for the model to achieve its projected savings to Medicare, as indicated in section I.G.12. of the Appendix A of this final rule. We agree with commenters that learning, practice transformation, and care improvement activities are intended to be continuous under the model. However, we disagree that this necessitates an extension of the period without downside financial risk for TEAM participants, new or otherwise. The presence of financial risk provides an incentive for participants to engage in care transformation and performance improvement activities, while existing provisions-- including lower-risk options for safety net and other special hospital types, stop-loss limits, and quality adjustments--help to protect against large financial losses.

Comment: A commenter requested that, in combination with the limited deferment period, CMS implement additional beneficiary protections to prevent inappropriate diversion from medically necessary SNF care. The commenter noted that current Medicare policy requires a beneficiary to be admitted to a SNF and receive care within 30 days of a qualifying hospital stay to retain eligibility for the SNF benefit, unless a “Medical Appropriateness Exception” applies. The commenter stated that the length of TEAM episodes, which extend for 30 days following discharge, could incentivize participants to delay or divert necessary SNF care to reduce episode spending. The commenter recommended that CMS expand the Medical Appropriateness Exception to include cases where TEAM hospitals delay or divert SNF placement, and in cases where diversion has occurred, reset the 30-day SNF eligibility clock to begin after the TEAM participant's accountability period ends. The commenter also suggested that CMS monitor for SNF-level diversion patterns, similar to the planned monitoring for shifting of high-cost patients to non-participant hospitals.

Response: We recognize that the financial incentives of the model could provide motivation for participants to delay necessary care until after the episode or shift care to a less appropriate setting to reduce costs. We agree that this possibility necessitates policy and monitoring protections to ensure that delays to and diversions from medically necessary care do not occur. We believe that the beneficiary protections and monitoring provisions in place will prevent delays to and diversions from medically necessary

care for TEAM beneficiaries. As established at Sec. 512.582, beneficiary protections prohibit TEAM participants from restricting beneficiary choice or access to medically necessary covered services, require TEAM participants to notify beneficiaries of potential financial liability during discharge planning, and prohibit TEAM participants and their downstream participants from selecting for or against treating certain beneficiaries based on factors that would render the beneficiary an “at-risk beneficiary” as defined at Sec. 425.20. We believe specifically that prohibiting TEAM participants from restricting beneficiary access to medically necessary covered services--which, in the case of SNF services, are expanded in TEAM by the 3-day SNF rule waiver--will protect beneficiary access to SNF care when their provider determines that SNF care is medically necessary. We believe that providers, in consultation with their patients, are in the best position to determine appropriate care destinations. Further, we expect that the financial incentive to avoid complications and readmissions will disincentivize participants from delaying or diverting medically necessary SNF care. As described in Sec. 512.590, CMS may conduct monitoring activities to ensure compliance by the TEAM participant and each of its downstream participants with the terms of TEAM. CMS reserves the right to monitor data from the TEAM participant and its downstream participants, including claims data, medical records, beneficiary interviews, and quality outcomes. We plan to monitor for abnormal patterns in post-acute care destinations and utilization and may take remedial action in the event of noncompliance, pursuant to Sec. 512.592. We believe that these combined elements of the model will provide comprehensive protection for beneficiaries, and we trust TEAM participants to appropriately pursue efficiencies in care delivery while maintaining care access and quality. We also plan to review monitoring findings across the model and may propose additional beneficiary protections in future notice-and-comment rulemaking if further provisions appear necessary.

Comment: A couple commenters requested that CMS provide hospitals in the proposed participation deferment period with monthly claims data to help them prepare for the model.

Response: We thank the commenters for their suggestion and recognize the value of claims data for participants in preparing for and managing episodes. As described in Sec. 512.562, CMS will make beneficiary-identifiable claims data available to TEAM participants annually, at least 1 month prior to the performance year, for baseline period data. This provision will apply regardless of when a participant joins TEAM. Additionally, as we have done and continue to do in the year prior to PY 1, we will consider additional ways to provide data and support to late-joining TEAM participants prior to their participation.

Comment: A commenter expressed support for the proposal to discontinue a hospital's TEAM participation the day that the hospital no longer meets the definition of TEAM participant.

Response: We thank the commenter for their support.

After consideration of the public comments, we are finalizing without modification the proposal at Sec. 512.508 for a limited deferment period for hospitals that open in a mandatory CBSA or for hospitals located in a mandatory CBSA that begin to satisfy the definition of TEAM participant after December 31, 2024. We are also finalizing without modification the proposal at Sec. 512.508(d) to monitor specifically for the potential shifting of patients with high anticipated episode spending from TEAM participants to non-participant hospitals. Additionally, we are finalizing without modification the proposal at Sec. 512.508(c)(2) to discontinue a hospital's TEAM participation the day that the hospital no longer meets the definition of TEAM participant. (3) Medicare Dependent Hospital Status

In the FY 2025 IPPS/LTCH PPS final rule (89 FR 68986), we designated hospital types that are eligible for participation in Track 2, which offers lower levels of upside and downside financial risk relative to Track 3, for PYs 2 through 5. As stated at 89 FR 69657, we believed that certain TEAM participants may benefit from a participation option that has limited two-sided financial risk so that their beneficiaries may receive high quality, coordinated care without imposing significant financial pressure.

The hospital types designated for Track 2 eligibility are safety net hospitals, rural hospitals, Medicare dependent hospitals (MDHs), sole community hospitals (SCHs), and essential access community hospitals. We noted in the proposed rule that section 1886(d)(5)(G)(iv) of the Act defines a MDH as a hospital that is located in a rural area (or, as amended by the Bipartisan Budget Act of 2018, a hospital located in a State with no rural area that meets certain statutory criteria), has not more than 100 beds, is not an SCH, and has a high percentage of Medicare discharges (not less than 60 percent of its inpatient days or discharges in its cost reporting year beginning in FY 1987 or in 2 of its 3 most recently settled Medicare cost reporting years). For additional information on the MDH program and associated policies in this rulemaking, we refer readers to section VI.E. of the preamble of this final rule. We also noted in the proposed rule, The Consolidated Appropriations Act, 2024 (CAA, 2024) (Pub. L. 118-42), enacted on March 9, 2024, extended the MDH program. Specifically, section 307 of the CAA, 2024, extended the MDH program under section 1886(d)(5)(G) of the Act through December 31, 2024. Subsequently, section 3202 of the American Relief Act, 2025 (ARA, 2025) (Pub. L. 118- 158), enacted on December 21, 2024, extended the MDH program for FY 2025 discharges occurring before April 1, 2025. We further noted in the proposed rule that most recently, section 2202 of the Full-Year Continuing Appropriations and Extensions Act, 2025 (Pub. L. 119-4), enacted on March 15, 2025, extended the MDH program, amongst other changes, for FY 2025 discharges occurring before October 1, 2025. Because the MDH program is not authorized by statute beyond September 30, 2025, we stated that beginning October 1, 2025, all hospitals that previously qualified for MDH status under section 1886(d)(5)(G) of the Act will no longer have MDH status and will be paid based on the IPPS Federal rate or other designation, such as SCH or RRC.

In the proposed rule we recognized the end of the MDH program on September 30, 2025, affects Track 2 participation eligibility. However, we also acknowledged that, historically, Congress has extended the MDH program, and in some instances retroactively reinstated the program. Therefore, we proposed that TEAM participants who are classified as MDHs would still be eligible for Track 2 participation as long as the MDH program is active at the time that participation track selections are due to CMS. As described in Sec. 512.520(b)(2), TEAM participants must notify CMS of its Track 2 selection prior to the performance year in a form and manner and by a date specified by CMS. For example, if CMS requests participation track selections by November 15, 2026, for PY 2 and the MDH program was set to expire on December 31, 2026, then TEAM participants with a MDH classification that submit their Track 2

selection by November 15, 2026, would be eligible for Track 2 for PY 2, regardless of whether the MDH program was active in PY 2. In contrast, using the previous scenario except that the MDH program expired on June 30, 2026, no TEAM participant could use their previous MDH classification for eligibility to participate in Track 2 for PY 2 because the MDH program was not active as of the deadline by which CMS requested participation track selections. We noted this proposal would not affect Track 2 eligibility for TEAM participants that meet the definition of safety net hospitals, rural hospitals, SCHs, or essential access community hospitals, as defined in Sec. 512.505.

In the proposed rule we believed that tying the eligibility for Track 2 participation for TEAM participants that have a MDH classification to the expiration of the MDH program allows TEAM participants to still take advantage of Track 2 participation while acknowledging that the MDH program is not indefinite. We anticipated that if the MDH program is not extended, then there would be minimal impact on Track 2 eligibility for this lower-risk participation track due to the overlap between the MDH classification as defined at Sec. 412.108 and TEAM's rural hospital definition, as defined at Sec. 512.505. Per Sec. 412.108, a necessary criterion for MDH classification is location in a rural area, which means any area outside an urban area as defined at Sec. 412.64, or, for hospitals located in a State with no rural area, satisfaction of any of the criteria for reclassification as rural as described in Sec. 412.103(a)(1) through (3) (65 FR 47048). For the purposes of TEAM, a rural hospital is defined as an IPPS hospital that meets one of the following criteria:

Is located in a rural area as defined under Sec. 412.64.

Is located in a rural census tract defined under Sec. 412.103(a)(1).

We noted in the proposed rule that qualification as rural under Sec. 412.64 encompasses all hospitals not located in an urban area, meaning a Metropolitan Statistical Area or a Metropolitan Division (in the case where a Metropolitan Statistical Area is divided into Metropolitan Divisions), as defined by the Office of Management and Budget (69 FR 49242). Qualification as rural under Sec. 412.103(a)(1) encompasses all hospitals located in a rural census tract of a Metropolitan Statistical Area as determined under the most recent version of the Goldsmith Modification,\405\ using the Rural-Urban Commuting Area codes and additional criteria, as determined by the Federal Office of Rural Health Policy (FORHP) of the Health Resources and Services Administration (HRSA), which is available at the web link provided in the most recent Federal Register notice issued by HRSA defining rural areas (65 FR 47048). For the purposes of TEAM, we stated in the proposed rule that a hospital's qualification as rural on the basis of location in a rural census tract as defined under Sec. 412.103(a)(1) is determined by location of the hospital's primary CCN within a rural census tract as defined under Sec. 412.103(a)(1), regardless of whether the hospital has applied for and received rural reclassification from CMS under Sec. 412.103.

\405\ The Goldsmith Modification was originally developed and used to identify rural Census tracts in large metropolitan counties. For additional information regarding the Goldsmith Modification, we direct readers to: https://www.ruralhealthinfo.org/pdf/improving-the-operational-definition-of-rural-areas.pdf.

We indicated in the proposed rule that since these two pathways to rural hospital designation cover both hospitals located outside of an urban area and hospitals located in a rural census tract within an urban area, we anticipated that a large proportion of hospitals that would have been designated as MDHs, and thus would have been eligible for participation in Track 2 during the TEAM performance period will continue to be eligible for participation in Track 2 due to rural hospital status.

We considered, but did not propose, continuing to classify hospitals in TEAM based on the existing MDH criteria beyond the expiration of the MDH program. While this option would maintain the list of Track 2-eligible hospitals as originally finalized in the FY 2025 IPPS/LTCH PPS final rule at Sec. 512.520(b)(4), we did not believe that it would be appropriate for TEAM to maintain hospital designations that are no longer maintained in Medicare more broadly. We also noted in the proposed rule that Sec. 412.108(b)(1) states that the Medicare Administrative Contractor (MAC) determines whether a hospital meets the criteria for MDH designation as specified in Sec. 412.108(a), and that Sec. 412.108(b) establishes classification procedures for MDH status (55 FR 15175). As a result, we did not believe that it would be appropriate for CMS to circumvent these established procedures for the purposes of TEAM. We also considered and are sought comment on, but did not propose, the potential for the CMS Innovation Center to provide support to TEAM participants that were designated as MDHs until the termination of the MDH designation, with such support including providing technical assistance in helping them determine their eligibility for other Track 2-eligible hospital designations, including rural and SCH. We stated in the proposed rule that such support may be necessary as the TEAM participant may not be aware of other hospital designations they may be eligible for given their potential long-standing participation in the MDH program. Table XI.A.-01 identifies the potential impact on TEAM participants if the MDH program were to expire. While we recognized in the proposed rule that hospitals with MDH designation may qualify for other hospital designations that are eligible to participate in Track 2 for PY 2 through 5 of TEAM, we also noted that provision of such assistance to TEAM participants could unfairly disadvantage non-participant hospitals that do not receive the same support from CMS.

[GRAPHIC] [TIFF OMITTED] TR04AU25.300

We sought comment on our proposal to determine MDHs' eligibility for Track 2 participation in TEAM based on the hospitals' status in the MDH program on the date CMS requires the TEAM participants to submit their track selections for the upcoming PY. We also sought comment on the potential for us to provide support to TEAM participants whose MDH designation ended as a result of the expiration of the MDH program in determining their eligibility for other hospital designations, such as rural and SCH, that are eligible for participation in Track 2 in PY 2 through 5 of TEAM.

The following is a summary of the public comments received on the proposed policy to determine MDHs' eligibility for Track 2 participation in TEAM, and our responses to these comments:

Comment: Some commenters expressed support for the proposal to determine MDHs' eligibility for Track 2 based on the hospitals' status in the MDH program on the date CMS requires the TEAM participants to submit their track selections for the upcoming PY.

Response: We thank the commenters for their support.

Comment: A few commenters recommended that CMS treat a hospital's MDH designation preceding PY 1 as qualification for Track 2 participation in all PYs of TEAM. A couple commenters indicated that the financial constraints and community needs faced by these hospitals would still be present even if the MDH designation were to be removed. A commenter stated that the additional certainty afforded to a hospital by locking in its Track 2 eligibility for the duration of the model based on its MDH status prior to PY 1 would allow the hospital to make additional investments in the model. A couple commenters recommended that CMS treat a hospital as an MDH for a given performance year if it held such designation in the previous performance year.

Response: We thank the commenters for their suggestions and recognize the financial challenges and community needs faced by MDHs and other rural hospitals. However, we believe that conferring Track 2 eligibility to a hospital for the full duration of the model based on its MDH status in 2025, or conferring Track 2 eligibility to a hospital for a given performance year based on its MDH status at the beginning of the prior performance year, would not be appropriate. As stated in the proposed rule, Sec. 412.108(b)(1) establishes that the Medicare Administrative Contractor (MAC) determines whether a hospital meets the criteria for MDH designation. We believe that it would not be appropriate for CMS to circumvent this procedure for the purposes of TEAM, nor for CMS to maintain hospital designations in TEAM that are not maintained within Medicare more broadly in the event that the MDH program is terminated. Additionally, we note that maintaining a hospital's eligibility for Track 2 in a given performance year based on its MDH status at a time other than the time of track selection for that performance year would unfairly disadvantage hospitals whose Track 2 eligibility determinations are made on the grounds of rural, SCH, or EACH status at the time of track selection. Finally, we remind commenters that rural hospital status in TEAM is determined by location in a rural area as defined under Sec. 412.64 or location in a rural census tract defined under Sec. 412.103(a)(1), regardless of whether the hospital has applied for and received rural reclassification from CMS under Sec. 412.103. Therefore, we anticipate that, if the MDH program is terminated, a large majority of hospitals that would have been eligible for Track 2 based on their MDH status will continue to be eligible for Track 2 by meeting the definition of a rural hospital in TEAM without requiring additional effort from the hospital to achieve this classification.

Comment: A few commenters requested that CMS provide technical assistance to hospitals that may lose MDH status.

Response: We thank the commenters for their suggestions. While we project that the majority of TEAM participants currently designated as MDHs would already qualify for Track 2 by being a safety net hospital, rural hospital, SCH, or EACH, we are actively exploring forms of support we could provide to MDHs if the MDH program is discontinued. Potential forms of support under consideration include, but are not limited to the following:

Targeted outreach to notify hospitals of changes in their MDH status.

Determination and notification of rural hospital status as defined in TEAM, regardless of existing rural reclassification from CMS.

Distribution of resources and interpretation of regulations related to qualification as a SCH or EACH.

We also welcome suggestions from TEAM participants on how we may best support them through potential changes in hospital classification and track eligibility.

After consideration of the public comments, we are finalizing without modification the proposal at Sec. 512.520(b)(4)(i) to determine MDHs' eligibility for Track 2 based on the hospitals' status in the MDH program on the date CMS requires the TEAM participants to submit their track selections for the upcoming PY. (4) Indian Health Services/Tribal Hospitals

As indicated earlier in section XI.A.2.a.(1). of the preamble of this final rule, and defined at Sec. 512.505, for a hospital to be a TEAM participant they must either--(1) initiate episodes and be paid under the IPPS with a CMS Certification Number (CCN) primary address located in one of the mandatory CBSAs selected for participation in TEAM; or (2) be a hospital that participates in either the BPCI Advanced Model or the CJR Model until the last day of the last performance period or last performance year of the respective model that voluntarily opts into TEAM and CMS approves their opt

in request. We indicated in the proposed rule that we received questions about Indian Health Service (IHS)/Tribal hospitals, as identified in section 1880 of the Act, participating in TEAM. In the FY2025 IPPS/LTCH PPS final rule, we discussed certain hospitals that would be ineligible for participation in TEAM due to not being paid under the IPPS and Outpatient Prospective Payment System (OPPS) (89 FR 69643). Specifically, hospitals located in the state of Maryland are precluded from being TEAM participants. We did not exempt IHS/Tribal hospitals from TEAM participation because IHS/Tribal hospitals are still paid under the IPPS. However, we noted that IHS/Tribal hospitals are not paid under the OPPS, as described in Sec. 419.20. We stated in the proposed rule that while the TEAM participant definition does not explicitly state a hospital needs to be paid under the OPPS to participate in the model, we recognized that allowing hospitals to participate in TEAM that are not paid under the OPPS may create challenges when constructing target prices for episodes that initiate in the hospital outpatient department, specifically for the LEJR and spinal fusion anchor procedures.

As described in section XI.A.2.c.(1) of the preamble of this final rule, TEAM participants will be provided with target prices for each MS-DRG/HCPCS episode type. These target prices will be calculated using 3 years of baseline data, trended forward to the performance year, at the level of MS-DRG/HCPCS episode type and region, with updates to be made using the performance year data during the reconciliation process. We noted in the proposed rule that while TEAM's target prices are constructed using regional level spending and would allow IHS/Tribal hospitals to receive a target price, including LEJR and spinal fusion target prices, there is concern on whether these target prices would accurately reflect the IHS/Tribal hospital's episode spending or allow them opportunity to achieve a reconciliation payment amount. That is because their historical spending for episodes initiated in the hospital outpatient department, specifically the hospital spending portion, would not be included in the regional spending since they are not paid under the OPPS, but rather Medicare pays them under an All- Inclusive Rate (AIR). We indicated in the proposed rule that all- inclusive rates are billed by encounter, which means the calculation of a rate accounts for all of the allowable costs of providing care. This differs from traditional fee-for-service rates, where specific services are billed at specific rates, even if more than one service is provided during an encounter.\406\ Therefore, it may be possible that IHS/Tribal hospital outpatient spending could be lower (or higher) compared to other hospitals in the same region. We further indicated in the proposed rule that since the regional target prices are constructed from IPPS and OPPS hospital spending, Medicare may be at risk for setting the LEJR and spinal fusion regional target prices too high or too low for IHS/Tribal hospitals, with the latter scenario making it more challenging for them to reduce LEJR and spinal fusion spending.

\406\ https://www.cms.gov/training-education/partner-outreach- resources/american-indian-alaska-native/ltss-ta-center/information/ ltss-financing/comparing-reimbursement- rates#:~:text=*%20All%2Dinclusive%20rates%20are%20billed%20by%20encou nter%2C,one%20service%20is%20provided%20during%20an%20encounter.

Given this concern, we considered but did not propose to exclude IHS/Tribal hospitals from initiating anchor procedures. Specifically, we considered updating Sec. 512.525(b) to not allow IHS/Tribal hospitals that are TEAM participants to have anchor procedure episodes attributed to them. This would mean that IHS/Tribal hospitals would not be able to initiate or have episodes attributed to them for LEJR and spinal fusions in the hospital outpatient department but would be able to initiate anchor hospitalizations, including LEJR and spinal fusion anchor hospitalizations. In the proposed rule we stated we believed this option would mitigate some of the concern with respect to regional prices being reasonable for IHS/Tribal hospitals. While we recognized that this could open an opportunity for patient shifting, given that episodes could be initiated in the inpatient setting but not the hospital outpatient department, we believed that the generally lower AIR, relative to IPPS rates, may disincentivize such actions. Nonetheless, given the potential incentive for patient shifting if IHS/ Tribal hospitals were only accountable for episode categories in one setting, we considered additional monitoring for IHS/Tribal hospitals in TEAM but we believed the existing monitoring requirements, as described in Sec. 512.590, would have been sufficient given the broad scope of monitoring requirements and the ability to impose a remedial action, as described in Sec. 512.592, if warranted.

We also considered, but did not propose, to exclude IHS/Tribal hospitals from initiating episode categories that include both anchor hospitalizations and anchor procedures. Specifically, we considered adding a provision to Sec. 512.525 that would exclude TEAM participants that are IHS/Tribal hospitals from the LEJR and spinal fusion episode categories. In other words, IHS/Tribal hospitals would not be eligible to initiate an anchor hospitalization or anchor procedure in the LEJR or spinal fusion episode category. This option would mitigate the potential concern for patient shifting and avoid the challenges of ensuring an accurate target price for IHS/Tribal hospitals. However, we were concerned that such an option would limit IHS/Tribal hospitals' participation in the model given the volume of episodes associated with the LEJR and spinal fusion episode categories, thus reducing the number of beneficiaries that would be captured in the model.

We also considered, but did not propose, excluding IHS/Tribal hospitals from the model, such that they would not satisfy the definition of TEAM participant. This would be done by updating the TEAM participant definition to state that a TEAM participant must be paid under IPPS and OPPS. We stated in the proposed rule that we recognized this consideration may not have a significant impact on the model with respect to episode volume. That is because we were aware that some IHS/ Tribal hospitals may not perform the procedures tested in TEAM at their hospital but may be a part of a beneficiary's follow-up care. In those instances, the IHS/Tribal hospital would not initiate an episode in TEAM because the anchor hospitalization or anchor procedure did not initiate at the IHS/Tribal hospital. However, we were concerned that fully excluding IHS/Tribal hospitals from TEAM, particularly for those IHS/Tribal hospitals that initiate anchor hospitalizations or anchor procedures, would limit beneficiary access to the potential benefits of the model, including high-quality coordinated care, and prevent IHS/ Tribal hospitals from gaining value-based care experience.

We also considered, but did not propose, constructing IHS/Tribal hospital specific target prices for anchor procedures. We stated in the proposed rule that this would also help to ensure that IHS/Tribal hospitals have reasonable target prices for anchor procedures. However, we recognized that creating an IHS/Tribal hospital specific target price would increase the target price calculation complexity, making it more challenging for IHS/Tribal hospitals to understand the

methodology and predict their episode spending.

Lastly, we also considered, but did not propose, including IHS/ Tribal hospitals as a hospital type eligible for Track 2 participation. However, we stated in the proposed rule that we also believed many IHS/ Tribal hospitals may already satisfy eligibility requirements for Track 2 due to being a safety net hospital or a rural hospital.

We sought comment on the alternatives we considered for IHS/Tribal hospitals. We also sought comment on alternatives that we may not have considered.

The following is a summary of the public comments received on the considerations for IHS/Tribal hospitals, and our responses to these comments:

Comment: Some commenters suggested the IHS/Tribal hospitals should be exempt from TEAM. A few commenters indicated that, because IHS/ Tribal hospitals are not paid OPPS, it would not be possible to construct accurate target prices for them and fairly assess their performance for LEJR and spinal fusion episodes. A few of these commenters indicated that limiting IHS/Tribal hospitals in the LEJR and spinal fusion episode categories to inpatient-only episodes would result in adverse selection between inpatient and outpatient episodes and recommended that, were CMS to not fully exempt IHS/Tribal hospitals from TEAM, they should, at minimum, exclude all LEJR and spinal fusion episodes at IHS hospitals. These commenters also expressed concern that simply limiting the IHS/Tribal hospitals participation in team to inpatient episodes would significantly reduce episode volume for LEJR and spinal fusion--because these procedures are increasingly provided in outpatient settings--resulting in low episode volume for these episode categories that may prevent accurate assessment of a hospital's performance. In response to our alternative considerations, a commenter suggested that participation in Track 2 would not provide sufficient protection for IHS/Tribal hospitals and that they should be provided the same protections as Track 1 hospitals. The same commenter suggested that a robust low-volume policy was also necessary to protect rural hospitals, sole community hospitals, and IHS/Tribal hospitals. Another commenter suggested that finalizing any alternative approach to calculating target prices and reconciliation payments for IHS/Tribal hospitals would not give these hospitals adequate time to plan for TEAM.

Response: We agree with commenters that inclusion of inpatient episodes but not outpatient episodes for LEJR and spinal fusion presents an opportunity for adverse selection and patient shifting between care settings which may not be clinically appropriate, as we previously stated in the proposed rule. We also agree with commenters that omitting outpatient episodes, while continuing to include inpatient episodes in TEAM, may make it difficult to establish fair and accurate target prices for IHS/Tribal hospitals and that lower episode volume due to exclusion only of outpatient episodes for LEJR and spinal fusion would result in an incomplete picture of a participant's performance for these episode categories. We further agree that proposing and finalizing any new, alternative approach to calculating target prices for IHS/Tribal in this final rule would not give these hospitals adequate time to plan for TEAM.

Therefore, we are finalizing a policy to exclude IHS/Tribal hospitals from the model by updating the TEAM participant definition to state that a TEAM participant must be paid under IPPS and OPPS. Specifically, we are finalizing a modification to the TEAM participant definition at Sec. 512.505 to define a TEAM participant as an acute care hospital that (1) initiates episodes and is paid under the IPPS and OPPS with a CMS Certification Number (CCN) primary address located in one of the mandatory CBSAs selected for participation in TEAM in accordance with Sec. 512.515; or (2) Makes a voluntary opt-in participation election to participate in TEAM in accordance with Sec. 512.510 and is accepted to participate in TEAM by CMS. We recognize that excluding IHS/Tribal hospitals from TEAM will reduce episode volume, thereby limiting the reach of the model. However, an internal analysis demonstrated that when using the first half of 2024 as a performance year, it was estimated that IHS/Tribal hospitals initiated only 158 (0.03%) episodes. Given the small episode footprint of IHS/ Tribal hospitals, we believe excluding IHS/Tribal hospitals from TEAM will not have a significant impact on TEAM in terms of episode volume and beneficiary access to the model. Further, IHS/Tribal hospitals' exclusion from TEAM does not exclude them or their clinicians from other value-based care initiatives, such as the Quality Payment Program. Therefore, clinicians may still gain value-based care experience, and beneficiaries still have access to clinicians focused on value and quality of care.

After consideration of the public comments, we are finalizing the exclusion of IHS/Tribal hospitals from TEAM by making a modification to the TEAM participant definition at Sec. 512.505 to state that a TEAM participant must be paid under the IPPS and OPPS. Lastly, we note that this policy applies to all IHS/Tribal hospitals without regard to episode volume. While we agree with commenters about the importance of a low-volume policy, which we are addressing in section XI.A.2.c.(8). of the preamble of this final rule, this low volume policy would not affect IHS/Tribal hospitals given their exclusion from TEAM. b. Quality Measures (1) Background

As discussed in the FY 2025 IPPS/LTCH PPS final rule (89 FR 68986), Medicare payment policy has moved away from FFS payments that are not linked to quality of care. As noted in the proposed rule, through the Medicare Modernization Act and the Affordable Care Act, we have implemented specific IPPS programs like the Hospital Inpatient Quality Reporting (IQR) Program (section 1886(b)(3)(B)(viii) of the Act), the Hospital Value-Based Purchasing (VBP) Program (subsection (o) of section 1886), the Hospital-Acquired Condition (HAC) Reduction Program (subsection (q) of section 1886), and the Hospital Readmissions Reduction Program (subsection (p) of section 1886), where payment reflects the quality of care delivered to Medicare beneficiaries.

TEAM's quality measures focus on care coordination, patient safety, and patient reported outcomes (PROs) which we believe represent areas of quality that are particularly important to patients undergoing acute procedures. We indicated in the proposed rule that wherever possible, we align TEAM quality measures with those used in ongoing models and programs to minimize participant burden, recognizing that introducing new reporting functions and requirements in a mandatory model would create additional burden. Hospitals are not required to report quality data separately to CMS for TEAM. CMS will use data already reported through existing CMS quality reporting programs, thereby avoiding duplicative reporting requirements. We also stated in the proposed rule that we aim to use quality measures in which all hospitals would have access and experience.

We finalized in the FY 2025 IPPS/LTCH PPS final rule a set of quality measures tied to payment, with these measures scored to calculate the Composite Quality Score (CQS). The CQS would be combined with the

TEAM participants' reconciliation amount during the reconciliation process to tie quality performance to payment. The finalized set of TEAM quality measures from the FY 2025 IPPS/LTCH PPS final rule have been summarized in Table XI.A.-02. [GRAPHIC] [TIFF OMITTED] TR04AU25.301

For performance year 1, we proposed and finalized three quality measures (noted later in this section) due to their: (1) alignment with the goals of TEAM; (2) hospitals' familiarity with the measures due to their use in other CMS hospital quality programs, including the Hospital IQR and HAC Reduction Programs; and (3) alignment to CMS priorities, including the CMS National Quality Strategy, which has goals that support safety, outcomes, and engagement. We stated in the proposed rule that we believe these three TEAM PY1 quality measures that link to payment reflect these goals and accurately measure hospitals' level of achievement on such goals.

These PY1 measures are--

For all TEAM episodes: Hybrid Hospital-Wide All-Cause Readmission Measure with Claims and Electronic Health Record Data (CMIT ID #356);

For all TEAM episodes: CMS Patient Safety and Adverse Events Composite (CMS PSI 90) (CMIT ID #135); and

For LEJR episodes: Hospital-Level Total Hip and/or Total Knee Arthroplasty (THA/TKA) Patient-Reported Outcome-Based Performance Measure (PRO-PM) (CMIT ID #1618).

Additionally, we proposed and finalized in the FY 2025 IPPS/LTCH PPS final rule the inclusion of three measures that were included in the Measures Under Consideration List (known as the MUC List) that were subsequently finalized (89 FR 69540 and 89 FR 69552), starting in PY 2 (2027), and will replace the PSI 90 measure. These three measures are as follows:

For all TEAM episodes: Hospital Harm--Falls with Injury (CMIT ID #1518) (starting in PY 2).

For all TEAM episodes: Hospital Harm--Postoperative Respiratory Failure (CMIT ID #1788) (starting in PY 2).

For all TEAM episodes: Thirty-day Risk--Standardized Death Rate among Surgical Inpatients with Complications (Inpatient Surgical Compilations Mortality Rate) (CMIT ID #134) (starting in PY 2).

We stated in the proposed rule that the Inpatient Surgical Complications Mortality Rate measure began mandatory reporting with the July 1, 2023-June 30, 2025, reporting period, while the other two (Hospital Harm--Falls with Injury and Hospital Harm--Postoperative Respiratory Failure) are available on the list of eCQMs from which hospitals must select to report three beginning with the CY2026 reporting period. This timeline will allow TEAM participants to have 1 year to gain experience reporting all three of these measures in the Hospital IQR program before their performance is tied to payment beginning in TEAM's second performance year (2027).

While we believe the TEAM quality measure set would provide CMS with sufficient measures to monitor quality and to calculate scoring on quality performance, we stated in the proposed rule that we may adjust the measure set in future performance years, via rulemaking, by adding new measures or removing measures if we determine those adjustments to be appropriate at the time. In this final rule, we will finalize several changes to and clarifications around the TEAM quality measure set finalized in the FY 2025 IPPS/LTCH PPS final rule. (2) Alignment of Hybrid Hospital-Wide Readmission Measure to Hospital IQR Program

As stated previously, TEAM aims to, whenever possible, align measures with existing reporting requirements so as not to introduce additional burden to participants. This includes aligning the TEAM Hybrid Hospital-Wide Readmission (HWR) Measure reporting requirements with what is required under the Hospital Inpatient Quality Reporting (IQR) Program. The Hybrid HWR measure combines claims data with electronic health record (EHR) data to risk-adjust hospital readmission rates, accounting for patient severity and illness at admission. We noted in the proposed rule that the Hospital IQR Program initially planned that the Hybrid HWR measure would be mandatory, beginning with the July 1, 2023-June 30, 2024, reporting period. However, after public feedback on reporting difficulties, the Hospital IQR Program finalized in the CY 2025 Hospital OPPS Final Rule (89 FR 93912) the continuation of voluntary reporting of the clinical data elements for the Hybrid HWR for the July 1, 2023, through June 30, 2024, reporting period and the July 1, 2024, through June 30, 2025, reporting period. Mandatory reporting will begin the following reporting period (July 1, 2025, through June 30, 2026), impacting TEAM's PY 1. Additionally, we stated in the proposed rule that CMS has recognized public input regarding the difficulties in reporting the clinical data elements and is finalizing proposals in section X.C. of the preamble of this final rule the following allowances: up to two missing laboratory results; up to two missing vital signs; the reduction of the CCDE (core clinical data elements) submission requirement to 70 percent or more of discharges, and; the reduction of the submission requirement of linking variables to 70 percent or more of discharges.

We noted in the proposed rule that we recognize that this change means that

the first year of mandatory reporting (July 1, 2025, through June 30, 2026) for the Hybrid HWR will serve as the baseline performance period for TEAM's PY1. We further stated in the proposed rule that in order to allow additional time to gain experience with the measure, we considered not aligning with the Hospital IQR Program and delaying mandatory reporting for TEAM for an additional period of time. However, since hospitals will have multiple years of voluntary reporting of the Hybrid HWR measure under the Hospital IQR Program prior to the mandatory requirement, and because the mandatory requirement contains additional allowances, we believed that TEAM participants will have sufficient time to prepare. Additionally, we believed that aligning the TEAM Hybrid HWR measure as closely as possible to the requirements under the Hospital IQR Program will be the most straightforward approach for TEAM participants.

Since TEAM aims to align with the Hospital IQR Program's requirement for the Hybrid HWR, we proposed to align with the requirements set forth at 89 FR 93912, including utilizing the mandatory reporting period of July 1, 2025-June 30, 2026, as TEAM's PY1 baseline period, and including the revised submission requirements.

We sought comment on aligning with the Hospital IQR Program, specifically utilizing the first mandatory reporting period of July 1, 2025, through June 30, 2026, as the TEAM PY1 quality measure performance period for the Hybrid HWR measure. Additionally, we also sought comment on alternate considerations, including whether TEAM should not align with the Hospital IQR Program and, as during the voluntary reporting period, only use claims-based elements of the Hybrid HWR for quality measurement.

The following is a summary of the public comments received on the proposed policy to align with the Hospital IQR Program on the Hybrid HWR measure, and our responses to these comments:

Comment: A few commenters supported the alignment of the Hybrid HWR measure with the IQR Program, stating this approach reduces participant burden and streamlines reporting.

Response: We thank the commenters for their support of the alignment of the Hybrid HWR measure with IQR Program and we agree that it is important to use measures in TEAM that minimize reporting burden so that TEAM participants can focus on making meaningful quality improvements.

Comment: Commenters expressed concerns about CMS' proposal to use the first mandatory reporting period of July 1, 2025, through June 30, 2026, as both the baseline and performance period for TEAM. This commenter noted that this timing creates problematic situations where hospitals will not have insight into national measure performance until January 2027, with hospital-specific reports unavailable until Spring 2026 and public data not available until Summer 2026. This commenter noted that hospitals will be in downside risk before knowing their performance on the measure.

Response: We acknowledge the commenter's concerns regarding the timing of using the first mandatory reporting period (July 1, 2025 through June 30, 2026) as both the baseline and performance period for TEAM. We thank the commenter for their input, and, as noted later in this section, we are opting to maintain the policy we finalized in the FY 2025 IPPS/LTCH PPS Final Rule that instead uses two separate periods for the PY1 CQS baseline period and PY1 measure performance period. That is to say for the Hybrid HWR measure in PY1, the CQS baseline period will be CY 2025 and the measure performance period is July 1, 2024, through June 30, 2025. We recognize that this measure performance period does not require hospitals to report the core clinical data elements and linking variables under the Hospital IQR Program. Therefore, for PY1, only the claims-based portion of the Hybrid HWR will be used in the CQS calculation. By focusing on the claims-based portion of the measure, we believe this will remove any influence the voluntary core clinical data elements portion of the measure will have on quality measure performance in TEAM. Further, we believe this approach maintains consistency and alignment with Hospital IQR Program's reporting periods for this measure, while allowing TEAM participants to establish benchmarks and build familiarity with reporting. However, we will continue to assess our quality measure approach, and if warranted, will make modifications in future notice and comment rulemaking.

Comment: Multiple commenters highlighted data collection and reporting challenges encountered during voluntary reporting of this measure that raise questions about the measure's readiness for implementation. Commenters reported difficulties with Electronic Health Record (EHR) derived data collection, concerns about data completeness, accuracy issues with vital signs and laboratory values, problems with linking variables, and complications with the patient matching process between EHR data and Medicare claims. A commenter made the recommendation to monitor hospitals' ability to collect and report on the Hybrid HWR measure due to existing concerns over the completeness of EHR data. A commenter also noted that patients may have been inappropriately included or excluded from measure calculations, indicating the methodology requires additional refinement. A commenter suggests to CMS to oversee hospitals' capability to report on this measure and to continue to refine the measure to better align with clinical workflows to ensure reliable and valid scores are produced. Commenters supported CMS's proposed reduction of data completeness thresholds from 95 percent to 70 percent but questioned whether modified reporting thresholds would apply to TEAM hospitals and expressed concerns about measure feasibility even with reduced thresholds.

Response: We understand the challenges related to accurate data and electronic health records that hospitals face when implementing quality measures. CMS heard feedback related to reporting burden and has made corresponding alterations in the Hospital IQR Program to extend voluntary reporting of the clinical data elements for the Hybrid HWR measure. For TEAM quality measurement, we believe alignment with existing CMS quality reporting requirements will reduce burden and enhance clarity for TEAM's quality measure approach. We will continue to listen to the public and hospital feedback and if adjustments are made to existing CMS quality reporting requirements, we would aim to adopt those changes in TEAM, where possible, and in future notice and comment rulemaking.

Comment: A commenter noted the inclusion of the Hybrid HWR measure in TEAM is duplicative since readmission costs are already embedded in episode spending. This commenter provided analysis showing that 81.3 percent of hospital readmissions are driven by non-surgical admissions while TEAM episodes are initiated by surgical procedures, and that only 7 percent of inpatient discharges correspond to MS-DRGs that would initiate a TEAM episode, meaning 93 percent of the measure denominator is unrelated to TEAM. This commenter deems the Hybrid HWR measure an unrelated quality performance measure to determine financial penalties in TEAM.

Response: We thank the commenter for their concerns regarding the appropriateness of including the Hybrid HWR measure in TEAM. While we understand the commenter's concern, we disagree that the measure is duplicative given the incentive structure and quality calculations in TEAM differs from other CMS quality reporting programs. Further, we believe this measure aims to drive positive change, not just for TEAM beneficiaries, but encourages hospitals to improve care delivery and reduce re-admissions for all inpatient beneficiaries. Therefore, using the same measure as other CMS quality reporting programs has the benefit of capitalizing on a measure that the hospital is already reporting, while also encouraging hospitals to implement protocols that reduce re-admissions for all inpatient beneficiaries, not just for those who have initiated a TEAM episode.

Comment: Commenters made various recommendations including delaying implementation by at least 1 year, using only claims-based elements initially during PY1 to reduce reporting burden, removing the measure entirely from the composite quality score (CQS), using the first mandatory reporting year as baseline rather than performance period, or implementing the legacy Hospital-Wide Readmission measure until the hybrid version is operational. A commenter raised equity concerns about safety net providers facing structural challenges in data collection due to patient demographics, health literacy, and language barriers, which, they stated, could result in unfair penalties based on patient population characteristics rather than care quality.

Response: We thank and recognize commenters vast recommendations that reflect genuine concerns around hospitals' readiness and capacity to implement the Hybrid HWR measure effectively. We acknowledge the thoughtful feedback regarding implementation timelines, data collection challenges, and the need for operational flexibility as hospitals navigate the transition to hybrid reporting methodologies. We are attentive to the concerns raised about safety net providers, recognizing that structural challenges related to patient demographics, health literacy, and language barriers could inadvertently result in penalties that reflect patient population characteristics rather than actual care quality. CMS remains committed to ongoing monitoring of measure feasibility and will continue to engage with stakeholders to ensure that quality measures accurately reflect quality of care rather than penalizing providers who serve vulnerable populations with complex healthcare needs.

After consideration of the public comments, we are not finalizing a change to the Hybrid HWR measure as proposed, but instead, will maintain the policy as finalized in the FY 2025 IPPS/LTCH PPS final rule. This finalized policy will utilize CY 2025 for the PY1 CQS baseline period and use July 1, 2024-June 30, 2025 as the measure performance period for the Hybrid HWR measure. Additionally, TEAM is maintaining alignment with the Hospital IQR Program. Given that CMS has extended the voluntary reporting of the core clinical data elements and linking variables for the Hybrid HWR measure through June 30, 2025, this means that for PY1, we will use the claims-only portion of the Hybrid HWR measure in the CQS calculation. In subsequent TEAM performance years, the complete Hybrid HWR Measure--incorporating both claims data and core clinical data elements--may be utilized once the core clinical data elements transition from voluntary to required reporting. Any changes or modifications, including modifications to the data used to construct the measure or the CQS baseline period, will be implemented through future notice and comment rulemaking. (3) Information Transfer Patient Reported Outcome-Based Performance Measure (Information Transfer PRO-PM)

We stated in the proposed rule that the existing quality measures finalized in the FY 2025 IPPS/LTCH PPS final rule for TEAM were selected based on their relevance to episode categories tested in the model, while also considering the reporting burden on participants. These measures focus on key domains, including hospital readmissions, patient safety, and patient reported outcomes, which we believe represents areas of quality that are particularly important to patients undergoing acute procedures. We continue to believe that quality measures used in TEAM should address one of these domains, given their importance to patient quality of care and relationship to episode care management.

As stated in FY 2025 IPPS/LTCH PPS final rule (89 FR 68986), we wish to incorporate more patient-reported outcome measures (PRO-PMs) into TEAM, as these measures provide valuable insights into the patient's perspective of care received. We indicated in the proposed rule that we also wish to incorporate quality measures that capture care in the outpatient setting, given the LEJR and Spinal Fusion episode categories initiate in the hospital outpatient department (HOPD) setting and all the measures finalized in the FY 2025 IPPS/LTCH PPS final rule (89 FR 68986) are measures of inpatient performance.

To identify potential quality measures for episode categories initiated in the HOPD, we stated in the proposed rule that we reviewed quality measures from the CMS Hospital Outpatient Quality Reporting Program (Hospital OQR Program) that align with the domains emphasized in TEAM. To maintain a reasonable volume of quality measures in TEAM, we aimed to identify a single measure that would be clinically meaningful for both the LEJR and Spinal Fusion episode categories, rather than adding separate quality measures for each. We identified one quality measure, the Risk-Standardized Hospital Visits Within 7 Days After Hospital Outpatient Surgery, that hospitals are required to report to the Hospital OQR Program, as well as two quality measures that hospitals may voluntarily report: the Risk-Standardized PRO-PM Following Elective Primary THA and/or TKA in the HOPD Setting, and the Information Transfer PRO-PM. We stated in the proposed rule that we evaluated the suitability of each quality measure for TEAM based on its pros and cons.

The Risk-Standardized Hospital Visits Within 7 Days After Hospital Outpatient Surgery is applicable to both the LEJR and Spinal Fusion episode categories, focuses on hospital readmissions, and could be included in TEAM for PY1 (CY 2026) given its current mandatory reporting status in the Hospital OQR program. However, it does not advance CMS's or the model's goal of increasing the number of PRO-PMs.

The Risk-Standardized PRO-PM Following Elective Primary THA and/or TKA in the HOPD Setting aligns well with the existing THA/ TKA PRO-PM for inpatient LEJR episodes and would increase the number of PRO-PMs in the model; however, it is only applicable to LEJR episodes, and mandatory reporting for the Hospital OQR Program will not begin until PY3 of TEAM (CY 2028).

The Information Transfer PRO-PM is applicable to both the LEJR and Spinal Fusion episode categories and would increase the number of PRO-PMs in the model; however, mandatory reporting for the Hospital OQR Program will not begin until PY2 of TEAM (CY 2027).

Since our aim is to create a meaningful and efficient quality

measure set, we stated in the proposed rule that we did not believe it is necessary to include all three measures in TEAM. Given that the Risk-Standardized PRO-PM Following Elective Primary THA and/or TKA in the HOPD Setting measure is only applicable to the LEJR episode category, we did not consider it beneficial to propose this measure for use in TEAM. Of the remaining two measures, we recognized the value of the Risk-Standardized Hospital Visits Within 7 Days After Hospital Outpatient Surgery; however, this focuses on hospital readmissions and did not provide the patient viewpoint afforded by PRO-PMs that we are prioritizing capturing in the model. As such, we proposed the addition of the Information Transfer PRO-PM for all episode categories initiated in the HOPD in TEAM. We stated in the proposed rule that the Information Transfer PRO-PM can apply to all episode categories initiated in the HOPD under TEAM as it evaluates how well information is transferred to patients after outpatient procedures, particularly in HOPDs. Additionally, we stated that this measure captures patient viewpoint afforded by PRO-PMs.

To ensure alignment with the Hospital OQR Program, we proposed using the following measure specifications, as detailed and updated here: https://www.cms.gov/files/document/patient-understanding-key-information-related-recovery-after-facility-based-outpatient-procedure-or.pdf. We indicated in the proposed rule that this document outlines key information related to the Information Transfer PRO-PM and highlights the need for improved patient education for post-discharge instructions. The measure was developed by Yale New Haven Services Corporation for CMS and tested across hospital outpatient departments. We stated in the proposed rule that the goal of this measure is to enhance recovery outcomes by standardizing information transfer. We also proposed including the Information Transfer PRO-PM starting in PY3 (CY 2028) with a CY 2027 CQS baseline period and the following quality measure performance periods as displayed in Table XI.A.-03. [GRAPHIC] [TIFF OMITTED] TR04AU25.302

We believed that including the Information Transfer PRO-PM in TEAM would enhance the model because it is a general measure not tied to a specific clinical diagnosis or procedure. We stated in the proposed rule that this flexibility means it could apply to current episode categories initiated in the HOPD and any future episode categories, if proposed and finalized in future rulemaking. We also emphasized the importance of increasing the number of PRO-PMs, as they offer a direct way to incorporate patient input into quality measure performance. We further believed that delaying the inclusion of the Information Transfer PRO-PM until PY3 would allow TEAM participants to gain 1 year of mandatory reporting experience before the measure is incorporated into TEAM, affecting their composite quality score (CQS) and ultimately their reconciliation amounts. Lastly, we stated in the proposed rule that similar to the other two measures that we considered but did not propose (THA/TKA PRO-PM and Hospital Visits within 7 Days after Hospital Outpatient Surgery), inclusion of the Information Transfer PRO-PM aligns with those used in ongoing models and programs (this measure aligns with already existing reporting requirements for the Hospital Outpatient Quality Reporting (OQR) Program) and therefore, would not increase TEAM participant burden.

We sought comment on our proposal to include the Information Transfer PRO-PM in TEAM starting in PY 3. We also sought comment on other quality measures, including options for capturing quality of care in the outpatient setting and other PRO-PMs appropriate for TEAM quality measurement.

The following is a summary of the public comments received on the proposed policy to include the Information Transfer PRO-PM in TEAM in PY3, and our responses to these comments:

Comment: Many commenters provided support for the inclusion of PRO- PM based measures, highlighting their importance in capturing the patient's voice in assessing healthcare quality, as well as provider- patient communication and the patient's understanding of their role in recovery and outcomes. Additionally, these commenters emphasized their appreciation that these PRO-PMs align with existing reporting requirements and therefore do not increase participant reporting burden.

Response: We thank the commenters for their feedback and support regarding the inclusion of the Information Transfer PRO-PM. We agree this quality measure emphasizes the importance of the ongoing collaborative relationship between the provider and patient, the need for clear and effective discharge instructions, and improving recovery outcomes. We also agree with the importance of aligning with existing reporting requirements so as not to increase participant reporting burden.

Comment: A couple of commenters stated their support in the inclusion of this quality measure in TEAM, highlighting the relevance of the Information Transfer PRO-PM in outpatient settings where clear post-discharge instructions and medication adherence are crucial. A commenter raised concerns for accurate information transfer assessment and patient understanding influenced by factors like health literacy and language barriers, especially among older, complex patients. A couple of commenters made suggestions for operationalizing this measure, including the availability of technical guidance, standardized tools and learning collaboratives, especially if this measure is expanded to other settings outside of the hospital outpatient setting.

Response: We thank the commenters for their support of the Information Transfer PRO-PM in the hospital outpatient setting. We agree that the elements this measure incorporates are indeed crucial for patient care, specifically the importance of clear post-discharge instructions and medication adherence, as these commenters highlighted. We also appreciate the suggestions for technical

guidance, standardized tools, and learning collaboratives to assist in the successful implementation of this measure, including how to address measurement challenges related to health literacy, language barriers and older, complex patients. We refer the commenters to the CY 2026 OPPS/ASC final rule (89 FR 94408) for measure specifications. We recognize the potential need for additional technical assistance and guidance as the model progresses and will consider this in the development of materials specifically for the inclusion in the TEAM model.

Comment: A few commenters supported the inclusion of the Information Transfer PRO-PM and suggested the inclusion of additional PRO-PM quality measures. A commenter encouraged CMS to include measures related to musculoskeletal episode categories and to work with subject matter experts to find the most appropriate for TEAM. Another commenter emphasized the need to include more robust functional outcome measures, such as the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 (PROMIS-10), to improve the evaluation of patient functional outcomes and the current wide use in orthopedic and rehabilitation cases. A commenter suggested incorporating the CollaboRATE Shared Decision-Making Tool for Outpatient or Ambulatory Surgery Patients into quality programs and future performance years of TEAM.

Response: We appreciate the commenters' support for the inclusion of the Information Transfer PRO-PM in outpatient settings. During model development, we did consider, but decided against, using the Patient- Reported Outcomes Measurement Information System (PROMIS) Global-10 generic PRO survey given the current episodes in TEAM and the concern of increasing participant and patient burden for generic PRO data. We will continue to assess the evolving inventory of measures and refine measures based on public comments, changes to payment methodologies, recommendations from TEAM participants and their collaborators, and new CMS episode measure development activities. While the CollaboRATE Shared Decision-Making Tool for Outpatient or Ambulatory Surgery Patients tool is not currently mandatory for CMS quality reporting, CMS encourages participants to use tools they find useful and helpful in gaining insight into shared decision making and improving quality and patient outcomes. We will continue to assess TEAM quality measures and refine as the model moves forward.

Comment: A commenter appreciated CMS's inclusion of the Information Transfer PRO-PM in TEAM. They stated that, in addition to the Hybrid Hospital-Wide Readmission (HWR) Measure, the Information Transfer PRO- PM was an important step toward evaluating care transitions and patient safety. However, the commenter encouraged CMS to expand the quality measurement framework to better reflect the full scope of recovery following surgery. They emphasized the critical role of post-acute care providers in helping beneficiaries regain mobility, self-care abilities, and independence and recommended CMS consider additional functional outcome measures across all episodes to recognize the contributions of post-acute care in supporting recovery and return to the community. They also highlighted the importance of cognitive health as a key determinant of recovery, particularly for older adults. They suggested CMS explore the inclusion of cognitive function measures or include cognitive function as an outcomes measure risk adjuster. The commenter encouraged TEAM to align with the IMPACT Act domains. The commenter stated there is an opportunity to further strengthen TEAM by facilitating post-acute care provider health information exchange interoperability capacity and CMS should focus on supporting and including incentives to improve bidirectional data exchange.

Response: We thank the commenter for their feedback and support of the inclusion of the Information Transfer PRO-PM and the Hybrid Hospital-Wide Readmission (HWR) Measure in TEAM, recognizing these measures as important steps toward evaluating care transitions and improving patient outcomes. We will continue to evaluate the need for additional patient-reported outcome measures, cognitive function measures or risk-adjustments for cognitive function in TEAM to capture the role of post-acute care in supporting recovery. We appreciate the feedback including suggestions to improve bidirectional data exchange, especially for post-acute care providers. We will continue to assess the need to expand quality measures in TEAM and how these measures provide continued support in improving numerous facets of overall care.

Comment: Many commenters expressed concerns about the new Information Transfer PRO-PM measure and the lack of reporting data and feedback on the measure prior to its inclusion in TEAM. A couple of commenters suggested quality measures included in the model should undergo mandatory reporting for at least 1 or 2 years before implementation in the model and quality scoring methodology. A couple of commenters recommended delaying its adoption until 2029 (TEAM PY4) to allow hospitals to understand their performance relative to others, while some other commenters requested this measure be excluded from the model.

Response: CMS's inclusion of the Information Transfer PRO-PM starting in PY3 (CY 2028) allows TEAM participants time for voluntary reporting and 1 year of mandatory reporting experience before the measure is incorporated into TEAM. We disagree with extending the timeframe further, as the current plan does not increase reporting burden by incorporating it into TEAM, as we are aligning with the mandatory reporting of the Hospital OQR program. As finalized later in this section, the Information Transfer PRO-PM will remain in TEAM beginning in PY3.

Comment: A few commenters requested CMS evaluate the fairness of the PRO-PM measure for safety net hospitals, specifically highlighting the need for risk adjustment and concerns of participants being penalized for low volume of responses.

Response: CMS will continue to evaluate the need to make modifications for safety net hospitals due to low volume responses. Any updates or changes made will be incorporated into future notice-and- comment rulemaking. Additionally, we refer the commenters to the CY 2026 OPPS/ASC final rule (89 FR 94408) for measure specifications.

Comment: Many commenters have expressed their disagreement with the inclusion of the Information Transfer PRO-PM, citing several issues. They believe its implementation increases the administrative burden on staff, and increases the need to build infrastructure, provide training, and adds costs, such as paying external vendors or hiring internal staff. Additionally, the commenters mention survey fatigue, selection bias, access issues, and electronic and language barriers among patients. Many of these commenters suggested the need for technical assistance with implementation and had questions regarding operationalizing the PRO-PM. They raised concerns about eligibility determination, survey anonymity and tracking, lack of EHR integration across providers, validation of the measure, data handling protocols, risk adjustment for those with reduction in cognitive function, and survey overlap. Many

commenters shared concerns regarding the reporting threshold and a commenter suggested reducing the survey volume to 35 percent for 2 additional years or allowing documentation of two failed attempts to collect follow-up data as a pass to help participants manage data capture without significant penalties and give patients time to become familiar with the measures. A commenter noted how participants with low volume may receive a neutral quality score with no path to improvement. Many commenters shared concerns including the measure's applicability to a broad patient population and not specific to TEAM episodes, increased burden on hospitals and patients, and operational challenges when surveying patients pre- and post-surgical events. Some commenters also noted the complexity and cost of administering PRO-PMs, the lack of comparative benchmarks, and the resource demands and technical difficulties associated with the measure.

Response: We acknowledge the concerns related to the operational challenges associated with implementing the Information Transfer PRO- PM. We believe the voluntary reporting period, followed by 1 year of mandatory reporting prior to its integration into TEAM, will provide participants with the opportunity to address these challenges. We refer the commenters to the CY 2026 OPPS/ASC final rule (89 FR 94408) for data sources and measure specifications. We recognize the potential need for additional technical assistance and guidance as the model progresses and will consider this in the development of materials specifically for the inclusion in TEAM. The broad scope of the Information Transfer PRO-PM was intentionally chosen to encompass all TEAM episodes and any future episodes added to the model.

Comment: Some commenters emphasized the need for episode-specific quality measures rather than general measures and did not support the inclusion of the Information Transfer PRO-PM. A commenter noted that the PRO-PM provides little insight into the quality of care for spinal fusion procedures since it is not specific to these procedures. A few commenters suggested using specialty society clinical data registries relevant to each specific episode included under the model. Another commenter noted that PRO-PMs do not provide timely feedback to make improvements in patient care. A commenter suggested only including the current THA/TKA PRO-PM instead of adding another PRO-PM. Another commenter recommended developing new quality measures specifically designed for TEAM. Additionally, a commenter encouraged the use of the 3-Item Care Transition Measure (CTM-3) as an alternative measure and a commenter proposed the THA/TKA PRO-PM that will be available in the OQR in 2028.

Response: We appreciate the feedback provided by the commenters. We acknowledge the preference for episode-specific measures among TEAM participants and we will consider incorporating such measures, including registries, where applicable in future rulemaking. The inclusion of general measures serves multiple goals of TEAM, including providing an indicator of overall quality of care at the hospital level. Additionally, the current measures are part of the hospital- required reporting program, which prevents duplicative reporting by participants. We will move forward with the inclusion of the Information Transfer PRO-PM as this measure encompasses a 9-question survey spanning across the three domains of applicability, medications, and daily activities, as opposed to the three questions in the CTM-31. Additionally, regarding the THA/TKA PRO-PM for outpatient reporting, this would only apply to our outpatient LEJR episodes. The Information Transfer PRO-PM applies to all outpatient episodes, and we believe it is important to use a measure that can capture quality in the outpatient setting for all episode categories rather than limiting it to a single episode category. Further, if we add other outpatient episode categories to the model through notice and comment rulemaking, we would not have to expand TEAM's quality measure set because the Information Transfer PRO-PM could be applied to future outpatient episode categories.

Comment: A couple of commenters discussed that the current quality measures capture all hospital patients, not just those specific to the episode being analyzed under TEAM. They expressed concerns that these measures do not provide a true picture of quality for TEAM episodes and a very small number of clinical episodes make-up the quality measure. A commenter discussed the concern that participants would not receive penalties for low-quality care with the current model structure. A commenter requested clarification on how volume constraints will be addressed in the measure calculation.

Response: Previous episode-based payment models, including the BPCI Advanced model, have utilized similar hospital-level quality measures to assess participant quality performance. Therefore, we believe this approach is consistent with other CMS models. We acknowledge TEAM participants' preference for episode-specific measures. We will consider incorporating episode-specific measures where applicable and may propose them in future notice and comment rulemaking. We disagree with the commenter that the Information Transfer PRO-PM does not assess quality, as it captures key information regarding the patient's understanding of discharge instructions, which benefits many aspects of their care and progress toward recovery. This measure allows hospitals to identify their strong areas of communication and where overall improvements can be made, which is vital to improving outcomes and reducing harm. We also recognize that participants may need clarification regarding measure calculation, including specifics related to low volume. As we continue to move forward with TEAM, this information will be considered as we develop informational materials to best support the needs of participants throughout the model period. Additionally, we refer the commenters to the CY 2026 OPPS/ASC final rule (89 FR 94408) for data sources and measure specifications.

Comment: A commenter noted that the measure does not accurately assess quality because it evaluates the patient's understanding of the information rather than the quality of the information provided. They also pointed out that the study CMS cited in support of the measure based its conclusions on documentation review rather than patient responses.

Response: We appreciate the feedback provided by the commenter. We disagree with the commenter that the Information Transfer PRO-PM does not accurately assess quality. The survey results provide hospitals with valuable patient-reported outcome (PRO) data designed to evaluate communication efforts. This data enables hospitals to mitigate the risk of patient harm that may occur if patients do not fully understand their recovery information. Patient responses are crucial for making overall improvements in the path to recovery. For more information, we refer the commenter to the Hospital OQR Specifications Manual, Patient Understanding of Key Information Related to Recovery After a Facility- Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure (PRO-PM) Measure ID #: OP-46.

Comment: A commenter discussed the current alignment of the Information

Transfer PRO-PM eligibility with the criteria used for the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) survey. The commenter stated this alignment narrows the original eligibility for the measure and requested a Current Procedural Terminology (CPT) crosswalk between TEAM episodes to ensure all of those who qualify for the Information Transfer PRO-PM are included in the data.

Response: We appreciate the commenter's suggestion and will consider it during the development of supporting documents for the model that align with the policies finalized in this rule.

Comment: A commenter requested CMS clarify who should administer the survey associated with the Information Transfer PRO-PM. The commenter also requested clarification on how the measure will be used and if there will be implications if beneficiaries do not submit the survey.

Response: We thank the commenter for their comment. We note that, in the CY 2025 OPPS/ASC Final Rule, the Information Transfer PRO-PM was adopted into the CMS Hospital Outpatient Quality Reporting (OQR) Program as a voluntary measure for the CY 2026 reporting period followed by mandatory reporting beginning with the CY 2027 reporting period/CY 2029 payment determination (89 FR 99406). The measure will also be used in TEAM, starting in performance year 3 (CY 2028), to assess quality performance via the composite quality score (CQS) for episodes initiated in the hospital outpatient department. We refer the commenter to the FY 2025 IPPS/LTCH PPS final rule for the methodology on how the CQS will be constructed (89 FR 69774) and the CY 2026 OPPS/ ASC final rule (89 FR 94408) for data sources and measure specifications. CMS finalized that the survey should be administered 2 to 7 days post-procedure and that survey administrators should allow a 65-day window for patient response. Additionally, only fully completed surveys are included in the measure calculation. We note there is a 300 minimum random sample size of completed surveys. Hospitals that are unable to collect 300 completed surveys will not be able to perform random sampling, and would instead be required to submit data on all survey responses. While the hospital is accountable for ensuring the electronic survey is offered to all patients meeting the measure's denominator specifications, and may administer it through their own internal means, a hospital is not precluded from using a third-party vendor to administer the survey electronically. For further information on the Information Transfer PRO-PM, we refer the commenter to the following resources: https://qualitynet.cms.gov/files/6830be4d662c6b68b52ddd2d?filename=1z_OP46MIF_v19.0.pdf and https://www.cms.gov/files/document/patient-understanding-key-information-related-recovery-after-facility-based-outpatient-procedure-or.pdf

After consideration of the public comments, we are finalizing without modification our proposals at Sec. 512.547(a)(3)(vi) for inclusion of the Information Transfer PRO-PM for all TEAM outpatient episodes beginning in PY3 with a CY 2027 CQS baseline period. We will continue to monitor the need for revisions, with any future updates incorporated into a subsequent notice and comment rulemaking. Given our inclusion of the Information Transfer PRO-PM in TEAM, Table XI.A.-04 represents all TEAM quality measures by performance year. [GRAPHIC] [TIFF OMITTED] TR04AU25.303

(4) Approach for When TEAM Participant has No Quality Measure Performance Data

As was outlined in Table X.A.-09 of the FY 2025 IPPS/LTCH PPS final rule (89 FR 69744), TEAM quality measures will be evaluated against a measure performance period. We stated in the proposed rule that the measure performance periods are consistent with those used in ongoing models and programs in which TEAM measures align, including the Hospital IQR Program and Hospital-Acquired Condition Reduction Program performance periods, so that there is no additional reporting burden on TEAM participants as a result of the quality measures used in TEAM. However, we recognized it was possible that some TEAM participants may not have a complete measure set during the performance period in which to measure their quality against. For example, in the proposed rule we stated that a newly established hospital that began seeing Medicare beneficiaries in early 2025 may have no or incomplete quality measure data given the quality measure performance periods for the

three quality measures used in PY 1 rely on quality measure performance periods starting on July 1, 2023, or 2024, through June 30, 2025. Additionally, we recognized some quality measures in TEAM, specifically the Hospital Harm--Falls with Injury (CMIT ID #1518) and the Hospital Harm--Postoperative Respiratory Failure (CMIT ID #1788) measures, are electronic clinical quality measure (eCQM) available for self-selection in the Hospital IQR Program. This means hospitals are not mandated to report these two measures for the Hospital IQR Program. Therefore, we noted in the proposed rule that it is possible that a TEAM participant may not select to report those two measures to the Hospital IQR Program, which would result in having no quality measure data for those two measures in TEAM. We stated in the proposed rule that we still believe it is important to be mindful of TEAM participant burden, and do not want to remove a TEAM participant's ability to self-select those measures. Therefore, having no or incomplete quality measure data may make calculating of the CQS, which is then used to adjust the TEAM participant's reconciliation amount, challenging. The CQS, as described in the FY 2025 IPPS/LTCH PPS final rule (89 FR 69744), is the pay-for- performance mechanism that ties quality measure performance to payment, ultimately incentivizing and rewarding cost savings in relation to the quality of episode care provided by the TEAM participant.

The CQS is constructed by converting the TEAM participant's raw quality measure score for the performance year into a scaled quality measure score. We explained in the proposed rule that TEAM participants that have no, or incomplete quality measure data would not have a raw quality measure score, making the conversion to a scaled quality measure score impossible. This would result in a CQS that is only based on the quality measures that had sufficient data to produce a scaled quality measure score or potentially a CQS that could not be calculated if all quality measures had lacked a raw quality measure score. We indicated in the proposed rule that we believe it is important for TEAM participants that may have no or incomplete quality measure data to not be penalized for a lack of quality measure data when they may in fact be providing high quality care to Medicare beneficiaries. Therefore, we proposed assigning a neutral quality measure score to TEAM participants with no or an incomplete raw quality measure score for a given quality measure. Specifically, a TEAM participant that does not have a raw quality measure score for a given quality measure would be assigned a scaled quality measure score of 50, which is the midpoint on the CQS scale of 0-100. We believed this approach would not disadvantage a TEAM participant who may be providing high quality care, because this neutral quality measure score ensures providers are not unfairly penalized due to insufficient quality measure data. Once the TEAM participant reaches the threshold for sufficient data to produce raw quality measure data, it will be converted into a scaled quality measure in the subsequent performance year. We considered but did not propose a policy under which hospitals have to meet certain criteria in order to receive a 50th performance percentile for quality measure when insufficient volume was present. For example, if a hospital had insufficient volume due to failure to report quality data, then they may receive a lower quality score, such as 25th percentile.

We noted in the proposed rule that this approach to assign participant hospitals a 50th performance percentile of a quality measure when a low volume hospital did not have reportable quality measure values (80 FR 73364) is consistent with the CJR model. Though there is a slight policy difference since this was for CJR hospitals that had a low volume of triggered episodes, the implication of having no or minimal information of quality data is similar, and therefore, why we proposed to utilize this approach.

We considered, but did not propose, a policy under which TEAM participants with no or incomplete quality measure data would receive the average scaled quality measure score across all TEAM participant hospitals for a given quality measure. While we believed this approach may result in a reasonable scaled quality measure score, we had concerns that a TEAM participant's scaled quality measure score is influenced by how well other TEAM participants perform in quality. Therefore, we believed our proposed approach of assigning a scaled quality measure score of 50 would be unbiased and easier to compute.

We sought comment on our proposal at Sec. 512.547(b)(1)(i)(D) to assign a scaled quality measure score of 50 when the TEAM participant has no or an incomplete raw quality measure score for a given quality measure.

The following is a summary of the public comments received on the proposed policy to assign a scaled quality measure score of 50 when the TEAM participant had no or an incomplete raw quality measure score for a given quality measure, and our responses to these comments:

Comment: Several commenters supported our proposal to assign a neutral scaled quality measure score of 50 when a TEAM participant has insufficient quality data for a given quality measure.

Response: We thank the commenters for their support of this proposed policy.

Comment: A few commenters supported the proposed policy, stating they appreciated the alignment and consistency with the CJR policy.

Response: We thank the commenters for their support and agree that aligning the neutral quality measure policy with that used in CJR allows for a consistent approach.

Comment: A few commenters expressed support for the proposed policy, specifically noting this would be helpful for participants with low episode volume. Commenters cited examples of rural hospitals and small hospitals, where low episode case counts may be prevalent.

Response: We thank the commenters for their support and feedback. We agree this policy will be valuable for TEAM participants with low episode counts, such as rural and small hospitals.

Comment: A few commenters expressed their appreciation for the proposed policy, noting that it does not add to reporting burden. A commenter specifically appreciated that the policy aims to ensure a fair assessment of all TEAM participants without increasing the reporting burden. This commenter also suggested that future model quality metrics should align with the hospital IQR program to maintain consistency throughout the model's duration. Another commenter appreciated the selection of quality measures that are already required, as this reduces the need for duplicate measures. Additionally, this commenter valued the movement toward universal quality measures.

Response: We thank the commenters for their support and input. We agree that TEAM's alignment with existing reporting requirements will not increase reporting burden or create duplicative reporting.

Comment: A commenter supported the proposed policy as a solution to avoid penalizing providers who deliver high-quality care but lack reportable data. They discussed the challenges hospitals face in reporting quality data, especially for new facilities and those with prior voluntary participation in IQR reporting. However, the commenter

suggested that CMS differentiate the causes of missing data in order to distinguish between hospitals unable to report due to structural factors and those that choose not to report. The commenter proposed a tiered scoring approach and encouraged transparency by publicly reporting whether a neutral score result was due to insufficient volume, new status, or non-reporting. Additionally, they suggested allowing voluntary submission of supplemental data to justify using a neutral quality score. This commenter also requested that CMS consider the impact on the CQS in areas where specialists do not have control over missing PRO or hybrid measure data, noting it should not disproportionally affect the CQS in ways clinicians cannot reasonably influence. Another commenter agreed that a neutral quality score for measures with insufficient data is important for those available for self-selection in the IQR program, as facilities might choose not to report on those particular measures and should not be penalized for lack of sufficient data due to the self-selection process.

Response: We thank the commenters for their thoughtful feedback. We agree that the proposed policy aims to fairly address hospitals providing high quality care but lacking sufficient quality data. We agree with the commenter that this policy does not remove a hospital's ability to self-select measures in the Hospital IQR program. TEAM participants that do not self-select eligible measures that are also used in TEAM and have insufficient data will receive a neutral scaled quality score of 50 for that measure. We also value the suggestions for the tiered approach, public reporting and voluntary supplemental data, and will take these into consideration, and if warranted, would propose in future notice and comment rulemaking.

Comment: A commenter stated the proposed policy may unfairly penalize hospitals for reasons unrelated to quality performance, such as their option to report on other voluntary measures. The commenter states this defeats the purpose of applying a standardized quality measure and urges CMS to make this model voluntary.

Response: We thank the commenter for their feedback. We did consider that the Hospital IQR allows for self-selection of quality measures and considered how to approach where TEAM quality measures are included in this self-selected set. We considered requiring TEAM participants report on all TEAM quality measures, but this would remove the flexibility for their Hospital IQR self-selection. We ultimately determined that in order to stay aligned with CMS quality reporting programs, we would continue to allow hospitals the option of self- selection, understanding that if they choose not to report on a quality measure used in TEAM, and there is insufficient data, they will receive a neutral scaled quality measure score of 50. We thank the commenter for their considerations and will monitor the impact of this policy. Any changes to TEAM's quality measure approach will occur through future notice and comment rulemaking.

Comment: Several commenters did not support the proposed policy and suggested alternative approaches for quality measures in cases where participants have insufficient data. Suggested alternatives included allowing supplemental quality data submissions, temporary exemptions or exclusion instead of a neutral score, setting the weight of these measures to zero, and using historical performance instead of a neutral value. Commenters expressed that these alternatives would avoid unfair penalties for participants facing data collection challenges while still reflecting actual performance.

Response: We thank the commenter for their insight and suggestions. We did consider other approaches for when a TEAM participant has insufficient quality data for a given quality measure. However, alternative approaches go against our effort to align with existing reporting requirements and to not increase participant reporting burden. We hear the commenters concern that alternative policies would better capture quality performance. We will monitor the impacts of this policy through the first performance year and, if needed, make adjustments through future notice and comment rulemaking.

Comment: A commenter expressed concerns related to the Hospital IQR Program reporting thresholds for the THA/TKA PRO-PM being difficult to achieve, stating this affects both large and small hospitals, with smaller facilities lacking resources to carry out the PRO-PM and larger ones unable to meet reporting percentages. Further, this commenter states that the neutral quality score could unfairly reduce reconciliation payments for hospitals lacking sufficient quality data, despite already having incentives to report under the Hospital IQR Program.

Response: We thank the commenter for their helpful insights. Though we understand the concerns related to achieving reporting thresholds, the strategic alignment of TEAM with established quality reporting programs minimizes participant administrative burden through the utilization of quality measures with which providers are already familiar. We will continue to monitor these requirements to determine whether this alignment continues to be most beneficial for TEAM participants. Additionally, we appreciate the commenters feedback related to the neutral quality score unfairly reducing reconciliation payments. In the case of insufficient data, CMS will be unable to determine if quality performance is high or low, therefore believes the approach that is most fair is to apply a neutral score.

Comment: A commenter stated that, though they appreciate the intent of this proposed policy, they are concerned it will lessen the role quality has in the model. The commenter stated that applying a neutral quality score lessens accountability and reduces the ability to apply comparisons between model participants. This commenter urged CMS to reconsider its quality strategy to better align with specific episodes and overall quality of care.

Response: We appreciate the commenter's feedback and share their desire for accountability and peer comparison. However, we disagree this approach lessens the role of quality in TEAM. We believe applying a neutral quality score will encourage TEAM participants with insufficient quality measure data to be more engaged in quality measure reporting, ultimately spurring them to improve beneficiary quality of care and allowing them to have sufficient quality measure data that results in a more accurate scaled quality measure score.

After consideration of the public comments, we are finalizing without modification our proposal at Sec. 512.547(b)(1)(i)(D) to assign a scaled quality measure score of 50 when the TEAM participant has no or an incomplete raw quality measure score for a given quality measure. We will continue to monitor the need for updates or changes, and any future updates will be incorporated into a subsequent notice and comment rulemaking. c. Pricing Methodology (1) Background

As finalized in the FY 2025 IPPS/LTCH PPS final rule (89 FR 68986) TEAM participants will be provided with target prices for each MS-DRG/ HCPCS episode type. These target prices will be calculated using 3 years of baseline data, trended forward to the performance year, at the level of MS-DRG/HCPCS episode type and region, with updates to be made using the performance year data during the

reconciliation process. The regions are defined as the nine U.S. census divisions and the MS-DRG/HCPCS episode type is based on the episode categories that will be tested in the model: Coronary Artery Bypass Graft (CABG), Lower Extremity Joint Replacement (LEJR), Major Bowel Procedure, Surgical Hip Femur Fracture Treatment (SHFFT), and Spinal Fusion.

We stated in the proposed rule that episode spending will be capped at the 99th percentile for each of the 29 MSDRG/HCPCS episode types and 9 regions, and the benchmark price will be calculated as the average capped and standardized spending in baseline year 3 dollars for each MS-DRG/HCPCS episode type in each region, resulting in 261 benchmark prices. Benchmark prices will be calculated using all hospitals in a region, regardless of TEAM participation status. CMS will apply a prospective trend factor and a discount factor to benchmark prices. During reconciliation, these preliminary target prices will be updated by updating the trend (subject to caps) and normalization factor (subject to caps) and by factoring in each participant's realized risk adjustment factors.

We stated in the proposed rule that risk adjustment factors will be calculated and made available to TEAM participants prior to the start of the performance year, so participants would be able to use them to estimate their episode-level target prices. Risk adjustment factors finalized in the FY 2025 IPPS/LTCH PPS final rule include age group, Hierarchical Condition Category (HCC) count, and beneficiary social risk as risk adjusters, as well as episode category-specific HCC adjusters and provider-level adjusters. The risk adjustment factors will be calculated at the MS-DRG/HCPCS level on baseline episodes, using a weighted linear regression where episodes are weighted differentially based on whether they belong to year 1, 2, or 3 of the baseline periods. Episodes from baseline year 1 will be weighted at 17 percent, baseline year 2 at 33 percent, and baseline year 3 at 50 percent. The risk adjustment factors will be held fixed and applied to performance year episodes at reconciliation based on the realized case mix of the TEAM Participant in the performance year.

We also stated in the proposed rule that after risk adjusting for the performance year case-mix, CMS will normalize the target prices to ensure that the average of the total risk-adjusted preliminary target price does not exceed the average of the total non-risk adjusted preliminary target price. The final normalization factor will be calculated as the national mean of the benchmark price for each MS-DRG/ HCPCS episode type divided by the national mean of the risk-adjusted benchmark price for the same MS-DRG/HCPCS episode type. However, it will be capped should this ratio exceed 5 percent of the prospective normalization factor. The final target prices will include a retrospective trend factor, which will be capped at being within 3 percent of the prospective trend. The retrospective trend factor will be calculated as the average capped performance year episode spending at the MS-DRG/HCPCS episode type and region level divided by the capped mean baseline episode spending in baseline year 3 dollars at the MS- DRG/HCPCS episode type and region level (that is, national mean benchmark price). Table XI.A.-05 provides a few examples of the calculation of the retrospective trend factor for three MS-DRG/HCPCS regions in which the retrospective trend factor is capped at 3 percent below the prospective trend factor, not capped, and capped at 3 percent above the prospective trend factor, respectively. [GRAPHIC] [TIFF OMITTED] TR04AU25.304

In summary, we indicated in the proposed rule that the reconciliation (final) target price will be calculated as the product of the capped mean baseline episode spending in baseline year 3 dollars, the capped retrospective trend, the risk adjustment multiplier using the performance year case-mix, and the capped final normalization factor. Table XI.A.-06 provides a few examples of reconciliation target price calculations for a fictional hospital with three MS-DRG/HCPCS and region combinations as finalized in the FY 2025 IPPS/LTCH PPS final rule (89 FR 68986). [GRAPHIC] [TIFF OMITTED] TR04AU25.305

As noted in the proposed rule, TEAM participants will have the opportunity to achieve a reconciliation payment amount, after accounting for quality performance, if their performance year spending is below the reconciliation target price, or they may owe a repayment amount if their spending is above the reconciliation target price. (2) Accounting for Future Changes to MS-DRGs and HCPCS

In the FY 2025 IPPS/LTCH PPS final rule (89 FR 68986), we acknowledged comments about how we would address episode pricing when there are Medicare Severity Diagnosis Related Group (MS-DRG) or Healthcare Common Procedure Coding System (HCPCS) code modifications or other payment system changes over the course of the model (89 FR 69719 and 69750). Specifically, we received multiple comments inquiring about this issue given the deletion of three spinal fusion MS-DRGs 453-455 and the addition of eight new spinal fusion MS-DRGs. In the FY 2025 IPPS/LTCH PPS final rule, we stated that we would be proposing a policy in future rulemaking for how to construct target prices when there are MS-DRG or HCPCS modifications or other payment system changes that may arise over the course of the model. In this final rule, we aim to clarify both our intention to incorporate these changes into the model when they occur and the specific methodology for target price construction in such a case. We stated in the proposed rule that failing to incorporate MS-DRG or HCPCS changes that arise between the baseline period and the performance year may lead to a significant drop in episode volume during the performance year and limit the number of beneficiaries exposed to the potential benefits of the model.

As an episode-based payment model, an important feature of TEAM is identifying the procedures or clinical conditions that would initiate an anchor hospitalization or anchor procedure. We stated in the proposed rule that TEAM relies on MS-DRG codes to initiate an anchor hospitalization and HCPCS codes to initiate an anchor procedure. However, MS-DRG and HCPCS codes, and more specifically the assignment of HCPCS codes to Ambulatory Payment Classifications (APCs), may be modified because of changes in treatment patterns, technology, and any other factors that may change the relative use of hospital and provider resources. Typically, CMS proposes and finalizes coding changes, as applicable, through established annual payment rules, such as the FY IPPS/LTCH proposed and final rules and the CY Outpatient Prospective Payment System (OPPS)/Ambulatory Surgical Center (ASC) proposed and final rules. MS-DRG or HCPCS changes resulting from these

rules may directly impact TEAM because they may alter which codes would initiate an anchor hospitalization and anchor procedure and subsequently may change the composition of episodes and its spending observed in the baseline period compared to the performance years for TEAM. We noted in the proposed rule that this is significant for two reasons: (1) TEAM uses a 3-year historical baseline period to construct target prices for a given performance year, and if the codes that existed in the baseline period do not exist or were modified, then this can lead to target prices that may not appropriately reflect episode spending in the performance year; and (2) new codes established during the performance year that did not exist in the baseline period would not have a target price since TEAM's target prices are based on the MS- DRG/HCPCS episode type.

To accommodate the spinal fusion MS-DRG changes from the FY 2025 IPPS/LTCH final rule, account for any future MS-DRG or HCPCS/APC changes, and construct preliminary target prices, we proposed a standard, three-step approach to account for MS-DRG and HCPCS/APC changes by remapping and adjusting relevant MS-DRG/HCPCS episode types during the baseline period to estimate performance year costs. Specifically, we proposed that Step 1 would be to identify diagnosis or procedure codes that are being moved from one MS-DRG or HCPCS/APC to another based on the FY IPPS/LTCH or CY OPPS/ASC final rules of the relevant performance year and then map these codes to the new or revised MS-DRGs or HCPCS/APCs. In other words, baseline period episodes are reassigned to the MS-DRG or HCPCS/APC they would have received had the episode occurred in the performance year. For example, the spinal fusion MS-DRG 453 existed in the baseline period but was removed in the FY 2025 IPPS/LTCH PPS final rule. The procedure codes under MS-DRG 453 would be moved under three new MS-DRGs finalized in the FY 2025 IPPS/ LTCH PPS final rule and based on the presence of specific procedure and diagnosis codes, as demonstrated in Table XI.A.-07. [GRAPHIC] [TIFF OMITTED] TR04AU25.306

Based on the mappings for a given performance year, we proposed that inpatient stays and outpatient procedures in the baseline would fall into one of three, mutually exclusive and collectively exhaustive mapping groups:

Group 1: Existing MS-DRGs or HCPCS/APCs which would be deleted and mapped to new or existing MS-DRGs.

Group 2: Existing MS-DRGs or HCPCS/APCs which would be retained but portions of them would be mapped to new or existing MS- DRGs or HCPCS/APCs.

Group 3: MS-DRGs or HCPCS/APCs where there would be no changes occurring.

For Step 2, we proposed to construct episodes using the remapped MS-DRG or HCPCS/triggers. We proposed that a baseline period episode would initiate an anchor hospitalization or anchor procedure based on whether the remapped MS-DRG or HCPCS, rather than the original MS-DRG or HCPCS, initiates a TEAM episode. Further, we proposed that preliminary prices would then be constructed in the same manner described in Sec. 512.540 of the FY 2025 IPPS/LTCH PPS final rule, with target prices for each MS-DRG/HCPCS episode type, inclusive of episodes initiated by anchor hospitalizations and anchor procedures that would be related to these newly incorporated diagnosis or procedure codes.

Lastly, we proposed that Step 3 would adjust the standardized allowed amounts, used in target price calculations, to account for changes in fee-for-service rates between the baseline period and performance year due to changes to MS-DRG or HCPCS/APC weights (which account for relative intensity of hospital resource use). To do this, we proposed to use a scaling factor, which we proposed to define at Sec. 512.505 to mean the ratio of the re-mapped MS-DRG or HCPCS/APC relative weight in the performance year, as applicable to the original MS-DRG or HCPCS/APC relative weight in the baseline period. We stated in the proposed rule that the scaling factor adjusts the standardized allowed amount to account for differences in the relative weights of the original and re-mapped MS-DRGs. This adjustment would replicate the payment the anchor hospitalization or anchor procedure would have received if the MS-DRG or HCPCS/APC assignments had been the same as they are in the performance year. Calculating the scaling factor as the ratio of the re-mapped MS-DRG relative weight in the performance year to the original MS-DRG relative weight in the baseline year also ensures the cost remains in baseline year dollars. Table XI.A.-08 provides an example of the scaling factor calculation for each of the three possible MS-DRG groups.

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After calculating the scaling factor, we proposed that the standardized allowed amount of the MS-DRG portion of the anchor hospitalization, or the HCPCS/APC portion of the anchor procedure, from the baseline year would be multiplied by the corresponding scaling factor to calculate the standardized allowed amount for the performance year. Table XI.A.-09 demonstrates application of the scaling factor for anchor hospitalizations while Table XI.A.-10 demonstrates application of the scaling factor for anchor procedures. [GRAPHIC] [TIFF OMITTED] TR04AU25.308

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As stated in the proposed rule, we believed this three-step approach allows the construction of preliminary target prices when there are MS-DRG or HCPCS/APC changes while ensuring anchor hospitalizations and anchor procedures maintain a consistent composition of patient cohorts. Further, we indicated that it creates a standard process to address Medicare payment rate changes across time by identifying MS-DRG and HCPCS codes that initiate an anchor hospitalization or anchor procedure in the baseline period and how it would be billed under current Medicare payment rates and rules. Lastly, we stated in the proposed rule that we believed this three-step approach for TEAM adequately captures the majority of year-to-year variation in Medicare spending and avoids unnecessary complexity by focusing on anchor hospitalization and anchor procedure costs. We noted in the proposed rule that TEAM's pricing methodology includes a retrospective trend factor that can help capture Medicare FFS rate changes for non-anchor hospitalization and anchor procedure costs, which makes capturing additional Medicare spending variation outside of the anchor hospitalization or anchor procedure unnecessary and less transparent to TEAM participants.

We considered an alternative approach to make different adjustments to claims in the post-discharge or post-procedure period. This approach would have incorporated a fourth step, similar to the method used in the BPCI Advanced model, to further adjust the mapped, performance year MS-DRG and HCPCS/APC using setting-specific update factors. We explained in the proposed rule that although this methodology more accurately captures the changes in episode spending related to shifts in MS-DRG HCPCS/APC composition and Medicare FFS rate updates, there are more steps involved which can increase the complexity and require a high level of effort to implement. We also considered an even more simplistic approach in which we would replace the standardized MS-DRG or APC allowed amount from the baseline year with the standardized allowed amount from the performance year. However, doing so would not account for other changes in pricing from year to year. Using a ratio of the relative weights better preserves these pricing changes. We sought comment on these alternatives.

We noted in the proposed rule that TEAM constructs preliminary target prices based on a performance year, which aligns with a calendar year timeframe, and would be shared with TEAM participants prior to each performance year. We also noted that typically, MS-DRG changes are aligned to a fiscal year and HCPCS/APC changes align to a calendar year. This means that the proposed three-step approach may not address MS-DRG changes that are implemented in the last quarter of a performance year. We considered, but did not propose, updating preliminary target prices for Medicare payment rule fiscal year updates, similar to how the BPCI Advanced model updates prices and how the early years of the CJR model updated prices. However, that would create two preliminary target prices for a given performance year, rather than one preliminary target price

as currently finalized. We stated in the proposed rule that having to manage two different preliminary target prices in a given performance year can increase participant burden and pricing methodology complexity. Further, updating the preliminary target price during the middle of the performance year can increase target price instability, even though it may produce more accurate target prices. We sought comment on whether we should update preliminary target prices during the performance year to account for any fiscal year or calendar year Medicare payment rule changes that occur after preliminary target prices are released to TEAM participants.

We sought comment on our proposal at Sec. 512.505 to define scaling and at Sec. 512.540(a)(2)(i) through (iii) to account for MS- DRG and HCPCS/APC changes between the baseline period and the performance year that arise from Medicare payment rule changes.

The following is a summary of the public comments received on the proposed policies to define scaling and to account for MS-DRG and HCPCS/APC changes between the baseline period and the performance year, and our responses to these comments:

Comment: Many commenters expressed support for the three-step methodology to account for coding changes that occur during the course of the model.

Response: We thank the commenters for sharing their support regarding the methodology to account for future changes to MS-DRGs and HCPCS.

Comment: A commenter recommended CMS add a scaling factor for the post-discharge period portion of the benchmark price to account for spending variations in the post-discharge period for MS-DRGs with new mappings. A commenter suggested CMS apply setting-specific update factors in response to MS-DRG coding changes, as was done in BPCI Advanced.

Response: We thank the commenters for recommending additional scaling factors representing costs incurred during the post-discharge period and the inclusion of setting-specific update factors. We would like to clarify that if the MS-DRG or HCPCS in the post-discharge period is a TEAM-eligible trigger code, the scaling factor will still be applied to the inpatient stay or outpatient procedure. We believe creating post-discharge period specific scaling factors and including setting-specific update factors would add considerable operational complexity to the implementation of TEAM. However, we will continue to monitor the necessity of these changes for MS-DRGs and HCPCS affected by updated mappings and, if warranted, would make any methodological changes in future notice and comment rulemaking.

Comment: A commenter requested CMS exclude any TEAM clinical episodes which are subject to MS-DRG coding changes.

Response: We thank the commenter for their suggestion but believe that the exclusion of TEAM episodes subject to MS-DRG coding changes will unnecessarily reduce participation in TEAM and the number of patients covered by value-based care arrangements. Furthermore, we believe that excluding specific MS-DRGs may create new opportunities for gaming by providers.

Comment: Some commenters suggested that CMS update preliminary target prices during the performance year when changes are made to MS- DRG or HCPCS fee-for-service (FFS) rates specific to those included in TEAM. A couple commenters opposed the process of updating preliminary target prices when changes are made to MS-DRG or HCPCS FFS rates as constructing two levels of target pricing for 1 performance year is undesirable and would increase program complexity.

Response: We thank the commenters for their suggestions regarding when updates to TEAM target prices should be made to incorporate changes to MS-DRGs. We believe that updating preliminary target prices during the performance year would add considerable complexity for TEAM participants. We plan to update the list of TEAM-eligible MS-DRGs and HCPCS for each performance year based on finalized coding changes. Inpatient hospitalizations and outpatient procedures will only be included if the updated performance year MS-DRGs and HCPCS are included in the list of TEAM-eligible trigger codes. We plan to release preliminary target prices during the last calendar year quarter preceding the upcoming performance year and calculate final target prices during reconciliation, which occurs after the completion of the performance year. We note that we intend to perform reconciliation after 6 months of claims runout, as noted in Sec. 512.550(b).

Comment: A couple commenters requested that CMS provide more details of the proposed mapping methodology that will occur for new or re-mapped MS-DRGs and HCPCS. One of these commenters noted concerns that the mapping strategy lacks transparency and invites mispricing. This commenter requested that CMS provide the public with an opportunity to review and provide feedback on the proposed mapping logic.

Response: We acknowledge the commenters requesting additional details and examples regarding the mapping and scaling methodology for MS-DRGs and HCPCS affected by coding changes. We intend to release additional materials ahead of the release of the performance year 1 preliminary target prices, tentatively scheduled to be released in the fourth quarter of 2025, so TEAM participants will be well-informed about the process.

Comment: A few commenters shared concerns regarding the MS-DRGs selected in TEAM for specific episode types and the downstream effect on target price construction. A commenter noted concerns for CABG MS- DRGs 231-236 which differ from each other with respect to patient acuity and the resource utilization needed to treat patients. The commenter requested that CMS clarify whether the target price paid to cover all costs associated with the episode of care for a qualifying CABG procedure will reflect the specific MS-DRG to which the patient is assigned, or whether that target price will be uniform across cases that fall under MS-DRGs 231-236. Another commenter noted concerns for Spinal Fusion MS-DRGs and HCPCS which represent a wide range of spinal fusion procedures, from simple to complex. This commenter noted that TEAM-specific components should not occur across blended categories of 2-7 level fusions, as the complexity of these procedures can vary substantially.

Response: We thank the commenters for their clarification questions and can confirm target prices will be constructed at the MS-DRG level. For example, there will be six different target prices constructed for MS-DRGs 231-236 for each TEAM participant, as applicable. Similarly, there will be separate target prices for each of the Spinal Fusion MS- DRGs, along with the MS-DRGs applicable to the remaining TEAM episode types. We agree that constructing target prices for each MS-DRG ensures the complexity and the resource utilization needed to treat patients is specific to the assigned MS-DRG.

After consideration of the public comments, we are finalizing without modification the definition of scaling factor at Sec. 512.505. We are also finalizing the proposed methodology at Sec. 512.540(a)(2)(i) through (iii) to account for future changes to MS-DRGs and HCPCS using the three-step mapping and scaling approach without modification.

(3) U.S. Territories and Census Division 9

In the FY 2025 IPPS/LTCH PPS final rule (89 FR 68986) that established TEAM, we noted that hospitals in the five U.S. territories (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands) will be grouped alongside Census Division 9 (that is, the Pacific region) for the purposes of construction of regional prices (89 FR 69751). In response to public inquiries asking which specific Census Division U.S. territories would be categorized into since it was not reflected in regulatory text, we proposed to revise the definition for region at Sec. 512.505 to more clearly reflect this policy. Therefore, we proposed that hospitals located in one of the five U.S. territories (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands) will be grouped alongside Census Division 9. Specifically, we proposed to revise the definition for region at Sec. 512.505 to mean one of the nine U.S. census divisions, as defined by the U.S. Census Bureau, with the U.S. territories included in Census Division 9. We stated in the proposed rule that we believed grouping the U.S. territories to Census Division 9 is the most appropriate given the majority of U.S. territories captured in this group are located in the Pacific region. Mean episode spending for hospitals within the five U.S. territories is lower than hospitals in Census Division 9 for most episode types, and episode counts are significantly smaller. Therefore, including hospitals within the five U.S. territories as part of Census Division 9 will not disadvantage them since the benchmarks are expected to be higher. Moreover, any differences in spending that are due to patient case-mix between these regions should be accounted for through risk adjustment, ensuring providers are not penalized within the five U.S. territories.

Further, we indicated in the proposed rule that this approach is similar to how the BPCI Advanced model grouped the U.S. territories for the Census Division peer group characteristic. This policy would address the one CBSA in Puerto Rico (10380: Aguadilla, PR) selected for participation in TEAM. TEAM participants in this CBSA would use regional target prices calculated for Census Division 9.

We considered but did not propose grouping hospitals in a U.S. territory into a separate group not based on Census Division but believed that doing so would create unnecessary complexity and reduce uniformity in how target prices are constructed in TEAM.

We sought comment on our proposal at proposed Sec. 512.505 to include U.S. territories in Census Division 9.

We did not receive any comments on the proposed policy to include U.S. territories in Census Division 9 and are finalizing the proposal without modification at Sec. 512.505. (4) Calculation and Application of Normalization Factors

In the FY 2025 IPPS/LTCH PPS final rule (89 FR 68986) that established TEAM, we finalized using a normalization factor in our calculation of preliminary and reconciliation target prices. The normalization factor is the ratio of the average benchmark price divided by the average risk-adjusted benchmark price. We stated in the proposed rule that we will multiply the risk-adjusted benchmark prices by the normalization factor to ensure the average benchmark price after risk adjustment does not exceed the average benchmark price prior to risk adjustment. If the average benchmark price is higher than the average risk-adjusted benchmark price, then the normalization factor will be greater than 1, and its application will increase the risk- adjusted benchmark prices. If the average benchmark price is lower than the average risk-adjusted benchmark price, then the normalization factor will be less than 1, and its application will decrease the risk- adjusted benchmark prices.

In the FY 2025 IPPS/LTCH PPS final rule, we finalized a policy to calculate a prospective normalization factor during the creation of preliminary target prices, which we would then modify (by no more than +/-5 percent) for the final normalization factor when constructing reconciliation target prices. We stated in the proposed rule that under our current policy, the prospective normalization factor will be calculated as the ratio of the average total risk-adjusted preliminary target price to the average total non-risk adjusted preliminary target price for each MS-DRG/HCPCS episode type. We also finalized in the FY 2025 IPPS/LTCH PPS final rule that the final normalization factor will be calculated as the national mean of the benchmark price for each MS- DRG/HCPCS episode type divided by the national mean of the risk- adjusted benchmark price for the same MS-DRG/HCPCS episode type.

To ensure consistency in our approach to calculating the prospective normalization factor(s) and the final normalization factor(s), we proposed to update the language at Sec. 512.505 to clarify that the prospective normalization factor will be calculated using the benchmark prices (that is, the average non-risk adjusted preliminary benchmark price divided by the average risk adjusted preliminary benchmark price) rather than using preliminary target prices. Specifically, we proposed to revise the definition for prospective normalization factor to mean the multiplier incorporated into the preliminary target price to ensure that the average of the total risk-adjusted benchmark price does not exceed the average of the total non-risk adjusted benchmark price, calculated as set forth in Sec. 512.540(b)(6). We similarly proposed revising the definition for final normalization factor at Sec. 512.505 to mean the benchmark price for each MS-DRG/HCPCS episode type and region divided by the mean of the risk-adjusted benchmark price for the same MS-DRG/HCPCS episode type and region. We stated in the proposed rule that benchmark prices are calculated prior to incorporating the trend factor and discount factor. Therefore, using benchmark prices rather than target prices for calculating the prospective normalization factor would preserve the effect of the trend and discount factors and would prevent the prospective normalization factor from being influenced by the trend and discount factors. The proposed policy would ensure consistency in the construction of the prospective and final normalization factors. We sought comment on our proposals at Sec. 512.505 to construct the prospective normalization factor using benchmark prices and to construct the final normalization factor to be based on MS-DRG/HCPCS episode type and region.

Additionally, in the FY 2025 IPPS/LTCH PPS final rule (89 FR 68986), we finalized a policy to calculate normalization factors at the MS-DRG/HCPCS level--that is, to calculate normalization factors as the average national non-risk adjusted benchmark price divided by the average national risk-adjusted preliminary benchmark price for each MS- DRG/HCPCS episode type. To further ensure consistency in our approach to calculating target prices, we proposed to calculate normalization factors at the MS-DRG/HCPCS region level. We proposed to calculate normalization factors as the average regional non-risk adjusted benchmark price divided by the average regional risk-adjusted preliminary benchmark price for each MS-DRG/HCPCS episode type. We stated in the proposed rule that this will produce a unique normalization factor for each

region and MS-DRG/HCPCS episode type for a total of 261 normalization factors (as opposed to just 29 normalization factors, as previously proposed). We believed this approach is preferable because it will ensure that the regional average MS-DRG/HCPCS target price is equal to the regional average MS-DRG/HCPCS benchmark price. We sought comment on our proposal at Sec. Sec. 512.540(b)(6) and 512.545(e)(1)(i) to construct the normalization factors for each MS-DRG/HCPCS at the region level.

Table XI.A.-11 provides a few examples of the proposed calculation of the prospective and final normalization factors for three MS-DRG/ HCPCS regions in which the final [GRAPHIC] [TIFF OMITTED] TR04AU25.310

We also stated in the proposed rule that we wished to clarify how normalization factors will be applied in the calculation of preliminary target prices and how preliminary target prices will be provided to TEAM participants. We previously finalized a policy to provide each TEAM participant within a region with the same preliminary target price for an MS-DRG/HCPCS episode type. We also stated that prospective normalization factors would be incorporated into this preliminary target price and that risk adjustment factors would be calculated and separately be made available to TEAM participants prior to the start of the performance year, so participants would be able to use them to estimate their episode-level target prices. In the proposed rule, we proposed that two separate preliminary target prices will be made available to all participants: (1) the regional average target price for each MS-DRG/HCPCS episode type, before application of the risk adjustment factors or normalization factors; and (2) a TEAM participant-specific preliminary target price, including the TEAM participant's average risk adjustment factors (calculated based on the TEAM participant's case mix in the baseline period) and the regional MS-DRG/HCPCS normalization factors. We believed that these two target prices will provide TEAM participants with the most complete information to both anticipate their final reconciliation target prices and understand their performance as compared to other participants within the same region. We sought comment on our proposal at Sec. 512.540(b)(8) to communicate and share preliminary target prices that are region specific and TEAM participant specific.

The following is a summary of the public comments received on the proposed policies to construct and apply the normalization factors, and our responses to these comments:

Comment: A few commenters expressed support for the proposed changes to the normalization factor. The commenters expressed support for these methodological changes that intend to increase the accuracy of the target prices, intend to make hospital spending more comparable both across and within markets, and intend to avoid unintended financial burden on providers.

Response: We thank commenters for their support of the proposed changes to the normalization factor, and we agree that the changes would improve target price accuracy and lead to better assessment of TEAM participants' performance in the model.

After consideration of the public comments, we are finalizing without modification the definition of the prospective normalization factor to be calculated using benchmark prices rather than preliminary target prices at Sec. 512.505. We are also finalizing without modification the proposal at Sec. Sec. 512.540(b)(6) and 512.545(e)(1)(i) for the calculation of the prospective and final normalization factors at the MS-DRG/HCPCS episode type and region level rather than at the national level. Lastly, we are finalizing without modification our proposal at Sec. 512.540(b)(8) to communicate and share preliminary target prices that are region specific and TEAM participant specific. (5) Calculation of the Prospective Trend Factor

In the FY 2025 IPPS/LTCH PPS final rule (89 FR 68986) that established TEAM, we finalized a pricing methodology using a 3 percent capped retrospective trend factor. We stated in the proposed rule that under this methodology, reconciliation target prices are based on average regional MS-DRG spending in the contemporaneous performance year. The retrospective approach ensures that reconciliation target prices accurately account for unpredictable year-to-year fluctuations in spending, including the introduction of new technologies and medical advancements and unexpected increases or decreases to health care utilization (for example, the COVID-19 public health emergency). However, as stated in the FY 2025 IPPS/LTCH PPS final rule (89 FR 69745), we believe that providing TEAM participants with preliminary target prices before each performance year--and ensuring the accuracy and reliability of preliminary target prices--is essential to participants' success. Accurate target prices enable participants to prepare and undertake appropriate care transformation. We also believe the methodology for setting prospective target prices should be sufficiently simple so that it is transparent for participants. With our methodology, we aimed to find the balance between simplicity and predictive accuracy.

The methodology finalized in the FY 2025 IPPS/LTCH PPS final rule calculates preliminary target prices by applying a trend factor to average regional MS-DRG spending in the final year of the baseline period. This trend factor is calculated as the 2-year percentage change from baseline year 1

(BY1) to baseline year 3 (BY3)--specifically average regional MS-DRG spending in BY3 divided by average regional MS-DRG spending in BY1. We proposed and finalized the use of a 2-year trend because of the 2-year lag between each performance year and spending data availability from prior years. For example, preliminary target prices for performance year 1, 2026, will be shared with participants during 2025, when the last available complete year of data will be from 2024. Therefore, there is a need to convert 2024 spending into 2026 prices. We believed the simplicity of this approach would ensure transparency in our methodology.

However, as stated in the proposed rule, further review of our methodology and testing using simulated reconciliation results, which relied on using baseline period data from 2019 and 2021 and a 2023 performance year, demonstrated potential shortcomings of this methodology. Specifically, the specification for the calculation of the 2-year trend factor used only spending data from BY1 and BY3, omitting data from BY2. Given expected variability in year-to-year spending, we noted in the proposed rule that BY2 is a potentially valuable data point to include in our trend predictions. Furthermore, its omission has the potential to produce year-to-year fluctuations in preliminary target prices which may not accurately reflect trends in the baseline period data.

Therefore, we proposed updating our preliminary target price calculation methodology to one which more fully incorporates available data and would more accurately represent year-to-year trends. First, we proposed to change the calculation of the prospective trend factor from a percentage change based between BY1 and BY3 to an annual percentage change calculated using a linear regression model. Specifically, we proposed to use a log-linear model which would fit the model to logarithmically transformed values of average regional MS-DRG spending for each of the baseline years. We explained in the proposed rule that logarithmic transformation of the spending variables serves two purposes. First, it reduces the effect of outliers on our coefficient estimates. Second, it allows for interpretation of the coefficients as an annual percentage change rather than an absolute change. The coefficient estimates would be interpretable as the anticipated 1-year percentage point change in the preliminary target price. For example, a coefficient of 0.03 reflects a 3 percent year-over-year increase in the average regional MS-DRG spending of the hospital. Conversely, a coefficient of -0.03 reflects a 3 percent year-over-year decrease in the average regional MS-DRG spending of the hospital. We clarify in this final rule that to convert the coefficient into a trend factor by which to multiply benchmark prices, we would exponentiate the coefficient estimate. For example, a coefficient estimate of 0.03 would be exponentiated as: e0.03 = ~1.03. We stated in the proposed rule that as there is a 2-year lag between the last baseline year and the performance year, we would square the exponentiated value of the coefficient estimate to calculate the 2-year prospective trend factor to predict the performance year spending. An exponentiated coefficient estimate of 1.03 would produce a 2-year prospective trend factor of: 1.03\2\ = ~1.061, meaning that average regional MS-DRG spending is expected to increase by 6.1 percent between the last baseline year and performance year. An exponentiated coefficient of 0.97 would produce a trend factor of 0.97\2\ = ~0.941, meaning that average regional MS-DRG spending is expected to decrease by 5.9 percent between the last baseline year and performance year. The 2-year trend factor will then proportionally adjust the benchmark price for each MS- DRG/HCPCS region preliminary target price based on the expected percentage increase or decrease in spending between the last baseline year and performance year.

Second, we proposed using 2 additional years of episode spending data in our calculation of the prospective trend factor. We proposed these 2 years be the 2 years immediately prior to the 3-year baseline period. Therefore, we proposed to define trend year at Sec. 512.505 to mean either of the 2 years immediately prior to the 3-year baseline period used in combination with the baseline period to calculate the prospective trend factor. For example, for performance year 1 (2026), the 3-year baseline period is 2022 through 2024. Therefore, the trend years for performance year 1 would be 2020 (trend year 1) and 2021 (trend year 2). We believed using 2 additional trend years to calculate the trend factor and estimate preliminary target prices would produce more accurate projections of future FFS costs and, therefore, more reliable preliminary target prices for TEAM participants. We proposed the use of trend years to only be applicable to construction of the prospective trend factor used in preliminary target price calculations. We stated in the proposed rule that we would continue to use the 3-year baseline period previously finalized in the FY 2025 IPPS/LTCH PPS final rule for all other purposes related to TEAM, including but not limited to: excluded services, safety net hospital determinations, and risk adjustment. We also proposed that trend years would roll forward on an annual basis in the same manner as the 3-year baseline period. We believed rolling the trend years forward annually with the baseline period is consistent with our previously finalized methodology, as well as with other CMMI models, and ensures a uniform approach to calculating prospective trends factors and preliminary target prices in each performance year. Lastly, we proposed to use a blend of regional and national trend factors in the calculation of preliminary target prices. In the FY 2025 IPPS/LTCH PPS rule we proposed and finalized a policy to calculate individual trend factors for each regional MS-DRG (89 FR 69756). We stated in the proposed rule that while we believe that preservation of potential variation in regional trends is an important element of our pricing methodology, we are concerned that a short baseline period--even when adding 2 trend years to the period used to make projections--may amplify short-term regional trends and unpredictable year-to year fluctuations that are not an accurate representation of longer-term cost trends for TEAM participants and are not likely to produce reliable preliminary target prices. Therefore, we proposed for each regional MS-DRG in each performance year to calculate the prospective trend factor as the average (arithmetic mean) of the regional trend factor (calculated as proposed previously in this rulemaking) and a national trend factor. The national MS-DRG trend factor would be calculated in the same manner as regional MS-DRG trend factors using a linear regression of logarithmically transformed national average MS-DRG spending.

Lastly, we proposed an additional change to how we calculate and apply the high-cost outlier cap finalized in the FY 2025 IPPS/LTCH PPS final rule (89 FR 69745). We stated in the proposed rule that currently, the high-cost outlier cap is an episode spending cap applied to the 99th percentile of regional spending for a given MS-DRG/HCPCS episode type in a given region across all 3 years of the baseline period. That is, the 99th percentile of regional spending for a given MS-DRG/HCPCS episode type is calculated for all episodes within the 3- year baseline period, rather than for each baseline year individually. As a result, episodes from different baseline years are not equally likely to be

capped. For example, if per episode spending increases year-to-year within the baseline period, episodes in more recent years will be more likely to be subject to the high-cost outlier cap than episodes in earlier years. Conversely, if the per episode spending decreases year- to-year within the baseline period, episodes in earlier years will be more likely to be capped. To ensure that the trend factor--as well as the benchmark price--are calculated in a way that treats all 3 baseline years equally, with respect to the high-cost outlier cap, we proposed to calculate the 99th percentile for a given MS-DRG/HCPCS episode type in a given region individually in each of the baseline and trend years. Although trend years are not used in the calculation of the benchmark price, we proposed to apply the high-cost outlier cap to episodes in the trend years as well to ensure consistency in the calculation of our trend factor. Therefore, we proposed to revise the definition for high- cost outlier cap at Sec. 512.505 to mean the 99th percentile of regional spending for a given MS-DRG/HCPCS episode type, region, and baseline year, which is the amount at which episode spending would be capped for purposes of determining baseline and performance year episode spending. We believed this approach would improve the accuracy of our benchmark prices and trend factors and, ultimately, of target prices.

We stated in the proposed rule that in proposing this revised methodology for calculating TEAM participants' preliminary target prices, we considered multiple alternatives for each proposed change. As alternatives to the proposed regression-based approach to calculating an annual prospective trend factor, we considered retaining the approach finalized in the FY 2025 IPPS/LTCH PPS rule as well as two similar approaches. The first alternative approach we considered would calculate the 2-year trend factor as double the average of the 1-year trend from BY1 to BY2 (that is, average regional MS-DRG episode spending in BY2 divided by average regional MS-DRG episode spending in BY1) and from BY2 to BY3. This approach would have the benefit of retaining the simplicity of the methodology previously finalized while also incorporating all 3 years of available baseline data. We also considered an approach that would use 4 years of data (3-year baseline plus 1 trend year, defined as the year prior to the start of the baseline period) to calculate the 2-year trend factor as the average of the 2-year trend from BY1 to BY3 and trend year 1 to BY2 (for example, for performance year 1, 2026, the average of the 2-year trend factor from 2022 [BY1] to 2024 [BY3] and the 2-year trend factor from 2021 [trend year 1] to 2023 [BY2]). We indicated in the proposed rule that we intended to conduct further analysis to evaluate the reliability of both of these approaches, as compared to the proposed approach, for historical episode spending as part of simulated reconciliation. We note the findings from this analysis in our comment responses in this section of the final rule. In the proposed rule we requested comment from stakeholders on whether either of these approaches would produce more accurate prospective trend factor estimates or meaningfully simplify our pricing methodology such that it would be easier for TEAM participants to replicate preliminary target price calculations and identify potential opportunities for spending efficiencies.

Additionally, we considered proposing the use of weights for different baseline and trend years for the regression-based approach. Specifically, we considered two alternatives to our proposed approach. In the first alternative, we would weight each of the 3 baseline years at 0.25 and each of the 2 trends years at 0.125. In the second, we considered weights of: BY3 = 0.3, BY2 = 0.25, and BY1 and both trend years = 0.15. We requested comment on whether weighting more recent years used in the calculation of prospective tend factors and projection of preliminary target prices would improve the accuracy of target price calculations.

Lastly, we considered alternatives to our proposal to use the average of the regional and national trend factors. Specifically, we considered using just the regional trend factor, as proposed and finalized in the FY 2025 IPPS/LTCH PPS, as well as the use of different weights on the regional and national trend factors, for example, a weight of 0.67 for the regional trend factor and 0.33 for the national trend factor. We stated in the proposed rule that we intended to conduct further analysis on whether alternative weights would provide better estimates of real FFS spending.

We noted in the proposed rule that we believe our proposed revisions to our methodology for the calculation of the prospective trend factor would produce more accurate and reliable preliminary target prices for TEAM participants and reduce adjustments to reconciliation target prices that are calculated during reconciliation. We will maintain the +/- 3 percent cap on the retrospective trend factor adjustment. However, we believed that by improving the accuracy of prospective trend factor construction used in preliminary target prices, the methodological changes proposed previously will reduce the frequency with which that 3 percent cap need be applied.

We sought comment on our proposals at Sec. 512.540(b)(7) to reconstruct the prospective trend factor and at Sec. 512.540(b)(4) to calculate the high-cost outlier cap for each baseline year in the baseline period.

The following is a summary of the public comments received on the proposed policy to calculate the prospective trend factor, and our responses to these comments:

Comment: Some commenters supported the proposed changes to the prospective trend methodology. They noted that including 2 additional years and using a log-linear regression to produce the prospective trend factor would result in a more reliable and accurate prospective trend factor, reducing uncertainty and large retrospective adjustments.

Response: We thank the commenters for their support of the proposed changes to the prospective trend factor methodology.

Comment: A commenter expressed concerns that capping the retrospective trend at 3 percent of the prospective trend factor would penalize participants and would lead to a 3 percent lower target price.

Response: We disagree with the commenter who expressed concerns about the 3% cap on the retrospective trend penalizing participants and reducing their target prices significantly. Preliminary target prices contain a prospective trend factor to project baseline episode spending forward to the performance year (PY). This prospective trend factor, along with the prospective normalization factor and the risk adjustment multiplier, is updated during reconciliation. The retrospective trend is calculated as the average capped PY episode spending at the MS-DRG/ HCPCS episode type and region level divided by the capped mean baseline episode spending in BY3 dollars at the MS-DRG/HCPCS episode type and region level. The retrospective trend factor is capped at +/- 3 percent of the prospective trend factor to make target price adjustment more predictable and prevent extreme, unexpected losses for both participants and CMS. As an example, if the prospective trend factor is 1.05 and the retrospective trend factor is 0.98, the capped retrospective trend factor will be 1.02 (3 points lower than the prospective trend factor as opposed to 7 points lower).

Comment: A couple of commenters expressed concerns that the 2 additional years (CYs 2020 and 2021) proposed to be used to calculate the prospective trend factor were significantly impacted by the COVID- 19 public health emergency and are not representative of general patterns of care. These commenters urged CMS to revert back to the prospective trend factor calculation finalized in the FY2025 IPPS rule.

Response: We thank the commenters who raised their concerns with adding data from CYs 2020 and 2021 to the prospective trend calculation. While these CYs have been significantly impacted by the COVID-19 PHE, the prospective trend factor approach finalized in the FY 2025 IPPS final rule would be more sensitive to COVID-19 and the changes in spending, as it only uses data from 2 calendar years (for TEAM PY1 it would use CY 2022 and CY 2024 data). The approach proposed in the current rule mitigates the year-to-year fluctuations by using a longer time period to establish the trends.

We also conducted analysis of the proposed approach and alternative approaches to calculating the prospective trend factor, as described in the preamble of this rule. That analysis demonstrated the proposed approach to use 5 years of data was more accurate at predicting performance year spending than alternative approaches when years most affected by the COVID-19 PHE (CYs 2020 and 2021) were included in the 5-year baseline and trend period. Therefore, we anticipate this approach to not only be more accurate over the long term but also more robust to potential short-term disruptions that may affect care patterns and provider spending.

Comment: A commenter requested CMS to provide more detail on the log-linear regression model, including restatements of historical trend factors using this approach.

Response: The log-linear regression will be run on 5 years of trend data at the MS-DRG and region level. The dependent variable will be the natural logarithm of the episode spending. The primary dependent variable will be the calendar year of the clinical episode based on episode end date. We intend to provide detailed methodology documents ahead of the release of the performance year 1 preliminary target prices in Fall 2025. For PY1 of TEAM the baseline period will include CYs 2022 through 2024 and CYs 2020 and 2021 will be used as additional trend years to produce the prospective trend factor. The baseline and trend years will roll forward with each PY.

Comment: A few commenters expressed concerns about the ratcheting effect. A commenter suggested to avoid rebasing the benchmark each year to minimize the ratcheting effect and another commenter expressed concerns that weighing the more recent baseline years more heavily would lead to difficulties in creating financial savings.

Response: We thank commenters for expressing their concerns about the ratcheting effect. In the FY 2025 IPPS/LTCH PPS final rule (89 FR 69750), we finalized a 3-year baseline period that is rebased annually. We believe that calculating target prices at the MS-DRG/HCPCS episode type and region level mitigates issues related to the provider-level ratcheting effect. Our analyses showed that the proportion of hospitals participating in similar models such as BPCI-A and CJR is low among all participants in a region, so any regional-level ratcheting effect is also minimized. We also believe that a longer baseline and trend period for calculating the prospective trend factor, with all years weighted equally, may mitigate the ratcheting effect compared to a shorter baseline period or more heavily weighting more recent years. Therefore, we are not making any change to our policy to roll the baseline period forward each performance year and will mimic this policy for the 2 trend years. However, we will take into consideration these comments as we implement and monitor TEAM participant performance, and if warranted, would propose new policies or policy modifications in subsequent notice and comment rulemaking, as appropriate.

Comment: A commenter supported the inclusion of the national trend in the prospective trend factor but recommended to use a different weighting approach where the weight on the national trend is proportional to the share of episodes a hospital contributes within its region for a given MS-DRG.

Response: We thank the commenter for supporting the inclusion of national trends and for providing their thoughts on alternative techniques to weighing national trends. We believe that having a different set of weights for each participant would increase administrative burden and increase the complexity of the model. We will monitor how the currently specified national trend performs in projecting target prices and may consider alternative weighing approaches in the future.

Comment: A commenter requested detailed examples of the preliminary target pricing and trend factor methodology to allow participants to validate and track their targets.

Response: We thank the commenter for submitting their public comment. We will provide technical assistance to TEAM participants throughout the duration of the model to allow TEAM participants to track their performance in TEAM. These materials will include fact sheets, FAQs, and specification documents. Many of these documents will be made publicly available on the TEAM website. Additionally, all TEAM participants will receive a target price summary report that details each component of the target price methodology including the prospective trend factor to help participants easily validate and track their targets.

Comment: A commenter supported applying the high-cost outlier cap to episodes in the trend years.

Response: We thank the commenter for their support.

After consideration of the public comments, we are finalizing without modification our proposal at Sec. 512.540(b)(7) to calculate the regional trend factor using a log-linear model which would fit the model to logarithmically transformed values of average regional MS-DRG spending for each of the baseline years and the 2 additional trend years immediately preceding the baseline years. We are also finalizing without modification at Sec. 512.540(b)(7) the calculation of the prospective trend factor as the average (arithmetic mean) of the regional trend factor and a national trend factor. The national MS-DRG trend factor would be calculated in the same manner as regional MS-DRG trend factors using a linear regression of logarithmically transformed national average MS-DRG spending. Lastly, we are finalizing the definition of trend year and high-cost outlier cap at Sec. 512.505 and finalizing without modification our proposal at Sec. 512.540(b)(4) to apply the high-cost outlier cap to episodes in the trend years in addition to each baseline year in the baseline period. (6) Standardizing Area Deprivation Index (ADI)

In the FY 2025 IPPS/LTCH PPS final rule (89 FR 68986) that established TEAM, we finalized a social need risk adjustment factor for beneficiary-level risk adjustment in the construction of our preliminary and reconciliation target prices. We finalized this variable as a single binary variable with a value of yes=1 if the beneficiary--(1) was eligible for full Medicaid benefits (referred to as a dual eligible beneficiary eligible to receive both full Medicare and Medicaid benefits); (2) was eligible

for the Medicare Part D Low Income Subsidy (LIS); or (3) resided in a census block group with an Area Deprivation Index (ADI) above the 80th percentile of either national ranking or 8th decile of the state-level ranking. We noted that we believed that accounting for multiple potential markers of beneficiary social risk would be most appropriate to ensure accurate representation of the additional resources required to treat beneficiaries with greater levels of social vulnerability and need. In the FY 2025 IPPS/LTCH PPS final rule, we also acknowledged concerns that the lack of standardization of ADI variables may make the ADI primarily a function of a subset of variables (namely income and home values) included in its calculation. Further, we further stated that we would continue to explore whether standardization of the ADI variables would be appropriate for the purposes of TEAM's risk adjustment approach and would propose any such changes in future rulemaking.

We stated in the proposed rule that as part of our preparation for TEAM and the calculation of preliminary target prices, we constructed episodes using a 2019 through 2021 baseline period to reassess the value of the social need risk adjustment factor. We calculated cross- tabulations of dual eligibility, LIS, and ADI status of episodes and beneficiaries identified as triggering a TEAM episode. We found that 99.9 percent of dual eligible beneficiaries who triggered an episode in TEAM (as well as 99.9 percent of episodes associated with a dual eligible beneficiary) were also qualified for LIS. We indicated in the proposed rule that this is consistent with the fact that LIS has more lenient asset and income requirements than Medicaid and that dual eligible beneficiaries automatically qualify for LIS without having to apply.

As previously suggested by commenters in response to the FY 2025 IPPS/LTCH PPS proposed rule, we explored options for the standardization of the ADI that would better measure deprivation in urban areas. The CMS Innovation Center's Accountable Care Organization REACH (ACO REACH) model included an adjustment that is a blend of one- third National ADI scores, one-third State ADI scores, and one-third Dual-Eligibility or Low-Income Subsidy status. We stated in the proposed rule that in performance year 2025, CMS will remove the National/State blended ADI from ACO REACH and replace it with an area- level deprivation measure that uses standardized variables. This will better identify deprived areas of the nation, particularly for populations in high housing cost areas where housing costs do not correlate with the other included economic variables.

Specifically, we noted in the proposed rule that ACO REACH has modified the census block group deprivation index, known as the Community Deprivation Index (CDI), which updates and standardizes the variables used in the construction of the ADI. Standardization refers to the process of making the individual indicators that comprise the ADI unit to be neutral by subtracting the mean and dividing by the standard deviation before combining them to form a composite measure. The primary purpose of standardization in the ADI is to prevent any single indicator from dominating the composite score due to differences in measurement scales. Without standardization, variables with larger numerical values or greater variance would disproportionately influence the final deprivation score. We stated in the proposed rule that given the extensive work the ACO REACH model has conducted to standardize the ADI, we believed it is important to use a similar approach to more accurately measure areas of deprivation and create alignment across CMS Innovation Center models with similar adjustments.

Based on our further research and analysis, we proposed a few changes to the construction of the social need risk adjustment factor for beneficiary-level risk adjustment in TEAM.

First, we proposed renaming the social needs risk adjustment factor to be the beneficiary economic risk adjustment factor and replace the use of the ADI in the construction of our beneficiary economic risk adjustment variable, with a similar but slightly modified census block group deprivation index, the Community Deprivation Index (CDI). We proposed using the same construction methodology as the ACO REACH model. Specifically, the CDI would be a factor-weighted composite measure of 18 variables collected from the Census Bureau. We proposed the deprivation scores would be percentile ranked relative to the Nation such that the resulting index would range from a score of 1, indicating the lowest level of relative deprivation, to 100, indicating the highest level of relative deprivation. We also proposed maintaining the use of the 80th percentile threshold for the CDI. For example, the TEAM beneficiary would be assigned a value of yes=1 on the beneficiary economic risk adjustment factor if the TEAM beneficiary's CDI was above the 80th percentile. We believed the updated variable name better represents what the variable is risk adjusting for. We also believed the use of the CDI instead of the ADI will better represent beneficiary-level deprivation in urban areas due to the standardization of variables prior to the construction of the composite measure.

Second, we proposed using only national-level CDI rankings in the construction of our beneficiary economic risk adjustment factor. In our initial proposal in the FY25 IPPS/LTCH PPS proposed rule (89 FR 36450), we stated that the use of national- and state-level ADIs would help mitigate potential concerns about the validity of the ADI as a measure of economic risk given its close correlation with home values. We believed that using a relative measure of deprivation within states, in addition to a national measure, would better identify high deprivation census block groups and beneficiaries in states with high incomes and home values. In the proposed rule, we stated that we believe that the standardization of variables in the CDI will adequately address the influence of these two variables in the aggregate measure, negating the need for the use of both national and state rankings.

Furthermore, we believed that the inclusion of too many measures of beneficiary deprivation will dilute risk adjustment for TEAM participants with beneficiaries with the highest levels of economic vulnerability. Although in the FY 2025 IPPS/LTCH PPS final rule (89 FR 69772) we confirmed that we would only make upward risk adjustments to target prices, target price increases through risk adjustment must be offset by across-the-board target price reduction with the application of the normalization factor in our target price methodology. Therefore, the more beneficiaries receive risk-adjusted target prices, the smaller those adjustments must necessarily be.

As an alternative to our proposed changes to the construction of the economic risk factor for beneficiary-level risk adjustment, we considered retaining the use of the ADI, including both the national- and state-level rankings, and dual eligibility status. As previously stated, we believed that the use of the CDI as a standardized alternative to the ADI provides a more reliable measure of economic risk and negates the need for use of the state-level rankings. We further believed that minimizing the number of variables used to identify economic risk both keeps the methodology simpler and reduces the extent to which positive risk adjustments must be offset by normalization, therefore ensuring that

beneficiaries with the highest levels of deprivation receive adequate risk adjustment. In the proposed rule, we also gave further consideration to additional alternatives to the ADI, including the Centers for Disease Control and Prevention's (CDC) Social Vulnerability Index (SVI). However, as stated in the FY 2025 IPPS/LTCH PPS final rule (89 FR 69799), we continued to believe that it would not have been appropriate to use the SVI in place of the ADI or CDI, given that SVI is not as granular as the ADI (SVI uses census tracts as opposed to census block groups), and given the limitations and timing of this source data, the American Community Survey (ACS) 5-year estimates. For these reasons, we did not propose the SVI as a potential risk adjustor in TEAM.

We sought comment on our proposal at Sec. 512.545(a) to rename the risk adjustment variable. We also sought comment on our proposal at Sec. 512.545(a)(3)(i) to use the CDI and remove a measurement of deprivation at the State level.

Finally, we considered but did not propose at this time to omit the dual eligibility (receiving both full Medicare and Medicaid benefits) variable from our construction of the single, binary economic risk adjustment factor. We stated in the proposed rule that while we continue to believe that dual eligibility is an important indicator of economic vulnerability, we believe the near complete overlap between dual eligibility and LIS status makes the use of dual eligibility status redundant. We indicated that removing the dual eligibility variable would simplify the construction of the economic risk adjustment factor without sacrificing the identification of beneficiaries with high economic risk. Furthermore, LIS also provides a nationally consistent measure of economic risk, as LIS eligibility is set at the national level, unlike Medicare-Medicaid dual eligibility. Lastly, the use of only LIS status, as opposed to both LIS and dual eligibility, is consistent with the specification used by CMS Innovation Center models, such as the Making Care Primary (MCP) Model.

While we did not propose any change at this time to the inclusion of the dual eligibility variable in our construction of the economic risk adjustment factor, we sought comment on whether the removal of this variable to streamline construction of the economic risk adjustment factor would be preferable.

The following is a summary of the public comments received on the proposed policies to rename the social needs risk adjustment factor and to replace ADI with CDI, and our responses to these comments:

Comment: Many commenters supported the proposal to replace the ADI with the CDI for the purposes of constructing the beneficiary economic risk adjustment variable. Some commenters stated that the CDI would improve on the ADI by standardizing the variables used to construct the index or by correcting the weighting of the home value and income variables, which is the result of this standardization. Some commenters noted that CDI would be better at measuring deprivation in urban, high cost, or underserved areas. Another commenter noted that the ADI had been demonstrated to mask disparities in certain areas.

Response: We thank the commenters for their support and agree that the fact that the CDI standardizes the variables used to construct the ADI will prevent variables with high nominal values such as income and home values from masking the other variables included in the index. As discussed in section XI.A.2.c.(6). of the preamble of this final rule and in the FY 2025 IPPS/LTCH PPS final rule (89 FR 69798), we have been tracking stakeholder concerns about the ADI's lack of standardization and monitoring ways to improve the index's ability to measure deprivation in urban areas. We believe that replacing the ADI with the CDI in the construction of the beneficiary economic risk adjustment variable will allow TEAM to better identify deprivation in areas with high cost of living and more accurately adjust TEAM target prices to account for beneficiary economic risk.

Comment: A commenter appreciated that the proposal would bring TEAM into alignment with ACO REACH.

Response: We thank the commenter for their support. ACO REACH used the ADI as part of its risk adjustment in the 2023 and 2024 performance year which has provided insight into the advantages and disadvantages of the index. We believe that incorporating the improvements made to ACO REACH through the replacement of the ADI with the CDI will not only increase the accuracy of risk adjustment in TEAM, but it will also increase alignment across CMS models.

Comment: A commenter questioned whether the proposal would be sufficient to properly capture economic risk, particularly for safety net hospitals. The commenter noted lack of transportation and inability to afford medications as social needs that were not properly accounted for under TEAM.

Response: We thank the commenter for their concern regarding properly accounting for beneficiary economic risk. We disagree that the binary economic risk variable will not sufficiently capture this risk, or that risk adjustment could be improved by adding additional economic risk variables such as lack of transportation and inability to afford medications. The binary economic risk variable was designed to capture multiple markers of beneficiary economic risk. The inability to afford medications is a measure of income, which is already captured in the variable through eligibility for the LIS and full Medicare/Medicaid dual eligibility status. The inability to access transportation is also related to income, and the percentage of households within a census block group that do not have access to a motor vehicle is one of the 18 variables used to construct the CDI, which is included in the binary economic risk variable. We are concerned that adding additional economic risk variables would overcomplicate risk adjustment. Additionally, adding more variables that captured economic risk would prevent CMS from enforcing sign restrictions on the binary economic risk variable. We believe that it is important for the variable to only impact preliminary or reconciliation target prices if its coefficient is positive. Furthermore, all safety net hospitals will have a provider-level safety net status risk adjuster included in the risk adjustment model to improve target price accuracy for the episode expenditure variation experienced by safety net providers.

Comment: A few commenters recommended that, should this proposal be finalized, CMS monitor the impact of the CDI given how new the index is. Several of these commenters stated that CMS should specifically monitor the impact of the CDI in rural areas, with one of these commenters adding that the impact of the change on these areas must be more thoroughly examined. Another commenter requested bias testing on the measure to ensure that it did not inadvertently disadvantage high- risk patient populations or under-resourced hospitals.

Response: We thank the commenters for their input. We agree that it is critical to ensure that TEAM's risk adjustment does not disadvantage high-risk patient populations or under-resourced hospitals, such as rural hospitals. While the CDI is a new index, as discussed previously, the refinement of the ADI has been taking place for years in ACO REACH. We will continue to monitor the impact that this index has on risk adjustment in TEAM to

ensure that it accurately captures risk across all areas and populations. We would also like to reiterate that the beneficiary economic risk variable will only be used to adjust target prices if the coefficient on this variable is positive and will not be used to lower target prices for any TEAM participants.

Comment: A few commenters requested additional clarity on the CDI, including the detailed methodology of how the CDI is calculated and further explanation of the 18 variables included in the index.

Response: We refer readers to Appendix C of the ACO REACH model PY2025 Financial Operating Guide (https://www.cms.gov/files/document/aco-reach-py25-fin-op-ovw.pdf) for additional information on the CDI methodology used for ACO REACH including the 18 variables used in the construction of the index. We also plan to release TEAM-specific technical guidance addressing the CDI's methodology subsequent to the publication of this final rule.

Comment: A commenter supported replacing the ADI but questioned why the CDI was chosen as the replacement and suggested that CMS work with stakeholders to identify the best index to measure economic risk at the geographic level. The commenter questioned whether the CDI was validated across a wide range of geographic areas, such as rural areas. The commenter suggested that CMS consider other indices, including the Vizient[supreg] Vulnerability IndexTM.

Response: We thank the commenter for their suggestions. We finalized the use of the ADI for the purposes of economic risk adjustment in the FY 2025 IPPS/LTCH PPS final rule. While we stated in that rule that we would assess the use of standardization in calculating the ADI, we had no intentions of utilizing an entirely new index. CMS is familiar with the strengths and weaknesses of the ADI, and accordingly, the updated CDI, through the use of the index in other value-based programs such as ACO REACH. We believe that refining this index, as opposed to a larger overhaul of economic risk adjustment, will both provide more accurate risk adjustment and minimize changes to the model.

Comment: A few commenters supported keeping dual eligibility in the economic risk variable, noting that this variable is consistent, accessible, and easy for hospitals to understand.

Response: We appreciate the commenters pointing out the value of the familiarity hospitals have with this variable. We will not be finalizing any changes to the use of dual eligibility in the economic risk adjustment variable.

After consideration of the public comments, we are finalizing without modification our proposal at Sec. 512.545(a)(3)(i) to use the CDI and remove a measurement of deprivation at the state level without modification. We did not receive any comments on our proposal to rename the social risk adjustment variable the beneficiary economic risk adjustment factor, which we are finalizing without modification at Sec. 512.545(a). (7) Hierarchical Condition Categories (HCC) in Risk Adjustment (a) Lookback Period

In the FY 2025 IPPS/LTCH PPS final rule (89 FR 68986) that established TEAM, we recognized the need to account for beneficiary acuity in setting target prices for episode categories tested in TEAM. We finalized the use of beneficiary level variables that are episode category specific. These beneficiary level variables are drawn from the HCCs used in the CMS-HCC risk adjustment model that informs the Medicare Advantage (MA) capitation rates and Part C and Part D Payment Policies. While the specific HCCs were finalized for each episode category in TEAM, we did not finalize the lookback period duration to capture the HCCs. Specifically, we did not specify how far back from the episode start date CMS would look to capture HCC data to determine the total count of HCCs and the episode-specific HCC variables.

We stated in the proposed rule that in the early years of BPCI Advanced, we used a 90-day lookback for each beneficiary, beginning with the day prior to the anchor hospitalization or anchor procedure. We would use the beneficiary's Medicare FFS claims from that 90-day lookback period to determine which HCC flags the beneficiary is assigned and create a count of those HCC flags. During the COVID-19 public health emergency (PHE), BPCI Advanced participants urged CMS to reconsider the 90-day lookback period because beneficiaries were hesitant to interface with providers during this time, which directly affected the risk adjustment and target price methodology. Given those concerns, BPCI Advanced began using a 180-day lookback period.

Since the COVID-19 PHE has ended and utilization is now once again similar to pre-PHE levels, we proposed in the FY 2025 IPPS/LTCH PPS proposed rule (89 FR 35934) that we would conduct a 90-day lookback for each beneficiary, beginning with the day prior to the anchor hospitalization or anchor procedure. We would use the beneficiary's Medicare FFS claims from that 90-day lookback period to determine which HCC flags the beneficiary is assigned and create a count of those HCC flags. This methodology would have been consistent with the earlier years of BPCI Advanced and would represent a more uniform way of measuring clinical complexity across beneficiaries. It would also reduce the incentive for increased coding intensity at the time of the initiating procedure. However, following feedback from public comments, we held off on finalizing a lookback period to take more time to consider alternatives, such as a longer lookback period.

We proposed in the proposed rule to conduct a 180-day lookback for each beneficiary, beginning with the day prior to the anchor hospitalization or anchor procedure. We proposed to use the beneficiary's Medicare FFS claims from that 180-day lookback period to determine which HCC variables (or flags) the beneficiary is assigned and determine the HCC episode specific flags as well as the TEAM HCC count flag. We also proposed that the TEAM beneficiary would need to meet beneficiary inclusion criteria, as described in Sec. 512.535, during the entire 180-day lookback period. We stated in the proposed rule that we believe a 180-day lookback period would sufficiently capture beneficiary acuity and ultimately improve the risk adjustment methodology to better reflect the level of spending outside of the hospital's control. This methodology would be consistent with the current BPCI Advanced methodology and would continue to represent a more uniform way of measuring clinical complexity across beneficiaries. We noted in the proposed rule that in past internal analyses, CMS has found that a 180-day lookback period may improve model fit in a risk adjustment model but may reduce episode volume. Internal analysis demonstrated that using a 180-day lookback period in BPCI Advanced reduced total episodes from 12,473,202 to 12,451,784 when looking at a period from October 1, 2015, through September 30, 2019. We further state that our analysis further found that extending the lookback period from 90 days to 180 days resulted in an average increase in regional MS-DRG benchmark prices of just 0.04 percent. The average change in regional MS-DRG benchmark prices was just +/-0.2 percent and only 16 of the 261 benchmark prices changed by more than

+/-0.5 percent. Use of 270-day and 365-day lookback periods produced only marginally different results.

However, because of the importance of accurate and complete data when risk-adjusting for TEAM, we stated in the proposed rule that we believe 180-days is the most appropriate duration as opposed to lookback periods longer than 180 days. The 180-day lookback period allows for improvements in model fit and modest adjustments in target price accuracy, relative to a 90-day lookback period, without a large drop in episode volume in the lookback period. Additionally, we believed a 180-day lookback period would address public commenters' concerns that the 90-day lookback period did not adequately account for past spending associated with beneficiary health status. It would also reduce the incentive for increased coding intensity at the time of the initiating procedure. Using a lookback period, rather than including diagnoses from the episode initiating admission/procedure, will minimize the opportunities for participants to change coding intensity among their patients relative to non-participants.

In the proposed rule we stated that we recognize other CMS initiatives may use different lookback periods. For example, the Enhancing Oncology Model uses HCCs from the previous calendar year, and some of the episode-based cost measures in the Merit-based Incentive Payment Systems that align with similar episode categories tested in TEAM use a 120-day lookback period. Therefore, we considered, but did not propose, a 90-day, 120-day, 270-day, or 365-day lookback period to determine which HCC flags the beneficiary is assigned. We did not consider lookback periods longer than 1 year as we believed that it would capture beneficiary acuity that may be unrelated to their episodic care in TEAM, and thus arbitrarily adjusting target prices. There is limited research into the most appropriate lookback period duration for risk adjustment; however, there are some findings that suggest that incorporating clinical information beyond 1 year does not improve risk adjustment. Although we did not propose this alternative, we sought comment on whether these alternative lookback periods would be appropriate for TEAM or if there are other lookback period options we should consider.

We sought comment on our proposal at proposed Sec. 512.545(a) to use a 180-day lookback period to determine which HCC flags the beneficiary is assigned.

The following is a summary of the public comments received on the proposed policy to use a 180-day lookback period to determine which HCC flags the beneficiary is assigned, and our responses to these comments:

Comment: A few commenters supported the 180-day lookback period, noting this would lead to improved data collection, quality improvement and a more comprehensive assessment of patient risk. A couple commenters also supported the proposal since this would align with the lookback period implemented in BPCI Advanced.

Response: We thank the commenters for their support.

Comment: A few commenters opposed the proposed lookback period. These commenters also noted that 180 days is not sufficient to document patient risk. A few commenters noted that a lookback period of only 180 days would create burden for providers to capture all risk factors during pre-operation visits within this period. Commenters were concerned that this may be especially challenging for unplanned surgical episodes and may unintentionally drive additional utilization if providers are concerned patient acuity may not otherwise be captured.

Response: We appreciate the commenters' concerns with the 180-day lookback period. We disagree that the 180-day lookback period would create additional reporting burden for providers. We believe that 180 days will significantly reduce any burden put on providers to capture risk factors during pre-operation visits relative to the 90-day lookback period, or even in-episode HCC risk adjustment. Additionally, the 180-day lookback period was used in BPCI Advanced. In that model, we believe there were minimal concerns on reporting burden put on providers with respect to the lookback period. We believe the issue with additional utilization may be more of a concern in the 90-day lookback period, and that a 180-day lookback period will mitigate this concern. We believe 180 days is long enough to capture relevant patient risk information without increasing reporting burden for providers. Based on internal analyses, there were insignificant differences in the risk-adjusted benchmark prices across the different lookback periods assessed (90, 180, 270, and 365 days). Specifically, only 2 out of 29 MS-DRG/HCPCS episode type risk-adjusted benchmark prices changed by more than 2 percent when extending the lookback period from 180 to 365 days. Thus, we believe 180 days is sufficient to document risk, since extending the lookback period beyond that did not significantly affect risk adjustment's impact on these benchmark prices. We acknowledge that it may be possible for less data to be captured in the lookback period for unplanned episodes compared to planned procedures. However, based on the results of the internal analyses, extending the lookback longer than 180 days did not capture data significant enough to change the risk-adjusted benchmark prices.

Comment: A commenter was concerned that a 180-day lookback period may disadvantage smaller, rural providers or those treating underserved populations, since they may not be able to capture as much clinical data in the 180-day lookback. Additionally, FFS hospitals may not have been previously incentivized to record diagnoses and may be disadvantaged by this lookback compared to providers who participated in the CJR model.

Response: We acknowledge the commenter's concern for smaller, rural providers, those treating underserved populations, and those who have not previously participated in CJR or other programs. We believe our risk adjustment model is robust enough to capture spending accurately, even for these provider types. Specifically, we include provider- specific risk adjusters, such as safety net status, bed size, and a beneficiary economic index variable to appropriately capture risk for these provider types. Further, we believe that extending the lookback period longer than 180 days will decrease episode volume since the lookback period will also apply to relevant episode-level exclusions, which could negatively impact the reach of the model, particularly for smaller providers.

Comment: Many commenters suggested a one-year lookback period for TEAM since it will capture more annual visits, and thus, more diagnoses recorded in the annual visits, compared to the 180-day lookback period. A few commenters proposed that a 365-day lookback would lead to better predictions in spending and a more comprehensive picture of patient health. Many commenters also noted that a 365-day lookback period also aligns with Medicare Advantage risk adjustment methodology and other CMS programs, such as the CJR model.

Response: We acknowledge the commenter's concerns that it is possible for fewer annual wellness visits to be captured in the 180-day lookback period relative to a 365-day lookback period. However, as stated in the proposed rule and in the previous responses, we do not believe that extending the lookback period from 180 days to 365 days would provide significantly more patient risk information or significantly impact pricing. As stated previously, only 2 of

29 risk-adjusted benchmark prices changed by more than 2 percent when extending the lookback period from 180 to 365 days. On the other hand, in these same analyses, extending the lookback decreased the episode volume by about 100,000 among all episode types across a 3-year baseline period. Since the lookback period for episode-level exclusions and risk adjustment must be consistent, we believe extending the lookback to a full year will decrease episode volume and negatively impact the reach of the model. Additionally, we thank the commenters for acknowledging that a 365-day lookback period would align with Medicare Advantage and the CJR model. We believe our risk adjustment model and list of specific risk adjusters is more robust, especially compared to CJR. Thus, we do not believe we need to align the lookback period with that of other models or programs if the risk adjusters included in TEAM risk adjustment methodology is not consistent with those other programs.

Comment: A few commenters suggested to extend the lookback period to also include in-episode HCCs, since not including them may have a negative effect for unplanned procedures, which have fewer pre-episode visits.

Response: We appreciate the commenters' suggestion to include HCCs on the claims incurred during the anchor hospital encounter or during the episode. However, as stated in the proposed rule, we believe that using Medicare FFS claims from the lookback period, as opposed to the anchoring claim, is beneficial since it will reduce the incentive for increased coding intensity at the time of the initiating procedure or elsewhere in the episode window. We are only including HCC risk adjustment data prior to the anchor hospitalization or procedure.

After consideration of the public comments, we are finalizing without modification our proposal at Sec. 512.545(a)(1) to use a 180- day lookback period to determine which HCC flags the beneficiary is assigned. The 180-day lookback period will also be applicable to episode-level exclusions which are dependent on the lookback period.

(b) HCC Version

In the FY 2025 IPPS/LTCH PPS final rule we finalized TEAM's approach to risk adjustment for target prices, which included episode category risk adjusters linked to specific HCCs that aimed to improve target price accuracy by accounting for beneficiary-driven episode expenditure variation (89 FR 69763). As indicated in the final rule, a Lasso regression analysis with additional input from a Technical Expert Panel (TEP) of clinicians was performed to identify the finalized risk adjusters, including the specific HCCs. The analysis used HCCs from version 22 (v22) of the CMS-HCC risk adjustment model as this version is the version used in the BPCI Advanced model which TEAM predicated its risk adjustment approach on. However, we stated in the proposed rule that we are aware that v22 is not the most updated version used in the CMS-HCC risk adjustment model. Currently, version 28 (v28), as finalized in the Risk Adjustment Data Validation (RADV) final rule (88 FR 6643), is used in Medicare Part C and other CMS initiatives. Given there is a more recent HCC version and its adoption across CMS and its initiatives, we believed it was important for TEAM to use a more recent HCC version that relies on ICD-10 diagnosis codes, rather than previous versions that include ICD-9 diagnosis codes, leading to more granular HCCs.

We stated in the proposed rule that given HCC v28 results in more granular HCCs, there is not a one-to-one mapping of the HCCs used in v22 to v28. As there is not a one-to-one match between HCCs in v22 and v28, a Lasso regression analysis with additional clinician input was repeated to identify the specific HCCs in v28 that would be used to risk adjust target prices in TEAM. We noted in the proposed rule that lasso regression analysis is a statistical modeling method used to identify a subset of risk adjusters which are most relevant for prediction of the natural log difference between clinical episode spending and the benchmark price. The objective of Lasso regression is to find the risk adjusters that minimize the residual sum of squares. In other words, the Lasso regression analysis identifies the risk adjusters that minimize the difference between the predicted and the actual values. We also noted in the proposed rule that clinician input helps to identify risk adjusters relevant to clinical practice and predicting target prices. Clinician input was informed by a literature review of perioperative comorbidities that would affect outcome and Lasso covariate estimates to support their recommendations.

Based on the Lasso analysis and clinician input, we proposed to use HCC v28 to identify the episode category specific HCC risk adjusters used in TEAM's risk adjustment methodology. Specifically, we proposed replacing the HCC episode category specific risk adjusters finalized in FY 2025 IPPS/LTCH PPS final rule with the following HCC episode category specific risk adjusters as demonstrated in Table XI.A.-12. BILLING CODE 4120-01-P

[GRAPHIC] [TIFF OMITTED] TR04AU25.311

[GRAPHIC] [TIFF OMITTED] TR04AU25.312

[GRAPHIC] [TIFF OMITTED] TR04AU25.313

BILLING CODE 4120-01-C

We recognized in the proposed rule that our proposed list of episode category specific HCCs is greater in number compared to what we finalized

in the FY 2025 IPPS/LTCH PPS final rule. There are approximately 25 risk adjusters per episode category, inclusive of non-HCC risk adjusters, that were finalized in the FY 2025 IPPS/LTCH PPS final rule as compared to the approximately 30 risk adjusters that would result from incorporating the proposed v28 HCCs. We believed this increase in HCCs is comparable given the HCC volume increased from v28 to v22. We also believed that the proposed list of episode category specific HCCs maintains our goal of a simplified risk adjustment methodology that aims to capture spending accurately, while aligning with the most recent HCC version.

We noted in the proposed rule that there are other episode category specific risk adjusters that were finalized in the FY 2025 IPPS/LTCH PPS final rule which are not HCCs. We did not propose replacing the non-HCC episode category specific risk adjusters. Nor did we propose to replace the beneficiary level risk adjusters applicable to all episode categories, such as HCC count and age bracket, or the provider-level risk adjusters, such as hospital bed size and safety net status. All of these risk adjusters were included in the Lasso regression analysis and clinical review and deemed appropriate for continued use in TEAM's risk adjustment methodology. However, we proposed to update the social need risk adjustment factor, as described in section XI.A.2.c.(6). of the preamble of this final rule.

We sought comment on our proposal at Sec. 512.545(a)(6)(i) through (v) to use HCC v28 to construct our episode category specific HCC risk adjusters.

The following is a summary of the public comments received on the proposed policy to use HCC v28 to construct episode category-specific HCC risk adjusters, and our responses to these comments:

Comment: Some commenters expressed support for our proposed changes to the HCC version used to construct episode category specific HCC risk adjusters. A commenter noted that HCC version 28 includes more detailed data on patient information and that it would be useful to assess year- over-year changes. Another commenter cited that using HCC version 28 would also be consistent with other CMS models.

Response: We thank the commenters for sharing their support for HCC version 28.

Comment: A commenter expressed support for the proposed list of HCC risk adjusters, noting it would make TEAM more sensitive to patient complexity.

Response: We thank the commenter for their support.

Comment: A few commenters did not believe the proposed risk adjustment methodology would sufficiently adjust target prices to reflect or adjust for patient complexity or social determinants, despite the inclusion of the Community Deprivation index.

Response: We appreciate the commenters' concerns. We disagree that the proposed methodology is not sufficient to accurately risk adjust target prices. We believe that the list of risk adjusters is robust enough to accurately capture spending, while maintaining a simpler risk adjustment methodology. We also note that there are additional risk adjusters beyond the HCCs noted in the proposed rule. The comprehensive list of risk adjusters is summarized later in this section.

Comment: A commenter suggested CMS make the risk adjustment methodology specific to each episode category.

Response: We appreciate the commenter's suggestion. The list of risk adjusters is specific to each episode type/category in TEAM. We refer the reader to the comprehensive list of risk adjusters in TEAM summarized within this section.

Comment: A few commenters expressed concern on the usage of HCCs in general. These commenters suggested other risk adjustment methodologies, such as the inferred risk model, the Society of Thoracic Surgeons risk models, the American College of Surgeons National Surgical Quality Improvement Program, using socioeconomic status and dual eligibility factors, and surgical complexity not captured in HCCs.

Response: We appreciate the commenters' recommendations on different risk adjustment methodologies. We note that we did not propose and are not considering other risk adjustment models instead of HCCs at this time. However, we will take into consideration these public comments as we implement the model and monitor TEAM's risk adjustment methodology.

Comment: Some commenters requested transparency on the list of risk adjusters used in TEAM.

Response: To provide clarity, we are listing the comprehensive list of patient and provider-level risk adjusters for TEAM by episode type. This includes both the HCCs listed in the proposed rule, as well as the other non-HCC risk adjusters which were finalized per the FY 2025 IPPS/ LTCH PPS final rule (89 FR 69773).

For CABG episodes, the following 28 risk adjustment variables are included: age bracket variable, HCC count variable, prior post-acute care use variable, beneficiary economic risk adjustment variable, hospital bed size variable (which is based on four categories: 250 beds or fewer, 251-500 beds, 501-850 beds, and 850 beds or more), safety net hospital status variable, and the following 22 HCCs:

HCC 37: Diabetes with Chronic Complications

HCC 48: Morbid Obesity

HCC 125: Dementia, Severe

HCC 126: Dementia, Moderate

HCC 127: Dementia, Mild or Unspecified

HCC 155: Major Depression, Moderate or Severe, without Psychosis

HCC 199: Parkinson and Other Degenerative Disease of Basal Ganglia

HCC 213: Cardio-Respiratory Failure and Shock

HCC 224: Acute on Chronic Heart Failure

HCC 226: Heart Failure, Except End-Stage and Acute

HCC 228: Acute Myocardial Infarction

HCC 229: Unstable Angina and Other Acute Ischemic Heart Disease

HCC 238: Specified Heart Arrhythmias

HCC 249: Ischemic or Unspecified Stroke

HCC 253: Hemiplegia/Hemiparesis

HCC 263: Atherosclerosis of Arteries of the Extremities with Ulceration or Gangrene

HCC 280: Chronic Obstructive Pulmonary Disease, Interstitial Lung Disorders, and Other Chronic Lung Disorders

HCC 298: Severe Diabetic Eye Disease, Retinal Vein Occlusion, and Vitreous Hemorrhage

HCC 326: Chronic Kidney Disease, Stage 5

HCC 327: Chronic Kidney Disease, Severe (Stage 4)

HCC 383: Chronic Ulcer of Skin, Except Pressure, Not Specified as Through to Bone or Muscle

HCC 409: Amputation Status, Lower Limb/Amputation Complications

For Surgical Hip/Femur Fracture Treatment (SHFFT) episodes, the following 30 risk adjustment variables are included: age bracket variable, HCC count variable, beneficiary economic risk adjustment variable, hospital bed size variable, safety net hospital status variable, and the following 25 HCCs:

HCC 36: Diabetes with Severe Acute Complications

HCC 37: Diabetes with Chronic Complications

HCC 38: Diabetes with Glycemic, Unspecified, or No Complications

HCC 48: Morbid Obesity

HCC 63: Chronic Liver Failure/End-Stage Liver Disorders

HCC 93: Rheumatoid Arthritis and Other Specified Inflammatory Rheumatic Disorders

HCC 109: Acquired Hemolytic, Aplastic, and Sideroblastic Anemias

HCC 125: Dementia, Severe

HCC 126: Dementia, Moderate

HCC 127: Dementia, Mild or Unspecified

HCC 180: Quadriplegia

HCC 181: Paraplegia

HCC 191: Quadriplegic Cerebral Palsy

HCC 198: Multiple Sclerosis

HCC 199: Parkinson and Other Degenerative Disease of Basal Ganglia

HCC 211: Respirator Dependence/Tracheostomy Status/ Complications

HCC 213: Cardio-Respiratory Failure and Shock

HCC 226: Heart Failure, Except End-Stage and Acute

HCC 238: Specified Heart Arrhythmias

HCC 249: Ischemic or Unspecified Stroke

HCC 253: Hemiplegia/Hemiparesis

HCC 280: Chronic Obstructive Pulmonary Disease, Interstitial Lung Disorders, and Other Chronic Lung Disorders

HCC 326: Chronic Kidney Disease, Stage 5

HCC 383: Chronic Ulcer of Skin, Except Pressure, Not Specified as Through to Bone or Muscle

HCC 402: Hip Fracture/Dislocation

For Major Bowel Procedure episodes, the following 30 risk adjustment variables are included: age bracket variable, HCC count variable, beneficiary economic risk adjustment variable, long-term institutional care use variable, hospital bed size variable, safety net hospital status variable, and the following 24 HCCs:

HCC 17: Cancer Metastatic to Lung, Liver, Brain, and Other Organs; Acute Myeloid Leukemia Except Promyelocytic

HCC 22: Bladder, Colorectal, and Other Cancers

HCC 37: Diabetes with Chronic Complications

HCC 48: Morbid Obesity

HCC 78: Intestinal Obstruction/Perforation

HCC 125: Dementia, Severe

HCC 126: Dementia, Moderate

HCC 127: Dementia, Mild or Unspecified

HCC 151: Schizophrenia

HCC 155: Major Depression, Moderate or Severe, without Psychosis

HCC 199: Parkinson and Other Degenerative Disease of Basal Ganglia

HCC 201: Seizure Disorders and Convulsions

HCC 211: Respirator Dependence/Tracheostomy Status/ Complications

HCC 213: Cardio-Respiratory Failure and Shock

HCC 224: Acute on Chronic Heart Failure

HCC 226: Heart Failure, Except End-Stage and Acute

HCC 238: Specified Heart Arrhythmias

HCC 253: Hemiplegia/Hemiparesis

HCC 267: Deep Vein Thrombosis and Pulmonary Embolism

HCC 280: Chronic Obstructive Pulmonary Disease, Interstitial Lung Disorders, and Other Chronic Lung Disorders

HCC 326: Chronic Kidney Disease, Stage 5

HCC 327: Chronic Kidney Disease, Severe (Stage 4)

HCC 383: Chronic Ulcer of Skin, Except Pressure, Not Specified as Through to Bone or Muscle

HCC 463: Artificial Openings for Feeding or Elimination

For LEJR episodes, the following 29 risk adjustment variables are included: age bracket variable, HCC count variable, procedure-related variable (ankle procedure or reattachment, partial hip procedure, partial knee arthroplasty, total hip arthroplasty or hip resurfacing procedure, and total knee arthroplasty), variable for disability as the original reason for Medicare enrollment, beneficiary economic risk adjustment variable, prior post-acute care use variable, hospital bed size variable, safety net hospital status variable, and the following 21 HCCs:

HCC 17: Cancer Metastatic to Lung, Liver, Brain, and Other Organs; Acute Myeloid Leukemia Except Promyelocytic

HCC 36: Diabetes with Severe Acute Complications

HCC 37: Diabetes with Chronic Complications

HCC 48: Morbid Obesity

HCC 125: Dementia, Severe

HCC 126: Dementia, Moderate

HCC 127: Dementia, Mild or Unspecified

HCC 151: Schizophrenia

HCC 155: Major Depression, Moderate or Severe, without Psychosis

HCC 199: Parkinson and Other Degenerative Disease of Basal Ganglia

HCC 224: Acute on Chronic Heart Failure

HCC 225: Acute Heart Failure (Excludes Acute on Chronic)

HCC 226: Heart Failure, Except End-Stage and Acute

HCC 238: Specified Heart Arrhythmias

HCC 253: Hemiplegia/Hemiparesis

HCC 267: Deep Vein Thrombosis and Pulmonary Embolism

HCC 280: Chronic Obstructive Pulmonary Disease, Interstitial Lung Disorders, and Other Chronic Lung Disorders

HCC 326: Chronic Kidney Disease, Stage 5

HCC 327: Chronic Kidney Disease, Severe (Stage 4)

HCC 383: Chronic Ulcer of Skin, Except Pressure, Not Specified as Through to Bone or Muscle

HCC 402: Hip Fracture/Dislocation

For Spinal fusion episodes, the following 31 risk adjustment variables are included in the TEAM risk adjustment methodology: age bracket variable, HCC count variable, prior post-acute care use variable, beneficiary economic risk adjustment variable, hospital bed size variable, safety net hospital status variable, and the following 25 HCCs:

HCC 17: Cancer Metastatic to Lung, Liver, Brain, and Other Organs; Acute Myeloid Leukemia Except Promyelocytic

HCC 18: Cancer Metastatic to Bone, Other and Unspecified Metastatic Cancer; Acute Leukemia Except Myeloid

HCC 37: Diabetes with Chronic Complications

HCC 48: Morbid Obesity

HCC 93: Rheumatoid Arthritis and Other Specified Inflammatory Rheumatic Disorders

HCC 125: Dementia, Severe

HCC 126: Dementia, Moderate

HCC 127: Dementia, Mild or Unspecified

HCC 155: Major Depression, Moderate or Severe, without Psychosis

HCC 180: Quadriplegia

HCC 181: Paraplegia

HCC 182: Spinal Cord Disorders/Injuries

HCC 192: Cerebral Palsy, Except Quadriplegic

HCC 193: Chronic Inflammatory Demyelinating Polyneuritis and Multifocal Motor Neuropathy

HCC 199: Parkinson and Other Degenerative Disease of Basal Ganglia

HCC 224: Acute on Chronic Heart Failure

HCC 226: Heart Failure, Except End-Stage and Acute

HCC 238: Specified Heart Arrhythmias

HCC 249: Ischemic or Unspecified Stroke

HCC 253: Hemiplegia/Hemiparesis

HCC 254: Monoplegia, Other Paralytic Syndromes

HCC 267: Deep Vein Thrombosis and Pulmonary Embolism

HCC 326: Chronic Kidney Disease, Stage 5

HCC 383: Chronic Ulcer of Skin, Except Pressure, Not Specified as Through to Bone or Muscle

HCC 401: Vertebral Fractures without Spinal Cord Injury

Comment: Some commenters urged CMS to include additional risk adjusters in TEAM. A couple commenters suggested risk adjusters to stratify by elective status to ensure target prices are equitable for hospitals more likely to provide non-elective procedures. A few commenters urged CMS to include more risk adjusters to account for clinical complexity within episode categories, such as inpatient versus outpatient setting, frailty and procedure-specific factors. A commenter recommended CMS include a risk adjuster for swing bed utilization, limited to rural participants or specific participation tracks. A couple commenters suggested to use the disability risk adjustment factor across all episode types.

Response: As stated in the proposed rule, we did not propose or consider changes to the non-HCC episode category risk adjusters. However, we will take into consideration these public comments as we implement the model and monitor TEAM's risk adjustment methodology. With respect to emergent versus elective procedures, as noted in the FY 2025 IPPS/LTCH PPS final rule (89 FR 69769), we believe that grouping emergent and elective procedures together, rather than stratifying them, reduces the incentive for increasing coding intensity. Similarly, we believe that setting separate target prices for inpatient versus outpatient settings may create incentives for adverse selection and gaming. We believe that the risk adjustment model, which includes clinical risk adjusters, should be sufficient in accounting for pricing differences and clinical complexities among emergent procedures.

Comment: Some comments requested hospital-specific risk adjusters in TEAM. Another couple commenters recommended HCC weights and HCC counts. A few commenters urged CMS to include more risk adjusters to account for clinical complexity within episode categories, such as fracture versus non-fracture, as well as demographic-specific factors.

Response: We thank the commenters for their recommendations. Hospital-specific (bed size and safety net status) and demographic- specific risk adjusters, as well as those for HCC counts are already included in TEAM. SHFFT and LEJR episode types also include a risk adjuster specific to Hip Fracture/Dislocation (HCC 402) and LEJR procedure-specific factors (for example, ankle procedures or reattachments, partial hip procedure, partial knee arthroplasty, total hip arthroplasty or hip resurfacing procedure, and total knee arthroplasty). We refer the readers to the comprehensive list of risk adjusters included in TEAM summarized within this section.

After consideration of the public comments, we are finalizing without modification our proposal to use HCC version 28 to construct our episode category specific HCC risk adjusters in TEAM. We are also finalizing our proposal without modification at Sec. 512.545(a)(6)(i) through (v) to use the updated list of HCC risk adjusters for each episode as a result of using HCC version 28. (8) Low Volume Hospitals

In both CJR and BPCI Advanced, we recognized that hospitals that perform a number of episodes below a certain volume threshold may have challenges taking on two-sided financial risk. As noted in the Episode- Based Payment Model Request for Information (88 FR 45872), episode volume is an important feature in an episode-based payment model because episode categories with sufficient volume help to reduce pricing volatility and spread financial risk. In the 2015 CJR final rule (80 FR 73285), we acknowledged that such hospitals might not find it in their financial interests to make systemic care redesigns or engage in an active way with the CJR model. At 80 FR 73292, we acknowledged commenter concerns about low volume providers, including but not limited to observations that low volume providers could be: less proficient in taking care of LEJR patients in an efficient and cost-effective manner, more financially vulnerable with fewer resources to respond to the financial incentives of the model, and disproportionately impacted by high-cost outlier cases. In spite of these potential challenges, we stated that the inclusion of low volume hospitals in CJR was consistent with the goal of evaluating the impact of bundled payment and care redesign across a broad spectrum of hospitals with varying levels of infrastructure, care redesign experience, market position, and other considerations and circumstances (80 FR 73292).

In the proposed rule for TEAM, we stated that in CJR, we set the low volume threshold as fewer than 20 CJR episodes across the 3-year baseline years of 2012 through 2014. Low volume hospitals received target prices based on 100 percent regional data, rather than a blended target price that incorporated their participant-specific data, because a target price based on limited data is less likely to be accurate and reliable. These hospitals were also subject to the lower stop-loss limits that we offered to rural hospitals, in recognition of the fact that they might be less prepared to take on downside risk than hospitals with higher episode volume. In the CJR 2017 final rule that reduced the number of mandatory MSAs, low volume hospitals were among the types of hospitals that were required to opt in if they wanted to remain in the model (82 FR 57072). In the CJR 2020 final rule, we removed the remaining low volume hospitals from the CJR extension when we limited the CJR participant hospital definition to those hospitals that had been mandatory participants throughout the model (86 FR 23497).

We stated in the proposed rule that in BPCI Advanced, our low volume threshold policy was to not provide a target price for a given clinical episode category if performed at a hospital that did not meet the 41 clinical episode minimum volume threshold during the 4-year baseline period. This meant that no BPCI Advanced episodes would be triggered for that particular clinical episode category during the applicable performance period at that hospital. However, participants could continue to trigger other clinical episode categories for which they had enrolled and for which there was sufficient baseline volume. Additionally, clinical episodes that occurred at the hospital during the performance period, though not triggering a BPCI Advanced episode, would count toward the low volume threshold when that year became part of a subsequent baseline period. Therefore, as the baseline shifted forward each year, bringing a more recent year into the baseline and dropping the oldest year, a hospital could potentially meet the volume threshold and receive a target price for the clinical episode category for a subsequent performance period.

Last year, in the FY 2025 IPPS/LTCH PPS proposed rule (89 FR 35934) that established TEAM, we proposed that TEAM would include a low volume threshold. We proposed that if a TEAM participant did not meet the proposed low volume threshold of at least 31 total episodes across all episode categories in the baseline period for PY1, CMS would still reconcile their episodes, but the TEAM participant would be subject to the Track 1 stop-loss and stop-gain limits for PY1. If a TEAM participant did not meet the proposed low volume threshold of at least 31 total episodes in the applicable 3-year baseline periods for PYs 2 through 5, the TEAM

participant would be subject to the Track 2 stop-loss and stop-gain limits for PY 2 through 5. However, after many comments that this policy was insufficient for low volume hospitals, in the FY 2025 IPPS/ LTCH PPS final rule (89 FR 68986), we determined we would not finalize a policy for low volume hospitals and instead would propose a new policy in future notice and comment rulemaking.

In the proposed rule, rather than offering a specific proposal, we proposed to maintain our current policy of having no low volume episode policy, given that Track 1 of the model has no downside risk and we expect most TEAM participants to select Track 1 for the first performance year. Rather, we sought comment on several potential policies to address prior commenters' concerns about low volume providers participating in TEAM.

First, we considered, but did not propose, that a low volume threshold would apply to specific episode categories in the baseline period for a given PY, similar to BPCI Advanced. If a TEAM participant did not meet the considered low volume threshold of at least 31 episodes in a given baseline period for a given episode category, CMS would still reconcile their episodes, but the TEAM participant would not be held accountable for any performance year episode spending that exceeded the reconciliation target price for each of the MS-DRG/HCPCS episode types in that given episode category during the applicable performance year. We stated in the proposed rule that this policy would effectively waive downside financial risk for the TEAM participant for episode categories in which they did not meet the considered low volume threshold. For example, in PY1, if a TEAM participant only initiated 30 episodes in the baseline period for the major bowel procedure episode category, and initiated 31 or more episodes in the baseline period for each of the other episode categories tested in TEAM, then the TEAM participant would not be held accountable for performance year episode spending that exceeded the reconciliation target price for the major bowel procedure episode category but would be accountable for performance year episode spending that exceeded the reconciliation target price for all the other episode categories for PY1. We noted that the baseline period for a given performance year in TEAM rolls forward each year. Therefore, we acknowledged in the proposed rule that it is possible for a TEAM participant to not meet the low volume threshold for a given episode category in one performance year and then meet the low volume threshold the next performance year because the baseline period rolled forward and captured a different volume of baseline period episodes. We stated in the proposed rule that we did not anticipate there would be a significant number of hospitals meeting the threshold one performance year and not the next (and vice versa), because procedure volumes tend to remain consistent across performance years.

We noted in the proposed rule that this considered policy may address commenters' concerns, by placing the low volume threshold at the episode category level rather than across all episode categories and acknowledge commenters' concerns regarding the level of financial risk that is tolerable for low volume hospitals, especially hospitals that are safety net hospitals or rural hospitals. We stated in the proposed rule that TEAM participants with low volume may not have enough episode volume to spread the risk or create efficient care pathways sufficient for downside risk. Further, and as compared to the BPCI Advanced model, this considered policy would allow TEAM participants to still initiate episodes and earn a reconciliation payment amount if they can reduce spending and provide quality care. However, we were concerned that waiving downside risk for low volume hospitals may affect potential TEAM savings for CMS. Additionally, we stated in the proposed rule that the 31-episode category threshold may not be the optimal threshold to ensure a low volume policy adequately addresses the concerns of TEAM participants and stakeholders affected by a potential low volume policy. A 31-episode is a similar approach to capturing the per baseline year threshold in BPCI Advanced, but this threshold could theoretically be too low to capture all TEAM participant hardship caused by episode volatility. It could also be too high and exclude too many episodes from the model and thus deprive TEAM participants an opportunity to enhance patient quality of care or provider efficiency and earn associated reconciliation payments.

We also considered, but did not propose, different low volume thresholds for the previously considered policy in the baseline period for a given episode category, including 91, 61, 51, 41, 21, and 11 episodes. In the proposed rule we stated that in an internal analysis of hospitals that were potentially eligible for TEAM using claims data from calendar year 2023, we found that 30 percent of acute care hospital (ACH)-clinical episode category (CEC) combinations had 10 or fewer episodes and were not flagged as a low volume hospital using the baseline period methodology of fewer than 31 episodes in a given CEC. Presumably, these could be seen as false negative results for low volume status or indications that the fewer than 31-episode threshold was set too high. Among these ACH-CEC combinations, the average episode count was seven. Additionally, 14 percent of these ACH-CEC combinations had five episodes or fewer. We noted that it could be the case that the 31 or fewer episode threshold could include hospitals that are not truly so low volume as to justify waiving downside risk. Alternatively, hospitals may just barely cross the 31 or fewer episode threshold and thus be subject to downside risk and may still be fundamentally similar to identified low volume TEAM participants experiencing hardship from the natural volatility involved in having fewer qualifying episodes. Though this is true of any threshold, the likelihood of this increases at lower thresholds than larger thresholds. Therefore, we considered alternative thresholds such as fewer than 91 episodes (approximately 3 times the fewer than 31 episode threshold), fewer than 61 episodes (approximately 2 times the fewer than 31 episode threshold), fewer than 51 episodes (the fewer than 31 episode threshold plus 3 times the average count of episodes for ACH-CEC combinations in our mock reconciliation not cited as low volume), fewer than 41 episodes (the fewer than 31 episode threshold plus one-third the threshold), fewer than 21 episodes (3 times the average count of episodes for ACH-CEC combinations in our mock reconciliation not cited as low volume), and fewer than 11 episodes (a threshold that should only flag ACH-CEC combinations at the lowest threshold found in our analysis).

We considered, but did not propose, limiting the scope of a potential low volume policy to safety net and rural hospitals only, since these hospital types are more likely to initiate lower volumes of episodes. However, we were concerned that this restriction would unfairly hinder other low-volume providers (which are not safety net or rural) from gaining efficiency in care coordination, since they would still bear the same financial risk as higher volume hospitals. We stated in the proposed rule that in an internal analysis, approximately 343 acute care hospitals are not designated as safety net hospitals or rural hospitals. Of these hospitals, approximately 109 acute care hospitals would have at least one episode category that had fewer than 31

episodes in the baseline period and would meet the definition of low volume if safety net hospital status or rural hospital status was not required for a low volume qualification. We stated that excluding non- safety net hospitals and non-rural hospitals from a low volume status could unfairly hinder nearly one-third of non-safety net hospitals or non-rural hospitals.

We also considered, but did not propose, including alternative approaches to a low episode volume threshold in TEAM, including an approach similar to BPCI Advanced, where if a TEAM participant did not meet the 31 episode low volume threshold for a given episode category in the baseline period, the TEAM participant would not be held accountable for that episode category for the performance year that aligned with the baseline period. In other words, they would not be eligible to initiate episodes in that episode category during the performance year and would not be eligible to earn any reconciliation payment amount or repayment amount for that given episode category during the performance year. However, we stated in the proposed rule that we were concerned that imposing a minimum volume threshold that removes TEAM participant accountability may restrict the number of hospitals eligible to participate in TEAM and limit beneficiary access to the benefits of value-based, coordinated care.

We also considered allowing low-volume episode types to be subject to a stop-loss/stop-gain limit of 5 percent, similar to Track 2, or a lower stop-loss/stop-gain limit of 3 percent, 2 percent, and 1 percent, such that TEAM participants are subject to a lower level of financial risk and gain, but still held accountable for the care provided under these episode categories. We noted in the proposed rule that under this approach, after creating the quality-adjusted reconciliation amount based on the TEAM participant's track selection, CMS would calculate the proportion of the quality-adjusted reconciliation amount that each episode category contributes to based on the PY episode weight. For example, Table XI.A.-13 demonstrates a TEAM participant, assuming Track 3 participation, meeting the low-volume threshold for the LEJR episode category but not for the SHFFT episode category. [GRAPHIC] [TIFF OMITTED] TR04AU25.314

Table XI.A.-14 continues the example by showing the stop-loss/stop- gain cap would then be applied to each episode category where the low- volume episode-type is subject to a 5 percent stop-loss/stop-gain cap while any other non-low volume episode types are subject to the stop- loss/stop-gain cap based on the TEAM participant's Track 3 selection. [GRAPHIC] [TIFF OMITTED] TR04AU25.315

However, as demonstrated by Tables XI.A.-13 and XI.A.-14, we were concerned that this approach adds complexity to the reconciliation calculations by adding additional steps. Further, we stated that we were also concerned that lower stop-loss/stop-gain limits would still not sufficiently protect low-volume episode TEAM participants from undue financial risk in the model.

We also considered implementing low episode volume thresholds during the performance year. Specifically, we considered not holding TEAM participants accountable for a given episode category if they initiated less than 11 or 6 episodes in a given episode category or less than 31 or 21 total episodes across episode categories in a performance year. However, we indicated in the proposed rule that we were concerned that including minimum episode volume thresholds during the performance year may introduce program integrity issues.

We sought comment on our considered policies. We also sought comment on low volume policy alternatives we have not considered.

The following is a summary of the public comments received on the considerations for low volume hospitals, and our responses to these comments:

Comment: Many commenters expressed concerns about the lack of a low volume policy in TEAM and urged CMS to establish one. Many commenters stated that a low volume policy was necessary to protect hospitals with low volumes from the volatility caused by small sample sizes. This volatility could result in hospitals facing large losses due to random variation over a small number of episodes. A couple of commenters also noted that, because of this variation,

performance on low volume procedures does not accurately reflect hospital performance. A few commenters stated that surgical excellence depended significantly on volume and repetition.

Response: CMS thanks the commenters for sharing their concerns regarding the lack of a low volume policy in TEAM. We acknowledge that low volume hospitals face barriers to success, as they may not have the procedure volume necessary to create efficiencies in a given episode category. We also acknowledge that evaluating these hospitals in episode categories where they display low volumes of episodes makes them vulnerable to losses from high-cost outlier cases that may be outside of their control. While TEAM will cap episodes at the 99th percentile of spending at the MS-DRG/HCPCS episode type and region level for each baseline year, we understand that this may not be sufficient to protect low volume hospitals who are more at risk for hitting the high-cost outlier cap. We do not want low volume hospitals to be exposed to unnecessary financial risk and want to provide low volume hospitals with the protection they need to succeed in TEAM.

Therefore, after consideration of comments received, we are convinced that TEAM needs a low volume policy to protect TEAM participants from undue financial harm and are finalizing a low volume policy in this final rule. We are finalizing one of the options we considered in the proposed rule that received a majority of public support, specifically the policy that if a TEAM participant does not meet a low volume threshold of at least 31 episodes in an episode category during the 3-year baseline period, CMS will still reconcile their episodes in the corresponding performance year, but the TEAM participant will not face downside risk in that category. In other words, if the TEAM participant's episode spending exceeds the final target prices in an episode category where they were classified as low volume in the baseline period, they will not owe any money to CMS in that episode category. However, they will still be held accountable for their performance in any episode category in which they were not classified as low volume in the baseline period per the participation tracks applicable to the hospital. Please note that all performance year episodes which are eligible for reconciliation will still be included in determining the CQS and stop-loss/stop-gain thresholds even if downside risk has been waived for those episodes. We believe this low volume policy not only financially protects low volume hospitals, but it allows these hospitals to continue participating in the model with a positive incentive to try and reduce spending.

Comment: Many commenters supported a low volume policy that would apply to specific episode categories. A few commenters added that under a low volume policy that applied across all episode categories, hospitals could reach the low volume threshold through high episode counts in one or two episode categories and face reconciliation in other categories in which they had very few episodes. For example, a hospital could have 30 episodes in the LEJR category, and one episode in each of the other categories. This would result in that hospital facing reconciliation for categories in which they did not have a significant number of episodes.

Response: We thank the commenters for their suggestions. We agree that the low volume policy should apply to specific episode categories, as opposed to across all episode categories. The low volume threshold previously considered and finalized in this rule will be applied at the episode category level. This will prevent hospitals with imbalanced episode volumes from facing reconciliation for episodes categories in which they had low episode volume. We recognize that systematic care redesigns made for one episode category will not always translate to other episode categories. Setting the threshold at the episode category level will ensure that hospitals only face risk for those categories in which they have a high enough volume of cases to meaningfully evaluate these redesigns. We believe that an additional threshold accounting for hospitals with a low total number of episodes would be redundant.

Comment: Many commenters stated that participants that do not meet the low volume threshold for a given episode category should not face downside risk in that episode category for the performance year. A commenter suggested that low volume hospitals be allowed to opt-in to participation in TEAM for episode categories in which they were below the threshold, or if forced to participate, be allowed to select Track 1 for the first 3 performance years of the model and Track 2 for the remaining years of the model for that episode category. A commenter stated that participants that do not meet the low volume threshold for a given episode category should be granted an exemption from participation in that episode category.

Response: We thank the commenters for their suggestions. While not holding TEAM participants who failed to reach the low volume threshold for a given episode category accountable for their performance in that category may result in higher savings for CMS, we are finalizing that these hospitals would still be able to receive reconciliation payment amounts because it both mitigates financial concerns for low volume hospitals and maintains an incentive for these hospitals to reduce spending and provide quality care for low volume procedures. This will have roughly the same impact as allowing hospitals to be placed in Track 1 for a given episode category. However, hospitals would retain the stop-gain limits for the participation track they had selected for that performance year. For example, if a Track 2 and a Track 3 hospital both fell below the low volume threshold for a given episode category in PY 2, and earned a reconciliation payment from CMS for that episode category, they would face stop gain limits of 5 percent and 20 percent, respectively.

Comment: A couple of commenters stated that participants that do not meet the low volume threshold for a given episode category should either be excluded from the model or be placed in Track 1 for the duration of the model, adding that anything less would provide insufficient protection for low volume hospitals.

Response: We disagree that TEAM participants that do not meet the low volume threshold for a given episode category for one performance year should be excluded from the model or protected under the low volume policy for the duration of the model. The combination of a 3- year baseline period and the fact that procedure volumes tend to remain consistent across years mean that it is likely that a hospital's status as low volume will remain constant for a given episode category across the duration of the model. However, if a hospital were to exceed the low volume threshold for a given baseline period, we believe that it would be inappropriate to continue to treat them as low volume.

Comment: Many commenters wrote in favor of specific low volume thresholds that would be appropriate in fairly assessing participant's performance. These suggestions included thresholds of 25, 30, 31, 40, 50, 72, 91, and even 200 episodes per episode category across a 3-year baseline period. A commenter also suggested an MS-DRG specific low- volume threshold of 50 episodes.

Response: We thank the commenters for their suggestions. When selecting the low volume threshold, we considered the need to minimize the financial risks

placed on low volume hospitals, the need to fairly evaluate participants, the goal of maximizing participants' incentives to invest in health care infrastructure, redesigned care processes, and provide higher value care, and potential savings to Medicare. We believe that a threshold of 31 episodes per episode category over three baseline years sufficiently protects low volume hospitals and provides a high enough volume for CMS to fairly assess their performance and for TEAM participants to fairly assess care transformation efforts made in these episode categories.

When assessing what protections should be provided to hospitals that fell below the low volume threshold, we determined that, in order to maximize incentives to transform care, it was important to continue to reconcile episodes for low volume hospitals who earn reconciliation payments from CMS. This approach, which exposes CMS to downside risk on low volume episodes, reduces savings for CMS, and that savings reduction increases as the low volume threshold rises.

Regarding the suggestion to set the low volume threshold at the MS- DRG level, while we recognize that pricing is done at this level, we believe that setting this granular of a low volume threshold would make the low volume threshold susceptible to increased coding intensity. While costs across MS-DRGs within an episode category may be different, we believe that care transformation efforts made within these categories will be largely transferable. Finally, we believe that annual thresholds, if assessed during the performance year, would also create gaming opportunities.

Comment: A few of commenters supported a threshold of 41 episodes per episode category across a 4-year baseline period, similar to BPCI Advanced.

Response: We thank the commenters for their suggestion. While we recognize that BPCI Advanced utilized a 4-year baseline period, TEAM has a 3-year baseline period. A threshold of 31-episode over 3 baseline years is the same per baseline year threshold as 41 episodes over 4 baseline years.

Comment: A commenter suggested that CMS adopt a tiered threshold or set a low volume threshold that is based on the percentage of total episodes within a category to account for the fact that some episode categories inherently have higher volumes than others.

Response: We thank the commenter for their suggestion. While we recognize that episode counts are inherently different across different episode categories, we believe that varying the low volume threshold by episode category would add unnecessary complexity to the model at this time.

Comment: A commenter expressed concern that Track 1 being optional in PY 1 meant that this track did not guarantee protection against financial vulnerability for low volume hospitals.

Response: We would like to clarify that, while Track 1 is optional for participants in PY 1, participants will be assigned this track unless they notify CMS that they would like to participate in Track 3. Therefore, the only TEAM participants that face downside risk under TEAM in PY 1 will be those that voluntarily elect to do so. We believe that this does guarantee protection against financial vulnerability for TEAM participants in PY 1.

Comment: A couple of commenters urged CMS to finalize a low volume policy prior to PY 1, stating that participants must know the key elements of TEAM prior to the start of the model for planning purposes. The commenters also noted that CMS should minimize mid-model changes. Another commenter stated that a low volume policy was one of several key features of TEAM that had not been determined, and that CMS should delay the model until these features were finalized so that hospitals had time to prepare for participation.

Response: We thank the commenters for their concerns regarding hospitals' ability to plan for TEAM and the importance of minimizing mid-model changes. We disagree that TEAM participants do not have adequate time to prepare for the model. There are approximately 17 months between the start date of TEAM and when hospitals were notified of their participation through the 2025 IPPS/LTCH PPS proposed rule. TEAM participants that elect to participate in Track 1 will have 12 additional months to prepare before they take on downside risk in PY 2, and TEAM participants that qualify as safety net will have up to 24 additional months to prepare before taking on downside risk in PY 4. We understand that the low volume policy is an important aspect of the model, and TEAM participants will have approximately 17 months between the low volume policy being finalized in this rule and when they are exposed to downside risk in PY 2. Furthermore, all TEAM participants will be notified whether or not they qualify as low volume in a given episode category based on the baseline period of that performance year ahead of the due dates for participation track selection for that performance year. TEAM participants will have the necessary information to decide what level of financial risk/reward they want to opt-into for a given performance year.

We recognize the importance of minimizing mid-model changes and will take the instability caused by such changes into account in future notice and comment rulemaking. However, we also recognize the importance of being responsive to TEAM participants. We will continue to monitor the low volume policy throughout the model test and may propose changes through future notice and comment rulemaking if we identify an approach that is more responsive to TEAM participants and spurs care improvements for beneficiaries at low volume hospitals.

Comment: A commenter expressed concerns that low volume providers would struggle to establish pre- and post-acute partnerships, causing them to struggle in TEAM.

Response: We thank the commenter for their feedback. We agree that these partnerships could significantly impact hospitals' ability to succeed in TEAM. We also recognize that factors outside of a hospital's control, such as geographic location and market dynamics, will impact their ability to form these partnerships. We believe that the low volume policy finalized in this rule, as well as other policies included in TEAM, such as the ability for rural hospitals to participate in Track 2, will help protect the TEAM participants most likely to struggle to form partnerships with providers for reasons outside of their control.

Comment: Some commenters noted that, for low volume providers, the upfront costs of participation in the model, such as updating analytics infrastructure or staffing, would outweigh the benefits of participating in the model, or that investing in care delivery improvements for specific episode categories would not be financially viable if hospitals performed low volumes of those procedures. A commenter added that low volume providers are not incentivized to make meaningful changes in care delivery under the model. A few commenters expressed concerns about the level of financial investment in infrastructure, analytics, and system redesigns hospitals would need to succeed under the model and some stated that the low volume threshold should be high enough that hospitals that met the threshold accrued enough episodes to determine if care delivery changes had a meaningful impact.

Response: We thank the commenters for their concern regarding low volume hospitals' ability to afford the upfront

costs needed to make meaningful changes in care delivery, their incentives to make these changes, and their ability to evaluate the impact of these changes. TEAM is intended to incentivize investments and changes in care processes that improve both the quality and efficiency of care. We understand that many of these improvements include fixed costs, and that it may be difficult for hospitals to justify these costs in areas where they have low volume of cases, as the hospital could provide greater quality and efficiency improvements by investing resources elsewhere. We acknowledge that it is difficult to justify major care changes without a high enough case volume to accurately measure the impact of these changes. We believe that the finalized low volume threshold of 31 episodes per episode category in a given baseline period represents a high enough volume for hospitals to evaluate the impact of changes made while participating in TEAM. Additionally, we believe that this policy will prevent hospitals from owing repayment amounts for episode categories in which they lack the incentive to invest in care transformation efforts.

Comment: Some commenters stated that the lack of a low volume policy would hurt rural, small, or safety net providers. A few commenters stated that safety net hospitals, which display low margins and depend on public payors, could not afford to invest in care teams for low volume procedures.

Response: We thank the commenters for their concerns for rural and safety net hospitals. While we are finalizing a low volume policy, we want to emphasize that TEAM provides significant protection for these hospitals outside of a low volume policy. Safety net hospitals, as defined at Sec. 512.505, will be able to participate in Track 1 with no downside risk for the first 3 performance years of the model. Additionally, we will incorporate a variable in the TEAM risk adjustment model that accounts for safety net status when calculating target prices, providing more accurate targets for hospitals whose spending may exceed the averages in their region for reasons outside of their control. Both safety net hospitals and rural hospitals, as defined at Sec. 512.505, will be able to participate in Track 2 for performance years 2 through 5 of the model with a 5 percent stop-gain and stop-loss limit. We believe that these protections, in conjunction with the low volume policy finalized in this rule, will allow rural and safety net hospitals the opportunity to succeed in TEAM.

Comment: Some commenters stated that CMS should apply the low volume threshold to all hospitals, as opposed to just rural and safety net hospitals.

Response: We thank the commenters for their suggestion. We agree that the difficulties that low volume hospitals face are not specific to rural and safety net hospitals. The low volume policy finalized in this rule will apply to all TEAM participants regardless of their status as rural or safety net hospitals.

Comment: Some commenters suggested that CMS maintain data sharing with hospitals that fell below the low volume threshold, as this data could help them prepare for future performance years in which they might exceed the threshold.

Response: We thank the commenters for their suggestion. Falling below the low volume threshold will have no impact on data sharing for TEAM participants. We agree with the commenters that continuing to share data with hospitals that fall below the low volume threshold is critical, as these hospitals are still TEAM participants and could exceed the threshold for future performance years. Given that hospitals who fall below the threshold for a given episode category will still have their episodes reconciled, just without facing downside risk, it would not make sense to withhold data from these hospitals.

Comment: A commenter stated that the low volume threshold should also apply to benchmarking calculations.

Response: We thank the commenter for their suggestion. While we recognize that low volume hospitals may generate outlier episodes, we believe that our current benchmarking methodology fairly accounts for those outliers. Additionally, because preliminary target prices are at the MS-DRG/HCPCS-region level, a regional low-volume policy would not be practical to implement as CMS will need to create target prices for all MS-DRG/HCPCS in all regions.

After consideration of the public comments, we are finalizing at Sec. 512.550(c)(1) through (7) a low volume threshold policy that received the majority of public comment support in TEAM such that if a TEAM participant did not meet the low volume threshold of at least 31 episodes in a given baseline period for a given episode category, CMS would still reconcile their episodes, but the TEAM participant would not be held accountable for any performance year episode spending that exceeded the reconciliation target price for each of the MS-DRG/HCPCS episode types in that given episode category during the applicable performance year. (9) Aligning Date Range in the Baseline and Performance Years and Timing of Reconciliation

In the FY 2025 IPPS/LTCH PPS final rule (89 FR 68986) that established TEAM, we finalized the policy that we would calculate preliminary target prices using a 3-year rolling baseline period as described in Sec. 512.540(b)(2). For example, for PY 1, covering the period from January 1, 2026, to December 31, 2026, we would use a baseline period from January 1, 2022, to December 31, 2024. We noted that we would attribute episodes to the baseline period based on the episode start date. An episode with an anchor hospitalization beginning in December 2022 and an anchor hospitalization discharge date in January 2023 would have an episode start date in 2022 and would be included in the baseline for PY 1 but not for PY 2, for which the baseline period is January 1, 2023, to December 31, 2025.

However, as indicated in Sec. 512.540(a)(3), we finalized our proposal to attribute episodes to performance years based on the date of discharge from the anchor hospitalization or the date of the anchor procedure for the purpose of assigning target prices. We further clarified this approach in section X.A.3.d.(3).(d) of the FY 2025 IPPS/ LTCH PPS final rule and gave the following example: If an episode has an anchor hospitalization or anchor procedure end date in December 2026 but an episode end date in January 2027, the episode is assigned to PY 1 and will have the PY 1 target price applied to it. However, if the episode starts in 2026 but both the anchor hospitalization discharge and episode end dates are in 2027, the episode is assigned to PY 2 and will have the PY 2 target price applied to it.

To better align our episode attribution and pricing methodologies across the baseline and performance periods, we proposed to modify our approach to attribution of episodes to baseline years for the purpose of calculating preliminary target prices. Specifically, we proposed adopting the same approach that we finalized for attribution of performance year episodes, as described previously. Therefore, we proposed that an episode with an anchor hospitalization beginning in a given baseline year and an anchor hospitalization discharge date in the subsequent baseline year would be attributed to the baseline year when the anchor hospitalization discharge date occurred. For example, an episode

with an anchor hospitalization beginning in December 2022 with an anchor hospitalization discharge date in January 2023 would be included in the baseline for both PY 1 (as baseline year 2 of a baseline period from January 1, 2022, to December 31, 2024) and PY 2 (as baseline year 1 of a baseline period from January 1, 2023, to December 31, 2025). We stated in the proposed rule that this modification does not make any change to the methodology for attribution of episodes to the performance year. We believed this approach simplifies the construction of baseline and performance year episodes and maintains consistent application of episode assignment between baseline and performance years.

We also indicated in FY 2025 IPPS/LTCH PPS final rule (89 FR 68986) that for episodes that begin in one performance year and end in a subsequent performance year we would reconcile episodes based on the episode end date. However, we recognized that reconciling an episode based on the episode's end date may unnecessarily increase operational burden when trying to manage when an episode would be reconciled, especially when comparing the target price to the performance year. For example, if an episode starts in one performance year and ends in a subsequent performance year, then a TEAM participant would have to wait an additional year before that episode would be reconciled even though its target price was aligned with the performance year of the anchor hospitalization discharge date. Table XI.A.-15 demonstrates how episodes starting in a one performance year and ending in a subsequent performance year are reconciled. [GRAPHIC] [TIFF OMITTED] TR04AU25.316

Therefore, we proposed to reconcile an episode based on the episode's anchor hospitalization or anchor procedure discharge date. We believed this approach would simplify tracking episodes and their reconciliation timing for TEAM participants. Additionally, we stated in the proposed rule that it would keep all episodes aligned to a given performance year based on target price construction to the same reconciliation time period. Table XI.A.-16 demonstrates the proposed approach to reconciling episodes based on anchor hospitalization or anchor procedure discharge date. [GRAPHIC] [TIFF OMITTED] TR04AU25.317

We sought comment on our proposal at Sec. 512.540(b)(2)(i) through (v) to construct baseline year episodes based on the anchor hospitalization or anchor procedure discharge date. We also sought comment on our proposal at Sec. 512.540(a)(3) to reconcile episodes based on anchor hospitalization or anchor procedure discharge date.

The following is a summary of the public comments received on the proposed policies to construct baseline year episodes and to reconcile episodes based on the anchor hospitalization or anchor procedure discharge date, and our responses to these comments:

Comment: A few commenters expressed support for our proposal to assign baseline year episodes to corresponding baseline years based on the anchor hospitalization or anchor procedure discharge date and also to reconcile episodes based on anchor hospitalization or anchor procedure discharge date.

Response: We thank the commenters for sharing their support.

Comment: Some commenters expressed concerns that the proposed change would delay reconciliation.

Response: We disagree that the proposed change would delay reconciliation. Rather, the policy has been proposed to avoid delays in reconciliation. For example, per the policy finalized in the FY2025 IPPS/LTCH final rule, an episode in PY1 that has an anchor hospitalization or anchor procedure discharge date in 2026 and an episode end date in 2026 will be reconciled in Fall 2027 whereas a PY1 episode with anchor hospitalization or anchor procedure discharge date in 2026 but an episode end date in 2027 will be reconciled in Fall 2028. Even though both episodes fall in the same performance year and have the same final target price applicable to them, they would be reconciled in different time periods due to the end dates falling in different calendar years. As noted in the proposed rule, this may unnecessarily increase operational burden and delay the timely delivery of reconciliation reports. Therefore, we had proposed to reconcile episodes based on anchor hospitalization or

anchor procedure discharge date and not the episode end date such that all episodes belonging to a given performance year are reconciled together. In the previous example, both episodes would be reconciled at the same time in Fall 2027 and TEAM participants will not have to wait until Fall 2028 to find the outcomes of some performance year 2026 episodes. We refer readers to tables XI.A.-15 and XI.A.-16 which illustrate when episodes would be reconciled based on episode end dates compared to anchor hospitalization or procedure discharge date.

Comment: Some commenters stated that TEAM should be consistent with past models and use episode end dates to determine attribution of both baseline and performance year episodes.

Response: While the proposed policy differs from BPCI Advanced where episodes are reconciled based on episode end dates, it aligns with the approach used in CJR model. The approach used in BPCI Advanced has increased operational burden for both CMS and BPCI Advanced participants as a fraction of episodes belonging to a given performance year are reconciled at a much later date relative to other episodes in the same performance year.

After consideration of the public comments, we are finalizing without modification our proposal at Sec. 512.540(b)(2)(i) through (v) to construct baseline year episodes based on the anchor hospitalization or anchor procedure discharge date. We are also finalizing our proposal at Sec. 512.540(a)(3) to reconcile episodes based on anchor hospitalization or anchor procedure discharge date.

(10) Converting Standardized Dollars to Real Dollars (a) Converting Target Prices and Reconciliation Amounts to Real Dollars

In the FY 2025 IPPS/LTCH PPS final rule (89 FR 68986) that established TEAM, we finalized the methodology for constructing regional target prices and, ultimately, determining performance year spending and reconciliation amounts. Spending and reconciliation amounts are based on Medicare allowed amounts (also referred to as “allowed amounts”), which include the amount Medicare reimburses providers as well as any beneficiary liability (that is, beneficiary deductibles and coinsurance) and payment from other payers. Specifically, we finalized an approach for using standardized dollar amounts (as also referred to as “standardized dollars”) as opposed to the actual, nominal dollar amounts reflected on claims (also referred to as “real dollars”) in the calculation of performance year spending and reconciliation amounts. Standardization of Medicare allowed amounts removes adjustments to payment amounts including but not limited to those from Medicare incentive programs (for example, the HVBP Program, the HAC Reduction Program, and the HIQR Program) and geographic or policy-driven payment system adjustments, such as hospital wage index or indirect medical education adjustments, from TEAM's target prices. Standardization of allowed amounts allows for meaningful comparison of resource use for services covered by CMS across provider types and geographic areas. We indicated in the proposed rule that when comparing standardized allowed amounts, cost differences primarily result from differences in practice patterns and health care delivery choices (for example, about the setting, provider type, or number of services provided). Not standardizing allowed amounts by removing adjustments and incentive payments would unduly penalize hospitals receiving additional payments for compliance and undermine the incentives of CMS reporting or quality programs. We noted in the proposed rule that without payment standardization, high-quality or reporting compliant hospitals may appear to have high episode payments under TEAM. Conversely, lower quality or non-reporting compliant hospitals that incur payment reduction penalties may appear to have low episode payments under TEAM. Additionally, removal of geographic adjustments is important given variation in episode payments across hospitals resulting from wage index adjustments. In the proposed rule, we stated that we want to avoid having the wage level or other adjustments for one hospital arbitrarily influence target prices for another hospital with a different wage level or adjustments, as this would introduce unintended pricing distortions not based on utilization pattern differences. Thus, we believed it is important to use standardized allowed amounts as the foundation for constructing target prices and determining performance year spending and reconciliation amounts (reconciliation payment amounts or repayment amounts) to ensure a TEAM participant's actual performance is not artificially improved or worsened because of adjustments or incentive payments.

However, in the proposed rule we acknowledged that when target prices and reconciliation amounts are denominated in standardized dollars, they may not reflect relative differences in costs faced by TEAM participants. We stated in the proposed rule that we expect that TEAM participants will use their reconciliation payment amounts to invest in care redesign, coordination, and delivery infrastructure, and we expect that the costs for such investments would vary by geography and by the type of hospital, such as due to differences in local wages or whether the hospital is a teaching hospital. For example, we expect that hiring a care coordinator would cost a TEAM participant more in San Francisco than in a rural part of Idaho. Therefore, we considered approaches to converting standardized target prices and reconciliation amounts back to real dollars as other CMMI models have done. For example, the BPCI Advanced model converted back to real dollars using a ratio of the sum of real clinical episode spending to standardized allowed amount spending at the episode initiator-clinical episode category level. In another approach, the CJR model used a wage factor derived from the IPPS wage index (aligned with the fiscal year and based on the episode start date) to account for differences in real costs between model participants.

We stated in the proposed rule that we believe that all these approaches have limitations that may unduly negatively impact TEAM participants. For example, if we used an approach similar to the BPCI Advanced model, TEAM participants that receive add-on payments unrelated to the direct costs associated with providing services (for example, low-volume volume payment adjustment payments and indirect medical payment adjustments) would have a higher real-to-standardized ratio than comparable participants that do not receive these payments. In the case where such a TEAM participant has a negative reconciliation amount (that is, owes a repayment amount to CMS), converting the reconciliation amount to real dollars would increase this repayment amount. We noted in the proposed rule that we are worried that such an increase may unduly burden TEAM participants with already limited resources. Furthermore, specific approaches have unique limitations. For example, we believe the approach used in the CJR model of converting standard dollars back to real dollars using a wage factor ignores two key considerations. First, we stated there may be significant differences in relative wages between the IPPS setting in which the episode is triggered and other claims settings in the post- discharge period. Therefore,

applying the IPPS-derived wage factor to the entire episode (that is, all claims grouped to it, including those in the post-discharge period) may not accurately reflect differences in real costs across participants and settings of care. Second, we stated that using only the wage factor fails to take into account non-wage differences in Medicare payment amounts such as outlier payments and provider-specific adjustments from other Medicare initiatives.

Given all of these considerations, we did not propose any methodology for converting standardized target prices and reconciliation amounts to real dollars at this time. Instead, we kept target prices and reconciliation amounts in standardized dollars, while requesting comment on whether we should convert to real dollars and the preferred methodology for doing so, including but not limited to all the approaches discussed herein.

We sought comment on whether and how to convert target prices and reconciliation amounts from standardized dollars to real dollars in a consistent manner.

The following is a summary of the public comments received on the considerations for converting target prices and reconciliation amounts to real dollars, and our responses to these comments:

Comment: A few commenters suggested CMS should convert standardized dollars to real dollars for both target prices and reconciliation amounts. A couple commenters urged CMS to establish a methodology to convert standardized dollars to real dollars to issue performance-based payments and recoupments from participating TEAM hospitals only during the reconciliation calculation for each performance year. Among commenters suggesting converting standardized dollars to real dollars for either the reconciliation amounts only or for both target prices and reconciliation amounts, a few commenters requested that CMS consider the wage factor conversion method used in the CJR model to best account for differences in hospitals' episode expenditures in relation to the target price. A commenter suggested reconciliation amounts should have a real-to-standardized dollar ratio applied, similar to the calculation in BPCI Advanced. However, this commenter suggested to exclude inpatient indirect medical education (IME) payments and disproportionate share hospital (DSH) payments. A couple commenters supported keeping target prices and reconciliation amounts in standardized dollars since it will better allow peer participants to compare themselves to a fixed reference point.

Response: We believe that keeping the reconciliation amounts in standardized dollars minimizes the risk of creating unfair rewards/ penalties for hospitals. Specifically, we believe it may negatively impact participants, who receive additional payments like IME and DSH payments leading to higher real to standardized ratio causing an amplification of TEAM repayment amounts. On the other hand, hospitals that receive deductions through various hospital programs may lead to lower rewards through lower real to standardized ratio.

Comment: A commenter noted that the conversion methodologies used in BPCI Advanced and CJR are imperfect and suggested a six-step conversion methodology which applied different wage factors based on the payment system (that is, IPPS, OPPS, Physician Fee Schedule) used in each of the clinical episodes.

Response: We appreciate the detailed six-step methodology outlined by the commenter but have concerns regarding the complexity and feasibility of such an approach. Given the multiple payment systems throughout the various anchor and post-discharge period claim settings, the ability to calculate wage factors and apply them to target prices which are established using baseline data adds considerably to the operational complexity of the model.

Comment: A commenter stated that the use of standardized dollars removes any elements that would make one provider's Medicare payment different from another provider's payment for the same claim.

Response: We disagree that the use of standardized dollars removes the ability to distinguish the cost of care between two claims. Standardized dollars allow fair comparisons by removing the impact of geographical factor like wage index for the same services between two different providers. Cost differences based on variations in practice patterns and health care delivery choices continue to exist and are avenues for potential additional savings.

We did not propose, and after consideration of public comments, we are not convinced that we should make any changes to the calculation of target prices and reconciliation amounts. Therefore, the calculation of target prices and reconciliation amounts will remain in standardized dollars. We believe the standardized dollar payments will continue to remove differences in wage indexes and hospital-level payment adjustments across target prices and reconciliation amounts for TEAM participants. (b) Converting Post-Episode Spending Amounts to Real Dollars

In the FY 2025 IPPS/LTCH PPS final rule (89 FR 68986) that established TEAM, we noted that some hospitals may have an incentive to withhold or delay medically necessary care until after an episode ends to reduce their actual episode payments. In order to identify and address such inappropriate shifting of care, we finalized a post- episode spending calculation methodology. In this approach, we would identify whether the average 30-day post-episode spending for a TEAM participant in any given performance year is greater than 3 standard deviations above the regional average 30-day post-episode spending, based on the 30-day post-episode spending for episodes attributed to all TEAM regional hospitals in the same region as the TEAM participant. We finalized that beginning with PY 1 for Track 3 TEAM participants, and PY 2 for Track 2 TEAM participants, if the TEAM participant's average post-episode spending exceeds this threshold, the amount above the threshold would be subtracted from the reconciliation amount or added to the repayment amount for that performance year.

In the proposed rule, we stated that we recognize it is important to remain consistent across our calculations when converting to real dollars. Therefore, we also sought comment on whether and how to convert the post-episode spending amounts from standardized dollars to real dollars. Specifically, we requested comment on whether, if a TEAM participant's average post-episode spending in the MS-DRG/HCPCS episode type exceeds the region's threshold in that MS-DRG/HCPCS episode type, the amount above the threshold should be converted from standardized to real dollars using a hospital-level real-to-standardized spending ratio.

Additionally, we considered that the post-episode spending amounts would be determined at a MS-DRG-hospital level rather than an episode level like our target price and reconciliation amount consideration because--

Average post-episode spending is more representative of consistent patterns in the delay of medically necessary services in the post discharge period by a hospital; and

Hospitals do not have the same incentives to not exceed the expected post-episode spending that they have with in-episode spending. Hence, TEAM participants may be subject to

higher penalties if the post-episode calculation is at an episode level compared to an aggregate hospital-level. Therefore, we stated in the proposed rule that were we to propose to convert from standardized dollars to real dollars, we would propose to do so at the hospital level to align with the hospital-level post-episode spending amounts. The hospital level real-to-standardized ratios would be determined as the ratio of sum of total post-episode spending in real dollars to sum of total post-episode spending in standardized dollars using the set of reconciled episodes in the corresponding MS-DRG/HCPCS episode type.

We sought comment on our consideration to determine post-episode spending amounts at the MS-DRG-hospital level rather than an episode level. We also sought comment on whether and how to convert post- episode spending amounts from standardized dollars to real dollars in a consistent manner.

The following is a summary of the public comments received on the considerations for post-episode spending amounts at the hospital rather than episode level and to convert post-episode spending amounts to real dollars, and our responses to these comments:

Comment: A commenter noted that CMS should carefully evaluate whether post-episode spending should be converted to real dollars as the conversion may improve transparency but could also introduce unintended financial risks for hospitals. This commenter requested that CMS further engage with stakeholders to determine whether real-dollar conversions would enhance financial predictability or create additional burdens for hospitals. Another commenter supported the use of real- dollar conversion for post-episode spending calculations as they believe the conversion will provide more meaningful insight into actual costs.

Response: We thank the commenters for sharing their thoughts regarding the conversion of post-episode spending amounts from standardized dollars to real dollars. We agree that hospitals in high wage index may incur high penalty amounts compared to low wage index areas, however it is not the primary factor of consideration for keeping the penalty amounts in standardized amounts since Medicare payments received by the providers are reflective of these wage- indexes. CMS believes provider-specific add-on payments like IME and DSH payments may lead to higher real to standardized ratio which in turn may unduly penalize the TEAM participants.

We did not propose, and after consideration of the public comments, we are not convinced that any changes should be made to the calculation of post-episode spending amounts. Therefore, the calculation of post- episode spending amounts will remain in standardized dollars and at the episode level. d. Health Data Reporting

As described in the FY 2025 IPPS/LTCH PPS final rule (89 FR 69800), we finalized voluntary reporting of three elements that aims to address reducing health disparities for TEAM beneficiaries. The elements include health equity plans, demographic data, and health related social needs data. We stated in the proposed rule that we continue to believe that it is important to understand and address health needs of all TEAM beneficiaries so that they can benefit from the care redesign interventions implemented by TEAM participants. However, due to the new Administration's priorities and concern over placing additional burdens on TEAM participants in a mandatory model, we recognized the need to remove the voluntary health equity plan and the health-related social needs data to reduce burden on TEAM participants. We noted in the proposed rule that we recognized that asking TEAM participants to submit health equity plans or report health related social needs data, even on a voluntary basis, could add an additional burden that CMS does not intend to add in the model. Even if TEAM participants choose to not voluntarily submit a health equity plan or report health related social needs data, we believed it would be a better use of TEAM participant resources to focus on care redesign activities that would help improve their performance in the model and improve the quality of care and care experience for the beneficiary, rather than spend resources on collecting and reporting health equity plan information or health related social needs data. Therefore, we proposed to completely remove the health equity plan and health related social needs data policies from TEAM, including all references to health equity plans. We stated in the proposed rule that though currently there is no replacement for these policies, CMS will consider adding elements that are consistent with the new Administration's focus on Making America Healthy Again. We believe there is opportunity through TEAM to encourage healthy habits among TEAM beneficiaries to drive improvements in overall health. We noted in the proposed rule that changes to TEAM that would incorporate the Administration's focus on prevention and healthy living would be proposed in future notice and comment rulemaking.

Given our desire to remove health equity plans, we also proposed to remove the “Health equity reporting” title to Sec. 512.563 and replace it with “Health data reporting”. Lastly, we also proposed removing the definition for “Health equity goal”, “Health equity plan”, “Health equity plan intervention strategy”, “Health equity plan performance measure”, and “Underserved community” from the definitions at Sec. 512.505.

Additionally, we proposed removing the voluntary collection of health-related social needs screening and reporting. This included removing voluntary reporting of the Screening for Social Drivers of Health measure, adopted at Sec. 512.563(b); and the Screen Positive Rate for Social Drivers of Health measure, adopted at Sec. 512.563(b).

In the proposed rule we stated that we also continue to believe voluntarily collecting demographic data is important to better understand TEAM beneficiaries. Therefore, we did not propose any changes to this element. We noted that we did discuss in the FY 2025 IPPS/LTCH PPS final rule (89 FR 69802) potential demographic data variables that CMS would voluntarily collect from TEAM participants such as race, ethnicity, language, disability, sexual orientation, gender identity, sex characteristics, and other demographics. While we have not specified the exact variables TEAM participants will report and will notify TEAM participants through sub-regulatory guidance of the demographic variables we wish to collect, as indicated in the final rule (89 FR 69804), we clarified in the proposed rule that we will not be collecting variables such as sexual orientation, race, ethnicity, or gender identity to align with the Administration's priorities and to reduce reporting burden on TEAM participants.

Finally, to align with the Administration's executive order to identify an individual's immutable biological classification as either male or female, we proposed to update the name of a beneficiary- identifiable data variable, that is not used for pricing or payment purposes, that we would share with TEAM participants, pursuant to a data request and executed TEAM data sharing agreement.\407\ Specifically, we

proposed the “gender” variable identified at Sec. 512.562(c)(3) to be renamed “sex”. We believe sex better represents the binary variable that we would be sharing with TEAM participants and allows for consistent interpretation of the term across Federal programs and initiatives.

\407\ Executive Order No. 14168 of January 20, 2025, Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government: https://www.whitehouse.gov/presidential-actions/2025/01/defending-women-from-gender-ideology-extremism-and-restoring-biological-truth-to-the-federal-government/./.

We sought comment on our proposal at Sec. 512.505 to remove from the definitions section health equity goal, health equity plan, health equity plan intervention strategy, health equity plan performance measure, and underserved community. We sought comment on our proposal at Sec. 512.563 to retitle the header and remove the health equity plan and health related social needs data elements. We also sought comment on our proposal at Sec. 512.562(c)(3) to rename the “gender” variable to “sex”.

The following is a summary of the public comments received on the proposed policies to remove health equity terms, remove the health equity plan and health related social needs data elements, and rename the gender variable, and our responses to these comments:

Comment: Some commenters supported CMS's decision to remove health equity plans from TEAM.

Response: We thank these commenters for their support.

Comment: A number of commenters did not support CMS's proposal to remove health equity plans from TEAM. These commenters recognized the plans were voluntary components of TEAM but noted environmental and social factors are important to understanding the context and health of patients fully. These commenters noted that this additional data on patients allows them to better understand and care for vulnerable patients.

Response: We thank these commenters for their feedback. We believe it is important for TEAM participants to have the autonomy and flexibility to determine how they can best meet the needs of their patient population. TEAM participants are permitted to collect additional information on their patients in the model, while remaining compliant with relevant laws and regulations, in order to improve quality of care and reduce Medicare spending. We anticipate that TEAM participants may work toward independently identifying and producing their own data, through electronic health records, health information exchanges, or other means that they believe are necessary to best evaluate the health needs of their patients, improve health outcomes, and produce efficiencies in the provision and use of services. Therefore, we support TEAM participants collecting additional information for their own use that could be beneficial to the health and wellbeing of their patients. We believe that removing health equity plans from the model does not prevent TEAM participants from collecting data that could give greater context to the care of patients. CMS is focused on reducing or not inflicting additional levels of administrative burden on TEAM participants. While we recognize health equity plans were voluntary, we believe removing health equity plans from TEAM will allow TEAM participants to direct their resources and attention to model requirements and achieving the goals of the model. We also believe removing health equity plans from TEAM will allow TEAM participants to make their own decisions on what data is the most useful to collect to provide the best care to patients.

Comment: A commenter noted voluntary submission of health equity plans would help CMS and participants identify where potential care and health disparities exist, tailor care redesign efforts to patient needs, and develop interventions that reduce avoidable complications and readmissions.

Response: We appreciate and sympathize with this commenter's concerns over avoidable complications and readmissions, as this is a major part of what TEAM is trying to reduce. If TEAM participants believe that collecting health equity data will help in this endeavor, they are free to do so, but TEAM participants will not incur the burden of submitting this data to CMS (as they may under the current voluntary policy), nor will CMS accept receipt of this data.

Comment: Some commenters supported CMS's decision to keep reporting requirements around patient demographic data, but remove specific portions relating to Social Determinants of Health (SDOH)

Response: We thank these commenters for their support.

Comment: Other commenters questioned why CMS should remove SDOH data from reporting requirements. These commenters noted that voluntary submission of SDOH data would help CMS and TEAM participants identify where disparities exist, tailor care redesign efforts to patient needs, and develop interventions that reduce avoidable complications and readmissions. These commenters stressed that collecting this data is not a burden to them but is considered an investment in using efficiently and effectively. They also believe this data collection aligns with the long-term goals of value-based care which leads to improving patient outcomes while reducing cost and raising quality of care.

Response: We appreciate these commenters concerns and their commitment to CMS's goals of improving quality while also reducing the cost of care for Medicare beneficiaries. We believe it is important to give TEAM participants more autonomy and flexibility to accomplish these goals. With this in mind, removing the SDOH reporting requirements from TEAM gives TEAM participants the flexibility to identify and focus on the non-medical needs for their specific patient population and cater their care redesign interventions to meet the needs of their patients. If TEAM participants believe collecting SDOH data will reduce costs and improve the quality of care, then TEAM participants are free to continue these data collection practices, but they will not need to report this data to CMS. However, if it is not clear to TEAM participants if this specific data collection will reduce costs or improve quality of care, there will no longer be any mechanisms in place for them to report such data to CMS.

After consideration of public comments, we are finalizing our proposal to remove Health Equity Plans from TEAM and remove the corresponding regulations at Sec. 512.505 and Sec. 512.563. We are also finalizing our proposal to remove voluntary reporting of the Screening for Social Drivers of Health measure and the Screen Positive Rate for Social Drivers of Health measure from TEAM and remove the corresponding regulations at Sec. 512.563(b). Lastly, we are finalizing our proposal to rename the “gender” variable to “sex” at Sec. 512.562(c)(3). e. Referral to Primary Care Services

In the FY 2025 IPPS/LTCH PPS final rule (89 FR 69850) we finalized the referral to primary care services requirement. To comply with this requirement, TEAM participants must (1) include in hospital discharge planning a referral to a supplier of primary care services for a TEAM beneficiary, on or prior to discharge from an anchor hospitalization or anchor procedure and (2) follow beneficiary freedom of choice requirements, as indicated in Sec. 512.582(a). We stated in the proposed rule that since a TEAM episode only lasts 30 days after the TEAM beneficiary is discharged from the hospital, the goal

of this policy is to integrate care during the transition from an acute event--an episode--back to longitudinal care relationships, such as primary care.

We noted in the proposed rule that we continue to believe there is value in maintaining this requirement in TEAM so that the TEAM beneficiary has continuity of care after the episode ends. Therefore, we did not propose a change to the current policy. However, we were aware that the current policy does not take into consideration the TEAM beneficiary's relationship with existing suppliers of primary care services. In other words, the TEAM participant may refer the TEAM beneficiary to a supplier of primary care services that is different from the supplier of primary care services that the TEAM beneficiary has an established relationship with, as documented through previous encounters via claims data, as long as it complies with beneficiary freedom of choice requirements. As such, we stated in the proposed rule that the TEAM participant may be incentivized to refer to their own suppliers of primary care services with whom they have a contractual relationship, even when complying with beneficiary freedom of choice requirements. While we anticipate most TEAM participants would refer TEAM beneficiaries back to suppliers with whom they have an existing relationship with, we sought comment on whether not specifically requiring that beneficiaries be referred back to suppliers with whom they have an existing relationship could disrupt fair competition as well as limit access to high-value care.

We considered, but did not propose, including in the referral to primary care services the requirement that TEAM participants refer the TEAM beneficiary back to the supplier of primary care services with whom they have an established relationship. We explained in the proposed rule that as part of the alternative, we considered identifying an established relationship by the TEAM beneficiary's interaction with a supplier of primary care services within the 2 previous years before the initiation of the episode and TEAM participants would still need to comply with beneficiary freedom of choice requirements. However, we were concerned that this consideration, namely requiring the TEAM participant to refer the TEAM participant back to a supplier of primary care services with whom they have an existing relationship, would increase TEAM participant administrative burden by having them review claims data for an existing relationship and may be challenging to operationalize given the window of time when the beneficiary is admitted to the hospital or hospital outpatient department and when they are required to submit the referral--before the TEAM beneficiary is discharged from the hospital or hospital outpatient department. As such, we considered extending the timeframe of when the referral to primary care services would occur. For example, we considered requiring the referral to primary care services to occur any time before the episode ends, rather than by the time the TEAM beneficiary is discharged from the hospital or hospital outpatient department. Given the administrative burden, we considered only requiring the referral for TEAM beneficiaries who do not have any relationship with a supplier of primary care services within the 2 previous years before the initiation of the episode as long as beneficiary freedom of choice requirements would be met, which would reduce burden since evidence from the BPCI Advanced model suggests most beneficiaries have some existing relationship. However, we recognized burden would not be diminished because it would still require the TEAM participant to identify through claims data whether the beneficiary had an established relationship or not.

We also considered, but did not propose, that a TEAM participant could refer the beneficiary to a supplier of primary care services other than their existing supplier, including referral to a TEAM participant's supplier of primary care services, as long as beneficiary freedom of choice requirements would be met, and the TEAM participant documented the TEAM beneficiary's preference. In the proposed rule, we recognized such a policy would increase administrative burden on TEAM participants to document a TEAM beneficiary's preference to be referred to a supplier of primary care services other than the supplier with whom they have an established relationship. However, we believed this additional documentation would help to ensure referrals are not influenced by a TEAM participant's financial or contractual relationships with certain suppliers of primary care services.

In the proposed rule, we noted that an internal analysis for the BPCI Advanced model demonstrated that approximately 94 percent of beneficiaries that initiated an episode, medical or surgical, had some primary care visit, as demonstrated through at least one evaluation & management (E&M), care management services, care planning, or wellness visit in 2 years prior to their episode. Additionally, among the small group that did not have a primary care visit in those 2 years before the episode, the BPCI Advanced model increased the share of beneficiaries getting a primary care visit within the 90-day post- discharge period by 9 percent for medical episodes. We stated in the proposed rule that this suggests that the majority of BPCI Advanced beneficiaries have interfaced with primary care prior to their episode of care and that they may have an existing relationship with a supplier of primary care services. However, we noted in the proposed rule that the benefit to requiring referral to primary care may be more practical for medical episodes rather than surgical episodes. This may be because the surgeon specialist has the expertise to manage the clinical follow- up, whereas a medical episode is generally an acute exacerbation of a chronic condition that primary care may typically manage. Given TEAM's current set episodes are all surgical, we recognized the primary care service referral may not be as impactful to driving primary care connections. We therefore considered, but did not propose, removing the referral to primary care services requirement from TEAM. This means that a TEAM participant would not be required to submit a referral to primary care services for any TEAM beneficiary. In addition to the internal analysis findings, we stated in the proposed rule that we believe many TEAM participants already have the mechanisms in place to refer the TEAM beneficiary back to their preferred supplier of primary care services, thus making the requirement inconsequential. Further, we also stated in the proposed rule that TEAM's testing of surgical episodes may also be contrary to a goal of the model. Meaning, referring back to a supplier of primary care services could result in unnecessary spending if the supplier of primary care services does not effectively manage the TEAM beneficiary's care. For example, a supplier of primary care services has the TEAM beneficiary go to the emergency department for surgical wound assessment, whereas the surgeon specialist may have informed the TEAM beneficiary the wound was healing as expected. Despite the consideration to removing the referral to primary care services requirement, we stated in the proposed rule that we still believe it is an important policy because it provides additional assurances the TEAM participant will connect the TEAM beneficiary to primary care services for ongoing care and follow-up that may help to reduce avoidable readmissions

and promote better longer-term outcomes.

We sought comment on our proposal to maintain the current policy as well as the alternative approaches for the referral to primary care services requirement as described previously. We also sought comment on alternatives that we may not have considered.

The following is a summary of the public comments received on the proposed policy to maintain the primary care services referral requirement and alternatives to this requirement, and our responses to these comments:

Comment: Many commenters supported the referral to primary care services requirement. The majority of the commenters that supported the requirement supported a referral back to an established supplier of primary care services. Of those commenters that supported a referral back to an established supplier of primary care services, many had concerns with using historical claims to identify the established supplier of primary care services due to operational burden and lack of insight. Several commenters supported having the TEAM participant refer to the supplier of primary care services recorded at the initiation of the hospitalization or outpatient procedure. Other commenters that supported the requirement suggested that the referral go to the ordering or primary follow-up physician rather than a primary care provider. A commenter recommended using CPTII codes to ensure beneficiaries are connected back to a provider to which they are already aligned.

Response: We thank the commenters for their support. As we noted in the FY 2025 IPPS/LTCH PPS final rule, TEAM provides an opportunity to further integrate care during the transition from an acute event- an episode- back to longitudinal care relationships, such as primary care (89 FR 69850). As such, the intent of the referral to primary care services requirement is to ensure the TEAM beneficiary can have continual clinical management from a longitudinal care provider after the episode ends. We do not intend for this requirement to disrupt existing patient-provider relationships nor replace any follow-up or management clinically necessary from a specialist or the clinician who performed the surgery. We agree that when including a referral to a supplier of primary care services in hospital discharge planning for a TEAM beneficiary, that the TEAM participant should take into account the TEAM beneficiary's primary care provider recorded during the hospital admission to the anchor hospitalization or recorded during the intake for the anchor procedure. We believe improved beneficiary quality of care can be achieved through consistent care management from suppliers who have an established relationship with the TEAM beneficiary. However, we recognize that there may be times that a TEAM beneficiary's preferences may change over the course of the anchor hospitalization or anchor procedure. Therefore, it is imperative that TEAM participants comply with beneficiary freedom of choice requirements, as described in Sec. 512.582(a), when including the referral for primary care services in the hospital discharge planning.

We agree that relying on claims data to identify an established supplier of primary care services would be operationally burdensome on the TEAM participant and that this data may not capture recent patient preferences, especially if the TEAM beneficiary moved or if the TEAM beneficiary opted to change providers.

We acknowledge the recommendation to use CPT II codes, as was used in BPCI Advanced for the Advanced Care Plan measure, to ensure a TEAM beneficiary is connected back to their established provider. However, we believe adding another step, such as including non-billable CPT II codes to a claim would increase TEAM participant burden unnecessarily.

We also recognize the value in referring the TEAM beneficiary to a supplier that may be more clinically attuned to managing the TEAM beneficiary's medical needs. As noted earlier, the referral to primary care services requirement should not replace any clinically appropriate follow-up care with a specialist or clinician that performed the surgical procedure. Outside of the referral to primary care services requirement, TEAM participants are not precluded from referring the TEAM beneficiaries to a specialist and we support the TEAM participant helping to coordinate a TEAM beneficiary's care with a specialist as that acute surgical event is typically the primary clinical focus after discharge from the hospital or hospital outpatient department. We believe the TEAM participant is well positioned to identify a supplier that they believe would be the most clinically appropriate to manage the TEAM beneficiary as long as the TEAM participant is complying with beneficiary freedom of choice requirements.

Given the majority of commenters' support for CMS to ensure TEAM beneficiaries are being referred to established suppliers, we believe that we need to modify the referral to primary care services requirement. Specifically, we will be adding clarifying language to Sec. 512.564(a) to state that a TEAM participant must include in hospital discharge planning a referral to an established supplier of primary care services, as recorded on admission to the hospital or hospital outpatient department, for a TEAM beneficiary, on or prior to discharge from an anchor hospitalization or anchor procedure. However, we recognize that there may be instances when a supplier of primary care services is not recorded on admission to the hospital or hospital outpatient department. We also want to prevent TEAM participants circumventing the documentation of an established supplier of primary care services to avoid the referral to primary care services requirement. In the event an established supplier of primary care services is not recorded on admission to the hospital or hospital outpatient department, such as because the TEAM beneficiary does not have an established supplier of primary care services, the TEAM participant must include in hospital discharge planning a referral to a supplier of primary care services for a TEAM beneficiary, on or prior to discharge from an anchor hospitalization or anchor procedure. In other words, if the supplier of primary care services was not recorded on admission to the hospital or hospital outpatient department, the existing referral to primary care services would apply. This ensures all TEAM beneficiaries are being connected back to a supplier of primary care services, not just those with an established supplier. No modifications will be made to Sec. 512.564(b); therefore, TEAM participants must continue to comply with beneficiary freedom of choice requirements. This means TEAM participants must continue to take into account TEAM beneficiary preferences when referring to a supplier of primary care services, which may include consideration of the supplier's location in relation of the TEAM beneficiary's place of residence.

We believe this addition will ensure that TEAM beneficiaries are being referred to the established provider with whom they have an existing relationship. Further, we believe the referral to primary care services requirement will promote collaboration between the TEAM participant and primary care providers, so that the TEAM beneficiary is being managed by a care team that includes clinicians who

can manage the surgical procedure and clinicians who focus on preventative care and can manage underlying, chronic conditions.

Comment: Several commenters supported a referral to primary care services but recommended CMS to not make it a requirement of the model. These commenters requested flexibilities for the TEAM participant to determine when a referral is appropriate and suggested the referral only be applicable to beneficiaries that do not have a supplier of primary care services. Some commenters also recommended that CMS include incentives for hospitals that successfully integrate primary care referrals into their care coordination strategies, rather than imposing strict compliance measures.

Response: We appreciate the commenters' recommendations. We recognize that a model requirement, as opposed to an optional model feature, may have the potential to increase TEAM participant burden. However, we believe that a referral to primary care services is already a common component to hospital discharge planning procedures and, as such, we expect that many TEAM participants will already have this policy integrated into their standardized discharge planning procedures and therefore have a minimal impact on burden. We also understand why commenters suggested this model requirement just focus on TEAM beneficiaries that do not have a supplier of primary care services since these are the patients that may eventually lack proper care management after the episode ends. Nonetheless, we believe having the referral to primary care services requirement apply to all TEAM beneficiaries is the most appropriate because we view the referral to primary care services as an important component of care coordination. Given a goal of the model is to improve transitions between care settings and providers, we believe it would be best practice for TEAM participants to refer all TEAM beneficiaries not just those without an established supplier of primary care services.

We acknowledge that the referral to primary care services is a requirement of the model but we do not believe that TEAM participants should be incentivized above and beyond the existing model incentive structure. Rather, we view the requirement as a mechanism to establish a standard care practice that we believe many hospitals already implement. We also believe the policy supports a step towards whole- person health where TEAM beneficiaries are being managed by the providers with the clinical expertise of their acute surgical event and then subsequently connected back to providers with longitudinal primary care expertise.

Comment: Some commenters requested CMS extend the referral period to anytime during the episode of care rather than limiting it to the time period before the TEAM beneficiary is discharged from the anchor hospitalization or anchor procedure.

Response: We acknowledge the commenters' recommendations to extend the referral period, which would provide the TEAM participant with more time to submit a referral to a supplier of primary care services. Still, we believe the best opportunity to have conversations with the TEAM beneficiary regarding longitudinal care management is when the TEAM participant can have in-person interaction with the TEAM beneficiary or the TEAM beneficiary's family or caregivers. This means we believe the most appropriate time frame to have these face-to-face conversations would be during the anchor hospitalization or anchor procedure. Further, we also believe that having these face-to-face discussions during the anchor hospitalization or anchor procedure is conducive to ensuring beneficiary freedom of choice is taken into account when submitting the referral during discharge planning.

Comment: A couple of commenters did not support CMS's consideration of requiring hospitals to refer patients specifically to a supplier of primary care services they have visited in the past 2 years, based on claims information, due to the TEAM participant's burden since claims are not integrated into electronic health records (EHRs). They further indicated that patients may have moved or deliberately changed their usual source of care in the previous 2 years, which could prevent hospitals from connecting patients to a more appropriate source of care. Lastly, they indicated that patients that recently switched their supplier of primary care services would not necessarily have their current supplier of primary care services reflected in the claims available to the hospital at the time of discharge.

Response: We recognize the challenge TEAM participants may have to identify a supplier of primary care services that has an established relationship with a TEAM beneficiary in the 2 years prior to the anchor hospitalization or anchor procedure when relying on claims data. While Medicare providers and suppliers are generally good at submitting timely claims, we acknowledge that TEAM beneficiaries that have recently switched suppliers of primary care services may have their new suppliers and preferences inadvertently overlooked given the lag in claims data. Additionally, as the commenters noted, claims data is not necessarily integrated within a hospital's EHR technology, and we realize the limitation to accessing historical claims data, especially claims data for items and services outside of the hospital's claims. We also understand that TEAM beneficiaries can be transient or seek care from multiple clinicians over the span of the 2 years and thus relying on claims data in the 2-year period prior to the anchor hospitalization or anchor procedure to identify an established supplier of primary care services may not be the most reliable or clinically appropriate method to support continuity of care, especially in light of current medical needs after a surgical procedure. Therefore, we agree it may not be appropriate or operationally feasible to rely on claims data in the 2 years prior to the anchor hospitalization or anchor procedure to identify a supplier of primary care services for a TEAM beneficiary. Given these concerns, we are not requiring the TEAM participant to rely on claims data in the two years prior to the anchor hospitalization or anchor procedure to identify an established supplier of primary care services.

Comment: Many commenters had concerns with the referral to primary care services requirement. Specifically, commenters wanted CMS to consider the impacts of the national physician shortage. These commenters indicated that hospitals, depending on their location, might experience challenges when referring patients after discharge and CMS should implement safeguards that would prevent clinicians from being penalized for situations beyond their control. A couple of commenters noted this referral to primary care services requirement fails to account for situations where patients are offered but decline the option. Another commenter noted the challenges of identifying providers in remote cities/counties outside of their primary service area. A couple of commenters stated that the requirement could lead to increased costs for patients and contribute to patient dissatisfaction. Lastly, another commenter noted concerns with the requirement conflicting with ACO patient assignment and it potentially resulting in double payment for postoperative visits. The same commenter indicated that hospitals are already implementing this requirement due to hospital conditions of participation at Sec. 482.24(d).

Response: We thank the commenters for sharing their concerns and we acknowledge the challenges that arise from provider shortages and the impact they have on the health care system and patient access to care. We agree that it would not be fair to have a policy that could result in remedial action when the conditions of the policy are beyond the provider's control. That is why the referral to primary care services only requires the TEAM participant to include a referral in discharge planning and does not require the follow-up appointment to be scheduled or for the TEAM beneficiary to be seen within a certain amount of time. While the goal is for the TEAM beneficiary to be connected back to a supplier of primary care services for ongoing longitudinal care, we recognize imposing requirements beyond a referral may unnecessarily put certain TEAM participants at a disadvantage, such as rural hospitals or hospitals where clinician supply is low. Further, the definition of primary care services, as defined at Sec. 512.505, is a broad definition that encompasses many different types of potential primary care services that can make compliance with the requirement much easier for the TEAM participant, especially hospitals that face provider shortage challenges.

We disagree that the referral to primary care services requirement fails to account for instances where the TEAM beneficiary may decline follow up care to a supplier of primary care services. The referral to primary care services requirement includes a provision that requires the TEAM participant to comply with beneficiary freedom of choice, as described in Sec. 512.564(b). This means that a TEAM beneficiary may decline being referred to a supplier of primary care services and the TEAM participant may not be subject to remedial action because they respected the TEAM beneficiary's choice. We note that just like any other discussion about the TEAM beneficiary's care during the anchor hospitalization or anchor procedure, documentation of the refusal should be included in the beneficiary's EHR.

We also disagree that the referral to primary care services would lead to increased patient costs and dissatisfaction. The conditions of participation the commenter referred to require hospitals to send notifications of admission and discharge/transfer to post-acute care providers or practitioners responsible for follow up care, not to identify specific primary care providers or refer beneficiaries to primary care services (42 CFR 482.24(d)). However, hospitals are required to have an effective discharge planning process which must be consistent with the patient's goals for care and treatment preferences, ensure an effective transition of the patient from hospital to post- discharge care, and reduce the factors leading to preventable hospital readmissions (42 CFR 482.43). Hospitals must also transfer necessary medical information to appropriate post-acute care providers at the time of discharge. We believe the model's referral to primary care services requirement is reinforcing existing Medicare conditions of participation, not increasing patient encounters or out-of-pocket costs. Further, proper ongoing care management may reduce unnecessary provider encounters leading to less patient out-of-pocket costs. We also disagree that the referral to primary care services would lead to patient dissatisfaction. On the contrary, we believe the referral to primary care services requirement will result in TEAM beneficiaries having improved care experiences because the referral supports communication and coordination between specialty and primary care, which ensures continuity of care and supports whole person health.

We disagree that the referral to primary care services requirement will disrupt beneficiary assignment in ACO models or result in duplicative post-operative visits. We believe that this requirement will promote better collaboration between TEAM participants and providers in ACOs models because TEAM participants should be referring TEAM beneficiaries to their established supplier of primary care services. Generally, beneficiaries aligned or assigned to an ACO have established suppliers of primary care services which would make compliance to the requirement easy and support handoff to longitudinal care management. We also disagree with the commenter that the referral to primary care services requirement would result in duplicative postoperative visits. The referral to primary care services requirement does not replace the specialty-specific care services, such as a postoperative visit with the surgeon specialist, a TEAM beneficiary may need after they are discharged from the anchor hospitalization or anchor procedure. Nor does the requirement require a follow-up visit with the supplier of primary care services during the episode of care or within a certain time period.

Lastly, we agree with the commenter that many hospitals may already be referring their patients to primary care services due to existing Medicare conditions of participation for hospitals. While the Medicare conditions of participation requirements do not explicitly require referral to a supplier of primary care services, the conditions do require hospitals to send notifications to post-acute care providers or practitioners responsible for follow up care, which may or may not be suppliers of primary care services. Further, the Medicare conditions of participation have similar goals as TEAM, such as ensuring effective care transitions and reducing preventable hospital readmissions. Therefore, we believe that TEAM's referral to primary care services requirement is complementary to the existing conditions of participation and does not create additional burden beyond what may already be required of hospitals participating in the Medicare program.

Comment: A commenter suggested that CMS should consider aligning the definition of primary care services with HEDIS measures for follow- up after ED visits for high-risk patients, or with primary care definitions used in the Medicare Shared Savings Program.

Response: We thank the commenter for their suggestion. We recognize there are multiple definitions of primary care services, and we understand the value of aligning across different CMS initiatives. However, we believe the broad definition of primary care services used in TEAM allows the TEAM participant flexibility to identify the most clinically appropriate supplier for the TEAM beneficiary's needs. We also believe that a narrow definition may result in a TEAM participant having difficulties identifying a supplier of primary care services when there are provider shortages.

Comment: A commenter suggested that CMS consider ways to ensure that primary care suppliers involved in care transitions take steps to prevent opioid misuse by requiring the TEAM participant to document a rationale for prescribing opioids and a plan for transitioning the beneficiary to a non-opioid alternative, as clinically appropriate. They also recommended for beneficiaries prescribed opioids at discharge, establishing a care plan that involves joint monitoring by the TEAM participant and primary care supplier to monitor for any signs of opioid misuse or opioid use disorder.

Response: We recognize that it is common for opioids to be prescribed after a surgical procedure for pain management and we support providers and suppliers taking action to prevent opioid misuse. Proper care management for beneficiaries that are prescribed

opioids may lead to better health outcomes, mitigate pain, and reduce risks associated with opioid use disorder, overdose, and death. We anticipate TEAM will drive improved care coordination between providers and suppliers and we encourage TEAM participants to work closely with a TEAM beneficiary's primary care provider to implement care plans attentive to the needs of the patient while promoting pathways to taper or discontinue opioid use, as clinically appropriate. We do not believe adding additional requirements, such as a documentation requirement, would result in reduced opioid misuse because we believe TEAM participants are already implementing safeguards to monitor patients for opioid misuse. TEAM participants are accountable for the quality of care and spending during an episode of care, which we believe will incentivize TEAM participants to closely manage beneficiaries and implement both patient-specific and patient-driven care plans. Further, the existing referral to primary care services requirement helps to connect TEAM beneficiaries back to primary care for continued care management beyond the episode which may help to minimize unnecessary long-term prescription opioid use.

Comment: A few commenters wanted to know if the referral to primary care services requirement was just a referral or if it included an actual follow-up visit to the supplier of primary care services. One of the commenters noted that post-operative follow-up visits are performed by the surgical specialist and not the primary care provider. Another commenter wanted to know if the TEAM participant needed to confirm a scheduled follow-up visit.

Response: We appreciate the commenters request to clarify the referral to primary care services requirement. TEAM participants are required to include in hospital discharge planning a referral to a supplier of primary care services for a TEAM beneficiary, on or prior to discharge from an anchor hospitalization or anchor procedure. TEAM participants are not required to ensure a visit is scheduled, nor are they required to confirm the beneficiary had the visit with the supplier of primary care services. We recognize there may be challenges outside the control of the TEAM participant, such as provider shortages, that could make scheduling a visit or requiring an actual visit to be burdensome or potentially difficult to be in compliance with. Further, we want to be mindful of beneficiary freedom of choice requirements and a beneficiary's right to refuse follow-up care.

To address the commenter's statement about post-operative follow-up visits being with a surgical specialist and not a primary care provider, we want to highlight that the referral to primary care services requirement does not intend to replace or bypass any follow-up visit with a surgical specialist or the supplier who performed the procedure. The intent of the referral to primary care services requirement is to ensure that the TEAM beneficiary is connected back to primary care, and that they have a clinician who can help to manage their care after the episode end

After consideration of the public comments, we are modifying the referral to primary care services requirement at Sec. 512.564(a) to add that a TEAM participant must include in hospital discharge planning a referral to an established supplier of primary care services, as recorded on admission to the hospital or hospital outpatient department, for a TEAM beneficiary, on or prior to discharge from an anchor hospitalization or anchor procedure. In the event an established supplier of primary care services is not recorded on admission to the hospital or hospital outpatient department, the TEAM participant must include in hospital discharge planning a referral to a supplier of primary care services for a TEAM beneficiary, on or prior to discharge from an anchor hospitalization or anchor procedure. f. Waivers of Medicare Program Requirements--3-Day SNF Rule

In the FY 2025 IPPS/LTCH PPS final rule (89 FR 69833), we finalized the 3-Day SNF Rule Waiver that waives the requirement for a 3-day inpatient hospital stay prior to a Medicare-covered, post-hospital, extended-care service for eligible beneficiaries if certain conditions are met. As finalized, the 3-Day SNF Rule Waiver allows TEAM participants to send eligible TEAM beneficiaries to qualified SNFs, as described in Sec. 512.580(b), which does not include hospitals with swing bed arrangements. We sought comment in the FY 2025 IPPS/LTCH PPS proposed rule on the potential to allow TEAM participants to use the SNF 3-day rule waiver for hospitals and Critical Access Hospitals (CAHs), as designated in Sec. 485.606, providing post-acute care (PAC) under swing bed arrangements (89 FR 36468). We considered including swing bed arrangements under the TEAM SNF 3-day rule waiver, but did not propose to do so at the time, citing concerns about the inability to ensure the quality of swing bed arrangements for post-acute care following an early hospital discharge. We received stakeholder feedback recommending that we allow TEAM participants to use the TEAM SNF 3-day rule waiver for PAC provided under swing bed arrangements on the grounds that the inclusion of swing beds would increase access to PAC services for beneficiaries in rural areas or areas with health care shortages (89 FR 69834). However, we did not alter our proposal and finalized the TEAM SNF 3-day rule waiver without including swing beds. In the final rule, we noted that greater risks may be present for patients following early inpatient hospital discharge, and that the SNF quality rating requirement for use of the SNF 3-day rule waiver, which requires SNFs to have a CMS Five-Star Quality Rating System rating of 3 stars or better for at least 7 of the past 12 months, offers an additional level of protection to beneficiaries following an early discharge by ensuring that all TEAM beneficiaries discharged to a SNF after a hospital stay of fewer than 3 days are admitted to a SNF that has demonstrated that it can provide quality care to patients with significant unresolved post-surgical symptoms and problems. Without a corresponding metric in place for swing bed arrangements, we declined to include swing beds under the TEAM SNF 3-day rule waiver.

To address stakeholder concerns surrounding PAC access in rural and underserved areas, we proposed to allow TEAM participants to use the TEAM SNF 3-day rule waiver for TEAM beneficiaries discharged to hospitals and CAHs providing PAC under swing bed arrangements.

We stated in the proposed rule that in order to furnish SNF services under a swing bed agreement, hospitals must be substantially in compliance with the SNF participation requirements specified at Sec. 482.58(b), whereas CAHs must be substantially in compliance with the SNF participation requirements specified at Sec. 485.645(d). However, per current TEAM regulations, TEAM participants are not permitted to use the TEAM 3-day SNF waiver for SNF services furnished under a swing bed agreement because: (1) The SNF 3-day rule waiver under the TEAM regulations at Sec. 512.580(b)(1) waives the requirement for a 3-day prior inpatient hospitalization only with respect to otherwise covered SNF services furnished by an eligible SNF and does not extend to otherwise covered post-hospital extended care services furnished by a provider under a swing bed agreement; and (2) CAHs and other rural hospitals furnishing SNF services

under swing bed agreements are not included in the CMS Five-Star Quality Rating System and, therefore, cannot meet the requirement at Sec. 512.580(b)(3) that, to be qualified for Medicare coverage of SNF services provided to a TEAM beneficiary discharged from the hospital with a stay of less than 3 days under the TEAM SNF 3-day rule waiver, the SNF must have an overall rating of 3 or higher under the CMS Five- Star Quality Rating System for 7 of the previous 12 months.

For the reasons described in stakeholder comments on the FY 2025 IPPS/LTCH PPS proposed rule as well as recent academic research on PAC access in rural areas,\408\ we believed it was necessary to offer hospitals participating under episode-based payment models and thereby assuming financial responsibility for their beneficiaries' PAC-- especially hospitals operating in areas where PAC access may be limited and SNF services specifically may only be available in non-traditional SNF settings--additional tools and flexibility to manage and coordinate care for their beneficiaries. We indicated in the proposed rule that we agreed with stakeholders that there are fewer SNFs in rural areas. We also agreed with stakeholders that risk-bearing hospitals in rural areas would be better able to coordinate and manage care, and thus to control unnecessary costs, if the SNF 3-day rule waiver extended to otherwise covered SNF services provided by a hospital or CAH under a swing bed agreement. We believed this proposal would primarily benefit hospitals located in rural areas because most CAHs and hospitals that are approved to furnish post-acute SNF-level care via a swing bed agreement are located in rural areas. Consistent with what we proposed, and in line with the Medicare Shared Savings Program regulations at Sec. 425.612(a)(1) introductory text and (a)(1)(iii)(A), we also proposed to revise the regulations governing the SNF 3-day rule waiver at Sec. 512.580(b)(1) to indicate that, for purposes of determining SNF qualification for the SNF 3-day rule waiver, SNFs include providers furnishing SNF services under swing bed arrangements. We stated in the proposed rule that we believe it is important to align the SNF 3-day rule waiver with other CMS programs and initiatives, where appropriate, to create more uniform policies and hopefully increase waiver utilization. In addition, we proposed to revise Sec. 512.580(b)(3) to specify that the minimum 3-star rating requirement for at least 7 of the past 12 months applies only if the provider furnishing SNF services is eligible to be included in the CMS Five-Star Quality Rating System. We indicated in the proposed rule that we did not have a comparable data element to the CMS Five-Star Quality Rating System for hospitals and CAHs under swing bed agreements; however, under Sec. Sec. 512.590 and 512.586(a), we reserved the right to monitor and audit the use of payment waivers. We will continue to monitor the use of the SNF 3-day rule waiver to ensure TEAM participants are not compromising beneficiary protections at Sec. 512.582(a) and reserve the right to perform remedial action under Sec. 512.592 if the waiver is used inappropriately or beneficiaries are not receiving appropriate care.

\408\ Sharma, H., Bin Abdul Baten, R., Ullrich, F., MacKinney, A.C., & Mueller, K.J. (2024). Nursing home closures and access to post-acute care and long-term care services in rural areas. The Journal of rural health: official journal of the American Rural Health Association and the National Rural Health Care Association, 40(3), 557-564. https://doi.org/10.1111/jrh.12822.

Additionally, we noted in the proposed rule the possibility that a beneficiary could be admitted to a hospital, have an inpatient stay of less than 3 days, and then be admitted to the same hospital under its swing bed agreement. As previously discussed, we believed hospitals that bear a degree of financial risk have a stronger incentive not to overutilize services and have an incentive to recommend a beneficiary for admission to a SNF only when it is medically appropriate. We also noted in the proposed rule that this scenario could occur when a beneficiary meets the generally applicable 3-day stay requirement. Thus, we did not believe extending the SNF 3-day rule waiver to include services furnished by a hospital under a swing bed agreement would create a new gaming opportunity.

We considered, but did not propose, including only swing bed arrangements at CAHs under the expanded TEAM SNF 3-day rule waiver. While stakeholder feedback received on the 2025 IPPS/LTCH PPS proposed rule focused on swing bed arrangements at CAHs, we believed that the inclusion of swing bed arrangements at other hospitals is better aligned with the swing bed eligibility requirements detailed in Sec. 482.58.

We sought comment on our proposal at Sec. 512.580(b)(3) to allow TEAM participants to use the TEAM SNF 3-day rule waiver for TEAM beneficiaries discharged to hospitals and CAHs providing post-acute care (PAC) under swing bed arrangements.

The following is a summary of the public comments received on the proposed policy to allow TEAM participants to use the TEAM SNF 3-day rule waiver for TEAM beneficiaries discharged to hospitals and CAHs providing post-acute care (PAC) under swing bed arrangements, and our responses to these comments:

Comment: Many commenters supported the proposal to allow TEAM participants to use the TEAM SNF 3-day rule waiver for TEAM beneficiaries discharged to hospitals and CAHs providing PAC under swing bed arrangements, indicating that this proposed expansion of the SNF 3-day rule waiver would increase access to PAC for beneficiaries in rural and underserved areas and provide additional flexibility to TEAM participants in determining appropriate care pathways.

Response: We thank the commenters for their support and agree with the stated benefits of broadening the TEAM 3-day SNF rule waiver to include swing bed arrangements.

Comment: A commenter recommended that CMS permit the use of swing beds under the TEAM 3-day SNF rule waiver regardless of star rating.

Response: We note that as part of the proposed broadening of the TEAM 3-day SNF rule waiver to include swing bed arrangements at hospitals and CAHs, we proposed to revise Sec. 512.580(b)(3) to specify that the minimum 3-star rating requirement for 7 of the past 12 months applies only if the provider furnishing SNF services is eligible to be included in the CMS Five-Star Quality Rating System.

Comment: A commenter recommended that CMS monitor the availability of eligible SNFs and swing beds in TEAM-participating regions to identify any gaps and adjust policy as needed.

Response: We thank the commenter for their suggestion. We believe that broadening the TEAM 3-day SNF rule waiver to include swing bed arrangements at hospitals and CAHs will increase access to PAC in areas where PAC providers, especially eligible SNFs, are limited. As noted in the proposed rule and established in Sec. Sec. 512.590 and 512.586(a), we reserve the right to monitor and audit the use of payment waivers. Such monitoring may include utilization of the 3-day SNF rule waiver across regions.

Comment: A commenter recommended that we align the TEAM 3-day SNF rule waiver with the MSSP 3-day SNF rule waiver.

Response: We note that the broadening of the TEAM 3-day SNF rule waiver to include swing bed arrangements at hospitals and CAHs

mirrors the MSSP 3-day SNF rule regulations at Sec. 425.612(a)(1).

After consideration of the public comments, we are finalizing without modification the proposal at Sec. 512.580(b)(3) to allow TEAM participants to use the TEAM SNF 3-day rule waiver for TEAM beneficiaries discharged to hospitals and CAHs providing post-acute care (PAC) under swing bed arrangements. g. Decarbonization and Resilience Initiative

In the FY 2025 IPPS/LTCH PPS final rule (89 FR 69859) we finalized the Decarbonization and Resilience Initiative (DRI). This initiative was designed to address threats posed by climate change to the Nation's health and health care system by collecting, monitoring, and assessing hospital carbon emissions and their effects on health outcomes, costs, and quality. The initiative includes two primary elements--

Emissions reporting in four priority areas: organizational, building energy, anesthetic gas, and transportation; and

Technical assistance on reducing emissions.

We stated in the proposed rule that while the DRI is a voluntary initiative for TEAM participants and their hospital corporate affiliates, we recognize it does not align with the Administration's priorities. We noted that it is not uncommon to reevaluate policies and programs, and that doing so is within an agency's discretion, especially after a change in Administration, to implement changes through rulemaking. Additionally, since TEAM is a mandatory model, we wanted to reduce the reporting burden and reduce administrative costs on TEAM participants as much as possible, so eliminating this initiative will reduce the amount of data TEAM participants may report and reduce the costs to set up the reporting infrastructure. We stated in the proposed rule that the Episode Payment Models and the Cardiac Rehabilitation (CR) Incentive Payment Model were cancelled because, at that time, those models were not in the best interest of the Agency or the providers affected by them (82 FR 57066), and we similarly believed that retaining the DRI in TEAM is not in the best interest of the Agency or providers who already a part of a mandatory model. We believed removing this initiative from TEAM will allow TEAM participants to focus on the requirements of the model, rather than a voluntary initiative. We also believed that removing the DRI from TEAM will offer CMS flexibility to design and test other initiatives in the future that align with the Administration's goals. We noted in the proposed rule that TEAM participants are not precluded from continuing their own efforts to reduce greenhouse gas emissions and are encouraged to engage in other areas that may help improve patient quality of care and reduce hospital spending and operating costs. Therefore, we proposed to remove the DRI from TEAM.

We sought comment on our proposal to remove the DRI from TEAM and remove the corresponding regulations at Sec. 512.598.

The following is a summary of the public comments received on the proposed policy to remove DRI from TEAM, and our responses to these comments:

Comment: Multiple commenters support CMS's proposal to remove the voluntary decarbonization reporting requirements from TEAM. These commenters applauded CMS's commitment to streamlining program requirements by reducing potential administrative burden. Commenters who supported the proposed removal of the voluntary decarbonization reporting requirement also noted this allows TEAM participants to focus on other areas of TEAM implementation.

Response: We thank the commenters for their support. We agree that removal of the voluntary Decarbonization and Resilience Initiative from TEAM will allow TEAM participants to concentrate on other areas of the model, such as improving care transitions to drive quality improvements and finding efficiencies to reduce Medicare spending.

Comment: Multiple commenters did not support the removal of the voluntary decarbonization reporting requirements. Many of those opposed noted the United States healthcare system contributes more pollution than many other sectors of the U.S. economy and these reporting requirements could help healthcare providers better understand their impact on the environment.

Response: We acknowledge the U.S. healthcare industry is large and emits large amounts of carbon. CMS's proposal to remove the Decarbonization and Resilience initiative would simply remove the administrative burden to report this information to CMS. TEAM participants are not precluded from continuing their own efforts to reduce carbon emissions and CMS encourages TEAM participants to innovate in ways beyond model requirements to improve the healthcare system and population health.

Comment: A commenter noted that a Decarbonization and Resilience Initiative could give TEAM participants data that would inform efforts to save money on energy expenses.

Response: CMS is only proposing to remove the Decarbonization and Resilience Initiative, not dictating any internal process improvement efforts of TEAM participants. TEAM participants are still free, and encouraged, to find ways to lower energy costs that would save money to provide more quality patient care.

Comment: Numerous commenters noted that air pollution, natural disasters, and changing climates cause millions of health problems every year. They noted that removing the Decarbonization and Resilience Initiative would allow TEAM participants to better track these climate events and respond to the health needs that follow.

Response: We support any TEAM participants or healthcare providers who institute policies to reduce environmental impacts on their patients. This is a separate matter than TEAM participant reporting requirements, however, and we believe TEAM participants should be free to institute their own ecofriendly policies and procedures without CMS imposing a voluntary initiative that may not meet the unique needs of each TEAM participant.

Comment: Some commenters noted that they will continue their efforts to reduce their carbon footprints regardless of the Decarbonization and Resilience Initiative's inclusion in TEAM.

Response: We support any TEAM participants who would like to continue the Decarbonization and Resilience Initiative in their private capacity. CMS does not want to interfere with the internal decision- making process of healthcare providers. To this end, by removing the Decarbonization and Resilience Initiative, CMS is giving TEAM participants the freedom to continue, alter, or end their own decarbonization efforts without government oversight or imposing reporting requirements.

After consideration of public comments, we are finalizing our proposal to remove the Decarbonization and Resilience Initiative from TEAM and remove the corresponding regulations at Sec. 512.598.

B. Health Data, Technology, and Interoperability: Electronic Prescribing, Real-Time Prescription Benefit, and Electronic Prior Authorization (HTI-2)