Medicare Beneficiary

What can I expect if my doctor is participating in the Accountable Care Coalition of Direct Contracting, an ACO Realizing Equity, Access, and Community Health (REACH) entity (ACO)?

You can expect your doctor will coordinate your care with specialists and other healthcare providers in your community to make sure you receive the right care at the right time. You may even experience additional benefits and enhancements. For people with complex conditions, for example, the doctor may introduce you to a care coordinator, at no additional fee, to help you maintain your best health.

Additional information about the ACO Realizing Equity, Access, and Community Health (REACH) Model from the Centers for Medicare & Medicaid Services appears below.

Information for Medicare Fee-For-Service, also known as Original Medicare, beneficiaries whose doctor is participating in the Accountable Care Coalition of Direct Contracting:

The Medicare ACO REACH Model was established by the Centers for Medicare & Medicaid Services (CMS) to help healthcare providers coordinate their beneficiaries’ care more closely with each other and see that they get the right care at the right time. Formerly the Global & Professional Direct Contracting (GPDC) Model, CMS has renamed the model to better align the name with the purpose of the model: to improve the quality of care for people with Medicare through better care coordination, reaching and connecting health care providers and beneficiaries, including those beneficiaries who are underserved.

Your Medicare benefits stay the same whether you use a physician participating in the Accountable Care Coalition of Direct Contracting or not. That means there are no changes in cost or coverage. You are not being enrolled into a Medicare Advantage or Health Maintenance Organization (HMO) plan, and this does not change your Medicare Supplement coverage. You can still choose to see any doctor or go to any hospital that accepts Medicare.

Your Primary Care Physician may continue to recommend that you see particular providers for your specific health needs, but it's always your choice of what doctors you use or hospitals you visit.

Although your benefits stay the same, you may experience new rewards and enhancements to your care due to your physician’s participation in the ACO REACH Model.

Beneficiary Enhancements

• Skilled Nursing Facility (SNF) 3-Day Rule: Under current Medicare law, Medicare only covers care in a skilled nursing facility if a patient has a prior three-day inpatient hospital stay. Medicare allows doctors who work with us to admit you to certain nursing homes any time you need skilled nursing care, even if you have not had a 3-day hospital stay. 
• Home Visits After Hospital Stays: Medicare allows doctors who work with us to send nurses and other staff to your home up to nine times after you're discharged from a hospital. They will help you follow the discharge plan your doctor writes, and can help with the sometimes-challenging transition between the hospital and home.
• Telehealth Expansion: Telehealth services allow beneficiaries to receive some health care services in the comfort of their home, rather than having to travel to see their physician or specialist, by using real-time communication between the beneficiary and his/herprimary care doctor or specialist. It is a way to visit your doctor or certain specialists using technology, such as a computer or smartphone. If you are interested in telehealth, ask your doctor about it.
• Reduced or Eliminated Out-of-Pocket Expenses: Medicare allows beneficiaries to reduce or eliminate costs for some Medicare Part B services delivered by our providers. Beneficiaries may receive support based on meeting specific criteria and approved by a committee. The benefit covers only services, and not prescription drugs or durable medical equipment. For more information, please consult with your provider.
• Care Management Home Visits: this enhancement waives the supervisionlevel for “incident to” services to allow personnel under a physician’s general supervision to make home visits under certain conditions. This enhancement is used for patients who are determined to be at risk of hospitalization but do not qualify for Medicare coverage of home health services.
• Home Health Homebound: this enhancement waives the requirements that a patient must be confined to the home to receive Medicare reimbursement for quality home health services for eligible beneficiaries.
• Concurrent Care for Beneficiaries that Elect the Medicare Hospice Benefit: this enhancement is available for Global ACOs and eliminates the requirement that beneficiaries who elect the Medicare Hospice Benefit give up their right to receive curative care (sometimes referred  to as “conventional care”) as a condition of electing the hospice benefit.

You can learn more about these initiatives by visiting the following web page: ACO REACH MODEL