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Federal Register / Vol. 86, No. 83 / Monday, May 3, 2021 / Rules and Regulations 5, each subset thereof, and applying the adjustments in paragraph e1v of this section, CMS establishes an NPRA
for each participant hospital for each of performance years 1 through 4 and for performance year 5, each subset thereof.

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iv Results from the performance year 6 reconciliation and post-episode spending calculations as described in paragraph m of this section are added together in order to determine the reconciliation payment or repayment amount for performance year 6.
v Results from the performance year 7 reconciliation and post-episode spending calculations as described in paragraph m of this section are added together in order to determine the reconciliation payment or repayment amount for performance year 7.
vi Results from the performance year 8 reconciliation and post-episode spending calculations as described in paragraph m of this section are added together in order to determine the reconciliation payment or repayment amount for performance year 8.

l Annual reconciliation for performance years 6 through 8. 1
Beginning 6 months after the end of each of performance years 6 through 8, CMS does all of the following:
i Performs a reconciliation calculation to establish an NPRA for each participant hospital.
ii For participant hospitals that experience a reorganization event in which one or more hospitals reorganize under the CCN of a participant hospital, performs A Separate reconciliation calculations for each predecessor participant hospital for episodes where the anchor hospitalization admission or the anchor procedure occurred before the effective date of the reorganization event; and B Reconciliation calculations for each new or surviving participant hospital for episodes where the anchor hospitalization admission or anchor procedure occurred on or after the effective date of the reorganization event.
2 CMS
i Calculates the NPRA for each participant hospital in accordance with paragraph m of this section including the adjustments provided for in paragraph m1vii of this section; and ii Assesses whether participant hospitals meet specified quality requirements under 510.315.
m Calculation of the NPRA for performance years 6 through 8. By
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comparing the reconciliation target prices described in 510.301 and the participant hospitals actual episode spending for the performance year and applying the adjustments in paragraph m1vii of this section, CMS
establishes an NPRA for each participant hospital for each of performance years 6 through 8.
1 In calculating the NPRA for each participant hospital for each performance year, CMS does the following:
i Determines actual episode payments for each episode included in the performance year other than episodes that have been canceled in accordance with 510.210b using claims data that is available 6 months after the end of the performance year.
Actual episode payments are capped at the amount determined in accordance with 510.300b5ii for the performance year, the amount determined in paragraph k of this section for episodes affected by extreme and uncontrollable circumstances, or the target price determined for that episode under 510.300 for episodes that contain a COVID19 Diagnosis Code as defined in 510.2.
ii Multiplies each episode reconciliation target price by the number of episodes included in the performance year other than episodes that have been canceled in accordance with 510.210b to which that episode reconciliation target price applies.
iii Aggregates the amounts computed in paragraph m1ii of this section for all episodes included in the performance year other than episodes that have been canceled in accordance with 510.210b.
iv Subtracts the amount determined under paragraph m1i of this section from the amount determined under paragraph m1iii of this section.
v Performs an additional calculation using claims data available at that time, to account for any episode cancelations due to overlap between the CJR model and other CMS models and programs, or for other reasons as specified in 510.210b.
vi Conducts a post-episode spending calculation as follows: If the average post-episode Medicare Parts A and B
payments for a participant hospital in the performance year being reconciled is greater than 3 standard deviations above the regional average post-episode payments for that same performance year, then the spending amount exceeding 3 standard deviations above the regional average post-episode payments for the same performance year is subtracted from the net reconciliation
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or added to the repayment for that performance year.
vii Applies the following prior to determination of the reconciliation payment or repayment amount:
A Limitation on loss. Except as provided in paragraph m1viiC of this section, the total amount of the NPRA for a performance year cannot exceed 20 percent of the amount calculated in paragraph m1iii of this section for the performance year.
The post-episode spending calculation amount in paragraph mvi of this section is not subject to the limitation on loss.
B Limitation on gain. The total amount of the NPRA for a performance year cannot exceed 20 percent of the amount calculated in paragraph m1iii of this section for the performance year. The post-episode spending calculation amount in paragraph mvi of this section are not subject to the limitation on gain.
C Limitation on loss for certain providers. Financial loss limits for rural hospitals, SCHs, MDHs, and RRCs for performance years 6 through 8. If a participant hospital is a rural hospital, SCH, MDH, or RRC, the amount cannot exceed 5 percent of the amount calculated in paragraph m1iii of this section.
2 Reserved

12. Section 510.310 is amended by a. Removing paragraph b4i;
b. Redesignating paragraphs b4ii, iii, and iv as paragraphs b4i, ii, and iii;
c. Revising newly redesignated paragraph b4iii;
d. Removing paragraph b5;
e. Redesignating paragraph b6 and 7 as paragraph b5 and 6; and f. Revising newly redesignated paragraph b6.
The revisions read as follows:
510.310

Appeals process.

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iii The procedures including format and deadlines for submission of briefs and evidence.

6 The CMS reconsideration official makes all reasonable efforts to issue a written determination within 30 days of the deadline for submission of briefs and evidence. The determination is final and binding.

13. Section 510.315 is amended by revising paragraphs d, f1, and f2
to read as follows:

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