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ACO REACH — the Accountable Care Organization Realizing Equity, Access, and Community Health model — is one of the most significant value-based care models the CMS Innovation Center (CMMI) operates. It launched January 1, 2023 as the redesigned successor to the Global and Professional Direct Contracting (GPDC) Model, which had been criticized for lacking health equity provisions and adequate beneficiary protections. ACO REACH was designed to address those criticisms while preserving the core Innovation Center goal: testing whether high-risk, capitated accountable care organizations can deliver better care at lower cost to traditional Medicare Fee-for-Service beneficiaries.

The model rests on Section 1115A of the Social Security Act (42 U.S.C. § 1315a), the CMS Innovation Center authority added by Section 3021 of the Patient Protection and Affordable Care Act of 2010 (Public Law 111-148, March 23, 2010). Section 1115A gives the Secretary of HHS authority to test innovative payment and service delivery models that have potential to reduce program expenditures while preserving or enhancing quality of care. ACO REACH is one of dozens of CMMI models past and present.

For Georgia Medicare Fee-for-Service beneficiaries, ACO REACH matters operationally because:

  • Multiple ACO REACH ACOs operate in Georgia — including ACOs affiliated with Aledade, Privia Medical Group, and other primary care-focused networks
  • Georgia FFS beneficiaries whose primary care provider participates in ACO REACH are typically aligned to the ACO automatically based on claims-based attribution
  • Beneficiaries retain all traditional Medicare benefits — ACO REACH does not change Medicare coverage, provider choice, or beneficiary cost-sharing
  • Beneficiaries receive an alignment notification letter explaining the alignment and how to opt out if they prefer
  • The Atlanta metropolitan area has high ACO penetration through both ACO REACH and the Medicare Shared Savings Program (MSSP)

ACO REACH operates through December 31, 2026 as its currently scheduled model end date. CMMI may extend, modify, or transition the model into a permanent Medicare benefit pursuant to Section 1115A(c) ("Expansion of Successful Models") if it meets statutory criteria.

This guide walks Georgia Medicare beneficiaries and providers through the full ACO REACH framework: the statutory authority, the two participation tracks, the three ACO types, the mandatory Health Equity Plan provisions, the 75% provider governance requirement, the capitation payment methodologies, the health equity benchmark adjustment, the beneficiary alignment methodology, the beneficiary protections, the quality reporting requirements, the Georgia participants, and what beneficiaries should understand about how ACO REACH interacts with their traditional Medicare benefits.

Key Takeaways (Callout)

  • ACO REACH is a CMS Innovation Center value-based care model operating under Section 1115A of the Social Security Act (added by Section 3021 of the Affordable Care Act of 2010).
  • The model launched January 1, 2023 as the redesigned replacement for the Global and Professional Direct Contracting (GPDC) Model, with mandatory health equity provisions, strengthened beneficiary protections, and provider-controlled governance.
  • ACO REACH operates through December 31, 2026 as its current model end date.
  • Two participation tracks: Professional (Primary Care Capitation, 50% shared savings/losses) and Global (Total Care Capitation, 100% risk).
  • Three ACO types: Standard ACO (traditional ACO experience), New Entrant ACO (organizations new to Medicare risk), and High Needs Population ACO (focused on chronically ill/complex populations).
  • Mandatory Health Equity Plan: every ACO REACH ACO must adopt a Health Equity Plan addressing health disparities in its aligned population.
  • Provider governance: at least 75% control of the ACO governing body must be held by participating providers (responding to GPDC criticism that investor-owned DCEs lacked clinical leadership).
  • Health Equity Benchmark Adjustment: ACO REACH uses the Area Deprivation Index (ADI) plus dual eligible status to adjust benchmarks in favor of ACOs serving more socioeconomically disadvantaged populations.
  • Beneficiary alignment: combination of claims-based (primary care utilization history) and voluntary alignment (beneficiary actively elects).
  • Beneficiary protections: beneficiaries receive an alignment notification letter, may opt out at any time, retain all traditional Medicare benefits, retain freedom of provider choice, and pay the same cost-sharing as if not aligned.
  • Georgia ACO REACH participants include Aledade-affiliated and Privia Medical Group-affiliated ACOs operating across multiple metropolitan and rural areas.

Statutory Authority and Model History

Section 1115A of the Social Security Act — CMS Innovation Center

Section 1115A (42 U.S.C. § 1315a) was added to the Social Security Act by Section 3021 of the Patient Protection and Affordable Care Act of 2010 (Public Law 111-148, March 23, 2010), creating the Center for Medicare and Medicaid Innovation (CMMI, often called the "CMS Innovation Center" or just "Innovation Center").

Section 1115A authorizes the Secretary of HHS to:

  • Test "innovative payment and service delivery models" that have potential to reduce Medicare/Medicaid/CHIP expenditures while preserving or enhancing quality
  • Establish testing parameters, populations, geographic scope, and other model design features
  • Evaluate models on cost and quality
  • Through Section 1115A(c) ("Expansion of Successful Models"), expand a successful model in scope and duration — including potentially making it a permanent feature of Medicare — if the model:
    • Reduces Medicare/Medicaid spending without reducing quality, OR
    • Improves quality without increasing spending
    • AND the Chief Actuary of CMS certifies the expansion would not increase Medicare/Medicaid spending

Section 1115A waives many normal Medicare statutory and regulatory requirements during model testing — a critical authority because innovative payment models often differ structurally from Medicare's standard fee-for-service mechanics.

CMMI has tested more than 50 models since 2010 across primary care, specialty care, hospital care, post-acute care, and care delivery. ACO REACH is one of CMMI's flagship total cost of care models.

From Pioneer ACO to GPDC to ACO REACH

CMMI's ACO model history:

  • Pioneer ACO Model (2012-2016): early CMMI ACO model for organizations experienced with shared savings/losses
  • Next Generation ACO Model (2016-2021): higher-risk ACO model
  • Direct Contracting Model — Global and Professional Tracks (GPDC) (April 1, 2021 - December 31, 2022): higher-risk capitated ACO model that succeeded Next Gen ACO
  • ACO REACH (January 1, 2023 - December 31, 2026): redesigned successor to GPDC

The GPDC-to-ACO REACH redesign was driven by:

  • Congressional and stakeholder criticism that GPDC lacked health equity provisions
  • Concern that some GPDC "Direct Contracting Entities" (DCEs) were investor-owned without sufficient clinical/provider governance
  • Concerns that GPDC's capitation mechanics resembled Medicare Advantage-like risk-bearing without commensurate beneficiary protections
  • Stakeholder calls for stronger beneficiary notification, opt-out rights, and care continuity

CMS's response was a comprehensive redesign — same fundamental high-risk capitated ACO architecture, but with mandatory Health Equity Plans, 75% provider governance, health equity benchmark adjustments, strengthened beneficiary protections, and a rebranding to "ACO REACH" to emphasize the equity reorientation.

Model Structure

Two Participation Tracks

Professional Track

  • Capitation type: Primary Care Capitation (PCC) — ACO receives capitated payments only for primary care services; specialty/hospital care continues to be paid on Medicare FFS
  • Risk: 50% shared savings/losses — ACO shares 50% of savings against benchmark or losses against benchmark
  • Use case: Organizations new to higher risk, primary care-focused networks, organizations preferring lower risk exposure

Global Track

  • Capitation type: Total Care Capitation (TCC) — ACO receives capitated payments for all Medicare Parts A and B services
  • Risk: 100% risk — ACO bears full risk for total cost of care above/below benchmark
  • Use case: Organizations experienced with full-risk capitation; integrated systems with capability to manage total cost of care

Three ACO Types

Standard ACO

  • Traditional ACO experience required
  • Operates similar to mature MSSP ACO populations
  • Typical primary care-focused population
  • Most numerous ACO type in ACO REACH

New Entrant ACO

  • Organizations new to Medicare risk
  • Designed to bring new entrants into value-based care
  • Smaller population thresholds
  • Glide path for accountability

High Needs Population ACO

  • Focused on chronically ill, complex, or otherwise high-needs populations
  • Lower beneficiary thresholds than Standard
  • Specialized care models for complex populations
  • Often integrates behavioral health, palliative care, and other complex care management

Mandatory Health Equity Plan

Every ACO REACH ACO must adopt and execute a Health Equity Plan that:

  • Identifies health disparities in the ACO's aligned population
  • Specifies interventions to address those disparities
  • Includes measurable goals
  • Reports on progress annually

Health Equity Plans are the centerpiece of the ACO REACH redesign and represent CMS's strongest mandatory equity requirement across CMMI models.

Governance — 75% Provider Control

Each ACO REACH ACO governing body must have at least 75% of voting control held by participating providers (or representatives thereof) — meaning physicians, nurse practitioners, physician assistants, hospitals, and other clinical participants actually delivering care. Beneficiary representatives must also serve on the governing body.

This requirement responds to GPDC criticism that investor-owned DCEs lacked clinical/provider control. The 75% provider governance standard is a defining feature of ACO REACH and represents one of CMMI's strongest provider-control requirements.

Payment and Benchmarking

Benchmarking

ACO REACH uses a benchmarking methodology adapted from MSSP:

  • Historical benchmark based on the ACO's aligned population's prior Medicare FFS spending
  • Trended forward using national/regional growth factors
  • Risk-adjusted using CMS-HCC (Hierarchical Condition Categories)
  • Adjusted using the Coding Intensity Factor (CIF) to prevent inappropriate inflation of risk scores

Health Equity Benchmark Adjustment

ACO REACH adds a Health Equity Benchmark Adjustment that:

  • Uses the Area Deprivation Index (ADI) — a small-area-level composite measure of socioeconomic disadvantage developed at the University of Wisconsin
  • Uses dual eligible status (Medicare-Medicaid dual eligibility)
  • Modifies benchmarks upward for ACOs serving more socioeconomically disadvantaged populations
  • Recognizes the additional resources required to deliver high-quality care to underserved populations

The Health Equity Benchmark Adjustment is among the first CMMI features to operationalize health equity in benchmark mathematics.

Performance Year Mechanics

  • Performance year matches the calendar year
  • Reconciliation of shared savings/losses occurs after performance year end (with claims runout)
  • Final reconciliation typically 12-18 months after performance year close
  • Multi-year benchmarking moderates year-to-year volatility

Beneficiary Alignment

Claims-Based Alignment

The primary mechanism. CMS attributes a beneficiary to an ACO REACH ACO based on the beneficiary's plurality of primary care utilization with participating providers, using a historical look-back at Medicare FFS claims.

Beneficiaries eligible for claims-based alignment:

  • Enrolled in traditional Medicare FFS (Part A and Part B)
  • Not enrolled in a Medicare Advantage plan (MA enrollees go through different attribution to MA)
  • Have qualifying primary care utilization with an ACO participating provider

Voluntary Alignment

Beneficiaries may actively elect ACO REACH alignment by signing an alignment form provided by their participating provider. Voluntary alignment generally takes priority over claims-based alignment.

Alignment Notification

Aligned beneficiaries receive an alignment notification letter from CMS explaining:

  • That the beneficiary is aligned to the ACO REACH ACO
  • What ACO REACH is (in plain language)
  • The beneficiary's continued rights and protections
  • How to opt out if the beneficiary prefers
  • Contact information for questions

Opt-Out Rights

Beneficiaries may opt out of ACO REACH alignment at any time. Opting out:

  • Does not change the beneficiary's Medicare coverage
  • Does not change the beneficiary's relationship with the primary care provider
  • Does not impose any penalty
  • Means the beneficiary's claims data is not used in the ACO's benchmark/financial reconciliation in the same way

What Doesn't Change for Aligned Beneficiaries

For an aligned beneficiary:

  • All traditional Medicare benefits remain
  • All Medicare provider choice remains (any Medicare-enrolled provider)
  • Cost-sharing (Part B deductible, coinsurance) is identical to non-aligned beneficiaries
  • Medicare Summary Notices and Medicare claims processing are unchanged
  • The beneficiary does not "enroll" in a new plan — alignment is administrative

Quality Reporting

ACO REACH ACOs report quality measures across:

  • Patient/caregiver experience (e.g., CAHPS for ACOs)
  • Care coordination/patient safety
  • Preventive care
  • At-risk populations (e.g., diabetes, hypertension)

Quality performance affects shared savings/losses calculations. The quality measure set evolves annually.

Beneficiary Protections — Comparison to GPDC

ACO REACH's beneficiary protection enhancements over GPDC include:

  • Mandatory beneficiary representation on ACO governing body
  • Strengthened alignment notification with plain-language explanation
  • Reaffirmed opt-out rights with clear procedures
  • Care continuity requirements when participating providers change
  • Marketing restrictions (ACO cannot conduct MA-like marketing to beneficiaries)
  • Beneficiary protections related to risk-based payment arrangements between ACO and participating providers

Georgia ACO REACH Participants

Multiple ACO REACH ACOs operate in Georgia. Without identifying specific participants by name (participant rosters change annually with new performance year cohorts), Georgia's ACO REACH landscape includes:

  • Aledade-affiliated ACOs: Aledade partners with independent primary care practices nationally; multiple Aledade ACOs include Georgia primary care practices
  • Privia Medical Group-affiliated ACOs: Privia operates a large medical group in Georgia (Privia Health Georgia) with ACO REACH participation
  • Other primary care-focused networks: various national and regional networks have Georgia ACO REACH participation

For the current list of ACO REACH participants and Georgia primary care practices, consult Medicare.gov or the CMS Innovation Center website. Beneficiaries whose PCPs participate will receive an alignment notification letter from CMS.

Worked Examples

Example 1: Fulton 70 — Atlanta Beneficiary Aligned Via PCP

A 70-year-old Atlanta beneficiary in Fulton County receives all of her primary care from a long-time PCP. The PCP joins an Aledade-affiliated ACO REACH ACO effective January 1 of a new performance year. The beneficiary receives an alignment notification letter from CMS explaining she is now aligned to the ACO. The letter explains: her traditional Medicare benefits do not change; she may see any Medicare provider she chooses; her cost-sharing is unchanged; she may opt out at any time. She continues to see her PCP without any change in her experience. Behind the scenes, the ACO's care coordination team identifies her as a candidate for diabetes management outreach because she has Type 2 diabetes and has a gap in HbA1c testing.

Example 2: DeKalb 75 — Dual Eligible Health Equity Benchmark Adjustment

A 75-year-old DeKalb County beneficiary is dually eligible for Medicare and Georgia Medicaid (full-benefit dual eligible). She lives in a neighborhood with a high Area Deprivation Index (ADI) score reflecting socioeconomic disadvantage. Her PCP participates in a High Needs Population ACO REACH ACO. Because of the beneficiary's dual eligible status and high ADI, the ACO receives a Health Equity Benchmark Adjustment that raises the ACO's benchmark, recognizing the additional resources required to deliver high-quality care to this population. The ACO uses the additional benchmark headroom to fund community health worker outreach, transportation assistance, and home-based primary care visits.

Example 3: Cobb 68 — Voluntary Alignment

A 68-year-old Cobb County beneficiary recently moved to Marietta and selected a new primary care physician who participates in an ACO REACH ACO. At her first visit, the practice's intake staff explains ACO REACH and offers her a voluntary alignment form. She signs the form. As a result, her alignment is established immediately rather than waiting for claims-based alignment to register through historical claims. She receives the same alignment notification letter from CMS and retains all her opt-out rights.

Example 4: Worth County 72 — Rural High Needs Population ACO

A 72-year-old Worth County (rural south Georgia) beneficiary has multiple chronic conditions — COPD, CHF, Type 2 diabetes, chronic kidney disease — and limited mobility. Her PCP participates in a High Needs Population ACO REACH ACO focused on complex chronically ill populations. The ACO's care model emphasizes home-based primary care visits, transitional care management after hospitalizations, palliative care integration, and multidisciplinary team-based care. She continues to see her existing PCP but now also receives proactive outreach from a nurse care manager.

Example 5: Bibb 80 — Care Continuity Protection

An 80-year-old Bibb County beneficiary's longtime PCP retires. The PCP's practice is acquired by a different organization. The beneficiary continues to see a new PCP within the same practice. Because the practice remains in the ACO REACH ACO, the beneficiary's alignment continues without interruption. She receives an updated notification letter confirming continued alignment with the (now successor) provider.

Example 6: Hall 67 — Opt-Out Preference

A 67-year-old Hall County beneficiary receives the ACO REACH alignment notification letter. He has concerns about his claims data being used for ACO benchmarking and prefers not to be aligned. He calls 1-800-MEDICARE and follows the opt-out instructions in the letter. He is opted out of alignment. His Medicare benefits, provider choice, and cost-sharing are unchanged. He continues to see his PCP, who continues to participate in the ACO REACH ACO — but his data is no longer used in the ACO's benchmarking/reconciliation in the same way.

Best Practices

  1. Read the alignment notification letter carefully — it explains what alignment means and how to opt out.
  2. Understand that traditional Medicare benefits do not change — alignment is administrative, not an enrollment in a new plan.
  3. Ask your PCP whether they participate in an ACO — many primary care practices participate in either ACO REACH or MSSP.
  4. Use 1-800-MEDICARE for alignment questions or to exercise opt-out.
  5. Continue to use Medicare Summary Notices to monitor claims — MSN processing is unchanged.
  6. Use GeorgiaCares SHIP at 1-866-552-4464 for any Medicare-related counseling, including ACO questions.
  7. Recognize that ACO care coordination may include proactive outreach — care manager calls or home visits are typically beneficial and beneficiary-friendly.
  8. For dual eligibles, recognize the Health Equity Benchmark Adjustment — dual eligible status may have positive implications for ACO resources serving your population.
  9. For providers: understand the 75% provider governance requirement — clinical leadership is mandatory.
  10. For providers: build out Health Equity Plan capability — mandatory equity provisions are central to ACO REACH.
  11. For providers: track CMS-HCC documentation and coding intensity — risk adjustment matters but coding intensity factor limits inappropriate inflation.
  12. For providers: prepare for performance year reconciliation timing — savings/losses settled 12-18 months after performance year close.
  13. For providers: integrate care coordination, transitional care management, and chronic care management billing alongside ACO mechanics.
  14. For all stakeholders: watch CMMI guidance for potential model extension or transition after December 31, 2026.

Common Issues

  1. Beneficiary confusion that alignment is "enrolling in Medicare Advantage" — it is not; alignment leaves traditional Medicare benefits intact.
  2. Beneficiary concerns about marketing pressure — ACO REACH has strict marketing restrictions; aggressive marketing is not permitted.
  3. Alignment notification letter overlooked or discarded — beneficiaries should keep the letter for reference.
  4. Opt-out confusion — opting out does not change the PCP relationship or any Medicare benefit.
  5. Voluntary alignment form pressure — practices must explain voluntary alignment clearly; beneficiaries should not feel coerced.
  6. Coding intensity disputes — ACOs may aggressively code HCC diagnoses; the CIF limits inappropriate inflation.
  7. Beneficiary movement across ACOs — if PCP changes, alignment may shift; care continuity protections aim to smooth transitions.
  8. Specialty care navigation — ACOs do not restrict specialty care under traditional Medicare; beneficiary may see any Medicare provider.
  9. Care manager outreach skepticism — beneficiaries unfamiliar with care management may dismiss legitimate outreach; SMP can help verify authenticity.
  10. Health Equity Plan implementation variability — quality varies; CMMI monitors and evaluates.
  11. ACO performance year reconciliation timing — savings/losses settle long after performance year; this affects provider cash flow planning.
  12. Risk-bearing arrangements between ACOs and downstream providers — beneficiary protections apply to these as well.
  13. Beneficiary protection complaints — can be reported to CMS via 1-800-MEDICARE.
  14. Model end date uncertainty post-2026 — Section 1115A authorizes expansion if criteria are met; CMMI may extend, modify, or sunset.

Frequently Asked Questions

Q1: What is ACO REACH?

A: ACO REACH stands for Accountable Care Organization Realizing Equity, Access, and Community Health. It is a CMS Innovation Center value-based care model operating under Section 1115A of the Social Security Act (added by Section 3021 of the Affordable Care Act of 2010). The model launched January 1, 2023 as the redesigned successor to the Global and Professional Direct Contracting (GPDC) Model and is currently scheduled to operate through December 31, 2026.

Q2: Does ACO REACH change my Medicare benefits?

A: No. ACO REACH alignment does not change your Medicare benefits, your provider choice, or your cost-sharing. You retain all traditional Medicare Parts A and B benefits. You may see any Medicare-enrolled provider. Your Part B deductible, coinsurance, and other cost-sharing are unchanged. ACO REACH is administrative attribution, not an enrollment in a new plan.

Q3: How does ACO REACH alignment work?

A: ACO REACH ACOs are assigned beneficiaries through two methods:

  • Claims-based alignment: CMS looks at where you have received your primary care over a historical period and assigns you to the ACO with which you have the most primary care utilization
  • Voluntary alignment: you actively sign an alignment form provided by your participating PCP

Aligned beneficiaries receive an alignment notification letter from CMS.

Q4: Can I opt out of ACO REACH alignment?

A: Yes — at any time. The alignment notification letter from CMS explains how. You can also call 1-800-MEDICARE to opt out. Opting out does not change your Medicare benefits, your PCP relationship, or your cost-sharing.

Q5: What is the difference between ACO REACH and Medicare Advantage?

A: They are fundamentally different. Medicare Advantage (MA) is a private insurance plan that replaces traditional Medicare; MA enrollment is voluntary, MA plans have networks, MA plans have separate premiums, and MA plans assume full insurance risk. ACO REACH does not replace traditional Medicare. ACO REACH beneficiaries remain on traditional Medicare with full provider choice and standard Medicare cost-sharing. ACO REACH is a CMS Innovation Center model testing whether high-risk capitated ACOs can deliver better care at lower cost — the ACO bears the risk, not the beneficiary.

Q6: What is the difference between ACO REACH and the Medicare Shared Savings Program (MSSP)?

A: Both are ACO models for traditional Medicare beneficiaries. MSSP is a permanent program established by Section 3022 of ACA, with multiple tracks ranging from upside-only shared savings (Basic Track) to higher-risk arrangements (Enhanced Track). ACO REACH is a CMS Innovation Center model under Section 1115A operating through December 31, 2026, with higher-risk capitation arrangements and mandatory Health Equity Plans. From a beneficiary experience standpoint, the two are similar — alignment, no benefit changes, opt-out rights.

Q7: What is the Health Equity Plan?

A: Every ACO REACH ACO must adopt a Health Equity Plan that identifies health disparities in the ACO's aligned population, specifies interventions to address those disparities, sets measurable goals, and reports annually. The Health Equity Plan is mandatory and is a defining feature of ACO REACH.

Q8: What is the Health Equity Benchmark Adjustment?

A: ACO REACH adjusts ACO benchmarks upward for ACOs serving more socioeconomically disadvantaged populations. The adjustment uses the Area Deprivation Index (ADI) — a small-area-level composite measure of socioeconomic disadvantage — and dual eligible status. The adjustment recognizes the additional resources required to deliver high-quality care to underserved populations.

Q9: What are the two ACO REACH tracks?

A:

  • Professional Track: Primary Care Capitation; 50% shared savings/losses
  • Global Track: Total Care Capitation; 100% risk

Q10: What are the three ACO types?

A:

  • Standard ACO: traditional ACO experience required; typical primary care-focused population
  • New Entrant ACO: organizations new to Medicare risk; smaller population thresholds; designed to bring new entrants into value-based care
  • High Needs Population ACO: focused on chronically ill, complex, or otherwise high-needs populations

Q11: What is the 75% provider governance requirement?

A: ACO REACH requires that at least 75% of voting control of the ACO's governing body be held by participating providers (physicians, nurse practitioners, PAs, hospitals, etc.). Beneficiary representatives must also serve on the governing body. This requirement responds to GPDC criticism that investor-owned DCEs lacked clinical/provider control.

Q12: Who can I call with ACO REACH questions?

A: Call 1-800-MEDICARE for ACO REACH-specific questions including opt-out. Call GeorgiaCares SHIP at 1-866-552-4464 for free Medicare counseling more broadly. You can also ask your participating PCP for information.

Q13: How do I know if my PCP participates in an ACO REACH ACO?

A: Ask your PCP directly. Many primary care practices in Georgia participate in either ACO REACH or MSSP. You can also consult Medicare.gov physician/provider lookup tools.

A: ACO REACH ACOs receive claims-and-claim-line-feed (CCLF) data from CMS for their aligned populations to enable care coordination and analytics. CCLF data is shared under data use agreements; beneficiaries retain all rights regarding their Medicare claims data and may opt out of alignment.

Q15: What happens after December 31, 2026?

A: ACO REACH's current model end date is December 31, 2026. Under Section 1115A(c), CMMI may expand a successful model — including potentially making it permanent — if statutory criteria are met. CMMI may alternatively transition, modify, or sunset the model. Watch for CMS guidance closer to the end date.

Q16: What is CMMI?

A: CMMI stands for the Center for Medicare and Medicaid Innovation, sometimes called the "CMS Innovation Center." CMMI was created by Section 3021 of the Affordable Care Act of 2010 and operates under Section 1115A of the Social Security Act. CMMI tests innovative payment and service delivery models in Medicare, Medicaid, and CHIP.

Q17: What is the Coding Intensity Factor (CIF)?

A: The Coding Intensity Factor is a benchmark adjustment that limits inappropriate inflation of CMS-HCC risk scores. ACOs may aggressively code beneficiaries' chronic condition diagnoses to inflate risk scores (and benchmarks); the CIF dampens this effect. Various CMMI models including ACO REACH apply CIF adjustments.

Q18: What is the Area Deprivation Index (ADI)?

A: The Area Deprivation Index is a small-area-level composite measure of socioeconomic disadvantage developed at the University of Wisconsin. It uses Census-tract level data on income, education, employment, and housing. Higher ADI scores indicate greater socioeconomic disadvantage. ACO REACH uses ADI as a component of the Health Equity Benchmark Adjustment.

Q19: Is there a list of Georgia ACO REACH participants?

A: Participant rosters change annually. Consult Medicare.gov or the CMS Innovation Center website for the current performance year participant list. Beneficiaries whose PCPs participate will receive an alignment notification letter from CMS.

Q20: How does ACO REACH coordinate with Medicare Advantage?

A: ACO REACH is a model for traditional Medicare Fee-for-Service beneficiaries — those who are NOT enrolled in a Medicare Advantage plan. MA enrollees are attributed to their MA plans, not to ACO REACH ACOs. If a beneficiary switches between MA and traditional Medicare, alignment status may change.

Q21: How does ACO REACH coordinate with Medicaid for dual eligibles?

A: ACO REACH ACOs may align dually eligible beneficiaries (Medicare + Medicaid). Dual eligible status is a component of the Health Equity Benchmark Adjustment. Medicaid coverage is separate and managed through Georgia Department of Community Health.

Q22: What are the marketing rules?

A: ACO REACH has strict marketing restrictions — ACOs cannot conduct MA-like marketing to beneficiaries. Communications about alignment are governed by CMS rules; ACOs may not coerce, induce, or pressure beneficiaries.

Q23: What are the beneficiary protections specific to ACO REACH?

A: Beneficiary protections include:

  • Alignment notification letter
  • Opt-out rights at any time
  • No change in Medicare benefits, provider choice, or cost-sharing
  • Beneficiary representation on ACO governing body
  • Mandatory Health Equity Plan
  • Care continuity protections
  • Marketing restrictions
  • Right to file complaints with CMS via 1-800-MEDICARE

Q24: Can I file a complaint about ACO REACH?

A: Yes. Call 1-800-MEDICARE to file a complaint. You can also call GeorgiaCares SHIP at 1-866-552-4464 for assistance.

Q25: Why does ACO REACH matter for Georgia beneficiaries?

A: Multiple ACO REACH ACOs operate in Georgia, including ACOs affiliated with Aledade and Privia Medical Group. Many Georgia primary care practices participate. Georgia FFS beneficiaries whose PCPs participate are aligned automatically, retain all traditional Medicare benefits, and may benefit from improved care coordination, chronic disease management, and (for dual eligibles or those in high-ADI neighborhoods) health equity-focused ACO investments.

Call to Action — Contacts and Resources

If you have questions about ACO REACH alignment, want to opt out, or need help understanding your Medicare benefits:

  1. Medicare: 1-800-MEDICARE (1-800-633-4227) — Medicare.gov
  2. GeorgiaCares SHIP: 1-866-552-4464 — free Medicare counseling
  3. CMS Innovation Center — innovation.cms.gov (ACO REACH model page)
  4. Medicare Rights Center: 1-800-333-4114
  5. Palmetto GBA Part A/B MAC: 1-866-238-9650
  6. Atlanta Legal Aid: 404-377-0701
  7. Georgia Legal Services: 1-800-498-9469
  8. Eldercare Locator: 1-800-677-1116
  9. 211 Georgia — 211
  10. Acentra Health QIO: 1-844-455-8708
  11. SSA: 1-800-772-1213
  12. BCRC (Medicare Secondary Payer): 1-855-798-2627
  13. Georgia Department of Community Health Medicaid: 404-656-4507 (for dual eligibles)
  14. HHS OIG Hotline (for suspected fraud): 1-800-HHS-TIPS
  15. Georgia Senior Medicare Patrol via GeorgiaCares: 1-866-552-4464
  16. CMS Beneficiary and Family Centered Care QIO: Acentra Health 1-844-455-8708
  17. State Health Insurance Assistance Program (SHIP) National Network: shiphelp.org

For every Georgia Medicare beneficiary whose PCP participates in ACO REACH, the most important things to understand are: your Medicare benefits do not change, you can see any Medicare provider, your cost-sharing is the same, and you can opt out at any time. ACO REACH is a CMS Innovation Center experiment to test whether better-coordinated, more equity-focused, higher-risk ACO arrangements can deliver better care at lower cost to the Medicare program.

The CMS Innovation Center has tested more than 50 models since Section 3021 of the ACA created it in 2010. ACO REACH is among the most ambitious — combining capitated risk with mandatory health equity, 75% provider governance, and the Area Deprivation Index-based health equity benchmark adjustment. Whether ACO REACH meets the Section 1115A(c) expansion criteria after the December 31, 2026 model end date will be one of CMMI's most consequential evaluations of the 2020s.

BC

Brevy Care Team

Expert eldercare guidance from Brevy's team of healthcare professionals and researchers.