Care Model Eligibility – CMS Oncology Care Model (OCM)

Patients enrolled in Medicare and have received chemotherapy treatment for cancer.

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Patient Segment Eligibility Description Data Source
Patients who received chemotherapy treatment for cancer Patients must meet the following criteria:

  • Enrolled in Medicare Parts A and B
  • Does not receive End Stage Renal Disease (ESRD) benefit
  • Received an included chemotherapy treatment for cancer
  • Has at least one Evaluation and Management (E&M) visit with an included cancer diagnosis
 Claims

  • Determine if patient is receiving ESRD benefit
  • Determine if patient received qualifying chemotherapy treatment
  • Determine if patient received E&M visit with a qualifying cancer diagnosis

Care Model Implementation – CMS Oncology Care Model (OCM)

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Time Frame Action
Trigger event Beneficiary begins an included chemotherapy treatment for cancer
During 6 months following trigger event Provide enhanced services:

  • Provide beneficiary with 24/7 access to an appropriate clinician who has real-time access to the practice’s medical records.
  • Provide the core functions of patient navigation to beneficiary
  • Document a care plan for the beneficiary that contains the 13 components in the Institute of Medicine Care Management Plan
  • Treat beneficiary with therapies that are consistent with nationally recognized clinical guidelines

Use certified electronic health record technology (CEHRT):

  • OCM practices must use CEHRT in a manner sufficient to meet the requirements of an “eligible alternative payment entity” under the MACRA rule implementing the Quality Payment Program.

Utilize data for continuous quality improvement:

  • Practices must collect and report clinical and quality data to the Center for Medicare & Medicaid Innovation (Innovation Center). In addition, the Innovation Center will provide participating practices with feedback reports for practices to use to continuously improve OCM patient care management.

Care Model Compliance – CMS Oncology Care Model (OCM)

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Intervention Intervention Description Data Source
Furnish OCM Service Provide enhanced services, use certified electronic health record technology, and utilize data for continuous quality treatment.

See additional information on previous slide for “Care Model: Oncology Care – Implementation”.

 Claims:

  • HCPCS Codes to determine if Monthly Enhanced Oncology Services (MEOS) are billed
  • Track expenditures for beneficiary episodes to be compared against benchmarks to determine performance-based payment

*Chronic Care Management (CCM), Transitional Care Management (TCM), Home Health Care Supervision, Hospice Care Supervision, and End Stage Renal Disease management services cannot be billed in same month as MEOS