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Expanding upon the example illustrated in Table 43, if we have issued a revised initial determination for PY 2022 in December 2025, for an ACO that renewed to continue its participation under a new agreement period beginning on January 1, 2025, our proposed policy would enable us to use the same methodology for calculating BY 2022 expenditures for PY 2025, in reaching the initial determination for PY 2025

As included in the APCM code descriptors, we are proposing to specify that the ongoing communication and coordinating receipt of needed services is with not only with home- and community-based service providers, but also with practitioners, community-based social service providers, hospitals, and skilled nursing facilities (or other health care facilities), as applicable. We are also proposing to add more detail about the communication documented in the patient's medical record in that it would include the patient's psychosocial strengths and needs, and functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors. Coordinated referral management with specialty groups and other community or healthcare organizations ensures referrals are properly managed, coordinated, and communicated

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