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On December 21, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that sets a new direction for the Medicare Shared Savings Program (Shared Savings Program). Referred to as “Pathways to Success,” this new direction for the Shared Savings Program redesigns the participation options available under the program to encourage Accountable Care Organizations (ACOs) to transition to performance based risk more quickly and, for eligible ACOs, incrementally, to increase savings for the Trust Funds. The policies also include changes to address the additional tools and flexibilities for ACOs established by the Bipartisan Budget Act of 2018 (BBA of 2018), specifically in the areas of new beneficiary incentives, telehealth services, and choice of beneficiary assignment methodology. We note that this final rule also finalizes the program’s policy for extreme and uncontrollable circumstances for performance year 2017, initially established with an interim final rule with comment period in December 2017.