If tiers are adopted, they should be limited to two levels: Mature ACOs, which have the infrastructure essential to be accountable for cost and quality and Provisional ACOs, those that have substantially all the capabilities and may reach maturity within 3 years.’ In addition to the general remarks above, AMGA commented on several of the specific criteria in the record. AMGA recommended NCQA get rid of the provision requiring ACOs to carry stop-loss insurance/reinsurance. Such insurance primarily applies to insurance firms that assume risk, not potential ACOs. Such a requirement would connect with only a handful of potential ACOs and can be premature at this time in ACO development.PML linked to the human being immunodeficiency virus accounts for approximately 80 percent of cases of PML and has continued that occurs even after the advent of extremely active antiretroviral therapy.13 PML in patients with multiple sclerosis who are being treated with natalizumab takes its novel presentation because of this disease.14 Regarding the patient described in this post, the diagnosis and detection of PML were produced following the identification of new focal neurologic abnormalities, MRI imaging displaying lesions in keeping with PML, and analysis of cerebrospinal fluid that demonstrated JC virus DNA.12,15 As the recognition of JC virus DNA in cerebrospinal fluid is specific but only approximately 60 to 80 percent sensitive, a brain biopsy must be thought to confirm unusual suspected cases of PML when no JC virus DNA is detected in the cerebrospinal fluid.