Advanced Alternative Payment Models (AAPMs)

The Medicare Access and CHIP Reauthorization Act (MACRA) permanently repealed the flawed sustainable growth rate (SGR) and set up the two-track Quality Payment Program (QPP) that emphasizes value-based payment models. This is your guide to the Advanced Alternative Payment Model (AAPM) track.

AAPM: One of Two Payment Tracks Under the Quality Payment Program (QPP)

The Advanced Alternative Payment Model (AAPM) offers physicians incentives to provide high-quality, cost-effective care and move away from the fee-for-service (FFS) model. The other track created under MACRA is the Merit-based Incentive Payment System (MIPS) track.

AAPMs for Primary Care

AAPMs available for primary care include:

• Comprehensive Primary Care Plus (CPC+)
  
• Medicare Shared Savings Program (MSSP) Tracks 2 and 3, BASIC Level E, and the ENHANCED track
  
• Medicare Accountable Care Organization (ACO) Track 1+
  
• Next Generation ACO Model
  
• Vermont Medicare ACO initiative (as part of the Vermont All-Payer ACO Model)
  
• Maryland Total Cost of Care Model (Maryland Primary Care Program)
  
• Additional models will be announced by CMS as they are approved
  

AAPMs: Criteria for Qualifying Participants

For the 2020 performance period, an AAPM entity must do one of the following for all  its eligible clinicians to be qualifying participants (QPs):

• Receive at least 50% of its Medicare Part B payments through the AAPM, or
  
• See at least 35% of its Medicare patients through the AAPM

Eligible clinicians that are not considered QPs can be considered partial QPs if the AAPM entity meets at least one of the following thresholds:

• Receive at least 40% of its Medicare Part B payments through the AAPM, or
  
• See at least 25% of its Medicare Part B patients through the AAPM.

QPs will be excluded from the MIPS reporting requirements. Partial QPs can opt to participate in MIPS and will be scored using the APM Scoring Standard.

ECs can also achieve QP status through the All-Payer Combination Option. This option allows ECs who do not meet the QP patient or payment threshold under their Medicare AAPM to count their participation in an Other Payer APM toward their QP status. The payment and patient thresholds remain the same under the All-Payer AAPM option, 50% and 35% respectively. However, an EC can reach these thresholds through a combination of payments or patients seen through the Medicare AAPM and the Other Payer AAPM. To become a QP through the All-Payer Combination Option, an EC must still meet minimum thresholds under the Medicare arrangement. ECs must:

• Receive at least 25% of Medicare Part B payments through the Medicare AAPM, or
  
• See at least 20% of Medicare patients through the Medicare AAPM.

An EC can be considered a partial QP through the All-Payer Combination Option if they meet the payment or patient threshold, 40% and 25% respectively. Partial QPs must meet the following minimum Medicare thresholds:

• Receive at least 20% of Medicare Part B payments through the Medicare AAPM, or
  
• See at least 10% of Medicare patients through the Medicare AAPM.

APM entities or eligible clinicians can request that CMS use the All-Payer Combination Option to determine their QP status. Entities and ECs must submit payment and patient data from their Other Payer APM for CMS to make this determination.

Advanced Alternative Payment Model participants can check their QP status using the QPP Participation Status Tool. Lists of Other Payer APMs can be found in the QPP Resource Library.

Qualifying participants (QPs) will receive an annual 5% lump-sum bonus. The bonus is based on the previous year’s Medicare Part B payments. The bonus applies in payment years 2019-2024.

Qualifying participants (QPs) will receive a 0.75% increase to their Medicare physician fee schedule (PFS) beginning in 2026.