MACRA defines any of the following as a qualifying Alternative Payment Model (APM):
In order for a clinician to receive a bonus payment through an APM, the APM must be considered an Advanced APM (AAPM) by meeting the following eligibility requirements:
Only AAPMs are eligible for the 5% bonus. The following APMs apply to primary care and are (AAPMs) for the performance period beginning in 2020:
To receive the 5% AAPM bonus, the eligible clinician (EC) must be considered a qualifying participant (QP). ECs are considered QPs if they receive a certain percentage of payments or see a certain percentage of patients through the AAPM. For the 2020 performance year, the payment threshold is 50% and the patient count threshold is 35%. QP determinations will be made at the group level. Participants who do not meet the QP thresholds may be considered a partial QP if they receive 40% of their payments or see 25% of their patients through an AAPM. Partial QPs can elect to participate in MIPS and will be scored under the APM scoring standard. Partial QPs will be excluded from MIPS unless the EC makes an explicit election to participate.
CMS will make QP determinations three times during the performance period. QPs will be identified on the following schedule: March 31 of the performance period; June 30 of the performance period; and August 31 of the performance period. To be included in the QP calculations, an EC must be on the AAPM’s participation list during at least one of these determination snapshots. Once determined to be a QP, an EC will retain QP status for the performance period even if they are not included in the AAPM’s participation list during all determination snapshots. For example, an EC included on the participation list and determined to be a QP during the March 31 snapshot, but not included on the participation list during the June 30 snapshot will be considered a QP for the performance period. ECs can check their QP status using the QPP Participation Status lookup tool(qpp.cms.gov).
The All-Payer Combination Option allows ECs to become QPs or Partial QPs by meeting QP thresholds through a pair of calculations that assess a combination of both Medicare Part B covered professional services furnished through Advanced APMs and services furnished through Other Payer AAPMs. To be considered a QP, an entity or EC must receive at least 50% of its payments through an AAPM or see 35% of its patients through an AAPM. At least 25% of payments received or 20% of patients seen must be through the Medicare AAPM. To be considered a partial QP, an entity or EC must have at least 40% of payments received or 25% of patient seen through an AAPM. A minimum of 20% of payments received or 10% of patients seen must be through the Medicare AAPM.
Other Payer APMs are non-Medicare fee-for-service payment arrangements that meet the AAPM criteria – required use of CEHRT, payment based on quality measures comparable to those in MIPS, and assumption of nominal risk. Other Payer AAPM include arrangements authorized under Title XIX (Medicaid), Medicare Health Plan payment arrangements, and payers with payment arrangements aligned with a CMS Multi-Payer model, and arrangements with commercial and other private payers. Payers or eligible clinicians can request that CMS determine whether an arrangement qualifies as an Other Payer AAPM. Additional information on Other Payer AAPMs can be found on the CMS QPP website(qpp.cms.gov).
If you are a QP, from 2019 through 2024, you will receive an annual 5% lump-sum bonus. The amount of the bonus is based on your Medicare Part B payments from the previous year’s claims. This bonus will be in addition to the incentive paid through existing contracts with the AAPM. Beginning in 2026, QPs will qualify for a 0.75% increase in Medicare PFS payments
Most physicians will move through MIPS until more AAPMs become available. However, family physicians interested in an AAPM model need to be prepared to start on the MIPS track. ECs can verify their QP status using the QPP Participation Status lookup tool(qpp.cms.gov). A list of AAPMs and MIPS APMs is available on the CMS QPP website(qpp.cms.gov).