MACRA Basics

    Merit-based Incentive Payment System (MIPS) Alternative Payment Models (APMs), or MIPS APMs

    A MIPS APM is a subset of alternative payment models that differ from Advanced Alternative Payment Models (AAPMs) in several important ways. Use this guide to help you learn the ins and outs of MIPS APMs.

    MIPS APM: An Overview

    The Medicare Access and CHIP Reauthorization Act (MACRA) was passed and signed into law in April of 2015. MACRA created the Quality Payment Program (QPP), which consists of two payment tracks and aims to transition Medicare from volume-based to value-based payment models. In the QPP, eligible clinicians (ECs) will participate in either the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (AAPM). ECs in certain APMs that do not meet the criteria to be an AAPM and those who do not meet the payment threshold or the patient threshold to receive the annual AAPM 5% bonus fall into a subset of APMs called “MIPS APMs.” Clinicians in MIPS APMs are scored using the APM Scoring Standard, which was established to reduce the reporting burden on participants by eliminating the need to report to both the APM and MIPS.

    MIPS APM Criteria

    MIPS APM include APMs that do not meet the criteria (e.g., taking on financial risk) to become an AAPM. However, APMs must still meet the following criteria to be a MIPS APM:

    • Entities must participate in the APM under an agreement with CMS or by law or regulation
    • APM requires participating entities to include at least one MIPS-eligible clinician
    • APM must base payment incentives on performance on quality and cost measures

    Primary care MIPS APMs include:

    • Comprehensive Primary Care Plus (CPC+)
    • Medicare Shared Savings Program (MSSP) All Tracks (1, 2, 3, BASIC A-E, ENHANCED)
    • 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 Program (Maryland Primary Care Program)
    • Additional models will be announced by CMS as they are approved

    Most AAPMs are also considered MIPS APMs. Eligible clinicians in AAPM entities that do not meet either the patient threshold or payment threshold to be qualifying participants (QPs) and are considered partial QPs can opt to participate in MIPS and will be scored using the APM Scoring Standard.

    MIPS APM Scoring and Reporting

    Using the APM Scoring Standard, one final score for the APM entity is calculated and applied to all ECs within the APM entity.

    Eligible clinicians in MIPS APMs are not eligible for the annual AAPM 5% bonus. However, they may qualify for positive MIPS payment adjustments and exceptional performance adjustments, based on the APM entity’s final score.

    Under the APM Scoring Standard, ECs are subject to the MIPS reporting requirements and payment adjustments. To ease the reporting burden for the quality performance category, CMS will use the APM quality data submitted by the MIPS APM on behalf of the participating MIPS-ECs. The cost performance category is weighted at 0% for MIPS APM participants. CMS will assign each MIPS APM an improvement activities score based on the APM model design and how it compared with the improvement activities available.

    MIPS APM are only required to self-report the promoting interoperability (PI) performance category under MIPS, as other categories are not subject to reporting requirements or the Centers for Medicare & Medicaid Services (CMS) will draw data from other sources. The PI performance category will require data submissions from the participating APM tax identification number (TIN). Each TIN’s score will then be aggregated as a weighted average (based on the number of ECs in each TIN) to produce a single APM entity group score for the PI performance category.

    The following is the APM Scoring Standard:

    MIPS Performance Category
    Reporting Requirement Performance Category Weight
    CMS will use data submitted to the CMS Web Interface on behalf of participating MIPS APM eligible clinicians to assess the quality category. 50%
    Cost CMS will not assess MIPS APM eligible clinicians on cost. 0%
    Improvement Activities CMS will assign a score based on the requirements of the MIPS APM compared to the improvement activities requirements. 20%
    Promoting Interoperability All TINs in the MIPS APM will need to submit data for the PI category. 30%