Merit-based Incentive Payment System (MIPS) Alternative Payment Model (APM)

MACRA Basics

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

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% lump-sum bonus payment 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 Overview

MIPS APM include APMs that do not meet the criteria (e.g., taking on financial risk) to become an AAPM. However, APMs must 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) Tracks 1, 2, and 3
  • Medicare Accountable Care Organization (ACO) Track 1+
  • Next Generation ACO Model
  • Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)
  • 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.

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% lump-sum bonus payment. 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-eligible clinicians. The cost performance category is scored 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 advancing care information (ACI) 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 ACI performance category will require data submissions from the participating APM tax identification number (TIN). The TIN’s scores 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 ACI performance category.

The following is the APM Scoring Standard:

MIPS Performance Category

Reporting Requirement

Performance Category Weight

MIPS Performance Category

:

Quality

Reporting Requirement

:

CMS will use data submitted to the CMS Web Interface on behalf of participating MIPS APM eligible clinicians to assess the quality category.

Performance Category Weight

:

50%

MIPS Performance Category

:

Cost

Reporting Requirement

:

CMS will not assess MIPS APM eligible clinicians on cost.

Performance Category Weight

:

0%

MIPS Performance Category

:

Improvement Activities

Reporting Requirement

:

CMS will assign a score based on the requirements of the MIPS APM compared to the improvement activities requirements.

Performance Category Weight

:

20%

MIPS Performance Category

:

Advancing Care Information

Reporting Requirement

:

All TINs in the MIPS APM will need to submit data for the ACI category.

Performance Category Weight

:

30%