A guide to MACRA’s QPP: MIPS, MIPS APM and AAPM
Unlock the key to MACRA’s impact on your Medicare payments.
The Medicare Access and CHIP Reauthorization Act (MACRA) was a landmark legislation that ushered in an era of Medicare payment reform. MACRA replaced the flawed sustainable growth rate formula with the Quality Payment Program (QPP), a value-based system that rewards improved patient outcomes over the volume of services provided.
Through QPP, you can earn incentives and avoid penalties by participating in one of two tracks:
Merit-based Incentive Payment System (MIPS): The default track for most physicians
Advanced Alternative Payment Models (AAPMs): For those participating in qualifying risk-based models
You can also participate through MIPS Alternative Payment Models (MIPS APMs), which combine features of both tracks but are considered part of MIPS.
About MIPS
MIPS adjusts Medicare Part B payments based on four categories: quality, cost, promoting interoperability and improvement activities. Performance in these areas is weighted and combined into a final score that determines whether your payment adjustment is positive, neutral or negative.
What to know
Physicians may report as individuals, groups, virtual groups or subgroups. Group scores apply to all National Provider Identifiers (NPIs) under that tax identification number (TIN).
MIPS scores follow physicians, affecting Medicare payment, and may be considered by future employers.
Beginning in 2026, large, multi-specialty groups must form subgroups to report MIPS Value Pathways (MVPs).
MIPS FAQs
Expand the questions below for quick answers about participating in MIPS.
MIPS is a Medicare reporting program that scores clinicians on quality, cost, promoting interoperability and improvement activities. The final score determines your Medicare Part B payment adjustment.
Most physicians who bill Medicare Part B are eligible to participate in MIPS, unless they meet any of these exclusion criteria:
Clinicians in their first year of billing Medicare.
Clinicians who fall below the low-volume threshold (200 or fewer Medicare Part B patients, $90,000 or less in allowed billing charges, or 200 or fewer covered services).
Clinicians who are qualifying participants (QPs) in an Advanced Alternative Payment Model (AAPM).
Additional details:
Clinicians meeting one or two, but not all, of the low-volume threshold criteria can opt in through the QPP portal. Opt-in elections apply for the full performance year and cannot be rescinded.
Resident physicians in their first year of billing are excluded. Second-year residents billing under their own NPI are subject to MIPS.
Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) are exempt from MIPS for services paid under their all-inclusive payment methodology. Any Medicare Part B services billed outside that payment are subject to MIPS adjustments.
Clinicians can check eligibility and exemption status using the QPP Participation Status Tool at cms.gov.
There are two hardship exceptions available to ECs. This includes a significant hardship exception for the promoting interoperability category and an extreme and uncontrollable circumstances (e.g., natural disaster) exception for the quality, cost, and improvement activities categories.
MIPS scoring is based on four performance categories. Each category contributes to your final score:
Quality: 30%
Cost: 30%
Promoting interoperability: 25%
Improvement activities: 15%
CMS combines these scores into a final score of 0 to 100, which is compared against a performance threshold.
What are the reporting requirements?
The reporting requirements depend on which reporting method you choose, traditional MIPS or MIPS Value Pathways (MVPs).
Quality: report six measures. CMS will score you on applicable administrative claims-based measures.
MVP participants report four measures from the MVP.
Cost: CMS calculates cost scores based on claims data.
MVP participants are assessed on the cost measures within the MVP.
Improvement activities: Perform two activities for a continuous 90-day period during the performance years. Small practices (with 15 or fewer ECs) only need to perform one activity.
MVP participants only need to report one improvement activity.
Promoting interoperability: report a set of required measures. You will receive a zero for the entire category if you fail to report any of the required measures.
Must also attest “yes” to:
- Completing an annual security risk analysis (An annual security risk analysis is also a HIPAA requirement)
- Complete the annual self-assessment using the 2025 High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide
- Two information blocking statements
All MIPS-eligible clinicians (ECs) are compared against a national performance threshold set annually by CMS. Your final score determines whether you receive a positive, neutral or negative payment adjustment.
Individual measures are compared against national benchmarks that are established using either performance year or historical performance data of anyone who reported the measure.
Clinicians in large, multi-specialty groups can report individually or as part of a group. Beginning in 2026, multi-specialty groups must form subgroups to report MIPS Value Pathways (MVPs). When reporting Traditional MIPS as a group, all eligible clinicians under the group’s TIN are included and the same final MIPS score applies to everyone in that group. ECs in a subgroup will receive the subgroup’s final score (unless they have a higher score under the same TIN/NPI from individual or group participation).
An MVP is one of the reporting options under MIPS. Each MVP includes a set of related measures around a specific specialty or condition. MVPs have reduced reporting requirements compared to Traditional MIPS. Beginning in 2026, multi-specialty groups with more than 15 ECs that want to report are required to form a subgroup to report MVPs or report as individuals. Those interested in reporting an MVP must register on the CMS website (April-November of the performance year).
Yes. The Value in Primary Care MVP was designed specifically for primary care physicians. MVPs are not restricted to specific specialties, and you can report any MVP that is relevant to your practice.
NOTE: ECs that wish to bill advanced primary care management (APCM) must either participate in an APM or report the Value in Primary Care MVP.
Yes, but you will receive zero points in the promoting interoperability category and face a greater reporting burden.
MIPS payment adjustments are applied to Medicare Part B claims based on your final score:
Scores above the annual threshold earn a positive payment adjustment.
Scores at the threshold receive a neutral adjustment.
Scores below the threshold receive a negative adjustment.
Adjustments are applied two years after the performance year (e.g., 2026 MIPS adjustments are based on MIPS final scores from 2024). Adjustments are budget neutral and made on a sliding scale, with higher scores eligible for greater positive adjustments. The maximum payment adjustment is ±9%. ECs who do not report or have a final score in the bottom quartile automatically receive the maximum negative payment adjustment.
Yes. If you believe CMS made an error in your MIPS score or payment adjustment, you can request a targeted review through the QPP Portal. A targeted review is a formal process that allows you to dispute calculation or eligibility issues for your MIPS performance year.
About AAPMs
AAPMs offer incentives to physicians to provide high-quality, cost-efficient care. To qualify as an AAPM, a model must:
Use quality measures comparable to those in MIPS
Use certified EHR technology
Assume more than nominal financial risk or be an expanded medical home model
Clinicians who meet the QP threshold earn a financial bonus and are exempt from MIPS reporting.
Examples of AAPMs
Accountable care organization Realizing Equity Access and Community Health (ACO REACH)
Medicare Shared Savings Program (BASIC Level E and ENHANCED)
Maryland Achieving Healthcare Efficiency through Accountable Design (AHEAD) Model, Maryland Care Redesign Program
AAPM FAQs
Expand for quick answers about Advanced APMs.
An APM is considered advanced if it meets CMS criteria for EHR use, includes comparable quality measures and involves financial risk.
Clinicians who meet CMS thresholds for payments or patients through an AAPM earn QP status. Partial QPs may choose to participate in MIPS.
For the 2028 payment year (2026 performance period):
QPs: at least 75% of Medicare Part B payments or 50% of Medicare patients through an AAPM
Partial QPs: at least 50% of payments or 35% of patients through an AAPM
Those with QP status in 2026 will receive a 3.1% lump-sum bonus in 2028. Beginning in 2026, QPs receive a 0.75% fee-schedule increase.
CMS makes QP determinations three times each year—March 31, June 30 and August 31.
Clinicians can check their status using the QPP Participation Status Tool. Once identified as a QP, that status applies for the full performance period.
The All-Payer Combination option allows clinicians to combine Medicare AAPM participation with Other Payer AAPMs to reach QP thresholds.
To qualify, you must meet a minimum level of participation in a Medicare AAPM (25% of payments or 20% of patients) and meet the combined thresholds of 75% of payments or 50% of patients across all payers.
These are non-Medicare payment arrangements that meet AAPM criteria, such as those under Medicaid, commercial payers aligned with CMS multi-payer models and other private payer arrangements. They must use certified EHR technology, include MIPS-comparable quality measures and assume nominal financial risk.
Key CMS links
About MIPS APMs
A MIPS APM is an APM that does not meet all the requirements to qualify as an AAPM but still ties payment to quality and cost performance. Participants report through the APM Performance Pathway (APP), which is a streamlined reporting option for APM entities.
Key facts
MIPS APMs are a reporting option under MIPS.
MIPS APM participants are assessed on the same categories as MIPS and subject to MIPS payment adjustments.
The cost category is weighted at 0% and participants automatically receive full credit for improvement activities.
APP measures cover readmissions, chronic-condition admissions, diabetes control, depression screening and blood-pressure control.
Primary care MIPS APM
ACO REACH
Maryland Achieving Healthcare Efficiency through Accountable Design (AHEAD) Model, Track 2
Medicare Shared Savings Program (all tracks)
MIPS APM FAQs
A MIPS-APM is an APM that meets certain CMS criteria but does not qualify as an AAPM. To qualify, the model must:
Operate under an agreement with CMS or by law or regulation
Include at least one MIPS-eligible clinician
Base payment incentives on performance for quality and cost measures
Final scores are based on the same performance categories as MIPS:
Quality: 50%
Improvement activities: 20%
Promoting interoperability: 30%
Cost: 0%
Participants automatically receive full credit for improvement activities. CMS calculates an APM Entity’s score as a weighted average of individual and group performance.
The APP and APP Plus are predetermined sets of measures that streamline reporting for MIPS APM participants. Medicare Shared Savings Program ACOs must report the APP Plus measure set.
Two administrative claims measures
Three (APP) or six (APP Plus) clinical quality measures (CQMs) or electronic CQMs (eCQMs)
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey
Key CMS links
QPP support from CMS
CMS offers free technical assistance, resources and learning systems to help your practice succeed under QPP.
CMS QPP resources
AAFP advocacy on payment models
The American Academy of Family Physicians (AAFP) advocates for payment systems that reward comprehensive, coordinated care and reduce administrative burden. AAFP’s long-standing push for value-based payment helped shape MACRA, which was a major win for family medicine. The Academy continues to work with Medicare and other payers to simplify reporting and strengthen payment models that reflect the full value of primary care.