An Alternative Payment Model (APM) is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.
1. APMs - Meet the statutory definition of an APM. MIPS eligible clinicians participating in an APM are also subject to MIPS.
2. MIPS APMs - MIPS APMs have MIPS eligible clinicians participating in the APM on their CMS-approved participation list.
3. Advanced APMs - An Advanced APM is a track of the Quality Payment Program that offers a 5 percent incentive for achieving threshold levels of payments or patients through Advanced APMs. If you achieve these thresholds, you are excluded from the MIPS reporting requirements and payment adjustment.
4. Advanced MIPS APMs - Most Advanced APMs are also MIPS APMs. MIPS Eligible clinicians participating in Advanced APMs are included in MIPS if they do not meet the threshold for payments or patients sufficient to become a Qualifying APM Participant (QP). The MIPS eligible clinician will be scored under MIPS according to the APM scoring standard.
5. All-Payer/Other-Payer Option - Starting in Performance Year 2019, eligible clinicians will be able to become Qualifying Alternative Payment Model Participants (QPs) through the All-Payer Option. To attain this Option, eligible clinicians must participate in a combination of Advanced APMs with Medicare and Other-Payer Advanced APMs. Other-Payer Advanced APMs are non-Medicare payment arrangements that meet criteria that are similar to Advanced APMs under Medicare.
Certain Alternative Payment Models (APMs) are considered MIPS APMs and their participants are eligible for certain scoring benefits under MIPS.
MIPS APMs are APMs that meet these criteria:
- APM entities that participate in the APM under an agreement with CMS;
- APM bases payment incentives on performance (either at the APM entity or eligible clinician level), on cost/utilization, and quality measures.
Advanced Alternative Payment Models (APMs) are a track of the Quality Payment Program that offer a 5 percent incentive payment for achieving threshold levels of payments or patients through Advanced APMs. If you achieve these thresholds, you become a Qualifying APM Participant (QP) and you are excluded from the MIPS reporting requirements and payment adjustment.
Advanced APMs are APMs that meet these 3 criteria:
- Requires participants to use certified EHR technology;
- Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and
- Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2) requires participants to bear a significant financial risk.
Qualifying APM Participant Potential Benefits:
- 5 percent APM incentive payment
- Exclusion from MIPS
Advanced APMs allow eligible clinicians to become a QP for an opportunity to receive a 5 percent APM incentive payment and to be excluded from MIPS.
To become a QP, you must receive at least 50 percent of your Medicare Part B payments or see at least 35 percent of Medicare patients through an Advanced APM entity during the QP performance period (January 1 - August 31). In addition, 75 percent of practices need to be using certified EHR Technology within the Advanced APM entity.
An APM entity group may also become a QP through the "All-Payer and Other Payer Option", which is a combination of Medicare and non-Medicare payer arrangements such as private payers and Medicaid.
All clinicians who participate in Advanced APMs and become Partial QPs may choose whether or not they want to participate in MIPS. If these clinicians choose to participate in MIPS, they must fulfill all MIPS reporting requirements; however, they may report through the APP or any other MIPS reporting method. If these clinicians choose not to participate, they will not be required to report to MIPS and will not receive a MIPS payment adjustment.
To become a Partial QP, you must receive at least 40 percent of your Medicare Part B payments or see at least 25 percent of Medicare patients through an Advanced APM entity during the QP performance period (January 1 - August 31).
During the 2022 QP Performance Period, eligible clinicians will be able to become Qualifying Alternative Payment Model Participant (QPs) through the All-Payer Combination Option. In order to do so, a clinician must be in a Medicare Advanced APM. A clinician can also combine their participation with an Other-Payer Advanced APM.
Eligible clinicians who are determined to be QPs will receive a 5 percent APM incentive payment in the payment year and will not be subject to the MIPS reporting requirements or payment adjustments.
The performance period is the same for both the Medicare Option and the All-Payer Combination Option. QP determinations are made using data submitted by eligible clinicians or APM entities for one of the snapshot dates: March 31, June 30, and August 31.
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