Types of APMs
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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 - These models have both types of participants under one model name. Each participant’s eligibility is based on the level of participation within the model.

5. All-Payer/Other-Payer Option - Starting in Performance Year 2019, eligible clinicians will be able to become Qualifying Alternative Payment Model Participant (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 like Advanced APMs under Medicare.

MIPS Alternative Payment Models

Certain Alternative Payment Models (APMs) include Merit-Based Incentive Payment System (MIPS) eligible clinicians as participants and hold their participants accountable for the cost and quality of care provided to Medicare beneficiaries. These types of APMs are called MIPS APMs, and participants receive special MIPS scoring under the APM scoring standard. All eligible clinicians should check their participation status to understand their MIPS participation.

MIPS APMs are APMs that meet these 3 criteria:

  • APM entities that participate in the APM under an agreement with CMS
  • APM entities that include 1 or more MIPS eligible clinicians on a Participation List
  • 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

Advanced Alternative Payment Models (APMs) are a track of the Quality Payment Program that offer a 5 percent incentive 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
  • Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2) requires participants to bear a significant financial risk.

Advanced APM Potential Benefits:

  • 5 percent bonus
  • APM-specific rewards
  • Exclusion from MIPS
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Qualifying APM Participant (QP)

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 meet or exceed 25 percent payments for professional services or 20 percent patients delivered professional services through an Advanced APM entity at one of the determination periods (snapshots). 50 percent of practices need to be using certified EHR Technology within the Advanced APM entity.

The APM entity differs by the APM structure. In some APMs, the APM entity is an Accountable Care Organization (ACO). ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to the Medicare patients they serve. Eligible clinicians 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.

Partial Qualifying APM Participant (Partial QP)

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, they must meet all MIPS reporting and scoring requirements. If these clinicians choose not to participate, they will not be required to report to MIPS and will not receive a MIPS payment adjustment.

If the Advanced APM also happens to be a MIPS APM, and the Partial QP chooses to participate in MIPS, then the Partial QP will be scored under the APM Scoring Standard. To become a Partial QP, you must meet or exceed 20 percent payments for professional services or 10 percent patients delivered professional services through an Advanced APM entity at one of the determination periods (snapshots).

All-Payer Advanced Alternative Payment Models

Starting in the 2019 QP Performance Period, eligible clinicians will be able to become Qualifying Alternative Payment Model Participant (QPs) through the All-Payer Option. This Option is attainable through participation in a combination of Advanced APMs with Medicare and Other-Payer Advanced APMs.

Qualifying APM Participant (QP)

The Advanced APM path provides 2 ways for eligible clinicians to become QPs:

  • The Medicare Option, which considers the clinician’s participation solely in Medicare Advanced APMs
  • The All-Payer Option, which considers the clinician’s participation in Advanced APMs both with Medicare and other payers

An eligible clinician’s QP status is determined by 2 thresholds for Advanced APM participation: one for patient count and one for payment amounts. Beginning in 2019, eligible clinicians who do not meet either threshold under the Medicare Option, but meet a minimum threshold under the Medicare Option, may request a QP determination under the All-Payer Option. Eligible clinicians who are determined to be QPs through either option 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.

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