Advanced APMs

Physicians who participate in Advanced Alternative Payment Models (A-APMs) are exempt from MIPS reporting requirements. 

Currently, there are several existing models that meet the definitions of Advanced APMs for performance years 2017 and 2018:

  • Comprehensive Primary Care Plus
  • Medicare Shared Savings Program – Track 2 and Track 3
  • Next Generation ACO Model
  • Oncology Care Model with 2-sided Risk
  • Comprehensive End Stage Renal Disease (ESRD) Care Model with 2-sided risk

For performance year 2018, CMS has identified two more eligible models:

  • Comprehensive Care for Joint Replacement Therapy - Track 1 CEHRT
  • Medicare Shared Savings Program – Track 1+

For performance year 2019, the following models are also eligible:

  • Bundled Payments for Care Improvement Advanced Model (BPCI Advanced)
  • Maryland All Payer Model
  • Maryland Total Cost of Care Model
  • Vermont Medicare ACO Initiative 

For more information on model eligibility, download this comprehensive list of alternative payment models that CMS published. This document details which A-APM criteria a model does and does not meet. 

To qualify for bonus payments, you’ll need to receive a minimum amount of payments or see enough patients through the Advanced APM.  In payment years 2019 and 2020, the participation requirements for Advanced APMs were only for Medicare payments or patients. Starting in payment year 2021 (performance year 2019), the participation requirements for Advanced APMs may include non-Medicare payers and patients, including those with Medicare Advantage plans. If you participate in an APM, but do not meet the participation requirements to be considered an Advanced APM under the QPP, you will be scored as a MIPS APM

Participation Requirements for Medicare Advanced APMs

 

 

 

 

 

 

  

Physicians practicing in an Advanced APM who meet certain other criteria will receive a 5% bonus between 2019 and 2024.  For 2026 and beyond, clinicians in an Advanced APM will receive a 0.75% increase in the Physician Fee Schedule.

You can choose to participate in several different APMs, including Accountable Care Organizations and demonstrations under the Medicare Health Care Quality Demonstration Program. 

Advanced APMs must meet a number of requirements:

  1. Participants must accept financial risk for providing coordinated, high-quality care.  In order to be considered an Advanced APM, the model must either withhold payments, reduce rates, or require the APM Entity to pay CMS back if the APM Entity’s actual expenditures exceed expected expenditures.  The amount of risk that an APM Entity potentially owes to CMS must be at least equal to:
    • 8% of the estimated average total Medicare Part A and B revenues of participating APM Entities for all performance periods through 2024, or
    • 3% of the expected expenditures for which an APM Entity is responsible under the APM payment arrangement.

  2. Payments must be based on quality measures that are evidence-based, reliable, and valid and must include an outcome measure, if applicable.

  3. In 2019, an Advanced APM must require 75% of their eligible clinicians to use 2015 CEHRT. This is up from 50% in 2018.

     

  4. Beginning in 2019, all payer types will be included in the All-payer Combination Option in the A-APM track. Starting in performance year 2019, ob-gyns and other health care providers may be able to quality for the 5% bonus in this track by participating in Medicaid and commerical APMs in addition to Medicare models. 

     

  5. Medical home models developed under the Center for Medicare and Medicaid Innovation (CMMI) authority can also qualify as Advanced APMs.  The medical home model financial risk criteria differ somewhat from the criteria applied to other Advanced APMs.  While ob-gyns may be able to participate in medical home models in Medicare and Medicaid in the future, at present there are no CMMI medical home models that include ob-gyns.
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