Advanced Alternative Payment Models
Advanced Alternative Payment Models (APMs) offer a bonus for achieving threshold levels of payments or patients.
Physicians who participate in advanced APMs are exempt from MIPS reporting requirements.
The following are several models that meet the definitions of advanced APMs:
- Comprehensive Primary Care Plus
- Medicare Shared Savings Program, Track 2 and Track 3
- Next Generation ACO Model
- Oncology Care Model with two-sided risk
- Comprehensive End Stage Renal Disease Care Model with two-sided risk
- Comprehensive Care for Joint Replacement Therapy, Track 1 CEHRT
- Medicare Shared Savings Program, Track 1+
- Bundled Payments for Care Improvement Advanced Model
- Maryland All-Payer Model
- Maryland Total Cost of Care Model
- Vermont Medicare ACO Initiative
For more information on model eligibility, view a comprehensive list of alternative payment models published by the CMS.
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 nonMedicare 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
|Payment Year||2019||2020||2021||2022||2023||2024 and Beyond|
|Percentage of Payments||25%||25%||50%||50%||75%||75%|
|Percentage of Patients||20%||20%||35%||50%||50%||50%|
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:
- 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.
- Payments must be based on quality measures that are evidence-based, reliable, and valid and must include an outcome measure, if applicable.
- In 2019, an advanced APM must require 75% of their eligible clinicians to use 2015 CEHRT. This is up from 50% in 2018.
- Beginning in 2019, all payer types will be included in the all-payer combination option in the advanced APM track. Starting in performance year 2019, obstetrician–gynecologists and other health care professionals may be able to quality for the 5% bonus in this track by participating in Medicaid and commercial APMs in addition to Medicare models.
- Medical home models developed under the Center for Medicare and Medicaid Innovation 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 obstetrician–gynecologists may be able to participate in medical home models in Medicare and Medicaid in the future, at present there are no Center for Medicare and Medicaid Innovation medical home models that include obstetrician–gynecologists.