andrewallenbruce
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7 months ago MAQI
The Medicare Advantage Qualifying Payment Arrangement Incentive Demonstration
The Centers for Medicare & Medicaid Services (CMS) is announcing the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration. The MAQI Demonstration will be tested under the authority of Section 402 of the Social Security Amendments of 1967 (as amended).
The MAQI Demonstration is designed to test whether exempting Merit-based Incentive Payment System (MIPS) -eligible clinicians who participate to a sufficient degree in certain payment arrangements with Medicare Advantage Organizations (MAOs) from the MIPS reporting requirements and payment adjustment will increase or maintain participation in payment arrangements similar to Advanced APMs with MAOs and change the manner in which clinicians deliver care. In the 2019 Physician Fee Schedule proposed rule, released today, CMS is proposing a regulation to effectuate the waivers contemplated under the MAQI Demonstration because the budget neutrality requirement in MIPS means that exempting MIPS eligible clinicians could have an impact on the payment adjustments for other MIPS eligible clinicians. Details of the MAQI Demonstration will remain under development until the 2019 Physician Fee Schedule proposed rule is finalized. The Demonstration will test whether:
- There is an increase in clinician participation in payment arrangements with MAOs that meet the criteria of Qualifying Payment Arrangements;
- Participating in Qualifying Payment Arrangements and Advanced APMs to the degree required to be eligible for the Demonstration Waiver incentivizes providers to transform their care delivery (assessed by interviews with participating clinicians);
- Whether there is a change in utilization patterns among participants in the Demonstration; and
- If there are changes in utilization, how those changes affect MA plan bids.
BACKGROUND
Under current law, eligible clinicians may participate in one of two paths of the Quality Payment Program (QPP): 1) MIPS, which adjusts Medicare payments based on combined performance on measures of quality, cost, improvement activities, and promoting interoperability, or 2) Advanced APMs, under which eligible clinicians may earn an incentive payment for sufficient participation in certain payment arrangements with Fee-for-Service (FFS) and, starting in the 2019 performance period, with a combination of those Medicare FFS arrangements and similar arrangements with other payers such as Medicare Advantage commercial payers, and Medicaid managed care. To participate in the Advanced APM path of QPP for a given year and earn an incentive payment, eligible clinicians must be determined to be Qualifying APM Participants (QPs); in addition to earning an APM incentive payment, QPs are excluded from the MIPS reporting requirements and payment adjustment. An eligible clinician may become a QP through one of two options: the Medicare Option (which only includes Medicare FFS, not Medicare Advantage), or the All-Payer Combination Option. Under the Medicare Option, which began with the 2017 performance period, eligible clinicians can be QPs if they meet certain thresholds for participation in Advanced APMs, which are Medicare FFS payment arrangements that meet certain criteria. Under the All-Payer Combination Option, which will begin with the 2019 performance period, eligible clinicians can also be QPs if they meet a minimum threshold for participation in Advanced APMs (lower than the threshold required under the Medicare Option) and certain All-Payer Combination Option thresholds that include participation in both Advanced APMs and Other Payer Advanced APMs, which are payment arrangements with other payers that meet similar criteria to those for Advanced APMs. Eligible clinicians who do not meet the thresholds to become QPs for a year can meet lower thresholds to become “Partial QPs,” which allows them the option to be excluded from the MIPS reporting requirements and payment adjustment, but does not earn them an APM incentive payment. An eligible clinician that does not meet the criteria to be a QP or a Partial QP for a given year is subject to MIPS for that year unless the clinician meets certain other MIPS exclusion criteria, such as being newly enrolled in Medicare or meeting the low volume threshold for Medicare FFS patients, payments, or services. The MAQI Demonstration will allow participating clinicians to have the opportunity to be eligible for waivers that will exempt them from the MIPS reporting requirements and payment adjustment for a given year if they participate to a sufficient degree in Qualifying Payment Arrangements with MAOs (combined with participation in Advanced APMs with Medicare FFS, if any) during the performance period for that year, without requiring them to be QPs or Partial QPs, or to otherwise meet MIPS exclusion criteria. The Demonstration will permit consideration of participation in “Qualifying Payment Arrangements” with Medicare Advantage plans that meet the criteria to be Other Payer Advanced APMs a year before the All-Payer Combination Option is available. Under the Demonstration, clinicians will not have to have a minimum amount of participation in an Advanced APM with Medicare FFS in order to be exempt from the MIPS reporting requirements and payment adjustment for a year. However, if clinicians participate in one or more Advanced APMs with Medicare FFS, that participation will also be counted towards the thresholds that qualify participants for the waiver under this Demonstration from the MIPS reporting requirements and payment adjustment. Demonstration participants who do not meet the thresholds to receive waivers from MIPS reporting requirements and payment adjustments for a given year may still continue participation in the Demonstration and will be notified with sufficient time to complete MIPS reporting for the year. The Demonstration will not grant QP status to participating clinicians; participating clinicians would still have to meet the thresholds for participation under the Medicare Option or All-Payer Combination Option in order to become QPs and earn the incentive payment. Under section 1848(q)(6)(F)(ii) of the Act, MIPS payment adjustments must be budget neutral in the aggregate. Therefore, removing MIPS eligible clinicians from the population across which positive and negative payment adjustments are calculated under MIPS may affect the payment adjustments for other MIPS eligible clinicians. The Demonstration would remove certain clinicians from the pool of MIPS eligible clinicians for which the MIPS payment adjustments are calculated, thereby decreasing the pool of MIPS eligible clinicians included in the budget neutrality determination. This may have the effect of increasing or decreasing the number of MIPS eligible clinicians receiving negative or positive payment adjustments. The Demonstration is contingent on the outcome of the proposed rule to adopt the waivers because of its effect on MIPS payment adjustments for other clinicians. In addition, the MAQI demonstration will include a waiver of the requirement that the Secretary permit all eligible professionals to voluntarily report even if they are not required to do so under MIPS regulations, so that the Demonstration will prohibit reporting under the MIPS by clinicians who participate in the Demonstration and meet the thresholds to receive the waivers from MIPS reporting and payment consequences for a given year. The first performance period for the Demonstration will be 2018, and the Demonstration will last for five years.
Thresholds to Qualify for Waiver
Eligibility for the Demonstration Waiver is conditioned on the participating clinician meeting a combined threshold for participation in Qualifying Payment Arrangements and Advanced APMs. There are two methods used to measure participation: payments and patients. The participation thresholds match the thresholds under the Medicare Option of the QPP. Similar to the QPP, clinicians may meet either of the two thresholds and the Demonstration will use whichever threshold is more advantageous to the clinician. The thresholds for the Demonstration will be:
| Performance Year | Payment Amount | Patient Count |
|---|---|---|
| 2018 | 25% | 20% |
| 2019 | 50% | 35% |
| 2020 | 50% | 35% |
| 2021 | 75% | 50% |
| 2022 | 75% | 50% |
The payment amount threshold score will be calculated by dividing a numerator (the aggregate of payments for Medicare Part B covered professional services furnished by the clinician during the Performance Period to beneficiaries attributed to the clinician through Advanced APM(s), plus the aggregate of MAO payments made to the clinician under the terms of the Qualifying Payment Arrangement(s) during the Performance Period) by a denominator (the aggregate of payments for Medicare Part B covered professional services furnished by the clinician to all eligible beneficiaries during the Performance Period, plus the aggregate of all MAO payments to the clinician during the Performance Period). The definition of eligible beneficiaries is listed below.
The patient count threshold score will be calculated by dividing a numerator (the number of beneficiaries attributed to the clinician through Advanced APM(s) to whom the clinician furnishes Medicare Part B covered professional services during the Performance Period, plus the number of patients to whom the clinician furnishes services that are included in the measures of aggregate expenditures used under the terms of all of their Qualifying Payment Arrangements during the Performance Period) by a denominator (the number of eligible beneficiaries to whom the clinician furnishes Medicare Part B covered professional services during the Performance Period, plus the number of beneficiaries to whom the clinician furnishes services for which MAOs pay during the Performance Period).
The definition of eligible beneficiaries as used in the Medicare FFS component of the denominators will be Medicare FFS beneficiaries who, during the Performance Period, are not enrolled in Medicare Advantage or a Medicare cost plan, do not have Medicare as a secondary payer, are enrolled in both Medicare Parts A and B, are at least 18 years of age, and are United States residents.
Payment amount method:
$ through Qualifying Payment Arrangements + $ through Advanced APMs Total $ from MAOs and from Medicare FFS
Patient count method:
no. beneficiaries under Qualifying Payment Arrangements + no. beneficiaries under Advanced APMS Total no. beneficiaries under MAOs and Medicare FFS
Top Level
Individual Scenario
Group Scenario
APMS Scenario
Virtual Groups Scenario
Special Scenario