Many observers view the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as a game changer for the delivery and payment of health care services.

On Oct. 14, 2016 the Centers for Medicare & Medicaid Services (CMS) published a final rule with comment period (final rule) implementing the bipartisan MACRA legislation. The rule finalizes regulations to replace the Medicare sustainable growth rate (SGR) formula. Under the new system, fee-for-service payment rates under the Medicare Physician Fee Schedule (MPFS) are linked to care delivery, quality and value-based variables.

MACRA’s implementation begins in earnest on Jan. 1, 2017. This article is part of a three-part series that examines various legal, operational and strategic considerations associated with MACRA. This article is based on the unpublished version of the final rule submitted to the Office of Management and Budget on Oct. 14, 2016.

Specifically, this article focuses on Alternative Payment Models (APM) under the “Quality Payment Program” (QPP), as established by MACRA and implemented by the final rule. Separate articles in this series examine:

• Essential elements of the QPP, including its policy objectives, participation alternatives, and operational details related to the program, and
• Details of the Merit Based Payment Incentive System (MIPS) participation vehicle.

This article addresses:

• Recap on MACRA Basics and Objectives
• APM Participation Game plan – Timing Concerns
• APM Incentive Payment Overview
• Overview of Advanced APM Requirements
• Advanced APM Financial Arrangements with CMS
• Financial Risk Requirements
• Excess of Nominal Risk Requirement
• Eligible Advanced APM Arrangements
• Qualified APM Participant (QP) Determination
• Payment Amount and Patient Count Thresholds
• Clinician Alignment with APMs—QPs and Partial QPs
• Medicare Option and All-Payer Combination Option Thresholds
• APM Incentive Payments
• APM Compliance Requirements
• Physician-Focused Payment Model
• Observations and Additional Information

To view or download a pdf of the full alert, please click here.

You can read part one of this series here.