January 19, 2021

Volume XI, Number 19


January 18, 2021

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CMS Advances MACRA Medicare Advantage APM Demonstration

The Medicare Advantage Qualifying Payment Arrangement Incentive demonstration would waive MeritBased Incentive Payment System requirements for clinicians taking sufficient risk in contracts with Medicare Advantage plans. The agency seeks comments on the information collection burdens associated with this demonstration that is under consideration for formal approval. More information on the request for comments is available here. Comments are due September 4, 2018.

The Centers for Medicare and Medicaid Services (CMS) is pursuing a demonstration project that would allow clinicians involved in risk contracts in Medicare Advantage (MA) to be exempt from the Merit-Based Incentive Payment System (MIPS). CMS announced an opportunity for public comment on information it would need to collect to carry out the demonstration.

Under the Medicare Access and CHIP Reauthorization Act (MACRA), eligible clinicians in traditional Medicare fall into one of two payment tracks: MIPS or Advanced Alternative Payment Models (APMs). To move into the Advanced APM track, clinicians are required to participate in one of a handful of riskbearing traditional Medicare models.

CMS now acknowledges that some MA plans are developing, or have developed, risk-bearing payment arrangements, similar to Advanced APMs in traditional Medicare. Under existing law, clinicians participating in those models are still subject to MIPS, even if they have substantial participation in Advanced APM contracts in MA. The Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) demonstration would offer these clinicians an opportunity to be exempt from MIPS.

According to the agency announcement, the MAQI demonstration could test whether exempting clinicians with sufficient participation in risk contracts with MA plans from MIPS will increase or maintain participation in Advanced APM arrangements with MA plans. In addition, the agency notes that the demonstration could permit participation in qualifying payment arrangements with MA plans that meet the other payer Advanced APM criteria a year before the all-payer combination option is available. Under existing law and regulation, beginning in the 2019 performance year (2021 payment year), MA risk contracts can be combined with participation in a qualifying traditional Medicare Advanced APM to achieve the thresholds to qualify as an Advanced APM qualifying participant (and qualify for the 5 percent Advanced APM bonus). This demonstration could potentially allow clinicians to count their MA revenue or patients a year earlier, with the first performance period tentatively planned for 2018, and the demonstration would last up to five years.

In order to implement the demonstration, CMS would need to collect information from participants on payment arrangements with MA plans, and on MA payments and patient counts. This information is necessary to determine whether the clinician or group is engaged in enough risk contracting to qualify for the MIPS exemption (similar to the requirements for Advanced APM participation in traditional Medicare). The agency states that the information collection would be similar to what is being collected for the other payer APM option. CMS is seeking feedback from stakeholders on the information it plans to collect, as well as feedback on how the agency can improve accuracy and minimize burden in the collection of information.

Should it move forward, the MAQI demonstration provides a pathway for clinicians to be exempt from the burdens of MIPS reporting. Interested stakeholders should submit comments by September 4, 2018. We expect additional information to be forthcoming and will provide updates as they become available.

© 2020 McDermott Will & EmeryNational Law Review, Volume VIII, Number 186



About this Author

Sheila Madhani, Senior Director, McDermott Consulting
Senior Director

Sheila advises clients on a wide variety of Medicare payment and regulatory issues. With more than 10 years of experience, Sheila is highly skilled in the areas of Medicare physician and hospital outpatient payment, Medicare quality programs, and the establishment and valuation of CPT® codes. Sheila has a deep understanding of emerging technology’s impact on Medicare reimbursement. She has facilitated relationships and discussions with physician specialty societies and industry stakeholders, helping to develop mutually beneficial collaborations. Sheila also has guided...