Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration

The Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration tests whether providing exclusions from the Merit-Based Incentive Payment System (“MIPS”) reporting requirements, payment adjustments, and performance feedback (collectively, the “MIPS exclusions”) for individual eligible clinicians who participate to a sufficient degree in certain payment arrangements with Medicare Advantage Organizations (“MAOs”) (combined with eligible clinician participation, if any, in Advanced Alternative Payment Models (“Advanced APMs”) with Medicare Fee-for-Service (“FFS”)) will increase or maintain eligible clinician participation in payment arrangements with MAOs that are similar to Advanced APMs, and change the manner in which those clinicians deliver care.

The MAQI Demonstration will be tested under the authority of Section 402 of the Social Security Amendments of 1967 (as amended).

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 in a payment year based on combined performance on measures of quality, cost, improvement activities, and promoting interoperability in a performance year, or 2) Advanced APMs, under which eligible clinicians may earn an incentive payment in a payment year for sufficient participation during a performance year in certain advanced 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 adjustments.

An eligible clinician may become a QP through one of two options: the Medicare Option, which only includes certain advanced payment arrangements under Medicare FFS (Advanced APMs), not Medicare Advantage; or the All-Payer Combination Option, which includes Advanced APMs and similarly advanced payment arrangements with other non-Medicare FFS payers (Other Payer Advanced APMs), including Medicare Advantage and other Medicare health plans. Both Advanced APMs and Other Payer Advanced APMs involve payment arrangements that meet certain criteria for CEHRT use, payment based on MIPS-comparable quality measures, and financial risk. Under the Medicare Option, which began with the 2017 performance period, eligible clinicians can become QPs if they meet certain thresholds for participation in Advanced APMs. Under the All-Payer Combination Option, which will begin with the 2019 performance period, eligible clinicians can also become QPs if they first meet a minimum threshold for participation in Advanced APMs (lower than the threshold required under the Medicare Option) and then meet a minimum threshold for combined participation in both Advanced APMs and Other Payer 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 who does not meet the criteria to be a QP or a Partial QP for a given year is subject to the MIPS reporting requirements and payment adjustments for that year unless the clinician meets certain other MIPS exclusion criteria (for example, being newly enrolled in Medicare, or having a low volume under Medicare FFS).

The MAQI Demonstration allows participating eligible clinicians to have the opportunity to receive the MIPS exclusions 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 meeting the criteria to be QPs or Partial QPs, or otherwise being excluded from MIPS. The Demonstration permits consideration of eligible clinicians’ 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. The Demonstration also allows participating eligible clinicians to receive the MIPS exclusions for the year even if they do not meet the threshold level of participation in Advanced APMs with Medicare FFS to be determined to be QPs under the All Payer Combination Option for a year. However, if an eligible clinician participates in one or more Advanced APMs with Medicare FFS, that participation will also be counted toward the thresholds for the MIPS exclusions under this Demonstration.

Demonstration participants who do not meet the thresholds to receive the MIPS exclusions for a given year continue their 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 eligible clinicians; participating clinicians would still have to meet the thresholds under the Medicare Option or All-Payer Combination Option in order to become QPs and earn the APM incentive payment for a year.

Demonstration Details

The Demonstration will test whether:

  • There is an increase in eligible clinician participation in payment arrangements with MAOs that we determine to be 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.

Under section 1848(q)(6)(F)(ii) of the Social Security Act (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.

Eligibility and How to Apply

Clinicians who meet the definition of eligible clinician under the QPP as defined under 42 CFR § 414.1305 will be eligible to participate in the MAQI Demonstration. Eligible clinicians must apply to the Demonstration up-front, prior to CMS determining whether they would qualify for the MIPS exclusions under the Demonstration. The application period for 2018 is closed. CMS plans to allow new applications from additional eligible clinicians in each year of the Demonstration. The next application period is anticipated to begin in the summer of 2019.

Eligible clinicians who are selected for participation in the Demonstration will receive the MIPS exclusions for the year if they: (1) submit the required documentation and (2) meet a threshold for sufficient combined participation in Qualifying Payment Arrangements with MAOs and Advanced APMs with Medicare FFS, if any. If they do not meet these conditions for a year, the eligible clinicians’ participation in the Demonstration will not be terminated, but they will not receive the MIPS exclusions for that year. Therefore, unless they become QPs or Partial QPs, or are otherwise excluded from MIPS, those eligible clinicians who are participating in the Demonstration but do not meet the criteria to receive the MIPS exclusions will be subject to the MIPS reporting requirements and payment adjustments for the applicable year.

Eligible clinicians who applied to the MAQI Demonstration for 2018 were notified about their application status in October 2018. Eligible clinicians who were selected for participation received instructions in October 2018 on how to finalize their participation in the Demonstration and submit information to be evaluated for the MIPS exclusions for the 2018 MIPS performance period and 2020 MIPS payment year.

Determinations will be made annually as to whether participating eligible clinicians meet the conditions set forth under the Demonstration to receive the MIPS exclusions for the year. Participation will continue for the remainder of the Demonstration, unless participation is voluntarily or involuntarily terminated under the terms and conditions of the Demonstration. For example, eligible clinicians who do not comply with the terms of the participation agreement or who present program integrity risks may be involuntarily terminated from the Demonstration. Participants will be required each year to submit the specified documentation regarding potential Qualifying Payment Arrangements and the amount of their revenue and/or patients covered by these arrangements.

Additional Information