Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration

The Medicare Advantage Qualifying Payment Arrangement Incentive (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 Alternative Payment Models (APMs) with MAOs and change the manner in which 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 based on combined performance on measures of quality, cost, improvement activities, and advancing care information, 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.

Demonstration Details

In the 2019 Physician Fee Schedule proposed rule, the Centers for Medicare & Medicaid Services (CMS) are 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.

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.

Eligibility and How to Apply

Clinicians who meet the definition of MIPS eligible clinician under the QPP as defined under 42 CFR § 414.1305 will be eligible to participate in the MAQI Demonstration. Clinicians will apply to the Demonstration up-front, prior to CMS determining whether they meet the conditions to qualify for the waiver from the MIPS reporting requirements and payment adjustment under the Demonstration. CMS plans to allow new clinicians to apply each year of the Demonstration. Clinicians who are selected for participation in the Demonstration will receive waivers from the MIPS reporting requirements and payment adjustment for the year if they: (1) meet the combined thresholds for sufficient participation in Qualifying Payment Arrangements with MAOs and Advanced APMs, and (2) submit the required documentation as outlined in the Submission Process for Qualifying Payment Arrangements section of the below fact sheet and in future guidance to be provided to potential applicants. If they do not meet these conditions for a year, the eligible clinician’s participation in the Demonstration will not be terminated but they will not be eligible for the waivers from the MIPS reporting requirements and payment adjustment for that year. Therefore, unless they become QPs or Partial QPs, or are otherwise excluded from MIPS, the participating clinicians will be subject to the MIPS reporting requirements and payment adjustment for the applicable year.

Eligibility for the waiver from the MIPS reporting requirements and payment adjustment based on meeting the conditions set forth in the Demonstration (the “Demonstration Waiver”) will be determined on an annual basis. Participation will last the duration of the Demonstration, unless participation is voluntarily or involuntarily terminated under the terms and conditions of the Demonstration.

The application period for eligible clinicians closed on September 7, 2018. No further applications are being accepted at this time. CMS will notify applicants if their demonstration status in Fall 2018.

Additional Information