MACRA is the Medicare Access and CHIP Reauthorization Act of 2015

  • Bipartisan federal legislation aimed to change the way the United States evaluates and pays for healthcare
  • Fundamental shift from fee-for-service (FFS) “Volume” to Value-Based “Quality” reimbursements
  • Repeals the Sustainable Growth Rate (SGR) formula
  • Directly effects an increase/decrease in Medicare Part B payments


Eligibility & Financial Impact:










*Maximum amount of incentive payments under MIPS could increase further for “exceptional performers.*


MACRA follows a two-year cycle from Performance to Payment Adjustment:


MACRA’s Quality Payment Program is an incentive program which rewards value and outcomes through:

  • The Merit-based Incentive Payment System (MIPS)
    • Submission of evidence-based and practice-specific quality data
  • Advanced Alternative Payment Models (APMs)
    • Incentive for Qualified Participants in key identified programs that take on risk related to their patients’ outcomes
  • APM Scoring Standard (MIPS APM)
      • Reduces reporting burden by accounting for APM involvement/requirements
      • Not excluded from MIPS but receive special scoring standards


What is MIPS?

MIPS is defined by four categories; three existing Medicare programs and a new category geared towards care coordination. Each individual category’s performance contributes to an annual MIPS final score of up to 100 points:

  • Quality 50%
    • Previously PQRS
  • Advancing Care Information (ACI) 25%
    • Previously Meaningful Use
  • Cost 10%
    • Previously Value-Based Payment Modifier
  • Improvement Activities 15%
    • New Category


Although MIPS inherits much from the MU, PQRS, and VBM programs, historical high performance or penalty avoidance under the previous programs do not guarantee the same under MIPS.


What are Advanced APMs?

Alternative Payment Models (APMs) are initiative programs which provide incentives for high-quality & cost-efficient care. Advanced Alternative Payment Models are a subset of APMs that bear financial risk related to outcomes. Qualified participants of an Advanced APM are exempt from MIPS and will earn a 5% lump sum of their Medicare Part B payments.

Below is a comprehensive list of Advanced APMs

  • Bundled Payments for Care Improvement Advanced Model (BPCI Advanced)**
  • Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1 – CEHRT)
  • Comprehensive ESRD Care (CEC) Model (LDO arrangement)
  • Comprehensive ESRD Care (CEC) Model (non-LDO two-sided risk arrangement)
  • Comprehensive Primary Care Plus (CPC+) Model**
  • Medicare Accountable Care Organization (ACO) Track 1+ Model
  • Medicare Shared Savings Program Accountable Care Organizations – Track 2
  • Medicare Shared Savings Program Accountable Care Organizations – Track 3
  • Next Generation ACO Model
  • Oncology Care Model (OCM) (two-sided Risk Arrangement)
  • Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)*

* See Reference “Alternative Payment Models in the Quality Payment Program as of January, 2018” Below*


What are MIPS APMs?

MIPS eligible Clinicians who participate in Alternative Payment Models that do not classify as Advanced APMs, or are not Qualified Participants of an Advanced APM, are subject to a special APM scoring standard. This method streamlines the eligible clinician’s reporting burden by maintaining focus on the goals and objectives of the Alternative Payment Model. Additionally, it aggregates eligible clinician MIPS scores to the APM entity level (ACO) for one MIPS Composite Performance Score.

ACO Medicare Shared Savings Program – Track 1 Participant’s category weights are as follows:

  • Quality 50%
  • Advancing Care Information (ACI) 30%
  • Improvement Activities 20%
  • Cost 10%


MACRA Year 2 (2018) Highlights:

  • MIPS Composite Performance Score Threshold Increase from 3 Points to 15 Points
  • Certified Electronic Health Record Technology (CEHRT) Requirement:
    • May use 2014 Edition and/or 2015 CEHRT
    • 5% category bonus for using only 2015 CEHRT
  • Complex Patient Bonus – 5 Point bonus for treating complex patients by medical complexity
    • Measured by Hierarchical Condition Category (HCC) risk score and percentage of dual eligible patients treated
  • Improvement Scoring Bonus for Quality & Cost
    • Quality – Assessed and Added at Category level (up to 10% Points)
    • Cost – Assessed at Measure level and Added to Category level (up to 1% Point)


Small Practices

  • 5 bonus points to the final scores of small practices – STANDARD MIPS ONLY
  • 3 points for measures in Quality category that do not met data completeness requirements – STANDARD MIPS ONLY
    • 60% for submission mechanism (increased from 50%)
  • Improvement Activity double weighted measures – STANDARD MIPS ONLY
  • Ability to form or join Virtual Groups to participate with other Practices


Reporting Requirements:

Standard MIPS

  •  Quality:
    • Clinicians choose 6 measures to report that best reflect their Practice. One must be an outcome measure
  • Advancing Care Information:
    • Report on key measures of interoperability and information exchange.  Awarded base and performance points
  • Improvement Activities:
    • Selection of Measures that display Practice’s care coordination,  beneficiary engagement, and patient safety
      • Double Weight for Small Practices
  • Cost:
    • Calculated from Medicare Spending per Beneficiary & Total Per Capita Cost measures


  • Quality:
    • ACO quality measures submitted to the CMS Web interface on behalf of their participating MIPS eligible clinicians.
  • Advancing Care Information:
    • All ACO participant TINs in the ACO submit under this category according to the MIPS group reporting requirements.
  • Improvement Activities:
    • No additional reporting necessary.
  • Cost:
    • MIPS clinicians will not be assessed on cost.


Submission Methods:



Centers for Medicare and Medicaid Services “Quality payment program Year 2 Final Rule Overview”

Centers for Medicare and Medicaid Services “Final ule with Comment Period for Quality Payment program Year 2 (2018)”

Centers for Medicare and Medicaid Services “Alternative Payment Models in the Quality Payment program as of February 2018”