2019 ALL-PAYER COMBINATION OPTION OVERVIEW WEBINAR Tuesday, May 21, 2019
Disclaimers This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this presentation. 2
Presentation Overview • Overview of Alternative Payment Models (APMs) and Advanced APMs • All-Payer Combination Option Basics • Other Payer Advanced APMs Criteria • QP Determination Process • Payment Arrangement Options • Help and Support • Question & Answer 3
ALTERNATIVE PAYMENT MODELS (APM S ) 4
What is an APM? Alternative Payment Models (APMs) are new approaches to paying for medical care through Medicare that incentivize quality and value. The CMS Innovation Center develops new payment and service delivery models. Additionally, Congress has defined — both through the Affordable Care Act and other legislation — a number of demonstrations that CMS conducts. ✓ CMS Innovation Center model (under section 1115A, other than a Health Care Innovation Award) As defined by ✓ MSSP (Medicare Shared Savings Program) MACRA, APMs s ✓ inclu inc lude: Demonstration under the Health Care Quality Demonstration Program ✓ Demonstration required by federal law 5
APM Overview • A payment approach that Advanced APMs are e provides added incentives to a Subset t of of APMs clinicians to provide high-quality and cost-efficient care. • Can apply to a specific condition, care episode or population. • May offer significant MIPS Advanced APMs APMs opportunities for eligible clinicians who are not ready to participate in Advanced APMs. 6
ADVANCED APM S 7
Advanced APMs Clinicians and practices can: • Receive gr greater rewards for taking on some risk related to patient outcomes. + Advanced APMs Adv Advanced AP APM- spe pecif ific ic rewards “So what?” - It is important to understand that the Quality Payment Program does not change the design of any particular APM. Instead, it creates extr xtra incentives for a sufficient degree of participation in Advanced APMs. 8
Advanced APMs Incentive Structure Potential financial rewards Not ot in in APM In In APM In In MIP IPS APM In Advanced APM In APM PM Scor orin ing Standard MIPS adjustments MIPS adjustments toward MIPS adjustments + + APM-specific APM-specific APM-specific rewards rewards rewards + If you are a Quali ualify fyin ing g AP APM Par artic icip ipant (QP) (QP) 5% % lum ump sum um bo bonu nus 9
Advanced APMs Advanced APM Criteria To be an Advanced APM, the following three requirements must be met. The APM: Either: (1) is a Med Eith edical Provides payment for Hom ome Model covered professional exp xpanded under CMS services based on Requires participants Innovation Center qu quality mea easures to use certi certifi fied EH EHR authority OR (2) comparable to those tec echnology; requires par parti ticipants used in the MIPS to o be bear r a a mor ore tha than quality performance nom nominal am amount of of category; and financial ris risk. . 10
Advanced APMs Terms to Know • APM En Entity tity - An entity that participates in an APM or payment arrangement with a non-Medicare payer through a direct agreement or through Federal or State law or regulation. • Adv dvanced APM – Advanced APMs must meet three specific criteria: Require CEHRT use, base payment on MIPS-comparable quality measures, and either be a Medicare Medical Home or require participants to bear a more than nominal amount of risk. • Affi filiated Pract ctiti tioner r - An eligible clinician identified by a unique APM participant identifier on a CMS- maintained list who has a contractual relationship with the Advanced APM Entity for the purposes of supporting the Advanced APM Entity's quality or cost goals under the Advanced APM. • Affi filiated Pract ctiti tioner r List - The list of Affiliated Practitioners of an APM Entity that is compiled from a CMS- maintained list. • MIPS APM – Most Advanced APMs are also MIPS APMs so that if an eligible clinician participating in the Advanced APM does not meet the threshold for sufficient payments or patients through an Advanced APM in order to become a Qualifying APM Participant (QP), thereby being excluded from MIPS, the MIPS eligible clinician will be scored under MIPS according to the APM scoring standard. The APM scoring standard is designed to account for activities already required by the APM. • Parti artici cipati tion List - The list of participants in an APM Entity that is participating in an Advanced APM, compiled from a CMS-maintained list. • Qu Qualify fying APM Parti artici cipant (QP) ) - An eligible clinician determined by CMS to have met or exceeded the relevant QP payment amount or QP patient count threshold for a year based on participation in an Advanced APM Entity. 11
Advanced APMs Current List of Advanced APMs for 2019 • Bundled Payments for Care Improvement (BPCI) Advanced Model* • Comprehensive Care for Joint Replacement Model • Comprehensive ESRD Care Model (LDO Arrangement) • Comprehensive ESRD Care Model (non-LDO Two-sided Risk Arrangement) • Comprehensive Primary Care Plus (CPC+) Model • Medicare Accountable Care Organization (ACO) Track 1+ Model • Maryland Total Cost of Care Model (Care Redesign Program) • Maryland Total Cost of Care Model (Maryland Primary Care Program) • Next Generation ACO Model • Shared Savings Program – Track 2 • Shared Savings Program – Track 3 • Oncology Care Model (OCM) – Two-Sided Risk Arrangement • Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model) *BPCI Advanced began in October 2018, and participants will have an opportunity to achieve QP status, or be scored under the APM scoring standard for MIPS, starting in performance year 2019. 12
ALL-PAYER COMBINATION OPTION Basics 13
All-Payer Combination Option Overview The MACRA statute created two pathways to allow eligible clinicians to become QPs. Medicare Op Option All-Payer Com Combin ination Op Option • Available for all performance • Available for Performance Year years. 2019. • Eligible clinicians achieve QP • Eligible clinicians achieve QP status exclusively based on status based on a combination of participation in Advanced APMs participation in: with Medicare. - Advanced APMs with Medicare; and - Other Payer Advanced APMs offered by other payers. 14
All-Payer Combination Option Basics • The Medicare Advanced APM option has been available since 2017 and the All-Payer Combination Option is new for the 2019 performance year. The All-Payer Combination Option allows eligible clinicians to become QPs through participation in a combination of Advanced APMs with Medicare and Other Payer Advanced APMs. 15
OTHER PAYER ADVANCED APMS Basics 16
Other Payer Advanced APMs Basics Other Payer Advanced APMs are non-Medicare payment arrangements that meet criteria that are similar to Advanced APMs under Medicare. Payer types that may have payment arrangements that qualify as as Ot Other Payer Adv dvanced APM PMs s include: ✓ Title XIX (Medicaid) ✓ Medicare Health Plans (including Medicare Advantage) ✓ Payment arrangements aligned with CMS Multi-Payer Models ✓ Other commercial and private payers 17
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