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Alternative Payment Models (APMs)

An Alternative Payment Model (APM) is a new approach to paying for medical care that financially rewards clinicians for delivering high-quality, cost-effective care.

Latest Updates!

On April 22, 2019, CMS announced its Primary Cares Initiative, which includes two new APMs intended to transform primary care. For more information on the new models and how to apply, click on the respective ACP fact sheets below. Please note that as more information is made available, ACP will update these fact sheets and develop other educational resources.

On December 21, 2018, CMS finalized a rule that overhauled the Medicare Shared Savings Accountable Care Program (MSSP), Medicare’s flagship Accountable Care Organization (ACO) Program. Many changes take effect July 1, 2019. View the below fact sheet for more information.

  • ACP’s MSSP Fact Sheet (coming soon!)

Major 2019 Changes

  • Under the new All-Payer Combination Threshold Option, clinicians can now count their participation in Medicare Advantage, Medicaid, and CMS Multi-Payer Models toward qualifying for the AAPM track. Check out questions 2 and 3 below for more information. 
  • Revenue-based risk threshold will remain at 8% through 2024
  • Qualifying AAPM Participant (QP) determinations can now also be made at the TIN level (in addition to the NPI and APM Entity levels)

What is an Advanced APM (AAPM)?

Advanced APMs (AAPMs) is a term used to designate a smaller group of select APMs that meet advanced risk, quality, and technology requirements. Clinicians who significantly participate in AAPMs enter a separate “track” under the Quality Payment Program (QPP) that excludes them from participating in MIPS and awards them certain incentives, including a 5% bonus. 

Note: Clinicians who participate in APMs that do not qualify as AAPMs may receive special scoring under MIPS through the APM scoring standard. Visit our MIPS page to learn more.

Background on AAPMs

How do APMs qualify to be Advanced APMs?

To qualify as an Advanced APM, a model must:

  1. Base payment on quality measures comparable to those in MIPS; 
  2. Require the use of certified EHR technology; and 
  3. Either: 
    • Bear more than “nominal” financial risk for monetary losses (i.e. 3% of expenditures or 8% of revenue); OR 
    • Are a Medical Home Model, as expanded under the authority of the Centers for Medicare and Medicaid Innovation. 

What models currently qualify as Advanced APMs?

In 2019, Medicare, Medicare Advantage, Medicaid, and CMS multi-payer models can qualify towards a clinician qualifying for the AAPM track. Click each of the options below to find out what models qualify in each category.

National Medicare AAPMs:

State Medicare AAPMs:

Medicaid AAPMs

CMS Multi-Payer AAPMs

What do I need to do to be considered a Qualifying AAPM Participant (QP)?

To be a QP in an AAPM, a MIPS eligible clinician must have a significant portion of their patients or payments flow through AAPMs. Clinicians may qualify based on their participation in Medicare AAPMs alone under the Medicare Threshold Option. Starting in 2019, clinicians can also qualify based on their combined participation in both Medicare and other payer models under the All Payer Combination Threshold Option. Starting in 2019, participation in Medicare Advantage, Medicaid, and CMS multi-payer AAPMs will count. Starting in 2020, private payer AAPMs will also count. The 2019-2020 QP thresholds are listed below.

Medicare Threshold Option

  Payments Patients
QP 50% 35%
Partial QP 40% 25%

All-Payer Combination Threshold Option 

  Payments Patients
QP 50% (25%) 35% (20%)
Partial QP 40% (20%) 25% (10%)

In performance year 2019, ECs who do not meet the patient or payment threshold under the Medicare Option, but do meet a Medicare minimum threshold (in parentheses), may ask for a QP determination under the All-Payer Combination Option.

How do I find out if I qualify?

Visit CMS’ QPP Participation Status Lookup Tool and enter your National Provider Identifier number to view your QPP participation status by performance year, including whether or not you qualify as a QP in an AAPM.

What rewards do clinicians who participate in AAPMs receive?

MIPS eligible clinicians who achieve QP status in AAPMs will: 

  • Receive supplemental or performance-based payments according to the rules established under their APM (e.g., care coordination or infrastructure payments, shared savings, bundled payments, etc.);
  • Be exempted from participating in MIPS;
  • Receive a 5% lump sum bonus payment on their fee-for-service reimbursements for payment years 2019-2024 (based on performance in 2017-2022).
  • Receive a 0.5% higher Physician Fee Schedule update starting in 2026 (0.75% instead of 0.25%).

AAPM Resources

ACP Resources:

CMS Resources: