CMS Increases Advanced APM Thresholds for 2021
By Joey Berlin


If you participated in Medicare’s Quality Payment Program (QPP) this year as a Qualifying Alternative Payment Model Participant (QP), you’ll need to keep an eye on your status for 2021.

The thresholds for QP and partial QP status are changing for the next performance year, and physicians who have been QPs or partial QPs in previous years may have to participate in the program through the Merit-Based Incentive Payment System (MIPS) instead. Physicians required to participate in QPP must do so either through MIPS or through an advanced alternative payment model (APM).

The Centers for Medicare & Medicaid Services (CMS) recently released a notice about the changing QP and partial QP thresholds. To qualify as a QP or partial QP, participants must meet  one of two criteria set by the agency: payment amount or patients attributed to an advanced APM.For QP status, the thresholds for 2021 will be:

  • Payment amount: 75% of Medicare Part B payments, up from 50% in 2020; or
  • Patient count: 50% of Medicare patients through an advanced APM entity, up from 35% in 2020.

For partial QP status, the 2021 thresholds are:

  • Payment amount: 50% of Medicare Part B payments, up from 40% in 2020; or
  • Patient count: 35% of Medicare patients through an advanced APM entity, up from 25% in 2020

The agency also notes that for QPs (but not partial QPs), 75% of practices in the advanced APM entity need to be using certified electronic health record technology.

CMS says it will use three “snapshot dates” in 2021 – March 31, June 30, and Aug. 31 – to review clinicians’ data and make determinations on their QP status. The agency will make those determinations approximately four months after each snapshot date, and then physicians can check the QPP Payment Participation Status Tool for updates to their APM status.

Physicians who don’t qualify as either a QP or a partial QP will be required to participate in MIPS, CMS says. Partial QPs will be able to choose whether to participate through MIPS or through an advanced APM but will not be eligible for the 5% APM incentive payment that QPs may be eligible for.

 CMS has released a QP Quick Start Guide and MIPS Eligibility Decision Tree for 2021. More information is available in the Learning Resources for QP Status and APM Incentive Payment files released by CMS.

Medicare’s Physician Fee Schedule final rule for 2021, which will include details of the coming year’s version of QPP, is expected to be released around Dec. 1. In the meantime, the Texas Medical Association offers a host of resources to help navigate the QPP on its MACRA Resource Center.

Last Updated On

November 13, 2020

Originally Published On

November 13, 2020

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Joey Berlin

Associate Editor

(512) 370-1393

Joey Berlin is associate editor of Texas Medicine. His previous work includes stints as a reporter and editor for various newspapers and publishing companies, and he’s covered everything from hard news to sports to workers’ compensation. Joey grew up in the Kansas City area and attended the University of Kansas. He lives in Austin.

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