The Journey to Healthcare Payment Reform

The Journey to Healthcare Payment Reform
MACRA Fee - for - Service Pay - for - Reporting Pay - for - Performance Year Two The Journey to Healthcare Payment Reform

MACRA Timeline April, 2015 Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 April, 2016 Department of Health and Human Services issued a Notice of Proposed Rulemaking for MACRA October, 2016 CMS released the Final Rule which was published in the Federal Register on 11/4/2016 January, 2017 First Quality Payment Program performance year begins Second Quality Payment Program performance year begins January, 2018

MACRA Highlights Repealed Medicare’s Sustainable Growth Rate (SGR) physician fee schedule formula Replaced / Consolidated existing PQRS, Meaningful Use and Value- Based Modifier reporting programs Established the new value based reimbursement system called the Quality Payment Program (QPP)

Eligible for Quality Payment Program (QPP) Reporting in 2018
Individuals and Groups Consisting of the Following Eligible Providers: Physician (MD, DO, DMD, DDS) beyond 1st year of Medicare Part B participation Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist Meeting the Following Thresholds During 1 of 2 Determination Periods: Sept. 1, – Aug. 31, OR Sept. 1, 2017 – Aug. 31, (Includes a 30-day claims runout) Bill Medicare more than $90,000 of allowed charges a year (Medicare Advantage claims do not apply to the required threshold) Provide care for more than 200 Medicare patients a year (Medicare Advantage patients do not apply to the required threshold) It is estimated that 35% of Medicare clinicians will fall below the volume participation threshold in 2018, creating a more competitive program

Two Quality Payment Program (QPP) Pathways
Merit-Based Incentive System (MIPS) Advanced Alternative Payment Models (AAPMs)

MIPS Merit-Based Incentive Program
Quality Payment Program (QPP) Path #1 MIPS Merit-Based Incentive Program One of the Two Quality Payment Programs (QPP) Replaces the PQRS, EHR Meaningful Use and Value Based Modifier Programs Consists of Four Categories: Quality Clinical Performance Improvement Activities Advancing Care Information Cost

Eligible for MIPS Reporting for 2018
Eligible Individual Providers (EPs) Group of Eligible Providers – TIN with multiple NPI numbers Virtual Groups – Groups of practices (TINs) each with 10 or less clinicians and solo practitioners exceeding low-volume threshold that are scored for MIPS as if a group sharing a single TIN No location nor specialty restrictions on the formation of virtual groups Practices must sign agreement and apply to CMS by December 31st CMS predicts approximately 16 virtual groups will form in 2018 CMS published a virtual group toolkit MIPS APMs – Defined as certain APMs that include eligible MIPS providers as participants Partial Qualifying Advanced APMs *Reporting optional

MIPS, PQRS, MU & VBM Payment Adjustment Timeline
MIPS payment adjustments (+4%/-4% in 2019) are based on Medicare Part B annual payments for covered services and items Medicare Part B drug payments are included in the calculation of MIPS incentive and penalty payments Annual inflationary increases of .5% to the CMS fee schedule applies to the payment years of 2016 – 2019 An annual inflationary increase of .25% to the CMS fee schedule applies to the payment year of 2026, onward (X = Budget Neutrality Factor ) 2016 2017 2018 2019 2020 2021 2022+ Last performance year for PQRS, MU & VM Last payment year for PQRS, MU & VM MIPS +4%*X MIPS +5%*X MIPS +7%*X MIPS +9%*X 3/31 Deadline for submitting 2017 MIPS data 3/31 Deadline for submitting 2018 MIPS data First performance year for MIPS Second performance year for MIPS First MIPS payment year Second MIPS payment year MIPS -4% MIPS -5% MIPS -7% MIPS -9%

Performance Year MIPS Reporting Weights

2018 Performance Year MIPS Reporting Weights for Hospital-Based & Non-Patient Facing Providers
Hospital-Based Providers are defined as those performing 75% of services in POS 19, 21, 22, or 23 for twelve months beginning with 9/1 of the calendar year preceding the performance year Beginning in 2019, Hospital-Based Providers will have the option to be scored according to their facility’s performance. Non-Patient Facing are defined as individual eligible providers who perform fewer than 100 procedures with patient facing codes annually and/or groups where at least 75% of eligible clinicians within the group or virtual group are designated as non-patient facing

2018 Performance Year MIPS Reporting Basics
12-Months 90-Days Clinical Practice Improvement Activities Advancing Care Information Quality Cost 50 Points 15 Points 25 Points 10 Points 100 Points Any MIPS EP or small group in a small practice (15 or fewer EPs) may earn up to 5 points to be added to their final composite score, as long as data is submitted on at least 1 performance category in an applicable performance period Do Not Participate or Report and Receive a negative 5% payment penalty in 2020

2017 & 2018 MIPS Hardship Waivers for Extreme and Uncontrollable Circumstances
CMS is extending hardship waivers to EPs which have been affected by natural disasters across the country which occurred during the 2017 MIPS performance period, including Hurricanes Harvey, Irma, Maria and the California wildfires An interim final rule with comment period (CMS-5522-IFC) was published in the CY 2018 QPP final rule with comment period CMS will use enrollment data listed in PECOS to identify EPs located in FEMA-designated disaster areas including FL, GA, LA, PR, SC and some parts of TX and CA EPs will automatically be exempt from a 2017 performance period / 2019 payment year MIPS penalty, no exemption application required EPs that do submit data /report for 2017 performance period will be scored on the data submitted This final rule with comment period applies to the 2018 MIPS performance period as well EPs will need to submit a hardship exception application by 12/31/2018 This policy does not apply to APMs

MIPS Performance Thresholds (PT) and Payment Adjustments
In 2018 the break even performance threshold (PT) is 15, for Providers to receive a 0% neutral payment adjustment To achieve a PT = 15 one of the following reporting scenarios must be met: Report all required Improvement Activities (for maximum of 40 points) Meet the Advancing Care Information base score and submit 1 Quality measure that meets data completeness Meet the Advancing Care Information base score, by reporting the 5 base measures, and submit one medium- weighted Improvement Activity Submit 6 Quality measures that meet data completeness Providers meeting a performance threshold (PT) above 15 may earn base incentives up to 5% PT = eligible for positive adjustment greater than 0% PT = 70+ eligible for positive adjustment greater than 0% AND exceptional performance/additional performance bonus at 0.5%+ Providers not meeting a performance threshold (PT) of 15 will receive a negative payment adjustment PT = will receive a negative payment adjustment greater than -5% and les than 0% PT = will receive a negative payment adjustment of -5%

MIPS Budget Neutrality Factor
Due to the budget-neutral design of MIPS, the total amount of performance threshold bonuses awarded to EPs will continue to be equal to the total amount of penalties assessed CMS’ adjustment to the 2018 low-volume participation threshold is expected to reduce the number of participating EPs by 35%; making the program more competitive CMS has set aside an additional $500 million each year between , to fund high performing bonuses awarded to EPs with a composite performance score of 70 points or higher The budget neutrality factor, X, is determined by total composite scores of all MIPS-eligible providers falling below, meeting or exceeding performance thresholds (PT) Ex: If total number of providers achieving a high composite score is low, the neutrality factor, X, can be increased up to a factor of 3 Ex: If total number of providers achieving a high composite performance score is higher, the neutrality factor, X, can be lowered down to 1 to ensure budget neutrality The budget neutrality factor, X, is capped at 3.0 Reaching the 3.0 cap would only be feasible if more providers received penalties rather than incentives as a result of their overall composite performance scores, since the budget neutrality must be maintained Ex: For performance year 2018, maximum base incentive payment adjustment could = 5% x budget neutrality factor of 3.0 = 15% Ex: For performance year 2018, maximum possible incentive for exceptional performance could = 5% x budget neutrality factor of % bonus = 25%

Meet the Required MIPS Composite Performance Scores (CPS) for 2018 using
DocsInk’s Mobile Charge Capture platform allows individual providers to submit their Quality measures via the claims-based method, required for the Quality category in the performance year of 2018 DocsInk’s Care Coordination platform allows providers to meet two medium-weighted Clinical Practice Improvement Activity (CPIA) measures, providing ½ the points needed (20 points) in the CPIA category to qualify for the maximum 40 points in the performance year of 2018 DocsInk Secure Communication platform meets all HIPAA standards and simply interfaces with certified EHR (CEHRT) used by EPs to meet the required Advancing Care Information (ACI) measures in the performance year of 2018 DocsInk’s Chronic Care Management (CCM) and Transition Care Management (TCM) solutions promote better health outcomes and reduction of readmissions, designed to reduce the per capita cost of attributed beneficiaries and Medicare spending per beneficiary (MSPB) used to score the Cost performance category in the performance year of 2018

MIPS QUALITY Reporting for 2018
Replaces PQRS and quality portion of Value-Based Modifier programs For 2018, report at least 6 measures or 1 specialty-specific measure set on 60% of applicable patient encounters (meeting the data completeness threshold) for a period of 12 months, one of which much be an Outcome measure or High-priority measure, to receive a score of 15 points which is sufficient to avoid a negative payment adjustment in 2019 Over 270 individual quality measures and 30 specialty measure sets published Find them here at CMS’ interactive website: 3-point floor for all measures 60% data completeness threshold for all submission methods except for Web Interface and CAHPS Measure that do not need data completeness criteria will earn 1 point instead of 3 Small practices with less than 15 EPs will continue to get 3 points when data completeness is not met 20-case minimum for all measures except for all-cause hospital readmission measure, which has a 200–case minimum requirement for groups of 16 or more

Quality Measures are worth from 1-10 points each, with the exception of topped out measures Topped out measures with benchmarks that have been topped out for at least 2 consecutive years will be worth up to 7 points Measures are defined as topped out when meaningful distinctions and improvement in performance can no longer be made 6 Quality Measures have been finalized as topped out in 2018 which will be scored on a maximum of 7 points, including: Perioperative Care – Quality Measure ID: 21 Melanoma – Quality Measure ID: 224 Perioperative Care – Quality Measure ID: 23 Image Confirmation of Successful Excision of Image-Localized Breast Lesion – Quality Measure ID: 262 Optimizing Patient Exposure to Ionizing Radiation – Quality Measure ID: 359 Chronic Obstructive Pulmonary Disease – Quality Measure ID: 52

Total Quality performance score is the sum of the points assigned, divided by the total points available, and then weighted to count for 50% of total MIPS score Quality performance scoring will be based on the rate of improvement at the performance category level Bonus for additional high priority measures (up to 10% of possible total) Bonus for end-to-end electronic reporting (up to 10% of denominator for performance category) Bonus for the treatment of complex patients based on a combination of Hierarchical Condition Categories (HCCs) and number of dually eligible patients treated (up to 5 points) DocsInk’s Mobile Charge Capture platform allows individual providers to submit their Quality measures via the claims-based method, required for the Quality category in the performance year of 2018

MIPS QUALITY Reporting Methods for 2018
Claims (individual providers only) Qualified Registry or QCDR EHR Vendors QCDR CMS Web Interface (groups of 25 or more) Individual providers reporting via Claims must report on at least 50% of all MIPS eligible provider’s Medicare Part B patients If reporting via Registry, EHR, or Qualified Clinical Data Registries (QCDR) data must be submitted on at least 50% of all MIPS eligible provider or group’s patients; regardless of payer If reporting via Qualified Clinical Data Registries (QCDR) data must be reported on all approved measures If reporting via CMS Web Interface data must report on all included measures & must populate data for first 248 consecutively ranked and assigned beneficiaries; or 100% of patients if less than 248

MIPS CLINICAL PRACTICE IMPROVEMENT ACTIVITY (CPIA) Reporting for 2018
The Clinical Practice Improvement Activity (CPIA) category does not replacing any existing legacy reporting programs, and is meant to emphasize improving patient outcomes CPIA score is determined by dividing the sum of points earned by the provider by 40 maximum points, and then weighted to count for 15% of total MIPS score 40 maximum points available based on 112 activities in 9 categories found here at CMS’ interactive website: Heavy weighted activities = 20 points Medium weighted activities = 10 points Expanded Patient Access Population Management Care Coordination Beneficiary Assignment Patient Safety & Practice Assessment Participation in APM Achieving Health Equity Integrating Behavioral & Mental Health Emergency Preparedness & Response

MIPS CLINICAL PRACTICE IMPROVEMENT ACTIVITY (CPIA) Reporting for 2018
Groups that are small (less than 15 providers), rural, or located in a health professional shortage area (HPSA), or non-patient facing providers must only complete 1 high-weighted or 2 medium-weighted activities for 90 days to receive full credit of 40 points If reporting as a group or a virtual group, only 1 eligible provider needs to report on CPIA for the entire group or virtual group to get full credit Eligible providers participating in a certified Comprehensive Primary Care Plus (CPC+), Patient-Centered Medical Home (PCMH), Shared Savings Program Track 1, 2, 3, or Oncology Care Model will receive full credit of 40 points 50% of practice sites within a TIN or TINs that are part of a virtual group must be recognized as a PCMH to receive full credit for CPIA in 2018 Eligible providers participating in other APM’s will earn half credit of 20 points and can report additional activities to increase their score

CMS Web Group (groups of 25 or more)
MIPS CLINICAL PRACTICE IMPROVEMENT ACTIVITY (CPIA) Reporting Methods for 2018 Qualified Registry QCDR EHR CMS Web Group (groups of 25 or more) Attestation For 2018, all eligible providers, groups and third party entities submitting CPIA data must use a “YES/NO” response, certifying that all activities have been performed Administrative claims method is meant to be utilized only when feasible Ex: Eligible providers or groups using telehealth modifier “GT”, could get automatic credit for this activity DocsInk’s Care Coordination platform allows providers to meet two Clinical Practice Improvement Activity (CPIA) measures, providing ½ the points needed (20 points) in the CPIA category to qualify for the maximum 40 points for the performance year of 2018

MIPS CLINICAL PRACTICE IMPROVEMENT ACTIVITY (CPIA) Measures for 2018
Two CPIA Measures Achieved with DocsInk’s Care Coordination Platform ACTIVITY NAME ACTIVITY DESCRIPTION ACTIVITY ID SUBCATEGORY NAME ACTIVITY WEIGHTING Care transition documentation practice improvements Implementation of practices/processes for care transition that include documentation of how a MIPS eligible clinician or group carried out a patient-centered action plan for first 30 days following a discharge (e.g., staff involved, phone calls conducted in support of transition, accompaniments, navigation actions, home visits, patient information access, etc.). IA_CC_10 Care Coordination Medium Implementation of additional activity as a result of TA for improving care coordination Establish standard operations to manage transitions of care that could include one or more of the following: Establish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/or Partner with community or hospital-based transitional care services. IA_CC_11

MIPS ADVANCING CARE INFO (ACI) Reporting for 2018
Replaces Meaningful Use program Comprises 25% of total MIPS score for all eligible providers CMS will reweight the ACI performance category to 0 and reallocate the 25% to the Quality performance category for EPs meeting special status criteria Automatic reweighting for: hospital-based providers non-physician practitioners non–patient facing EPs & groups ambulatory surgical center-based EPs Reweighting through an approved application (due by 12/31 of the performance period) for: EPs in small practices (15 or fewer clinicians) facing hardship EPs whose EHR was decertified EPs facing providers facing significant hardship

Qualified Registry EHR CMS Web Interface (groups of 25 or more) Attestation QCDR Find ACI objectives and measures here at CMS’ interactive website: Based on the Burden Reduction Aim EPs may use either the 2014 or 2015 Certified Electronic Health Technology (CEHRT) Two separate measure sets are available based on EHR technology utilized 2018 transitional measures (modified state 2 meaningful use) 2018 measures (stage 3 measures) DocsInk Secure Communication platform meets all HIPAA standards and simply interfaces with certified EHR (CEHRT) used by EPs to meet the required Advancing Care Information (ACI) measures in the performance year of 2018

Base Score = Possible 50 points Report a 1 in the numerator and denominator or “yes” for selected measures as required CMS finalized exclusions for certain measures: E-prescribing exclusion Health Information Exchange Measures exclusions Send summary of Care Measure exclusion applies to EPs who transfers or refers a patient <100 times during performance year Request/Accept Summary of Care Measure exclusion applies to EPs who have encountered patient <100 times during performance year Select “YES” to the exclusion and submit a null value for the measure Successfully meeting and reporting all of the Base Score Measures is required and failure to do so will result in a zero in the ACI category for MIPS reporting

Performance Score = Possible 90 points Each measure reported will be calculated individually by dividing the numerator by the denominator Some performance measures are also included in the base measure category, but will earn additional points towards performance score for values higher than 1 in numerator EPs and groups will earn 10% for reporting to any one of the Public Health and Clinical Data Registry Reporting measures as part of the performance score Bonus Score = Possible 25 points 5 bonus points for reporting to a public health or clinical registry that was not included under the ACI performance score 10 bonus points for using a certified EHR (CEHRT) for at least 1 of 21 identified Improvement Activities under CPIA category 10 bonus points for reporting ACI Objectives and Measures for exclusively using only edition CEHRT CMS intends this to be a one-time only bonus offered in performance period 2018

MIPS COST Reporting for 2018
Replaces 2 cost measures formerly used in Value-Based Modifier program Total per capita cost of care for attributed beneficiaries Medicare spending per beneficiary (MSPB) Comprises 10% of total 2018 MIPS performance year score for eligible providers Will comprise 30% of total MIPS score in performance years 2019 and beyond Administrative claims will be used to calculate EP and group performance, and no other reporting is necessary The 10 episode-based cost measure adopted for the 2017 MIPS performance period will not be used for the 2018 performance period CMS is developing new episode-based measures with input from stakeholders and plans to solicit feedback on some of these measures during the fall of 2018 New proposed measures are expected to be introduced in future rulemaking before they are included in MIPS

The Cost Performance category is scored using both achievement points earned and by calculating improvement Total MIPS Cost score = total # of Cost achievement points earned by EP / total # of available achievement points + the cost improvement score EP performance compared to performance of other MIPS EPs and groups during the same/current performance period Can’t see performance benchmarks ahead of time Cost achievement points earned are calculated using the average of the per capita cost and MSPB measures If only 1 measure can be scored, that score will equal the performance achievement score Cost improvement scores are calculated by comparing performance in current MIPS performance period to performance in immediately preceding performance period Improvement scoring based on statistically significant changes at the measure level Improvement score only calculated when there is sufficient data showing EP used same identifier in 2 consecutive performance periods and was scored on the same cost measures for 2 consecutive periods Up to 1% is available for Cost improvement

DocsInk’s Chronic Care Management (CCM) and Transition Care Management (TCM) solutions promote better health outcomes and reduction of readmissions, designed to reduce the per capita cost of attributed beneficiaries and Medicare spending per beneficiary (MSPB) used to score the Cost performance category in the performance year 2018

AAPMs Advanced Alternative Payment Models
Quality Payment Program (QPP) Path #2 AAPMs Advanced Alternative Payment Models One of the Two Quality Payment Programs (QPP) Subset of APMs which Provides Incentives for High Quality and Cost-Effective Care, Requiring Shared Risk Related to Performance Standards

Qualifying Advanced APM (AAPM) Entities for 2018
Comprehensive Care for Joint Replacement (CEHRT track) Comprehensive Primary Care Plus (CPC+) Model Medicare Shared Savings Program ACOs Tracks 1+,2 & 3 Comprehensive ESRD Care Model (Two-Sided Risk Arrangement)* Oncology Care Model (Two-Sided Risk Arrangement)* Next Generation ACO Model CMS estimates 185,000 – 250,000 clinicians will participate in AAPMs in * Indicates not currently accepting new applicants

Advanced APM (AAPM) Specifics for 2018
Exempt from MIPS reporting Report Quality Measures as normally required by CMS using GPRO Web Interface at the group TIN level The Qualifying Participant (QP) performance period for each payment year will be from January 1 – August 31, of the calendar year that is 2 years prior to the payment year Receive annual lump sum payment bonus = 5% of previous year’s Part B annual payments for covered professional services; regardless of level of performance Receive a 0.5% higher fee schedule update from 2026 forward

Eligibility for Advanced APM (AAPM) Participation in 2018
Qualifying Advanced APM Requirements: Requires APM group participants use certified EHR technology (CEHRT) Provides services for payment based on quality measures comparable to those in MIPS Either bears more than a nominal financial risk for monetary losses (representing at least 8% of average estimated total Medicare A & B revenues or 3% of the AAPM Entity’s expected expenditures), or is a Medical Home expanded under CMS Innovation Center Authority with total potential risk of 2.5% of average estimated total Medicare A & B revenues Medical Home model revenue-based standard applies to entities with <50 EPs in their parent organization Entities enrolled in Round 1 of the CPC+ model is exempt from this EP volume requirement Meeting the Following Thresholds: Receive 25% of total Medicare payments through an Advanced APM (AAPM) Treat 20% of Medicare patients through an Advanced APM (AAPM) Starting in 2019 performance period, “All-Payer Advanced APMs” can contribute to thresholds

Eligibility for Advanced APM (AAPM) Participation in 2018
Qualifying participant (QP) determination occurs at the Advanced APM (AAPM) Entity There can be multiple AAPM individual provider and/or group/TINs (QPs) within an Advanced APM (AAPM) Entity The collective threshold score from all individual and group/TIN determines whether the AAPM Entity is a Qualified Participant (QP), Partially Qualified Participant (PQP) or MIPS APM Eligible Participant All providers in the AAPM receive the same QP determination CMS determines the eligible provider group QP status by calculating the threshold score 3 times during the performance year; March 31, June 30 and August 31 of the performance period Eligible providers will be notified of the QP status after each QP determination period A provider’s QP status cannot change for the performance year once they are deemed a QP by one of the snapshots

Payment Incentives for Advanced APM (AAPM) Participation in 2018
The 5% incentive is paid at the TIN qualifying participant (QP) level of the AAPM Entity based on the Part B annual payments for covered professional services received during the incentive payment base period (year that falls between the performance year and payment year); regardless of level of performance If eligible provider bills Medicare Part B in multiple AAPM group TINs (in the same or multiple AAPM entities), the totals will be combined to calculate the 5% incentive The 5% incentive is paid to the group TIN under the AAPM entity, where the eligible provider is determined to be a qualifying participant (QP) at the time of the incentive payment year If a provider is determined to be a QP in multiple AAPM entities, the incentive will be split among the TINs proportionally If a provider is not deemed a QP through any one single AAPM entity but through their aggregated totals in multiple AAPM entities, then CMS splits the incentive between the TINs proportionally

Partial Qualifying Advanced APM (AAPM) (Partial QP) for 2018
CMS determines the Partial Qualifying AAPM (Partial QP) classification at the group level of AAPMs; not the individual clinician level Defined as any group of AAPM eligible providers, that do not collectively meet the necessary Medicare 25% payment or 20% patient threshold scores, but meet 20% or 10% respectively Not eligible to receive the 5% APM lump sum incentive payment May opt out of the MIPS reporting program without any negative payment adjustment, but the decision is made at the entity level and applies to all eligible providers Receives favorable MIPS scoring The Partial QP group may decide as an entity to report under MIPS on behalf of all its identified participating eligible clinicians, subjecting the group to both positive and negative payment adjustments

MIPS APMs for 2018 MIPS APM entities meet the following criteria:
Participate under an agreement with CMS (not another payer) Have at least one eligible provider on an APM participation list Base payment incentives determined by performance, cost and quality measures It is possible for an APM to be a MIPS APM, an Advanced APM (AAPM), both or neither Not eligible to receive the 5% APM lump sum incentive payment MIPS APM eligible providers belong to an APM (advanced or non-advanced) who are also subject to MIPS reporting Eligible providers must be on an APM participation list on one of the four snapshot dates of March 31, June 30, or August 31 during the performance period Fourth snapshot to determine participation in Full TIN MIPS APMs (MSSP) on December 31

MIPS APM Reporting for 2018 MIPS APM classification provides streamlined reporting and special scoring for participating eligible providers and all MIPS APM payment adjustments are applied at the TIN/NPI Level All scores from eligible providers participating in a MIPS APM entity are aggregated so that each provider receives the same final MIPS score MIPS APM QPs automatically receive full credit for Improvement Activities category MSSP ACOs & Next Generation ACOs Scored as MIPS APMs CATEGORY REPORTING METHOD SUBMISSION METHOD % Quality CMS Web Portal Group Submission for Entire ACO’s TIN # 50% Improvement Activities Any Approved Submission Method *Group Submission for Each TIN # Participating in ACO for Averaged Score 20% Advancing Care 30%

All-Payer Advanced APMs for Performance Year 2019
Beginning in performance year 2019, providers may become a QP in an All-Payer Advanced APM based on a combination of 2 pathways: Participation in Advanced APMs within Medicare fee-for-service Participation in Other Payer Advanced APMs For the 2019 performance year, the All-Payer AAPM QP determinations will be allowed at the APM- level using 3 snapshot dates of March 31, June 30 & August 31 Determinations are conducted so that the Medicare fee-for-service Option is applied prior to the All-Payer Combination Option EPs who do not meet the thresholds to become QPs under the Medicare Option may then request a QP determination under the All-Payer Option All-Payer AAPM QP payment and patient volume threshold requirements will be at 25% and 20% respectively All-Payer AAPM Partial QP payment and patient volume threshold requirements will be at 20% and 10% respectively Qualifying Other Payer Advance APM criteria includes the following: Minimum of 50% of EPs use CEHRT Provides services for payment based on quality measures comparable to those in MIPS Participants bear more than a nominal amount of financial risk or is a Medical Home expanded under CMS Innovation Center Authority

There will be 2 processes allowing a payment arrangement to be determined as an Other Payer Advanced APM Voluntary Payer-Initiated determinations: Medicaid requests accepted from 1/2018 – 4/2018 with a determination posted by 9/2018 CMS-Multi Payer requests accepted from 1/2018 – 6/2018 with a determination made by 9/2018 Medicare plans (including Medicare Advantage plans) requests accepted from 1/2018 – 6/2018 with a determination made in 9/2018 Other payers (including commercial and private payers) not available for performance year 2019, requests accepted 1/2018 – 12/2018 and determination made by 12/2019 Eligible Clinician-initiated determinations: Medicaid requests accepted from 9/2018 – 11/2018 with a determination posted by 12/2018 CMS-Multi Payer requests accepted from 8/2019 – 12/2019 with a determination made by 12/2019 Medicare plans (including Medicare Advantage plans) requests accepted from 8/2019 – 12/2019 with a determination made in 12/2019 Other payers (including commercial and private payers) not available for performance year 2019, requests accepted 8/ /2019 and determination made by 12/2019

Beginning in performance year 2019, the 4 payer types that may have payment arrangement that qualify as Other Payer Advanced APMs include the following: Title XIX (Medicaid) Medicare Health Plans (including Medicare Advantage) CMS Multi-Payer Models Other commercial & private payers

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