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The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) makes sweeping reforms to payments under Medicare Part B, which could lower or increase the amount your agency is reimbursed by Medicare.

The Centers for Medicare and Medicaid Services’ (CMS) Quality Payment Program has two parts: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (Advanced APMs). Both mechanisms focus on moving from payment for volume to payment for quality and value, and non-participation will result in reductions in reimbursement. The vast majority of behavioral health organizations that bill Medicare Part B are subject to MIPS.

On November 2, 2017, CMS released a Final Rule for Performance Year 2018 of the Quality Payment Program (QPP) under MACRA. CMS is continuing many of their 2017 transition policies, while implementing modest changes, including:

  • Raising the performance threshold to 15 points in Year 2 (from 3 points in the transition year)
  • Allowing the use of 2014 Edition and/or 2015 Certified Electronic Health Record Technology (CEHRT) in Year 2, and giving a bonus for using only 2015 CEHRT
  • Giving up to 5 bonus points on final scores for treatment of complex patients
  • Automatically weighting the Quality, Advancing Care Information, and Improvement Activities performance categories at 0% of the final score for clinicians impacted by hurricanes Irma, Harvey and Maria and other natural disasters
  • Adding 5 bonus points to the final scores of small practices

CMS also added more options for small practices (15 or fewer clinicians) including:

  • Excluding individual MIPS eligible clinicians or groups with less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries
  • Adding 5 bonus points to the final scores of small practices
  • Giving solo practitioners and small practices the choice to form or join a Virtual Group to participate with other practices
  • Continuing to award small practices 3 points for measures in the Quality performance category that don’t meet data completeness requirements
  • Adding a new hardship exception for the Advancing Care Information performance category for small practices

What is MIPS?

Under MIPS, performance is measured through the data clinicians report in four areas:

The first performance period (Performance Year 2017) closed December 31, 2017 and the first payment adjustments based on performance went into effect on January 1, 2019.

Data for Performance Year 2018 can be submitted and updated through the QPP website between January 22, 2019 and April 2, 2019, 8 pm EDT when the submission window closes. CMS launched a data submission system that eligible clinicians can use to submit performance data as required under MACRA. Clinicians can submit their MIPS data through one platform on the Quality Payment Program website. CMS released a fact sheet, press release, and the following instructional videos:

Depending on the track of the Quality Payment Program you choose and the data you submit, your Medicare payments will be adjusted up, down, or not at all. The size of your payment adjustment will depend both on how much data you submit and your quality results.


Who is Eligible?

Your eligibility for MIPS may change each Performance Year due to policy changes and may also change throughout the Performance Year as CMS will review twice starting in 2019. Clinicians that will be counted for the 2019 reporting year include physicians (including psychiatrists), nurse practitioners, physician assistants, clinical nurse specialists, nurse anesthetists, and groups or virtual groups that include one or more of these clinician types.

In 2019, MIPS does NOT apply to:

  • Licensed clinical social workers
  • First-year Medicare providers
  • Qualifying Advanced APM clinicians
  • Hospitals and facilities
  • Clinicians or groups that have billed $90,000 or less in Physical Fee Schedule (e.g. FQHCs and partial hospitalization programs) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries
  • Clinicians or groups that have 200 or fewer Medicare Part B FFS beneficiaries

How to Prepare

  • Start NOW. 2021 payment adjustments will be based on 2019 performance.
  • Determine MIPS eligibility. Are you below the low-volume threshold of seeing fewer than 200 Medicare patients AND billing Medicare less than $90,000 per year? Is 2019 your first year billing Medicare? Is your organization an FQHC, hospital or facility? If the answer is yes, MIPS does NOT apply to you in 2019.
  • Educate your team. Make sure that your staff and leadership understand MIPS, how it will measure performance, and how it may affect Medicare reimbursements starting in 2021.
  • Explore National Council learning community opportunities and other technical resources that can improve your performance under MIPS.
  • Familiarize yourself with the 2019 Quality Measures (you can filter by Mental/Behavioral Health special measure set). Which quality measures best suit your clinical practice? Check these measures against measures for other quality program initiatives to maximize efficiency and performance levels.
  • Connect with the CMS-funded Transforming Clinical Practice Initiative (TCPI). TCPI supports 29 Practice Transformation Networks and Support and Alignment Networks across the country, which provide resources and technical support to help practices improve quality of care, reduce costs, and prepare for value-based payment arrangements. Visit or contact the National Council to learn more.
  • Connect with a Quality Innovation Network (QIN)-Quality Improvement Organizations (QIOs): The QIO Program’s 14 QIN-QIOs bring Medicare beneficiaries, providers, and communities together in data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality. More information about QIN-QIOs can be found here.
  • If you have an EHR, make sure it is Certified EHR Technology. A well-designed CEHRT can help you fulfill current quality reporting requirements and provide real-time summaries of your progress on quality measures.
  • If you don’t have an EHR, use a clinical data registry. Clinical data registries can streamline reporting, help identify high-risk populations, and improve clinical practice.
  • Learn as much about the QPP as you can—even if MIPS does not apply to you. Value-based payments are an important goal for all the major payers, not just Medicare. To meet these demands, all behavioral health organizations will need to cultivate an organizational culture that embraces change, and develop the infrastructure needed to measure progress, demonstrate value and improve health outcomes.
  • Stay Up-to-Date. The National Council will help you stay informed so you can meet your requirements every year. Subscribe to the National Council’s Capitol Connector blog.

2017 Submission Resources

Physicians have until April 2, 2019, 8 pm EDT to submit and update data for Performance Year 2018 through the QPP website.

Additional Resources for Performance Year 2 (2018)


Need more? Stay up-to-date with the National Council Capitol Connector Blog. For more information or questions, contact Dana Foney at