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Elizabeth Arend

Quality Improvement Advisor

CMS Finalizes Medicare Payment Rule

October 20, 2016 | Medicare | Comments
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On Friday, October 14th, the Centers for Medicare and Medicaid Services (CMS) released the final Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rule, which makes sweeping reforms to how physicians are paid under Medicare Part B. The final rule will apply to the vast majority of eligible behavioral health providers when MACRA goes into effect in 2017 and includes several positive changes made in response to the National Council’s written comments.

Considered one of the most significant pieces of Medicare legislation in decades, MACRA eliminates the Sustainable Growth Rate formula, and establishes a new Quality Payment Program that will fundamentally change the way in which Medicare reimburses clinicians. Among those reforms is the establishment of CMS’s Merit-based Incentive Payment System (MIPS). As a reminder, MIPS combines three existing reporting programs – the Physician Quality Reporting System, Value-based Modifier Program, and EHR Incentive Payment Program—and adds a new category to incentivize clinical quality improvement activities.

A proposed rule outlining the details of how this would work was published in April 2016. With input from our members, the National Council submitted comments to CMS on the proposed rule in June. In order to reduce the burden on behavioral health providers in small, solo, and rural practices, the National Council recommended that CMS increase the dollar threshold under which Medicare Part B clinicians would be exempt from reporting. The National Council expressed concern about the insufficient number of behavioral health-related MIPS quality measures, which would negative impact behavioral health providers’ quality performance score. The National Council also commented that the MIPS resource use performance category, which initially constituted 10 percent of clinicians’ total performance score, did not include clinical condition groupings or treatment episode-based measures that are applicable to the services or conditions for people with serious mental illness or addiction disorders.

The National Council is pleased that the final rule includes several positive changes in response to these comments. These changes will apply to the vast majority of eligible behavioral health providers when MACRA goes into effect on January 1, 2017:

  • Referring to 2017 as a “transition year,” CMS will allow MIPS-eligible clinicians to “pick their pace” and choose one of three reporting options to avoid a negative payment adjustment in 2019.
  • Option 1: Test the Quality Payment Program.As long as you submit some data via MIPS, including data from after January 1, 2017, you will avoid a negative payment adjustment. This option is designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019.
  • Option 2: Participate for part of the calendar year.You may choose to submit MIPS data for a reduced number of days. This means your first performance period could begin later than January 1, 2017 and your practice could still qualify for a small positive payment adjustment.
  • Option 3: Participate for the full calendar year.For practices that are ready to go on January 1, 2017, you can choose to submit MIPS data information for the full calendar year. This means your first performance period would begin on January 1, 2017.
  • CMS adjusted the low-volume threshold: If you serve fewer than 100 Medicare patients AND bill Medicare less than $30,000 in 2017, MIPS will NOT apply to you.
  • CMS will not factor cost of care into eligible clinicians’ 2017 MIPS performance score. The MIPS resource use performance category (formerly known as the value-based modifier) will be used to calculate performance scores starting in 2018.
  • CMS adjusted the weight of the Quality performance category—and relaxed reporting requirements. The MIPS Quality performance category will be weighted at 60% (instead of 50%, as initially proposed), and if fewer than six measures apply to an individual MIPS eligible clinician or group, then the MIPS eligible clinician or group will only be required to report on each measure that is applicable.


Find out more during the National Council’s webinar on Tuesday, November 8th. The webinar will provide an in-depth look at the MACRA final rule and its impact on behavioral health care providers, and offer strategies for providers to avoid future negative payment adjustments. In the meantime, check out CMS’s new Quality Program Website, our MACRA webpage, and get the latest MACRA news on the National Council’s Capitol Connector blog.

If you have questions contact Elizabeth Arend at