partial qualifying APM participant
(1) Establishment (A) In general Subject to the succeeding provisions of this subsection, the Secretary shall establish an eligible professional Merit-based Incentive Payment System (in this subsection referred to as the “MIPS”) under which the Secretary shall— (i) develop a methodology for assessing the total performance of each MIPS eligible professional according to performance standards under paragraph (3) for a performance period (as established under paragraph (4)) for a year; (ii) using such methodology, provide for a composite performance score in accordance with paragraph (5) for each such professional for each performance period; and (iii) use such composite performance score of the MIPS eligible professional for a performance period for a year to determine and apply a MIPS adjustment factor (and, as applicable, an additional MIPS adjustment factor) under paragraph (6) to the professional for the year. Notwithstanding subparagraph (C)(ii), under the MIPS, the Secretary shall permit any eligible professional (as defined in subsection (k)(3)(B)) to report on applicable measures and activities described in paragraph (2)(B). (B) Program implementation The MIPS shall apply to payments for covered professional services (as defined in subsection (k)(3)(A)) furnished on or after January 1, 2019 . (C) MIPS eligible professional defined (i) In general For purposes of this subsection, subject to clauses (ii) and (iv), the term “MIPS eligible professional” means— (I) for the first and second years for which the MIPS applies to payments (and for the performance period for such first and second year), a physician (as defined in section 1395x(r) of this title ), a physician assistant, nurse practitioner, and clinical nurse specialist (as such terms are defined in section 1395x(aa)(5) of this title ), a certified registered nurse anesthetist (as defined in section 1395x(bb)(2) of this title ), and a group that includes such professionals; and (II) for the third year for which the MIPS applies to payments (and for the performance period for such third year) and for each succeeding year (and for the performance period for each such year), the professionals described in subclause (I), such other eligible professionals (as defined in subsection (k)(3)(B)) as specified by the Secretary, and a group that includes such professionals. (ii) Exclusions For purposes of clause (i), the term “MIPS eligible professional” does not include, with respect to a year, an eligible professional (as defined in subsection (k)(3)(B)) who— (I) is a qualifying APM participant (as defined in section 1395l(z)(2) of this title ); (II) subject to clause (vii), is a partial qualifying APM participant (as defined in clause (iii)) for the most recent period for which data are available and who, for the performance period with respect to such year, does not report on applicable measures and activities described in paragraph (2)(B) that are required to be reported by such a professional under the MIPS; or (III) for the performance period with respect to such year, does not exceed the low-volume threshold measurement selected under clause (iv). (iii) Partial qualifying APM participant For purposes of this subparagraph, the term “partial qualifying APM participant” means, with respect to a year, an eligible professional for whom the Secretary determines the minimum payment percentage (or percentages), as applicable, described in paragraph (2) of section 1395 l (z) of this title for such year have not been satisfied, but who would be considered a qualifying APM participant (as defined in such paragraph) for such year if— (I) with respect to 2019 and 2020, the reference in subparagraph (A) of such paragraph to 25 percent was instead a reference to 20 percent; (II) with respect to each of 2021 through 2025— (aa) the reference in subparagraph (B)(i) of such paragraph to 50 percent was instead a reference to 40 percent; and (bb) the references in subparagraph (B)(ii) of such paragraph to 50 percent and 25 percent of such paragraph 7 were instead references to 40 percent and 20 percent, respectively; and (III) with respect to 2026 and subsequent years— (aa) the reference in subparagraph (C)(i) of such paragraph to 75 percent was instead a reference to 50 percent; and (bb) the references in subparagraph (C)(ii) of such paragraph to 75 percent and 25 percent of such paragraph 7 were instead references to 50 percent and 20 percent, respectively. (iv) Selection of low-volume threshold measurement The Secretary shall select a low-volume threshold to apply for purposes of clause (ii)(III), which may include one or more or a combination of the following: (I) The minimum number (as determined by the Secretary) of— (aa) for performance periods beginning before January 1, 2018 , individuals enrolled under this part who are treated by the eligible professional for the performance period involved; and (bb) for performance periods beginning on or after January 1, 2018 , individuals enrolled under this part who are furnished covered professional services (as defined in subsection (k)(3)(A)) by the eligible professional for the performance period involved. (II) The minimum number (as determined by the Secretary) of covered professional services (as defined in subsection (k)(3)(A)) furnished to individuals enrolled under this part by such professional for such performance period. (III) The minimum amount (as determined by the Secretary) of— (aa) for performance periods beginning before January 1, 2018 , allowed charges billed by such professional under this part for such performance period; and (bb) for performance periods beginning on or after January 1, 2018 , allowed charges for covered professional services (as defined in subsection (k)(3)(A)) billed by such professional for such performance period. (v) Treatment of new Medicare enrolled eligible professionals In the case of a professional who first becomes a Medicare enrolled eligible professional during the performance period for a year (and had not previously submitted claims under this subchapter such as a person, an entity, or a part of a physician group or under a different billing number or tax identifier), such professional shall not be treated under this subsection as a MIPS eligible professional until the subsequent year and performance period for such subsequent year. (vi) Clarification In the case of items and services furnished during a year by an individual who is not a MIPS eligible professional (including pursuant to clauses (ii) and (v)) with respect to a year, in no case shall a MIPS adjustment factor (or additional MIPS adjustment factor) under paragraph (6) apply to such individual for such year. (vii) Partial qualifying APM participant clarifications (I) Treatment as MIPS eligible professional In the case of an eligible professional who is a partial qualifying APM participant, with respect to a year, and who, for the performance period for such year, reports on applicable measures and activities described in paragraph (2)(B) that are required to be reported by such a professional under the MIPS, such eligible professional is considered to be a MIPS eligible professional with respect to such year. (II) Not eligible for qualifying APM participant payments In no case shall an eligible professional who is a partial qualifying APM participant, with respect to a year, be considered a qualifying APM participant (as defined in paragraph (2) of section 1395l(z) of this title ) for such year or be eligible for the additional payment under paragraph (1) of such section for such year. (D) Application to group practices (i) In general Under the MIPS: (I) Quality performance category The Secretary shall establish and apply a process that includes features of the provisions of subsection (m)(3)(C) for MIPS eligible professionals in a group practice with respect to assessing performance of such group with respect to the performance category described in clause (i) of paragraph (2)(A). (II) Other performance categories The Secretary may establish and apply a process that includes features of the provisions of subsection (m)(3)(C) for MIPS eligible professionals in a group practice with respect to assessing the performance of such group with respect to the performance categories described in clauses (ii) through (iv) of such paragraph. (ii) Ensuring comprehensiveness of group practice assessment The process established under clause (i) shall to the extent practicable reflect the range of items and services furnished by the MIPS eligible professionals in the group practice involved. (E) Use of registries Under the MIPS, the Secretary shall encourage the use of qualified clinical data registries pursuant to subsection (m)(3)(E) in carrying out this subsection. (F) Application of certain provisions In applying a provision of subsection (k), (m), ( o ), or (p) for purposes of this subsection, the Secretary shall— (i) adjust the application of such provision to ensure the provision is consistent with the provisions of this subsection; and (ii) not apply such provision to the extent that the provision is duplicative with a provision of this subsection. (G) Accounting for risk factors (i) Risk factors Taking into account the relevant studies conducted and recommendations made in reports under section 2(d) of the Improving Medicare Post-Acute Care Transformation Act of 2014, and, as appropriate, other information, including information collected before completion of such studies and recommendations, the Secretary, on an ongoing basis, shall, as the Secretary determines appropriate and based on an individual’s health status and other risk factors— (I) assess appropriate adjustments to quality measures, resource use measures, and other measures used under the MIPS; and (II) assess and implement appropriate adjustments to payment adjustments, composite performance scores, scores for performance categories, or scores for measures or activities under the MIPS.