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The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and NCQA Recognition Programs


What is MACRA?


The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) replaces the Sustainable Growth Rate (SGR) formula for how Centers for Medicare and Medicaid Services (CMS) pays clinicians that care for Medicare beneficiaries in the traditional Medicare program.

How does MACRA impact clinician payment?


Beginning in 2019, clinicians will receive payments through either the new Merit-based Incentive Payment System (MIPS) or Alternative Payment Models (APMs) (the majority of clinicians will receive payments through MIPS). The 2019 payment will be based on what clinicians are doing and reporting on in 2017.

Clinicians in MIPS will get bonuses or penalties to their fee-for-service payments based on measures in four areas. The proportions of the four areas that make up MIPS scores scale up until 2021, when they become permanent:

MACRA and NCQA 

MACRA builds on work the National Committee for Quality Assurance (NCQA) has pioneered for more than 25 years. MACRA rates clinicians based on quality metrics, including many of NCQA’s HEDIS® measures, and directly rewards clinicians who earn NCQA Patient-Centered Medical Homes (PCMHs) and Patient-Centered Specialty Practices (PCSPs) recognition. The law also rewards clinicians in many other ways for results they can achieve by being patient-centered. 

MIPS and NCQA Recognition 

Becoming an NCQA-Recognized PCMH or PCSP directly increases clinicians’ payments through MIPS. 

  • • Clinicians in NCQA-Recognized PCMHs or PCSPs automatically get full credit in the MIPS CPIA category. 
  • • Clinicians in NCQA-Recognized PCMH and PCSP practices will likely do well in other MIPS categories. 

    • Quality Measures: NCQA’s PCMH and PCSP programs increase the use of high-value care, including prevention and good chronic care management and actively promotes quality improvement that will be reflected in MIPS quality measures. 
    • Advancing Care Information: Recognition emphasizes coordination of care and the use of HIT to share care information. 
    • Resource Use Measures: A growing body of scientific evidence shows that the PCMH model is saving money by reducing hospital and emergency department visits, mitigating health disparities and improving patient outcomes.

Alternative Payment Models 

Alternative Payment Models move clinicians farther away from fee-for-service toward more quality and population-based payments. Clinicians in APMs meeting specific dollar and patient volume thresholds qualify as “Advanced APMs” that are exempt from MIPS and eligible for automatic 5 percent bonuses on their Medicare payments. However, for clinicians in APMs that do not meet the thresholds, the proposed MACRA rule rewards clinicians in APMs with NCQA Recognized PCMHs and PCSPs. Here’s how that works: 

  • CMS will first score each clinician in an APM individually. It will average scores for all clinicians in the APM and apply that average score to each clinician. 
  • Clinicians in NCQA PCMHs and PCSPs get automatic full CPIA credit. Clinicians who have not earned recognition only get half CPIA credit for being in the APM. Then, they have to earn additional CPIA points for individual CPIA activities. 
  • Having more PCMH and PCSP clinicians in an APM automatically gives all of that APMs’ clinicians higher MIPS scores. 

If you are a practice or health system interested in NCQA recognition, contact us today. If you are current customer with questions about MACRA, ask them through your My NCQA portal.