United States: MACRA: Top 10 FAQs

Last Updated: October 17 2016
Article by Radha V. Bachman, Caycee D. Hampton and Elizabeth Scarola

Significant changes to the Medicare payment system are underway. The Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) is set to take effect January 1, 2017.

MACRA represents a deliberate departure by the Centers for Medicare and Medicaid Services (CMS) from the traditional, volume-based, fee-for-service business model. By way of MACRA, CMS demands providers assume greater risk for outcomes and rewards high quality and efficient care, rather than volume.

Although the final rule is set to be unveiled next month, CMS recently announced that providers will have the flexibility to choose their pace for the first performance year (beginning January 1, 2017). As providers contemplate which pace is best, this article answers 10 frequently asked questions on the topic.

1. What is MACRA?

MACRA repealed and replaced the Sustainable Growth Rate (SGR) formula with a new method for controlling Medicare costs. Whereas the SGR set payment rates through a formula based on economic growth, MACRA links Medicare reimbursement to quality metrics, rewarding providers for value-based, quality care.

2. What is the reimbursement model under MACRA?

Under MACRA, eligible providers can choose to be paid on a fee-for-service basis with pay-for-performance incentives and penalties via the Merit-Based Incentive Payment System (MIPS), or receive a financial incentive for participation in an Advanced Payment Model (APM). These two options form the framework for MACRA's value-based reimbursement plan, the Quality Payment Program (QPP). Medicare payments will vary among providers, with some potentially receiving 27 percent more than others based on higher performance. So, providers will want to contemplate their selection of a path carefully.

3. Who is affected by MACRA?

Beginning in 2017, MACRA will apply to Medicare Part B physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and their associated groups. CMS anticipates expanding MIPS in the future to include other clinicians such as physical or occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dieticians, and nutritional professionals.

MACRA will also affect the provider and hospital partners with whom eligible providers do business. Hospitals should consider whether they will support employed physicians in meeting advanced APM and MIPS requirements and whether they will provide a compatible infrastructure for affiliated physicians.

4. What is the difference between MIPS and APMs?

MIPS is the consolidation of three existing CMS programs: the Physician Quality Reporting System (PQRS), the Physician Value-Based Payment Modifier (VM) and the Medicare Electronic Health Record (EHR) Incentive Program.

Providers selecting the MIPS track will report data across four performance categories and will receive a composite score from 1-100. Medicare payments will then be negatively or positively adjusted based on composite scores.

Clinicians choosing to participate in APMs are exempt from MIPS payment adjustments and instead qualify for a 5 percent Medicare Part B incentive payment.

However, only two-sided risk programs qualify as APMs and clinicians must receive enough of their payments or see enough of their patients through Advanced APMs to meet the APM exception. The list of approved APMs currently includes:

  • Comprehensive End-Stage Renal Disease Care;
  • Comprehensive Primary Care Plus;
  • Medicare Shared Savings Program Tracks 2 and 3;
  • Next Generation ACO; and,
  • Oncology Care Model with two-sided risk, (available in 2018).

CMS will update the list of qualifying APMs annually to add new payment models, and beginning in 2019, clinicians may qualify for incentive payments based on participation in APMs developed by non-Medicare payers.

5. What kind of reporting does MACRA require?

The first year, all providers participating in MIPS and APMs must report either individually or as a group. Providers may report via qualified registries, health IT vendors or CMS-approved survey vendors on the following four performance categories:

  1. Quality (50 percent of total score in Year 1)
  2. Resource Use (10 percent of total score in Year 1)
  3. Clinical Practice Improvement Activities (15 percent of total score in Year 1)
  4. Advancing Care Information / Meaningful Use of Certified EHR Technology (25 percent of total score in Year 1)

In an effort to enhance transparency and engage beneficiaries, CMS will make QPP results available to the public on the Physician Compare website.

6. Do reporting requirements account for differences between specialties?

Providers may choose their own reporting measures across all four performance areas from CMS options that accommodate unique specialty and practice considerations.

7. How will providers be paid?

MIPS composite performance scores will result in positive, negative, or neutral adjustments to Medicare Part B payments. In the first year, there will be no negative adjustments under MIPS. Thereafter, the maximum MIPS payment adjustment will increase until 2022, when it will level off at 9 percent. An additional bonus, up to 10 percent higher than the respective positive payment, is also permitted for exceptionally high performers in the first five years of the MIPS program.

APM participating providers are eligible to receive a lump-sum incentive payment of 5 percent of Medicare revenue per year and will not face additional downside risk within the QPP.

8. When do I have to be ready for this change?

MACRA will take effect January 1, 2017 with the first performance period lasting from January 1, 2017 through December 31, 2017. Payments based on the 2017 performance year will be made in 2019.

Beginning January 1, 2017, providers have four participation options from which to choose to ensure no negative payment adjustment in 2019:

  1. Test the Quality Payment Program: As long as a provider submits "some data" to the quality payment program, he/she will avoid a negative payment adjustment;
  2. Participate in Part of the Calendar Year: Providers can begin participation later than January 1, 2017 and the practice can still qualify for a small, positive payment adjustment;
  3. Participate for the Full Calendar Year: Those participating for the full calendar year (beginning January 1, 2017), will qualify for a modest, positive payment adjustment; and,
  4. Participate in an Advanced Alternative Payment Model (as of January 1, 2017), those who participate in an APM will quality for up to a 5 percent incentive payment in 2019.

9. Is there any option for providers to continue on a fee for service model?

Medicare Part B clinicians will be exempt from the payment adjustment under MIPS if they (1) are newly enrolled in Medicare; (2) have less than or equal to $10,000 in Medicare charges and less than or equal to 100 Medicare patients; or, (3) are significantly participating in an APM.

Medicare Part B clinicians who choose not to participate in MIPS and APMs may continue to see Medicare patients. They will receive Medicare fee-for-service based payments for treating their patients, and will experience a reduction in Medicare payments two years later. These payments will be reduced by the amount of the maximum MIPS penalty. In 2019, the maximum penalty will be 4 percent. It will increase to 9 percent in 2021.

10. How do I prepare?

Start now. Familiarize yourself with the legislation and pick your pace for January 1, 2017. As you choose which criteria your practice will report, consider implementing clinical practice improvement activities, ensuring adequate use of electronic health records, tracking internal costs and implementing quality improvement initiatives.

If you have additional questions about how MACRA will affect you and your practice, you should contact a qualified health care attorney or your billing provider.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Similar Articles
Relevancy Powered by MondaqAI
In association with
Related Topics
Similar Articles
Relevancy Powered by MondaqAI
Related Articles
Related Video
Up-coming Events Search
Font Size:
Mondaq on Twitter
Mondaq Free Registration
Gain access to Mondaq global archive of over 375,000 articles covering 200 countries with a personalised News Alert and automatic login on this device.
Mondaq News Alert (some suggested topics and region)
Select Topics
Registration (please scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions

Mondaq.com (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of www.mondaq.com

To Use Mondaq.com you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.


The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.


Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions