Alternative Payment Models (APMs)

Primary Care First (PCF)  is a voluntary, multi-payer, five-year model operating in 26 regions of the country that offers enhanced payments to support advanced primary care services. Practices can receive performance-based payments in addition to a combination of a flat primary care visit fee and a population-based payment (PBP) that is calculated using the complexity of the patient population. Primary Care First includes two cohorts of participating practices: Cohort 1 began in January 2021 and Cohort 2 started in January 2022. There are currently 3,000 practices participating in both cohorts, and 24 payer partners. Additional resources can be found below:

• Primary Care First Cohort 2 Webinar with CMS Staff (Member Login Required)
• Primary Care First Cohort 2: Frequently Asked Questions (Member Login Required)
• ACP Primary Care First (PCF) Fact Sheet

The redesigned Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model, previously known as The Global and Professional Direct Contracting Model has three main priorities:

• Advance health equity to bring the benefits of accountable care to underserved communities
• Promote provider leadership and governance
• Protect beneficiaries and the model with more participant vetting, monitoring, and greater transparency

The Global and Professional Direct Contracting Model is a voluntary, five-year ACO model that started on April 1, 2021, and will become the ACO REACH Model in 2023. This model currently offers partially or fully capitated payments for relevant Medicare Part A and Part B services and features two distinct tracks; 1) the Professional Option, which is 50% shared savings/losses and primary care capitation; and 2) the Global Option, which is 100% shared savings/losses and primary care or total care capitation. The redesign requires compliance with new changes starting in 2023. Check out ACP's Direct Contracting Model Fact Sheet for more information on the current requirements. Find additional information here.

The Kidney Care Choices (KCC) Model builds on the existing ESRD Care Model structure, in which dialysis facilities, nephrologists, and other clinicians form ESRD-focused ACOs to manage care for beneficiaries with ESRD. This model adds fixed payments for clinicians who manage care for Medicare beneficiaries with late-stage chronic kidney disease and ESRD. The goal is to delay the onset of dialysis and incentivize kidney transplantation. The model will have four distinct payment Options: the CMS Kidney Care First Option and the Comprehensive Kidney Care Contracting Graduated, Professional, and Global Options.  The KCC Model Performance Period began on January 1, 2022, and will continue through December 31, 2026. CMS began solicitating applications for a second cohort of KCC Model participants which ended March 25, 2022. This cohort will begin on January 1, 2023. Subscribe to the KCC listserv to receive updates specifically regarding the KCC Model.

The Medicare Community Health Access and Rural Transformation (CHART) Model offers up front funding for innovation in rural communities. It features the "Community Transformation Track” for new networks of community partners led by a Lead Organization, that represents a rural Community, comprised of either a single county or census tract or a set of contiguous or non-contiguous counties or census tracts. In 2021, CMS awarded cooperative agreement to four entities under the CHART Community Transformation Track. These four Lead Organizations are expected to coordinate efforts across the community to ensure that access to care is maintained and various stakeholders are understood and accounted for in the transformation plan.  Applications were due in Spring 2021. The performance period will begin January 2023 and end December 2028. Find more information here.

Comprehensive Primary Care Plus (CPC+), was a five-year, multi-payer program, began in January 2017 with the aims of improving quality, access, and efficiency of primary care. The program comprises 2,610 primary care practices in 18 regions with two primary care practice tracks. Practices are supported by 52 aligned payers, from whom they receive additional payment outside of the fee-for-service system for providing comprehensive primary care. This program ended on December 31, 2021, and participating practices are invited to participate in another CMMI model, if they are able to do so. Other model options include Primary Care First, the Direct Contracting Model, and/or the Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs). Additional CPC+ resources can be found below.

• CMS’ CPC+ Website
• ACP’s Joint Letter with AAFP - Recommendations on Improving the PCF Model

Click here for a full list of qualifying 2022 Advanced APMs, including Medicare Advantage and private payer models.

2022 Medicare Threshold Option

Clinicians who participate in Advanced APMs but fall short of the QP threshold may reach a separate, smaller threshold and qualify as a Partial QP. Partial QPs have the option to opt out of MIPS. APM- participating clinicians who do choose to participate in MIPS will be scored under the MIPS APM Performance Pathway. Partial QP determinations are made at the APM Entity level. If a clinician opts out of MIPS, it will apply to all of their TIN/NPI combinations.

MIPS eligible clinicians who achieve QP status in Advanced APMs will: 

• Receive supplemental or performance-based payments according to the rules established under their APM (e.g., care coordination or infrastructure payments, shared savings, bundled payments, etc.);
• Be exempted from participating in MIPS;
• Receive a 5% lump sum bonus payment on their fee-for-service reimbursements through the 2024 payment years (based on 2022 performance).
• Receive a 0.5% higher Physician Fee Schedule update starting in 2026 (0.75% instead of 0.25%).