Eligibility Requirements and Exemptions in MACRA

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What are the eligibility prerequisites and exemptions for MIPS?

The eligibility cap for MIPS expands over the first few years as explained below:

  • CY2017 and CY2018 performance years: Physicians (MD/DO and DMD/DDS), Physician Assistants, Certified Registered Nurse Anesthetists and Clinical Nurse Specialists
  • CY2019+ performance years: Expanded to occupational and physical therapists, speech-language pathologists, nurse midwives, audiologists, clinical psychologists, clinical social workers, and nutritional/dietitians professionals
  • Only those clinicians who are eligible in the above categories and bill for Medicare Part B (in other words known as the Physician Fee Schedule) or Critical Access Hospital (CAH) Method II payments named to the CAH
    • Excluded from MIPS payment settlements: Payments from Medicare Part A, Advantage Part C, Part D, FQHC, or Rural Health Clinic facility payments invoiced under comprehensive payment methodologies and CAH Method I facility payments

Exemptions from MIPS

For the CY2017 performance year, only three exemptions from MIPS are provisioned for clinicians who otherwise meet the above eligibility requirements:

  • Clinicians in their 1st year of Medicare Part B participation
  • Clinicians billing Medicare Part B up to $30,000 in permitted charges or providing care to up to hundred Part B patients in one-year duration
  • Clinicians in entities satisfactorily participating in an Advanced APM for which either:
    • The combined Part B payments for the services provided by the Advanced APM entity’s clinicians to patients who are attributed to the entity is at least twenty-five percent of the payments for services provided by the entity’s clinicians to all patients who could, but may not, be attributable to the entity (“attribution-eligible”)

The aggregated number of patients who receive services provided by the Advanced APM’s clinicians and are attributed to the Advanced APM is at least twenty percent of all the patients who are attribution-eligible and have received services provided by the Advanced APM’s clinicians

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