U.S. flag

An official website of the United States government

Search (beta)
Help

All-Payer Advanced APMs

Performance Year

Select your performance year.

During the 2023 Qualifying APM Participant (QP) Performance Period, eligible clinicians are able to become QPs through the All-Payer Combination Option. To do so, an eligible clinician must be in a Medicare Advanced APM and an Other-Payer Advanced APM.

Eligible clinicians who achieve QP status will receive a 3.5 percent APM Incentive Payment in the 2025 payment year and will not be subject to the MIPS reporting requirements or payment adjustments.

The performance period is the same for both the Medicare Option and the All-Payer Combination Option. QP determinations are made using data submitted by eligible clinicians or APM entities on one of the  dates: March 31, June 30, and August 31.

Learn more about QPs.

Other Payer Advanced Alternative Payment Models (APMs)

What’s an Other Payer Advanced APM?

Other Payer Advanced APMs are non-Medicare Fee For Service (FFS) payment arrangements with other payers such as Medicaid, Medicare Health Plans (including Medicare Advantage, Medicare-Medicaid Plans, 1876 Cost Plans, and Programs of All Inclusive Care for the Elderly (PACE) plans), payers with payment arrangements in Aligned Other Payer Models, and other commercial and private payer arrangements that meet the criteria to be an Other Payer Advanced APM.

By statute, the criteria for payment arrangements to be Other Payer Advanced APMs are similar, but not identical, to the criteria for Advanced APMs under Medicare.

To be an Other Payer Advanced APM, payment arrangements must meet the following three criteria:

1. Require use of (CEHRT).

Use CEHRT certified under the ONC Health IT Certification Program that meets the 2015 Edition Base EHR definition, or subsequent Base EHR definition (as defined in 45 CFR 170.102); and any other ONC health IT certification criteria adopted or updated in 45 CFR 170.315 that are determined applicable for the APM, for the year, considering factors such as clinical practice area, promotion of interoperability, relevance to reporting on applicable quality measures, clinical care delivery objectives of the APM, or any other factor relevant to documenting and communicating clinical care to patients or their health care providers in the APM.

2. Base payments for on quality measures that are comparable to those used in the MIPS Quality performance category.

The payment arrangement must base payment on quality measures that are finalized on the MIPS final list of measures, endorsed by a consensus-based entity, or determined by CMS to be evidence-based, reliable, and valid. At least one measure must be an outcome measure if there is an applicable outcome measure on the MIPS quality measure list.

3. Require participants to bear a certain amount of financial risk.

The arrangement must require participants to bear a certain amount of financial risk. A payment arrangement meets the financial risk requirement if the APM Entity’s actual expenditures exceed expected expenditures during a specified QP Performance Period, or if the payment arrangement is a Medicaid Medical Home Model that meets criteria comparable to the Medical Home Model that has been expanded. 

CMS Determination of Other Payer Advanced APMs

What’s the Other Payer Advanced APM Determination Process?

To collect the necessary information and determine whether an Other Payer payment arrangement meets the criteria to be an Other Payer Advanced APM, we will use the following two processes:

  1. Payer Initiated Other Payer Advanced APM Determination Process (Payer Initiated Process); and
  2. Eligible Clinician Initiated Other Payer Advanced APM Determination Process (Eligible Clinician Initiated Process)

Payer Initiated Process

What’s the Payer Initiated Process?

CMS will allow certain payers—State Medicaid Agencies,1 Medicare Advantage, and other Medicare Health Plans, and payers participating in CMS Multi-Payer Models2—to voluntarily submit information to CMS about their payment arrangements with eligible clinicians. This Payer Initiated Process is designed to reduce reporting burden for APM Entities and eligible clinicians, while allowing CMS to collect the information it needs to make Other Payer Advanced APM determinations. Payers that choose to participate would assist their networks of clinicians by carrying out the task of sending the information regarding the payment arrangement to CMS.

If a payer chooses not to submit their payment arrangement information to CMS (or isn’t eligible to do so), then eligible clinicians or APM Entities participating in the payment arrangement would be able to do so instead. Learn more about the Payer Initiated Process here.

Payer Initiated Submission Process

To initiate this review for the 2023 Performance Period payers must submit their payment arrangement as an Other Payer Advanced APM Determination Process. You can find additional details about the submission process in the form itself.

Submit an Other-Payer Advanced APM Determination request

Payer Initiated Other Payer Determination Process Time Periods

To learn more, download the Learning Resources for All-Payer

Eligible Clinician Initiated Process

What’s the Eligible Clinician Initiated Process?

The Eligible Clinician Initiated Process is designed to provide eligible clinicians and APM Entities with an opportunity to submit information to CMS about any payment arrangements they are participating in when their payer does not do so (or isn’t eligible to do so).

The primary difference between the Payer Initiated and Eligible Clinician Initiated Processes is that the Payer Initiated Process happens before the QP Performance Period, and the Eligible Clinician Initiated Process generally happens afterward (except for Medicaid payment arrangements, where both the Payer Initiated Process and the Eligible Clinician Initiated Process happen before the QP Performance Period). Additional information about the timeline and the Eligible Clinician Initiated Process is available in the Learning Resources for All-Payer.

After the QP Performance Period, if we haven’t already determined that a payment arrangement is an Other Payer Advanced APM under the Payer Initiated Process, then eligible clinicians (or their APM Entities) have the option to submit their information and ask for a determination. To complete the process, eligible clinicians may submit an Other-Payer Advanced APM Determination request.