ACAP Comment Letter on 2017 MACRA Final Rule

December 12, 2016

Andy Slavitt, Acting Administrator
Centers for Medicare and Medicaid Services
United States Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington, D.C. 20201

Submitted via e-mail to:

Re: Medicare Program; Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models

Dear Mr. Slavitt:

The Association for Community Affiliated Plans (ACAP) greatly appreciates the opportunity to provide comments to the Centers for Medicare & Medicaid Services (CMS) on the Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for PhysicianFocused Payment Models.

ACAP is an association of 57 not-for-profit, community-based Safety Net Health Plans located in 26 states. Our member plans provide coverage to over fifteen million individuals enrolled in Medicaid, Children’s Health Insurance Program (CHIP) and Medicare Advantage Dual-Eligible SNPs. Nationally, ACAP plans serve approximately one-third of all Medicaid managed care enrollees. Eighteen of our plans are D-SNPs and 14 of our plans participate in the Financial Alignment Demonstration.

Please find below ACAP’s comments on the criteria for the Other Payer Advanced APM:

  • Advanced APM determination: Medicaid Managed Care plans and MA plans have already been working on APMs for a number of years, at the encouragement of CMS. When determining whether an APM is considered an Advanced APM, CMS and the Physician-Focused Payment Model Technical Advisory Committee (PTAC) should set guidelines that are flexible and inclusive of existing Medicaid Managed Care plan and Medicare Advantage (MA) plan APMs. Moreover, rather than having to seek review and approval by the PTAC, Medicaid managed care plans and MA plans should be able to selfcertify that their programs meet the criteria. This will reduce administrative burden and ease the process and timeline for Advanced APM approval.
  • Criteria for whether quality measures are comparable to MIPs: CMS has indicated that the agency will be inclusive of existing Medicaid Managed Care quality measures when determining whether measures are comparable to MIPs measures. We agree with this approach and encourage CMS and PTAC to take a broad, inclusive perspective that considers that Medicaid managed care plans cover populations different than Medicare, which necessitates use of different measures.
  • Calculation of risk-bearing for providers: Providers that serve Medicaid beneficiaries, including dual-eligible beneficiaries, differ in the degree of risk they are prepared and financially able to undertake. CMS’ definitions of nominal and financial risk should flexible to account for the amount of risk providers are able to assume. In particular, there is concern that safety net providers, such as FQHCs, do not have the financial reserves to assume downside risk. The important role of these providers in caring for Medicaid beneficiaries and dualeligible beneficiaries should be acknowledged and strengthened, rather than jeopardized, by the move towards Advanced APMs. CMS should exclude or create an exception for safety net providers from the criteria to assume downside risk.
  • Criteria for Medicaid Medical Homes: Many states have been working with CMS to implement system delivery reform that include the creation of Medicaid Medical Homes. Some states have already developed Medicaid Medical Home roadmaps and other states are pursuing SIM grants or DSRIP projects which involve definitions of Medicaid Medical Homes. Existing state Medicaid Medical Homes should be deemed acceptable as Other Payer Advanced APMs as they currently exist. CMS should not expect states, plans, and providers to change the criteria of Medicaid Medical Homes after those programs have already been determined.


ACAP is prepared to assist with additional information, if needed. If you have any questions, please do not hesitate to contact Deborah Kilstein at (202) 341-4101 or


Margaret A. Murray
Chief Executive Officer

ACAP Comment Letter on 2017 MACRA Final Rule