The Quality Payment Program (QPP) is a CMS Medicare Part B value-based payment program. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) created the QPP. Performance in either of two tracks adjusts Medicare Part B physician payments by up to plus or minus 9 percent.
The Centers for Medicare and Medicaid Services (CMS) administers the QPP. MACRA replaced the Sustainable Growth Rate (SGR) formula and folded three legacy programs (PQRS, the Value Modifier, and Meaningful Use) into MIPS. This guide covers QPP definition, the two tracks, eligibility rules, scoring, and reporting deadlines.
What is the Quality Payment Program?
The Quality Payment Program (QPP), a federal value-based payment program administered by CMS, ties Medicare Part B physician payments to quality and value. The QPP operates under statutory authority granted by MACRA, Public Law 114-10. CMS reissues QPP policy annually through the Medicare Physician Fee Schedule (MPFS) Final Rule.
The QPP serves three functions. First, the QPP measures clinician performance against national benchmarks. Second, the QPP distributes positive and negative Medicare Part B payment adjustments. Third, the QPP rewards clinicians who accept downside financial risk through Advanced APMs.
Key facts about the Quality Payment Program:
- Administering Agency: Centers for Medicare and Medicaid Services (CMS), under the U.S. Department of Health and Human Services (HHS)
- Statutory Basis: MACRA Section 101, codified at 42 U.S.C. 1395w-4
- Payment System Affected: Medicare Part B (physician services under the MPFS)
- Adjustment Range: Plus or minus 9 percent
- First Performance Year: 2017
- Current Performance Year: 2026
What are the two paths of the Quality Payment Program?
The Quality Payment Program contains two participation tracks. Eligible clinicians report through either track based on financial-risk arrangements with CMS.
- Merit-Based Incentive Payment System (MIPS): the default track. Clinicians submit performance data across four categories and receive a Final Score from 0 to 100.
- Advanced Alternative Payment Models (Advanced APMs): the second track. Models require downside financial risk and the use of Certified Electronic Health Record Technology (CEHRT).
- MIPS APMs: a hybrid sub-track. Participants report under MIPS using APM-specific scoring standards.
- MIPS Value Pathways (MVPs): a specialty-aligned reporting framework inside MIPS.
- Qualifying APM Participant (QP) path: clinicians inside an Advanced APM who meet payment or patient thresholds. QP status excludes the clinician from MIPS reporting.
MIPS remains the most common track for solo practitioners and small groups. Advanced APMs concentrate among hospital-affiliated groups, accountable care organizations (ACOs), and primary-care networks. The Merit-Based Incentive Payment System (MIPS) is covered in depth at the Merit-Based Incentive Payment System (MIPS) hub.
How was the Quality Payment Program created (MACRA, 2015)?
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) created the Quality Payment Program. MACRA was signed into law on April 16, 2015. The House passed MACRA by a 392–37 vote; the Senate passed MACRA by a 92–8 vote, one of the most bipartisan Medicare reforms in decades.
MACRA repealed the Sustainable Growth Rate (SGR) formula, which had threatened annual physician payment cuts since 1997. Congress had enacted 17 temporary SGR patches between 1997 and 2014. MACRA ended that cycle.
MACRA Section 101(c) created the Quality Payment Program framework. MACRA folded three legacy Medicare quality programs into MIPS: the Physician Quality Reporting System (PQRS), the Value Modifier (VM), and Meaningful Use (now called Promoting Interoperability). Each of those programs operated independently before 2017. MIPS unified them into a single scoring system.
QPP performance began January 1, 2017. CMS issued the first QPP Final Rule in October 2016 (81 Fed. Reg. 77,008). Each subsequent CY Physician Fee Schedule Final Rule updates the QPP rules for the next performance year. MACRA legislative history provides full statutory citations.
How does the Quality Payment Program affect Medicare Part B payments?
The Quality Payment Program adjusts Medicare Part B payments by up to plus or minus 9 percent. The adjustment occurs two performance years after data submission. Each clinician’s MIPS Final Score is compared to the MIPS Performance Threshold to set the adjustment direction and magnitude.
The MIPS Performance Threshold sits at 75 points for performance years 2024 through 2028. CMS finalized this multi-year stability policy in the CY 2026 Physician Fee Schedule Final Rule (90 FR 49757, November 5, 2025).
The following table maps performance year to payment year:
| Performance Year | Final Score Threshold | Payment Year | Adjustment Range |
|---|---|---|---|
| PY 2024 | 75 points | 2026 | plus or minus 9% |
| PY 2025 | 75 points | 2027 | plus or minus 9% |
| PY 2026 | 75 points | 2028 | plus or minus 9% |
Scores at or above 75 points produce a positive or neutral adjustment. Scores below 75 trigger a negative adjustment on a linear sliding scale, reaching the maximum 9 percent penalty at scores of 18.75 points or lower.
What rewards do Qualifying APM Participants receive?
Qualifying APM Participants (QPs) receive a separate reward. The 5 percent APM Incentive Payment expired after performance year 2024 (paid at 1.88 percent for the 2026 payment year under the statutorily reduced rate). Beginning in payment year 2026, QPs receive a 0.75 percent MPFS conversion-factor differential. Non-QP clinicians receive the standard 0.25 percent update.
The financial impact scales with practice size. A 20-clinician group billing $4 million in Medicare Part B charges faces $360,000 in exposure between the maximum positive and maximum negative adjustment. Macralytics MIPS reporting services help clinicians avoid the -9 percent MIPS penalty.
Who is required to participate in the Quality Payment Program?
Thirteen clinician types are eligible for the Quality Payment Program. Each eligible clinician type must report MIPS when Medicare Part B billing exceeds the low-volume threshold.
The 13 MIPS eligible clinician types are:
- Physicians (MD, DO, DDS, DMD, DPM, OD)
- Physician assistants (PAs)
- Nurse practitioners (NPs)
- Clinical nurse specialists (CNSs)
- Certified registered nurse anesthetists (CRNAs)
- Physical therapists (PTs)
- Occupational therapists (OTs)
- Qualified speech-language pathologists (SLPs)
- Qualified audiologists
- Registered dietitians or nutrition professionals
- Clinical psychologists
- Clinical social workers
- Certified nurse-midwives
The low-volume threshold has three numeric criteria. A clinician or group exceeds the threshold by meeting all three of the following:
- More than $90,000 in Medicare Part B allowed charges for covered professional services
- More than 200 Part B-enrolled Medicare beneficiaries
- More than 200 covered professional services to Part B patients
Clinicians who exceed all three criteria during both segments of the MIPS Determination Period must report MIPS. Clinicians below one or more thresholds may opt-in voluntarily. CMS publishes the QPP Participation Status Lookup tool at qpp.cms.gov, which returns eligibility, special-status flags, and APM affiliation for any TIN/NPI combination. Clinicians can check QPP eligibility using that lookup.
What are the QPP performance year and reporting deadlines?
The Quality Payment Program performance year runs from January 1 through December 31. The MIPS data submission window opens on January 2 and closes on March 31 of the calendar year after the performance year ends. The payment adjustment applies two calendar years after the performance year.
The following table maps PY 2026 reporting milestones:
| Stage | Date Range |
|---|---|
| PY 2026 performance period | Jan 1 to Dec 31, 2026 |
| MIPS submission window | Jan 2 to Mar 31, 2027 |
| Targeted Review window | 60 days from final performance feedback (typically Aug to Oct 2027) |
| PY 2026 payment year | 2028 |
CMS publishes final performance feedback in mid-summer following the submission window. The Targeted Review window opens at that point and runs for exactly 60 days. Clinicians who disagree with the calculated Final Score must submit a Targeted Review request inside that window.
Late submissions receive no scoring credit. Failure to submit by March 31 of the year after the performance year results in the maximum negative adjustment two years later. See the MIPS reporting deadlines page for category-specific rules.
What is the difference between MIPS and Advanced APMs?
The Quality Payment Program splits eligible clinicians into MIPS or Advanced APM based on financial-risk participation. MIPS participants submit performance data without accepting downside financial risk. Advanced APM participants enter CMS-designated models that require both downside risk and CEHRT use.
The following table compares MIPS and Advanced APM on the dimensions that decide track selection:
| Feature | MIPS | Advanced APM |
|---|---|---|
| Financial risk | None required | Downside risk required |
| Reporting unit | Individual, group, virtual group, or APM Entity | APM Entity only |
| Scoring system | MIPS Final Score 0 to 100 | APM-specific quality benchmarks |
| MIPS reporting required | Yes | No (for QPs) |
| Payment reward | Plus or minus 9% MPFS adjustment | 0.75% MPFS conversion-factor differential (PY 2026+) |
| CEHRT use required | Strongly weighted in PI category | Mandatory at 75% of participants |
| Example track | Traditional MIPS, MVPs, APP | MSSP Levels E and ENHANCED, ACO REACH, Primary Care First |
MIPS suits solo practitioners, small specialty groups, and clinicians without infrastructure for downside risk. Advanced APMs suit hospital-affiliated networks, ACOs, and primary-care practices with population-health analytics already in place.
A clinician inside an Advanced APM who fails to reach the QP threshold falls back into MIPS reporting through the MIPS APM track. The threshold-by-threshold mechanics sit at the MIPS vs Advanced APM detailed comparison page.
What are MIPS Value Pathways (MVPs) and how do they evolve QPP reporting?
MIPS Value Pathways (MVPs) are specialty-aligned, condition-based reporting alternatives to traditional MIPS. CMS designed MVPs as a step toward retiring open-ended measure selection. Each MVP groups quality measures, improvement activities, and a cost measure around a single specialty or clinical condition.
Three examples of CMS-finalized MVPs are:
- Advancing Care for Heart Disease MVP for cardiology and internal medicine clinicians treating coronary artery disease, heart failure, and arrhythmia
- Optimizing Chronic Disease Management MVP for primary-care clinicians managing diabetes, hypertension, and chronic kidney disease
- Surgical Care MVP for general surgery, vascular, and orthopedic clinicians performing inpatient and ambulatory procedures
CMS finalized 21 MVPs for performance year 2026 in the CY 2026 Physician Fee Schedule Final Rule. CMS has stated rulemaking intent to transition all MIPS reporting to MVPs over time. The current Final Rule does not name a mandatory transition year. Detailed measure lists sit at the MIPS Value Pathways guide.
What is the foundation layer of an MVP?
The foundation layer, the cross-MVP measure set common to every MIPS Value Pathway, includes Population Health measures, Promoting Interoperability (PI) measures, and Improvement Activities (IA). The foundation layer applies regardless of which MVP a clinician reports.
The foundation layer has three components:
- Population Health Measures: Administrative claims-based outcome measures, scored by CMS without separate data submission.
- Promoting Interoperability Measures: CEHRT-based measures of health information exchange and patient access.
- Improvement Activities: Attestation-based activities covering care coordination, patient safety, and population management.
CMS reweights the foundation layer for clinicians with hardship exceptions or special statuses.
What is the role of Advanced APMs in the QPP?
Advanced Alternative Payment Models (Advanced APMs) are the second participation track of the Quality Payment Program. Advanced APMs require downside financial risk, the use of CEHRT, and quality measures comparable to those used in MIPS.
Clinicians inside an Advanced APM who meet QP payment or patient thresholds achieve Qualifying APM Participant (QP) status. QP status excludes the clinician from MIPS reporting and grants the 0.75 percent MPFS conversion-factor differential beginning in payment year 2026.
The three QP status tiers are:
- Full QP Status: at least 75 percent of Medicare Part B payments or at least 50 percent of Medicare patients through an Advanced APM Entity
- Partial QP Status: at least 50 percent of Medicare Part B payments or at least 35 percent of Medicare patients through an Advanced APM Entity
- Non-QP Status: below Partial QP thresholds. Clinician falls back to MIPS APM or traditional MIPS reporting.
Partial QPs may elect to report MIPS or remain outside MIPS scoring. Named Advanced APMs include the Medicare Shared Savings Program (MSSP), ACO REACH, Primary Care First, and BPCI Advanced. Full mechanics sit at the Advanced APM track page.
What named Advanced APMs are CMS-recognised for the current performance year?
CMS designates the following Advanced Alternative Payment Models for performance year 2026:
- Medicare Shared Savings Program (MSSP) BASIC Level E
- Medicare Shared Savings Program (MSSP) ENHANCED Track
- ACO REACH (74 participating ACOs across all 50 states, DC, and Puerto Rico)
- ACO Primary Care Flex (ACO PC Flex) for MSSP Level E and ENHANCED participants
- Primary Care First (PCF), Cohorts 1 and 2
- Bundled Payments for Care Improvement (BPCI) Advanced
- Kidney Care Choices (KCC) CKCC Professional, Global, and Graduated tracks
- Making Care Primary (MCP)
- Enhancing Oncology Model (EOM)
CMS publishes the annual Advanced APM list at qpp.cms.gov each November in the MPFS Final Rule. ACO REACH concludes after PY 2026; the LEAD Model launches in 2027 as the announced successor.
What scoring mechanism does the Quality Payment Program use?
The Quality Payment Program uses the MIPS Composite Performance Score, a 0-to-100 Final Score weighted across four performance categories. The MIPS Performance Threshold for PY 2026 sits at 75 points.
The following table lists the four MIPS performance categories and PY 2026 weights:
| Category | PY 2026 Weight | Reweighting Triggers |
|---|---|---|
| Quality | 30% | Insufficient measures, hospital-based status |
| Cost | 30% | Insufficient attributed cases, hardship |
| Promoting Interoperability (PI) | 25% | Small practice, non-patient-facing, CEHRT hardship |
| Improvement Activities (IA) | 15% | Standard reporting; rarely reweighted |
Three bonus and adjustment mechanisms apply to qualifying clinicians:
- Small-practice bonus: 6 points added to the Final Score for practices with 15 or fewer NPIs under one TIN
- Complex-patient bonus: up to 3 points based on dual-eligibility share and Hierarchical Condition Category (HCC) risk score
- Reweighting: any category that cannot be scored redistributes proportionally to remaining scored categories
Quality data submission accepts five collection types:
- MIPS Clinical Quality Measures (CQMs)
- Electronic Clinical Quality Measures (eCQMs)
- Qualified Clinical Data Registry (QCDR) measures
- Medicare Part B claims (small practices only)
- CMS Web Interface (Shared Savings Program ACOs)
The full scoring formula sits at the MIPS scoring methodology page.
What QPP special statuses adjust scoring or reporting?
CMS recognizes seven QPP special statuses that adjust reporting requirements or scoring. Each special status applies based on practice size, geography, clinical setting, or extenuating circumstance.
The seven QPP special statuses are:
- Small Practice: 15 or fewer NPIs under one TIN. Receives 6-point Final Score bonus and automatic PI reweighting.
- Non-Patient-Facing Clinician: 100 or fewer Medicare patient-facing encounters during the determination period. Receives automatic PI reweighting.
- Hospital-based Clinician: 75 percent or more of services in inpatient hospital, on-campus outpatient hospital, or emergency department settings. Receives automatic PI reweighting.
- ASC-based Clinician: 75 percent or more of services in place-of-service 24 (Ambulatory Surgical Center). Receives automatic PI reweighting.
- Health Professional Shortage Area (HPSA) clinician: practices in a CMS-designated HPSA. Eligible for complex-patient bonus consideration.
- Rural Clinician: practices in a CMS-designated rural zip code. Eligible for complex-patient bonus consideration.
- Hardship Exception / Extreme and Uncontrollable Circumstances (EUC) Policy: application-based reweighting for circumstances beyond clinician control (decertified EHR, natural disaster, public health emergency).
Hardship and EUC applications close on December 31 of the performance year. Late applications receive no reweighting. Eligibility criteria for the small-practice MIPS bonus sit at the dedicated page.
How does the small-practice bonus differ from the complex-patient bonus?
The QPP small-practice bonus and complex-patient bonus apply to different eligibility criteria and reward different practice attributes. The following table compares the two bonuses on five dimensions:
| Feature | Small-Practice Bonus | Complex-Patient Bonus |
|---|---|---|
| Trigger | 15 or fewer NPIs under one TIN | Dual-eligible share and HCC risk score above CMS thresholds |
| Point value | 6 points (fixed) | Up to 3 points (variable) |
| Calculation method | Automatic from CMS claims data | Calculated from dual-eligible % and HCC risk score |
| Application required | None | None |
| Stacking | Stacks with complex-patient bonus | Stacks with small-practice bonus |
Both bonuses add directly to the MIPS Final Score. A small practice serving a high-acuity dual-eligible population can capture up to 9 bonus points across the two mechanisms.
How do MIPS APMs differ from MIPS and Advanced APMs?
A MIPS APM is an APM Entity that participates in the Quality Payment Program but does not meet the financial-risk threshold for Advanced APM classification. MIPS APM participants report under MIPS using APM-specific scoring standards.
The following table compares the three QPP participation patterns:
| Feature | Traditional MIPS | MIPS APM | Advanced APM |
|---|---|---|---|
| Financial risk | None required | Some risk; below Advanced APM threshold | Downside risk required |
| Reporting unit | Individual, group, or virtual group | APM Entity | APM Entity |
| Scoring standard | Standard MIPS scoring | APM Performance Pathway (APP) or APP Plus | APM-specific quality measures |
| MIPS-exempt status | No | No | Yes (for QPs) |
| Payment adjustment | Plus or minus 9% MPFS | Plus or minus 9% MPFS via APM scoring | 0.75% MPFS conversion-factor differential |
| Required reporting framework | Traditional MIPS, MVPs, or APP | APP or APP Plus | None for QPs |
The APM Performance Pathway (APP) Plus measure set applies to Medicare Shared Savings Program ACOs beginning in PY 2025. MIPS APM participants who fall below the Advanced APM downside-risk threshold remain inside the MIPS payment adjustment system.
Is participation in the Quality Payment Program mandatory?
Yes, Quality Payment Program participation is mandatory for eligible clinicians, when Medicare Part B billing exceeds the low-volume threshold. Clinicians below all three low-volume threshold criteria may opt-in voluntarily. The three criteria are $90,000 in charges, 200 Part B patients, and 200 covered services. Clinicians below any one of these criteria may also skip MIPS reporting without penalty.
Can a clinician participate in both MIPS and an Advanced APM?
Yes, through the MIPS APM track. A clinician inside an Advanced APM falls into one of three states. The states are full MIPS exemption as a QP, Partial QP status with optional MIPS reporting, or MIPS APM reporting under APM-specific scoring. Track placement depends on QP threshold attainment.
Does the Quality Payment Program penalize non-participation?
Yes, non-reporting eligible clinicians receive a negative 9 percent Medicare Part B payment adjustment two years after the performance year. A 10-clinician primary-care group billing $2 million in Medicare Part B charges loses $180,000 in revenue from the maximum penalty alone. Macralytics MIPS reporting services help clinicians avoid the -9 percent MIPS penalty exposure.
Are small practices exempt from the Quality Payment Program?
No, small practices are not categorically exempt. Eligible small-practice clinicians (15 or fewer NPIs under one TIN) who exceed the low-volume threshold must report MIPS. Qualifying small practices receive a 6-point Final Score bonus and a complex-patient bonus multiplier of up to 3 additional points.
Does the Quality Payment Program apply to Medicaid services?
No, the Quality Payment Program applies to Medicare Part B services only. State Medicaid programs operate separate value-based payment frameworks, including the Texas Quality Incentive Payment Program (QIPP) and the California Medi-Cal Quality Incentive Pool. Medicaid-only billers fall outside QPP scope.
Can hardship exemptions waive QPP reporting requirements?
Yes, in defined circumstances. CMS grants hardship and EUC exceptions for three trigger types. The trigger types are small-practice hardship, decertified or unavailable CEHRT, and Extreme and Uncontrollable Circumstances (natural disasters, public health emergencies, vendor failures). The hardship application closes on December 31 of the performance year.
