MACRA (2015) created the Quality Payment Program; CMMI's Vermont All-Payer ACO Model (2017 agreement) tests whether one statewide ACO can move a whole state off fee-for-service. The CY 2027 proposed rule would sunset traditional MIPS after 2028 and make MVPs mandatory from 2029.
Two national tracks: MIPS and Advanced APMs. CY 2027 proposed rule & proposed MVP transition timeline.
2 key docsCMMI ↔ State of Vermont / Green Mountain Care Board ↔ OneCare Vermont ACO. Statewide all-payer test, 2018–2022 performance years evaluated.
3 docsClinicians sign in to the QPP portal with a HARP account; MIPS eligibility turns on the low-volume threshold (≤ $90,000 in allowed charges, ≤ 200 Medicare beneficiaries, or ≤ 200 covered services → exempt), newly-enrolled-clinician status, and QP status (QPs are exempt from MIPS).
Register for HARP, connect to an organization or as a clinician, Security Official role, ACO-MS access for Shared Savings Program ACOs.
6 docsLow-volume threshold, newly enrolled, QP exemption — checked against the scoring guide and small-practice resources.
3 docsFour ways to report. Small practices (≤ 15 clinicians) get dedicated guides; MVPs are the proposed mandatory future state from 2029.
Report all four categories; the default track, proposed to sunset after 2028.
3 docsSpecialty/condition-focused subsets; registration required; mandatory from 2029 under the CY 2027 proposal.
7 docsAPM Performance Pathway — required for Shared Savings Program ACOs, optional for other MIPS APM participants.
4 docsQualifying APM Participant status exempts MIPS and triggers the APM Incentive Payment track (L5b).
6 docsFour MIPS performance categories roll up into the 0–100 final score. (2026 category weights are set out in the 2026 Traditional MIPS Scoring Guide — see L5.)
Pick & report measures across six collection types (eCQM, MIPS CQM, QCDR, Part B claims, CAHPS, admin claims). Full per-measure specifications in Measure-Specifications/.
guides + ~190 spec filesEpisode- and population-based measures scored from claims — no submission needed. THATKA, Heart Failure, MCC specs included.
7 docs + 6 spec filesAttest to activities from the 2026 inventory; 4-step select–implement–document–submit.
4 docsCEHRT-based objectives: e-Prescribing, PDMP, HIE/TEFCA exchange, public-health reporting, security risk analysis, SAFER.
2 guides + 18 measure specsEvery reported measure is scored against its benchmark: quality measures earn 1–10 points by decile (with topped-out and flat-benchmark rules, and special handling for multiple-performance-rate measures); cost measures are benchmarked against national performance. Files span 2023–2026 with version histories.
Benchmark CSVs pulled 2026-09-13, user guides, version histories, 2023 performance-period results.
12 docsPerformance-period cost benchmark fact sheets, decile scoring, benchmark CSVs, version history.
5 docsMeasures scored under more than one performance rate, by year (XLSX).
3 docsCategory scores roll into a final score of 0–100. The performance threshold is 75 points — exactly 75 is neutral. Adjustments apply to Medicare Part B payments two years after the performance year, redistributed budget-neutrally. Two payment tracks run side by side:
Sliding-scale ± adjustment on Part B, max −9% (in effect since payment year 2022). Exceptional-performance bonus expired after payment year 2024.
2 docsLump-sum APM Incentive Payment: 5% (PY 2019–2024) → 3.5% (PY 2025) → 1.88% (PY 2026, last enacted lump sum) → permanent conversion-factor differential +0.75% QP vs +0.25% non-QP from PY 2026; 3.1% incentive restored for PY 2028 by CAA 2026.
6 docsCMS audits submitted data against validation criteria (42 CFR § 414.1390): 45-day document production on request, 6-year record retention. Results are published on Care Compare — Doctors & Clinicians, including star ratings.
2026 validation criteria for all four categories, year-over-year changes, detection-rate calculator.
8 docsCY 2024 Doctors & Clinicians release: performance information, star ratings fact sheet & cut-offs, Compare tool fact sheet.
4 docsThe money-back layer. Negative adjustments, a narrow provider challenge channel (targeted review), and CMS's own reopening & recoupment powers.
MIPS negative adjustment up to −9% below the 75-point threshold. 2022 performance year: 14% of 624,209 adjusted clinicians penalized; 2% received the max −9%. Payment year 2025: ~78,000 negative adjustments; mean −3.59% among non-reporters.
2 docs42 CFR § 414.1385: calculation-error review via the QPP portal; opens at final-score release, closes 30 days after payment-adjustment publication (closed Nov 14, 2025 for the 2024 performance year). Decisions are final — no further appeal; methodology, standards & measures are statutorily unreviewable (SSA § 1848(q)(13)). APM side: QP determinations unreviewable except narrow clerical-error targeted review (42 CFR § 414.1455).
3 docsCMS may reopen/revise MIPS adjustments (§ 414.1390(c) via §§ 405.980–405.986: 1 year any reason, 4 years good cause, unlimited for fraud). False certification ("cherry-picking") triggers audit + recoupment. ACO shared savings reopenable (§ 425.315); ACOs terminable (§ 425.218); advance investment payments repayable on termination (§ 425.630(g)(6)).
3 docsIndependent evaluation of the Vermont All-Payer ACO Model. NORC's Fourth Evaluation Report (2018–2022): gross Medicare spending −$789 PBPY (−6.6%) and net −$758 PBPY (−6.3%), both statistically significant; quality-withhold clawbacks of $196,758 (2019) and $786,302 (2022). OneCare Vermont reports annually to the Green Mountain Care Board.
Evaluation of the Vermont All-Payer ACO Model 2018–2022 (CMS/CMMI, June 2024) + 129-page technical appendix.
2 docsOneCare Medicare Benchmarking Report to the Green Mountain Care Board (Oct 2022), per the FY22 ACO Budget Order.
1 doc| Layer | Track A — MIPS (clinicians/groups outside Advanced APMs) | Track B — Advanced APM / QP (incl. Vermont All-Payer ACO Model) |
|---|---|---|
| L1 Access & Eligibility | HARP account → QPP portal. Eligible unless below low-volume threshold (≤$90k / ≤200 beneficiaries / ≤200 services) or newly enrolled. | Same portal; clinicians in an Advanced APM Entity are checked for QP status. QPs are exempt from MIPS entirely. |
| L2 Pathway | Traditional MIPS (sunset proposed after 2028) or an MVP (mandatory from 2029 under CY 2027 proposal); small-practice options. | APP / APP Plus reporting for APM participants (required for Shared Savings Program ACOs); QP determination via threshold scores. |
| L3 Performance Categories | All four: Quality, Cost, Improvement Activities, Promoting Interoperability. | APP measure set (reduced, standardized); APM Entity-level reporting; QP status depends on payment/patient counts in the APM, not MIPS categories. |
| L4 Benchmarks | Quality decile benchmarks (2023–2026 files), cost benchmarks, topped-out/flat rules, multiple-performance-rate handling. | APP quality measures benchmarked the same way; ACO financial benchmarks set by CMMI/Medicare (Vermont: statewide all-payer & Medicare growth targets). |
| L5 Scoring & Payment | Final score 0–100 vs 75-point threshold → sliding-scale ± Part B adjustment (max −9%), budget-neutral, two years later. | Lump-sum APM Incentive Payment 5% (PY19–24) → 3.5% (PY25) → 1.88% (PY26, last enacted lump sum) → +0.75% vs +0.25% conversion-factor differential from PY26; 3.1% restored PY28 (CAA 2026). Vermont: shared savings/losses vs ACO benchmark. |
| L6 Validation & Monitoring | Data-validation audits (§ 414.1390), 45-day production, 6-year retention; Care Compare public reporting & star ratings. | CMMI/state monitoring of the ACO; NORC independent evaluation; OneCare annual benchmarking to the Green Mountain Care Board. |
| L7 Penalties & Review | Negative adjustment to −9%; targeted review (§ 414.1385) for calculation errors only; CMS reopening 1 yr / 4 yrs good cause / unlimited fraud. | QP determinations unreviewable except clerical-error targeted review (§ 414.1455); ACO shared savings reopenable (§ 425.315), termination (§ 425.218), advance investment payments repayable (§ 425.630(g)(6)); Vermont quality-withhold clawbacks ($196,758 in 2019; $786,302 in 2022). |
| Payment year | Performance year | Clinicians | Result | Source |
|---|---|---|---|---|
| 2022 | 2020 | 933,545 eligible | 1.88% negative; max +1.87% / −9% | CMS 2020 QPP Experience Report |
| 2023 | 2021 | 698,859 eligible | 3.31% negative; max +2.34% | CMS 2021 QPP Experience Report |
| 2024 | 2022 | 624,209 adjusted | 14% negative; max +8.26% — last exceptional-performance-bonus year | CMS 2022 QPP Experience Report |
| 2025 | 2023 | 541,421 adjusted | Max +2.15%; ~$698M redistributed (CMS estimate) | CMS 2023 QPP Experience Report |
| 2026 | 2024 | 520,035 adjusted | 88% positive; max +1.05%; ~$491M redistributed (CMS estimate) | CMS 2024 QPP Experience Report |
| Payment year | Rate | Total paid | Recipients | Source |
|---|---|---|---|---|
| 2022 | 5% | $612.7M | 199,298 NPIs | CMS QP / APM Incentive Payment public notice files |
| 2023 | 5% | $643.6M | 226,681 NPIs | CMS QP / APM Incentive Payment public notice files |
| 2024 | 5% | $840.3M | 384,111 NPIs | CMS QP / APM Incentive Payment public notice files |
| 2025 | 3.5% | ~$678M | ~460,000 NPIs | MedPAC Jul 2026 Data Book (estimate) |
| 2026 | 1.88% | Totals not yet published — last enacted lump-sum year; conversion-factor differential begins | MedPAC Jul 2026 Data Book | |
| Year | Flow | Amount | Source |
|---|---|---|---|
| 2017 | Start-up funding | $9.5M | NORC 4th Evaluation Report |
| 2018 | Medicare ACO initiative payments | $350.0M | NORC 4th Evaluation Report |
| 2019 | Medicare ACO initiative payments | $412.4M | NORC 4th Evaluation Report |
| PY1–PY2 | Net shared savings | ~$7.9M | NORC 4th Evaluation Report |
| 2019 | Quality-withhold clawback | $196,758 | NORC 4th Evaluation Report |
| 2022 | Quality-withhold clawback | $786,302 | NORC 4th Evaluation Report |
| Performance year | ACOs earned | Net to Medicare | Source |
|---|---|---|---|
| 2022 | ~$2.5B | $1.8B | CMS Shared Savings Program results |
| 2023 | $3.1B | $2.1B | CMS Shared Savings Program results |
| 2024 | $4.1B | $2.4B — 16 ACOs owed $20.3M in shared losses | CMS Shared Savings Program results |