Healthmonix Advisor

MIPS Eligibility and Exemptions

Posted by Lauren Patrick on October 4, 2016

After hosting our first ever MIPS webinar, we found that the majority of the questions being asked surrounded MIPS eligibility. In particular, the low-volume threshold was of interest. Since this is a topic we have yet to fully delve into, we decided that we should do so now!

Compared to the current CMS quality initiatives, the pool of eligible clinicians (formerly called eligible providers) will be shrinking significantly for the 2017 performance year. However, any clinician that bills Medicare Part B can practice reporting for MIPS in 2017. Considering that by 2019, when the pool of eligible clinicians will expand, the MIPS payment adjustment will be up to 9%, it is likely wise to report even if you are not an eligible clinician in 2017.

yellowalert.pngALERT: This post was published before the release of the MACRA final rule on 10/14/2016. Please view our MIPS website for up to date regulations.

MIPS Eligibile Clinicians

Here is a breakdown of who is eligible, and when. Please note that CMS defines a physician as "a doctor of medicine, doctor of osteopathy (including osteopathic practitioner), doctor of dental surgery, doctor of dental medicine, doctor of podiatric medicine, or doctor of optometry, and, with respect to certain specified treatment, a doctor of chiropractic legally authorized to practice by a State in which he/she performs this function."[2]

    MACRA /  MIPS Eligible Clinicians                         


Adjustment Year

MIPS Eligible Clinicians



Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists



Physical / Occupational Therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dietitians/nutritional professionals

For the purposes of this article, we will be discussing who will and will not be eligible to be penalized for the 2017 performance year. This eligibility criteria is based on the latest version of the MACRA Quality Payment Proposed Rule on the date of publishing.

MIPS Eligibility Exemptions

As noted above, Physicians, Physician's Assistants, Nurse Practitioners, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists (CRNA) are all expected to participate in MIPS in 2017. However, there are 3 possible exemptions for clinicians that would otherwise be considered eligible. Additionally, there are exemptions for individual performance categories, which we will cover in our next article!

1.png   Participation in an Advanced Alternative Payment Model (APM)

If an eligible clinician is a part of a qualifying APM, then they are exempt from MIPS reporting. Current examples of APMs are Accountable Care Organizations (ACO), Patient Centered Medical Homes, and bundled payment models.

2.pngMACRA / MIPS Low-volume Threshold

Otherwise eligible clinicians will be exempt from MIPS reporting if they bill ≤ $10,000 and provide care for ≤ 100 Medicare Part B patients.

From the original context from the MACRA Proposed Rule:

"We propose at § 414.1305 to define MIPS eligible clinicians or groups who do not exceed the low-volume threshold as an individual MIPS eligible clinician or group who, during the performance period, have Medicare billing charges less than or equal to $10,000 and provides care for 100 or fewer Part B-enrolled Medicare beneficiaries. We believe this strategy is value-oriented as it retains as MIPS eligible clinicians those MIPS eligible clinicians who are treating relatively few beneficiaries, but engage in resource intensive specialties, or those treating many beneficiaries with relatively low-priced services. By requiring both criteria be met, we can meaningfully measure the performance and drive quality improvement across the broadest range of MIPS eligible clinician types and specialties. Conversely, it excludes MIPS eligible clinicians who do not have a substantial quantity of interactions with Medicare beneficiaries or furnish high cost services." [1]


3.pngNewly Enrolled in Medicare

If a clinician enrolls in Medicare in the middle of a performance year, they do not have to participate in MIPS reporting that year. For example, if a clinician was to enroll in Medicare on February 6, 2017, they would be exempt for the 2017 performance year (January 1, 2017- December 31, 2017).

It should also be noted that payment adjustments do follow a provider's individual NPI, so changing practices (or, more importantly, TINs) in the middle of a performance year WILL NOT create a MIPS exemption.

In our next post, we will discuss how providers can be exempt (or partially exempt) from individual MIPS performance categories.

[1] Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Proposed Rule, 42 CFR § 414 (2016).
[2] The Centers for Medicare and Medicaid Services. (2016). The Medicare Access & CHIP Reauthorization Act of 2015 [PowerPoint slides]. Retrieved from

Topics: MACRA & MIPS, Policy, Eligibility