Medicare and Medicaid Programs; CY 2026 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; and Medicare Prescription Drug Inflation Rebate Program

1. MIPS Final Score Methodology a. Performance Category Scores (1) Background

Sections 1848(q)(1)(A)(i) and (ii) and (5)(A) of the Act provide, in relevant part, that the Secretary shall develop a methodology for assessing the total performance of each MIPS eligible clinician according to certain specified performance standards and, using such methodology, provide for a final score for each MIPS eligible clinician. Section 1848(q)(6)(A) of the Act specifies that, to then determine a MIPS payment adjustment factor for each MIPS eligible clinician for an applicable MIPS payment year, we must compare the MIPS eligible clinician's final score for the given year to the performance threshold we established for that same year in accordance with section 1848(q)(6)(D) of the Act. We refer readers to section IV.B.2. of this final rule for further discussion of the performance threshold, and our calculation of MIPS payment adjustment factors, and our proposals with respect thereto.

Section 1848(q)(2)(A) of the Act provides that the Secretary must assess each MIPS eligible clinician with respect to four performance categories in determining each MIPS eligible clinician's final score: quality, resource use (referred to as “cost”), clinical practice improvement activities (referred to as “improvement activities”), and meaningful use of certified EHR technology (referred to as “Promoting Interoperability”). Section 1848(q)(2)(B) of the Act describes the measures and activities that must be specified under each performance category. Section 1848(q)(3) of the Act provides that we must establish performance standards with respect to the measures and activities specified under the four performance categories for a performance period, considering historical performance standards, improvement, and the opportunity for continued improvement. To calculate a final score for each MIPS eligible clinician for the performance period of an applicable MIPS payment year, section 1848(q)(5)(A) of the Act provides that we must develop a methodology for assessing the total performance of each MIPS eligible clinician according to the performance standards we have established with respect to applicable measures and activities specified for each performance category, using a scoring scale of 0 to 100.

In calculating the final score, we must apply different weights for the four performance categories, subject to certain exceptions, as set forth in section 1848(q)(5) of the Act and at Sec. 414.1380. Unless we assign a different scoring weight pursuant to these exceptions, for the CY 2026 performance period/2028 MIPS payment year, the scoring weights for each performance category are as follows: 30 percent for the quality performance category; 30 percent for the cost performance category; 15 percent for the improvement activities performance category; and 25 percent for the Promoting Interoperability performance category.

For the CY 2026 performance period/2028 MIPS payment year, we proposed to update our scoring methodologies to respond to statutory requirements and impacts observed in performance data (90 FR 32754 through 32762). Specifically, we proposed to--

Modify the existing approach for identifying measures impacted by limited measure choice and subject to topped-out measure benchmarks by applying the existing analysis to MVPs;

Apply defined topped out benchmarks for certain topped-out measures for clinicians impacted by limited measure choice; and

Modify the benchmarking methodology for scoring administrative claims-based measures in the quality performance category.

The policies in this section of the final rule for scoring the quality performance category within traditional MIPS would apply to MVP scoring under Sec. 414.1365(d)(3)(i) since a quality performance category score for MVP Participants is calculated in accordance with Sec. 414.1380(b)(1) based on measures included in the MVP.

We did not propose any changes to our scoring policies for the cost, improvement activities, or Promoting Interoperability performance categories. (2) Scoring the Quality Performance Category for the Following Collection Types: Medicare Part B Claims Measures, eCQMs, MIPS CQMs, QCDR Measures, the CAHPS for MIPS Survey Measure, and Administrative Claims Measures

We refer readers to the CY 2017, CY 2018, and CY 2019 Quality Payment Program final rules, the CY 2020, CY 2021, CY 2022, CY 2023, and CY 2024 PFS final rules, and Sec. 414.1380(b)(1) for our current policies regarding, among other things, quality measure benchmarks, calculating total measure achievement points, calculating the quality performance category score, including achievement and improvement points, the small practice bonus, and scoring flexibilities (81 FR 77276 through 77308, 82 FR 53716 through 53748, 83 FR 59841 through 59855, 84 FR 63011 through 63018, 85 FR 84898 through 84913, 86 FR65490 through 65509, 87 FR 70088 through 70091, and 88 FR 79368 and 79369). In the CY 2025 PFS final rule (89 FR 98427 through 98439), we finalized policies for scoring topped-out measures in specialty measure sets with limited measure choice at Sec. 414.1380(b)(1)(iv)(C) and (b)(1)(ii)(E) and a Complex Organization Adjustment for virtual groups and APM Entities at Sec. 414.1380(b)(1)(vii)(C). (a) Scoring for Topped-Out Measures With Limited Measure Choice (i) Background on Scoring Topped-Out Measures

We refer readers to the CY 2017, CY 2018, and CY 2019 Quality Payment Program final rules, the CY 2023 and 2025 PFS final rules (81 FR 77282 through 77287, 82 FR 53721 through 53727, 83 FR 59761 through 59765, 88 FR 70090 and 70091, and 89 FR 98429 through 98435), and Sec. 414.1380(b)(1)(iv) for established topped out measure scoring policies.

Topped out measures are measures for which measure performance is considered so high and unvarying that meaningful distinctions and improvements in performance can no longer be made (81 FR 77136). Section 1848(q)(3)(B) of the Act requires that in establishing performance standards with respect to measures and activities, we consider, among other things, the opportunity for continued improvement. Topped out measures do not provide an opportunity for continued improvement, nor do payment adjustments based on topped out measures incentivize clinicians to improve their care. As a result, we finalized policies in the CY 2018 Quality Payment Program final rule (82 FR 53723 through 53727) to identify and cap the scoring potential of such measures. Additionally, we established practices for the removal of such measures, such as establishing the topped-out measure lifecycle, to continue to drive quality improvement in areas where such improvement is possible and necessary. The topped-out measure lifecycle is described in the CY 2018 Quality Payment Program final rule (82 FR 53721 and 53727). We established at Sec. 414.1380(b)(1)(iv)(B) that we will cap scoring for topped-out measures at 7 measure achievement points in the second consecutive year

that the measure benchmark is identified as topped out. If a measure has been identified as topped out for 3 consecutive years after being originally identified through the benchmarks, such measure may then be proposed for removal through notice-and-comment rulemaking (83 FR 59761). This timeline, however, is not fixed. We noted our concern that removal of topped-out measures may leave clinicians with fewer than 6 applicable measures to report and that such removal in those instances will impact some specialties more than others (82 FR 53721). We stated that consideration for ensuring available applicable measures would be made when considering measure removals (83 FR 59763).

In the CY 2018 Quality Payment Program final rule (82 FR 53727), we established the topped-out scoring cap to encourage MIPS eligible clinicians to submit measures that are not topped out. However, we created an exemption to this policy in the CY 2025 PFS final rule (89 FR 98430) for certain measures, which are frequently used by certain specialties impacted by limited measure choice. To address scoring scenarios in which limited measure choice compels clinicians to report topped-out measures with scoring caps, we finalized in the CY 2025 PFS final rule (89 FR 98429 through 98432) at Sec. 414.1380(b)(1)(iv)(C) that beginning with the CY 2025 performance period/2027 MIPS payment year, topped-out measures frequently used by certain specialties reporting specialty measure sets that are impacted by limited measure choice (specified in accordance with Sec. 414.1380(b)(1)(ii)(E)) are not subject to the 7-point scoring cap. As part of the CY 2025 PFS final rule, we finalized at Sec. 414.1380(b)(1)(ii)(E) that beginning with the CY 2025 performance period/2027 MIPS payment year, we will annually publish a list in the Federal Register of topped-out measures determined to be impacted by limited measure choice (89 FR 98432). Measures included in the list are scored from 1 to 10 measure achievement points according to defined topped-out measure benchmarks calculated from performance data in the baseline period, in which a performance rate of 97 percent corresponds to 10 percent of the performance threshold for the corresponding performance year.

In the CY 2025 PFS final rule (89 FR 98432 through 98435), we also finalized our approach for identifying the list of measures impacted by limited measure choice and subject to defined topped-out measure benchmarks. Specifically, we finalized that each specialty measure set is reviewed by collection type to identify if the prevalence of topped- out measures within such a set hinders a clinician's ability to successfully participate in the MIPS quality performance category. To make such a determination, we finalized that we analyze the ability of clinicians reporting the specialty measure sets under review to reasonably achieve 75 percent of available quality achievement points based upon the measures available to them and program requirements. Specifically, at the collection type level, each measure is assigned points based upon the current benchmarking data: new measures receive 7 or 5 points based on year in the program, measures with benchmarks are given points based upon the highest decile achievable with a less than perfect score (less than 100 percent or greater than 0 percent for inverse measures), and measures with no available historic benchmark are given 0 points. All measure set points are added together to get an output of scoring potential; the Medicare Part B claims collection type measure sets have an additional 6 points added to the output to account for the small practice bonus. The sum of quality achievement points for each measure set are then compared to the analysis threshold, which is currently 75 percent of available quality achievement points, based upon the number of available measures. Any measure sets that are not able to meet or exceed the threshold are flagged as 'at-risk.' Additional factors that we take into consideration include whether the topped-out measure within the specialty measure set under review is considered a cross-cutting measure or is a broadly applicable measure, which we consider to be a measure included in three or more specialty sets. We also consider in reviewing topped-out measures within a specialty measure set whether the specialty measure set contains more than ten measures, by collection type (89 FR 98432 through 98435). (ii) Measures To Be Subject to the Defined Topped-Out Measure Benchmark for the CY 2026 Performance Period/2028 MIPS Payment Year

In the CY 2026 PFS proposed rule (90 FR 32754 through 32756), beginning with the CY 2026 performance period/2028 MIPS payment year, we proposed to modify the previously finalized approach for identifying measures impacted by limited measure choice (89 FR 98432 through 98435) by applying the analysis and criteria to MVPs, in addition to the analysis of specialty measure sets. For the CY 2026 performance period/ 2028 MIPS payment year, we also proposed in the CY 2026 PFS proposed rule (90 FR 32754 through 32756) to continue to use an analysis threshold of 75 percent of available quality achievement points in our determination of which measures would not be subject to the 7-measure achievement point cap, reflecting the MIPS payment adjustment performance threshold of 75 points. We refer readers to section IV.B.2.b.(2) of this final rule where we finalize a performance threshold of 75 points for the CY 2026 through CY 2028 performance periods/2028 through 2030 MIPS payment years.

MVPs, like specialty measure sets, contain a limited set of quality measures for a clinician to choose from. We have received feedback from interested parties and independently verified that clinicians reporting MVPs in which there is high presence of topped-out measures receiving the 7-point cap are often facing both limited measure choice and limited scoring opportunities. Given the limited number of available measures, the prevalence of topped-out measures within an MVP may similarly hinder a clinician's ability to successfully participate in the MIPS quality performance category. Using the same methodology applicable to topped-out measures within specialty measure sets, we proposed to conduct an analysis of each MVP to identify if the prevalence of topped-out measures within such MVP hinders a clinician's ability to successfully participate in the MIPS quality performance category. According to the approach finalized in the CY 2025 PFS final rule for specialty measure sets (89 FR 98432 through 98435), at the collection type level, each quality measure in an MVP would be assigned points based upon the current benchmarking data: new measures would receive 7 or 5 points based on year in the program, measures with benchmarks would be given points based upon the highest decile achievable with a less than perfect score (less than 100 percent or greater than 0 percent for inverse measures), and measures with no available historic benchmark would be given 0 points. All points would be added together to get an output of scoring potential; the Medicare Part B claims collection type measures would have an additional 6 points added to the output to account for the small practice bonus. The sum of quality achievement points for each MVP would be compared to the analysis threshold, which is currently 75 percent of available quality achievement points, based upon the number of available measures. Any MVPs that are not able

to meet or exceed the threshold would be flagged as 'at-risk.' Additional factors that we would take into consideration would include whether the topped-out measure within the MVP under review is considered a cross-cutting measure or is a broadly applicable measure, which we would consider to be a measure included in three or more MVPs or specialty sets. We would also consider when reviewing topped-out measures within an MVP whether the MVP contains more than ten measures, by collection type.

Table C-I1 contains the list of measures that meet the criteria for topped-out measures impacted by limited measure choice in specialty measure sets and MVPs, and for which we proposed in the CY 2026 PFS proposed rule (90 FR 32756 and 32757) to apply the defined topped-out measure benchmark for the CY 2026 performance period/2028 MIPS payment year. We had considered proposing MIPS CQM 424: Perioperative Temperature Management to be subject to the defined topped-out measure benchmark for the CY 2026 performance period/2028 MIPS payment year since it met the criteria for topped-out measures in specialty measure sets impacted by limited measure choice, according to the methodology finalized in the CY 2025 PFS final rule (89 FR 98432 through 98435). However, we did not propose that measure for the defined topped-out measure benchmark for the CY 2026 performance period/2028 MIPS payment year because it was proposed for removal for the CY 2026 performance period/2028 MIPS payment year in the CY 2026 PFS proposed rule (90 FR 32717). We refer readers to section IV.A.4.d.(1)(c)(ii) of this final rule for discussion of the quality performance category measure inventory.

[GRAPHIC] [TIFF OMITTED] TR05NO25.145

We solicited comments on the following proposals beginning with the CY 2026 performance period/2028 MIPS payment year: (1) include MVPs in the analysis used to identify the list of topped-out measures impacted by limited measure choice ; (2) continue using an analysis threshold of 75 percent of available quality achievement points in our determination of which measures would be subject to the defined topped-out measure benchmark;

and (3) list of topped-out measures impacted by limited measure choice and subject to the defined topped-out measure benchmark.

We received public comments on these proposals. The following is a summary of the comments we received and our responses.

Comment: Many commenters supported the proposal to identify topped- out measures impacted by limited measure choice in specialty measure sets and MVPs. Several commenters supported the proposed list of measures subject to the defined topped-out measure benchmark for the CY 2026 performance period/2028 MIPS payment year.

Response: We thank commenters for their support.

Comment: Several commenters expressed concerns with the methodology CMS uses to identify topped-out measures in specialty measure sets and MVPs as “at risk” and, therefore, eligible for the defined topped-out measure benchmark. A few commenters urged CMS to assess the issue of limited measure choice at the subspecialty level, citing concern that assessing only at the specialty level does not address scenarios where subspecialists may have a limited number of clinically relevant, non- topped-out measures available to them. A commenter recommended that CMS apply a subspecialty analysis to MVPs as well as to specialty sets to evaluate whether all types of clinicians who could report a specific MVP could succeed based on the available measures in the MVP. A commenter urged CMS to incorporate additional factors into the decision, including clinical relevance, patient impact, and alignment with value-based care principles. A commenter recommended that CMS set a 2-year timeframe for reevaluating measures selected for the list of topped-out measures impacted by limited measure choice.

Response: The defined topped-out measure benchmark policy seeks to provide scoring relief for clinicians whose MIPS performances are most impacted by limited measure choice and who would otherwise be unable to avoid a negative payment adjustment due to limited measure choice and the topped-out measure scoring cap. The policy evaluates specialty measure sets and MVPs because these are defined measure sets that may contain fewer measures for certain clinicians to choose from. We do not conduct analysis at the subspeciality level because subspecialties do not have a defined set of measures in the Quality Payment Program. While this policy focuses on addressing measures with topped out status for specialties with limited measure choice, we consider clinical relevance, patient impact, and value-based care principles in our maintenance of the quality measure inventory. We will continue to monitor the impacts of this policy on clinicians' ability to meaningfully participate in MIPS.

We do not apply the defined topped-out measure benchmarks for a 2- year timeframe because measure performance varies each year, and thus a measure's topped out status may change each year.

Comment: A few commenters recommended that the defined topped-out measure benchmark apply to all topped-out measures, stating their belief that limiting the policy to selected measures is arbitrary, adds complexity, and favors some specialties over others. Several commenters specifically requested that CMS apply the defined topped-out measure benchmark to additional measures. Several commenters requested that the hospitalist measure set be added to the defined topped-out measure benchmark policy, stating that all four measures in the specialty set are topped out which places hospitalist clinicians at a disadvantage in the MIPS program, as they also may have the Promoting Interoperability and cost performance categories reweighted. A few commenters recommended that QCDR measures should be included in the defined topped-out measure benchmark policy. A commenter requested that several podiatry measures be scored according to defined topped-out measure benchmarks.

Response: As discussed in section XX of this final rule, topped-out measures are measures with performance so high and unvarying that meaningful distinctions and improvements in performance can no longer be made, the measures do not provide an opportunity for continued improvement, and payment adjustments based on topped-out measures do not incentivize clinicians to improve their care. We cap scoring for topped-out measures at 7 measure achievement points in the second consecutive year that the measure benchmark is identified as topped out to incentivize clinicians to report measures for which continued improvement is still possible. The topped-out measure scoring cap is a useful tool for communicating that there is limited opportunity for continued quality improvement. Clinicians without limited measure availability can choose to report measures that are not topped out and for which they can receive up to 10 measure achievement points.

This policy aims to identify measures impacted by limited measure choice and apply defined topped-out measure benchmarks to only those measures, while retaining the 7-point scoring cap for topped-out measures that are not impacted by limited measure choice.

Topped-out measures in the hospitalist specialty measure set were not proposed to be scored according to the defined topped-out measure benchmark because the measures are cross-cutting or broadly applicable. In accordance with CMS' established methodology, as stated in the CY 2025 PFS final rule (89 FR 98432 through 98435), additional factors CMS takes into consideration in determining which measures may be subject to defined topped out measure benchmarks include whether the topped out measure within the specialty measure set is considered a cross-cutting measure or is a broadly applicable measure. Cross-cutting quality measures are broadly applicable to all clinicians regardless of their specialty; broadly applicable measures are those included in three or more specialty sets. We do not include such measures in the defined topped-out measure benchmark policy in order to retain the 7-point topped-out measure scoring cap for clinicians who do not experience limited measure choice. Measures in the podiatry specialty measure set were not proposed to be scored according to the defined topped-out measure benchmark because the specialty measure set did not meet the criteria for being `at risk' of not meeting the performance threshold of 75 due to limited measure choice and the topped-out measure scoring cap. We will continue to monitor the topped-out status of measures in the podiatry specialty measure set to determine if proposed inclusion in the defined topped-out measure benchmark policy is warranted in future years.

QCDR measures were not included in the scope of this policy because they are governed by another policy at Sec. [thinsp]414.1400(b)(4)(iii)(C) stating that CMS may revoke a measure's second year approval if identified as topped out.

Comment: Several commenters expressed concerns about the overall impact of the scoring cap for topped-out measures, especially for specialties with a limited number of available measures such as physical therapy, physical medicine and rehabilitation, and gastroenterology. A few commenters recommended that CMS comprehensively reevaluate the scoring methodology for topped-out measures.

Response: The 7-point scoring cap for topped-out measures seeks to incentivize clinicians to report measures for which meaningful distinctions in performance can be made and continued improvement is still possible. We did not propose measures in the physical therapy or physical medicine specialty measure sets to be scored according to defined topped-out measure benchmarks because the “at-risk” topped- out measures are either cross-cutting or in three or more specialty measure sets. In Table C-I1 we proposed one measure in the gastroenterology specialty measure set to be scored according to the defined topped-out measure benchmark (Medicare Part B Claims Measure 320: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients), however we did not propose additional topped-out gastroenterology measures because the “at-risk” measures are cross- cutting. We will evaluate the impact of our scoring policies and consider scoring alternatives for topped-out measures.

Comment: A few commenters recommended that CMS refine the defined topped-out measure benchmark by removing the lowest decile instead of the ninth because they believe it will result in more consistent and fair scoring.

Response: We clarify that the defined topped-out measure benchmark does not remove any decile and contains 10 deciles. In the CY 2025 PFS final rule (89 FR 98429 through 98432), we discussed that we proposed to remove the ninth decile for the defined topped-out measure benchmark, however, that policy was not finalized. We finalized the defined topped-out measure benchmark to include the 9th decile, which corresponds to a performance rate from 99 to 99.9 percent.

Comment: A commenter opposed allowing selected specialties to earn full quality measure achievement points when reporting topped-out measures, expressing skepticism that the MIPS quality measure inventory does not include measures that could apply to specialists. The commenter believes that this policy sends a mixed message about the importance of meeting high quality standards.

Response: To identify measures for the defined topped-out measure benchmark policy, we evaluate the ability of clinicians reporting specialty measure sets and MVPs to achieve the performance threshold because clinicians reporting specialty measure sets and MVPs have fewer measures from which to choose. The policy seeks to limit the scoring relief to only those who would otherwise receive a negative payment adjustment only due to limited measure choice and the topped-out scoring cap. The defined topped-out measure benchmark distribution is intended to encourage high performance and clinical quality improvement by having a performance rate of 97 percent correspond to 7.5 achievement points for the CY 2026 performance period/2028 MIPS payment year.

Comment: A commenter expressed concern that two oncology quality measures, Quality ID 143: Oncology: Medical and Radiation--Pain Intensity Quantified (eCQM, MIPS CQM) and Quality ID 144: Oncology: Medical and Radiation--Plan of Care for Pain (MIPS CQM) were proposed to receive topped-out measure benchmarks for the 2026 MIPS performance period. The comment stated that the measures continue to be meaningful and should be reported and expressed the concern that without these two measures, radiation oncologists would only have two reportable measures in the specialty set.

Response: We clarify that measures included in this proposal would not be removed from the specialty measure set and would be available for clinicians to report. Topped-out measures included in this proposal would have the 7-point scoring cap removed and be scored according to the defined topped-out measure benchmark.

After consideration of public comments, we are finalizing as proposed to include MVPs in the analysis used to identify the list of topped-out measures impacted by limited measure choice beginning with the CY 2026 performance period/2028 MIPS payment year. We are also finalizing as proposed to continue using an analysis threshold of 75 percent of available quality achievement points in our determination of which measures would be subject to the defined topped-out measure benchmark for the CY 2026 performance period/2028 MIPS payment year.

We are also finalizing as proposed the list of topped-out measures impacted by limited measure choice and subject to the defined topped- out measure benchmark for the CY 2026 performance period/2028 MIPS payment year. (b) Benchmark Methodology for Scoring Administrative Claims-Based Quality Measures in the Quality Performance Category (i) Background on Scoring Administrative Claims Measures in the Quality Performance Category

At Sec. 414.1325, we specify that there is no data submission requirement for cost measures or administrative claims measures in the quality performance category as these measures are calculated on behalf of participants by CMS using administrative claims data. CMS calculates MIPS eligible clinicians' performance on these measures using administrative claims data, which includes claims submitted with dates of service during the applicable performance period that are processed no later than 60 days following the close of the applicable performance period. In the CY 2017 Quality Payment Program final rule (81 FR 77130), we finalized a policy that clinicians would be scored on applicable administrative claims-based global or population health (henceforth referred to only as population health measures) in addition to the six required submitted quality measures. We refer readers to the CY 2017 Quality Payment Program final rule and the CY 2021 PFS final rule (81 FR 77130 through 77136 and 85 FR 84871 through 84873, respectively) and Sec. 414.1325(a)(2)(i) for our previously established policies regarding administrative claims measures in the quality performance category.

We have codified our quality performance category scoring policies at Sec. 414.1380(b)(1). Under Sec. 414.1380(b)(1)(i), except as provided under paragraph (b)(1)(i)(C) beginning with the CY 2023 performance period/2025 MIPS payment year, MIPS eligible clinicians receive between 1 and 10 measure achievement points (including partial points) based on their performance on each measure. At Sec. 414.1380(b)(1)(i)(A)(2)(ii), each administrative claims-based measure that does not have a benchmark or meet the case minimum requirement is excluded from a MIPS eligible clinician's total measure achievement points and total available measure achievement points.

We also refer readers to the CY 2017, CY 2018, CY 2019 Quality Payment Program final rules (81 FR 77277 through 77282, 82 FR 53699 through 53718, and 83 FR 59841 through 59842, respectively) and CY 2020, CY 2021, and CY 2023 PFS final rules (84 FR 63014 through 63016, 85 FR 84901 through 84904, and 87 FR 70088 through 70090, respectively) for our

previously established benchmarking policies.

In the CY 2017 Quality Payment Program final rule (81 FR 77276 through 77282), we finalized that we will use MIPS eligible clinicians' performance in the baseline period to set benchmarks for the quality performance category, with the exception of new quality measures, quality measures that lack historical data, or quality measures where we do not have comparable data from the baseline period. In these cases, we will calculate benchmarks using data submitted during the applicable performance period. We defined the baseline period to be the 12-month Calendar Year that is 2 years prior to the performance period for the MIPS payment year.

Moreover, in the CY 2023 PFS final rule (87 FR 70088 through 70090), we finalized beginning with the CY 2023 performance period/2025 MIPS payment year, that we would score administrative claims measures using performance period benchmarks (Sec. 414.1380(b)(1)(ii)(D)). We stated that we believe that using a performance period benchmark to score these measures would allow for scores that are more reflective of current performance, while adding no additional burden to clinicians.

As discussed in the CY 2017 Quality Payment Program final rule (81 FR 77277 through 77282), we establish benchmarks as a standardized method to evaluate and compare the performance of quality measures relative to the performance of peers. We use a decile-based approach to create benchmarks, which is done by dividing measure performance rates into deciles, with each decile containing a range of performance rates. CMS assigns measure achievement points based on which benchmark decile range the measure performance rate falls between. CMS assigns partial points to prevent performance cliffs for performance rates near the decile breaks. Additionally, the four administrative claims-based quality measures currently available to MIPS eligible clinicians are inverse measures, meaning the lower the measure performance rate, the higher the measure achievement points. Therefore, lower benchmark deciles are associated with higher performance rates. MIPS eligible clinicians with higher performance rates of administrative claims-based measures (for example, the number of acute unplanned cardiovascular- related admissions per 100 person-years at risk for admission during the measurement period) will have rates that fall into lower benchmark deciles and will score fewer measure points than MIPS eligible clinicians with lower measure performance rates. [GRAPHIC] [TIFF OMITTED] TR05NO25.146

Table C-I2 provides an example of using benchmark deciles along with partial achievement points to assign achievement points for the Risk-standardized Acute Cardiovascular-rated Hospital Admission Rates for Patients with Heart Failure under the Merit-based Incentive Payment System administrative claims-based quality measure under our current methodology. For this measure, that outcome is the number of acute unplanned cardiovascular-related admissions per 100 person-years at risk for admission during the measurement period. Additionally, this measure is an inverse measure. The following formula is used to determine the number of partial points awarded to the MIPS eligible clinician:

Benchmark Decile # + [(performance rate-bottom of benchmark decile range)/(top of benchmark decile range--bottom of benchmark decile range)] = Quality Measure Achievement Points.

For the example measure presented in Table C-I2, the median performance rate is 69.71, which falls within Benchmark Decile 6. If a MIPS eligible clinician's performance rate for the measure is 73.82, the MIPS eligible clinician's performance rate falls within Benchmark Decile 2, for which the MIPS eligible clinician may receive between 2.0 and 2.9 achievement points. Based on the partial points calculation formula, the clinician would receive 0.83 partial points, resulting in a quality measure score of 2.83 out of 10 achievement points for the administrative claims-based quality measure under this example.

Based on our analysis of quality measure scores for the CY 2022 performance period/2024 MIPS payment year, we observed lower scores for the administrative claims-based quality measures than for the non- administrative claims-based quality measures. Means for administrative

claims-based quality measure achievement scores tend to be around 5 to 6 points out of 10, whereas means for non-administrative claims-based measures tend to be around 7 to 9 points out of 10.

There are key factors that may contribute to lower measure scores for the administrative claims-based measures, compared to the other quality measures. First, administrative claims-based quality measures are scored against a performance period benchmark, rather than a benchmark determined based on historical data, which is used, wherever possible, for non-administrative claims-based quality measures. Benchmarks established based on historical data provide MIPS eligible clinicians with helpful performance targets in advance of or during the performance period. Meanwhile, the performance period benchmarks for the administrative claims-based quality measures do not provide information about performance targets before or during the performance period. However, since these measures require no data submission, using performance period benchmarks allows for the calculation of more current and representative measure scores that better track clinician performance and progress over time. We are concerned that the current decile-based, performance period benchmark is a key contributor to lower scores for the administrative claims-based quality measures. Specifically, the current quality benchmark methodology uses a decile range based on linear percentile distributions and assigns 5.0 to 6.9 achievement points to clinicians with measure performance rates within the 50th to 60th percentiles. As a result, clinicians who perform around the median on administrative claims-based measures will receive achievement points below 7.5 points, the equivalent of the performance threshold.

Second, in traditional MIPS, MIPS eligible clinicians are scored on each administrative claims-based quality measure for which the established case minimum is met, and a benchmark can be calculated. Further, not all MIPS eligible clinicians are scored on administrative claims-based quality measures. Therefore, if a clinician is scored on one or multiple administrative claims-based quality measures with measure achievement scores around 5 to 6 points out of 10, these measure scores may have the effect of lowering the MIPS eligible clinician's quality performance category score, especially in comparison to a clinician who is not scored on any administrative claims-based quality measure. (ii) Background on Scoring Measures in the Cost Performance Category

In the CY 2025 PFS final rule (89 FR 98438 through 98446), we addressed concerns raised by MIPS eligible clinicians about cost performance category scoring having a negative impact on their final MIPS score. We noted how, under the cost scoring methodology for the CY 2017 performance period/2019 MIPS payment year through the CY 2023 performance period/2025 MIPS payment year, a MIPS eligible clinician scoring near the median on a cost measure would need to score perfectly (or nearly perfectly) within the other three performance categories to receive a final score slightly above the performance threshold and to avoid a negative payment adjustment (89 FR 98439 through 98442). To address this concern, we modified the methodology for scoring the cost performance category, as set forth at Sec. 414.1380(b)(2), beginning with the CY 2024 performance period/2026 MIPS payment year (89 FR 98441 through 98446; 89 FR 98563).

The cost scoring methodology we finalized at Sec. 414.1380(b)(2) is now based on standard deviation, median, and an achievement point value that is derived from the performance threshold. Specifically, for a MIPS eligible clinician whose average costs attributed under a cost measure is equal to the median cost for all MIPS eligible clinicians that had the measure attributed them, we assign an achievement point value equal to 10 percent of the performance threshold. For example, for the CY 2024 performance period/2026 MIPS payment year, if a MIPS eligible clinician's average costs under the measure is equal to the median costs of all MIPS eligible clinicians attributed the same measure, then we assign the MIPS eligible clinician 7.5 achievement points, based on a performance threshold of 75 as finalized at Sec. 414.1405(b)(9)(iii). For each cost measure, the cut-offs for benchmark ranges are calculated based on standard deviations, expressed in dollars, from the median. We refer readers to Table C-I3 for an example of how the cost scoring methodology could be implemented for a specific cost measure when the performance threshold is set to 75 points, which is the same example we provided in the CY 2025 PFS final rule (89 FR 98441 and 98442). [GRAPHIC] [TIFF OMITTED] TR05NO25.147

This modification in our scoring methodology for cost measures aligns the assignment of achievement points for cost measures so that clinicians with costs near the measure's 50th percentile (median) do not receive a disproportionately low score. Our intended goal for this modification to the scoring methodology was to ensure that MIPS eligible clinicians who deliver care at an average cost near the median costs for all MIPS eligible clinicians attributed the measure receive scores at, or very close to, the performance threshold-derived score (89 FR 98442 and 98443). Additionally, this modification addressed MIPS eligible clinicians' concerns that cost measure scoring negatively impacts their final scores more than other performance categories, including disparate negative effects for MIPS eligible clinicians who are scored on the cost performance category compared to clinicians not scored on the cost performance category (89 FR 98443). (iii) Modification to Scoring Methodology for Administrative Claims- Based Quality Measures in the Quality Performance Category Beginning With CY 2025 Performance Period/2027 MIPS Payment Year

Given the similarities between scoring cost measures and administrative claims-based quality measures, we proposed to modify the methodology for scoring the administrative claims-based measures within the quality performance category beginning with the CY 2025 performance period/2027 MIPS payment year (90 FR 32762). The proposed administrative claims-based quality measure scoring methodology would be based on standard deviation, median, and an achievement point value that is derived from the performance threshold. Specifically, for a MIPS eligible clinician whose performance rate under an administrative claims-based measure would be equal to the median performance rate for all MIPS eligible clinicians that are scored on that measure, we would assign an achievement point value equal to 10 percent of the performance threshold. For example, for the CY 2026 performance period/ 2028 MIPS payment year, the median would have an achievement point value of 7.5, based on a performance threshold of 75 points as finalized in section IV.B.2.b.(2) of this final rule. For each administrative claims-based quality measure, the cut-offs for benchmark ranges would be calculated based on standard deviations from the median.

The benchmark ranges, the median, and the performance threshold- derived achievement point values aligned with the median would be dynamic and responsive to changes in performance rates assessed by administrative claims-based quality measures and performance thresholds for each CY performance period/MIPS payment year. The performance threshold-derived point values could change based on the performance threshold established for each performance period/MIPS payment year. The standard deviations from the median used to determine cutoffs for benchmark ranges for each year would be reviewed for any necessary updates on an annual basis based on performance across MIPS eligible clinicians and the performance threshold established for the performance period/MIPS payment year. We would perform analyses when the performance threshold changes to set the benchmark ranges. To determine the benchmark ranges, we will adhere to the following principles: (1) center the majority of performance rates around the performance threshold-derived point value; (2) determine benchmark ranges according to the statistical distribution curve of the performance rate; and (3) distribution of achievement points for administrative claims-based quality measures should be reflective of overall program performance. We refer readers to Table C-I4 for an example of how the proposed administrative claims-based quality measure scoring methodology could be implemented for a specific quality measure when the performance threshold is set to 75 points. [GRAPHIC] [TIFF OMITTED] TR05NO25.148

Continuing with the Risk-standardized Acute Cardiovascular-rated Hospital Admission Rates for Patients with Heart Failure under the Merit-based Incentive Payment System administrative claims-based quality measure example, now presented in Table C-I4 as an example of implementation of the proposed scoring methodology, the median (50th percentile) performance rate would remain 69.71. Under the proposed scoring methodology, for the CY 2025 performance period/2027 MIPS payment year, a MIPS eligible clinician

with a performance rate equal to the median performance rate of all MIPS eligible clinicians scored on that measure would receive 7.5 achievement points out of 10 possible achievement points, which falls within the Benchmark Rage 7 in Table C-I4.

Using the same example as previously presented in section IV.B.1.a.(2)(b)(i) of this final rule, we would apply the proposed scoring benchmark methodology as shown in Table C-I4 to a MIPS eligible clinician with a performance rate for this measure that is 73.82 (a rate of 4.11 above the median rate). Based on the analysis of data in this example, the standard deviation for the example administrative claims-based quality measure would be 4.38. This value for the standard deviation would then be used to calculate the benchmark ranges in Table 69 by plugging in this value for the standard deviation for each benchmark range. For example, “69.71 + (1 x 4.38)” would be calculated for “Median performance rate + (1 standard deviation)” for the bottom of Benchmark range 6. As shown with the example in Table C- I4, under our proposed scoring methodology, the MIPS eligible clinician's average performance rate of 73.82 percent would fall within Benchmark Range 6 for the example administrative claims-based quality measure, for which the MIPS eligible clinician may receive between 6.0 and 6.9 achievement points.

In alignment with the cost measure scoring methodology finalized last year (89 FR 98563), this proposed scoring methodology for administrative claims-based quality measures would be based on standard deviation, median, and an achievement point value derived from the performance threshold. For each administrative claims-based quality measure, standard deviations would be used to calculate the benchmark ranges which are then used to determine the measure scores for each MIPS eligible clinician scored on that measure based on their measure performance rate.

Under our proposal to modify the administrative claims-based quality measure scoring methodology for individual measures, we would continue to use our established formula to assign partial achievement points:

Benchmark Range # + [(performance rate-bottom of benchmark range)/(top of benchmark range--bottom of benchmark range)] = Administrative Claims-based Quality Measure Achievement Points.

As a result, using the example shown in Table C-I4, under our proposed administrative claims-based scoring methodology, the MIPS clinician would receive 6.12 quality measure achievement points (6 + [(73.82-74.09)/71.92-74.09)] = 6.12). The assignment of 6.12 achievement points under the proposed administrative claims-based quality measure scoring methodology would be closer to the performance threshold equivalent of 7.5 than the assignment of 2.83 achievement points under the current scoring methodology, as discussed in our previous example in section IV.B.1.a.(2)(b)(i) of this final rule.

This proposed modification in our scoring methodology for administrative claims-based quality measures would align the assignment of achievement points for such measures so that clinicians with performance rates near the measure's 50th percentile (median) would not receive a disproportionately low score. Based on our analysis utilizing data from the CY 2024 performance period/2026 MIPS payment year, this proposed methodology would increase the mean quality performance category score from 76.75 out of 100 to 80.42 out of 100 (an increase of 3.67 points). Further, this proposed scoring methodology would increase the means for each administrative claims-based quality measure score by amounts ranging from 1.46 to 1.96 points. For example, the mean measure score for the Risk-Standardized Acute Cardiovascular- Related Hospital Admission Rates for Patients with Heart Failure under the Merit-based Incentive Payment System administrative claims-based quality measure would increase from 5.59 points out of 10 to 7.05 points out of 10. Our analyses showed that, under the proposed methodology, the mean final score would increase by 1.63 points for MIPS eligible clinicians assessed on at least one administrative claims-based quality measure and receiving a quality performance category score.

Specifically, our analyses support the intended goal for the proposed modification to the scoring methodology: MIPS eligible clinicians who perform near the median performance rate for all MIPS eligible clinicians scored on the administrative claims-based measure would receive scores at, or very close to, the performance threshold- derived score. Additionally, the proposed modification would align the scoring methodologies for administrative claims-based measures in the quality and cost performance categories.

We also proposed to modify Sec. 414.1380(b)(1)(i) to specify that, except as specified otherwise under paragraph (b)(1)(ii), the number of measure achievement points received for each such measure is determined based on the applicable benchmark decile category and the percentile distribution. We did not propose any modifications to the remainder of the language currently at Sec. 414.1380(b)(1)(i).

We also proposed to codify benchmarking methodology at Sec. 414.1380(b)(1)(ii)(D) to specify that beginning with the CY 2025 performance period/2027 MIPS payment year, for each administrative claims-based quality measure, CMS determines 10 benchmark ranges based on the median performance rate of all MIPS eligible clinicians scored on the measure, plus or minus standard deviations and that CMS awards achievement points based on which benchmark range a MIPS eligible clinician's performance rate for an administrative claims-based quality measure corresponds. We also proposed to codify at Sec. 414.1380(b)(1)(ii)(D) that, beginning with the CY 2025 performance period/2027 MIPS payment year, CMS awards achievement points equivalent to 10 percent of the performance threshold for a MIPS eligible clinician whose performance rate is equal to the median performance for all MIPS eligible clinicians scored on the measure.

We solicited comments on our proposals to modify our scoring methodology for administrative claims-based quality measures. We also solicited comments on our proposal to codify the scoring methodology for administrative claims-based quality measures in the quality performance category at Sec. 414.1380(b)(1)(i) and (b)(1)(ii)(D).

We received public comments on these proposals. The following is a summary of the comments we received and our responses.

Comment: Many commenters supported the proposal to modify the benchmarking methodology for administrative claims-based quality measures to align with the benchmarking methodology used for cost measures, starting with the CY 2025 performance period/2027 MIPS payment year. Many commenters believe that the proposed methodology change would enhance fairness, promote a more consistent, equitable, and statistically sound scoring process, and improve clinician confidence in the MIPS program. Specifically, several commenters supported the proposal to assign an achievement point value equal to 10 percent of the performance threshold for clinicians whose performance rate equals the median and stated their belief that this adjustment

better reflects average performance and helps ensure that clinicians are not penalized for falling near the statistical center of the distribution. Several commenters noted that the current decile-based benchmark methodology for administrative claims-based measures may result in disproportionately lower scores compared to non- administrative-claims-based measures and noted their belief that this discrepancy undermines the fairness and consistency of MIPS scoring and may inadvertently penalize clinicians--particularly small practice and primary care physicians--who rely on administrative claims-based measures due to limited reporting options or practice infrastructure. A commenter expressed their belief that the proposed approach better reflects how most clinicians are performing, without giving an unfair boost to top outliers.

Response: We thank the commenters for their support.

Comment: Several commenters suggested that CMS apply the proposed benchmarking methodology to all quality measures, not only administrative claims measures. A few commenters believe that the proposed methodology would be an improvement over the existing decile- based quality measure benchmark methodology, as the points assigned to the median performance level from the benchmark period would be 10 percent of the MIPS performance threshold, not 6.0 as it is today. A commenter believes that under the decile-based methodology, if most clinicians' scores differ only slightly from each other, then a small difference in a clinician's score could lead to a large penalty. A few commenters also believe that the proposed methodology, if applied to all quality measures, would encourage clinicians to report more specialty or condition-specific measures and would reduce the complexity and administrative burden clinicians currently face in trying to determine why they received a high or low MIPS quality score as clinicians would be scored by a singular methodology in MIPS. A few commenters did not believe that it is necessary to use a different approach to benchmark non-administrative claims-based measures.

Response: We acknowledge the commenters' recommendation to implement the proposed modified policy for all quality measures in MIPS. In the CY 2017 QPP final rule (81 FR 77286), we finalized that measures submitted by MIPS eligible clinicians are scored using a percentile distribution, separated by decile categories and that for each set of benchmarks, we calculate the decile breaks for measure performance and assign points based on which benchmark decile range the MIPS eligible clinician's measure rate is between. (81 FR 77284).

Based on our analysis of quality measure scores for the CY 2022 performance period/2024 MIPS payment year, we observed substantially lower scores for the administrative claims-based quality measures than for the non-administrative claims-based quality measures. The average quality measure median score for non-administrative claims-based quality measures was above 8 points, while the average quality measure median score for the administrative claims-based quality measures was about 5.5 points. MIPS eligible clinicians who perform near the median performance rate for all MIPS eligible clinicians scored on non- administrative claims-based measure are already receiving scores at or above the performance threshold-derived score. We wanted to ensure that MIPS eligible clinicians who perform near the median performance rate for all MIPS eligible clinicians scored on the administrative claims- based measure would receive scores at, or very close to, the performance threshold-derived score.

The differences in scores between administrative claims-based measures and non-administrative claims based measures, including their medians, led us to propose to modify the methodology for scoring the administrative claims-based measures within the quality performance category beginning with the CY 2025 performance period/2027 MIPS payment year, basing the methodology on standard deviation, median, and an achievement point value that is derived from the performance threshold. Currently, we do not believe that applying the proposed benchmarking methodology to all quality measures is appropriate. While we do acknowledge the complexity with using different benchmarking policies for administrative claims-based measures and non- administrative claims-based quality measures, we note that clinicians would not need to do anything differently under this new scoring methodology since we automatically score administrative claims-based quality measures using claims data. Additionally, the proposed methodology aligns with the benchmarking methodology used for cost measures, which are also administrative claims-based measures and automatically calculated by CMS. We will continue to monitor the benchmarking methodologies for quality measures to determine if additional proposals are warranted in future years.

Comment: Several commenters suggested that CMS be transparent about how benchmark ranges and standard deviations are set each year, establish specific benchmark range thresholds, determined by standard deviations from the median, in regulation, and solicit formal comments before changing the thresholds. A commenter expressed concern regarding CMS adjusting the ranges to increase the penalties for low scores without adequately assessing the impact of those changes. A commenter requested that CMS provide clear guidance and education to help clinicians understand how their scores are derived under the new methodology and provide frequent and timely feedback to clinicians on their performance throughout the measurement year to allow them time to improve. A commenter recommended that CMS provide additional transparency by publishing illustrative data showing how 2024 performance would have been scored under the proposed benchmarking approach.

Response: We thank the commenters for their recommendations. The methodology for determining the benchmark ranges was described in the CY 2026 PFS proposed rule (90 FR 32760). As proposed, the benchmark ranges, the median, and the performance threshold-derived achievement point values aligned with the median would be dynamic and responsive to changes in performance rates assessed by administrative claims-based quality measures and performance thresholds for each CY performance period/MIPS payment year. Additionally, as performance thresholds are established for each performance period/MIPS payment years, the performance threshold-derived point values could also change. At this time, we review the standard deviations from the median used to determine cutoffs for benchmark ranges for each administrative claims- based quality measure for each year based on measure performance across MIPS eligible clinicians and the performance threshold established for the performance period/MIPS payment year. We perform analyses when the performance threshold changes to set the benchmark ranges. To determine the benchmark ranges, we adhere to the following principles: (1) the center of performance rates aligns with the performance threshold- derived point value; (2) determination of benchmark ranges according to the statistical distribution curve of the performance rate; and (3) distribution of achievement

points for administrative claims-based quality measures in alignment with and within expected ranges seen in the quality performance category overall. Any change to the cutoffs for benchmark ranges is based on performance and the impact of these changes would be analyzed. The benchmark ranges, once available, are posted at https://qpp.cms.gov/benchmarks.

We will continue to monitor the impact of these scoring changes on MIPS eligible clinicians and consider making available additional data. Additionally, we plan to make available additional examples and educational materials to inform MIPS eligible clinicians about the new administrative claim-based quality measure benchmarking methodology modifications and the anticipated impact. We will consider this feedback as we continue to work to improve the quality performance category overall.

Regarding the commenters' requests for frequent and timely feedback for MIPS eligible clinicians on their performance, we currently provide annual MIPS Performance Feedback that includes information on MIPS eligible clinicians' performance for the previous performance period. This feedback typically becomes available during the summer in between the performance period and the MIPS payment year, which is as soon as feasible. We provide these reports on an annual basis, as we calculate administrative claims-based quality measures following the end of the performance period. This is because MIPS administrative claim-based quality measure scores are calculated using benchmarks that are derived from data from all MIPS eligible clinicians, groups, and virtual groups that met the measure's case minimum for that performance period. MIPS eligible clinicians have episodes of care that begin and end at various times throughout the performance period, so to calculate an accurate comparison across clinicians, CMS has historically calculated all scores following the end of the performance period. Calculating the MIPS cost measures during the performance period may provide an incomplete indication of how a MIPS eligible clinician is performing. We are continuing to work towards providing meaningful and timely information on quality measures generally and we recognize the importance of providing this information for measures implemented in MIPS.

Comment: A few commenters suggested that CMS explore the use of prior year data when benchmarking administrative claims-based measures, like used for setting benchmarks for measures derived from EHRs or registries since, unlike cost measures, quality performance does not have “inflation” which would preclude the use of prior year data from setting administrative claims-based quality measure benchmarks.

Response: We appreciate the commenters' suggestions. However, we continue to believe that since administrative claims-based quality measures require no data submission, using performance period benchmarks allows for the calculation of more current and representative measure scores that better track clinician performance and progress over time. While quality performance does not have inflation, we continue to believe that using a performance period benchmark to score these measures, instead of a historical benchmark based on prior year data, allows for measure scores that are more reflective of current performance.

Comment: A commenter requested that CMS monitor for any unintended effects, like reduced score variability or less distinction between high and low performers, and readjust the methodology, if needed. A commenter urged CMS to ensure that the revised methodology does not inadvertently disadvantage small or rural practices with limited patient volume and to monitor the impact of the new scoring approach on measure reliability and clinician engagement. A commenter encouraged CMS to continue refining the benchmarking methodologies to ensure balanced assessments across practice sizes and specialties.

Response: We thank the commenters for their recommendation to monitor the impact of the revised methodology and to readjust, if needed. At this time, our analyses support our intended goal for the proposed modification to the scoring methodology: MIPS eligible clinicians with administrative claims-based quality measure performance near the median for all MIPS eligible clinicians attributed the measure would receive scores at, or very close to, the performance threshold- derived score. We will continue to monitor the impact of these scoring changes on MIPS eligible clinicians on performance, measure reliability, and clinician engagement. We will also monitor the impact of these changes across practice sizes, rurality, and specialties.

After consideration of public comments, we are finalizing our proposals, as proposed, to modify our scoring methodology for administrative claims-based quality measures beginning with the CY 2025 performance period/2027 MIPS payment year and codify the scoring methodology for administrative claims-based quality measures in the quality performance category at Sec. [thinsp]414.1380(b)(1)(i) and (b)(1)(ii)(D). 2. MIPS Payment Adjustments a. Background

Section 1848(q)(6)(A) of the Act requires that we specify a MIPS payment adjustment factor for each MIPS eligible clinician for a year. This MIPS payment adjustment factor is a percentage determined by comparing the MIPS eligible clinician's final score for the given year to the performance threshold we established for that same year in accordance with section 1848(q)(6)(D) of the Act. The MIPS payment adjustment factors specified for a year must result in differential payments such that MIPS eligible clinicians with final scores above the performance threshold receive a positive MIPS payment adjustment factor, those with final scores at the performance threshold receive a neutral MIPS payment adjustment factor, and those with final scores below the performance threshold receive a negative MIPS payment adjustment factor.

For previously established policies regarding our determination and application of MIPS payment adjustment factors to each MIPS eligible clinician, we refer readers to the CY 2017 Quality Payment Program final rule (81 FR 77329 through 77343), CY 2018 Quality Payment Program final rule (82 FR 53785 through 53799), CY 2019 PFS final rule (83 FR 59878 through 59894), CY 2020 PFS final rule (84 FR 63031 through 63045), CY 2021 PFS final rule (85 FR 84917 through 84926), CY 2022 PFS final rule (86 FR 65527 through 65537), CY 2023 PFS final rule (87 FR 70096 through 70102), CY 2024 PFS final rule (88 FR 79373 through 79380), and CY 2025 PFS final rule (89 FR 98448 through 98455). b. Establishing the Performance Threshold (1) Statutory Authority and Background

As discussed in this section of this final rule, to determine a MIPS payment adjustment factor for each MIPS eligible clinician for a year, we must compare the MIPS eligible clinician's final score for the given year to the performance threshold we established for that same year in accordance with section 1848(q)(6)(D) of the Act. Section 1848(q)(6)(D)(i) of the Act requires that we compute the performance threshold such that it is the mean or median (as selected by the Secretary) of the final

scores for all MIPS eligible clinicians with respect to a prior period specified by the Secretary. Section 1848(q)(6)(D)(i) of the Act also provides that the Secretary may reassess the selection of the mean or median every 3 years.

Sections 1848(q)(6)(D)(ii) through (iv) of the Act provided special rules, applicable only for certain initial years of MIPS, for our computation and application of the performance threshold for our determination of MIPS payment adjustment factors. These special rules are no longer applicable for establishing the performance threshold beginning with the CY 2022 performance period/2024 MIPS payment year. We refer readers to the CY 2024 PFS proposed rule (88 FR 52596) for further information on these previously applicable requirements as they explain our prior computations of the performance threshold.

In the CY 2025 PFS final rule (89 FR 98448 through 98451), we selected the mean as the methodology for determining the performance threshold for the CY 2025 performance period/2027 MIPS payment year through CY 2027 performance period/2029 MIPS payment year. We codified this policy in our regulation at Sec. 414.1405(g)(2), providing that, for each of the 2027, 2028, and 2029 MIPS payment years, the performance threshold would be the mean of the final scores for all MIPS eligible clinicians from a prior period as specified at Sec. 414.1405(b)(10) (89 FR 98448 through 98451; 89 FR 98564). In the CY 2025 PFS final rule, we established the performance threshold for the CY 2025 performance period/2027 MIPS payment year by calculating the mean of the final scores for all MIPS eligible clinicians using CY 2017 performance period/2019 MIPS payment year data (89 FR 98451 through 98455). We also codified this performance threshold at Sec. 414.1405(b)(10)(i) (89 FR 98451 through 98455; 89 FR 98564).

We note that, in previous years, we have established the performance threshold for each performance period during the rulemaking cycle immediately preceding the performance period. However, section 1848(q)(6)(D)(i) of the Act does not specify when the Secretary shall compute a performance threshold that would apply for each MIPS payment year. Instead, section 1848(q)(6)(D)(i) of the Act provides the Secretary shall compute a performance threshold for each MIPS payment year based on the mean or median (selected once every 3 years) of the MIPS final scores for all MIPS eligible clinicians with respect to a prior period specified by the Secretary. We have determined that the performance threshold may be established with respect to the applicable year at any time as long as the performance threshold continues to be based on a prior period specified by the Secretary. In other words, we could establish a performance threshold that would apply to multiple MIPS payment years. We note that we may not always establish the performance threshold for multiple MIPS payment years, but we will consider this as an option as we continue to ensure that the performance threshold is truly reflective of MIPS eligible clinicians' performance in MIPS. Due to several large programmatic changes (such as, transitioning to reporting MVPs and digital quality measures and potential introduction of “Core Elements” for selection of quality measures in MVPs) discussed further in sections IV.A.3.b. and IV.A.4.c. of this final rule, establishing the same performance threshold for the 2028, 2029, and 2030 payment years would allow us to provide stability and predictability to MIPS eligible clinicians as they adapt to and implement our policy changes for MIPS.

As further discussed under section IV.B.2.b.(2) of this final rule, we proposed to continue using the mean of the final scores for all MIPS eligible clinicians from the CY 2017 performance period/2019 MIPS payment year to establish the performance threshold as 75 points for the CY 2026 performance period/2028 MIPS payment year through the CY 2028 performance period/2030 MIPS payment year. We recognized that our proposal to establish the performance threshold for MIPS payment years 2028, 2029, and 2030 extends beyond the period for which we have established the mean methodology to determine the performance threshold. However, given the current statutory requirement, which allows us to reassess the methodology every 3 years, there is no requirement that prevents us from setting the methodology for a longer time frame. We plan to reassess the methodology in future rulemaking.

For further information on our current performance threshold policies, we refer readers to the CY 2017 Quality Payment Program final rule (81 FR 77333 through 77338), CY 2018 Quality Payment Program final rule (82 FR 53787 through 53792), CY 2019 PFS final rule (83 FR 59879 through 59883), CY 2020 PFS final rule (84 FR 63031 through 63037), CY 2021 PFS final rule (85 FR 84919 through 84923), CY 2022 PFS final rule (86 FR 65527 through 65532), CY 2023 PFS final rule (87 FR 70096 through 70100), CY 2024 PFS final rule (88 FR 79373 through 79380), and CY 2025 PFS final rule (89 FR 98448 through 98455).

We codified the performance thresholds for each of the first 9 years of MIPS at Sec. 414.1405(b)(4) through (10). These performance thresholds are shown in Table C-J1.

[GRAPHIC] [TIFF OMITTED] TR05NO25.149

(2) Performance Threshold for the CY 2026 Performance Period/2028 MIPS Payment Year Through the CY 2028 Performance Period/2030 MIPS Payment Year

In the CY 2026 PFS proposed rule, we proposed to use the mean of 75 points from the CY 2017 performance period/2019 MIPS payment year as it continues to be the most appropriate for establishing the performance threshold for the 2028, 2029, and 2030 MIPS payment years for several reasons (90 FR 32763 through 32765). As further described in this section of this final rule, these reasons include providing stability and predictability for MIPS eligible clinicians, allowing MIPS eligible clinicians to gain experience with MVPs and other new MIPS policies, and continuing to support solo, small, and rural practices. [GRAPHIC] [TIFF OMITTED] TR05NO25.150

At the time of the CY 2026 proposed rule, we had data available on MIPS eligible clinicians' final scores from the CY 2017 performance period/2019 MIPS payment year through CY 2023 performance period/2025 MIPS payment year. As shown in Table C-J2, we calculated the mean values of MIPS eligible clinicians' final scores for each year from the CY 2017 performance period/2019 MIPS payment year through the CY 2023 performance period/2025 MIPS payment year. As discussed in the CY 2026 proposed rule, we did not have MIPS eligible clinicians' final scores available from the CY 2024 performance period/2026 MIPS payment year and, therefore, the mean final score for the CY 2024 performance period/2026 MIPS payment year was not included for consideration as a potential performance threshold value for the 2028, 2029, and 2030 MIPS payment years. As discussed further in this section of this final rule, we believe that the mean of 75 points from the CY 2017 performance period/CY 2019 MIPS payment year continues to be the most appropriate option that would provide stability and predictability for MIPS eligible clinicians while still encouraging high quality of care.

First, when looking at the data for purposes of establishing a performance threshold for the 2028 through 2030 MIPS payment years, we did not consider any data from the CY 2019 performance period/2021 MIPS payment year through the CY 2021 performance period/2023 MIPS payment year, as they were impacted by the Public Health Emergency (PHE) for the Coronavirus Disease 2019 (COVID-19), which we discussed in further detail in the CY 2025 PFS final rule (89 FR 98451 through 98453). The geographic differences of COVID-19 incidence rates along with different impacts resulting from Federal, State, and local laws and policy changes implemented in response to the PHE for COVID-19 may have affected which MIPS eligible clinicians were able to submit data for the CY 2019 performance period. This may have led to final scores that were not wholly representative of performance for all MIPS eligible clinicians. Also, for the CY 2020 performance period/2022 MIPS payment year and the CY 2021 performance period/2023 MIPS payment year, we extensively applied our reweighting policies, described at Sec. 414.1380(c)(2)(i), to MIPS eligible clinicians nationwide due to the PHE for COVID-19.

Inherently, these actions, particularly re-weighting the performance categories, skewed the final scores from those years such that they are not an appropriate indicator for future performance of

MIPS eligible clinicians. Specifically, we are concerned that the final scores during the PHE for COVID-19 reflect the performance of only MIPS eligible clinicians that may have been less impacted by the pandemic, and do not accurately represent MIPS eligible clinician performance overall during this period. Since the Federal PHE for COVID-19 expired on May 11, 2023,\469\ many of the flexibilities and exceptions applied during the PHE for COVID-19, such as the extreme and uncontrollable circumstances reweighting policies described at Sec. 414.1380(c)(2)(i), are no longer being applied in the context of the pandemic. In the interest of establishing a performance threshold using data that is reflective of clinician performance that is not affected by the-PHE for COVID-19, continuing to use data from the CY 2017 performance period/2019 MIPS payment year to establish a performance threshold for the 2028, 2029 and 2030 MIPS payment years will allow us time to gather additional data that is more reflective of clinician performance outside of the PHE for COVID-19. We acknowledge more recent data will be available between CY 2026 performance period/2028 MIPS payment year through CY 2028 performance period/2030 MIPS payment year; however, with the various programmatic changes discussed in this section of the proposed rule, we aim to provide stability and predictability to MIPS eligible clinicians as they transition, implement, and adapt to these changes.

\469\ https://www.hhs.gov/coronavirus/covid-19-public-health-emergency/index.html.

As new MVPs and their related changes are being introduced into the program, and as more MIPS eligible clinicians transition to MVP reporting, we want to provide some stability for MIPS eligible clinicians and allow time for more MVP data to become available. Specifically, in section IV.A.3. of this final rule, we discuss several policies to support our goal of phasing out traditional MIPS and fully transitioning to MVP reporting. As stated in the CY 2025 PFS proposed rule, we discussed that we anticipate to fully transition to MVPs by the CY 2029 performance period/2031 MIPS payment year (89 FR 62012). In section IV.A.3.b. of this final rule, we solicited comments in an RFI for a potential policy wherein MVP Participants would select one quality measure from a subset of quality measures in each MVP, referred to as “Core Elements” and MVP Participants would select the other 3 required quality measures and would still have to meet existing MVP reporting requirements. We are considering proposing the Core Elements policy in the CY 2027 PFS proposed rule and proposing the policy for implementation prior to sunsetting traditional MIPS. Further, as discussed in section IV.A.4.c. of this final rule, we aim to fully transition to a digital quality measure (dQM) landscape that promotes interoperability and increases the value of reporting quality measure data. As we continue to consider these potential policy changes over the next several years, we aim to provide consistency to MIPS eligible clinicians by maintaining the performance threshold at 75 points for the 2028, 2029, and 2030 MIPS payment years. Meanwhile, we will continue to evaluate how the performance threshold can best reflect clinicians' performance in MIPS.

While the CY 2018 performance period/2020 MIPS payment year's data predate the PHE for COVID-19, we continue to be concerned that an increase in the performance threshold will inadvertently harm certain clinician types, specifically small practices and solo practitioners. As we stated in the CY 2024 PFS final rule, we want to consider the impacts of the performance threshold and its related policies on small practices (88 FR 79377). As discussed in the CY 2025 PFS final rule, we have received feedback that many small practices and solo practitioners face challenges in their ability to participate in MIPS, including the costs to implement and maintain certified electronic health record (EHR) technology (CEHRT), staff and training costs, and limited staff capacity to manage the complexity of the program (89 FR 98451 through 98453). As discussed in the CY 2025 PFS final rule, we also learned that increases in the performance threshold add administrative and financial burden for small practices that discourage their participation in MIPS (89 FR 98451 through 98454).

Further, in a survey distributed during the summer of CY 2024, we learned that, of the small practices and solo practitioners that participated in the survey, the three major barriers for submitting MIPS data included: the burden of data collection and submission, lack of administrative support, and high costs associated with participating in the program. The small practices and solo practitioners that responded to the survey indicated that simplified reporting requirements, free technical assistance, and better informational resources may improve their participation in MIPS.

Though we have several policies within MIPS that continue to support small and solo practices, including scoring and reweighting policies, we are interested in understanding how to best support small practices and enhance their ability to successfully participate in MIPS as MIPS continues to evolve (89 FR 98451 through 98453). As such, we continue to perform qualitative analysis through engagement with small practices, third party intermediaries, and other interested parties to gather information about the experience of small practices participating in the program. Maintaining a performance threshold of 75 points for the 2028, 2029, and 2030 MIPS payment years would allow us to continue developing strategies to reduce barriers for small practices and solo practitioners participating in MIPS.

Finally, as discussed in section IV.B.1.a.(2) of this final rule, we are continuing to assess how to best address our topped-out scoring policy within the quality performance category. Historically, there have been concerns that certain specialties only have topped out measures to report, which would make it difficult for them to meet an increased performance threshold even if they perform very well on those measures. Hence, as we continue to evaluate these programs scoring policies, establishing the performance threshold at 75 points will avoid inadvertently harming these clinician types.

Alternatively, in the CY 2026 PFS proposed rule (90 FR 32765), we considered maintaining the performance threshold at 75 points for either: (1) the CY 2026 performance period/2028 MIPS payment year and CY 2027 performance period/2029 MIPS payment year (excluding the CY 2028 performance period/2030 MIPS payment year, which is currently proposed); or (2) only the CY 2026 performance period/2028 MIPS payment year. We also considered raising the performance threshold. However, as previously discussed, based on the data that we have available, we believe that our proposal to set the performance threshold at 75 points for the 2028, 2029, and 2030 payment years provides stability as MIPS enters a period of transition agnostic of our discretion to reassess the performance threshold methodology for the CY 2028 performance period/2030 MIPS payment year. We will reassess the use of the median or mean methodology in future rulemaking in accordance with section 1848(q)(6)(D)(i) of the Act. We refer readers to section IV.B.2.b.(3) of this final rule for Request for Information (RFI) on Future MIPS Performance Thresholds for more discussion on establishing the

performance threshold for single versus multiple years and potentially increasing the performance threshold in future rulemaking.

We refer readers to the section VII.I.5.d.(4)(c) of this final rule for an estimate of the percent of MIPS eligible clinicians that would receive a negative payment adjustment for the CY 2026 performance period/2028 MIPS payment year if the performance threshold is set at 75 points as proposed.

Maintaining a performance threshold of 75 points allows additional time for more MVP data to become available, continues to provide opportunities for clinicians to become familiar with the transition to MVPs, and ensures that we continue to support certain clinician types, such as small practices, solo practitioners, rural providers, and clinicians who have several topped out measures. Therefore, we proposed to establish a performance threshold of 75 points for the 2028, 2029, and 2030 MIPS payment years based on the mean of MIPS eligible clinicians' final scores from the CY 2017 performance period/2019 MIPS payment year. We also proposed to codify this performance threshold by adding Sec. 414.1405(b)(10)(ii).

We solicited public comments on our proposal to establish a performance threshold of 75 points for the 2028, 2029, and 2030 MIPS payment years based on the mean of MIPS eligible clinicians' final scores from the CY 2017 performance period/2019 MIPS payment year. We also solicited comments on our proposal to codify this performance threshold by adding Sec. 414.1405(b)(10)(ii).

We received public comments on these proposals. The following is a summary of the comments we received and our responses.

Comment: Many commenters supported the proposal to continue using the mean of 75 points from CY 2017 performance period/2019 MIPS payment year for the CY 2026 performance period/2028 MIPS payment year. Many commenters agreed that this proposal would provide stability and predictability for clinicians as they transition to MVPs and adjust to the cost performance category changes. Some suggested that it would also alleviate the burden on smaller practices as they do not have adequate resources to meet an increased performance threshold. A few commenters shared their belief that this would help alleviate the burden on physicians as they deal with inflation. At least one commenter appreciated the stability as they work on developing additional quality measures for their specialty.

Response: We thank the commenters for their support.

Comment: A commenter stated that they do not support the performance threshold of 75 for the CY 2026 through 2028 performance periods/CY 2028 through 2030 MIPS payment years due to concerns that the CY 2017 performance/2019 MIPS payment year data being used to establish the mean is too old. More specifically, the comment stated that MIPS participation in 2017 was significantly lower than today and using data from the CY 2017 performance/2019 MIPS payment year is not necessarily reflective of the program today.

Response: We thank the commenter for their feedback. We acknowledge that we want to utilize the data that is most reflective of MIPS eligible clinicians' performance for the purpose of establishing the performance threshold. However, as noted, for the 2028 through 2030 MIPS payment years, we did not consider any data from the CY 2019 performance period/2021 MIPS payment year through the CY 2021 performance period/2023 MIPS payment year, as they were impacted by the PHE for COVID-19 and related policies. Additionally, while we have CY 2018 performance period/2020 MIPS payment year data available which predates the PHE for COVID-19, we note that the mean of the performance period data from that time would be 87 points and we continue to be concerned that an increase in the performance threshold will inadvertently harm certain clinician types, specifically small practices and solo practitioners. Hence, in the interest of establishing a performance threshold using data that is reflective of clinician performance that is not affected by the-PHE for COVID-19, we continue to use data from the CY 2017 performance period/2019 MIPS payment year to establish a performance threshold for the 2028, 2029 and 2030 MIPS payment years. This will also allow time to continue to gather additional data that is more reflective of clinician performance outside of the PHE for COVID-19.

Comment: A commenter supported the proposal to continue using the mean of 75 points from CY 2017 performance period/2019 MIPS payment year for the CY 2026 performance period/2028 MIPS payment year but expressed concerns with small and rural practices and how they continue find it challenging to meet the performance threshold compared to larger group practices.

Response: We have several policies within MIPS that continue to support small and rural practices, including bonus points (83 FR 59847 through 59850) and reweighting policies (86 FR 65521 through 65524), and opportunities to apply for hardships (81 FR 77240 through 77243). As we continue to conduct related analysis, we will continue to consider the impact of the performance threshold on small and rural practices.

Comment: A commenter expressed concerns that it was not within statutory limitations to establish the performance threshold for multiple years.

Response: We disagree. Section 1848(q)(6)(D)(i) of the Act provides the Secretary shall compute a performance threshold for each MIPS payment year based on the mean or median of the MIPS final scores for all MIPS eligible clinicians with respect to a prior period specified by the Secretary. We have determined that the performance threshold may be established with respect to the applicable year at any time if the performance threshold continues to be based on a prior period specified by the Secretary.

After consideration of public comments, we are finalizing as proposed to establish a performance threshold of 75 points for the 2028, 2029, and 2030 MIPS payment years based on the mean of MIPS eligible clinicians' final scores from the CY 2017 performance period/ 2019 MIPS payment year. We are also finalizing our proposal to codify this performance threshold by adding Sec. 414.1405(b)(10)(ii). (3) Request for Information on Future MIPS Performance Thresholds

As we consider the potential changes within MIPS while aiming to ensure that the performance threshold reflects clinician performance, we also requested public feedback on the following issues:

Establishing the performance threshold for single versus multiple years (for example, 1, 2, or 3 years at a time) via rulemaking; and

As we approach later years in MIPS, increasing the performance threshold based on data from a prior period which potentially would provide larger positive MIPS payment adjustments for MIPS eligible clinicians with MIPS final scores higher than such performance threshold.

We appreciate the feedback we received in response to this comment solicitation. We may consider this information to inform future rulemaking.

Figure C-J1 provides an illustrative example of how various final scores would be converted to a MIPS payment adjustment factor using the statutory formula and based on our proposed policies for the CY 2026 performance period/2028 MIPS payment year. In Figure C-J1, the performance threshold is set at 75 points, as we have proposed in section IV.B.2.b.(2) of this final rule.

For purposes of determining the maximum and minimum range of potential MIPS payment adjustment factors, section 1848(q)(6)(B) of the Act defines the applicable percentage as 9 percent for the CY 2026 performance period/2028 MIPS payment year. We calculate the MIPS payment adjustment factor using a linear sliding scale in accordance with section 1848(q)(6)(F)(i) of the Act. This linear sliding scale is calculated based on MIPS final scores from zero to 100, with zero being the lowest possible score which receives the negative applicable percentage and resulting in the lowest payment adjustment, and 100 being the highest possible score which receives the highest positive applicable percentage and resulting in the highest payment adjustment.

However, there are two modifications to this linear sliding scale. First, as specified in section 1848(q)(6)(A)(iv)(II) of the Act, there is an exception for a final score between zero and one-fourth of the performance threshold (zero and 18.75 points based on the proposed performance threshold of 75 points for the CY 2026 performance period/ 2028 MIPS payment year). All MIPS eligible clinicians with a final score in this range will receive a negative MIPS payment adjustment factor equal to 9 percent (the applicable percentage). Second, the linear sliding scale for the positive MIPS payment adjustment factor is adjusted by the scaling factor, which cannot be higher than 3.0, as required by section 1848(q)(6)(F)(i) of the Act.

If the scaling factor is greater than zero and less than or equal to 1.0, then the MIPS payment adjustment factor for a final score of 100 will be less than or equal to 9 percent (the applicable percentage). If the scaling factor is above 1.0 but is less than or equal to 3.0, then the MIPS payment adjustment factor for a final score of 100 will be greater than 9 percent. Only those MIPS eligible clinicians with a final score equal to 75 points (the performance threshold proposed for the CY 2026 performance period/2028 MIPS payment year) will receive a neutral MIPS payment adjustment.

Beginning with the CY 2023 performance period/2025 MIPS payment year, the additional MIPS payment adjustment for exceptional performance described in section 1848(q)(6)(C) of the Act is no longer available. For this reason, Figure 5 does not illustrate an additional adjustment factor for MIPS eligible clinicians with final scores at or above the additional performance threshold described in section 1848(q)(6)(D)(ii) of the Act. [GRAPHIC] [TIFF OMITTED] TR05NO25.151

Table C-J3 illustrates the changes in payment adjustment based on the final policies from the CY 2025 PFS final rule (89 FR 98448 through 98455) for the CY 2025 performance period/2027 MIPS payment year and the finalized policies for the CY 2026 performance period/2028 MIPS payment year, as well as the applicable percent required by section 1848(q)(6)(B) of the Act.

[GRAPHIC] [TIFF OMITTED] TR05NO25.152