CMS-1849-P CJR-X FY27 IPPS Proposed Rule · Mandatory PY1 · Oct 1 2027 · 2% discount factor · 90-day episode · 100% regional benchmark

CJR-X Opportunity & Risk Analyzer

Per-hospital analytical workbench for the proposed CJR-X mandatory bundle. 2,663 acute-care hospitals with reportable LEJR volume joined across five CMS public datasets. Inpatient (DRG 469/470/521/522) and HOPD (APC 5115 / HCPCS 27130 & 27447) financial exposure, hip/knee excess readmission ratios, Hospital Overall Star Ratings, and CJR-Model historical performance — composited into an opportunity score and a CQS readiness tier estimate. Filter, map, and drill in.

N Hospitals

—

IP + HOPD LEJR activity

Mandatory · CMS-1849-P

—

≥31 LEJR episodes/yr

Anchor Spend (A+OPPS)

—

Part A + OPPS, anchor only

Est. Total 90-Day Spend

—

all episodes combined · anchor × 1.65

2% Discount Exposure

—

flat discount × episode spend

Projected ±20% Risk Band

—

CJR & TEAM precedent

Total Procedures

—

IP discharges + HOPD svc

IP Part A

—

DRG 469/470/521/522

HOPD OPPS

—

APC 5115 / 27130 · 27447

CJR Alumni

—

prior CJR Model participants

Hospital IQR PRO-PM Penalty Exposure

FY2026 modeled · applies to all Medicare IPPS inpatient revenue (not only LEJR)

Market-basket update % IQR fraction forfeited

PRO-PM Exposure (filtered)

—

filtered hospitals · 0.725% × OP IPPS base

Effective Rate Applied

0.725%

IQR fraction × market-basket update

FY2026 Modeled IPPS Base

—

Σ operating IPPS payments, filtered set

Hospitals With Impact-File Match

—

of filtered set · gaps explained below

Methodology note — estimated figures. "Est. 90-Day Episode Spend," "2% Discount Exposure," and "±20% Risk Band" are derived by applying a ×1.65 national multiplier to anchor-admission spend. This multiplier reflects the finding that anchor hospitalization represents ~60% of total 90-day episode cost (Barnett et al., NEJM 2019; CMS CJR Evaluation Reports PY6-7). It is a national average and does not account for hospital-specific post-acute utilization patterns — hospitals with high SNF/IRF referral rates will have higher true episode costs, and those with strong home-health pathways will have lower. These figures are planning estimates, not claims-level calculations. Actual CJR-X target prices will be set by CMS using regional benchmarks and 29 risk adjusters applied to hospital-specific episode data.

Methodology · IQR PRO-PM Penalty — full derivation, sources, and caveats

Statutory basis. Section 1886(b)(3)(B)(viii) of the Social Security Act requires that subsection (d) hospitals that do not submit required IQR quality data have their "applicable percentage increase" (the annual market-basket update to the standardized amount) reduced by one-quarter for the applicable fiscal year. The Hip/Knee THA/TKA Patient-Reported Outcome-Based Performance Measure (PRO-PM) — NQF #3559e — is required as part of the IQR program beginning with FY2028 payment determinations. Hospitals that fail to report it at the required threshold (≥50% of eligible elective primary THA/TKA cases with pre-op and 300-to-425-day post-op data in the reporting cohort) lose 25% of their applicable market-basket update.

Formula.
PRO-PM Penalty $ = IQR fraction × Market-basket update % × Operating IPPS revenue
At the default of 0.25 × 2.9%, the effective rate is 0.725% of the operating IPPS base per hospital per year. Both constants are user-overridable in the panel above.

Operating IPPS revenue — per-CCN construction. Computed from the CMS FY 2026 IPPS Final Rule Impact File (August 2025 release, CMS-1833-F) using the same payment logic CMS uses to model payments in that file:

Standardized amount = labor rate × Wage Index + non-labor rate × COLA (COLA = 1.0 unless AK/HI). Rates from Tables 1A/1B/1C; table applied per hospital WI and PR status (Table 1C for Puerto Rico).
Operating federal per weight = standardized amount × (1 + TCHOP + DSHOPP), using Impact File fields for indirect medical education adjustment (TCHOP) and disproportionate share (DSHOPP).
Capital federal per weight = federal capital rate (Table 1D) × GAF × (1 + TCHCP + DSHCPP).
Scale to annual hospital payment = (op_fed + cap_fed) per weight × CASETA43 × TACMIV43, where CASETA43 is transfer-adjusted Medicare cases and TACMIV43 is transfer-adjusted case mix index under Grouper V43 — the product CMS itself uses to model FY2026 hospital payments in the Impact File.
Uncompensated care / IHS / PR supplemental per-claim payment is scaled by CASETA43 (flat per-claim adder; not subject to CMI).
The penalty base (denominator of the 0.25 × MBU multiplier) is the operating portion only — the market-basket update adjusts the standardized amount by statute, so capital federal and UC per-claim payments are not exposed to the IQR reduction.

What's intentionally excluded from the modeled base.

Outlier payments — paid from a separate pool, not subject to market-basket update. The Impact File OUTFACT_F is retained for a warning flag on our table rows but not added to the PRO-PM base.
Sole Community Hospital / Medicare-Dependent Hospital hospital-specific rates — SCH and MDH providers may be paid their HSP rate if higher than the federal rate. The Impact File models federal-rate payments; SCH/MDH hospitals paid under HSP will see the modeled federal number under-represent true Medicare revenue. Flag: provider_type = 7 (SCH) or 14/15 (MDH).
VBP, HRRP, HAC penalty/bonus adjustments — the Impact File proxy fields (Proxy Readmission Adjustment Factor, Proxy Quality Reduction, Proxy EHR Reduction) are not applied to the modeled base. They belong to a separate reconciliation stream; the IQR statute references the pre-adjustment standardized amount.
Pass-through payments (GME, Medicare bad debt, organ acquisition, new-technology add-ons) — paid via cost report settlement, not through the IPPS standardized amount.
Medicare Advantage case payments — IME for MA cases is paid separately and is not in the IQR update base.
Hospitals not in the FY2026 Impact File — 3,173 CCNs appear in the file; the CJRX universe is 2,663. Hospitals without a match (e.g. newly certified, rebranded under a new CCN, or subacute facilities) show — in the PRO-PM column and are excluded from the aggregate KPI. The "Hospitals With Impact-File Match" KPI surfaces this gap.

Comparability. The aggregate FY2026 modeled operating IPPS payment across all 3,173 matched CCNs is ~$100.7B; all-in (operating + capital + UC) is ~$115.9B. These numbers are in the range of CMS' own budget tables for the IPPS program ($~115B–$130B), and the difference vs. published totals is attributable to the exclusions listed above — principally outlier, HSP-rate payments to SCH/MDH hospitals, and supplemental pass-throughs that do not flow through the Impact File's federal-rate model.

Use as a planning figure, not a reconciliation. A hospital's actual PRO-PM exposure is the reduction to next year's standardized amount applied across that year's discharges, reconciled in the mid-year PSF updates. The figures here project forward using this year's volumes and rates as a proxy — accurate to within the volume variance of the hospital from one year to the next, typically ±5–10%.

Sources. CMS-1833-F (FY 2026 IPPS Final Rule) · FY 2026 IPPS Final Rule Impact File (August 2025) · Tables 1A–1E and Table 5 from the Final Rule · Medicare Program Statistics IPPS aggregate payments · §1886(b)(3)(B)(viii) SSA · NQF #3559e Hospital-Level PRO-PM specifications.

Loading aggregates…

Start Here

What is CJR-X and what does this tool do?

This page is built for hospital administrators, finance teams, consultants, and anyone trying to understand Medicare's newest bundled payment program and how it could affect a specific hospital. No jargon required — everything is explained below.

▸The big pictureWhat is CJR-X?

CJR-X stands for Comprehensive Care for Joint Replacement — Expanded. It is a proposed Medicare rule (formally called CMS-1849-P) that would require most U.S. hospitals performing hip, knee, and ankle replacements to take financial responsibility for a patient's full care episode — not just the surgery itself, but all related costs for 90 days after discharge.

If a hospital's total episode cost comes in below a regional benchmark, it keeps some of the savings. If it comes in above, it owes Medicare back. CMS applies a flat 2% discount factor to the benchmark price upfront, representing Medicare's guaranteed savings. Hospitals that achieve "Good" or "Excellent" quality categories (via the Composite Quality Score) can see a reduced effective discount at reconciliation — meaning they keep more of their savings. Hospitals rated "Below Acceptable" are ineligible for any reconciliation payments.

Safety-net and certain rural hospitals are protected with a 5% stop-loss cap throughout all performance years. The standard stop-loss limit for other hospitals has not been explicitly defined in the proposed rule text, though the original CJR model used a phased approach reaching 20%. The model uses 29 risk adjusters (up from 3 in original CJR) to account for patient complexity.

The program is mandatory for hospitals with 31 or more LEJR episodes during the baseline period (hip, knee, and ankle combined, inpatient and outpatient). Hospitals with fewer than 31 episodes are classified as "low-volume" and excluded from financial reconciliation. It would begin October 1, 2027.

Why does this matter? Over 2,000 hospitals and $6.4 billion in Medicare joint replacement spending would be affected. Under the 2% discount alone, the aggregate exposure is ~$129M. But actual downside risk exposure is significantly larger — safety-net hospitals face up to 5% of episode spend, and standard hospitals could face substantially more under the full reconciliation framework. Hospitals that are not prepared risk paying money back to CMS. This tool helps identify which hospitals face the most exposure and how ready they appear to be.

▸Key termsGlossary of acronyms

LEJR
Lower-Extremity Joint Replacement — hip and knee replacements. The procedures CJR-X bundles.
DRG
Diagnosis-Related Group — how Medicare classifies inpatient hospital stays. DRGs 469, 470, 521, and 522 are the hip/knee replacement groups.
APC 5115
Ambulatory Payment Classification — how Medicare classifies outpatient (HOPD) procedures. APC 5115 is where outpatient hip/knee replacements are billed.
HOPD
Hospital Outpatient Department — the outpatient surgery setting (as opposed to a traditional inpatient stay).
IP
Inpatient — a traditional hospital admission, usually overnight.
ERR
Excess Readmission Ratio — measures whether a hospital's readmission rate is higher or lower than expected. An ERR of 1.0 means exactly average; above 1.0 means more readmissions than expected.
CQS
Composite Quality Score — CJR-X's 5-measure quality score that determines whether a hospital gets a reduced discount (better quality = smaller penalty).
CCN
CMS Certification Number — the unique 6-digit ID Medicare assigns to every hospital.
HCPCS 27130 / 27447
Procedure codes for total hip replacement and total knee replacement, respectively.
Star Rating
CMS Hospital Overall Star Rating (1–5 stars) — a public quality score based on mortality, safety, readmissions, patient experience, and timely care.
HRRP
Hospital Readmissions Reduction Program — a separate CMS program that penalizes hospitals with higher-than-expected readmission rates by reducing their Medicare inpatient payments up to 3%. THA/TKA (hip/knee) is one of six HRRP measures. Hospitals already penalized under HRRP face compounding risk under CJR-X.
CJR Alumni
Hospitals that participated in the original CJR bundled payment model (2016–2024). Their historical performance data gives us early signals about how they might perform under CJR-X.

▸Reading the numbersWhat the columns and scores mean

Opportunity Score (0–100)
A composite number we calculate to rank hospitals by how much is at stake. Higher = more dollars at risk AND more room for quality improvement. It blends: total spend (35%), readmission risk (30%), star rating gap (20%), and CJR historical performance (15%).
Annual LEJR Spend
How much Medicare paid this hospital for hip/knee replacements last year — inpatient Part A plus outpatient OPPS combined. This is the anchor-admission payment only (see "Why are volumes low?" below).
Anchor Spend
The Medicare payment for the anchor admission (IP Part A) or anchor procedure (HOPD OPPS) only. This is what our public datasets contain. It does NOT include post-discharge costs (SNF, HHA, IRF, physician visits, readmissions, Part B).
Est. 90-Day Episode
Estimated total 90-day episode cost, calculated as anchor spend × 1.65. This multiplier is derived from the CJR evaluation literature (Barnett et al., NEJM 2019; CMS CJR PY6-7 Annual Reports), which found anchor hospitalization represents approximately 60% of total episode spending. The remaining ~40% covers SNF, HHA, IRF, physician/Part B, and readmissions. This is the spend figure that would be compared against the CJR-X target price.
±20% Risk Band
Projected maximum dual-sided financial exposure per hospital based on CJR and TEAM precedent. Both models ramped to 20% stop-loss (downside repayment) and 20% stop-gain (upside savings) in later performance years. This is a two-way risk corridor: hospitals can owe CMS up to 20% of episode spend OR earn up to 20% back. Safety-net hospitals are capped at ±5%. Not yet explicitly confirmed for CJR-X — shown as a projected planning figure.
Hip/Knee ERR
The hospital's excess readmission ratio for hip/knee patients. Below 1.0 = fewer readmissions than expected (good). Above 1.0 = more than expected (risk flag).
Readiness Tier
Our estimate of where this hospital would land on the CJR-X quality spectrum, based on its current star rating and readmission rate. Ranges from "Likely Good/Excellent" (reduced effective discount, lowest financial risk) to "At Risk — Below Acceptable" (full 2% discount with no reconciliation eligibility).
IP Vol / HOPD Vol
How many inpatient discharges (IP) and outpatient services (HOPD) this hospital performed for hip/knee replacement. Small numbers are expected — see below.

Why are the volumes small? This data only counts Medicare fee-for-service claims. It excludes Medicare Advantage (which covers ~50% of Medicare beneficiaries), all commercial insurance, Medicaid, self-pay, and VA. A hospital doing 500 total joint replacements/year might show only 80–120 in this dataset. The spend figures are similarly Medicare-only. Actual total joint replacement volume at most hospitals is 3–5× higher than what appears here.

▸How to use this toolQuick start guide

1. Browse the table — Hospitals are ranked by opportunity score (highest first). Use the filters above the table to narrow by state, star rating, quality tier, alumni status, or setting type.

2. Click any row — Expanding a hospital row shows the full detail card: DRG-level volume breakdown, inpatient vs. outpatient split, score component bars, and CJR alumni history if applicable.

3. Explore the map — Scroll down to see all hospitals plotted geographically. Dots are color-coded by readiness tier. Clusters show counts; zoom in to see individual hospitals. Click any dot for a quick-stats popup.

4. Check methodology — The "Methodology" section documents every data source and scoring formula. The "Rule" section summarizes the CJR-X program parameters with citations to the actual regulation.

Remember: CJR-X is a proposed rule. CMS has not published the final participant list, quality score thresholds, or regional benchmarks. This tool is a planning workbench — use it alongside the actual CMS-1849-P regulatory text.

Jump straight to a hospital

Search by hospital name, city, or 6-digit CCN to open the filtered results below.

01 · Hospital Table

Per-hospital opportunity ranking

Top 500 results by composite opportunity score (0–100). Filter by state, star rating, readiness tier, alumni status, mandatory eligibility, and LEJR setting. Click a row for the full CJR-X readiness profile, including DRG-level volume mix and score component breakdown.

Score	Hospital	St	Star	IP Vol	HOPD Vol	Anchor Spend	Est. 90-Day Total	±20% Risk	PRO-PM $/yr	PRO-PM % Anchor	Hip/Knee ERR	Readiness Tier
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Can't find your hospital? This dataset includes 2,663 IPPS acute-care hospitals from CMS public files. Hospitals may appear with limited data or be absent if CMS suppresses volume counts below 11 cases, if the facility had fewer than 20 Medicare FFS LEJR episodes in the reporting period, or if claims were reported under a parent CCN. Try searching by CCN, city, or a partial name. If your hospital is still missing, let us know.

02 · Geographic Distribution

Hospital map · color = CQS tier · clustered

Each dot is one hospital geocoded from CMS Provider Data. Color indicates the provisional CQS readiness tier. At low zoom, dots cluster into count badges — zoom in to see individual hospitals. Click any dot for a quick-stats popup or jump to its full row in the table. Map respects the engine filters above.

Likely Good/Excellent Acceptable – Neutral Risk of Repayment Below Acceptable

03 · Equity & Cost Analysis

Where cost and community disadvantage intersect

An exploratory descriptive analysis of per-episode unit cost across three axes: urban-rural geography, community deprivation (proxied by the CMS-validated dual-eligible proportion), and procedural volume. The dual-eligible proportion is the same measure CMS uses for HRRP peer-grouping and is highly correlated with the tract-level Area Deprivation Index in the published literature. Findings here are observational and deliberately restrict to mandatory-eligible hospitals with ≥ 31 LEJR episodes.

0.50

Pearson r · Cost per episode vs. dual-eligible share

Every 10-point rise in dual-eligible share predicts a meaningful rise in inpatient cost per episode.

28%

Cost gap · Higher-deprivation vs. Lower-deprivation hospitals

Mean IP LEJR cost/episode — $16,897 (D8–10) vs. $13,246 (D1–3).

194

High-Cost High-Risk hospitals

Top-quartile unit cost AND (ERR > 1.0 OR HRRP penalized). Flagged on the map.

F1Unit cost rises monotonically with community deprivation decile

Each cell is the mean inpatient Medicare payment per LEJR episode among hospitals in that decile of dual-eligible share (1 = lowest deprivation, 10 = highest). The gradient is a classic dose-response.

n shown in each cell · error bars are IQR (p25–p75) · excludes hospitals below the 31-episode mandatory threshold.

F2Cost by urban-rural classification

Classification derived from hospital density (neighbors within 10 & 25 miles).

F3Cost by community deprivation tier

Lower = deciles 1–3; Moderate = 4–7; Higher = 8–10.

F4Cost by annual LEJR volume

CJR-X mandatory threshold is 31 episodes/yr.

F5Dual-eligible-to-cost slope by urban-rural stratum

Simple OLS fit of inpatient cost/episode on dual-eligible proportion, computed separately for urban, suburban, and rural hospitals.

Slope interpretation: the coefficient on dual-eligible share (expressed per 10 pp rise).

Why this matters for CJR-X

Under CJR-X's regional benchmark design, a hospital's target price is drawn from its regional peers. A hospital serving a high-deprivation catchment that consistently exceeds its regional average will face compounding risk: (1) higher unit cost, (2) higher readmission risk flagged by HRRP, and (3) no reconciliation eligibility if it lands in "Below Acceptable" CQS. The 5% safety-net stop-loss (§ 512.645) is meaningful but asymmetric — it caps downside, not upside gap. The 194 HCHR hospitals flagged above are the practical focus list for CJR-X readiness interventions.

Analytical note — Dual-eligible proportion is the CMS-validated SES peer-grouping variable used in HRRP since FY 2019 (21st Century Cures Act §15002). It correlates strongly with tract-level Area Deprivation Index but is available at the hospital level without geocoding. Where tract-level ADI overlay is required (e.g. for catchment-area work), the patient-ZIP to ADI crosswalk from the University of Wisconsin Neighborhood Atlas is the recommended secondary layer.

04 · Data Sources & Methodology

Six CMS public datasets, joined on CCN

All data is public CMS Provider Data and CMS data-api/v1 — no proprietary claims, no private feeds. Scoring weights and tier thresholds are documented inline. Reproducible and auditable.

▸Click to expandAll data sources, joining logic, scoring weights, and tier thresholds

Hospital universe

Acute Care Hospitals from CMS Hospital General Information. Star rating, CCN, address, city/county. Joined to any CCN reporting either inpatient trigger DRG or HOPD APC 5115 activity. Federal suppression of counts <11 applies.

data.cms.gov/provider-data/dataset/xubh-q36u

Geocoding

Hospital addresses joined to ZIP centroid coordinates from the 2024 Census ZCTA Gazetteer. 2,569 of 2,663 hospitals (96.5%) successfully geocoded; remainder are unique-purpose ZIPs (PO box, military, territorial) excluded from the map but retained in all tables and aggregates.

census.gov · 2024 ZCTA Gazetteer

Inpatient LEJR exposure

Sum of Tot_Dschrgs × Avg_Mdcr_Pymt_Amt across DRGs 469, 470, 521, 522 per CMS-1849-P. Anchor-admission Medicare Part A only. True 90-day episode cost also includes physician, SNF, HHA, IRF, readmissions, Part B.

data.cms.gov · Medicare Inpatient Hospitals by Provider and Service

HOPD LEJR exposure

Sum of CAPC_Srvcs × Avg_Mdcr_Pymt_Amt across APC 5115 (Level 5 Musculoskeletal / Comprehensive APC) — the OPPS bucket routing HCPCS 27130 and 27447. Facility payment only; excludes physician Part B. APC 5115 captures a small fraction of non-LEJR major MSK procedures (documented widening caveat).

data.cms.gov · Medicare Outpatient Hospitals by Provider and Service

Mandatory eligibility

CMS-1849-P requires ≥31 LEJR episodes/yr across IP+OP combined. Default view filters to eligible. Toggle CJR-X Eligibility to see sub-threshold hospitals. Suppressed HOPD counts (<11) use reported volume only — eligibility may be conservatively understated for ~367 hospitals.

CMS CJR-X Model page

Readmission risk

Hip/knee excess readmission ratio (ERR) from HRRP READM-30-HIP-KNEE measure — public analog of CJR-X RSCR (CMIT #350), which carries 50% weight in the inpatient Composite Quality Score.

data.cms.gov/provider-data/dataset/9n3s-kdb3

CJR Model alumni prior

297 hospitals participated in the original CJR Model. Their published complication percentile (comp_hipknee) and HCAHPS percentile serve as directional priors for performance on the closest CJR-era analog to the new CQS complications domain.

data.cms.gov/provider-data/dataset/tqkv-mgxq

HRRP penalty history

FY2025 and FY2026 HRRP Supplemental Data Files joined on CCN. Per-hospital: payment adjustment factor (0.97–1.00), payment reduction percentage, THA/TKA-specific penalty indicator (Y/N), peer group assignment (1–5 based on dual-eligible proportion), and peer group median ERR. 975 hospitals penalized for THA/TKA readmissions in at least one of the two years; 503 penalized in both.

cms.gov · Hospital Readmissions Reduction Program

Opportunity score (0–100)

Composite signal weighting four normalized components:

0.35 × log10(annual LEJR spend), normalized
0.30 × hip/knee ERR headroom above 0.95
0.20 × star rating headroom below 5
0.15 × CJR complication percentile (alumni only)

Higher score = larger dollars + wider readiness gap. Weights are disclosed for sensitivity analysis.

deterministic · build pipeline

Readiness tier estimate

Provisional CQS tier mapping based on star rating × ERR:

Likely Good/Excellent — star ≥4 and ERR ≤1.0
Acceptable – Neutral — mixed signals
Acceptable – Risk of Repayment — 3-star or ERR >1.05
At Risk – Below Acceptable — 1- or 2-star

Directional proxy, not a forecast. CMS will publish actual CQS coefficients before PY1.

CMS CJR-X Model page

Query engine

Browser-resident DuckDB-WASM (1.29.0). Parquet (zstd) loaded once into a registered file buffer; all filters execute as SQL against an in-memory view. No server, no database, no proprietary feed. Source code in app.js.

duckdb.org · DuckDB-WASM

05 · Key Resources

CMS policy documents and references

Primary source documents for the CJR-X proposed rule and the quality programs it interacts with.

CJR-X Model Page

CMS Innovation Center's official page for the CJR-X (Comprehensive Care for Joint Replacement Expanded) Model, including program details and participant information.

cms.gov · CJR-X Model

CMS Newsroom — CJR-X Announcement

CMS press release on the CJR-X Model and FY 2027 IPPS Proposed Rule, including key program parameters and fact sheets.

cms.gov · CJR-X Press Release

Hospital Readmissions Reduction Program

HRRP program overview, supplemental data files (FY2025, FY2026), methodology, and penalty adjustment factor downloads.

cms.gov · HRRP

Hospital Overall Star Ratings

CMS's methodology for the 1–5 star hospital quality rating system, including measure weights and the current technical report.

cms.gov · Overall Hospital Quality Star Ratings

CMS Provider Data Catalog

The central repository for all CMS public use files including Hospital General Information, Inpatient/Outpatient Provider-level data, and HRRP measures.

data.cms.gov · Provider Data

Original CJR Model

The predecessor bundled payment model (2016–2024). Performance data, evaluation reports, and lessons learned that inform CJR-X program design.

cms.gov · CJR Model (CMMI)

06 · Rule Specification

CJR-X parameters · CMS-1849-P

Effective

PY1 begins Oct 1, 2027 · 5 performance years · reconciliation aligned to Federal Fiscal Year

CMS-1849-P

Participation

Mandatory · acute-care IPPS hospitals with ≥31 LEJR episodes during baseline period (IP+OP combined). Low-volume hospitals (<31) excluded from reconciliation

CMS-1849-P

Episode trigger

IP DRG 469, 470, 521, 522 · HOPD HCPCS 27130, 27447 · ankle replacements (new)

CMS-1849-P

Episode scope

All Medicare Part A + Part B spending during anchor procedure plus 90-day post-discharge period (physician, SNF, HHA, IRF, readmissions, Part B)

CMS-1849-P

Pricing benchmark

100% regional average · rolling 3-year baseline · risk-adjusted with 29 risk adjusters (up from 3 in original CJR)

CMS-1849-P

Discount factor

Flat 2.0% applied upfront to benchmark — CMS retains this as guaranteed savings. "Good" and "Excellent" CQS categories reduce the effective discount at reconciliation

CMS-1849-P

Quality score

Composite Quality Score (CQS) determines quality category and reconciliation eligibility. "Below Acceptable" hospitals are ineligible for savings

CMS-1849-P

Stop-loss (safety-net)

Maximum aggregate downside capped at 5% of episode spend for safety-net hospitals (high dual-eligible proportion), rural, Medicare-dependent, and Sole Community Hospitals

CMS-1849-P

Stop-loss (standard)

Standard hospital stop-loss limit not explicitly specified in proposed text. Original CJR model phased to 20% by PY4-5

42 CFR 510

Risk adjustment

29 risk adjusters accounting for patient acuity and complexity; designed to prevent penalizing hospitals treating sicker patients

CMS-1849-P

Exclusions

TEAM participants (transition to CJR-X in 2031) · Maryland all-payer hospitals · Critical Access Hospitals · Rural Emergency Hospitals

CMS-1849-P

Reconciliation

Annual reconciliation after each performance year. Episode spending vs. quality-adjusted target price determines net payment

CMS-1849-P

Sources: CMS CJR-X Model page · CMS Press Release · HFMA Analysis · 42 CFR Part 510 (Original CJR)

07 · Work With Us

Prepare for CJR-X with Revel AI Health

Revel AI Health provides AI-powered care navigation and analytics solutions for episode-of-care management under CMS bundled payment models — helping hospitals, ASCs, and physician practices reduce episode costs and improve quality scores.

Tell us about your hospital or organization and we'll reach out to discuss your CJR-X readiness strategy.

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