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42 U.S.C. 1302, 1315a, and 1395hh.
85 FR 61362, Sept. 29, 2020, unless otherwise noted.
90 FR 50022, Nov. 5, 2025, unless otherwise noted.
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Subscribe to: 42 CFR Part 512 Subpart G - Performance Categories and Scoring
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(a) General. As further described in §§ 512.725, 512.730, 512.735, and 512.740:
(1) An ASM participant receives a specific number of points for its performance on each measure or activity within an ASM performance category.
(2) CMS assigns the total amount of points an ASM participant may receive for its performance on a measure or activity.
(3) CMS calculates a final score as described at § 512.745 using the points received across all four ASM performance categories.
(b) Data sources.
(1) CMS uses Medicare claims data and Medicare administrative data reported to calculate measure scores included in the quality and cost ASM performance categories under §§ 512.725 and 512.730.
(2) CMS uses model-specific data reported under § 512.720 to calculate applicable measure or activity scores for the quality, improvement activities, and Promoting Interoperability ASM performance categories under §§ 512.725, 512.735, and 512.740.
(a) Applicable performance categories and data submission requirements.
(1) Except as provided in paragraph (a)(2) of this section, as applicable, ASM participants must submit data on measures and activities for the quality, improvement activities, and Promoting Interoperability ASM performance categories described in §§ 512.725(b) and (c), 512.735(b), and 512.740 in accordance with this section. The data may also be submitted on behalf of the ASM participant by a third-party intermediary.
(i) For the quality ASM performance category, a data submission must—
(A) Include numerator and denominator data for at least one applicable quality measure described in § 512.725(b) or (c) that is not an administrative claims-based collection type and meets the data completeness requirement as specified at § 512.725(f) and
(B) Be submitted at the TIN/NPI level, unless the ASM participant is excepted under paragraph (f) of this section.
(ii) For the improvement activities ASM performance category, a data submission must—
(A) Include an attestation of meeting the specifications of each required improvement activity described in § 512.735(c); and
(B) Be submitted at the TIN level;
(iii) For the Promoting Interoperability ASM performance category, a data submission must do all of the following:
(A) Include all of the following elements:
(1) Performance data, including any claim of an applicable exclusion, for the measures in each objective, as specified by CMS at § 512.740(b).
(2) Required attestation statements, as specified by CMS at § 512.740(b).
(3) CMS EHR Certification ID (CEHRT ID) from the Certified Health IT Product List (CHPL).
(4) The start date and end date for the applicable performance period as set forth in § 512.740(a).
(B) Be submitted at the TIN level.
(2) There are no data submission requirements for the cost ASM performance category measures and activities described under § 512.730(b) or administrative claims-based quality measures as described in § 512.725(b) or (c). Performance in the cost ASM performance category and administrative claims-based quality measures are calculated by CMS 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.
(b) Data submission types for ASM participants. An ASM participant must submit their data using the following:
(1) For the quality ASM performance category, the direct and login and upload submission types.
(2) For the improvement activities and Promoting Interoperability ASM performance categories, the direct, login and upload, or login and attest submission types.
(c) Use of multiple data submission types. ASM participants may submit their data using multiple data submission types for any ASM performance category described in paragraph (a)(1) of this section provided that the ASM participant uses the same identifier for all ASM performance categories and all data submissions.
(d) Data submission deadlines. The data submission deadline is March 31st of the calendar year following the close of the applicable ASM performance year or a later date as specified by CMS for the direct, login and upload, and login and attest submission types.
(e) Treatment of multiple data submissions.
(1)
(i) For multiple data submissions received in the quality and improvement activities ASM performance categories in accordance with paragraphs (a)(1)(i) and (ii) of this section for an individual ASM participant from submitters in multiple organizations (for example, qualified registry, practice administrator, or EHR vendor), CMS calculates and scores each submission received and assign the highest of the scores.
(ii) For multiple data submissions received for an individual ASM participant from one or multiple submitters in the same organization, CMS scores the most recent submission.
(2) For multiple data submissions received for the Promoting Interoperability ASM performance category in accordance with paragraph (a)(1)(iii) of this section, CMS calculates a score for each data submission received and assigns the highest of the scores.
(f) Small practice quality measures submission. ASM participants who are part of a small practice may report quality measures in the quality ASM performance category at the TIN level.
(a) ASM performance year for quality measures. Beginning with 2029 ASM payment year, the ASM performance year for quality measures is the full calendar year from January 1 to December 31 that occurred 2 years prior to the applicable ASM payment year, except as otherwise specified for administrative claims-based measures.
(b) Quality measures for ASM heart failure cohort. CMS uses the following quality measures, as specified by CMS for the MIPS quality performance category unless otherwise stated, to assess performance for ASM heart failure participants in the quality ASM performance category:
(1) Risk-Standardized Acute Unplanned Cardiovascular-Related Admission Rates for Patients with Heart Failure for the Merit-based Incentive Payment System (MIPS Q492) with minor modification to the measure specifications to attribute solely to ASM participants who have had one (1) or more visits with the beneficiary.
(2) Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) (MIPS Q008).
(3) Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD) (MIPS Q005).
(4) Controlling High Blood Pressure (MIPS Q236).
(5) Functional Status Assessments for Heart Failure (MIPS Q377).
(c) Quality measures for ASM low back pain cohort. CMS uses the following quality measures, as specified by CMS for the MIPS quality performance category unless otherwise stated, to assess performance for ASM low back pain participants in the quality ASM performance category:
(1) Use of High-Risk Medications in Older Adults (MIPS Q238).
(2) Preventive Care and Screening: Screening for Depression and Follow-Up Plan (MIPS Q134).
(3) Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan (MIPS Q128).
(4) Functional Status Change for Patients with Low Back Impairments (MIPS Q220).
(d) Removal, addition, and maintenance of technical specifications of quality measures. CMS uses notice-and-comment rulemaking to communicate any updates or changes to the quality measure sets described in paragraphs (b) and (c) of this section.
(e) Data submission criteria for the quality ASM performance category.
(1) CMS uses quality measures as described in paragraphs (b) and (c) of this section with the following data collection types:
(i) MIPS CQMs.
(ii) eCQMs.
(iii) Administrative claims-based.
(2) Data submission requirements.
(i) An ASM heart failure participant must submit data on all quality measures specified in paragraph (b) of this section using MIPS CQMs or eCQMs.
(ii) An ASM low back pain participant must submit data on all quality measures specified in paragraph (c) of this section using MIPS CQMs or eCQMs, unless otherwise stated.
(iii) For eCQMs, the submission of data requires the utilization of CEHRT, as defined at § 414.1305.
(3) An ASM participant is not required to submit data for the calculation of administrative claims-based measures so long as data submission requirements as specified at § 512.720(a)(1)(i) are met.
(f) Data completeness requirement for the quality ASM performance category.
(1) Except as specified at paragraph (e)(3) of this section and for each required measure specified in paragraphs (b) or (c) of this section, ASM participants must submit data on at least 75 percent of the ASM participant's patients that meet the measure's denominator criteria, regardless of payer.
(2) ASM participants receive zero measure achievement points for each measure required in paragraphs (b) or (c) of this section that does not meet the data completeness requirement, as specified at paragraph (f)(1) of this section.
(3) CMS excludes from an ASM's participant total measure achievement points and total available measure achievement points any measures required under paragraphs (b) or (c) of this section that meet the respective measure's data completeness requirement, but do not have a benchmark.
(g) Minimum case requirements.
(1) Unless otherwise specified by CMS, the minimum case requirement for each quality measure required in paragraphs (b) or (c) of this section is 20 cases.
(2) CMS excludes from an ASM's participant total measure achievement points and total available measure achievement points any measures required under paragraphs (b) or (c) of this section that meet the respective measure's data completeness requirement as specified at paragraph (f)(1) of this section but do not meet the measure's case minimum requirement as specified at paragraph (g)(1) of this section.
(h) Quality measure achievement points and quality ASM performance category scoring. Unless a different scoring weight is assigned by CMS, performance in the quality ASM performance category comprises of 50 percent of a ASM participant's final score for each ASM payment year.
(1) Measure achievement points.
(i) For each ASM performance year, ASM participants receive between 1 and 10 measure achievement points (including partial points) for each required measure as specified in paragraphs (b) or (c) of this section on which data is submitted in accordance with paragraph (e) of this section that does all of the following:
(A) Has a benchmark specified in paragraph (h)(2) of this section.
(B) Meets the case minimum requirements specified in paragraph (g) of this section.
(C) Meets the data completeness criteria specified in paragraph (f) of this section.
(D) For each administrative claims-based measure with a benchmark as described at paragraph (h)(2)(iii) of this section and meets the case minimum requirement at paragraph (g) of this section.
(ii) The number of ASM measure achievement points received for each measure is determined based on the applicable benchmark decile category and the percentile distribution.
(iii) ASM participants receive zero ASM measure achievement points for each measure required in paragraphs (b) or (c) of this section on which no data is submitted in accordance with § 512.720.
(iv) ASM participants who submit data in accordance with paragraphs (e) through (g) of this section on a single required measure via multiple applicable collection types are scored only on the data submission with the greatest number of measure achievement points.
(2)
(i) Benchmarks. Except as provided in paragraph (h)(2)(iii) of this section, CMS bases benchmarks on an ASM participant's performance by collection type, from one following data sources:
(A) Reported by ASM participants, to the extent feasible, during the ASM performance year.
(B) A previous ASM performance year, if available.
(C) Another period determined by CMS.
(ii) Each benchmark must have a minimum of 20 ASM participants who reported the measure having met the following criteria:
(A) The case minimum requirements in paragraph (g) of this section.
(B) The data completeness requirement as specified in paragraph (f) of this section.
(C) A performance rate that is greater than zero.
(iii) CMS calculates a benchmark for an administrative claims quality measure using the performance on the measure during the current ASM performance year.
(iv) CMS determines a benchmark using decile categories based on the applicable period of data used to determine the measure's benchmark.
(3) Topped out measures. CMS identifies topped out measures in the benchmarks for each ASM performance year based on within-model performance on each measure.
(4) Calculation of the quality ASM performance category score.
(i) Unless otherwise specified by CMS, an ASM participant's quality ASM performance category score is the sum of all measure achievement points assigned for the applicable measures for the quality ASM performance category.
(A) The sum is divided by the total available measure achievement points.
(B) The quality ASM performance category score cannot exceed 100 percentage points.
(ii) For each measure that is submitted, if applicable, and impacted by significant changes or errors prior to the applicable data submission deadline at § 512.720(d), performance is based on data for 9 consecutive months of the applicable ASM performance year.
(A) Significant changes or errors means changes to or errors in a measure that are outside the control of the clinician and its agents and that CMS determines may result in patient harm or misleading results. Significant changes or errors include, but are not limited to the following:
(1) Changes to codes (such as ICD-10, CPT, or HCPCS codes) or the active status of codes.
(2) The inadvertent omission of codes or inclusion of inactive or inaccurate codes.
(3) Changes to clinical guidelines or measure specifications.
(B) CMS publishes a list of all measures scored in a form and manner specified by CMS.
(C) If the data are not available or CMS determines that they may result in patient harm or misleading results, the measure is excluded from an ASM participant's total measure achievement points and total available measure achievement points.
(iii) An ASM participant does not receive a quality ASM performance category score if the ASM participant meets the quality ASM performance category data submission requirements specified at § 512.720(a)(1)(i) but does not meet the case minimum requirements specified in paragraph (g) of this section for any required quality ASM performance category measure specified in paragraphs (b) or (c) of this section, as applicable, that has a benchmark as specified in paragraph (h)(2) of this section.
[90 FR 50022, Nov. 5, 2025; 91 FR 12081, Mar. 12, 2026]
(a) ASM performance year for cost performance measures. Beginning with the 2029 ASM payment year, the ASM performance year for cost measures is the full calendar year from January 1 to December 31 that occurred 2 years prior to the applicable ASM payment year.
(b) Cost measures. For purposes of assessing performance of ASM participants on the cost ASM performance category, CMS—
(1) For ASM heart failure participants, assess and score the participants on the Heart Failure EBCM (COST_HF_1), as specified under MIPS.
(2) For ASM low back pain participants, assess and score the participants on the Low Back Pain EBCM (COST_LBP_1), as specified under MIPS.
(c) Adding or removing cost measures. CMS may add new cost measures to, or remove existing cost measures from, the cost ASM performance category through notice and comment rulemaking.
(d) Minimum case requirements. Unless otherwise specified by CMS, the minimum case requirement for each cost measure is 20 cases.
(1) Each cost measure is attributed at the TIN/NPI level according to the measure specification for the applicable ASM performance year.
(2) An ASM participant must meet the minimum case volume to be scored on a cost measure.
(e) Cost measure achievement points and cost ASM performance category scoring. Unless a different scoring weight is assigned by CMS, performance in the cost ASM performance category comprises 50 percent of an ASM participant's final score for each ASM performance year.
(1) ASM measure achievement points.
(i) For each cost measure attributed to an ASM participant, the ASM participant receives one to ten achievement points (including partial points) based on the ASM participant's performance on the cost measure during the ASM performance year compared to the cost measure's benchmark.
(ii) Achievement points are awarded based on which benchmark range the ASM participant's performance on the measure is in.
(2) Benchmarks
(i) CMS bases cost measure benchmarks on cost measure performance during the ASM performance year.
(A) Each benchmark must have a minimum of 20 ASM participants who meet the minimum case volume specified in paragraph (d) of this section for CMS to determine a benchmark for the cost measure.
(B) If a benchmark is not determined for a cost measure, then the measure is not scored.
(ii) CMS determines 10 benchmark ranges based on the median cost of all ASM participants attributed the measure, plus or minus standard deviations. CMS awards achievement points based on which benchmark range an ASM participant's measure score corresponds.
(3) Calculation of the cost ASM performance category score. Except as otherwise specified in paragraph (e)(3)(i) of this section, the cost ASM performance category score is the sum of the total number of achievement points earned by the ASM participant divided by the total number of available achievement points, not to exceed 100 percent.
(i) An ASM participant does not receive a cost ASM performance category score if the ASM participant is not attributed the required cost measure for the ASM performance year specified in paragraph (b) of this section because the ASM participant has not met the case minimum specified in paragraph (d) of this section for the required cost measure or if a benchmark has not been created for a required cost measure as specified in paragraph (e)(2) of this section.
(ii) If data used to calculate a score for a cost measure are impacted by significant changes or errors affecting the ASM performance year, such that calculating the cost measure score would lead to misleading or inaccurate results, then the affected cost measure is excluded from the ASM participant's cost ASM performance category score and a cost ASM performance category score is not calculated.
(A) Significant changes or errors means changes to or errors in a measure that are outside the control of the clinician and its agents, and that CMS determines may result in patient harm or misleading results.
(B) Significant changes or errors include, but are not limited to, changes to codes (such as ICD-10, CPT, or HCPCS codes) or the active status of codes, the inadvertent omission of codes or inclusion of inactive or inaccurate codes, or changes to clinical guidelines or measure specifications.
(C) CMS empirically assesses the affected cost measure to determine the extent to which the changes or errors impact the calculation of a cost measure score such that calculating the cost measure score would lead to misleading or inaccurate results that negatively impact the measure's ability to reliably assess performance.
[90 FR 50022, Nov. 5, 2025; 91 FR 12081, Mar. 12, 2026]
(a) ASM performance year for improvement activities. Beginning with the 2029 ASM payment year, the ASM performance year for improvement activities is a minimum of a continuous 90-day period within the calendar year that occurs 2 years prior to the applicable ASM payment year, up to and including the full calendar year.
(b) Improvement activities. CMS uses the improvement activities specified in paragraph (c) of this section to evaluate performance of ASM participants in the improvement activities ASM performance category.
(c) Improvement activities specifications —
(1) Improvement Activity 1 (IA-1): Connecting to Primary Care and Ensuring Completion of Health-Related Social Needs Screening. An ASM participant must have evidence of processes, workflows, or technology that require the ASM participant to do all of the following:
(i) Confirm the ASM beneficiary has access to primary care services and, if not, assist the ASM beneficiary in finding a clinician who provides primary care services.
(ii) Communicate relevant information back to the ASM beneficiary's primary care provider following the ASM beneficiary's visit with the ASM participant.
(iii) Determine whether the ASM beneficiary has received an annual health-related social needs screening in the primary care setting and, if not, encourage the primary care services provider to conduct the screening or allow the ASM participant to conduct the health-related social needs screening.
(2) Improvement Activity 2 (IA-2): Establishing Communication and Collaboration Expectations with Primary Care using Collaborative Care Arrangements. An ASM participant must do all of the following:
(i) Have at least one executed collaborative care arrangement between a primary care practice with which the ASM participant shares ASM beneficiaries.
(ii) The collaborative care arrangement must include collaborative efforts related to at least three of the following five elements:
(A) Data sharing, which includes setting expectations for bi-directional sharing of patient information between the parties to the collaborative care arrangement, including but not limited to test results, treatment plans, and follow-up recommendations.
(B) Co-management, which includes defining co-management approaches, where the parties to the collaborative care arrangement work together to furnish complementary care for patients with complex or chronic conditions.
(C) Transitions in care planning, which includes defining protocols for seamless transitions of care between ASM participants, the primary care practice, or different care settings.
(D) Closed-loop communication, such as clearly articulated processes enforcing parameters on how ASM beneficiaries may be referred between the parties to the collaborative care arrangement.
(E) Care coordination integration comprised of structured processes to embed care coordination processes into the ASM participant's practice workflow.
(d) Scoring for improvement activities ASM performance category —
(1) ASM measure achievement points. ASM participants receive 10 ASM measure achievement points for attesting “yes” for each improvement activity specified in paragraph (c) in compliance with the data submission requirements at § 512.720.
(2) Calculation of the improvement activities ASM performance category score. Unless otherwise specified by CMS, CMS sums the total achievement points for all submitted improvement activities and divides this sum by the total number of available achievement points for the required improvement activities as specified in paragraph (c) of this section, not to exceed 100 percent.
(a) ASM performance year for the Promoting Interoperability ASM performance category. Beginning with the 2029 ASM payment year, the ASM performance year for Promoting Interoperability measures is the minimum of a continuous 180-day period within the calendar year that occurs 2 years prior to the applicable ASM payment year, up to and including the full calendar year.
(b) Reporting for the Promoting Interoperability ASM performance category. To earn an ASM performance category score greater than zero for the Promoting Interoperability ASM performance category for inclusion in the final score, an ASM participant must be a meaningful EHR user and meet the following criteria:
(1) CEHRT. Use CEHRT as defined at § 414.1305 for the ASM performance year.
(2) ASM Promoting Interoperability objectives and measures. Report on the following MIPS Promoting Interoperability measures, as specified by CMS through rulemaking:
(i) An ASM Participant must report both of the following measures or claim an exclusion or exclusions to fulfill the e-Prescribing objective:
(A) e-Prescribing (Measure ID #: PI_EP_1).
(B) Query of PDMP (Measure ID # PI_EP_2).
(ii) An ASM Participant must fulfill the Health Information Exchange objective through one of the following three options:
(A) Report the Support Electronic Referral Loops by Sending Health Information (Measure ID # PI_HIE_1) and Support Electronic Referral Loops by Receiving and Reconciling Health Information (Measure ID # PI_HIE_4).
(B) Health Information Exchange (HIE) Bi-Directional Exchange (Measure ID # PI_HIE_5).
(C) Enabling Exchange Under the Trusted Exchange Framework and Common Agreement (TEFCA) (Measure ID # PI_HIE_6).
(iii) An ASM Participant must fulfill the Provider to Patient Exchange objective by reporting the Provide Patients Electronic Access to Their Health Information measure (Measure ID # PI_PEA_1).
(iv) An ASM Participant must fulfill the Public Health and Clinical Data Exchange objective by reporting both measures:
(A) Immunization Registry Reporting (Measure ID # PI_PHCDDR_1).
(B) Electronic Case Reporting (Measure ID PI_PHCDRR_3).
(3) Reporting ASM Promoting Interoperability objectives and measures. Comply with the following reporting requirements:
(i) For each measure under paragraph (b)(2) of this section, report—
(A) The numerator (of at least one) and denominator;
(B) Yes/no statement; or
(C) An exclusion that includes an option for the exclusion.
(ii) Report that the ASM participant completed the actions included in the MIPS Promoting Interoperability Security Risk Analysis measure (Measure ID # PI_PPHI_1) within the calendar year of the ASM performance year.
(iii) Submit an affirmative attestation regarding the ASM participant's completion of the annual self-assessment checklist under the MIPS Promoting Interoperability High Priority Practices Guide of the SAFER Guides measure (Measure ID # PI_PPHI_2) within the calendar year of the ASM performance year.
(4) Supporting use of CEHRT. ASM participants must support the use of CEHRT by fulfilling the following requirements:
(i) Supporting the use and performance of CEHRT. To fulfill ASM requirements to engage in activities related to supporting clinicians with the performance of CEHRT, the ASM participant:
(A) Must attest by providing all of the following:
(1) Acknowledgement of the requirement to cooperate in good faith with ONC direct review of the ASM participant's health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received.
(2) If requested, cooperation in good faith with ONC direct review of the ASM participant's health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that the technology meets, or can be used to meet, the definition of CEHRT, including by permitting timely access to the technology and demonstrating its capabilities as implemented and used by the ASM participant in the field.
(B) May attest to the following objectives and measures:
(1) Acknowledgement of the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received.
(2) If requested, cooperation in good faith with ONC-ACB surveillance of the ASM participant's health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that the technology meet, or can be used to meet, the definition of CEHRT, including by permitting timely access to the technology and demonstrating its capabilities as implemented and used by the ASM participant in the field.
(ii) Actions to limit or restrict the compatibility or interoperability of CEHRT. To fulfill ASM requirements for activities related to limiting or restricting the compatibility or interoperability of CEHRT, the ASM participant must not knowingly and willfully take action, such as to disabling functionality, to limit or restrict the compatibility or interoperability of CEHRT.
(c) Scoring the Promoting Interoperability ASM performance category —
(1) ASM measure achievement points.
(i) An ASM participant earns a score for each measure by fulfilling the reporting requirements specified at paragraph (b) of this section. Score amounts are set forth in the MIPS measure specifications.
(ii) If an exclusion is reported for a measure, the points available for that measure are redistributed to another measure as set forth in the MIPS measure specifications.
(2) Promoting Interoperability ASM performance category score. Unless otherwise specified by CMS, CMS sums the scores for each of the required measures and divides this sum by the total number of available Promoting Interoperability points. The Promoting Interoperability ASM performance category score cannot exceed 100 percent.
(a) Final score calculation. CMS calculates a final score of zero to 100 points using the formula specified at paragraph (a)(5) of this section for each ASM participant that meets the requirements to receive a final score as specified in paragraph (a)(2) of this section.
(1) ASM performance category weights and scoring adjustments. CMS calculates the final score using the ASM performance category weights and scoring adjustments as follows:
(i) Quality ASM performance category weight is 50 percent.
(ii) Cost ASM performance category weight is 50 percent.
(iii) The improvement activities ASM performance category has a scoring adjustment that is applied to the final score without weighting.
(A) ASM participants that achieve a 100 percent score for the improvement activities ASM performance category do not receive an improvement activities ASM performance category scoring adjustment to final score.
(B) ASM participants that receive a 50 percent improvement activities ASM performance category score receive an improvement activities ASM performance category scoring adjustment of negative 10 points to the final score.
(C) ASM participants that receive a zero percent improvement activities ASM performance category score receive an improvement activities ASM performance category scoring adjustment of negative 20 points to the final score.
(iv) The Promoting Interoperability ASM performance category has a scoring adjustment that is applied to the final score without weighting.
(A) To determine the Promoting Interoperability ASM performance category scoring adjustment as described in paragraph (a)(1)(iv) of this section, the Promoting Interoperability ASM performance category score is multiplied by 100, the product is then subtracted from 100 and divided by the maximum negative Promoting Interoperability ASM performance category scoring adjustment of 10 points.
(B) The maximum Promoting Interoperability ASM performance category scoring adjustment is negative 10 points.
(2) Requirements to receive a final score. Except as described at § 512.780(c)(1), CMS determines whether an ASM participant receives a final score for the applicable ASM performance year depending on the data submitted by the ASM participant.
(i) Except as described in paragraph (a)(2)(iii) of this section, CMS calculates a final score greater than zero but not exceeding 100 as described in paragraph (a) of this section for the applicable ASM performance year for all ASM participants that meet the quality ASM performance category data submission requirements as specified at § 512.720(a)(1)(i).
(ii) CMS assigns a final score of zero for the applicable ASM performance year to all ASM participants who do not meet the quality ASM performance category data submission requirements as specified at § 512.720(a)(1)(i).
(iii) CMS does not assign a final score for the applicable ASM performance year to ASM participants who do all of the following:
(A) Meet the quality ASM performance category data submission requirements as specified at § 512.720(a)(1)(i).
(B)
(1) Do not receive a quality ASM performance category score under § 512.725(h)(4)(iii); or
(2) Do not receive a cost ASM performance category score under § 512.730(e)(3)(i).
(3) Complex patient scoring adjustment. CMS adds a complex patient scoring adjustment to the final score for the ASM performance year, if applicable, if an ASM participant meets the requirements to receive a final score greater than zero as described in paragraph (a)(2)(i) of this section and the criteria defined in paragraph (a)(3)(i) of this section for the applicable ASM performance year.
(i) The complex patient scoring adjustment is limited to ASM participants with a risk indicator at or above the risk indicator calculated median for their ASM cohort. To determine the median for the respective risk indicator (HCC and dual eligible proportion) for each ASM cohort, risk indicators associated to an ASM participant in the corresponding ASM cohort from the calendar year preceding the applicable ASM performance year, for all ASM participants within an ASM cohort who meet the data submission requirements for the quality ASM performance category at § 512.720(a)(1)(i) are used.
(ii) Beginning with the 2027 ASM performance year, for ASM participants, the complex patient scoring adjustment components are calculated as follows for the specific risk indicators:
(A) Medical complex patient scoring adjustment component = 1.5 + 4 * associated HCC standardized score calculated with the average HCC risk score assigned to beneficiaries (under the HCC risk adjustment model established by CMS in accordance with section 1853(a)(1) of the Act) seen by the ASM participant.
(B) Social complex patient scoring adjustment component = 1.5 + 4 * associated dual proportion standardized score.
(C) The components specified in paragraphs (a)(3)(ii)(A) and (B) of this section are added together to calculate one overall complex patient scoring adjustment. A standardized score for each risk indicator is determined based on the mean and standard deviation of the raw risk indicator score and provides a standardized measurement of how far each risk score is from the mean: (raw risk indicator score−risk indicator mean)/risk indicator standard deviation.
(iii) The complex patient scoring adjustment cannot exceed 10 and cannot be below zero.
(4) Small practice scoring adjustment —
(i) Scoring adjustment for an ASM participant that is in a small practice and is not a solo practitioner. CMS adds 10 points to the final score of an ASM participant that meets all of the following:
(A) Is in a small practice.
(B) Is not a solo practitioner.
(C) Meets the requirements to receive a final score greater than zero as described in paragraph (a)(2)(i) of this section for an applicable ASM performance year.
(ii) Scoring adjustment for ASM participant that is a solo practitioner. CMS adds 15 points to the final score of an ASM participant that is a solo practitioner and meets the requirements to receive a final score greater than zero as described in paragraph (a)(2)(i) of this section for an applicable ASM performance year.
(5) Final score formula. Final score = [quality ASM performance category score × quality ASM performance category weight) + (cost ASM performance category score × cost ASM performance category weight)] × 100 + improvement activities ASM performance category scoring adjustment + Promoting Interoperability ASM performance category scoring adjustment + complex patient scoring adjustment + small practice scoring adjustment. The final score cannot be below zero points or exceed 100 points.
(b) ASM performance report. For each ASM performance year, CMS provides each ASM participant with an ASM performance report, in a form and manner determined by CMS, containing all of the following:
(1) The ASM participant's score for each ASM performance category.
(2) The ASM participant's complex patient scoring adjustment under paragraph (a)(3) of this section, as applicable.
(3) The ASM participant's small practice or solo practitioner scoring adjustment under paragraph (a)(4) of this section, as applicable.
(4) The ASM participant's final score, as applicable.
(5) The ASM payment adjustment factor under § 512.750(c)(1).
(6) The ASM payment multiplier under § 512.750(c).
[90 FR 50022, Nov. 5, 2025; 91 FR 12081, Mar. 12, 2026]