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| General | 512.700 – 512.710 | ||||||||||
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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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The Code of Federal Regulations (CFR) is the official legal print publication containing the codification of the general and permanent rules published in the Federal Register by the departments and agencies of the Federal Government. The Electronic Code of Federal Regulations (eCFR) is a continuously updated online version of the CFR. It is not an official legal edition of the CFR.
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(a) Basis. This subpart implements the test of the Ambulatory Specialty Model (ASM) under section 1115A of the Act.
(b) Scope. This subpart sets forth the following:
(1) The method for selecting ASM participants.
(2) The methodology for ASM participant performance assessment and scoring for purposes of the improvement activities ASM performance category, quality ASM performance category, cost ASM performance category, and Promoting Interoperability ASM performance category, including beneficiary inclusion and episode-based cost measures.
(3) Data submission for applicable ASM performance categories.
(4) The schedule and methodologies for payment adjustments.
(5) Appeals process.
(6) Data sharing with ASM participants.
(7) ASM beneficiary incentives.
(8) Collaborative care arrangements.
(9) Application of the CMS-sponsored model arrangements and patient incentives safe harbor.
(10) Medicare program waivers.
(11) Except as specifically noted in this subpart, the regulations under this subpart do not affect the applicability of other provisions affecting providers and suppliers under Medicare fee for service, including the applicability of provisions regarding payment, coverage, or program integrity.
(c) Applicability. Except as otherwise specified in this subpart, ASM participants are subject to the standard provisions for Innovation Center models specified in subpart A of this part 512 and in subpart K of part 403 of this chapter.
For purposes of this part, the terms in this part have the same meanings as 42 CFR 512.110 and 414.1300 unless otherwise stated.
ASM beneficiary means a Medicare FFS beneficiary who is being treated by an ASM participant for a targeted chronic condition.
ASM cohort means a group of ASM participants who treat the same ASM targeted chronic condition, specifically the ASM heart failure cohort and the ASM back pain cohort.
ASM data sharing agreement means an agreement between the ASM participant, and CMS that includes the terms and conditions for any beneficiary-identifiable data being shared with the ASM participant under § 512.760(e).
ASM heart failure cohort refers to all ASM heart failure participants.
ASM heart failure participant means an ASM participant who meets the ASM participant eligibility criteria related to heart failure.
ASM incentive pool means a fixed percentage of the total amount of Medicare Part B covered professional services claims paid to ASM participants with final scores within an ASM cohort during an ASM performance year that would be distributed in the form of scaled payment adjustments during an ASM payment year. CMS calculates an ASM incentive pool for each ASM cohort for each ASM payment year as described at § 512.750(c)(1)(iii).
ASM low back pain cohort refers to all ASM low back pain participants.
ASM low back pain participant means an ASM participant who meets the ASM participant eligibility criteria related to low back pain.
ASM participant means an individual clinician who, for at least one ASM performance year, satisfies the ASM participant eligibility criteria and has been selected for participation in the model as described at § 512.710(g).
ASM participant eligibility criteria means the set of criteria defined at § 512.710(b) that CMS uses to determine whether a clinician is selected to participate in ASM.
ASM payment adjustment factor means a percent value based on an ASM participant's final score as described at § 512.750(c)(1) that CMS uses in calculating adjustments to the ASM participant's Medicare Part B payments for covered professional services during an ASM payment year.
ASM payment multiplier means the numerical value equal to 1 plus the ASM payment adjustment factor determined for an ASM participant for an applicable ASM payment year as described at § 512.750(c).
ASM payment year means a calendar year in which CMS applies the ASM payment multiplier to Medicare Part B payments for covered professional services based on the final score achieved by that ASM participant for the ASM performance year 2 years prior.
ASM performance category means a group of applicable measures or activities used to assess ASM participant's performance on quality, cost, improvement activities, or Promoting Interoperability.
ASM performance category score means the assessment of each ASM participant's performance on the applicable measures and activities for a performance category during an ASM performance year based on the performance standards described at §§ 512.715, 512.725, 512.730, 512.735, and 512.740.
ASM performance report means the notification that CMS provides to the ASM participant for each ASM performance year, which contains the information specified at § 512.745(b).
ASM performance year means a 12-month period beginning on January 1 and ending on December 31 of each year during the first 5 calendar years of ASM test period.
ASM redistribution percentage means a percentage of Medicare Part B covered professional services payments to ASM participants during an ASM performance year that CMS distributes in the form of payment adjustment to ASM participants during an ASM payment year as described at § 512.750(c)(1)(iii).
ASM risk level means the magnitude of the maximum positive or negative net payment adjustment percentage to which an ASM participant would be subject to during an ASM payment year as described at § 512.750(c)(1)(i).
ASM targeted chronic condition means a medical condition that is a core focus of ASM; that is, heart failure or low back pain.
ASM test period means the 7-year period from January 1, 2027, to December 31, 2033, that includes all ASM performance years and ASM payment years.
ASTP/ONC stands for the Assistant Secretary for Technology Policy/Office of the National Coordinator on Health Information Technology.
CY means calendar year.
CEHRT stands for Certified Electronic Health Records Technology that meets the requirements set forth in § 414.1305 of this chapter, except all instances of references to Merit-based Incentive Payment System (MIPS) are to be replaced with references to ASM.
Clinician has the same meaning as “eligible professional” as defined in section 1848(k)(3) of the Act, as identified by a unique TIN and NPI combination.
CMS EHR Certification ID means the identification number that represents the combination of Certified Health Information Technology that is owned and used by providers and hospitals to provide care to their patients and is generated by the Certified Health IT Product List.
Collaborative care arrangement means an arrangement that meets all of the requirements set forth in § 512.771.
Core Based Statistical Area (CBSA) means a statistical geographic area, based on the definition as identified by the Office of Management and Budget in the OMB Bulletin 23-01 issued on July 21, 2023, with a population of at least 10,000, which consists of a county or counties anchored by at least one core (urbanized area or urban cluster), plus adjacent counties having a high degree of social and economic integration with the core (as measured through commuting ties with the counties containing the core).
Covered entity has the meaning set forth at 45 CFR 160.103.
Covered professional services means “covered services” and has the meaning set forth in § 512.110 of this chapter.
CQM stands for Clinical Quality Measures.
Days means calendar days unless otherwise specified by CMS.
Dual eligible proportion means the share of a participant's beneficiaries who are dually eligible Medicare beneficiaries
Dually eligible Medicare beneficiary means a beneficiary enrolled in both Medicare and full Medicaid benefits.
EBCM stands for episode-based cost measure and means the standardized Medicare-allowed cost for the items and services furnished to a patient during an episode of care, based on FFS claims and Medicare Part D claims data.
eCQM stands for electronic clinical quality measures.
EHR stands for Electronic Health Record and means a “Base EHR,” as defined at 45 CFR 170.102.
Exchange function means the function used to translate an ASM participant's final score into an ASM payment adjustment factor as described at § 512.750(c)(1)(ii)..
Episode means all the relevant health care services a patient receives during a specified period for the treatment of a physical or behavioral health condition.
FFS stands for fee-for-service.
Final score means a composite assessment (using a scoring scale of zero to 100) for each ASM participant for an ASM performance year determined using the methodology for assessing the total performance of an ASM participant according to performance standards for applicable measures and activities for each ASM performance category as described in § 512.745.
HCC risk score stands for Hierarchical Condition Category risk score and means the risk score assigned to a Medicare beneficiary in accordance with the HCC risk adjustment model established by CMS under section 1853(a)(1) of the Act.
Health-related social need means an unmet, adverse social condition that can contribute to poor health outcomes and is a result of underlying social determinants of health, which refer to the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.
Improvement activities mean activities relating to care coordination, integration of specialty and primary care, and addressing health-related social needs of patients.
Mandatory geographic area means a CBSA or metropolitan division as defined by the Office of Management and Budget and selected by CMS under the terms of § 512.710(f).
Meaningful EHR user means an ASM participant who possesses CEHRT, uses the functionality of CEHRT, reports on applicable objectives and measures specified for the Promoting Interoperability ASM performance category for a performance period in the form and manner specified by CMS, does not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of CEHRT, and engages in activities related to supporting providers with the performance of CEHRT.
Measure achievement points mean numerical values assigned to an ASM participant's reported performance data, that CMS uses to calculate an ASM performance category score.
Metropolitan division means—
(1) A county or group of counties (or equivalent entities) delineated within a larger metropolitan statistical area, provided that the larger metropolitan statistical area contains a single core with a population of at least 2.5 million and other criteria are met; and
(2) Consists of one or more main or secondary counties that represent an employment center or centers, plus adjacent counties associated with the main/secondary county or counties through commuting ties.
Metropolitan statistical area means the county or counties (or equivalent entities) associated with at least one urban area of at least 50,000 population, plus adjacent counties having a high degree of social and economic integration with the core as measured through commuting ties.
MIPS stands for the Merit-based Incentive Payment System.
NPI stands for National Provider Identifier.
ONC-ACB stands for ONC-Authorized Certification Bodies.
Physician has the meaning set forth in section 1861(r) of the Act.
Primary care services has the meaning set forth in section 1842(i)(4) of the Act.
Risk indicator refers to hierarchical condition category (HCC) risk scores under the HCC risk adjustment model established by CMS under section 1853(a)(1) of the Act or the proportion of beneficiaries with dual eligible status used in calculating the complex patient scoring adjustment as defined at § 512.745(a)(3).
SAFER stands for Safety Assurance Factors for EHR Resilience.
Scaling factor means a numerical value calculated by CMS to ensure that the total estimated payment adjustments in an ASM payment year are equal to the ASM incentive pool for the applicable ASM payment year as described at § 512.750(c)(1)(iv).
Small practice means a practice consisting of 15 or fewer clinicians at the time we identify ASM participants for an ASM performance year as described at § 512.710(g).
Specialty type means a medical specialty as determined by the specialty code indicated on the plurality of a clinician's Medicare Part B claims.
Solo practitioner means a practice consisting of 1 clinician at the time we identify ASM participants for an ASM performance year as described at § 512.710(g).
Submission type means the mechanism by which the ASM submitter submits data to CMS in the form and manner specified by CMS, including, but not limited to all of the following:
(1) Direct.
(2) Log in and upload.
(3) Log in and attest.
Third -party intermediary has the meaning set forth in § 414.1305 of this chapter.
TIN stands for Taxpayer Identification Number.
Topped out measure has the meaning of either topped out process measure or topped out non-process measure set forth in § 414.1305 of this chapter.
U.S. Territories has the meaning set forth in § 512.110 of this chapter.
[90 FR 50022, Nov. 5, 2025; 91 FR 12081, Mar. 12, 2026]
(a) Mandatory ASM participation.
(1) Unless otherwise specified, any clinician who meets all ASM participant eligibility criteria as specified in paragraph (b) of this section and furnishes covered services during any applicable ASM performance year within the ASM test period is considered an ASM participant for the duration of the model.
(i) 2027 ASM performance year: ASM participants—
(A) Are measured for performance and exempted from MIPS participation, if applicable, during CY 2027;
(B) Report and are scored during CY 2028; and
(C) Receive payment adjustments for CY 2027 performance in CY 2029.
(ii) 2028 ASM performance year: ASM participants—
(A) Meeting ASM eligibility criteria for the 2028 performance year are measured for performance and exempted from MIPS participation, if applicable, during CY 2028;
(B) Report and are scored during CY 2029; and
(C) Receive payment adjustments for CY 2028 performance in CY 2030.
(iii) 2029 ASM performance year: ASM participants—
(A) Meeting ASM eligibility criteria for the 2029 performance year are measured for performance and exempted from MIPS participation, if applicable, during CY 2029;
(B) Report and are scored during CY 2030; and
(C) Receive payment adjustments for CY 2029 performance in CY 2031.
(iv) 2030 ASM performance year: ASM participants—
(A) Meeting ASM eligibility criteria for the 2030 performance year are measured for performance and exempted from MIPS participation, if applicable, during CY 2030;
(B) Report and are scored during CY 2031; and
(C) Receive payment adjustments for CY 2030 performance in CY 2032.
(v) 2031 ASM performance year: ASM participants—
(A) Meeting ASM eligibility criteria for the 2031 performance year are measured for performance and exempted from MIPS participation, if applicable, during CY 2031;
(B) Report and are scored during CY 2032; and
(C) Receive payment adjustments for CY 2031 performance in CY 2033.
(2)
(i) For any ASM performance year within the ASM test period that an ASM participant does not meet the criteria for mandatory participation set forth in this section, the ASM participant is not subject, for the applicable ASM performance year, to §§ 512.715, 512.720, 512.745, and 512.750.
(ii) For a ASM performance year described in paragraph (a)(2)(i) of this section, the ASM participant is no longer eligible for the waivers as described at § 512.775 and is instead subject to MIPS reporting obligations, if applicable.
(b) ASM participant eligibility criteria. CMS uses the following set of criteria to determine whether a clinician is an ASM participant:
(1) Is a clinician who bills claims under the Medicare Physician Fee Schedule.
(2) Is identified by TIN/NPI as a selected specialty type as described in paragraph (d) of this section.
(3) Meets the EBCM episode volume threshold applicable to an ASM targeted chronic condition as described at paragraph (e) of this section.
(4) Is located in one of the mandatory geographic areas selected in accordance with paragraph (f) of this section.
(c) Participant exclusion due to change in TIN during an ASM performance year.
(1) An ASM participant who stops assigning billing rights to the TIN used to identify the ASM participant and begins assigning billing rights to a new TIN during an applicable ASM performance year must notify CMS of the change in a form and manner determined by CMS within 30 days of the change.
(2)
(i) An ASM participant who notifies CMS of a change in TIN during an ASM performance year is not subject, for the applicable ASM performance year, to §§ 512.715, 512.720, 512.745, and 512.750.
(ii) The ASM participant described in paragraph (c)(2)(i) of this section is no longer eligible for the waivers as described at § 512.775 and is instead subject to MIPS reporting obligations, if applicable.
(d) Specialty type. ASM participants have one of the following Medicare Part B specialty codes indicated on the plurality of their Medicare Part B claims:
(1) Heart failure specialty type 3⁄4
(i) Cardiology.
(ii) [Reserved]
(2) Low back pain specialty type 3⁄4
(i) Anesthesiology.
(ii) Interventional Pain Management.
(iii) Neurosurgery.
(iv) Orthopedic Surgery.
(v) Pain Management.
(vi) Physical Medicine and Rehabilitation.
(e) EBCM episode volume. To determine if a clinician meets the ASM participant eligibility criterion defined in paragraph (b)(3) of this section, CMS uses the volume of EBCM episodes related to ASM targeted chronic conditions that are attributed to a clinician using the applicable EBCM specifications and attribution methodology.
(1) Heart failure EBCM. Clinicians who have a specialty designation type described at § 512.710(d)(1) and 20 or more heart failure EBCM episodes attributed in accordance with the heart failure episode-based cost measure as specified under MIPS during the calendar year 2 years prior to the applicable ASM performance year meet the ASM participant eligibility criterion defined in paragraph (b)(3) of this section.
(2) Low back pain EBCM. Clinicians who have a specialty designation type described at § 512.710(d)(2) and 20 or more low back pain EBCM episodes attributed in accordance with the low back pain episode-based cost measure as specified under MIPS during the calendar year 2 years prior to the applicable ASM performance year meet the ASM participant eligibility criterion defined in paragraph (b)(3) of this section.
(f) Mandatory geographic areas. CMS uses a stratified random sampling methodology described in paragraphs (f)(2) and (f)(3) of this section to select CBSA and metropolitan divisions (in cases where OMB divides large metropolitan statistical areas into metropolitan divisions) from which CMS identifies clinicians for participation in ASM.
(1) Exclusions. CMS excludes from the selection of CBSAs and metropolitan divisions applicable areas that meet any of criteria described in paragraph (f)(1)(i) or (ii) of this section.
(i) Areas that do not meet the criteria described in paragraphs (f)(1)(i)(A) and (f)(1)(i)(B) of this section:
(A) Have at least one clinician with a specialty designation type described at § 512.710(d)(1) with 20 or more heart failure EBCM episodes attributed between January 1, 2024 and December 31, 2024.
(B) Have at least one clinician with a specialty designation type described at § 512.710(d)(2) with 20 or more low back pain EBCM episodes attributed between January 1, 2024 and December 31, 2024.
(ii) Areas located entirely in U.S. Territories.
(2) CBSA and metropolitan division stratification process. Prior to sampling CBSAs and metropolitan divisions, CMS stratifies CBSAs and metropolitan divisions, excluding those described in paragraph (f)(1) of this section, into six mutually exclusive strata based on three CBSA/metropolitan division-level characteristics (average total Part A and Part B episode spending, volume of eligible episodes, and metropolitan division status) as described in paragraphs (f)(2)(i) through (vi) of this section. “Average total episode spending” as the term is used in paragraphs (f)(2)(i) through (vi) of this section, is measured using the average total Part A and Part B episode spending using claims data from January 1, 2024 to December 31, 2024 relating to heart failure and low back pain episodes, as specified under the episode-based cost measures described in § 512.710(e). Values below the median are characterized as “Low” average total episode spending. Values at or above the median are characterized as “High” average total spending. “Eligible episode volume” as the term is used in paragraphs (f)(2)(i) through (vi) of this section, is measured as the total count of eligible heart failure and low back pain episodes, as specified under the episode-based cost measures described in § 512.710(e), in a CBSA between January 1, 2024 and December 31, 2024. CMS categorizes CBSAs with values below the median as “Low;” CBSAs at-or-above the median and below the 95th percentile as “High;” and CBSAs at-or-above the 95th percentile as “Very High.”.
(i) CBSAs with “Low” average total episode spending and “Low” eligible episode volume.
(ii) CBSAs with “Low” average total episode spending and “High” eligible episode volume.
(iii) CBSAs with “High” average total episode spending (as defined below) and “Low” eligible episode volume.
(iv) Eligible CBSAs with “High” average total episode spending and “High” eligible episode volume.
(v) Eligible CBSAs with “Very High” eligible episode volume.
(vi) Eligible metropolitan divisions.
(3) Sampling of CBSAs and metropolitan divisions. CMS selects approximately 40 percent of CBSAs and metropolitan divisions from each stratum to select the mandatory geographic areas. If 40 percent of a given stratum does not result in a whole number of CBSAs or metropolitan divisions, CMS rounds up to the next whole number to ensure that at least 40 percent of areas from each stratum are selected.
(4) Assignment of CBSA or metropolitan division code to clinicians. CMS assigns a CBSA or a metropolitan division code to every TIN/NPI with attributed EBCM episodes related to ASM targeted chronic conditions for the applicable calendar year as described in paragraph (e) of this section to determine ASM participation eligibility for an applicable ASM performance year:
(i) CMS assigns each attributed EBCM episode a ZIP Code, which represents the service location where the attributed TIN/NPI encounters the beneficiary attributed to the episode the most, based on the plurality of Part B claims used to construct the episode. If the ZIP Codes representing service location where the attributed TIN/NPI appears in equal number in the Part B claims used to construct the episode, then CMS assigns the ZIP Code based on the ZIP Code that represents the Part B claim with—
(A) The highest total cost indicated by the total standardized allowed amount; or
(B) Most recent date.
(ii) CMS assigns each attributed EBCM episode a CBSA or metropolitan division code based on the ZIP Code assigned to the episode as described in paragraph (f)(4)(i) of this section. If the ZIP Code assigned to the EBCM episode is in multiple CBSAs or metropolitan divisions, then CMS assigns the EBCM episode the CBSA or metropolitan division code where the ZIP Code has the highest proportion of—
(A) Total addresses; or
(B) Business addresses.
(iii) CMS assigns each TIN/NPI combination a single CBSA or metropolitan division code based on the most common CBSA or metropolitan division code assigned to episodes attributed to the TIN/NPI as described in paragraph (f)(4)(ii) of this section. If the TIN/NPI has equal number of episodes across multiple CBSAs or metropolitan divisions, then CMS assigns the TIN/NPI a CBSA or metropolitan division with the CBSA or metropolitan division that has either of the following:
(A) The highest total risk-adjusted episode spending across all episodes assigned to the CBSA or metropolitan division.
(B) Episodes with more recent dates.
(g) Selection and notification process for ASM participants. For each ASM performance year, CMS identifies all clinicians furnishing covered services using the ASM participant eligibility criteria specified in paragraph (b) of this section and applicable data from 2 calendar years prior to each ASM performance year. Any clinician selected for participation for any year of the model is considered an ASM participant for the remainder of the ASM test period.
(1) 2027 ASM performance year only —
(i) Preliminarily eligible ASM participants. Using applicable data from calendar year 2024, CMS identifies all clinicians who meet the ASM participant eligibility criteria for participation starting in the 2027 ASM performance year/2029 ASM payment year. The clinicians identified as preliminarily eligible ASM participants are made public in a form and manner determined by CMS.
(ii) Final ASM participants. CMS identifies the final ASM participants selected for participation starting in the 2027 ASM performance year/2029 ASM payment year by confirming that the preliminarily eligible ASM participants identified under paragraph (g)(1)(i) of this section meet the ASM participant eligibility criteria using applicable data from CY 2025. The clinicians selected as ASM participants starting in the 2027 ASM performance year/2029 ASM payment year is made public in a form and manner determined by CMS.
(2) 2028 ASM performance year and subsequent years.
(i) Beginning with the 2028 ASM performance year/2030 ASM payment year, CMS determines if the previously selected ASM participants continue to meet the ASM participant eligibility criteria for the upcoming ASM performance year/ASM payment year using applicable data from the calendar year 2 years prior to the applicable ASM performance year. An ASM participant who does not meet the ASM participant eligibility criteria for the upcoming ASM performance year/ASM payment year is not subject to provisions described at §§ 512.715, 512.720, and 512.745 and must, if applicable, participate in MIPS. The final ASM participants selected for participation for each applicable ASM performance year is made public in a form and manner determined by CMS.
(ii) Beginning with the 2028 ASM performance year/2030 ASM payment year and prior to the start of each ASM performance year, CMS determines if additional clinicians not previously identified as ASM participants meet the ASM participant eligibility criteria for the upcoming ASM performance year/ASM payment year using applicable data from the calendar year 2 years prior to the applicable ASM performance year. The final ASM participants selected for participation for each applicable ASM performance year is made public in a form and manner determined by CMS.
[90 FR 50022, Nov. 5, 2025; 91 FR 12081, Mar. 12, 2026]