CMS has released the 2026 Proposed Rule for the Quality Payment Program (QPP), continuing its incremental shift toward MIPS Value Pathways (MVPs), adjusting quality and cost strategies, and laying groundwork for future interoperability and digital measures. While 2026 introduces fewer sweeping changes, clinicians and Accountable Care Organizations (ACOs) should take note of important updates across the Merit-Based Incentive Payment System (MIPS) and the Medicare Shared Savings Program (MSSP). Below is a breakdown of what’s proposed and how it may affect you.
MIPS Structure and Participation
CMS is aiming for stability in the MIPS program structure, with few changes to participation options or scoring thresholds in the 2026 performance year.
- Performance Threshold: CMS proposes maintaining the performance threshold at 75 points through the 2028 performance year (for the 2030 payment adjustment).
- Reporting Options: CMS will continue offering three MIPS reporting options:
- Traditional MIPS
- MIPS Value Pathways (MVPs)
- APM Performance Pathway (APP)
MIPS Value Pathways (MVPs): Still Optional, But Expanding
While MVP reporting remains optional in 2026, CMS is expanding the framework with new pathways and refinements that signal its growing role in the future of MIPS.
Six new MVPs are proposed for 2026:
- Diagnostic Radiology
- Interventional Radiology
- Neuropsychology
- Pathology
- Podiatry
- Vascular Surgery
All 21 previously finalized MVPs would be updated to align with proposed changes to quality and improvement activity inventories.
MVP Reporting
Groups would self-attest their specialty composition (either single-specialty or multispecialty) during MVP registration, rather than CMS making that determination. Small multispecialty practices (15 or fewer clinicians) would continue to have the option to report MVPs at the group level. Subgroup reporting would remain optional for these practices.
Qualified Clinical Data Registries (QCDRs) and Qualified Registries would be given one year after an MVP is finalized before they are required to support it fully, providing more time for technical implementation.
Quality Category: Streamlining Measure Inventory and Policy Refinements
CMS is proposing moderate updates to the Quality performance category in 2026, including adjustments to the measure inventory, measure definitions, and scoring methodologies. These changes reflect a continued emphasis on meaningful quality improvement while reducing redundancy.
Proposed Quality Measure Inventory changes include:
- 5 new quality measures proposed (including 2 eCQMs)
- 10 existing measures proposed for removal
- 32 existing measures would be substantively updated
A list of proposed new measures, along with their collection types, is outlined in the table below.
| Proposed New Quality Measures | Collection Type |
| Patient Reported Falls and Plan of Care American Academy of Neurology | MIPS CQM |
| Prevalent Standardized Kidney Transplant Waitlist Ratio (PSWR) | MIPS CQM |
| Diagnostic Delay of Venous Thromboembolism in Primary Care | eCQM |
| Screening for Abnormal Glucose Metabolism in Patients at Risk of Developing Diabetes | eCQM |
| Hepatitis C Virus (HCV): Sustained Virological Response (SVR) | MIPS CQM |
Several measures have been proposed for removal next year.
| Proposed Quality Measures to be Removed in 2026 | Collection Type |
| #185 Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use | MIPS CQM |
| #264 Sentinel Lymph Node Biopsy for Invasive Breast Cancer | MIPS CQM |
| #290 Assessment of Mood Disorders and Psychosis for Patients with Parkinson's Disease | MIPS CQM |
| #322 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients | MIPS CQM |
| #419 Overuse of Imaging for the Evaluation of Primary Headache | MIPS CQM |
| #424 Perioperative Temperature Management | MIPS CQM |
| #443 Non-Recommended Cervical Cancer Screening in Adolescent Females | MIPS CQM |
| #487 Screening for Social Drivers of Health | MIPS CQM |
| #498 Connection to Community Service Provider | MIPS CQM |
| #508 Adult COVID-19 Vaccination Status | MIPS CQM |
High Priority Measures
In addition to inventory changes, CMS proposes to remove “health equity” from the definition of high priority measures, narrowing the scope to core clinical domains such as outcomes, safety, and care coordination.
Topped Out Measures
To address limited measure choice in certain specialties, CMS will continue to apply alternative benchmarks for 19 topped-out measures, allowing clinicians in those areas to still earn meaningful points.
Claims-based Measures
Finally, CMS proposes to revise the scoring methodology for claims-based measures, aligning it with cost measure benchmarking by using median-based scoring and standard deviations to determine performance thresholds.
Improvement Activities: Targeted Changes, New Focus on Wellness
CMS proposes targeted updates to the Improvement Activities (IA) performance category for 2026, with a focus on streamlining the inventory and introducing activities that reflect emerging priorities in care delivery.
- 3 new Improvement Activities added, 7 modified, 8 removed.
- The “Achieving Health Equity” subcategory would be retired and replaced with a new subcategory: “Advancing Health and Wellness.”
CMS has proposed the following three new Improvement Activities for the 2026 performance year:
- Improving Detection of Cognitive Impairment in Primary Care
- Integrating Oral Health Care in Primary Care
- Patient Safety in Use of Artificial Intelligence (AI)
CMS has proposed removing eight activities from the inventory for the 2026 performance year.
| Improvement Activities Proposed for Removal |
| IA_ AHE_5 MIPS Eligible Clinician Leadership in Clinical Trials or CBPR |
| IA_AHE_8 Create and Implement an Anti-Racism Plan |
| IA_AHE_9 Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols |
| IA_AHE_11 Create and Implement a Plan to Improve Care for Lesbian, Gay, Bisexual, Transgender, and Queer Patients |
| IA_AHE_12 Practice Improvements that Engage Community Resources to Address Drivers of Health |
| IA_PM_26 Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B |
| IA_PM_6 Use of Toolsets or Other Resources to Close Health and Health Care Inequities Across Communities |
| IA_ERP_3 COVID-19 Clinical Data Reporting with or without Clinical Trial |
CMS had previously finalized the removal of several improvement activities effective for the 2026 performance period and beyond.
| Improvement Activities Previously Finalized for Removal in 2026 |
| IA_PM_12 Population Empanelment |
| IA_CC_1 Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop |
| IA_CC_2 Implementation of Improvements that Contribute to More Timely Communication of Test Results |
| IA_BMH_8 Electronic Health Record Enhancements for BH Data Capture |
Promoting Interoperability: Technical Updates to Support Security and Flexibility
While the Promoting Interoperability (PI) category maintains its overall structure and weight in the 2026 proposed rule, CMS is proposing several technical updates to strengthen data security, modernize guidance, and add flexibility in response to real-world reporting challenges.
- The Security Risk Analysis measure would now require an additional attestation confirming that clinicians conducted risk management activities, as outlined under the HIPAA Security Rule.
- Clinicians would be required to use the updated 2025 SAFER Guides for their self-assessments under the High Priority Practices measure.
- A new bonus measure would be added for public health data exchange using the Trusted Exchange Framework and Common Agreement (TEFCA), supporting broader interoperability goals.
PI Measure Suppression
In response to operational barriers, CMS proposes to suppress the Electronic Case Reporting measure for the 2025 performance period due to CDC delays in onboarding new providers and public health agencies.
To proactively address similar issues in the future, CMS also proposes a new measure suppression policy. This would allow CMS to suppress PI measures when unexpected challenges make compliance infeasible or unfair for clinicians.
Cost Category: Stable Inventory, More Insight Into Future Measures
The Cost performance category remains largely unchanged in the 2026 proposed rule, but CMS is introducing refinements that aim to improve fairness and provide more transparency for future cost scoring.
- No new cost measures are being proposed, and none are being removed. The total number remains at 35 for the 2026 performance year.
- CMS proposes updates to the Total Per Capita Cost (TPCC) measure, refining the attribution logic and service timing criteria to better target primary care relationships and reduce misattribution.
- Looking ahead, CMS proposes a 2-year informational-only feedback period for any new cost measures finalized in future years. During this time, clinicians would see performance feedback without the measure contributing to their MIPS final score—giving practices time to understand and adapt before any financial impact.
APMs & ACOs: More Flexibility, Better Alignment with Attribution
CMS is proposing modest but meaningful updates to APM and ACO participation in the Quality Payment Program, with a focus on improving flexibility in QP determinations and reducing reporting burdens for Shared Savings Program ACOs.
- For Qualifying APM Participant (QP) status, CMS would begin making determinations at both the individual clinician level and the APM Entity level, offering more granular eligibility tracking. The calculation would be expanded to include all Covered Professional Services, not just E/M services, for better representation of participation.
- Within the APP Plus measure set, CMS proposes removing the Screening for Social Drivers of Health (Quality ID 487) if it is finalized for removal from the broader MIPS inventory.
- For ACOs reporting Medicare Clinical Quality Measures (CQMs), CMS proposes a revised definition of eligible beneficiaries. This change would create greater overlap with the ACO’s assignable population, simplifying patient matching and reducing administrative burden.
Final Thoughts
Traditional MIPS remains in place for 2026, but CMS is steadily advancing MVPs as the long-term direction of the program. Clinicians should review proposed changes across the MIPS performance categories, as updates or removals may impact scoring. For ACOs, updates to Medicare CQM reporting are intended to ease burden and improve alignment with assigned populations, reflecting CMS’s broader shift toward more streamlined and data-driven performance measurement.
CMS is accepting comments on the proposed rule through September 12, 2025. To be assured consideration, comments must be received by 5 p.m. ET on that date via www.regulations.gov or by mail using the addresses listed in the rule.
Leave a comment