The 2027 Physician Fee Schedule Final Rule gives Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program limited flexibility to exclude participant taxpayer identification numbers (TINs) from their submission of quality measure data. ACOs must report data from all participant TINs unless the exclusion requirements are met. The policy begins with performance year 2026 and also applies to the new Medicare eCQMs collection type beginning in 2027.
What the Final Rule Allows
In limited circumstances, an ACO may exclude participant TINs from its eCQM, MIPS CQM, or Medicare CQM submission. This flexibility also applies to Medicare eCQMs beginning with performance year 2027.
CMS describes the policy as a safeguard for "limited and unusual circumstances." Each exclusion requires a qualifying reason, sufficient representation of assigned beneficiaries, and supporting documentation.
Qualifying Reasons for TIN Exclusions
An ACO may exclude a TIN only for one of these reasons:
- An unforeseen circumstance outside the ACO's control. CMS's example is a practice closing mid-year, such as when a solo provider retires and the ACO can no longer access the practice's data.
- Certified EHR technology (CEHRT) intended for specialty use that, because of that focus, does not capture the data needed for the affected APP Plus quality measures. CMS's example is an ophthalmology practice whose EHR was never designed to capture primary care-focused quality data.
- Other circumstances determined by CMS. CMS has not established a process for ACOs to request additional qualifying circumstances. CMS will identify and communicate those circumstances, as appropriate.
When TIN Exclusions Are Not Permitted
An ACO can't exclude a TIN because of its patients' demographics or health status, or because of the TIN's expected effect on the ACO's quality performance.
CMS also declined to add or broaden exclusions and related exceptions requested by commenters:
- An EHR’s inability to support the APP Plus measures does not automatically qualify a TIN for exclusion. To qualify under the specialty EHR exclusion, the TIN must use certified EHR technology intended for specialty use that was not designed to capture the data elements needed to support the affected APP Plus measures. Otherwise, another qualifying reason must apply.
- Exclusions based solely on low volume, small practice size, restrictive EHR or billing vendor data-transmission fees, or inability to produce QRDA files. These TINs may still qualify if they meet one of the three allowed reasons and the other requirements. CMS also did not add Promoting Interoperability exclusions or hardship exemptions as separate qualifying reasons.
- Excluding only part of a TIN. The exclusion applies to the entire participant TIN for the affected measure, rather than selected practices, specialties, or clinicians within that TIN. A practice with its own TIN may qualify if all exclusion requirements are met.
CMS also rejected requests for a lower beneficiary threshold, alternative calculation methods, an attestation process, a phase-in for smaller ACOs, and a process for requesting additional exclusion circumstances.
The 95% Assigned-Beneficiary Requirement
When an ACO uses a qualifying TIN exclusion, the remaining TINs must represent at least 95% of its assigned beneficiaries for each affected measure, before applying measure specifications. This requirement applies only when TINs are excluded.
New CMS reports: CMS will provide a beneficiary-TIN report in the ACO-MS Data Hub showing how assigned beneficiaries are matched to participant TINs. ACOs must use the Quarter 4 report to check the requirement; Quarter 3 is a preview. For performance year 2026, Quarter 3 is scheduled for November 2026 and Quarter 4 for February 2027.
Important limitation: Assigned beneficiaries without an eligible primary care claim during the performance year with a TIN included in the ACO’s submission do not count toward the 95%, but remain in the total assigned population. Some ACOs, particularly those using prospective assignment, may therefore be unable to meet the requirement and use an exclusion.
Data completeness: After qualifying TIN exclusions, the ACO must still report on at least 75% of patients who meet each measure’s denominator criteria.
2026 Medicare CQM note: The reporting population includes assignable beneficiaries, some of whom are not assigned to the ACO. The 95% requirement uses assigned beneficiaries. Medicare CQM reporting shifts to an assigned-beneficiary population in performance year 2027.
No Pre-Approval, but CMS Can Audit
CMS will not review exclusions in advance. Each ACO is responsible for deciding whether an exclusion applies and for keeping documentation that supports it. CMS may audit and request that documentation, and reporting that is not accurate, complete, and timely may result in compliance actions.
Next Steps for ACOs
- Plan to report on every participant TIN.
- For any qualifying exclusion, verify the 95% requirement using the Quarter 4 report and retain the calculation, supporting evidence, excluded TINs, and affected measures.
- For hard-to-report practices, evaluate collection type options rather than planning on an exclusion.
MDinteractive will continue to follow CMS guidance on this provision and update ACO customers as CMS releases education materials and example calculations.
Source: CY 2027 Physician Fee Schedule Final Rule, section III.G.3.d.(2); 42 CFR 425.508(c)(1)–(4)