MIPS eligibility and participation

For 2026, MIPS may apply to clinicians who are included in a MIPS eligible clinician type, enrolled in Medicare before January 1, 2026, not identified as a Qualifying APM Participant, and above the low-volume threshold. Eligibility also depends on whether the clinician is being evaluated individually, under a group TIN, through a virtual group, as a subgroup for MVP reporting, or through an applicable APM pathway.

A clinician type alone does not make a provider required to report. The provider must also meet the other eligibility requirements, including Medicare enrollment timing, low-volume threshold status, and APM participation status.

According to the 2026 QPP eligibility framework, MIPS eligible clinician types include:

• Physicians, including MD, DO, DDS, DMD, DPM, and OD
• Osteopathic practitioners
• Chiropractors
• Physician assistants
• Nurse practitioners
• Clinical nurse specialists
• Certified registered nurse anesthetists
• Physical therapists
• Occupational therapists
• Clinical psychologists
• Qualified speech-language pathologists
• Qualified audiologists
• Registered dietitians or nutrition professionals
• Clinical social workers
• Certified nurse-midwives

If a clinician is not one of the MIPS eligible clinician types, they are generally excluded from MIPS reporting. However, practices should still confirm status through official QPP resources, especially when reviewing group reporting, specialty changes, provider type updates, or clinicians associated with multiple TINs.

For the 2026 performance year, MIPS eligibility is generally determined using four major factors:

• Clinician type
• Medicare enrollment timing
• Volume of Medicare Part B covered professional services
• Advanced APM or Qualifying APM Participant status

A clinician is generally required to participate in MIPS when they are an eligible clinician type, enrolled in Medicare before January 1, 2026, not identified as a Qualifying APM Participant, and above the low-volume threshold.

Eligibility should be reviewed by TIN/NPI combination. If a clinician bills under more than one TIN, each TIN/NPI combination should be checked separately because eligibility can differ by practice.

For 2026, clinicians and groups generally exceed the low-volume threshold only when they exceed all 3 criteria:

• More than $90,000 in Medicare Part B allowed charges for covered professional services under the Physician Fee Schedule
• More than 200 Medicare Part B patients
• More than 200 covered professional services furnished to Medicare Part B patients

If a clinician or group does not exceed all 3 criteria, they may not be required to participate in MIPS. Some clinicians or groups that exceed 1 or 2 of the criteria may be opt-in eligible, while others may only be able to report voluntarily depending on their official QPP status.

For the 2026 performance year, eligibility is reviewed across two 12-month segments:

• Segment 1: October 1, 2024 to September 30, 2025
• Segment 2: October 1, 2025 to September 30, 2026

Practices should review both initial and final eligibility status. Initial eligibility helps guide planning, but final eligibility should be confirmed before submission decisions are finalized.

MIPS participation can happen at different levels. A clinician may report individually under a TIN/NPI combination. A practice may choose group reporting when the group is eligible at the TIN level. Some practices may also participate through a virtual group, subgroup for MVP reporting, or APM Entity when applicable.

• Individual participation: eligibility is reviewed for the clinician's TIN/NPI combination
• Group participation: the practice's TIN may be evaluated at the group level
• Opt-in participation: may be available when an otherwise eligible clinician or group exceeds 1 or 2, but not all 3, low-volume threshold criteria
• Voluntary reporting: may be available when the clinician or group is not required to participate but still wants to submit traditional MIPS data for feedback
• Advanced APM participation: Qualifying APM Participant status can change MIPS participation requirements

The decision to report as an individual, group, subgroup, virtual group, or APM Entity can affect whose data is included and who may receive a payment adjustment. Practices should confirm eligibility and reporting options before building the reporting workflow.

Before selecting measures or building a reporting plan, practices should verify eligibility through official QPP resources. The review should include each applicable clinician, each TIN/NPI combination, group-level status, low-volume threshold status, special statuses, and any Advanced APM participation.

Even if a practice believes its clinicians are not eligible based on prior years, eligibility should be confirmed for each new performance year. Changes in billing volume, clinician type updates, threshold changes through rulemaking, or new APM participation can all affect eligibility status.