MIPS payment adjustments explained

For MIPS, the performance year and payment year are separated by roughly 2 years. Data collected during the 2026 performance year is submitted after the performance year closes and generally affects the 2028 MIPS payment year.

• 2026 performance year: January 1 through December 31, 2026
• 2026 data submission window: generally January 2 through March 31, 2027
• 2028 MIPS payment year: payment adjustments are generally applied during calendar year 2028
• The adjustment is based on the final MIPS score for the applicable clinician, group, subgroup, virtual group, or APM Entity
• The adjustment can be positive, neutral, or negative depending on the final score and QPP rules

This timing matters because a practice may not see the financial effect of 2026 reporting until the 2028 payment year. That is why eligibility review, measure selection, data completeness, documentation, and submission preparation should happen during the performance year, not after the year has ended.

For the 2026 performance year, the MIPS performance threshold is 75 points. The performance threshold is the final score a participant generally needs to receive a neutral payment adjustment and avoid a negative payment adjustment under QPP scoring rules.

• Final scores are calculated on a 0 to 100 point scale
• The 2026 performance threshold is 75 points
• A score below 75 points generally results in a negative payment adjustment
• A score of exactly 75 points generally results in a neutral payment adjustment
• A score above 75 points generally results in a positive payment adjustment, subject to budget-neutral scaling
• The performance threshold remains 75 points through the 2028 performance period and 2030 MIPS payment year under current finalized policy

The maximum negative payment adjustment for the 2026 performance year and 2028 MIPS payment year is -9%. Positive adjustments are not guaranteed at a specific percentage because they depend on budget neutrality and the distribution of final scores across MIPS participants.

For the 2026 performance year, the relationship between the final score and the performance threshold determines whether the 2028 payment adjustment is positive, neutral, or negative.

• Positive adjustment: final score above 75 points, subject to budget-neutral scaling
• Neutral adjustment: final score exactly at 75 points
• Negative adjustment: final score below 75 points
• Maximum negative adjustment: -9% for scores from 0.00 to 18.75 points
• Scaled negative adjustment: scores from 18.76 to 74.99 points receive a negative adjustment between -9% and 0%
• Positive adjustment amounts vary because MIPS is designed to be budget neutral

A score above the performance threshold may qualify for a positive adjustment, but the final percentage depends on QPP budget-neutral scaling and the distribution of scores across all participants for that performance year.

MIPS is structured as a budget-neutral program under its original legislative framework. This means that positive payment adjustments are funded in part by the pool generated from negative payment adjustments across all MIPS participants. The positive adjustment a practice receives is not a fixed percentage. It depends on the total amount available in the positive adjustment pool and how it is distributed across participants who scored above the performance threshold.

A scaling factor is applied to positive adjustments when calculating the final payment adjustment amount. Practices should not assume a specific positive adjustment percentage based only on their final score. The actual positive adjustment percentage is determined by CMS after all 2026 performance year scores are finalized, and the details are published through official QPP resources.

• Positive adjustments are funded from the pool generated by negative adjustments
• A scaling factor is applied when distributing positive adjustments across participants
• Higher final scores may receive proportionally larger positive adjustments within the available pool
• Positive adjustment percentages vary by performance year and cannot be guaranteed in advance
• The actual positive adjustment amount should be verified through official QPP score and payment feedback

MIPS payment adjustments are delayed because CMS needs time to collect submitted data, calculate final scores, apply scoring rules, and determine the applicable payment adjustment for the future payment year.

• 2026 performance data is collected during calendar year 2026
• Submission generally occurs from January 2 through March 31, 2027
• Final score and performance feedback are released later by QPP
• The resulting payment adjustment generally applies during the 2028 MIPS payment year
• Practices should monitor official QPP feedback and targeted review timelines when final scores and payment adjustments are released

Because the payment impact is delayed, practices should not wait until the payment year to evaluate performance. By then, the data collection period has already passed.

A MIPS payment adjustment generally depends on whether the clinician, group, subgroup, virtual group, or APM Entity is eligible and has a final score for the applicable performance year. Eligibility and payment adjustment application can vary by TIN/NPI combination, reporting level, Advanced APM status, and official QPP determinations.

• MIPS eligible clinicians may receive an adjustment based on their applicable final score
• Group reporting can affect the adjustment applied to clinicians billing under the group TIN
• A clinician billing under multiple TINs may need separate TIN/NPI review
• Qualifying APM Participants are generally excluded from MIPS reporting and MIPS payment adjustments for the applicable year
• Clinicians or groups below the low-volume threshold may not be required to participate
• Opt-in and voluntary reporting status can affect whether a payment adjustment applies
• Practices should verify payment adjustment applicability using official QPP eligibility and feedback resources

The reporting level and TIN/NPI relationship matter. Do not assume every clinician in a practice receives the same payment adjustment.

A neutral adjustment generally means the final score met the performance threshold exactly and the payment adjustment is 0%. A clinician or group may also have no MIPS payment adjustment if they are not subject to MIPS payment adjustments for the applicable year based on official QPP eligibility, exclusion, or participation status.

• Neutral adjustment generally means a final score of 75 points
• No adjustment may occur when the clinician or group is not subject to MIPS payment adjustments
• New Medicare enrollment status, low-volume threshold status, and Advanced APM status can affect applicability
• Voluntary reporting may not always produce a payment adjustment
• Final applicability should be verified through official QPP resources