CJR-X FAQs: All Your Questions About the Proposed Mandatory Payment Model, Answered

CJR-X (Comprehensive Care for Joint Replacement Expanded) is a mandatory nationwide Medicare bundled payment model proposed by CMS in the FY2027 IPPS Proposed Rule. If finalized, it expands the original CJR Model, tested from 2016–2024 in selected Metropolitan Statistical Areas, to all eligible acute care hospitals across the United States, beginning October 1, 2027.

Under CJR-X, hospitals are financially accountable for the total cost and quality of care for lower extremity joint replacement (LEJR) episodes, including knee, hip, and ankle replacements, from the initial procedure through 90 days post-discharge.

CMS proposes a start date of October 1, 2027. Unlike the previous model, CJR-X performance years align with the federal fiscal year (October 1 – September 30), not the calendar year. CMS chose FY alignment because CJR-X will be governed through the annual IPPS rulemaking cycle, giving hospitals more than one year of lead time after the final rule is published.

Participation is mandatory for all acute care hospitals located in any of the 50 US states, the District of Columbia, or US territories that both:

• Initiate LEJR episodes, and
• Are paid under both the IPPS and the OPPS.

The dual IPPS/OPPS requirement ensures CMS can construct consistent target prices for both inpatient and outpatient LEJR episodes.

Yes. The following hospitals are excluded:

• TEAM participants — Hospitals currently in the Transforming Episode Accountability Model (mandatory or voluntary) are exempt for the duration of TEAM, to avoid concurrent LEJR accountability under two models with different methodologies (TEAM uses 30-day episodes; CJR-X uses 90-day).
• Maryland hospitals — Excluded due to Maryland's unique all-payer rate-setting authority. CMS may revisit this exclusion as Maryland's rate-setting authority concludes at the end of 2027.
• Critical Access Hospitals (CAHs), Rural Emergency Hospitals, Indian Health Service and Tribal hospitals, and hospitals in the Rural Community Hospital Demonstration — Excluded because they are not paid under both IPPS and OPPS.

The episode covers the anchor hospitalization or procedure plus the full 90-day post-discharge period. It includes all related Medicare Parts A and B items and services, including:

• Physician services
• Inpatient IPPS hospital services
• Skilled Nursing Facility (SNF) stays
• Home Health Agency (HHA) services
• Inpatient Rehabilitation Facility (IRF) services
• Long-Term Care Hospital (LTCH) services
• Inpatient Psychiatric Facility (IPF) services
• Most outpatient services

Certain readmissions unrelated to the LEJR procedure, high-cost drugs, new technology add-on payments, and other specified services are excluded.

Episodes in CJR-X are triggered by:

• MS-DRG 469 — Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity with Major Complications or Comorbidities (MCC) or Total Ankle Replacement
• MS-DRG 470 — Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity without MCC
• MS-DRG 521 — Hip Replacement with Principal Diagnosis of Hip Fracture with MCC
• MS-DRG 522 — Hip Replacement with Principal Diagnosis of Hip Fracture without MCC
• HCPCS 27447 — Total Knee Arthroplasty
• HCPCS 27130 — Total Hip Arthroplasty

Outpatient total ankle arthroplasty (HCPCS 27702) is not included in the proposed CJR-X.

CJR-X uses a retrospective bundled payment model. The process each performance year is as follows:

• Step 1 — Before the year begins, CMS issues a preliminary target price for each MS-DRG/HCPCS episode type within each US Census Division. All hospitals in the same region receive the same benchmark price; prices are not set individually per hospital.
• Step 2 — Throughout the year, all providers continue to be paid under standard Medicare fee-for-service (FFS) rates. No payment changes occur in-year.
• Step 3 — At the end of the year, preliminary target prices are updated at reconciliation to reflect the retrospective trend factor and the realized patient case mix, producing a final reconciliation target price.
• Step 4 — CMS compares each hospital's actual total episode spending against the reconciliation target price. If spending is below target, reconciliation payment eligibility and amount depend on the hospital's Composite Quality Score (CQS). If spending exceeds target, the hospital may owe repayment, capped by stop-loss limits. Repayment obligations are not affected by quality score.

CJR-X target prices are based on regional data, rather than a blend of hospital-specific and regional spending. CMS uses average standardized episode spending for each MS-DRG/HCPCS episode type in each US Census Division over a 3-year baseline period. All hospitals in the same region receive the same benchmark price, making CJR-X an achievement-based model where hospitals compete against regional peers, not their own historical performance.

The baseline rolls forward every year, with more recent years weighted more heavily (baseline year 3 = 50%, year 2 = 33%, year 1 = 17%). Benchmark prices are then adjusted by:

• Prospective trend factor — Estimates expected spending changes between the baseline period and the performance year, included in the preliminary target price shared before the year begins.
• Retrospective trend factor — Applied at reconciliation, capped at ±3%, to capture realized spending changes during the performance year not accounted for in the prospective estimate.
• 2.0% discount factor — Medicare's share of expected savings, reduced from the 3.0% used in the original CJR Model. High-quality hospitals can reduce their effective discount factor through the Composite Quality Score (CQS).
• Risk adjustment — Episode-level adjustments using the same methodology as TEAM: beneficiary-level adjusters for age, HCC count, beneficiary economic risk, prior post-acute care use, disability status, and a 180-day look-back for recent medical history, plus hospital-level adjusters for bed size and safety net status.
• Normalization factor — Ensures risk adjustment does not inflate target prices overall, capped at ±5% at reconciliation.

High-Cost Outlier Cap: Both baseline episode spending (used to set benchmark prices) and performance year episode spending (used at reconciliation) are capped at the 99th percentile of spending for each MS-DRG/HCPCS episode type and region. This prevents catastrophically expensive individual cases from skewing benchmark prices upward or a hospital's reconciliation outcome. A hospital is not held responsible for episode spending that exceeds the cap.

Low-Volume Protection: Hospitals with fewer than 31 LEJR episodes during the 3-year baseline period are classified as low-volume hospitals and are excluded from reconciliation entirely for that performance year. Their episodes do not trigger CJR-X accountability, though volume counts accumulate as the baseline rolls forward annually, meaning a growing program may become accountable in a future year.

CJR-X caps both reconciliation payments and repayment obligations as a percentage of each hospital's aggregate reconciliation target price:

• Most hospitals — Symmetrical 20% stop-loss (maximum repayment owed) and 20% stop-gain (maximum reconciliation payment received).
• Protected categories — Rural hospitals, Medicare-Dependent Small Rural hospitals (MDH), Sole Community Hospitals (SCH), and safety net hospitals receive a reduced 5% stop-loss limit. Their stop-gain limit remains 20%.

Post-episode spending: CMS monitors the 30-day period after each episode ends. If a hospital's average post-episode spending exceeds three standard deviations above the regional average, it must repay that excess amount. This repayment is not subject to the stop-loss limits above and is designed to prevent care from being delayed until after the episode concludes.

Yes. CJR-X proposes sharing arrangement provisions allowing hospitals to distribute reconciliation payments to CJR-X collaborators, including orthopedic surgeons, hospitalists, post-acute care providers, and other clinicians, who contribute to cost and quality improvements. Collaborators may also bear downside risk (alignment payments) if the hospital owes Medicare repayment.

Hospitals may not charge collaborators a fee to appear on a preferred provider list, nor accept such payments. All financial arrangements must comply with applicable fraud and abuse law.

CJR-X uses a Composite Quality Score (CQS) on a 0–20 point scale that determines both a hospital's eligibility to receive a reconciliation payment and the effective discount factor applied to its reconciliation target price. The base discount factor is 2.0%. Higher quality performance reduces that discount, raising the reconciliation target price and improving the hospital's financial position.

Repayment obligations when spending exceeds target are not affected by the quality tier.

CMS proposes five measures across three domains. All are drawn from existing CMS quality reporting programs, so CJR-X participants do not need to submit additional data specifically for CJR-X:

Complications Domain (50% of CQS)

• Hospital-Level RSCR Following Elective Primary THA and/or TKA (CMIT ID #350) — Captures mortality, MI, pneumonia, sepsis, pulmonary embolism, bleeding, infection, and mechanical failure from admission through 90 days. Reported through the Hospital IQR Program.
• Hospital Visits Within 7 Days of HOPD Surgery (CMIT ID #344, OP-36) — Captures unplanned inpatient admissions, observation stays, and ED visits within 7 days of outpatient surgery. Reported through the Hospital OQR Program.

Patient Experience Domain (40% of CQS)

• HCAHPS Survey (CMIT ID #338) — Measures patient perceptions of hospital care including provider communication, staff responsiveness, and discharge information. Reported through the Hospital IQR Program.
• OAS CAHPS Survey (CMIT ID #162) — Measures patient experience in hospital outpatient surgery settings, including preparation, staff communication, and recovery instructions. Reported through the Hospital OQR Program.

Patient-Reported Outcomes Domain (10% of CQS)

• Hospital-Level THA/TKA PRO-PM (CMIT ID #1618) — Measures change in patients' pain, physical function, and quality of life from before surgery through recovery. Reported through the Hospital IQR Program. Given this measure does not become mandatory in the OQR until 2028, CMS proposes using the inpatient THA/TKA PRO-PM to assess quality of care for all LEJR episodes under CJR-X, irrespective of setting.

Hospitals below the 30th percentile on any measure receive zero points for that measure. Hospitals without a reportable value are assigned the 50th percentile by default. The overall CQS blends inpatient and outpatient sub-scores weighted by each hospital's actual episode volume split between inpatient and outpatient settings.

No. Unlike the original CJR Model, CJR-X does not award points for year-over-year quality improvement. The CQS is based entirely on absolute achievement relative to the national distribution of all IPPS-eligible hospitals. CMS chose this approach to promote sustained, consistent quality accountability rather than rewarding short-term gains that may reflect random variation or changes in case mix rather than genuine clinical improvement.

CMS proposes two APM participation tracks for CJR-X participants:

• AAPM Option — For hospitals that voluntarily attest to meeting Certified EHR Technology (CEHRT) requirements annually. Affiliated clinicians may be eligible for Qualifying APM Participant (QP) status, yielding financial incentives and reduced MIPS reporting burden.
• Non-AAPM Option — For hospitals that do not attest to CEHRT use. These hospitals are still APM entities, and their MIPS-eligible clinicians may receive APM Performance Pathway (APP) scoring benefits under MIPS.

The CEHRT attestation does not otherwise change a hospital's CJR-X requirements or financial obligations. All CJR-X participants with eligible clinicians, regardless of APM track, must submit quarterly Financial Arrangements Lists and Clinician Engagement Lists to CMS to support QP determinations and MIPS scoring.

Under standard Medicare rules, a patient must have a qualifying 3-day inpatient hospital stay before Medicare covers a Skilled Nursing Facility (SNF) stay. CJR-X proposes to waive this requirement, allowing LEJR patients to be discharged to a SNF after fewer than 3 inpatient days while still receiving Medicare Part A SNF coverage. This supports earlier, more efficient transitions to lower-acuity post-acute settings when clinically appropriate.

The receiving SNF must have a CMS Five-Star Quality Rating of 3 stars or better for at least 7 of the prior 12 months. CMS will publish and update a quarterly list of qualifying SNFs.

If a hospital discharges a patient to a non-qualifying SNF without a 3-day stay and fails to provide the required discharge planning notice, the hospital bears financial liability for the non-covered SNF stay. If the notice is provided and the patient voluntarily chooses a non-qualifying SNF, the patient assumes financial liability.

CJR-X proposes two telehealth flexibilities for services delivered during the 90-day episode window:

• Geographic and Originating Site Waiver — Waives Medicare's standard requirements that restrict telehealth to rural areas or approved facility settings, allowing physicians and qualified practitioners to deliver evaluation and management (E/M) services via telehealth directly to CJR-X beneficiaries in their home or place of residence.
• New Home Visit Telehealth G-Codes (GXX12–GXX15) — New HCPCS codes for remote E/M visits for established patients at home, aligned with CPT 99212–99215, with payment rates comparable to office-based E/M services. For level 4–5 visits, licensed clinical staff must be present in the patient's home, or the physician must document why this was not required.

CJR-X proposes to continue the waiver of the Medicare "incident to" supervision rule, allowing licensed clinical staff (such as nurses, regardless of whether they are employed by the hospital or not) to furnish post-discharge assessment and care coordination visits in the patient's home under the general supervision of a physician who is an employee or contractor of the hospital, without requiring the physician's direct presence normally required under the standard rule. Visits are billed by the supervising physician or nonphysician practitioner (or by the hospital, if the physician has reassigned billing rights) using a CJR-X-specific HCPCS G-code, reimbursed at approximately $50 under the Physician Fee Schedule. The G-code may not be billed during any 30-day period already covered by a transitional care management code.

Up to 9 post-discharge home visits may be billed and paid per 90-day episode. Visits are available for beneficiaries who do not qualify for Medicare home health services. They may include clinical status assessment, safety and fall prevention, medication reconciliation, functional status monitoring, and connections to community services. This waiver supports safe discharge to home and may reduce reliance on costlier institutional post-acute care settings. TEAM did not include this waiver; CJR-X carries it forward from the CJR Model.

CMS will make two types of data available to CJR-X participants:

• Beneficiary-Identifiable Claims Data — Available in summary (aggregated) and raw (claims-level) formats upon request and execution of a data sharing agreement. Covers Medicare Parts A and B services for the anchor hospitalization or procedure plus the 30-day post-discharge period. This is narrower than the full 90-day episode accountability window; CMS considered extending data sharing beyond 30 days but did not propose it. Provided for a 3-year baseline period and updated as frequently as monthly during performance years, with 6 months of claims run-out after each year. Substance use disorder records are excluded.
• Regional Aggregate Data — De-identified average episode spending for the US Census Division where the hospital is located. No data sharing agreement required.

To receive beneficiary-identifiable claims data, hospitals must sign an annual CJR-X data sharing agreement, attesting that they are requesting the minimum data necessary for permissible health care operations and will comply with all applicable HIPAA and privacy requirements.

Additionally, hospitals must submit two clinician lists to CMS quarterly:

• Financial Arrangements List — All eligible clinicians who have entered into sharing, distribution, or downstream distribution arrangements with the hospital or its collaborators. Used for QP determinations and MIPS APM scoring.
• Clinician Engagement List — Eligible clinicians who participate in CJR-X activities and have a contractual relationship with the hospital but are not on the Financial Arrangements List.

Hospitals must attest quarterly if there are no individuals to report on either list.

CJR-X hospitals must provide written notification to every covered patient prior to discharge from their anchor hospitalization or outpatient procedure. The notice must:

• Explain the CJR-X model and how it may affect the patient's care
• Confirm the patient retains full freedom of choice to select any Medicare-participating provider
• Explain how to access care records via patient portals and Blue Button®
• Disclose that the hospital may receive beneficiary-identifiable claims data
• Remind patients of standard Medicare protections, including the right to contact 1-800-MEDICARE or a Quality Improvement Organization (QIO)
• Provide a list (or public web link) of the hospital's CJR-X financial collaborators

CJR-X collaborators must also provide written notice to patients the first time they furnish a service during the episode. Patients cannot opt out of CJR-X, consistent with how Medicare payment systems work generally, but they retain full freedom to seek care from any provider, and CJR-X does not increase their cost-sharing or limit their covered benefits.

• Geographic scope — CJR-X is nationwide; the original CJR Model covered only selected MSAs.
• Performance year alignment — CJR-X aligns with federal fiscal years (Oct–Sep); original CJR used calendar years (Jan–Dec).
• Discount factor — CJR-X uses a 2.0% base discount; the original CJR Model used 3.0%.
• Target pricing — CJR-X uses 100% regional pricing from PY1. The original CJR Model blended hospital-specific and regional data in PYs 1–3, transitioning to 100% regional only in PY4.
• Trend factor — CJR-X uses both a prospective trend factor (in the preliminary price) and a ±3% capped retrospective trend factor (applied at reconciliation). The original CJR Model used fully prospective pricing in early years, with the CJR Extension adding a fully retrospective market trend factor (without the ±3% cap).
• Risk adjustment — CJR-X adopts the same, more comprehensive risk adjustment methodology as TEAM. The original CJR used a simpler methodology.
• Downside risk in PY1 — The original CJR Model waived downside risk in its first performance year. CJR-X does not; hospitals face full downside risk from PY1.
• SNF waiver — CJR-X permits swing-bed use without the 3-star rating requirement for certain hospitals; the original CJR Model did not. TEAM introduced this flexibility first.
• Quality improvement points — The original CJR Model awarded points for year-over-year improvement. CJR-X does not; scoring is based entirely on absolute achievement.
• Post-discharge home visits — CJR-X carries forward the 9 post-discharge home visit waiver (~$50 G-code) from the CJR Model.
• New telehealth G-codes — CJR-X proposes new home visit telehealth E/M codes not present in the original model.

TEAM (Transforming Episode Accountability Model) began January 1, 2026 and includes LEJR as one of five surgical episode types for selected hospitals. Key differences from CJR-X:

• Episode length — TEAM uses a 30-day post-discharge period; CJR-X uses 90 days. This is the primary reason TEAM hospitals are excluded from CJR-X during the TEAM duration; CMS wants a clean comparison between the two episode lengths.
• Participation scope — TEAM covers selected hospitals; CJR-X applies to all eligible hospitals nationwide.
• Post-discharge home visits — TEAM did not include the post-discharge home visit waiver; CJR-X does.
• Quality improvement points — Neither TEAM nor CJR-X includes quality improvement points; both use absolute achievement scoring only.

The CJR Model's financial trajectory had three distinct phases:

• PY1 through PY4 — Mandatory hospitals generated approximately $72 million in cumulative savings while maintaining quality, though these savings were not statistically significant.
• PY5 — COVID-19 PHE adjustments effectively waived downside risk for all episodes, resulting in $95.4 million in statistically significant Medicare losses, fully offsetting all prior estimated savings.
• PY6 and PY7 (the CJR Extension) — The model returned to a positive trajectory, generating $112.7 million in net savings while maintaining quality of care. These results formed the basis for CMS's determination to expand the model nationwide as CJR-X.

The CMS Chief Actuary has certified that nationwide expansion via CJR-X would reduce or not increase net Medicare program spending.

CJR-X holds hospitals accountable for the full 90-day post-discharge period: the same window Force was built to manage. The platform engages patients from surgery scheduling through recovery, delivering provider-prescribed education, virtual physical therapy, and remote monitoring throughout the episode. This continuous engagement helps hospitals reduce avoidable readmissions, complications, and unnecessary post-acute care utilization: the primary drivers of episode overspend.

CJR-X's Composite Quality Score includes the THA/TKA Patient-Reported Outcome-Based Performance Measure (PRO-PM), and Force is among the most capable platforms for PRO collection at scale. The platform automates PRO collection via encrypted, no-password text and email links, achieving an average 82% PROMs completion rate across clients. Force is a participant in the American Academy of Orthopaedic Surgeons (AAOS) PROMs Vendor Program and automatically submits PROs to registries such as the American Joint Replacement Registry (AJRR), reducing administrative burden and supporting compliance.

Higher PRO completion rates directly support hospitals in achieving the "Good" or "Excellent" CQS thresholds that unlock reduced discount factors and improved reconciliation payment eligibility.

Two of the most heavily weighted CJR-X quality measures — the RSCR (inpatient complication rate) and Hospital Visits Within 7 Days of HOPD Surgery (outpatient) — are directly affected by a hospital's ability to identify and intervene with at-risk patients post-discharge. Force's real-time clinician dashboards flag patients with high pain scores, low engagement, or declining functional status, enabling care teams to intervene before complications escalate to ER visits or readmissions. The platform also tracks postoperative patients who have visited urgent care or the ER and alerts care teams to respond.

A major source of costs in joint replacements is typically unnecessary discharges to SNF and IRF, as well as the use of outpatient physical therapy. Force provides the digital infrastructure to support low-cost high-quality care under CJR-X: the platform delivers clinically validated virtual physical therapy, two-way messaging, photo and video sharing, and video-based education directly to patients on any device. This aligns with the CJR-X framework, supporting safe discharge to home and reducing reliance on costlier institutional post-acute settings for appropriate patient cohorts.

Understanding where episode spending is going is critical for hospitals competing against regional peers under CJR-X's achievement-based pricing model. Force works with hospitals to identify sources of episode spending and assess where there are opportunities to improve measures such as length of stay, post-acute utilization, readmissions, patient satisfaction, and cost savings across the full episode. These insights help service line and value-based care teams identify care redesign opportunities, benchmark against peers, and respond to negative trends before reconciliation.

With CJR-X applying to all eligible acute care hospitals nationwide, many institutions will be new to episode-based payment accountability. Force helps hospitals scale care management without proportionally increasing staff: the platform reduces phone calls through automated patient communications, enabling a single navigator to manage a significantly larger patient panel. This is especially valuable as hospitals preparing for the October 2027 CJR-X start date will likely look to add or refine a substantial amount of patient education materials and care resources.

Force was built in direct partnership with leading orthopedic programs specifically for THA and TKA episodes: the same procedures at the core of CJR-X. With over 15 years of experience, more than 110 published clinical research studies, and care partners including some of the leading orthopedic departments in the country, Force brings deep evidence and proven pathways to LEJR care management. Hospitals entering CJR-X for the first time can leverage Force's established protocols immediately rather than building from scratch.