The Centers for Medicare & Medicaid Services (CMS) has finalized the Comprehensive Care for Joint Replacement Expanded Model (CJR-X) in its FY 2026 Inpatient Prospective Payment System (IPPS) final rule. With this finalization, what was proposed earlier this year is now confirmed: CJR-X will be the first mandatory, nationwide, episode-based payment model ever rolled out in the United States, holding hospitals accountable for the cost and quality of care across the full 90-day episode for hip, knee, and ankle replacements in both inpatient and outpatient settings. For a deeper primer on the model, our updated CJR-X FAQ answers the most common questions from orthopedic care teams.
The most consequential update from the proposed rule is timing. CMS listened to the field on implementation readiness and moved the start date back. CJR-X now begins January 1, 2028, not October 1, 2027, and its performance years run on the calendar year rather than the federal fiscal year. Beyond that shift, CMS finalized the vast majority of its proposals largely as written. Below is a summary of what changed in response to public comments, what CMS held firm on, and how the core provisions from the proposed rule ultimately landed.
A Quick Refresher on CJR-X
CJR-X is an expansion of the original Comprehensive Care for Joint Replacement (CJR) model, which was tested in 34 Metropolitan Statistical Areas from 2016 through the end of 2024. Under CJR-X, participating hospitals continue to be paid under the existing Fee-for-Service model, but each performance year their total episode spending is reconciled against a target price. Depending on spending and quality performance, a hospital either receives a reconciliation payment or repays a portion of its episode spending. The goal is familiar: reward care coordination and reduce avoidable episode costs, from unnecessary skilled nursing facility (SNF) discharges to extended lengths of stay, readmissions, and over-utilization of physical therapy, while protecting quality.
What makes CJR-X different is its scale. Participation is mandatory for nearly every acute care hospital paid under both the IPPS and OPPS, with narrow exceptions for hospitals participating in the Transforming Episode Accountability Model (TEAM), Maryland hospitals, and hospitals not paid under those systems. When TEAM ends, those hospitals roll into CJR-X. And unlike the original CJR, CJR-X has no specified end date. This is a strong signal that mandatory bundles for joint replacement are now a permanent feature of the payment landscape. CMS estimates the model will save Medicare $725 million across its first five performance years.
The Headline Change: A January 2028, Calendar-Year Start
In the proposed rule, CJR-X would have begun on October 1, 2027, with performance years aligned to the federal fiscal year. Commenters raised significant concerns about implementation readiness, and CMS agreed. The final rule sets a January 1, 2028 model start date and aligns performance years with the calendar year, which is the same cadence as TEAM.
The practical effect is roughly a 17-month runway between publication of the final rule and the first day of financial accountability. CMS was explicit that this additional time is meant to let hospitals establish governance structures, engage physicians and post-acute care providers, build care management workflows, evaluate their historical performance, and stand up the operational processes needed to manage episodes before dollars are on the line. Notably, CMS declined requests for an upside-only first performance year; the later start date is the concession, but risk begins in year one. The timing change also cascaded through the rule, prompting conforming updates to quality measure performance periods and to how claims are captured at reconciliation. Hospitals that will transition from TEAM into CJR-X will begin their participation on January 1, 2031.
What Changed in Response to Comments
Aside from timing, most of the adjustments CMS made were refinements rather than reversals. The agency clarified the “CJR-X participant” definition to specify a hospital in any of the 50 states, D.C., or U.S. Territories that initiates lower extremity joint replacement (LEJR) episodes and is eligible for payment under both the IPPS and OPPS. It restructured the model’s termination provisions, breaking the notice-of-termination language into its own section. It streamlined the “anchor hospitalization” and “anchor procedure” definitions by removing extraneous cross-references. And it modified the SNF 3-day stay waiver to apply within 30 days following discharge from the anchor hospitalization or procedure, preserving continuity with the waiver policy hospitals already know from the original CJR model.
Proposed vs. Finalized: CJR-X at a Glance
The table below summarizes how the major provisions moved from proposal to final rule, separating the items CMS changed in response to public comments from those it finalized as proposed, including several finalized despite commenter objections.
What CMS Held Firm On
The table also shows that CMS finalized the core pricing and risk architecture largely as proposed, even where commenters pushed back. On rebasing, the agency kept its rolling three-year baseline and heavier weighting of recent spending, declining alternatives designed to soften year-over-year “price ratcheting.” On the discount factor, it retained a uniform 2 percent, rejecting requests for a glide path or variation by hospital type. And it preserved the 20 percent stop-loss/stop-gain framework, with the 5 percent stop-loss floor for rural, Medicare-dependent, sole community, and safety-net hospitals intact. For hospitals, the takeaway is that the financial mechanics they modeled off the proposed rule are, by and large, the mechanics they will operate under.
How the Rest of the Proposal Landed
When we covered the proposed rule, several provisions stood out as especially consequential for care teams. Here is where they ended up.
The quality-first principle and composite quality score (CQS) were finalized as proposed: Reconciliation remains conditioned on meeting a minimum quality standard, so a hospital that comes in under its target price but fails to clear the quality bar is not eligible for a reconciliation payment. That design, intended to discourage cutting care utilization purely to capture savings, carried through unchanged.
The five CQS measures and their domain weights were finalized without modification: The composite is built on complications (Hospital-Level RSCR following elective primary THA/TKA and Hospital Visits within 7 days of HOPD surgery), patient experience (HCAHPS and OAS CAHPS), and patient-reported outcomes (the Hospital-Level THA/TKA PRO-PM). CMS finalized the proposed domain weighting: 50 percent to complications, 40 percent to patient experience, and 10 percent to the PRO-PM. As under TEAM, this makes long-term PROMs performance a direct, quality-based input into reimbursement, not merely a reporting threshold to clear. For orthopedic teams, that elevates the stakes on consistently capturing patient-reported outcomes across the full episode.
The expanded risk adjustment methodology was finalized as proposed: CJR-X will risk-adjust target prices at the hospital level using bed size and a safety-net designation, alongside episode-level acuity adjusters for individual patient complexity. CMS declined requests to create separate target prices or episode tracks for dual-eligible beneficiaries, concluding that the safety-net adjustment and stop-loss protections already address those concerns. It is not a perfect system, but it is a more sophisticated one than what CJR participants navigated before.
Equity protections held: The 5 percent stop-loss cap for rural and safety-net hospitals (those serving a high proportion of dual-eligible beneficiaries, geographically rural facilities, Medicare-dependent small rural hospitals, and Sole Community Hospitals) was finalized to limit financial exposure for the providers with the least infrastructure to absorb it.
Looking Ahead
With CJR-X now final, the question for hospitals is no longer whether mandatory bundles are coming. It is whether their organization will be ready when accountability begins on January 1, 2028. The extra runway CMS built into the timeline is helpful, but the work it is meant to accommodate is serious and time consuming. As Force Therapeutics CEO Bronwyn Spira has noted, one of the most consequential drivers of episode performance is something hospitals cannot directly control: what patients do when they go home. Under CJR-X, those gaps carry financial implications.
Hospitals that succeed will be those that engage patients consistently before and after surgery, standardize care delivery to reduce variation, shift appropriate recovery to the home to avoid unnecessary post-acute spend, and give care teams real visibility into patient progress across the full 90-day episode. With deep experience helping hospitals succeed under the original CJR and a platform built for exactly this kind of episode management, PROMs collection, and post-acute resource optimization, Force Therapeutics is ready to help.
Reach out to us through the form below to learn how we can support your organization ahead of CJR-X:
