2026 MIPS Performance Year: What Changed and What Practices Need to Do by January 1

The 2026 MIPS performance year (January 1 through December 31, 2026) determines your 2028 Medicare Part B payment adjustment. The maximum positive adjustment is +9%; the maximum negative adjustment is −9%. For the average Medicare-billing practice that swing is more than $10,000 per provider. CMS has formally published the 2026 final rule, and the changes from 2025 are meaningful enough that every practice should have five things configured before January 1.

1. The performance threshold stays at 75 points

After speculation that CMS would raise the performance threshold to 80, the 2026 final rule held it at 75 points. The exceptional performance bonus threshold remains at 89 points and the additional adjustment pool is unchanged in structure. This is good news for practices in the 70-78 point range — the bar didn't move. It also removes the most common excuse to wait on configuration work.

2. Quality measure removals reshape the eligible set

CMS removed eight quality measures from the 2026 set and finalized substantive changes to seventeen more. Two patterns matter:

• Topped-out measures retired. Measures where median performance reached 95%+ are gone. If your practice was scoring on a now-retired measure, you have to replace it.
• Outcome measures elevated. CMS continues to reward outcome measures over process measures. Practices submitting six process measures will score lower than those with at least one outcome measure in the mix.

Before January 1, confirm that your six chosen measures still exist in 2026 and that at least one is an outcome measure. If you're unsure which ones changed, the 2026 MIPS Survival Guide includes the full delta table.

3. The MVP pathway keeps expanding

MIPS Value Pathways (MVPs) are now a viable alternative to traditional MIPS for many specialties. The 2026 set includes additional specialty MVPs and the reporting burden for MVP submission is meaningfully lower than the full four-category MIPS path. For specialty practices that historically struggled with quality measure selection, MVP is worth evaluating. The catch: once you choose MVP for a performance year, you cannot switch back mid-year.

4. Cost performance category weight unchanged at 30%

Cost is the only MIPS category your practice doesn't actively submit data for — CMS calculates it from Medicare claims. The 30% weight is unchanged from 2025. The actionable point: most practices score below benchmark on Cost because they don't see the numerator (their patients' Medicare Spending Per Beneficiary) until reconciliation. Pulling claims-derived Cost analytics through the year is the only way to spot trouble early.

5. Promoting Interoperability now requires SAFER Guides attestation

Beginning with the 2026 performance year, every clinician submitting to MIPS-PI must attest to having reviewed the ONC SAFER Guides (Safety Assurance Factors for EHR Resilience). The attestation itself is straightforward, but it's a new line item in your PI submission. If your PI score zeroed out in 2025 because of an oversight on a single measure, build the attestation into your December 31 prep checklist.

What to do by January 1

1. Confirm your six quality measures still exist in the 2026 set and include at least one outcome measure.
2. Decide MVP vs traditional MIPS for the year. Document the decision.
3. Wire up Cost-category claims analytics so MSPB doesn't surprise you in October.
4. Schedule the SAFER Guides review for your PI submission.
5. If your EHR connector to your analytics platform hasn't been stood up yet, do it now — running 2026 on manual exports is how penalties accumulate. Vizier connector setup takes 24-48 hours after IT approval.

The practices that hit 75 in 2026 will all do the same thing: they configure in December, they monitor monthly, and they intervene by Q3 when a measure starts drifting. The ones that miss will all do the same thing too: they wait until December 2026.