(a) Mandatory ASM participation. (1) Unless otherwise specified, any clinician who meets all ASM participant eligibility criteria as specified in paragraph (b) of this section and furnishes covered services during any applicable ASM performance year within the ASM test period is considered an ASM participant for the duration of the model.

(i) 2027 ASM performance year: ASM participants—

(A) Are measured for performance and exempted from MIPS participation, if applicable, during CY 2027;

(B) Report and are scored during CY 2028; and

(C) Receive payment adjustments for CY 2027 performance in CY 2029.

(ii) 2028 ASM performance year: ASM participants—

(A) Meeting ASM eligibility criteria for the 2028 performance year are measured for performance and exempted from MIPS participation, if applicable, during CY 2028;

(B) Report and are scored during CY 2029; and

(C) Receive payment adjustments for CY 2028 performance in CY 2030.

(iii) 2029 ASM performance year: ASM participants—

(A) Meeting ASM eligibility criteria for the 2029 performance year are measured for performance and exempted from MIPS participation, if applicable, during CY 2029;

(B) Report and are scored during CY 2030; and

(C) Receive payment adjustments for CY 2029 performance in CY 2031.

(iv) 2030 ASM performance year: ASM participants—

(A) Meeting ASM eligibility criteria for the 2030 performance year are measured for performance and exempted from MIPS participation, if applicable, during CY 2030;

(B) Report and are scored during CY 2031; and

(C) Receive payment adjustments for CY 2030 performance in CY 2032.

(v) 2031 ASM performance year: ASM participants—

(A) Meeting ASM eligibility criteria for the 2031 performance year are measured for performance and exempted from MIPS participation, if applicable, during CY 2031;

(B) Report and are scored during CY 2032; and

(C) Receive payment adjustments for CY 2031 performance in CY 2033.

(2)(i) For any ASM performance year within the ASM test period that an ASM participant does not meet the criteria for mandatory participation set forth in this section, the ASM participant is not subject, for the applicable ASM performance year, to §§ 512.715, 512.720, 512.745, and 512.750.

(ii) For a ASM performance year described in paragraph (a)(2)(i) of this section, the ASM participant is no longer eligible for the waivers as described at § 512.775 and is instead subject to MIPS reporting obligations, if applicable.

(b) ASM participant eligibility criteria. CMS uses the following set of criteria to determine whether a clinician is an ASM participant:

(1) Is a clinician who bills claims under the Medicare Physician Fee Schedule.

(2) Is identified by TIN/NPI as a selected specialty type as described in paragraph (d) of this section.

(3) Meets the EBCM episode volume threshold applicable to an ASM targeted chronic condition as described at paragraph (e) of this section.

(4) Is located in one of the mandatory geographic areas selected in accordance with paragraph (f) of this section.

(c) Participant exclusion due to change in TIN during an ASM performance year. (1) An ASM participant who stops assigning billing rights to the TIN used to identify the ASM participant and begins assigning billing rights to a new TIN during an applicable ASM performance year must notify CMS of the change in a form and manner determined by CMS within 30 days of the change.

(2)(i) An ASM participant who notifies CMS of a change in TIN during an ASM performance year is not subject, for the applicable ASM performance year, to §§ 512.715, 512.720, 512.745, and 512.750.

(ii) The ASM participant described in paragraph (c)(2)(i) of this section is no longer eligible for the waivers as described at § 512.775 and is instead subject to MIPS reporting obligations, if applicable.

(d) Specialty type. ASM participants have one of the following Medicare Part B specialty codes indicated on the plurality of their Medicare Part B claims:

(1) Heart failure specialty type 3/4

(i) Cardiology.

(ii) [Reserved]

(2) Low back pain specialty type 3/4

(i) Anesthesiology.

(ii) Interventional Pain Management.

(iii) Neurosurgery.

(iv) Orthopedic Surgery.

(v) Pain Management.

(vi) Physical Medicine and Rehabilitation.

(e) EBCM episode volume. To determine if a clinician meets the ASM participant eligibility criterion defined in paragraph (b)(3) of this section, CMS uses the volume of EBCM episodes related to ASM targeted chronic conditions that are attributed to a clinician using the applicable EBCM specifications and attribution methodology.

(1) Heart failure EBCM. Clinicians who have a specialty designation type described at § 512.710(d)(1) and 20 or more heart failure EBCM episodes attributed in accordance with the heart failure episode-based cost measure as specified under MIPS during the calendar year 2 years prior to the applicable ASM performance year meet the ASM participant eligibility criterion defined in paragraph (b)(3) of this section.

(2) Low back pain EBCM. Clinicians who have a specialty designation type described at § 512.710(d)(2) and 20 or more low back pain EBCM episodes attributed in accordance with the low back pain episode-based cost measure as specified under MIPS during the calendar year 2 years prior to the applicable ASM performance year meet the ASM participant eligibility criterion defined in paragraph (b)(3) of this section.

(f) Mandatory geographic areas. CMS uses a stratified random sampling methodology described in paragraphs (f)(2) and (f)(3) of this section to select CBSA and metropolitan divisions (in cases where OMB divides large metropolitan statistical areas into metropolitan divisions) from which CMS identifies clinicians for participation in ASM.

(1) Exclusions. CMS excludes from the selection of CBSAs and metropolitan divisions applicable areas that meet any of criteria described in paragraph (f)(1)(i) or (f)(2)(ii) of this section.

(i) Areas that do not meet the criteria described in paragraphs (f)(1)(i)(A) and (f)(1)(i)(B) of this section:

(A) Have at least one clinician with a specialty designation type described at § 512.710(d)(1) with 20 or more heart failure EBCM episodes attributed between January 1, 2024 and December 31, 2024.

(B) Have at least one clinician with a specialty designation type described at § 512.710(d)(2) with 20 or more low back pain EBCM episodes attributed between January 1, 2024 and December 31, 2024.

(ii) Areas located entirely in U.S. Territories.

(2) CBSA and metropolitan division stratification process. Prior to sampling CBSAs and metropolitan divisions, CMS stratifies CBSAs and metropolitan divisions, excluding those described in paragraph (f)(1) of this section, into six mutually exclusive strata based on three CBSA/metropolitan division-level characteristics (average total Part A and Part B episode spending, volume of eligible episodes, and metropolitan division status) as described in paragraphs (f)(2)(i) through (vi) of this section. “Average total episode spending” as the term is used in paragraphs (f)(2)(i) through (vi) of this section, is measured using the average total Part A and Part B episode spending using claims data from January 1, 2024 to December 31, 2024 relating to heart failure and low back pain episodes, as specified under the episode-based cost measures described in § 512.710(e). Values below the median are characterized as “Low” average total episode spending. Values at or above the median are characterized as “High” average total spending. “Eligible episode volume” as the term is used in paragraphs (f)(2)(i) through (vi) of this section, is measured as the total count of eligible heart failure and low back pain episodes, as specified under the episode-based cost measures described in § 512.710(e), in a CBSA between January 1, 2024 and December 31, 2024. CMS categorizes CBSAs with values below the median as “Low;” CBSAs at-or-above the median and below the 95th percentile as “High;” and CBSAs at-or-above the 95th percentile as “Very High.”.

(i) CBSAs with “Low” average total episode spending and “Low” eligible episode volume.

(ii) CBSAs with “Low” average total episode spending and “High” eligible episode volume.

(iii) CBSAs with “High” average total episode spending (as defined below) and “Low” eligible episode volume.

(iv) Eligible CBSAs with “High” average total episode spending and “High” eligible episode volume.

(v) Eligible CBSAs with “Very High” eligible episode volume.

(vi) Eligible metropolitan divisions.

(3) Sampling of CBSAs and metropolitan divisions. CMS selects approximately 40 percent of CBSAs and metropolitan divisions from each stratum to select the mandatory geographic areas. If 40 percent of a given stratum does not result in a whole number of CBSAs or metropolitan divisions, CMS rounds up to the next whole number to ensure that at least 40 percent of areas from each stratum are selected.

(4) Assignment of CBSA or metropolitan division code to clinicians. CMS assigns a CBSA or a metropolitan division code to every TIN/NPI with attributed EBCM episodes related to ASM targeted chronic conditions for the applicable calendar year as described in paragraph (e) of this section to determine ASM participation eligibility for an applicable ASM performance year:

(i) CMS assigns each attributed EBCM episode a ZIP Code, which represents the service location where the attributed TIN/NPI encounters the beneficiary attributed to the episode the most, based on the plurality of Part B claims used to construct the episode. If the ZIP Codes representing service location where the attributed TIN/NPI appears in equal number in the Part B claims used to construct the episode, then CMS assigns the ZIP Code based on the ZIP Code that represents the Part B claim with—

(A) The highest total cost indicated by the total standardized allowed amount; or

(B) Most recent date.

(ii) CMS assigns each attributed EBCM episode a CBSA or metropolitan division code based on the ZIP Code assigned to the episode as described in paragraph (f)(4)(i) of this section. If the ZIP Code assigned to the EBCM episode is in multiple CBSAs or metropolitan divisions, then CMS assigns the EBCM episode the CBSA or metropolitan division code where the ZIP Code has the highest proportion of—

(A) Total addresses; or

(B) Business addresses.

(iii) CMS assigns each TIN/NPI combination a single CBSA or metropolitan division code based on the most common CBSA or metropolitan division code assigned to episodes attributed to the TIN/NPI as described in paragraph (f)(4)(ii) of this section. If the TIN/NPI has equal number of episodes across multiple CBSAs or metropolitan divisions, then CMS assigns the TIN/NPI a CBSA or metropolitan division with the CBSA or metropolitan division that has either of the following:

(A) The highest total risk-adjusted episode spending across all episodes assigned to the CBSA or metropolitan division.

(B) Episodes with more recent dates.

(g) Selection and notification process for ASM participants. For each ASM performance year, CMS identifies all clinicians furnishing covered services using the ASM participant eligibility criteria specified in paragraph (b) of this section and applicable data from 2 calendar years prior to each ASM performance year. Any clinician selected for participation for any year of the model is considered an ASM participant for the remainder of the ASM test period.

(1) 2027 ASM performance year only—(i) Preliminarily eligible ASM participants. Using applicable data from calendar year 2024, CMS identifies all clinicians who meet the ASM participant eligibility criteria for participation starting in the 2027 ASM performance year/2029 ASM payment year. The clinicians identified as preliminarily eligible ASM participants are made public in a form and manner determined by CMS.

(ii) Final ASM participants. CMS identifies the final ASM participants selected for participation starting in the 2027 ASM performance year/2029 ASM payment year by confirming that the preliminarily eligible ASM participants identified under paragraph (g)(1)(i) of this section meet the ASM participant eligibility criteria using applicable data from CY 2025. The clinicians selected as ASM participants starting the 2027 ASM performance year/2029 ASM payment year is made public in a form and manner determined by CMS.

(2) 2028 ASM performance year and subsequent years. (i) Beginning with the 2028 ASM performance year/2030 ASM payment year, CMS determines if the previously selected ASM participants continue to meet the ASM participant eligibility criteria for the upcoming ASM performance year/ASM payment year using applicable data from the calendar year 2 years prior to the applicable ASM performance year. An ASM participant who does not meet the ASM participant eligibility criteria for the upcoming ASM performance year/ASM payment year is not subject to provisions described at §§ 512.715, 512.720, and 512.745 and must, if applicable, participate in MIPS. The final ASM participants selected for participation for each applicable ASM performance year is made public in a form and manner determined by CMS.

(ii) Beginning with the 2028 ASM performance year/2030 ASM payment year and prior to the start of each ASM performance year, CMS determines if additional clinicians not previously identified as ASM participants meet the ASM participant eligibility criteria for the upcoming ASM performance year/ASM payment year using applicable data from the calendar year 2 years prior to the applicable ASM performance year. The final ASM participants selected for participation for each applicable ASM performance year is made public in a form and manner determined by CMS.