CMS issued a proposed rule on April 10, 2026 that would expand its Comprehensive Care for Joint Replacement model nationwide under a new name, CJR-X. The model would cover hip, knee, and ankle replacements in both inpatient and hospital outpatient settings. The first performance year is set to begin October 1, 2027. Participation would be mandatory for most acute care hospitals paid under the Inpatient Prospective Payment System.
Buried in the proposal is the detail anesthesia and orthopedic practices should care about. Certified Registered Nurse Anesthetists and CRNA group practices would qualify as collaborators under CJR-X. That status, paired with the participating hospital meeting CEHRT criteria, can make CRNAs eligible to be Qualifying APM Participants under MACRA. Translation: a higher Medicare Part B conversion factor at a moment when anesthesia reimbursement has been compressing for years.
The American Association of Nurse Anesthesiology filed a comment letter to CMS Administrator Mehmet Oz on June 2, 2026, endorsing the CRNA collaborator pathway and pushing back on the parts of the rule that create operational friction. The public comment period closed June 9, 2026. CMS is now reviewing input ahead of the final rule.
Key Takeaways
- CMS proposes expanding the Comprehensive Care for Joint Replacement model nationwide as CJR-X, starting October 1, 2027.
- The model covers hip, knee, and ankle replacements (ankle is new) in both inpatient and hospital outpatient settings.
- Participation would be mandatory for most acute care hospitals under IPPS. Excluded: TEAM participants, Maryland all-payer hospitals, critical access hospitals, and rural emergency hospitals.
- CRNAs and CRNA group practices would qualify as collaborators and may earn Advanced APM Qualifying Participant status if the participating hospital meets CEHRT criteria.
- Hospitals are explicitly prohibited from charging collaborators a fee to be on preferred-provider lists.
- AANA opposes a proposed requirement that every collaborator deliver a written beneficiary notice, calling it unworkable for anesthesia at the point of service.
What exactly is CJR-X, and how is it different from the original CJR Model?
The original CJR Model ran from April 2016 through December 2024 and held hospitals accountable for the cost and quality of a 90-day joint replacement episode. CMS evaluated it as generating Medicare savings while maintaining quality. CJR-X scales that experiment up. Three changes matter most.
First, it would be mandatory nationwide for most IPPS hospitals. Second, ankle replacements join hip and knee for the first time. Third, the model is no longer inpatient-only. Procedures performed in the hospital outpatient setting are now in scope. That last one is the structural shift orthopedic practices should pay attention to.
Why does Qualifying APM Participant status matter for CRNAs and anesthesia groups?
Under MACRA, clinicians who hit Qualifying APM Participant thresholds through an Advanced Alternative Payment Model receive a higher Medicare Part B conversion factor than clinicians who do not. For CRNAs, who have watched the Medicare Physician Fee Schedule conversion factor erode year after year, that delta is not theoretical. It is direct revenue.
The CJR-X proposal lays out that the participating hospital is the APM entity, and its collaborators with financial arrangements (and the right EHR posture) can be assessed for QP status. CRNAs have been Medicare Part B providers billing at 100% of the Physician Fee Schedule since 1989. Until now, the pathway to APM bonuses has been narrow. CJR-X widens it.
How will the no-fee rule for collaborators change ASC and hospital negotiations?
CMS makes one thing explicit. Hospitals participating in CJR-X cannot charge a CRNA, anesthesia group, or other collaborator a fee to be included on any preferred-provider list. The hospital also cannot accept such a payment. That removes a quiet barrier to participation that has shown up in past sharing arrangements.
Practically, this means an anesthesia group should not be asked to pay for the privilege of being aligned with a CJR-X participant. Sharing arrangements move to gainsharing tied to cost and quality performance, which is the structure CMS prefers. If your hospital partner has been floating informal “preferred lane” fees, the rule kills that conversation.
What is the friction point AANA is pushing CMS to fix?
The proposed rule at 42 CFR 512.622(b) would require every CJR-X collaborator to give each beneficiary they treat written notice describing the sharing arrangement. AANA called this duplicative and impractical for anesthesia providers, given when and how anesthesia services are actually delivered. Most patients meet their CRNA in the holding area minutes before induction. That is not a workable consent-style notification window.
AANA recommends CMS build a web-based searchable portal instead, using the financial arrangements lists hospitals already have to submit under 42 CFR 512.615(b). Beneficiaries who want to know which clinicians are collaborators could look it up by hospital. Whether CMS adopts that solution in the final rule will signal how seriously the agency is taking provider-side workflow concerns.
Where could orthopedic practices and ASCs feel the squeeze?
CJR-X anchors to acute care hospitals, not ASCs. ASCs are not the participating entity. But the model explicitly covers hospital outpatient department settings, which is where the competitive math gets interesting. Hospitals will have a sharper financial incentive to keep lower-extremity joint volume inside their own HOPD walls and capture the bundled-payment upside.
For ASCs competing for total joint cases against a hospital outpatient department, the new question is whether the HOPD setting now has a structural advantage on coordinated post-acute spend. That answer changes payer negotiation strategy and surgeon recruitment economics. Practices should not wait until October 2027 to model this.
What This Means for Your Practice
For anesthesia groups: Map your CJR-X exposure now. Identify which IPPS hospitals you cover that perform lower-extremity joint replacements. Confirm whether each hospital plans to be a CJR-X participant and whether it meets CEHRT criteria. If a hospital cannot meet CEHRT, your collaborator status does not unlock QP status, and the Advanced APM bonus disappears. Begin scoping the sharing arrangement framework you would accept, with gainsharing terms tied to cost and quality performance.
For orthopedic practices and ASCs: The inclusion of hospital outpatient settings is the structural change to plan around. Run the math on referral patterns and HOPD competition in your market under a scenario where the hospital captures bundled-payment upside on outpatient joints. Reassess payer negotiation leverage in light of that incentive shift.
For RCM operations: The clean documentation work happens before October 2027. CMS uses the financial arrangements list submitted by each CJR-X participant to assign Qualifying APM Participant determinations. If a clinician is missing from that list because of a contracting gap, the bonus they should earn evaporates. This is a back-office data integrity question with direct payment consequences.
Frequently Asked Questions
Is CJR-X final?
No. It is a proposed rule, CMS-1849-P, issued April 10, 2026. The public comment period closed June 9, 2026. CMS is expected to issue a final rule before the proposed October 1, 2027 start date. Details could change between now and then.
Does CJR-X apply to ASCs?
No, not directly. CJR-X is anchored to acute care hospitals paid under IPPS, and procedures are covered when performed in inpatient or hospital outpatient settings. ASCs are not the participating entity. That said, anesthesia and orthopedic groups working across both settings will see incentive structures spill over into how hospitals negotiate volume, post-acute coordination, and referral patterns.
Which hospitals are excluded?
Hospitals participating in the TEAM model, hospitals in Maryland under the all-payer model, critical access hospitals, and rural emergency hospitals. For everyone else paid under IPPS, participation would be mandatory.
What is the practical impact of the no-fee rule for collaborators?
Hospitals cannot demand a payment from CRNAs or other clinicians as the price of admission to a preferred-provider list. That eliminates a quiet barrier to anesthesia group participation. It pushes the conversation toward legitimate gainsharing arrangements tied to cost and quality, which is the structure CMS prefers.
What should an anesthesia group do this quarter?
Three actions. Confirm which IPPS hospitals in your portfolio perform lower-extremity joint replacements. Ask each hospital whether it will be a CJR-X participant and whether it meets CEHRT criteria. Begin drafting the sharing arrangement framework, including gainsharing terms you would accept, so you are not negotiating from a cold start when participating hospitals begin contracting in 2027.
How Cosentus Can Help
Cosentus works with anesthesia, orthopedic, ASC, and other specialty practices to model the revenue impact of payment reform before the rules take effect. CJR-X is the latest example of a proposal where back-office contracting, EHR posture, and sharing arrangement documentation determine whether your clinicians actually capture the Advanced APM bonus they qualify for on paper.
To talk through what CJR-X means for your specific hospital contracts, anesthesia coverage agreements, and downstream RCM workflow, visit cosentus.com/contact or call (800) 378-0049.
