Table of Contents
On April 10, CMS proposed CJR-X. The move sent a clear signal to every ortho service line in the country. If this model goes final, more than 2,500 hospitals will face bundled payment rules starting October 1, 2027. It would be the first time CMS has made an episode-based payment program both mandatory and nationwide.
Most early coverage has framed CJR-X as a hospital story. That framing misses the point. Yes, the hospital owns the bundle. But the real costs of a 90-day episode play out downstream. They show up in the ASC where the surgery happens. They show up in the SNF or home health agency that cares for the patient after discharge. If you run an ortho program, an ASC, or a post-acute service line, CJR-X is your problem too. You have roughly 18 months to get ready.
The model in brief
CJR-X builds on the original CJR Model. That program ran from 2016 through 2024 in 34 metro areas. It saved Medicare an estimated $112.7 million across performance years 6 and 7, all while keeping care quality steady. CMS says those results clear the bar for a national rollout.
Here are the key details for non-hospital players:
The model is mandatory and nationwide. Most acute care hospitals paid under both IPPS and OPPS must participate. Maryland hospitals are exempt, as are hospitals already enrolled in the TEAM model — though only until TEAM ends on December 31, 2030.
The bundle covers hip, knee, and ankle procedures. On the inpatient side, it is triggered by MS-DRGs 469, 470, 521, and 522. On the outpatient side, HCPCS codes 27130 (total hip) and 27447 (total knee) apply. Ankle cases are new to the bundle, but only when performed as inpatient — CMS plans to exclude outpatient ankle cases at launch, with future rules potentially adding them.
Once triggered, the episode runs 90 days. The hospital is responsible for all Part A and Part B spending from the day of surgery through 90 days post-discharge — whether the case started inpatient or in a hospital outpatient setting. For low-acuity cases, CMS is applying site-neutral pricing. That last point is the one ASCs should read twice.
Why site-neutral pricing reshapes the ASC picture
Under fee-for-service, hospitals have long had a payment edge for outpatient joint cases done in the HOPD versus the same case at an ASC. CJR-X changes that. Its site-neutral pricing for low-acuity cases levels the playing field inside the bundle. The target price does not care where the surgery took place. It only cares about total episode cost.
This shifts hospital behavior in two ways at once. Which way wins depends on the system.
The first pull is toward the ASC. For the right patients, a case at an ASC costs less than the same case in the HOPD. Recovery is shorter. Fewer patients end up in a SNF. Hospitals facing downside risk on every Medicare joint will want those cases at the lowest-cost site that still delivers good results — but only if they control the bundle. Expect health systems to ramp up ASC deals, joint ventures, and management contracts that keep volume inside their financial perimeter.
The second pull is away from stand-alone ASCs. Some hospital systems may try to pull volume back in-house, especially if their HOPDs are already lean. ASCs that have been winning commercial joint cases from hospitals may find those referral ties tested when the same surgeons send Medicare cases that land in someone else’s bundle.
The key question for ASC leaders is not whether CJR-X affects you. It does — through every surgeon with hospital ties. The real question: does your ASC become a preferred partner in a bundled-payment plan, or a rival to one?
There is one more twist. The proposed rule includes a Request for Information on whether to bring ASCs into CJR-X triggers down the road. ASCs are excluded at launch. But CMS is asking for input on direct ASC inclusion. Comments close June 9, 2026. The ASC industry’s voice in this window will shape whether future years pull ASC cases straight into the bundle — and on what terms.
What CJR 1.0 taught us about post-acute
The original CJR Model (2016–2024) is the best preview of how hospitals will act under a mandatory bundled payment program at national scale. The pattern showed up again and again: hospitals moved patients to lower-cost settings — mostly home — and locked in tighter bonds with the post-acute providers they chose to keep.
A recently published research looked at 22 CJR and BPCI hospitals. It found two main plays. First, hospitals cut SNF referrals. They used risk tools, patient teaching, home care supports, and links with home health agencies to send more patients home. Second, hospitals built preferred SNF networks. 15 of the 22 hospitals formed them, trading referral volume for more say over SNF quality and cost. Nine of those 15 had 10 or more SNFs in their networks. All 22 hospitals tried new ways to work with SNFs — sharing clinical staff, granting EMR access, and adding care coordinators.
The lesson for post-acute providers under CJR-X is blunt. If you are not in the network, you will not get the referral. With 2,500-plus hospitals all entering bundle risk at the same time, the race for preferred-partner status will heat up in every market at once. That is a very different picture than the original CJR, which touched only 34 metro areas and let everyone else watch from the sidelines.
What this means by setting
SNFs. A landmark study of the first two CJR years found that episode spending fell by about $812 per case. The authors noted the savings came “nearly exclusively” from cuts to SNF and rehab facility use. Under CJR-X, hospitals with no prior bundle experience will learn this lesson fast. SNFs that offer real-time data sharing, open readmission tracking, and outcome-based contracts will make preferred networks. Those that do not will lose referrals.
Home health agencies. Home health is the clear winner in bundled joint care. It costs less than a SNF stay. Patients tend to prefer it. Early-discharge-to-home plans cut the inpatient days that drive up episode costs. Hospitals will seek home health partners who can take same-day or next-day discharges, deliver strong therapy, and catch problems before they become readmissions. Agencies that can prove their outcomes — not just their capacity — will win the partner conversation.
IRFs. Inpatient rehab facilities face the most pressure. Even under the first CJR, hospitals swapped SNF for IRF care in some fracture cases, since SNF is cheaper inside the 90-day window. IRFs that treat complex joint patients — high acuity, many health conditions, real need for intensive rehab — must make that clinical case clearly to hospital partners. IRFs used for routine post-surgical rehab out of habit or convenience will see those referrals shift.
The intake and payment gap no one is talking about
The biggest failure point in bundled payment is not post-acute care. It is what happens before the patient reaches the OR. Bundled models punish surprises. A patient who shows up without confirmed benefits, complete intake forms, or a cleared balance is already driving up episode costs before the first cut.
For ASCs and hospital outpatient teams, digital intake and payment tools are a direct lever on the bottom line. When intake is paper-based, staff chase data they should already have. When patient cost shares are not settled before surgery day, post-acute overruns hit harder because front-end revenue is still in limbo.
Smooth pre-access — insurance checks, eligibility, medical history, and consent, plus upfront payment clearance — CERTIFY Health and CERTIFY Pay handle pre-surgical intake and payment clearance so clinical teams can focus on care coordination and discharge planning.
Coverage gaps are caught before the case goes on the schedule — early enough to act on them. Intake confirms what the patient owes before surgery day, so there are no financial surprises on an already complex care day. Patient balances are collected at the point of service before the 90-day episode opens, rather than chased through the post-acute tail. That sequence keeps clinical teams focused on care and discharge planning — not on admin left over from the front end.
18 months is not as long as it sounds
The comment period for the CJR-X rule closes June 9, 2026. CMS expects the model to save Medicare $725 million over five years. Those savings will come mostly from post-acute care. The final rule is due in late 2026. The model kicks off October 1, 2027. For groups that have never worked inside a bundled payment deal, 18 months sounds like plenty of time. It is not.
Building preferred post-acute networks takes real work. You need to find the right partners, set up data-sharing deals, track outcomes, and hash out contracts. Changing discharge plans to send more patients home means new clinical paths, patient education tools, and community support systems. Reviewing referral patterns, spotting high-cost sites, and swapping in better partners is a multi-quarter project.
ASCs thinking about joint ventures or deals with hospitals should start those talks now. Do not wait until hospitals are under pressure and making snap choices. Post-acute providers who have not pitched their hospital sources on a bundled-care value story need to pick up the pace.
The first CJR gave only 34 markets a head start. CJR-X puts every market on the same clock. The groups that move first — building the right ties, the data tools, and the care skills the model rewards — will land in preferred networks. The ones that wait will learn the hard way: bundled payment loyalty follows outcomes, not history.
Schedule a workflow assessment to see how CERTIFY Health and CERTIFY Pay can reduce episode cost exposure before CJR-X begins
