CMS TEAM Model

CMS TEAM Model

New 2025 Inpatient Prospective Payment System Rule

a new mandatory payment model proposed by CMS in the 2025 IPPS Rule. Its goal is to improve the care given to Medicare beneficiaries by holding hospitals accountable for specific episodes of care.

Transforming Episode Accountability Model

Why is CMS Doing this?

• Fragmented and costly care for Medicare beneficiaries

• Need for improved care coordination and health outcomes

CMS's Goal

• Financial accountability to incentivize care coordination

• Reduction of unnecessary or duplicate services

• Enhancing overall care experience for beneficiaries

If the proposed TEAM proves successful, it could pave the way for 'managing episodes as a standard practice in Traditional Medicare'

Page 1083 for more context

Hospitals will be assessed based on their actual spending compared to the target price, as well as their performance on certain quality measures

How TEAM Payments Work

Hospitals bill Medicare but they will receive target prices for specific episodes

Target prices are based on 3 years of baseline data and adjusted for factors like region and complexity of the episode

The target price is calculated as all the projected payments to the physician, hospital, and other health care provider and supplier services combined into a target price

Hospitals will be assessed based on their actual spending compared to the target price, as well as their performance on certain quality measures

How TEAM Payments Work

Hospitals bill Medicare but they will receive target prices for specific episodes

Target prices are based on 3 years of baseline data and adjusted for factors like region and complexity of the episode

The target price is calculated as all the projected payments to the physician, hospital, and other health care provider and supplier services combined into a target price

'If hospitals spends less than the target price and meet quality standards, they will receive a payment from Medicare. However, if they spend more than the target price, they will owe Medicare a payment '

The Team Model only inculdes five specific episodes. These episodes represent high-expenditure, high volume care delivered to Medicare beneficiaries.

Spinal Fusion

Surgical Hip/Femur Fracture Treatment (SHFFT)

TEAM Eligible Episodes

Coronary Artery Bypass Graft (CABG)

Lower Extremity Joint Replacement (LEJR)

Major Bowel Procedure

TEAM Quality Measures

1. (For all episodes) Hybrid Hospital-Wide All-Cause Readmission Measure
2. (For all episodes) PSI90*
3. (For LEJR episodes only) THA/TKA PRO-PM (Inpatient)

5 Performance Years (Calendar Years) PY1-PY5

Performance Year 1 January 1, 2026 - December 31, 2026

Performance Year 4 January 1, 2029 - December 31, 2029

Performance Year 3 January 1, 2028 - December 31, 2028

Performance Year 5 January 1, 2030 - December 31, 2030

Perormance Year 2 January 1, 2027 - December 31, 2027

PY4

PY3

PY5

PY2

PY1

TEAM Model Performance Period

TEAM is a 5 - year program that starts January 1, 2026, and ends on December 31, 2030. Final data submission of Clinical data elements and quality measures in CY 2031.

Beneficiaries who meet all of the following criteria at the time of admission to the anchor hospitalization or anchor procedure:

• Have a Medicare as primary payer
• Enrolled in Medicare Part A abd Part B
• Are not eligible for Medicare on the basis of ESRD
• Are not enrolled in any managed care plan (for example: Medicare Advantage)
• Are not covered under a United Mine Workers of America health plan

Which Beneficiaries are included in TEAM?

To find out which hospitals are included, click the link below:

A TEAM participant (hospital is defined as:

• an acute-care hospital
• that initiates episodes
• paid under Inpatient Prospective Payment System (IPPS)
• has a CMS Certification Number (CCN)
• has a primary address located in one of the geographic areas selected for participation in TEAM

Which Hospitals are Required to Participate in TEAM?

Questions?