What Is CJR-X? A Guide to Medicare’s 2028 Joint Replacement Model

CJR-X, or Comprehensive Care for Joint Replacement Expanded, is Medicare’s mandatory nationwide episode-based payment model for qualifying hip, knee, and ankle replacement procedures. CMS finalized the model in July 2026, and CJR-X will begin on January 1, 2028.¹

Under CJR-X, eligible hospitals will be financially accountable for the cost and quality of care delivered during an episode that begins with a qualifying procedure and continues through 90 days after discharge or completion of the outpatient procedure.¹ The model includes qualifying procedures performed in both inpatient and hospital outpatient settings.

For hospitals preparing for CJR-X, the model creates new expectations around episode spending, quality performance, patient-reported outcomes, care coordination, and post-acute care. This guide explains the finalized CJR-X requirements, who must participate, how payment works, which quality measures matter, and how CJR-X differs from Medicare’s original CJR model.

CJR-X final rule update: CMS finalized CJR-X on July 31, 2026. The model will begin January 1, 2028. CMS had originally proposed an October 1, 2027 start date, so resources published before the final rule may still reference the earlier date.¹

What Is CJR-X?

CJR-X stands for Comprehensive Care for Joint Replacement Expanded. It is a mandatory Medicare payment model that holds participating hospitals accountable for both spending and quality across episodes of care for qualifying lower extremity joint replacements.¹

Rather than paying each provider without considering the total cost of an episode, CJR-X evaluates Medicare spending across the full episode and compares it with a target price established by CMS.

An episode generally includes the qualifying joint replacement procedure and related Medicare-covered care for the following 90 days. That can include hospital services, physician services, rehabilitation, skilled nursing, home health, outpatient therapy, and other services associated with recovery.

CJR-X Requirements at a Glance

These requirements make CJR-X broader than the original Comprehensive Care for Joint Replacement model and place greater emphasis on managing an entire episode of care rather than focusing primarily on the procedure itself.

Who Must Participate in CJR-X?

CJR-X is designed as a mandatory nationwide model for hospitals that meet CMS participation requirements.¹ Unlike voluntary alternative payment models, qualifying hospitals generally do not elect whether to join.

Participation centers on hospitals paid under Medicare’s Inpatient Prospective Payment System and Outpatient Prospective Payment System that furnish qualifying procedures.

Because participation is tied to Medicare payment status and other program criteria, hospitals should confirm their inclusion using CMS participation information rather than assuming that all facilities performing joint replacement procedures will be subject to the model.

Who Is Excluded From CJR-X?

Several categories of hospitals are excluded from CJR-X under the finalized model.

One of the most important exclusions involves hospitals participating in Medicare’s Transforming Episode Accountability Model, or TEAM. TEAM participants will remain outside CJR-X while participating in TEAM. The two models should therefore be treated as related but separate Medicare initiatives rather than programs that eligible hospitals will necessarily manage simultaneously.¹

Other exclusions apply based on Medicare payment arrangements and model-specific participation rules.

Organizations should confirm their participation status before building reporting or operational workflows specifically around CJR-X.

What Procedures Are Included in CJR-X?

CJR-X covers qualifying lower extremity joint replacement procedures involving the hip, knee, and ankle.¹

The model applies to eligible procedures furnished in both hospital inpatient and outpatient settings. Including both settings reflects the continued migration of many joint replacement procedures from inpatient hospitalization to outpatient care.

This means hospitals need visibility into the full episode regardless of where the qualifying procedure occurs.

From an operational standpoint, the procedure itself is only the beginning of the CJR-X episode. Medicare spending associated with rehabilitation, follow-up care, post-acute services, readmissions, and other covered services during the episode can affect financial performance.

How Long Is a CJR-X Episode?

A CJR-X episode extends from the qualifying joint replacement procedure through 90 days after hospital discharge or completion of the outpatient procedure.¹

That 90-day period is important because much of the variation in joint replacement spending occurs after the patient leaves the hospital.

Services during the episode can include:

• Physician and other professional services

• Skilled nursing facility care

• Home health services

• Outpatient rehabilitation

• Inpatient rehabilitation

• Follow-up hospital services

• Readmissions

• Other Medicare-covered services associated with the episode

Hospitals, therefore, have a financial reason to understand what happens after discharge, even when those services are furnished by outside organizations.

When Does CJR-X Start?

The finalized CJR-X start date is January 1, 2028.¹

CMS initially proposed beginning the model on October 1, 2027. The final rule moved implementation to January 1, 2028.

That distinction matters because older CJR-X resources may still list October 1, 2027 as the model’s start date.

Hospitals now have the remainder of 2026 and all of 2027 to prepare data systems, quality workflows, patient-reported outcome collection, post-acute partnerships, and financial monitoring before the first CJR-X performance period begins.

How Does CJR-X Financial Accountability Work?

CJR-X uses a retrospective reconciliation approach.

CMS establishes a target price for an episode. After the episode is complete, Medicare spending is compared with that target price while quality performance and other model policies are applied.

If episode spending falls below the applicable target and quality requirements are met, a participating hospital may qualify for a reconciliation payment.

If spending exceeds the applicable target, the hospital may owe money back to Medicare, subject to the model’s financial risk rules and applicable limits.

CJR-X Target Prices

Target prices establish the spending benchmark against which a hospital’s episode performance is evaluated.

Because target prices are determined before final reconciliation, participating hospitals will need the ability to compare expected episode spending with actual utilization throughout the performance period.

This creates a stronger incentive to identify avoidable spending, variation in post-acute care, preventable readmissions, and other patterns that can increase total episode cost.

CJR-X Reconciliation

Reconciliation occurs after CMS has sufficient claims and quality information to evaluate performance.

The basic relationship can be understood as:

Episode spending + quality performance → comparison with target price → reconciliation result

A lower-cost episode does not automatically produce a positive payment result. Quality performance is also part of the CJR-X methodology.

That makes clinical outcomes and patient experience financially relevant rather than separate from the payment model.

What Are the CJR-X Quality Measures?

Quality measurement plays a central role in CJR-X.

CMS uses measures addressing outcomes such as complications, hospital utilization, patient experience, and patient-reported outcomes when evaluating participating hospitals.¹

The finalized quality framework includes measures related to:

• Complications following elective primary total hip and total knee arthroplasty

• Hospital-level patient-reported outcomes following total hip and total knee arthroplasty

• Hospital visits following outpatient surgery

• Patient experience

• Additional quality performance incorporated into the CJR-X Composite Quality Score

These measures mean that reducing episode spending alone will not determine success under CJR-X.

Hospitals will also need reliable processes for collecting and submitting required quality data.

Patient-Reported Outcomes Under CJR-X

Patient-reported outcomes are particularly important for joint replacement episodes because they measure aspects of recovery that cannot be captured from claims data alone.

Measures can assess areas such as pain, physical function, and the patient’s perceived improvement following surgery.

For CJR-X, hospitals need more than a questionnaire platform. A reporting process must identify eligible patients, use the required instruments, collect responses during the specified windows, and maintain enough documentation to support reporting requirements.

Missing patients or collecting data outside an accepted measurement window can affect the usability of the data even when the questionnaire itself was completed.

How the CJR-X Composite Quality Score Affects Payment

CMS combines quality performance into a Composite Quality Score, or CQS, that helps determine how quality influences reconciliation.

The score is important because CJR-X is not structured as a simple comparison between Medicare spending and a target price.

Instead, quality performance can affect the financial calculation and whether a hospital qualifies for certain reconciliation payments.

In simplified form:

Quality measure performance → Composite Quality Score → payment adjustment and reconciliation eligibility

Hospitals preparing for CJR-X should therefore monitor financial and quality performance together.

An organization that manages episode spending well but performs poorly on required quality measures may not receive the same financial result as an organization that performs well on both.

How Is CJR-X Different From the Original CJR Model?

CJR-X builds on Medicare’s earlier Comprehensive Care for Joint Replacement model, but the two programs are not identical.

The original CJR model tested episode-based payment for lower extremity joint replacement across selected geographic areas. CJR-X applies a revised version of the approach much more broadly.

CJR-X should therefore be viewed as a new Medicare model informed by the original CJR program rather than a simple extension of the earlier model.

CJR-X vs. TEAM

CJR-X and TEAM are separate Medicare episode-based payment models with different participation rules, procedure categories, and timelines. Hospitals participating in TEAM are excluded from CJR-X while they remain in TEAM.

For a deeper comparison of eligibility, episode structure, payment methodology, and implementation requirements, see our guide to CJR-X vs. TEAM.

How Hospitals Can Prepare for CJR-X Before 2028

The January 1, 2028 start date gives hospitals time to assess whether existing joint replacement programs can support the reporting and financial requirements of CJR-X.

Several areas deserve attention before implementation.

Establish reliable patient-reported outcome collection

Hospitals should determine how eligible patients will be identified, contacted, and followed through required preoperative and postoperative measurement periods.

The process should also document when responses were collected and whether the required instruments and reporting rules were followed.

Track performance across the full 90-day episode

Hospital performance under CJR-X extends well beyond discharge.

Organizations should assess where patients receive care after surgery and identify patterns associated with higher spending, readmissions, or poor outcomes.

Review post-acute care patterns

Variation in skilled nursing, home health, outpatient rehabilitation, and other post-acute services can materially affect episode spending.

Hospitals should understand current utilization patterns before financial accountability begins.

Connect quality and financial reporting

CJR-X quality performance can influence reconciliation.

Quality teams and financial teams should therefore work from a shared view of episode performance rather than reviewing these areas independently.

Establish a CJR-X baseline before 2028

Hospitals do not need to wait until the model begins to study joint replacement performance.

Using current patient populations, organizations can estimate episode spending, review post-acute utilization, measure completion rates for patient-reported outcomes, and identify areas where current workflows may not meet future reporting needs.

CJR-X FAQs

What is CJR-X?

CJR-X, or Comprehensive Care for Joint Replacement Expanded, is a mandatory Medicare episode-based payment model for qualifying hip, knee, and ankle replacement procedures. Participating hospitals are accountable for spending and quality across a 90-day episode of care.¹

When does CJR-X start?

CJR-X begins January 1, 2028. CMS originally proposed an October 1, 2027 start date but moved implementation to January 2028 in the final rule.¹

Is CJR-X mandatory?

Yes. CJR-X is a mandatory Medicare model for hospitals that meet CMS participation criteria, subject to specified exclusions.¹

How long is a CJR-X episode?

A CJR-X episode generally begins with the qualifying procedure and continues through 90 days after discharge or completion of the outpatient procedure.¹

What procedures are included in CJR-X?

CJR-X includes qualifying lower extremity joint replacement procedures involving the hip, knee, and ankle in inpatient and hospital outpatient settings.¹

What is the difference between CJR-X and TEAM?

CJR-X focuses on qualifying lower extremity joint replacement episodes, while TEAM covers several surgical episode categories. Hospitals participating in TEAM are excluded from CJR-X while participating in TEAM.¹

CJR-X expands Medicare’s use of episode-based accountability for joint replacement care and aligns spending, quality, patient-reported outcomes, and post-acute performance within a single payment framework.

With the model beginning January 1, 2028, hospitals have an opportunity to use the preparation period to understand current episode performance, strengthen outcome collection, and identify where existing joint replacement workflows differ from finalized CJR-X requirements.

References

¹ Centers for Medicare & Medicaid Services. Comprehensive Care for Joint Replacement Expanded Model (CJR-X).
https://www.cms.gov/priorities/innovation/innovation-models/cjr-x

² Centers for Medicare & Medicaid Services. FY 2027 Hospital Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System Final Rule (CMS-1849-F). July 31, 2026.
https://www.cms.gov/newsroom/fact-sheets/fy-2027-hospital-inpatient-prospective-payment-system-long-term-care-hospital-prospective-payment