What Are the MIPS Eligibility Criteria?

The MIPS eligibility criteria are the CMS-defined rules that determine mandatory reporting under the Merit-Based Incentive Payment System (MIPS). The criteria apply per performance year to clinicians billing Medicare Part B under the Physician Fee Schedule.

The MIPS eligibility criteria require two tests for mandatory reporting in the 2026 performance year (January 1 to December 31, 2026). The first test is clinician type, and the second test is exceeding the low-volume threshold ($90,000 / 200 / 200). 

CMS determines PY2026 eligibility across two segments, with preliminary status posted in December 2025 and final status in December 2026. Clinicians who exceed one or two threshold elements, but not all three, may opt in.

What Does MIPS Eligibility Mean?

MIPS eligibility means CMS has determined that a clinician must report under the Merit-Based Incentive Payment System for a given performance year. The Merit-Based Incentive Payment System (MIPS) is one track of the CMS Quality Payment Program (QPP), the Medicare Part B value program created under MACRA.

MIPS eligibility is a status, not a score. CMS calculates MIPS eligibility status across two determination periods, called segment 1 and segment 2. The status sits at the TIN/NPI level and feeds the QPP Participation Status Lookup tool.

A clinician confirmed as MIPS eligible faces a Medicare Part B payment adjustment of up to plus or minus 9 percent. The adjustment applies two years after the performance year, so 2026 performance affects 2028 Medicare payments.

For program-wide context, see the Merit-Based Incentive Payment System guide.

What Are the Two MIPS Eligibility Criteria?

CMS uses two criteria to determine MIPS eligibility, and a clinician must meet both. The first criterion is clinician type. The second criterion is exceeding the low-volume threshold. The following table shows both criteria and their source.

Criterion	Test	Source
Eligible clinician type	Clinician role appears on the CMS eligible-clinician list	qpp.cms.gov
Low-volume threshold	All three LVT elements exceeded ($90,000 Part B AND 200 patients AND 200 services)	PFS Final Rule

A clinician failing either criterion is not subject to mandatory MIPS reporting. That clinician may still be eligible to opt in or to report voluntarily. The next two sections drill into each criterion.

Which Clinician Types Are MIPS Eligible?

CMS recognizes the following clinician types as MIPS eligible for performance year 2026. The list below counts physicians as one umbrella category covering MD, DO, DDS, DMD, DPM, and OD. CMS also lists osteopathic practitioners and chiropractors as distinct clinician types.

• Physicians (MD, DO, DDS, DMD, DPM, OD)
• Osteopathic practitioners
• Chiropractors
• Physician assistants (PAs)
• Nurse practitioners (NPs)
• Clinical nurse specialists (CNSs)
• Certified registered nurse anesthetists (CRNAs)
• Physical therapists (PTs)
• Occupational therapists (OTs)
• Qualified speech-language pathologists (SLPs)
• Qualified audiologists
• Clinical psychologists
• Registered dietitians or nutrition professionals
• Clinical social workers
• Certified nurse-midwives

Clinician type is determined by the specialty codes in Medicare claims billed under a TIN/NPI combination. A clinician whose role does not appear on the CMS list is excluded from MIPS and the MIPS payment adjustment.

One edge case applies. A Medicare Diabetes Prevention Program (MDPP) supplier is carved out and does not count as a MIPS-eligible clinician type. For the full breakdown, see the MIPS eligible clinician types complete list.

What Is the MIPS Low-Volume Threshold?

The MIPS low-volume threshold has three criteria. A clinician must exceed all three in the determination period to be required to report MIPS. The 2026 Medicare Physician Fee Schedule Final Rule kept the same three values.

• $90,000 in Medicare Part B allowed charges for covered professional services
• 200 Medicare Part B patients
• 200 covered professional services

The logic is AND, not OR. A clinician must exceed $90,000 AND 200 patients AND 200 services to trigger mandatory reporting. Falling below any single value removes the mandatory-reporting requirement.

A short example clarifies the threshold. A clinician billing $80,000 in Medicare Part B allowed charges falls below the low-volume threshold, regardless of patient or service counts. For the deeper drill-down, see the MIPS low-volume threshold 3 criteria.

How Is MIPS Eligibility Determined for a Performance Year?

CMS determines MIPS eligibility by checking each clinician against the eligible-clinician list and the low-volume threshold across two 12-month determination-period segments. The 2026 performance year runs from January 1 to December 31, 2026. The table below maps the full PY2026 eligibility cycle with each exact date.

Stage	Date or window	What happens
Determination Segment 1	Oct 1, 2024 – Sep 30, 2025	First low-volume threshold check against Part B claims and PECOS data
Preliminary eligibility published	December 2025	Initial PY2026 status posted to the QPP Participation Status Lookup tool
Performance period	Jan 1 – Dec 31, 2026	MIPS-eligible clinicians collect performance data
Determination Segment 2	Oct 1, 2025 – Sep 30, 2026	Second low-volume threshold check
Final eligibility published	December 2026	Reconciled PY2026 status, treated as final
Data submission window	Jan 2 – Mar 31, 2027	Eligible clinicians submit 2026 performance data
Payment adjustment year	Jan 1 – Dec 31, 2028	Adjustment of up to plus or minus 9 percent applied to Part B claims

A clinician who bills Medicare Part B in both segments must exceed the low-volume threshold in both segments to be required to report. Falling below the threshold in either segment results in exemption. Eligibility can change between the preliminary December 2025 result and the final December 2026 result.

CMS publishes each determination through the QPP Participation Status Lookup tool, which is queryable by NPI. The tool returns MIPS eligibility, special statuses, and APM affiliation. Practices with mid-year volume changes can verify MIPS eligibility before the March 31, 2027, submission window closes.

Who Is Exempt From MIPS Reporting?

Five categories of clinicians are exempt from MIPS reporting. Exemption removes the mandatory-reporting requirement and the associated payment-adjustment exposure. The five categories appear below.

• Below-threshold clinicians who do not exceed all three low-volume threshold elements
• Newly enrolled Medicare clinicians in their first year of Medicare enrollment
• Qualifying APM Participants (QPs) who meet Advanced APM participation thresholds
• Clinician roles not on the CMS eligible-clinician list
• MDPP suppliers, carved out from the eligible-clinician list

Exemption differs from special status. A special status, such as small practice or rural, adjusts the scoring or reporting load but does not remove eligibility. For the distinction in detail, see MIPS special statuses and exemptions.

Can a Clinician Opt In to MIPS Voluntarily?

Yes. A clinician who exceeds one or two low-volume threshold elements, but not all three, may opt in to MIPS. Opt-in is distinct from voluntary participation, and the payment-adjustment consequence is the main difference. The table below separates the two.

Feature	Opt-in	Voluntary participation
Who qualifies	Exceeds 1 or 2 (not all 3) LVT elements	Exceeds none of the 3 LVT elements
Payment adjustment	Yes, positive, negative, or neutral	No adjustment applied
Data submission	Required once the clinician opts in	Optional, for feedback only
Reversible	No, the clinician is bound for the PY	Yes, no binding effect

A clinician who opts in becomes a MIPS-eligible clinician for that performance year. A voluntary participant submits data for feedback and receives no payment adjustment. The two paths carry different financial stakes, so the opt-in decision is irreversible once elected.

How Does MIPS Eligibility Differ for Individuals vs Groups?

MIPS eligibility is determined at the individual NPI level or at the aggregated TIN level, depending on the reporting election. Individual eligibility tests one TIN/NPI combination. Group eligibility aggregates all NPIs billing under a single TIN. The table compares both units.

Feature	Individual (NPI)	Group (TIN)
Data unit	One TIN/NPI combination	All NPIs under one TIN
Threshold test	NPI-level against the LVT	Aggregated TIN-level against the LVT
Eligibility scope	One clinician	Every clinician billing under the TIN
Adjustment attribution	The individual NPI	All NPIs in the group

Group aggregation can change the outcome. A clinician exempt as an individual may become eligible when the practice reports as a group because TIN-level volume exceeds the threshold. Reporting unit selection therefore affects both eligibility and payment exposure. For the mechanics, see MIPS group reporting.

What Happens After MIPS Eligibility Is Confirmed?

A clinician confirmed as MIPS eligible for the 2026 performance year must report data across the four MIPS performance categories. Data collection runs January 1 to December 31, 2026. The four categories carry fixed weights for traditional MIPS in 2026, shown below.

Performance category	2026 weight
Quality	30%
Cost	30%
Promoting Interoperability (PI)	25%
Improvement Activities (IA)	15%

The four weighted scores combine into a MIPS Final Score from 0 to 100. CMS set the 2026 performance threshold at 75 points and committed to hold 75 points through the 2028 performance year. Clinicians submit 2026 data by March 31, 2027, and CMS applies the Medicare Part B adjustment in 2028. A Final Score below 75 produces a negative adjustment. For category-level detail, see the MIPS performance categories deep-dive.

What Is MIPS Facility-Based Scoring Eligibility?

A MIPS-eligible clinician qualifies for facility-based scoring when 75 percent or more of covered professional services occur in inpatient, on-campus outpatient, or emergency-department settings. CMS applies the hospital Value-Based Purchasing measures as the scoring source for these clinicians.

CMS auto-applies facility-based scoring when the facility-based result is higher than the clinician’s submitted MIPS data. The clinician does not elect facility-based scoring manually. This path suits hospital-based clinicians whose service mix concentrates in facility settings. For the workflow, see the facility-based scoring path.

What MIPS Eligibility Considerations Apply by Practice Type?

CMS treats five practice-type considerations as eligibility-adjacent. The eligibility rules apply uniformly, while special statuses adjust the scoring outcome for certain practice types. The five considerations appear below.

• Solo practitioners, tested at the individual NPI level
• Small practices of 15 or fewer clinicians under one TIN, which receive a 6-point Quality bonus and automatic PI reweighting
• Large groups, tested at the aggregated TIN level
• Federally Qualified Health Center (FQHC) clinicians, eligible when billing Part B covered professional services
• Rural Health Clinic (RHC) clinicians, eligible under the same Part B billing rule

Practice type does not change the two core criteria. Practice type changes the scoring relief a clinician receives after eligibility is confirmed. For practice-specific guidance, see MIPS by practice type.

How Does Virtual Group Eligibility Differ From Individual or TIN-Level Eligibility?

A Virtual Group combines two or more solo or small-practice TINs that elect to report MIPS together. Virtual Group eligibility aggregates Medicare claims across all elected TINs, which differs from both individual and single-TIN group eligibility. The table compares all three units.

Feature	Individual	Group TIN	Virtual Group
Eligibility unit	One TIN/NPI	One TIN	2 or more TINs combined
Election deadline	Not applicable	Not applicable	December 1 before the PY
Threshold test	NPI-level	TIN-level	Combined across elected TINs
Scoring attribution	The NPI	All NPIs in the TIN	All NPIs across the Virtual Group

A Virtual Group election binds the participating TINs for the full performance year. The election deadline is December 1 of the year before the performance year. For the formation rules, see MIPS virtual groups.

What Is the Determination Period for the MIPS Low-Volume Threshold?

CMS assesses the MIPS low-volume threshold across two determination-period segments. Segment 1 covers October 1, 2024, through September 30, 2025, for performance year 2026. Segment 2 covers October 1, 2025, through September 30, 2026.

A clinician billing in both segments must exceed the low-volume threshold in both segments to be required to report. CMS releases segment 1 results as preliminary eligibility and reconciles segment 2 into the final determination in December of the performance year.

What Roles Count as Non-Patient-Facing for MIPS Eligibility?

CMS designates a clinician as non-patient-facing when 100 or fewer covered professional services occur in the determination period. The roles most often falling into this status appear below.

• Pathologists
• Radiologists
• Anesthesiologists (in many practice settings)

Non-patient-facing status triggers automatic performance-category reweighting. Non-patient-facing status does not remove MIPS eligibility. A non-patient-facing clinician who exceeds the low-volume threshold remains an MIPS-eligible clinician.

When Does Group Reporting Eligibility Outperform Individual Reporting Eligibility?

Group reporting eligibility outperforms individual reporting eligibility in two scenarios. The two scenarios appear below with their deciding conditions.

1. Lower-performing NPIs benefit from aggregation with stronger peers, raising the group Final Score above what weak NPIs would earn alone.
2. A TIN with a mix of below-threshold and above-threshold NPIs wants every NPI to receive a payment adjustment, which group reporting applies across the full TIN.

Group reporting also spreads measurement burden across the practice. Individual reporting isolates each clinician’s Final Score and adjustment. The choice depends on the practice’s score distribution and adjustment goals.

Are MIPS Eligibility Criteria the Same as the MIPS Bicycle or Ski Helmet Protection System?

No. MIPS eligibility (Merit-Based Incentive Payment System eligibility) is a CMS Medicare program rule. MIPS-helmet (Multi-directional Impact Protection System) is an unrelated cycling and ski helmet safety brand. This article covers only the CMS Medicare entity.

Are CRNAs and Certified Nurse-Midwives MIPS-Eligible Clinicians?

Yes. Certified registered nurse anesthetists (CRNAs) and certified nurse-midwives both appear on the CMS eligible-clinician list. Eligibility still requires exceeding the low-volume threshold in the determination period.

Does the MIPS Low-Volume Threshold Update Each Performance Year?

Yes. CMS reviews the low-volume threshold annually in the Physician Fee Schedule Final Rule. The 2026 values stayed at $90,000 in Medicare Part B allowed charges, 200 patients, and 200 covered services. For current-year timing, see the MIPS performance year calendar.

Can an Opt-In Clinician Earn MIPS Payment Adjustments?

Yes. Opt-in clinicians are eligible for MIPS payment adjustments, positive, negative, or neutral. Voluntary participation clinicians receive no payment adjustment and submit data for feedback only. Once a clinician opts in, the election binds that clinician for the performance year.

Can a Hardship Exemption Override MIPS Eligibility?

No. Hardship exceptions do not remove MIPS eligibility. Approved hardship and Extreme and Uncontrollable Circumstances (EUC) applications reweight performance categories rather than removing eligibility status. Practices needing hardship support can verify MIPS hardship eligibility.

Does CMS Notify Clinicians of Their MIPS Eligibility Status?

CMS publishes eligibility status through the QPP Participation Status Lookup tool, not through individual notification letters. Clinicians check status proactively by entering an NPI. Group and TIN administrators access aggregated status reports for all clinicians billing under the TIN.