MIPS Eligibility in 2026: Do You Have to Report?

Every MIPS mistake we are hired to fix started in one of two places: a practice that reported badly, or a practice that did not know it had to report at all. The second group is larger than you would think, and it pays the full 9 percent penalty for an oversight that takes five minutes to check.

MIPS eligibility for 2026 is unchanged from 2025, which means it is unchanged in its ability to surprise people. Eligibility is decided per TIN/NPI combination, from claims data you generated before the performance year even started, and it can differ between two practices where the same clinician works. Here is how the determination works, and what to do with each possible answer.

Start Here: Check the Tool

CMS publishes your status in the QPP Participation Status Tool. Enter an NPI and it returns MIPS eligibility, APM participation, and special statuses for every associated TIN. Initial 2026 status has been available since December 2025; final status posts in December 2026 after the second determination segment closes. Check now, and check again in December, because the two can differ.

The Low-Volume Threshold: The Three-Part Test

You are required to report MIPS in 2026 only if you exceed all three elements of the low-volume threshold, in both segments of the determination period:

Fall at or under any one element in either segment and you are not required to participate. The thresholds are evaluated from Medicare claims and PECOS enrollment data, separately for you as an individual (TIN/NPI) and for each practice as a group (TIN), which is why the tool can show you as individually exempt but group-eligible at the same practice.

The Determination Period: Two Windows, Both Counted

CMS runs the test twice for the 2026 performance year:

• Segment 1: October 1, 2024 through September 30, 2025
• Segment 2: October 1, 2025 through September 30, 2026

Two segment rules decide the edge cases. First, if you were not eligible at an existing practice based on the first segment, you will not become eligible at that same practice based on the second; the second look can remove obligations, not add them at a practice where you already billed. Second, if you begin billing under a new TIN during the second segment, your eligibility at that practice is determined from that segment’s data alone. Clinicians who changed practices in 2026 should treat the December final determination as the real answer.

Who Can Be MIPS Eligible, and Who Is Excluded

Eligibility is limited to specific clinician types: physicians (including doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry, plus chiropractors), physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists, physical therapists, occupational therapists, qualified speech-language pathologists, qualified audiologists, registered dietitians or nutrition professionals, clinical social workers, and certified nurse-midwives. If your clinician type is not on the list, you are excluded regardless of volume.

Volume does not settle it either. Clinicians who enroll as Medicare providers on or after January 1, 2026 are excluded for the 2026 performance year no matter what they bill. So are Qualifying APM Participants: clinicians who meet the Advanced APM thresholds, generally at least 75 percent of Medicare Part B payments or 50 percent of Medicare patients through an Advanced APM entity, leave MIPS entirely and earn the APM track incentives instead. Beginning in 2026, CMS makes QP determinations at both the individual and APM Entity level and counts all covered professional services in the calculation, and Partial QPs sit in between, choosing for themselves whether to participate.

One forward note: clinicians selected for the Ambulatory Specialty Model will be exempt from MIPS during the model, but ASM does not begin until January 1, 2027. For 2026, ASM-listed clinicians still owe a full MIPS year. Details on our ASM page.

Opt-In and Voluntary Reporting: What Each Actually Buys

Exceed one or two threshold elements, but not all three, and you are opt-in eligible. You then have three choices, and they are not close to equivalent:

1. Opt in. You become a MIPS eligible clinician for the year: scored, subject to the payment adjustment in 2028 (positive or negative), and publicly reported on the Doctors and Clinicians section of Care Compare. Opting in is irreversible for the year once elected at submission.
2. Report voluntarily. You submit data and receive performance feedback, but no payment adjustment and no penalty exposure. This is the low-risk way to learn the program before it becomes mandatory for you.
3. Do nothing. Entirely permitted, and for many below-threshold clinicians, entirely rational.

The honest math on opting in: with the maximum bonus at 1.05 percent in the 2026 payment year, the financial upside of opting in is small even for a strong performer, while the downside of a weak year is a real penalty you volunteered for. The cases where opting in makes sense are usually strategic rather than financial: building a public quality record on Care Compare, establishing scoring history before an MVP or ASM future arrives for your specialty, or aligning a group where most clinicians are required anyway. If you are weighing it, run the projected score first; we do this as a standard engagement step.

Individual vs. Group: The Level Question

Eligibility, like reporting, operates at two levels. You can be required as an individual, required only as part of the group, both, or neither. If your practice reports as a group, all clinicians in the TIN who exceed the threshold at the group level are scored with the group and receive the group’s adjustment. If you are individually eligible at a TIN, you receive an adjustment there whether the group reports or not, which is the scenario that catches clinicians at practices that “handle MIPS centrally” but missed one NPI. Reconcile the tool’s answer for every clinician against your reporting plan by name, not by assumption.

Special Statuses: Check These While You’re in the Tool

The Participation Status Tool also flags special statuses that change your requirements without changing your eligibility: small practice (15 or fewer clinicians), rural, Health Professional Shortage Area, non-patient-facing, hospital-based, and ASC-based. These drive automatic Promoting Interoperability reweighting, the single-activity Improvement Activities requirement, small-practice quality scoring accommodations, and more. Practices routinely qualify for flexibilities they never claim; the statuses are printed on the same screen as your eligibility, so read the whole screen.

What to Do With Your Answer

Required: build the reporting plan now instead of in the submission window. The 2026 MIPS reporting guide covers the four categories and the mid-year checklist, and the deadline guide has every date left in the cycle.

Opt-in eligible: decide deliberately, with a projected score in hand, before the submission window forces the choice.

Exempt: confirm nothing changes in the December final determination, consider voluntary reporting if MIPS is in your future, and revisit annually; a growing Medicare panel walks practices across the threshold all the time, usually without anyone noticing until the remittance shows it.

If the tool’s answer surprised you, or two practices show different answers for the same clinician, send us the screenshots. Untangling eligibility is a fifteen-minute conversation in July and an expensive one in March.

MIPS Eligibility FAQs