CMS-1848-P: What Medicare’s 2027 ACO Rule Really Asks of You

CMS has proposed changes to the Medicare Shared Savings Program that could reshape ACO benchmark economics, track selection, quality reporting, and beneficiary engagement. The comment period has closed, but the work for ACOs is just beginning: leaders should start modeling the financial and operational implications now.

The short version

What’s changing: more downside risk, more of each patient’s journey to manage, and quality proven with clean, electronic data pulled straight from the record.

Where the opportunity is: the savings and the scores both hinge on care transitions — the discharge, the admission, the handoff where records go missing.

Do this now: pressure-test your 2025 settlement exposure, revisit your BASIC Level E vs. ENHANCED track choice, and confirm your quality data is complete enough to report from the EHR.

On July 14, 2026, the Centers for Medicare & Medicaid Services (CMS) released its proposed Medicare payment rule for 2027 (CMS-1848-P). It includes substantial changes to the Medicare Shared Savings Program (MSSP), from benchmarking and risk arrangements, to quality reporting and beneficiary cost sharing.

CMS is now reviewing the comments it received and will issue a final rule, most likely in November. Most of the changes will take effect on January 1, 2027, leaving ACOs with a relatively short window to understand how the changes may affect their financial strategy, quality program, and data infrastructure.

Key dates

Nov 2026 — final rule expected
Jan 1, 2027 — most changes take effect
Apr 1, 2027 — option to cover patients’ Part B cost-sharing (if approved)
2028 — beneficiary assignment changes begin

The major changes that may affect your bottom line

More credit for the savings you’ve already earned. Credit for prior-year savings rises from 50% to 75%
A new limit on the yearly trend rate, and it looks backwards. A new cap keeps the yearly trend rate within about a point of actual national cost growth, applies retroactively to 2024-2026 starters, and pushes the 2025 settlement to November 2026.
A rebalancing of BASIC Level E and ENHANCED. Level E gets more rewarding and ENHANCED’s edge shrinks, so you can pick the track you can actually manage instead of chasing the highest payout.
More room for ACOs that take on sicker patients. Risk-adjusting the 5% benchmark cap, plus a new growth adjustment, gives more room to ACOs managing complex patients and expanding their panels.
The option to cover patients’ out-of-pocket Part B costs. Starting April 1, 2027, ACOs can cover patients’ Part B cost-sharing (drugs and DME excluded) with CMS approval–an ACO-funded tool to use deliberately.
Quality reporting keeps moving toward electronic data. From 2027 the old interoperability requirement is replaced with one of 3 options, the simplest being to report at least one quality measure straight from the EHR.
Two smaller items with firm dates. Advance-payment options end after the 2027 cycle. Jan 1, 2027 applicants get a short window to switch tracks, and beneficiary-assignment changes arrive in 2028.

What it all adds up to

The largest operational and savings opportunity for an ACO sits at care transitions. The savings an ACO earns usually come from exactly those seams: the hospital discharge that never reaches the primary care doctor, the nursing-home admission that arrives with no records, the handoff where nobody follows up. That’s where avoidable costs pile up, and they’re where doing better pays off under this rule.

If a patient’s information isn’t into the record, it can’t count toward your quality score. And quality is what unlocks the savings.

Where Cascala fits

Cascala is built for those seams between settings, the moments where the records get lost and savings leak out. It pulls in the hospital admission, discharge, and transfer feeds along with records from health information exchanges, and it lays them out in a clear summary right alongside the electronic health record, within your existing workflow. The result is one reliable clinical picture that follows the patient across the whole journey: from primary care, to the hospital or emergency department, to post-acute, to home.

Three of the rule’s provisions map directly onto that gap:

Rule provision	The gap it exposes	How Cascala closes it
Electronic quality reporting rewards complete records	Quality is scored one patient at a time, straight from the record	Builds a more complete, source-backed picture at every transition. We partner with HIEs and data vendors to fill in gaps in the record.
Sicker patients must be understood at the handoff	The rule pays you to take on higher-need patients and manage them across settings.	Surfaces recent stays, medications, functional status, and readmission risk the moment a patient moves
Easing the ratchet only helps if you capture the savings	The gap it exposes The bigger savings credit rewards early savings	Closes the loop on the transitions where costs leak, so discharges reach primary care and admissions arrive with their records.

Case Study: at Palm Beach ACO, Cascala cut the time to get records after a patient transfer by 71%, with its AI recommendations proving accurate over 98% of the time. Cascala deployments can typically go live in 1–2 weeks, depending on scope and integration requirements.

What to sort out before the final rule

☐ Understand your exposure on the 2025 settlement. The backward-reaching trend limit and delayed settlement mean numbers you thought were final may still move

☐ Take another look at your track choice. With Level E keeping more savings and ENHANCED losing part of its regional bonus, the math has shifted

☐ Check whether your quality data is ready to report electronically. If pulling one measure straight from your records would be a struggle today, 2027 is when that becomes a scored problem

☐ Decide whether covering Part B costs fits your patients. It’s a real tool for getting patients needed care, but you’d be paying for it

The bottom line

Medicare is asking ACOs to take on more risk, manage more of each patient’s journey, and prove all of it with cleaner, electronic data. The comment period is over, but the time to get ready is not. The ACOs that spend the rest of this year making sure their information is complete across every setting will be the ones positioned to earn what 2027 puts on the table.

Cascala helps you get more records, faster, and turns them into clear, source-backed information at every transition, before a gap becomes a missed quality measure or a lost dollar.

Talk to our team

One more thing to keep in mind: this is still a proposed rule, so some of these details may change before the final version. When it lands in November, we’ll follow up with a short piece on what actually made it through.