Don’t sleep on two important new changes hitting Jan. 1: Mandatory TEAM model and CMS-HCC V28 full payment shift

By Brian Murphy

January 1 is rapidly closing in, and 2026 is bringing new rules and regulations impacting the mid-revenue cycle.

Here’s two you shouldn’t forget about. Consider this a public safety announcement.

1. V28 of CMS-HCCs

Say goodbye to V24, and hello (fully) to V28.

This one feels manageable. We’ve all been dealing with the transition for the last couple years; this year CMS risk-adjusted payments to Medicare Advantage plans derived 67% from V28, and 33% from V24.

However, the full payment impact is just hitting, and it will be felt even heavier when 100% of MA risk scores are derived from V28 starting Jan. 1.

Cotiviti describes the shift as a “strategic and comprehensive change” rather than just an update. It offers a pretty good example of how something like metastatic cancer requires a much greater level of coding and identifying primary and secondary tumors (see link below).

Other conditions that impacted payment in V24 have been completely removed from the new model. These include:

• Protein calorie malnutrition
• Angina Pectoris
• Dialysis status
• Acute renal failure
• Complications of specified implanted device or graft

While seemingly small, these changes make big rippled across patient populations that land on many shores. UnitedHealthcare’s shrinking margins under V28, while a source of celebration for some, get passed off in the form of higher member premiums, reduced benefits and smaller networks.

Other conditions including CKD stage 4 have greater weight and reimbursement under the new model.

What impact have you felt from V28? Do you consider it an improvement, or regression?

2. TEAM

Have you forgotten about the new Transforming Episode Accountability Model (TEAM) program for CMS? You shouldn’t, it’s a mandatory model for 750 hospitals in the new year. And if it proves successful over its five performance years (January 1, 2026, to December 31, 2030), I expect to see it rolled out full-scale.

The model pertains to five broad “episode categories” that begin with one of the following procedures: coronary artery bypass graft (CABG), lower extremity joint replacement (LEJR), major bowel procedure, surgical hip and femur fracture treatment (SHFFT), and spinal fusion. CMS has assigned each of these a “target price.”

Hospitals are responsible for overseeing a patient’s care from hospital admission or outpatient procedure through 30 days after the individual leaves the hospital, including coordination and communication between providers across all care settings and with the patient and family.

TEAM participants and all Medicare providers and suppliers associated with an episode will continue to bill Medicare FFS, as usual. They will get paid as usual. But, if participants perform well in the model, they may earn an additional payment. How? By spending below CMS’ target price for these episodes. If participants perform poorly (i.e., they spend above the target price), they will likely owe CMS a repayment amount. Year 1 is upside risk only.

I’ve linked a video below that explains how TEAM works and offers tips to perform well in the model.

References

• CMS, TEAM: https://www.cms.gov/priorities/innovation/innovation-models/team-model
• Cotiviti, Navigating the 2026 ICD-10-CM coding updates: https://blog.cotiviti.com/navigating-the-2026-icd-10-cm-coding-updates
• Healthcare IT Today, Making the TEAM Work: https://www.healthcareittoday.com/2025/12/04/making-the-team-transforming-episode-accountability-model-work/
• Norwood, CMS-HCCs V28 Survival Guide: https://www.norwood.com/resource/cms-hccs-v28-survival-guide/