42 CFR § 512.436 - Extreme and uncontrollable circumstances.

---
identifier: "/us/cfr/t42/s512.436"
source: "ecfr"
legal_status: "authoritative_unofficial"
title: "42 CFR § 512.436 - Extreme and uncontrollable circumstances."
title_number: 42
title_name: "Public Health"
section_number: "512.436"
section_name: "Extreme and uncontrollable circumstances."
chapter_name: "CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES"
subchapter_number: "H"
subchapter_name: "HEALTH CARE INFRASTRUCTURE AND MODEL PROGRAMS"
part_number: "512"
part_name: "STANDARD PROVISIONS FOR MANDATORY INNOVATION CENTER MODELS AND SPECIFIC PROVISIONS FOR CERTAIN MODELS"
positive_law: false
currency: "2026-04-05"
last_updated: "2026-04-05"
format_version: "1.1.0"
generator: "[email protected]"
authority: "42 U.S.C. 1302, 1315a, and 1395hh."
regulatory_source: "85 FR 61362, Sept. 29, 2020, unless otherwise noted."
cfr_part: "512"
---


# 512.436 Extreme and uncontrollable circumstances.

(a) *General.* CMS—

(1) Applies determinations made under the Quality Payment Program with respect to whether an extreme and uncontrollable circumstance has occurred and the affected area during the PY; and

(2) Has sole discretion to determine the period during which an extreme and uncontrollable circumstance occurred and the percentage of attributed patients residing in affected areas.

(b) *Downside risk payment.* In the event of an extreme and uncontrollable circumstance, as determined by the Quality Payment Program, CMS may reduce the amount of the IOTA participant's downside risk payment, if applicable, prior to recoupment. CMS determines the amount of the reduction by multiplying the downside risk payment by both of the following:

(1) The percentage of total months during the PY affected by the extreme and uncontrollable circumstance.

(2) The percentage of attributed patients who reside in an area affected by the extreme and uncontrollable circumstance.