The Department of Health and Human Services have again pushed back dates for new bundled payment models, making the the start date for certain provisions to be Jan. 1, 2018.

It was the third time in 2017 that bundled payment models and changes to the Comprehensive Care for Joint Replacement Model have been pushed back.

The rule, first published in late December 2016, introduced three new cardiac care-focused payment models and one for patients who undergo non-replacement surgery following a hip fracture. The rule also included “refinements” of the CJR model.

The effective dates for some of the rule’s provisions were changed in February from Feb. 18 to March 21 “to allow Department officials the opportunity for further review and consideration of new regulations” following President Donald Trump’s inauguration. The agency released an interim rule in March that moved the effective date back a again, to May 20, as well as changing the start date of the programs from July 1 to Oct. 1.

The interim rule also solicited comments on the possibility of pushing the implementation date back a third time to Jan. 1, 2018 — a move the agency confirmed with the release of a final rule on Thursday.

The new rule solidifies May 20 as the effective date of the final rule, and pushes the start date of certain provisions to Jan. 1, 2018.

“We agree with the majority of commenters that an additional delay prior to the start of the [episode payment models] and [cardiac rehabilitation] incentive payment model is necessary,” the agency wrote in its final rule. “This would ensure that, in the case of any policy changes, participants would have a clear understanding of the governing rules before episodes begin and have the opportunity to take additional steps to adjust to any potential changes that may be effectuated.”

HHS also noted that it wouldn’t be responding to stakeholders’ comments about making the models voluntary instead of mandatory, but could take them into consideration in future rules.

Responding to commenters who asked the agency to withdraw the rules completely, HHS said it disagreed, believing “these models will further our goals of improving the efficiency and quality of care for Medicare beneficiaries.”