2026 CMS OPPS Proposed Rule
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CMS Releases Proposed 2026 OPPS Rule: Key Highlights for Providers and Stakeholders
The Centers for Medicare & Medicaid Services (CMS) has released the proposed 2026 Outpatient Prospective Payment System (OPPS) rule, introducing several important updates that affect outpatient care delivery, reimbursement, and policy alignment. These proposals reflect CMS’s ongoing efforts to modernize payment systems, encourage innovation, and ensure equitable access to high-quality care across all settings.
Below are the key highlights from the proposed rule:
Efficiency Adjustment
- What’s Changing: CMS proposes an efficiency adjustment to the Medicare Economic Index (MEI) to better reflect productivity improvements in outpatient services.
- Details: The adjustment would increase the reduction to the OPPS conversion factor for non-drug items and services from 0.5% to 2%, starting in CY 2026.
- Why It Matters: This change is designed to accelerate repayment of the estimated $7.8 billion in overpayments from 2018–2022 due to the 340B policy, with a revised repayment timeline ending in 2031 (instead of 2041).
- Exemptions: Hospitals that enrolled in Medicare after January 1, 2018, would be excluded from this adjustment.
Telehealth Services
- Expanded Access: CMS proposes removing frequency limitations for:
- Shared/Split Visits (SHV)
- Skilled Nursing Facility Visits (SNHV)
- Critical Care (CC) consultations
- Supervision Flexibility: Allows “direct” audio/visual (A/V) supervision for services that do not have a 10- or 90-day global period.
- Ongoing Review: CMS is still seeking comments on how to handle 000-day global procedures in the telehealth context.
Improving Global Surgery Payment Accuracy
- Focus: CMS aims to improve the accuracy of global surgery payments.
- Key Areas:
- Better defining and tracking the transfer of post-operative care.
- Establishing clearer practice standards and division of responsibilities between surgeons and post-op care providers.
- Goal: Ensure payments reflect actual services delivered and support coordinated, high-quality surgical care.
Chronic Illness & Behavioral Health Integration
- New G-Codes: CMS proposes three new add-on G-codes for Advanced Primary Care Management (APCM) to support:
- Behavioral Health Integration (BHI)
- Collaborative Care Model (CoCM)
- Expanded Coverage: Payment expansion for digital mental health treatment (DMHT) devices, especially for ADHD.
- Future Planning: CMS is considering separate coding and payment for a broader range of digital tools that complement mental health care plans.
Skin Substitutes
- Current Model: Skin substitutes are currently reimbursed under Medicare Part B using the Average Sales Price (ASP) methodology.
- Spending Surge: Costs rose from $252 million in 2019 to over $10 billion in 2024, largely due to price increases.
- Proposed Changes:
- Treat skin substitutes as incident-to supplies when used in covered procedures.
- Base payment on FDA regulatory categories (e.g., 361 HCT/Ps, PMAs, 510(k)s).
- Use a single payment rate initially, with plans to differentiate by category in future years.
- Apply changes across both hospital outpatient and physician office settings.
Drugs and Biologicals Under Medicare Part B
- Site-Neutral Payment Expansion: CMS proposes applying Physician Fee Schedule (PFS) equivalent rates to drug administration services in excepted off-campus provider-based departments (PBDs).
- Estimated Savings: This change is expected to reduce OPPS spending by $280 million, with $210 million saved by Medicare and $70 million by beneficiaries through lower coinsurance.
- Provider Impact: May result in lower reimbursement for hospital-affiliated outpatient clinics.
- Skin Substitutes Policy Shift: CMS also plans to unpackage skin substitute products from their procedures and create new APCs based on FDA categories, promoting payment accuracy and innovation.
Conclusion
The 2026 OPPS proposed rule represents a strategic shift toward greater efficiency, transparency, and alignment with clinical practice. Providers, stakeholders, and industry leaders are encouraged to review the proposed changes and submit comments to help shape the final rule. Staying informed and engaged is essential to ensure future policies support both provider sustainability and patient-centered care.
CMS is also seeking specific information from healthcare providers, researchers, stakeholders, health and drug plans, and other members of the public to inform the development and implementation of strategies to support the goals of the EO 14162 – Prosperity through Deregulation. They are seeking comment in regard to (1) Streamlining Regulatory Requirements, (2) Opportunities to Reduce Administrative Burden of Reporting and Documentation, and (3) Identification of Duplicative Requirements. The link to participate is below.
Resources
CMS – 2026 Proposed Rule FACT Sheet
CMS – MEI Fact Sheet