CMS Releases CY 2026 OPPS/ASC Final Rule
On Nov. 21, the Centers for Medicare & Medicaid Services (CMS) released the calendar year (CY) 2026 final payment rule updating the Medicare Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) payment system. CMS finalized a 2.6% rate update for both payment systems, reflecting a 3.3% market basket update, a 0.7 percentage point decrease for the Affordable Care Act mandated productivity adjustment.
Under the final rule, CMS did not finalize its proposal to change the 340B final remedy payment reduction to the OPPS conversion factor. This means that the current codified conversion factor reduction of 0.5% will remain in effect until further action is taken. However, CMS did state that it anticipates a larger reduction beginning in CY 2027. Additionally, CMS will move forward with plans to conduct a survey on acquisition costs for each separately payable drug acquired by all OPPS hospitals in early CY 2026 with the intention to use survey results to inform policymaking beginning with the CY 2027 OPPS/ASC proposed rule.
CMS did expand its site-neutral payment policy to include reimbursement for drug administration services furnished in excepted off-campus provider-based departments (PBDs). Starting in CY 2026, CMS will apply the Medicare Physician Fee Schedule equivalent payment rate for any codes assigned to the drug administration ambulatory payment classifications (APCs) when provided at an excepted off-campus PBD.
Additionally, CMS finalized its proposal to eliminate the Inpatient Only (IPO) list over a three-year period, starting with 285 mostly musculoskeletal procedures in 2026. CMS also finalized several changes to hospital price transparency requirements, including the attestation procedure required when hospitals make their machine-readable files available online. Additional information on these changes is available in a CMS fact sheet.
In the coming weeks, IHA will provide additional analysis of the CY 2026 OPPS/ASC final rule, as well as hospital-specific estimated financial impact reports in the IHA C-Suite. A CMS fact sheet with additional information about the CY 2026 OPPS/ASC final rule is also available.
Staff contact: Cassie Yarbrough
UPDATE: IHA Telehealth Waiver Fact Sheet
IHA’s Telehealth Waiver Fact Sheet has been updated to reflect new coverage and billing guidance released in an updated FAQ by the Centers for Medicare & Medicaid Services (CMS) on Nov. 20. The agency will continue to pay telehealth claims in the same way they had been paid before Oct. 1, 2025. Telehealth flexibilities will apply retroactively as if there had not been a lapse in telehealth flexibilities. On Nov. 12, President Trump signed a Continuing Resolution (CR, HR 5371) that funds the federal government following a 43-day government shutdown, the longest in history. The CR restores temporary Medicare provisions retroactive to Oct. 1, 2025 until Jan. 30, 2026, including telehealth waivers—clearing the path for CMS to release held telehealth claims. The telehealth flexibilities listed in the fact sheet will expire again at the end of January if government funding is not extended.
CMS also added information on how to suppress street address details so practitioners can continue to use their currently enrolled practice location instead of their home address on Medicare enrollment and billing forms when they provide telehealth services from their home. Specifically, physicians and practitioners can either mark the address as a “Home office for administrative/telehealth use only” location in the Provider Enrollment, Chain, and Ownership System (PECOS), which will suppress street address details, or email the Quality Payment Program (QPP) Service Center to suppress the street address and/or phone number. Virtual-only telehealth practitioners will still need to enroll their home address as a practice location, but they will have the option to suppress their street address details.
Staff contact: Lia Daniels
HFS Announces Medicaid Coverage for Home Visiting Services
The Illinois Dept. of Healthcare and Family Services (HFS) announced the launch of new coverage for home visiting services for pregnant and parenting Medicaid customers. HFS said the newly covered services and supports, effective as of Nov. 21, are intended to meet the needs of pregnant and parenting individuals in order to create better health outcomes for both parents and their children. Covered prenatal home visits will include health education, blood pressure monitoring, behavioral health screenings, domestic and intimate partner violence education and screenings, stress management, and service referrals. These services, among others, will be delivered in accordance with HFS-recognized, evidence-based and research-informed nurse and non-nurse home visiting models.
Cook County Funding Opportunity: Diabetes Education, Support Services
The CARES: Cook County Diabetes Management & Prevention team has announced a Request for Application (RFA) for a funding opportunity of $10,000 per organization to support type 2 diabetes management service providers with funding to launch and/or expand Diabetes Self-Management Education and Support (DSMES) services for people with diabetes at highest risk of unmanaged diabetes in Cook County. The application deadline is Dec. 12 at 5 p.m. CT. Click here for more information about the program, funding uses, eligibility criterial and application information. Click here to view the application in Spanish.
Deadline Sunday, Nov. 30: Medicaid Provider IMPACT Revalidations Due
The Illinois Dept. of Healthcare and Family Services (HFS) is currently conducting IMPACT Medicaid provider revalidations. Providers in the November cohort must complete IMPACT revalidations by this Sunday, Nov. 30. If you are in this revalidation cycle and do not submit your revalidation information by Nov. 30 you will be disenrolled from the IMPACT system and cannot receive retroactive enrollment. NOTE: If a physician providing services at your hospital does not revalidate, your hospital will not receive payment for services provided by that physician. HFS has provided IHA with step-by-step instructions to check the status and due date of servicing providers that you can access here. The IMPACT Provider Revalidation website includes step-by-step instructions, a frequently asked questions document and a townhall webinar recording.
