Proposed Payment Rules
- CY 2027 Hospital Outpatient Prospective Payment System & Ambulatory Surgical Center Proposed Rule
- CY 2027 Home Health Prospective Payment System Proposed Rule
News
- CMS Launches Medicare GLP-1 Bridge, Expanding Access to GLP-1 Medications
- Hospital Price Transparency: New Resources
- Clinical Diagnostic Laboratory Reporting: Are You an Applicable Lab?
Compliance
Claims, Pricers & Codes
Proposed Payment Rules
CY 2027 Hospital Outpatient Prospective Payment System & Ambulatory Surgical Center Proposed Rule
CMS issued a proposed rule that would update Medicare payment policies and rates for hospital outpatient and ambulatory surgical center (ASC) services under the Hospital Outpatient Prospective Payment System (OPPS) and ASC Payment System Proposed Rule for CY 2027. CMS is publishing this proposed rule consistent with the legal requirements to update Medicare payment policies for hospital outpatient and ASCs annually.
The proposed rule also includes:
- Updates to OPPS and ASC payment rates
- Expanding the method to control unnecessary increases in the volume of outpatient services
- Reduced payments for 340B-acquired drugs based on the Medicare OPPS Drugs Acquisition Cost Survey
- Eliminating the inpatient only list
- Request for Information on strengthening the standardization and comparability of hospital price transparency data – rider
- Hospital Outpatient Quality Reporting Program
- ASC Quality Reporting Program
- Prior authorization for additional botulinum toxin injection codes
More Information:
- Full fact sheet
- CMS Acts to Strengthen Care Quality, Cut Drug Costs & Slash Out-of-Pocket Expenses for Medicare Beneficiaries press release
- Hospital OPPS webpage
CY 2027 Home Health Prospective Payment System Proposed Rule
CMS issued a proposed rule that announces policy changes under the Home Health (HH) Prospective Payment System (PPS), consistent with the legal requirements to update Medicare payment policies for home health agencies (HHAs) annually.
The proposed rule includes:
- Medicare provider enrollment
- CY 2027 proposed payment and policy updates for HHAs
- HH Quality Reporting Program
- Expanded Home Health Value-Based Purchasing Model
- DME benefit expansion for infusion pumps and drugs
- Improvements to the DMEPOS Competitive Bidding Program
- DMEPOS requirements for identical replacement items
More Information:
- Full fact sheet
- CMS Proposes Updates to Strengthen Medicare Program Integrity, Combat Fraud & Expand Access to Home Health Care press release
- HHA Center webpage
- HH PPS webpage
News
CMS Launches Medicare GLP-1 Bridge, Expanding Access to GLP-1 Medications
Eligible Medicare beneficiaries may now get certain GLP-1 medications for $50 per month through the Medicare GLP-1 Bridge, a new CMS initiative designed to expand access to innovative treatments and test the impacts of increased access to GLP-1 drugs for weight management on the Medicare program.
More Information:
- Full press release
- Medicare GLP-1 Bridge webpage for providers and pharmacies
- Prescriber Fact Sheet (PDF): Key information for prescribers referring patients to the Medicare GLP-1 Bridge
- Pharmacy Fact Sheet (PDF): Guidance for pharmacies on billing and dispensing under the demonstration
- Prior Authorization Form: Outline of clinical criteria for Medicare GLP-1 Bridge eligibility
- Weight loss drugs information for your patients
Hospital Price Transparency: New Resources
CMS posted Guidance on Encoding Outlier Contracting Clauses in a Hospital’s Machine-Readable File (PDF) with instructions for encoding information about outlier provisions. We also published updated Hospital Price Transparency FAQs (PDF) with additional information on encoding standard charge information in a hospital’s machine-readable file.
Visit the Hospital Price Transparency Resources webpage for more information.
Clinical Diagnostic Laboratory Reporting: Are You an Applicable Lab?
Watch Is My Lab an Applicable Lab? and find out if you meet the definition of an applicable laboratory under the Clinical Laboratory Fee Schedule (CLFS). If so, you must report your data from May 1 – July 31, 2026.
See the CLFS & PAMA Reporting and Resources webpage for more information.
Compliance
Skilled Nursing Facilities: Accurately Report Your Related Party Costs
In a report, the Office of Inspector General found that some skilled nursing facilities (SNFs) didn’t comply with Medicare requirements for reporting related party costs. These SNFs failed to report related parties on their Medicare Cost Reports or reported the costs inaccurately, resulting in overstated costs to the Medicare Program.
Review the SNF Billing Reference educational tool to find out:
- Why related party costs must be reported accurately
- How to accurately report these costs and required documentation
Claims, Pricers & Codes
Non-Invasive Bone Growth Stimulators
After further consideration following Transmittal 13805, Change Request 14513, CMS is not making any changes to the fee schedules for HCPCS codes E0747, E0748, and E0760 at this time. Claims for HCPCS codes E0747, E0748, and E0760 with dates of service on or after May 18, 2026, must be billed with the KF modifier. More information will be available in a revision to the July 2026 DMEPOS fee schedule update.
RARCs, CARCs, Medicare Remit Easy Print & PC Print: July Update
Get updated remittance advice remark codes (RARCs) and claim adjustment reason codes (CARCs). Watch for software updates if you use Medicare Remit Easy Print or PC Print.
More Information:
- Medicare Claims Processing Manual, Chapter 22, sections 40.5, 60.2, and 60.3
- Instruction to your Medicare Administrative Contractor (PDF)
Subscribe to the MLN Connects® newsletter, or read past editions.
View the Medicare Learning Network® Content Disclaimer and Department of Health & Human Services Disclosure.
The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).