In the OPPS rule, CMS increases payment rates by 2.9%; complete new Terms of Participation

Centers for Medicare & Medicaid Services November 1 issued a final rule which increases Medicare hospital outpatient prospective payment system rates by a net 2.9% in calendar year 2025 compared to 2024. This includes a 3.4% market basket upgrade, offset by a 0.5 point reduction percentage of productivity.

One statement shared with the media, AHA Senior Vice President Ashley Thompson said, “Sustained and substantial underpayment of Medicare hospitals has spanned nearly two decades, and today’s outpatient final rule only exacerbates this chronic problem. The agency’s final increase of less than 3 percent for hospital outpatient services will make it more difficult to provide care, invest in the health care workforce, and address new challenges such as cybersecurity threats. These inadequate payments will negatively impact patient access to care, particularly in rural and underserved communities nationwide.

AHA fully shares CMS’ goals to improve maternal health outcomes and reduce inequities in maternal care. While we appreciate that the final rule provides hospitals with additional implementation time and greater flexibility in how they meet certain requirements, we remain concerned about CMS’ excessive use of the Conditions of Participation to drive its policy agenda and the potential risk that these requirements to reduce inadvertently. access to maternal care. We believe that a less punitive and more collaborative approach would be more effective, given that the key drivers of maternal health outcomes are highly complex and multi-stakeholder. AHA remains committed to working with the administration and other stakeholders to advance a full range of solutions to improve maternal outcomes.”

In addition, CMS finalized its proposals to adopt three health equity measures for the ambulatory, ambulatory surgical center, and rural emergency hospital quality reporting programs and to expand voluntary data reporting for two hybrid measures in the quality reporting for inpatients.

The rule also finalizes several changes to drug payment. These include providing separate payment for diagnostic radiopharmaceuticals with costs per day above a $630 threshold, excluding certain eligible cell and gene therapies from bundling under the Comprehensive Outpatient Payment Classification Policy, and payment for pre-exposure prophylaxis drugs at HIV and related services in the hospital. outpatient departments.

CMS also finalized new and updated Medicare Conditions of Participation for Hospitals and Critical Access Hospitals, including new standards focused on obstetric services and maternal health care. Beginning in January 2026, CMS will phase in certain requirements for hospitals and CAHs that provide maternal health services, including standards for the availability of certain obstetric equipment and staff training. In addition to the maternity care requirements, CMS finalized a discharge planning standard for transfer protocols and established new emergency services requirements for certain types of equipment and supplies and staff training. Discharge planning and emergency services requirements will also be phased in from July 2025.

The final rule takes effect on January 1. AHA members will receive a Special Bulletin on November 4th with more details.