CY 2026 OPPS Final Rule: The Centers for Medicare and Medicaid Services (CMS) have released the awaited Outpatient Prospective Payment System (OPPS) CY 2026 rule. Next week’s edition will include a deep dive into the final rule. In the meantime, click here for AHPA’s high-level summary or here for the CMS fact sheet. CMS finalizes changes including: 

  • The elimination of the Inpatient Only (IPO) list; 
  • Site-neutral payments (to be equivalent to the Physician Fee Schedule rate) for drug administration services; 
  • Adopting the 340B claw back policy but with a less aggressive timeframe. Instead of lowering payments by 2% for non-drug services, CMS will lower payments by 0.5%.  
  • Adding more services to the Ambulatory Services Covered list.  
  • New hospital price transparency requirements.  

 

CY 2026 PFS Final Rule: CMS has also released the final Physician Fee Schedule for CY 2026. Click here for AHPA’s summary of the final rule. Highlights include: 

  • A one-year conversion factor increase of 3.26 for non-APM participants and 3.77% for APM participants.  
  • Downward adjustments were made throughout (e.g., a -2.5 efficiency adjustment and further practice expense reimbursement reductions); 
  • The permanent allowance of virtual presence for teaching physicians, depending on the setting;  
  • Separate payment for skin substitutes when furnished as “incident-to” supplies in conjunction with a covered procedure.

CMS Information Sharing with ICE Notice 

  • CMS released a notice on November 25th that it will begin sharing certain Medicaid-related information with the Department of Homeland Security (DHS) and Immigration and Customs Enforcement (ICE) for immigration enforcement purposes, effective immediately. 
  • CMS will now provide ICE with biographical information, citizenship/immigration status, addresses, contact information and potentially other data, much of which comes directly from state Medicaid eligibility files. 
  • This policy will largely impact people with emergency Medicaid and may result in some individuals being hesitant to apply for emergency Medicaid. 

CY 2026 End-Stage Renal Disease Final Rule 

White House Proposal on Enhanced Subsidies 

Although the details have not been released, the White House is rumored to have drafted a proposal that would extend the Affordable Care Act (ACA) enhanced subsidies for another two years and make additional changes. The official release of that proposal has been postponed amid pushback from Republicans in Congress; changes to any plan are very likely considering the political divide on this issue. Congress must vote on another funding bill by January 30th to keep the government open. Action on the enhanced subsidies is expected to largely impact that vote. As a reminder, the telehealth flexibilities and funding for other programs, such as the Medicare Dependent Hospital and the Low Volume Hospital programs, were extended until January 30th and are subject to that vote. AHPA continues to monitor these discussions and will provide updates.  

Changes to Federal Student Loans Impacting Nursing. The Department of Education (DOE) released an FAQ regarding recent proposed changes to the definition of “professional degree” for the purpose of setting funding limits for federal graduate loans. Within that proposed definition, nursing was not included as a “professional degree.” Below are key things to know:  

  1. The change is not final. A proposed and final rule will be released before July 1, 2026, and DOE could change that definition in response to public comments. 
  2. The change would impact the ability to secure federal loans, not nursing licensing. The definition of a “professional degree” is only an internal definition used by the DOE to distinguish among programs that qualify for higher loan limits. It doesn’t mean that nurses are no longer considered professionals in the health care field.  
  3. The One Big Beautiful Bill Act (OBBA) instituted federal lending caps for graduate degrees. It didn’t specify in statute how “professional degrees” should be defined, allowing changes via rulemaking. It imposes a lifetime cap of $100,000 in borrowing for graduate students and a $200,000 cap for students in “professional degrees.” Graduate students will be able to borrow no more than $20,500 a year while “professional degree” students will be able to borrow up to $50,000 annually.  
  4. The policy, if finalized, is expected to impact mid-level clinicians (e.g., Anesthesia, Occupational Therapy, Physician Assistants) the most as those are the graduate programs that tend to cost above the $100,000 life-time funding cap.  

          For more information regarding changes to federal student loans, click here.   

Senate Conducts Hearing on Health Care Costs. On Wednesday, November 19th, the Senate held a hearing titled “The Rising Cost of Health Care: Considering Meaningful Solutions for All Americans.” The hearing largely focused on the extension of the Affordable Care Act (ACA) enhanced subsidies. A vote on the subsidies, which expire at the end of this year, was promised by Senate Majority Leader Thune in exchange of passing a resolution to open the federal government following the longest shutdown in U.S. history. To watch the hearing, click here. For a detailed AHPA summary, click here.