What’s happening: The Centers for Medicare & Medicaid Services (CMS) issued its calendar year (CY) 2025 outpatient prospective payment system (OPPS) final rule, including a net market basket update of 2.9%.
What else to know: CMS also establishes new health and safety standards for obstetrical services to be phased in over two years.
As a result of all proposed changes, CMS estimates that hospital outpatient payments will increase by $2.2 billion in CY 2025, excluding changes in enrollment, case mix, and utilization.
Other key provisions of the final rule include:
- Obstetrical Services Conditions of Participation: CMS establishes new Conditions of Participation (CoPs) for hospitals and critical access hospitals for obstetrical services, including new requirements for maternal quality assessment and performance improvement (QAPI); baseline standards for the organization, staffing, and delivery of care within obstetrical units; staff training on evidence-based maternal health practices; and new emergency services CoPs and changes to discharge planning CoPs for all hospitals. CMS will implement the new policies in three phases over two years.
- Ambulatory Surgical Center Payment Update: CMS increases payments by 2.9% for ambulatory surgical centers that meet quality reporting requirements, resulting in an increase in payments relative to 2024 of $308 million.
- Partial Hospitalization Program (PHP) and Intensive Outpatient Programs (IOP): CMS maintains the existing rate structures for IOP and PHP services as established in previous rulemaking. To calculate cost information, the agency will use CY 2023 claims data and the OPPS data set to identify services eligible for payment under the IOP and PHP benefits.
- Inpatient Only List (IPO): CMS has added three liver allograft procedures to the IPO list and removed one pelvic fixation code from the IPO list.
- Remote Services: CMS clarifies policies for remotely furnished outpatient therapy services, diabetes self-management training (DSMT), medical nutrition therapy services (MNT), and mental health services furnished remotely in beneficiaries’ homes by hospital staff to maintain alignment across payment systems. Absent legislation extending COVID-19 public health emergency telehealth flexibilities, CMS will no longer pay for outpatient therapy DSMT, and MNT services when furnished remotely by hospital staff to beneficiaries in their home. CMS will also reinstate periodic in-person visit requirements for remote mental health services.
- Diagnostic Radiopharmaceuticals Separate Payment: CMS has created a separate payment for high-cost radiopharmaceuticals with a per-day cost greater than $630.
- Exclude Cell and Gene Therapies: CMS excludes qualifying therapies from Comprehensive Ambulatory Payment Classification (C-APC) Packaging policies.
- Policies Related to Incarcerated Individuals: CMS has narrowed the definition of “custody” to reduce the population affected by the incarnation payment exclusion. It is also making similar changes to the Medicare special enrollment period for incarcerated individuals.
- Quality Reporting Programs: CMS has added new measures to the hospital outpatient quality reporting program — including health equity measures and a patient-reported outcome measure — and removed two measures. CMS also extends an additional year of voluntary reporting for the inpatient quality reporting program Hybrid Hospital-Wide Readmission and Hybrid Hospital-Wide Standardized Mortality measures. The final rule also includes policies for the Ambulatory Surgical Center and Rural Emergency Hospital quality reporting programs.
CMS published a detailed fact sheet on the final rule. CHA will make a detailed summary available in the coming weeks.
