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2026 OPPS Final Rule: What Hospitals Need to Know
Episode 121
Tuesday, 13 January, 2026
The Centers for Medicare and Medicaid Services has finalized the 2026 Outpatient Perspective Payment System (OPPS) rule, with most policies taking effect on January 1, 2026. Jenna Stern, Vice President of Regulatory Affairs and Public Policy at Vizient, joins host Carolyn Liptak, Pharmacy Executive Director in Vizient's Center for Pharmacy Practice Excellence, to discuss key updates to payment policies, payment rates, and quality provisions affecting Medicare beneficiaries receiving care in hospital outpatient departments and ambulatory surgical centers. Guest speaker: Jenna Stern Vice President of Regulatory Affairs and Public Policy Vizient Host: Carolyn Liptak, MBA, RPh Pharmacy Executive Director Vizient Verified Rx Host Show Notes: 00:05 — Introduction Announcer welcomes listeners to VerifiedRx. Host Carolyn Liptak, Pharmacy Executive Director at Vizient, introduces the episode focus: the 2026 CMS Outpatient Prospective Payment System (OPPS) Final Rule. Guest: Jenna Stern, VP of Regulatory Affairs and Public Policy at Vizient. 01:12 — Overview of the OPPS Final Rule OPPS sets Medicare payment for most hospital outpatient services. Published annually (typically November), effective January 1. Covers payment rates, policies, quality programs, and compliance requirements. Note: CMS delayed enforcement of hospital price transparency requirements until April 1, 2026. 01:34 — Key Takeaways From the 2026 Final Rule Jenna’s high-level insights: Hospitals will continue facing financial pressure in 2026. Modest payment rate increase combined with reimbursement-reducing policies. Expansion of site-neutral payment policies will be particularly impactful. Rule reflects emerging administration priorities shaping future policy. 02:21 — OPPS Payment Rate Update for 2026 CMS finalized a 2.6% OPPS schedule increase factor for hospitals meeting quality reporting requirements. 02:40 — What the 2.6% Increase means Based on: 3% market basket update –0.7% productivity adjustment Results in a modest net increase. Slightly better than the proposed 2.4% increase, though still viewed as inadequate. CMS estimates $8 billion increase in total OPPS payments compared to 2025. 03:37 — 340B Remedy Offset: Background From 2018–2022, CMS paid for 340B drugs at ASP –22.5%. Prior Supreme Court decision from 2022 found that CMS lacked authority to vary rates as finalized in prior rulemaking (e.g., without using drug acquisition cost surveys to inform policy). 04:13 — 340B Remedy Offset in the 2026 Final Rule CMS considered increasing the remedy offset from 0.5% to 2%. Stakeholders strongly opposed the increase due to hospital financial strain. 05:10 — Final Outcome CMS retained the 0.5% offset for 2026. CMS signaled that larger offsets may be proposed for 2027. This marks the first year the remedy offset takes effect, 06:00 — Site-Neutral Payment Policy: What It Is Concept: same service = same payment, regardless of site of care. Hospital concern: policy reduces hospital reimbursement without accounting for site of care differences, patient acuity, overhead, or service complexity. 06:15 — Site-Neutral Expansion in the 2026 Rule CMS expanded site-neutral payment to include drug administration services at excepted off-campus provider-based departments. 07:08 — Financial Impact Reimbursement aligns with Physician Fee Schedule rates. CMS estimates $290 million reduction in outpatient spending for 2026. $220 million of savings accrue directly to Medicare. Not implemented in a budget-neutral manner. 08:14 — Non-Opioid Pain Management Payments Temporary additional payments began January 1, 2025. Authorized under the NO PAIN Act (Consolidated Appropriations Act of 2023). 08:28 — What’s New for 2026 CMS finalized the renewal of: 5 drugs 13 medical devices eligible for separate payment in HOPD and ASC settings. Per statue, payments available through December 31, 2027. 09:32 — Process Improvements CMS will allow more frequent consideration of new qualifying products (not limited to annual updates). Quality criteria unchanged; timing flexibility added. CMS released guidance on how stakeholders can engage for inclusion. 10:58 — OPPS Drug Acquisition Cost Survey CMS finalized plans to survey hospitals on acquisition costs for separately payable OPPS drugs. 11:21 — Why CMS Is Advancing the Survey Addresses Supreme Court requirements from prior 340B litigation. Aligns with White House Executive Order on lowering drug prices. Positions CMS to use survey data for 2027 rulemaking. 12:47 — OPPS Packaging Thresholds for 2026 Drugs and biologics: Threshold remains at $140. Diagnostic radiopharmaceuticals: Increased to $655 (from $630). Products below thresholds retain Status Indicator “N” (packaged payment). 13:26 — Why Billing Packaged Drugs Still Matters Even though not separately payable, hospitals must bill for packaged drugs. Billing data feeds cost reports used to calculate future bundled payments. Failure to bill can result in inaccurately low reimbursement. 14:14 — Elimination of the Inpatient-Only (IPO) List CMS finalized a three-year transition to eliminate the IPO list by January 1, 2029. 14:32 — Why This Change Is Significant IPO list historically ensured certain services were provided inpatient only. CMS emphasizes provider judgment in determining site of care. Raises concerns about: Patient safety Payer coverage changes Pressure to move services outpatient 16:28 — ASC Covered Procedure List Expansion CMS expanded the ASC Covered Procedure List. Enables more Medicare covered services to be performed in the ASC settings. 16:48 — Price Transparency: Still a Priority No major overhaul, but continued refinement. CMS exploring new uses of price transparency data beyond patient comparison. 17:46 — Most Critical Policies to Watch Jenna highlights: Modest OPPS payment increase Site-neutral payment expansion 340B remedy offset Drug acquisition cost survey Broader regulatory activity beyond OPPS 18:43 — Available Vizient Resources OPPS Final Rule Summary Government Relations & Public Policy Summaries Advocacy 19:20 — Closing Carolyn thanks Jenna for her insights. Reminder to subscribe, like, and share feedback. VerifiedRx is produced by the Vizient Center for Pharmacy Practice Excellence. Links | Resources: Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs; Overall Hospital Quality Star Rating; Hospital Price Transparency; and Notice of Closure of a Teaching Hospital and Opportunity To Apply for Available Slots: Click Here CMS fact sheet on the Final Rule: Click Here Outpatient Prospective Payment System (OPPS) Drug Acquisition Cost Survey: Click Here Vizient Office of Public Policy and Government Relations final rule summary: Click Here Final List of Qualifying Products for Separate Payment for non-opioid pain medications: (Table 136, pgs. 1138-1140) VerifiedRx Listener Feedback Survey: We would love to hear from you - Please click here Subscribe Today! Apple Podcasts Spotify YouTube RSS Feed
