In OPPS rule, CMS increases payment rates by 2.9%; finalizes new Conditions of Participation

The Centers for Medicare & Medicaid Services Nov. 1 issued a final rule that 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 update, offset by a 0.5 percentage point cut for productivity.

In a statement shared with the media, AHA Senior Vice President Ashley Thompson said, "Medicare's sustained and substantial underpayment of hospitals has stretched for almost two decades, and today's final outpatient rule only worsens this chronic problem. The agency's final increase of less than 3% for outpatient hospital services will make the provision of care, investments in the health care workforce, and addressing new challenges, such as cybersecurity threats, more difficult. These inadequate payments will have a negative impact on patient access to care, especially in rural and underserved communities nationwide.

The AHA fully shares CMS' goals of improving maternal health outcomes and reducing 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 Conditions of Participation to drive its policy agenda and the potential risk for these requirements to inadvertently reduce access to maternal care. We believe a less punitive and more collaborative approach would be more effective given that the key drivers of maternal health outcomes are highly complex and involve multiple stakeholders. The 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 measures related to health equity for the outpatient, ambulatory surgical center and rural emergency hospital quality reporting programs and to extend voluntary data reporting for two hybrid measures in the Inpatient Quality Reporting Program.

The rule also finalizes several changes to payment for drugs. These include providing separate payment for diagnostic radiopharmaceuticals with per-day costs above a threshold of $630, excluding certain qualifying cell and gene therapies from packaging under the comprehensive ambulatory payment classification policy, and paying for HIV pre-exposure prophylaxis drugs and related services in hospital outpatient departments.

CMS also finalized new and updated Medicare Conditions of Participation for hospitals and critical access hospitals, including new standards focused on obstetrical services and maternal health care. Beginning January 2026, CMS will phase in certain requirements for hospitals and CAHs that offer maternal health services, including standards for the availability of certain obstetric equipment and staff training. In addition to the maternal 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. The discharge planning and emergency services requirements will also be phased beginning in July 2025.

The final rule goes into effect Jan. 1. AHA members will receive a Special Bulletin Nov. 4 with more details.