CMS releases proposed Medicare payment rates for outpatient, ASC services

Editor's Note

On July 10, CMS proposed Medicare payment rates for hospital outpatient and ambulatory surgery center (ASC) services for 2025.  Published annually, the Hospital Outpatient Prospective Payment System (OPPS) and ASC Payment System Proposed Rule will have a 60-day comment period, which this year ends September 9 prior to the issuance of the final rule in early November. The rule includes policies addressing health disparities, expanding behavioral health care access, improving health system transparency, and promoting patient-centered care.

Key updates include a 2.6% payment rate increase for OPPs and ASCs, maintaining rate structures for Intensive Outpatient Program (IOP) and Partial Hospitalization Program (PHP) services, and implementing additional payments for certain nonopioid pain relief treatments from 2025 through 2027. The rule also proposes clarifying OPPS payments for remote services and introducing add-on payments for high-cost drugs provided by Indian Health Service (IHS) and tribal hospitals. Additionally, CMS is seeking information on paying all IHS and tribally operated clinics the IHS Medicare outpatient all-inclusive rate (AIR).

Other significant proposals include refining the packaging policy for diagnostic radiopharmaceuticals, establishing a new add-on payment for domestically produced Tc-99m starting in 2026, and narrowing the definition of “custody” in Medicare’s payment exclusion rule and revise the special enrollment period for formerly incarcerated individuals. Additionally, proposed changes to the Hospital Inpatient and Outpatient Quality Reporting (IQR and OQR) Programs include new measures for health equity and social drivers of health, measure suspension policies, and electronic health record (EHR) certification requirements.

For Rural Emergency Hospital and Ambulatory Surgical Center Quality Reporting (REHQR and ASCQR) Programs, CMS proposes new measures for health equity and modifying the immediate measure removal policy. Lastly, CMS is seeking comments on potential modifications to the Overall Hospital Quality Star Rating methodology and new Conditions of Participation (CoPs) for OB services to ensure high-quality maternity care.

CMS also proposes updates for Medicaid and the Children’s Health Insurance Program (CHIP), including requiring 12 months of continuous eligibility for children under 19 and federal reimbursement for services furnished outside the “four walls” of clinics by IHS/Tribal clinics, behavioral health clinics, and clinics in rural areas.