It's been said that legislation—or regulation, for that matter—often consists of a wide variety of provisions that don’t necessarily follow a common theme. The 2026 Outpatient Prospective Payment System (OPPS) final rule is a bit like a box of chocolates, full of assorted and disparate provisions. Last week, we presented our readers with some of the main highlights arising from the rule. This week, we bring you additional provisions as summarized by a fact sheet published by the Centers for Medicare & Medicaid Services (CMS).
Drugs Acquisition Cost Survey
Section 1833(t)(14)(D)(ii) of the Act requires the secretary of the U.S. Department of Health and Human Services (hereinafter, “the Secretary”) to periodically conduct surveys of hospital acquisition costs for each specified covered outpatient drug for use in setting the payment rates for such drugs. Accordingly, CMS will be conducting a required survey by early CY 2026 on the acquisition costs for each separately payable drug acquired by all hospitals paid under the OPPS. CMS intends for the survey to be completed in time for the survey results to be used to inform policymaking beginning with the CY 2027 OPPS proposed rule.
Non-Opioid Treatments for Pain Relief
The final rule continues to provide temporary additional payments for certain non-opioid treatments for pain relief in the hospital outpatient department (HOPD) from January 1, 2025, through December 31, 2027. CMS finalized five drugs and 11 devices that qualified as non-opioid treatments for pain relief. These products will be paid separately in the HOPD setting, starting in 2026.
Add-on Payment
In the CY 2025 OPPS final rule, CMS finalized a proposal to incentivize domestic production of Molybdenum-99 (Mo-99) by establishing a new add-on payment of $10 per dose of Technetium-99m (Tc-99m) derived from domestically produced Mo-99, starting on January 1, 2026. The 2026 OPPS final rule codifies the definition for domestically produced Mo-99 and establishing new HCPCS C-code C9176 [Tc-99m from domestically produced non-HEU Mo-99 (minimum 50 percent) full cost recovery add-on, per study dose]. CMS also finalized that at least fifty percent of the Mo-99 used in the Tc-99m generator that produced a dose of Tc-99m must have been domestically produced for the dose to qualify for the add-on payment.
Price Transparency
CMS is finalizing several modifications to the Hospital Price Transparency (HPT) regulations to ensure that hospitals provide meaningful, accurate information about the amount they charge for health care items and services. Beginning January 1, 2026, hospitals will be required to calculate and encode the median, 10th and 90th percentile allowed amounts, as well as the count of allowed amounts in their machine-readable file (MRF), when payer-specific negotiated charges are based on percentages or algorithms.
In addition, hospitals will be required to attest in the MRF that, to the best of its knowledge and belief, the hospital has included all applicable standard charge information and that the information encoded is true, accurate and complete as of the date in the file. The attestation also states that (a) the hospital has provided in the MRF all applicable payer-specific negotiated charges in dollars that can be expressed as a dollar amount, and (b) for payer-specific negotiated charges that cannot be expressed as a dollar amount or are not knowable in advance, the hospital has provided in the MRF all necessary information available to the hospital for the public to be able to derive the dollar amount.
Hospitals will also be required to encode the following:
- The name of the hospital’s chief executive officer, president or senior official designated to oversee the encoding of true, accurate and complete data.
- The hospital’s national provider identifiers (Type 2 NPIs) in the MRFs
Lastly, to encourage faster resolution and payment of civil monetary penalties (CMPs) and in exchange for the hospital’s acceptance of CMS’s determination that the hospital violated HPT requirements, CMS is finalizing the proposal that offers a reduction to the amount of a hospital’s CMP by 35 percent, under certain circumstances, when the hospital waives its right to an Administrative Law Judge (ALJ) hearing in certain situations. The effective date for the new data elements required in the MRF is January 1, 2026, but CMS will delay enforcement of those requirements until April 1, 2026.
We will be sharing additional details from the 2026 OPPS final rule in upcoming alerts.