CMS issued the 2025 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule Nov. 1, with several new elements for hospital outpatient departments.
Ten things to know:
1. CMS finalized a 2.9% payment rate increase for hospital outpatient and ASC services in 2025, aimed at supporting hospitals that meet quality reporting requirements. This increase is based on a 3.4% market basket update, reduced by a 0.5 percentage points for a productivity adjustment. The adjustment aligns with CMS's goals of balancing inflationary pressures with productivity improvements in healthcare.
2. CMS updated Medicare payment rates for Intensive Outpatient Programs and Partial Hospitalization Programs in hospital outpatient departments to improve behavioral health service access. These programs serve patients with acute mental health needs or substance use disorders, paid on a per diem basis. By expanding support for IOPs and PHPs, CMS aims to address rising mental health care needs within communities.
3. In alignment with the NOPAIN Act, CMS will now provide separate payments for approved non-opioid pain management drugs and devices in outpatient settings, starting January 1, 2025. This policy promotes the use of non-opioid alternatives, part of a broader effort to combat the opioid crisis. The payments are available through 2027 and include FDA-approved drugs and devices that reduce post-surgical opioid use.
4. CMS will begin reimbursing high-cost diagnostic radiopharmaceuticals separately if they exceed $630 per day, ensuring that outpatient departments are fairly compensated. This policy shift is intended to improve patient access to crucial nuclear medicine tests, particularly those requiring high-cost diagnostic agents. By removing the radiopharmaceuticals' cost from bundled payments, CMS aims to support more efficient and effective diagnostic care.
5. CMS introduced a $10 add-on payment for Technetium-99m produced in the U.S. without using highly enriched uranium, effective January 1, 2026. This add-on encourages the use of domestically produced radiopharmaceuticals, which may be more costly due to limited production infrastructure. Supporting domestic production helps stabilize supply chains and supports diagnostic imaging needs.
6. CMS implemented new conditions of participation to enhance maternal care quality in hospitals and critical access hospitals. These standards focus on quality assessment, patient safety, staffing, and training to ensure consistent, high-quality care for pregnant and postpartum patients. This response aims to improve maternal health outcomes, addressing the maternal health crisis and disparities affecting communities.
7. CMS added health equity-focused measures to the Hospital Outpatient Quality Reporting Program, including the "Commitment to Health Equity" and social drivers of health screening measures. These new measures are designed to encourage hospitals to identify and address health disparities in their communities.
8. CMS is considering adjustments to support the higher costs hospitals incur when purchasing domestically produced personal protective equipment, particularly surgical N95 respirators. Hospitals have emphasized the importance of a stable, reliable PPE supply, especially since the COVID-19 pandemic. CMS plans to address potential payment adjustments in its 2026 rulemaking to support sustainable domestic PPE production.
9. CMS revised Medicare access rules to reduce barriers for individuals released from incarceration, such as those on parole, probation, or home detention. This change redefines "custody" to help these individuals qualify for Medicare benefits. By expanding eligibility criteria, CMS aims to support healthcare access and reintegration for formerly incarcerated individuals in need of medical care.
10. The update also focused on obstetrics and maternal care. The final rule mandates hospitals ensure OB services align with recognized standards of practice, organized for the scope of services offered and integrated with other departments. The OB units must also be supervised by qualified professionals and grant privileges based on written criteria. OB facilities must also have basic equipment, including cardiac monitors and fetal dopplers, available. Low-volume facilities can stock emergency supplies differently if they meet minimum equipment requirements.
Finally, CMS developed training policies for OB staff following evidence-based practices. The training topics must be reviewed every two years and documented in staff records to improve maternal healthcare delivery.