On July 15, the Centers for Medicare & Medicaid Services (CMS) released the CY 2026 Proposed Rule for the Medicare Outpatient Prospective Payment System (OPPS). The proposed rule introduces several significant policy changes that will impact hospitals and ambulatory surgical centers (ASCs) beginning Jan. 1.  From updates to the 340B payment policy and ambulatory payment classifications (APCs) to the elimination of the Inpatient-only (IPO) list and expanded reporting requirements, the CY 2026 OPPS rule is one of the most comprehensive updates in recent years.   CMS projects an overall $1.61 billion increase in OPPS payments before accounting for the 340B remedy offset, which is expected to reduce payments by $1.1 billion, resulting in a net increase of approximately $510 million.  This blog post breaks down the most important proposed changes, financial impacts and reporting requirements so your organization can prepare for compliance and optimize reimbursement strateg...

On July 14, the Centers for Medicare & Medicaid Services (CMS) released the calendar year (CY) 2026 proposed rule for the Medicare Physician Fee Schedule (PFS) . This annual update outlines changes to physician payment rates, policy refinements and adjustments to programs that affect healthcare providers nationwide. If finalized, the proposed updates will take effect for services provided on or after Jan. 1, 2026.  The rule introduces appreciable revisions that impact payment methodology, practice expense allocations and data sources used for setting reimbursement rates. Below are the most critical takeaways for healthcare providers and stakeholders.  Key proposed changes to the CY 2026 Medicare PFS proposed rule  CMS’s proposed changes address several major policy areas, including:  payment rate updates;  Relative Value Unit (RVU) updates;  GPCI updates;  Rural Health Clinics and Federally Qualified Health Centers;  Ambulatory Specialty Model...

On June 30, Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2026 Home Health Prospective Payment System (HH PPS) proposed rule . This annual rule outlines significant changes to Medicare home health payment policies, including rate adjustments, Patient-Driven Groupings Model (PDGM) recalibration, quality reporting updates and value-based purchasing modifications.  For home health agencies (HHAs), this year’s proposed rule carries major financial and operational implications. CMS estimates an overall $1.135 billion decrease in aggregate payments in CY 2026 compared to CY 2025, largely driven by permanent behavioral adjustments, temporary payment recoupments and changes to outlier payment thresholds.  In addition to payment updates, the rule introduces policy revisions to the Home Health Value-Based Purchasing (HHVBP) model, face-to-face encounter requirements, provider enrollment safeguards and durable medical equipment regulations.   Ove...

The 2026 NCQA PCMH annual reporting landscape  The National Committee for Quality Assurance (NCQA) released significant updates to the Patient-Centered Medical Home (PCMH) standards and the associated 2026 annual reporting requirements. These changes require enhanced practice procedures and expectations across nearly every concept area.  If your practice plans to maintain or achieve PCMH recognition, understanding these updates — and preparing early — is critical for success. It is essential for practices to maintain and monitor the PCMH Standards and Guidelines ongoingly in order to seamlessly report each year. The annual requirements do vary each year but will always stem from the core  criteria of the PCMH Standards and Guidelines.  Key changes from 2025 to 2026  Compared to 2025, NCQA’s 2026 standards updates require:  more robust documentation across all six concept areas;  new audit expectations — multi-site organizations must ensure every locati...

On July 31, the Centers for Medicare and Medicaid Services (CMS) finalized updates to the Transforming Episode Accountability Model (TEAM) in the federal fiscal year 2026 Inpatient Prospective Payment System (IPPS) final rule .  TEAM, a mandatory Medicare bundled payment initiative launching Jan. 1, 2026, was first introduced in the FFY 2025 IPPS proposed rule. 745 hospitals will advance into TEAM in the beginning of the year – 735 hospitals located in a Core-Based Statistical Area (CBSA) chosen for mandatory participation and 10 hospitals that have voluntarily opted into the model.    Earlier this year, CMS proposed changes to TEAM and sought feedback from hospitals, associations and other stakeholders. The final rule now cements those updates — changes that will directly impact TEAM participation requirements, quality measurement, payment methodologies and care delivery strategies. Any future model changes will go through the same rulemaking process.    Key T...

Second quarter 2025 Statewide Planning and Research Cooperative System (SPARCS) data submissions are due. In addition, the due dates for the third final warning (Sept. 15) and statements of deficiency (Oct. 15) for Q1 2025 are approaching. Here are the key dates hospitals, ambulatory surgery centers and health systems need to know to remain SPARCS compliant.  Key compliance dates for SPARCS Data: Q1 2025 and Q2 2025  Q1 2025 SPARCS compliance deadlines  Sept. 15  Final/third warning for Q1 2025 data   Hospitals and ASCs that have not resolved their Q1 2025 data errors after receiving three warnings will be issued an SOD.   Oct. 15  SOD issued for Q1 2025 data   Facilities will be issued an SOD on this date.  Q2 2025 SPARCS compliance deadlines   Sept. 30  Submission deadline for Q2 2025 data   The deadline for submitting Q2 2025 SPARCS data falls on this date. Ensure your data are accurate and submitted...

 Updated on July 9, 2025 The One Big Beautiful Bill Act (OBBBA) — a major budget reconciliation bill passed by the U.S. House of Representatives in May — became law on July 4. While the legislation covers a wide range of national issues, several key Medicare fee-for-service (FFS) provisions could have a direct and lasting impact on hospitals and health systems.  Because OBBBA has Medicare FFS implications, DataGen analyzed the impact of these major areas. Here’s a preview of what we’re seeing so far — and what hospital leaders need to keep on their radar:  update to physician Medicare payments;  potential 4.0% additional Pay-As-You-Go (PAYGO) sequestration reduction; and  Medicare Disproportionate Share Hospital uncompensated care impact.  1. Physician payment updates   For the calendar year 2026, physician payments are slated to increase by 2.5%.   2. The potential new 6% sequester  With the new legislation, Congress may allow the Statutory...

New updates as of July 2  CMS has released Transforming Episode Accountability Model (TEAM) performance year (PY) 1 baseline period data to a second wave of participating hospitals. Hospitals included in this wave had their Data Request and Attestation Form (DRA) and Data Sharing Agreement (DSA) submitted to CMS through the TEAM participant portal by May 26.  Any hospital that submitted their DRA and DSA to CMS after May 26 will not receive their TEAM PY1 baseline period data until fall 2025.  Important note:  If your hospital won’t receive its TEAM PY1 baseline data until fall 2025, don’t let that delay your preparation. Simulated TEAM episodes of care can still offer valuable insight into how your hospital is positioned ahead of the model’s launch.   All hospitals should also expect an update to their baseline data, including preliminary target prices, in the fall of 2025. This will account for the additional 2024 data run-out and pending methodological upda...

Key compliance dates for SPARCS Data: Q4 2024 and Q1 2025 First quarter 2025 Statewide Planning and Research Cooperative System (SPARCS) data submissions are due. In addition, the due dates for the third final warning (June 15) and Statements of Deficiency (July 15) for Q4 2024 are approaching. Here are the key dates hospitals, ambulatory surgery centers and health systems need to know to remain SPARCS compliant.   Q4 2024 SPARCS compliance deadlines  June 15  Final/third warning for Q4 2024 data   Hospitals and ASCs that have not resolved their Q4 2024 data errors after receiving three warnings will be issued an SOD.   July 15  SOD issued for Q4 2024 data   Facilities will be issued an SOD on this date.  Q1 2025 SPARCS compliance deadlines   June 30  Submission deadline for Q1 2025 data   The deadline for submitting Q1 2025 SPARCS data falls on this date. Ensure your data are accurate and submitted on ...

Is your practice ready to meet the latest requirements?  On May 27, DOH released key updates to the Patient-Centered Medical Home (PCMH) enhanced payment program for Medicaid providers. These changes tighten the enhanced payment requirements and introduce new reporting standards tied to Social Care Network (SCN) attestation and quality performance.  If your practice currently relies on PCMH incentive payments, here's what you need to know to stay compliant — and how DataGen can help.  What's changing?  Historically, all New York state PCMH-recognized practices received a $6 per-member-per-month (PMPM) payment for Medicaid patients. That core payment continues — but now, retaining the additional enhanced payment comes with new requirements over the next reporting period years.   Between April 1, 2024 and March 31, 2026:  All PCMH-recognized practices qualify for:  $6.00 PMPM for Medicaid patients; and  $4.00 PMPM for patients up to age 21 or $...

When you partner with DataGen and use our Medicare fee-for-service policy analytics solution, you receive Medicare IPPS proposed rule payment briefs, along with additional essential Medicare fee-for-service (FFS) updates and materials throughout the year.   DataGen provides an overview of the Centers for Medicare and Medicaid Services’ (CMS) federal fiscal year (FFY) 2026 proposed rule for the Medicare Inpatient Prospective Payment System (IPPS)    Overview of policies for the FFY 2026 IPPS new proposed rule The DataGen Medicare FFS policy analytics team summarized and analyzed the following policy changes in the new proposed rule:  utilizing FFY 2024 Medicare Provider and Review (MedPAR) and FFY 2023 Hospital Cost Reporting Information System (HCRIS) data for standard calculations;  updates to the Medicare Disproportionate Share Hospital (DSH) payment policies, including hospital eligibility for DSH Uncompensated Care (UCC) payments in FFY 2026 being...

 SCNs and the value-based care mandate in New York state New York’s 1115 Medicaid waiver represents a pivotal opportunity for providers to engage in value-based care models that improve outcomes and reduce costs. At the heart of this transformation are Social Care Networks (SCNs) — a state initiative designed to address health-related social needs (HRSN) such as food insecurity, housing instability and transportation barriers for Medicaid recipients.  SCNs are central to New York’s long-term strategy for integrating clinical and non-clinical care. For primary care providers (PCPs), engaging with SCNs offers not only a chance to better serve vulnerable populations but also to receive enhanced reimbursement through the waiver, particularly when paired with the National Committee for Quality Assurance’s (NCQA) Patient-Centered Medical Home (PCMH) recognition .  What are Social Care Networks (SCNs)?  SCNs are regional networks of community-based organizations (CBOs) an...