Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals (IPPS) and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year (FY) 2026 Rates; Changes to the FY 2025 IPPS Rates Due to Court Decision; Requirements for Quality Programs; and Other Policy Changes; Health Data, Technology, and Interoperability: Electronic Prescribing, Real-Time Prescription Benefit and Electronic Prior Authorization al payments per case from FY 2025 to FY 2026 for all hospitals (as shown in Table III). The geographic comparison shows that, on average, hospitals in both urban and rural classifications would experience an increase in capital IPPS payments per case in FY 2026 as compared to FY 2025. Capital IPPS payments per case will increase by an estimated 3.2 percent for hospitals in both urban and rural areas from FY 2025 to FY 2026. The comparisons by region show that the change in capital payments per case from FY 2025 to FY 2026 for urban areas range from a 1.6 percent increase for the New England urban region to a 5.5 percent increase for the West North Central urban region. Meanwhile, the change in capital payments per case from FY 2025 to FY 2026 for rural areas range from a 1.8 percent increase for the Pacific rural region to a 6.6 percent increase for the West North Central rural region. Capital IPPS payments per case for hospitals located in Puerto Rico are projected to decrease by 0.7 percent. These regional differences are primarily due to the changes in the GAFs. The comparison by hospital type of ownership (Voluntary, Proprietary, and Government) shows that voluntary hospitals a percent. These regional differences are primarily due to the changes in the GAFs. The comparison by hospital type of ownership (Voluntary, Proprietary, and Government) shows that voluntary hospitals are expected to experience an increase in capital payments per case from FY 2025 to FY 2026 of 3.2 percent. Proprietary hospitals are expected to experience an increase in capital payments per case from FY 2025 to FY 2026 of 3.5 percent. Government hospitals are expected to experience an increase in capital payments per case from FY 2025 to FY 2026 of 3.3 percent. Section 1886(d)(10) of the Act established the MGCRB. Hospitals may apply for reclassification for purposes of the wage index for FY 2026. Reclassification for wage index purposes also affects the GAFs because that factor is constructed from the hospital wage index. To present the effects of the hospitals being reclassified as of the publication of this final rule for FY 2026, we show the average capital payments per case for reclassified hospitals for FY 2026. Urban reclassified hospitals are expected to experience an increase in capital payments per case of 3.5 percent; urban nonreclassified hospitals are expected to experie assified hospitals for FY 2026. Urban reclassified hospitals are expected to experience an increase in capital payments per case of 3.5 percent; urban nonreclassified hospitals are expected to experience an increase in capital payments of 3.0 percent. Rural reclassified hospitals are expected to experience an increase in capital payments per case of 3.2 percent; rural nonreclassified hospitals are expected to experience an increase in capital payments per case of 3.3 percent. TABLE III.—COMPARISON OF TOTAL PAYMENTS PER CASE FY 2025 Payments compared to FY 2026 payments Number of hospitals Average FY 2025 payments/case Average FY 2026 payments/case Change All Hospitals .............................................................................................. By Geographic Location: Urban hospitals ......................................................................................... Rural hospitals .......................................................................................... 3,033 2,372 661 Bed Size (Urban): 0–99 beds ................................................................................................. 100–199 beds .................................... ........ 3,033 2,372 661 Bed Size (Urban): 0–99 beds ................................................................................................. 100–199 beds ........................................................................................... 200–299 beds ........................................................................................... 300–499 beds ........................................................................................... 500 or more beds ..................................................................................... Bed Size (Rural): 0–49 beds ................................................................................................. 50–99 beds ............................................................................................... 100–149 beds ........................................................................................... 150–199 beds ........................................................................................... 200 or more beds ..................................................................................... Urban by Region: New England ........................................................ ........... 200 or more beds ..................................................................................... Urban by Region: New England ............................................................................................ Middle Atlantic .......................................................................................... East North Central .................................................................................... West North Central ................................................................................... South Atlantic ........................................................................................... East South Central ................................................................................... West South Central .................................................................................. Mountain ................................................................................................... Pacific ....................................................................................................... Rural by Region: New England ....................................................................................... ................................................................................... Rural by Region: New England ............................................................................................ Middle Atlantic .......................................................................................... East North Central .................................................................................... West North Central ................................................................................... South Atlantic ........................................................................................... East South Central ................................................................................... West South Central .................................................................................. Mountain ................................................................................................... Pacific ....................................................................................................... Puerto Rico: Puerto Rico Hospitals ............................................................................... By Payment Classification: 647 6 .................................................... Puerto Rico: Puerto Rico Hospitals ............................................................................... By Payment Classification: 647 673 406 392 252 313 180 95 42 31 104 274 366 156 393 141 355 180 351 19 48 106 74 108 127 116 39 24 52 Urban hospitals ......................................................................................... Rural areas ............................................................................................... 1,611 1,422 1,182 1,215 814 903 1,017 1,111 1,213 1,442 675 781 787 889 981 1,314 1,365 1,138 1,137 1,072 1,000 1,097 1,219 1,552 1,052 938 815 799 747 732 722 865 1,055 609 1,116 1,232 1,220 1,254 840 935 1,046 1,146 1,251 1,493 699 805 815 918 1,007 1,335 1,419 1,170 1,199 1,113 1,032 1,142 1,254 1,581 1,081 969 834 852 768 747 748 904 1,074 605 1,149 1,275 3.2 3.2 3.2 3.5 2.9 3.2 3.1 3.5 3.6 3.1 3.6 3.3 2.7 1.6 4.0 2.8 5.5 3.8 3.2 4.1 2.9 1.9 2.8 3.3 2.3 6.6 2.8 2.0 3.6 4.5 1.8 -0.7 3.0 3.5 VerDate Sep 2014 00:36 Aug 02, 2025 Jkt 265001 PO 00000 Frm 00761 Fmt 4701 Sfmt 4700 E:\FR\FM\04AUR2.SGM 04AUR2 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k 37296 8 -0.7 3.0 3.5 VerDate Sep 2014 00:36 Aug 02, 2025 Jkt 265001 PO 00000 Frm 00761 Fmt 4701 Sfmt 4700 E:\FR\FM\04AUR2.SGM 04AUR2 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k 37296 Federal Register / Vol. 90, No. 147 / Monday, August 4, 2025 / Rules and Regulations TABLE III.—COMPARISON OF TOTAL PAYMENTS PER CASE—Continued FY 2025 Payments compared to FY 2026 payments Number of hospitals Average FY 2025 payments/case Average FY 2026 payments/case Change Teaching Status: Nonteaching .............................................................................................. Fewer than 100 residents ......................................................................... 100 or more residents .............................................................................. 1,756 986 291 Urban DSH: Non-DSH .................................................................................................. 100 or more beds ..................................................................................... Less than 100 beds .................................................................................. Rural DSH: Non-DSH .......................................... .................................... Less than 100 beds .................................................................................. Rural DSH: Non-DSH .................................................................................................. SCH .......................................................................................................... RRC .......................................................................................................... 100 or more beds ..................................................................................... Less than 100 beds .................................................................................. Urban teaching and DSH: Both teaching and DSH ............................................................................ Teaching and no DSH .............................................................................. No teaching and DSH .............................................................................. No teaching and no DSH ......................................................................... Special Hospital Types: RRC ...................................................................... .... No teaching and no DSH ......................................................................... Special Hospital Types: RRC .......................................................................................................... RRC with Section 401 Rural Reclassification .......................................... SCH .......................................................................................................... SCH with Section 401 Rural Reclassification .......................................... SCH and RRC .......................................................................................... SCH and RRC with Section 401 Rural Reclassification .......................... Type of Ownership: Voluntary ................................................................................................... Proprietary ................................................................................................ Government .............................................................................................. Medicare Utilization as a Percent of Inpatient Days: 0–25 .............................................................................................. ............................................... Medicare Utilization as a Percent of Inpatient Days: 0–25 .......................................................................................................... 25–50 ........................................................................................................ 50–65 ........................................................................................................ Over 65 ..................................................................................................... Medicaid Utilization as a Percent of Inpatient Days: 0–25 .......................................................................................................... 25–50 ........................................................................................................ 50–65 ........................................................................................................ Over 65 ..................................................................................................... FY 2026 Reclassifications: All Reclassified Hospitals ......................................................................... Non-Reclassified Hospitals ... ......................................... FY 2026 Reclassifications: All Reclassified Hospitals ......................................................................... Non-Reclassified Hospitals ....................................................................... Urban Hospitals Reclassified .................................................................... Urban Non-Reclassified Hospitals ............................................................ Rural Hospitals Reclassified Full Year ..................................................... Rural Non-Reclassified Hospitals Full Year ............................................. All Section 401 Rural Reclassified Hospitals ........................................... Other Reclassified Hospitals (Section 1886(d)(8)(B)) .............................. 346 909 356 93 227 863 41 198 527 58 738 288 131 657 218 37 119 49 1,902 724 406 1,548 1,388 65 13 1,917 992 91 32 1,093 1,940 979 1,407 268 379 811 50 965 1,103 1,594 1,011 1,159 831 1,115 837 1,277 1,108 685 1,215 1,084 1,022 967 916 1,328 788 969 882 1,128 1,183 1,094 1,284 1,247 1,117 1,117 936 1,084 1,337 1,512 1,565 1,231 1,126 1,282 1,112 833 784 1,297 830 995 1,140 1,647 1, 1,115 837 1,277 1,108 685 1,215 1,084 1,022 967 916 1,328 788 969 882 1,128 1,183 1,094 1,284 1,247 1,117 1,117 936 1,084 1,337 1,512 1,565 1,231 1,126 1,282 1,112 833 784 1,297 830 995 1,140 1,647 1,052 1,191 856 1,152 868 1,321 1,159 705 1,249 1,125 1,050 1,007 938 1,374 814 1,004 912 1,175 1,221 1,132 1,326 1,290 1,151 1,161 988 1,120 1,381 1,549 1,589 1,272 1,161 1,327 1,145 860 810 1,343 856 3.1 3.4 3.3 4.1 2.8 3.0 3.3 3.7 3.4 4.6 2.9 2.8 3.8 2.7 4.1 2.4 3.5 3.3 3.6 3.4 4.2 3.2 3.5 3.3 3.4 3.0 3.9 5.6 3.3 3.3 2.4 1.5 3.3 3.1 3.5 3.0 3.2 3.3 3.5 3.1 J. Effects of Payment Rate Changes and Policy Changes Under the LTCH PPS their estimated fiscal impact on the Medicare budget and on LTCHs. (that is, the impact analysis presented in Table IV is based on the data for 327 LTCHs). 1. Introduction and General Considerations In section IX. of the preamble of this final rule and section V. of the Addendum to this final rule, we set forth the annual update to the payment rates for the LTCH PPS for FY 2026. In the preamble of this final rule, we specify the statutory authority for the provisions that are presented, identify the policies for FY 2026, and present rationales for our provision S for FY 2026. In the preamble of this final rule, we specify the statutory authority for the provisions that are presented, identify the policies for FY 2026, and present rationales for our provisions as well as alternatives that were considered. In this section, we discuss the impact of the changes to the payment rate, factors, and other payment rate policies related to the LTCH PPS that are presented in the preamble of this final rule in terms of There are 329 LTCHs included in this impact analysis. We note that, although there are currently approximately 336 LTCHs, for purposes of this impact analysis, we excluded the data of all-inclusive rate providers consistent with the development of the FY 2026 MS–LTC–DRG relative weights (discussed in section IX.B.3. of the preamble of this final rule). Moreover, in the claims data used for this final rule, two of the 329 LTCHs included in our impact analysis only had claims for site neutral payment rate cases and, therefore, does not affect our impact analysis for LTCH PPS standard Federal payment rate cases presented in Table IV In the impact analysis, we used the payment rate, factors, and policies presented in this final rule, the 2. our impact analysis for LTCH PPS standard Federal payment rate cases presented in Table IV In the impact analysis, we used the payment rate, factors, and policies presented in this final rule, the 2.7 percent annual update to the LTCH PPS standard Federal payment rate, the update to the MS–LTC– DRG classifications and relative weights, the update to the wage index values and labor- related share, and the best available claims and CCR data to estimate the change in payments for FY 2026. Under the dual rate LTCH PPS payment structure, payment for LTCH discharges that meet the criteria for exclusion from the site neutral payment rate (that is, LTCH PPS standard Federal payment rate cases) is based on the LTCH PPS standard Federal payment VerDate Sep 2014 00:36 Aug 02, 2025 Jkt 265001 PO 00000 Frm 00762 Fmt 4701 Sfmt 4700 E:\FR\FM\04AUR2.SGM 04AUR2 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k Federal Register / Vol. 90, No. 147 / Monday, August 4, 2025 / Rules and Regulations 37297 rate. Consistent with the statute, the site neutral payment rate is the lower of the IPPS comparable per diem amount as determined under § 412.529(d)(4), including any applicable outl egulations 37297 rate. Consistent with the statute, the site neutral payment rate is the lower of the IPPS comparable per diem amount as determined under § 412.529(d)(4), including any applicable outlier payments as specified in § 412.525(a), reduced by 4.6 percent for FYs 2018 through 2026; or 100 percent of the estimated cost of the case as determined under § 412.529(d)(2). In addition, there are two separate high-cost outlier targets—one for LTCH PPS standard Federal payment rate cases and one for site neutral payment rate cases. Based on the best available data for the 329 LTCHs in our database that were considered in the analyses used for this final rule, we estimate that overall LTCH PPS payments in FY 2026 will increase by approximately 3.3 percent (or approximately $83 million) based on the rates and factors presented in section IX. of the preamble and section V. of the Addendum to this final rule. Based on the FY 2024 LTCH cases that were used for the analysis in this final rule, approximately 9 percent of those cases were classified as site neutral payment rate cases (that is, 9 percent of LTCH cases would not meet the statutory patient-level criteria for exclusion from t le, approximately 9 percent of those cases were classified as site neutral payment rate cases (that is, 9 percent of LTCH cases would not meet the statutory patient-level criteria for exclusion from the site neutral payment rate). In section IX.B.3.b of the preamble of this final rule, we outline how we considered the ending of the waiver of the application of the site neutral payment rate for LTCH cases under section 3711(b)(2) of the CARES Act when identifying site neutral payment rate cases based on the statutory patient criteria, admission date, and claim payment amounts. To estimate FY 2026 LTCH PPS payments for site neutral payment rate cases, we calculated the IPPS comparable per diem amounts using the FY 2026 IPPS rates and factors along with other changes that would apply to the site neutral payment rate cases in FY 2026. We estimate that aggregate LTCH PPS payments for these site neutral payment rate cases will increase by approximately 10.0 percent (or approximately $10 million). This projected increase in payments to LTCH PPS site neutral payment rate cases is primarily due to the updates to the IPPS rates and factors reflected in our estimate of the IPPS comparable per ion). This projected increase in payments to LTCH PPS site neutral payment rate cases is primarily due to the updates to the IPPS rates and factors reflected in our estimate of the IPPS comparable per diem amount, as well as an increase in estimated costs for these cases determined using the charge and CCR adjustment factors described in section V.D.3.b. of the Addendum to this final rule. We note that we estimate payments to site neutral payment rate cases in FY 2026 will represent approximately 4.1 percent of estimated aggregate FY 2026 LTCH PPS payments. Based on the FY 2024 LTCH cases that were used for the analysis in this final rule, approximately 91 percent of LTCH cases will meet the patient-level criteria for exclusion from the site neutral payment rate in FY 2026 and will be paid based on the LTCH PPS standard Federal payment rate. We estimate that total LTCH PPS payments for these LTCH PPS standard Federal payment rate cases in FY 2026 will increase approximately 3.0 percent (or approximately $73 million). This estimated increase in LTCH PPS payments for LTCH PPS standard Federal payment rate cases in FY 2026 is primarily due to the 2.7 percent annual update to the LTCH (or approximately $73 million). This estimated increase in LTCH PPS payments for LTCH PPS standard Federal payment rate cases in FY 2026 is primarily due to the 2.7 percent annual update to the LTCH PPS standard Federal payment rate and a projected 0.4 percent increase in high- cost outlier payments as a percentage of total LTCH PPS standard Federal payment rate payments, which is discussed later in this section. Based on the 329 LTCHs that were represented in the FY 2024 LTCH cases that were used for the analyses in this final rule presented in this appendix, we estimate that aggregate FY 2026 LTCH PPS payments will be approximately $2.583 billion, as compared to estimated aggregate FY 2025 LTCH PPS payments of approximately $2.500 billion, resulting in an estimated overall increase in LTCH PPS payments of approximately $83 million. We note that the estimated $83 million increase in LTCH PPS payments in FY 2026 does not reflect changes in LTCH admissions or case-mix intensity, which will also affect the overall payment effects of the policies in this final rule. The LTCH PPS standard Federal payment rate for FY 2025 is $49,383.26. For FY 2026, we are establishing an LTCH PPS stan will also affect the overall payment effects of the policies in this final rule. The LTCH PPS standard Federal payment rate for FY 2025 is $49,383.26. For FY 2026, we are establishing an LTCH PPS standard Federal payment rate of $50,824.51 which reflects the 2.7 percent annual update to the LTCH PPS standard Federal payment rate and the budget neutrality factor for updates to the area wage level adjustment of 1.0021275 (discussed in section V.B.6. of the Addendum to this final rule). For LTCHs that fail to submit data for the LTCH QRP, in accordance with section 1886(m)(5)(C) of the Act, we are establishing an LTCH PPS standard Federal payment rate of $49,834.74. This LTCH PPS standard Federal payment rate reflects the updates and factors previously described, as well as the required 2.0 percentage point reduction to the annual update for failure to submit data under the LTCH QRP. Table IV shows the estimated impact for LTCH PPS standard Federal payment rate cases. The estimated change attributable solely to the annual update of 2.7 percent to the LTCH PPS standard Federal payment rate is projected to result in an increase of 2.6 percent in payments per discharge for LTCH PPS stand attributable solely to the annual update of 2.7 percent to the LTCH PPS standard Federal payment rate is projected to result in an increase of 2.6 percent in payments per discharge for LTCH PPS standard Federal payment rate cases from FY 2025 to FY 2026, on average, for all LTCHs (Column 6). The estimated increase of 2.6 percent shown in Column 6 of Table IV also includes estimated payments for short- stay outlier (SSO) cases, a portion of which are not affected by the annual update to the LTCH PPS standard Federal payment rate, as well as the reduction that is applied to the annual update for LTCHs that do not submit the required LTCH QRP data. For most hospital categories, the projected increase in payments based on the LTCH PPS standard Federal payment rate to LTCH PPS standard Federal payment rate cases also rounds to approximately 2.6 percent. For FY 2026, we are updating the wage index values based on the most recent available data (data from cost reporting periods beginning during FY 2022 which is the same data used for the FY 2026 IPPS wage index). In addition, we are establishing a labor-related share of 72.9 percent for FY 2026, based on the most recent available data (I ing FY 2022 which is the same data used for the FY 2026 IPPS wage index). In addition, we are establishing a labor-related share of 72.9 percent for FY 2026, based on the most recent available data (IGI’s second quarter 2025 forecast) of the relative importance of the labor-related share of operating and capital costs of the 2022- based LTCH market basket. We are also applying an area wage level budget neutrality factor of 1.0021275 to ensure that the changes to the area wage level adjustment would not result in any change in estimated aggregate LTCH PPS payments to LTCH PPS standard Federal payment rate cases. For LTCH PPS standard Federal payment rate cases, we currently estimate high-cost outlier payments as a percentage of total LTCH PPS standard Federal payment rate payments will increase from FY 2025 to FY 2026. Based on the FY 2024 LTCH cases that were used for the analyses in this final rule, we estimate that the FY 2025 high-cost outlier threshold of $77,048 (as established in the FY 2025 IPPS/LTCH PPS final rule) will result in estimated high-cost outlier payments for LTCH PPS standard Federal payment rate cases in FY 2025 that are projected to be less than the 7.975 perc the FY 2025 IPPS/LTCH PPS final rule) will result in estimated high-cost outlier payments for LTCH PPS standard Federal payment rate cases in FY 2025 that are projected to be less than the 7.975 percent target. Specifically, using those FY 2024 cases we currently estimate that high-cost outlier payments for LTCH PPS standard Federal payment rate cases will be approximately 7.6 percent of the estimated total LTCH PPS standard Federal payment rate payments in FY 2025. Combined with our estimate that FY 2026 high-cost outlier payments for LTCH PPS standard Federal payment rate cases will be 7.975 percent of estimated total LTCH PPS standard Federal payment rate payments in FY 2026, this will result in an estimated increase in high-cost outlier payments as a percentage of total LTCH PPS standard Federal payment rate payments of approximately 0.4 percentage point between FY 2025 and FY 2026. We note that, in calculating these estimated high- cost outlier payments, we inflated charges reported on the FY 2024 claims by the charge inflation factor described in section V.D.3.b. of the Addendum to this final rule. We also note that, in calculating these estimated high- cost outlier payments ted on the FY 2024 claims by the charge inflation factor described in section V.D.3.b. of the Addendum to this final rule. We also note that, in calculating these estimated high- cost outlier payments, we estimated the cost of each case by multiplying the inflated charges by the adjusted CCRs that we determined using our finalized methodology described in section V.D.3.b. of the Addendum to this final rule. Table IV shows the estimated impact of the payment rate and policy changes on LTCH PPS payments for LTCH PPS standard Federal payment rate cases for FY 2026 by comparing estimated FY 2025 LTCH PPS payments to estimated FY 2026 LTCH PPS payments. (As noted earlier, our analysis does not reflect changes in LTCH admissions or case-mix intensity.) We note that these impacts do not include LTCH PPS site neutral payment rate cases as discussed in section I.J.3. of this appendix. Comment: A commenter expressed concern whether the proposed payment rate update will adequately support the operational and clinical demands faced by LTCHs. The commenter stated that these facilities provide extended inpatient care for patients with severe and complex conditions that often require prolonged me rational and clinical demands faced by LTCHs. The commenter stated that these facilities provide extended inpatient care for patients with severe and complex conditions that often require prolonged mechanical ventilation, intensive wound management, or post-sepsis recovery. The commenter stated that unlike general acute care hospitals, LTCHs must sustain high staffing ratios and specialized clinical protocols for weeks or months at a time, yet are reimbursed under models that VerDate Sep 2014 00:36 Aug 02, 2025 Jkt 265001 PO 00000 Frm 00763 Fmt 4701 Sfmt 4700 E:\FR\FM\04AUR2.SGM 04AUR2 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k 37298 Federal Register / Vol. 90, No. 147 / Monday, August 4, 2025 / Rules and Regulations assume tighter, episodic cost predictability. The commenter urged CMS to assess whether the current MS–LTC–DRG weighting methodology and outlier thresholds capture the intensity and unpredictability of extended LTCH care. Response: We appreciate commenters’ concerns about the proposed 2.2 percent increase in payment to LTCH PPS standard Federal payment rate cases. As explained in the proposed rule (89 FR 36635), that estimated increase of appro mmenters’ concerns about the proposed 2.2 percent increase in payment to LTCH PPS standard Federal payment rate cases. As explained in the proposed rule (89 FR 36635), that estimated increase of approximately 2.2 percent was primarily due to the proposed 2.6 percent annual update to the LTCH PPS standard Federal payment rate being partially offset by a projected 0.3 percent decrease in high-cost outlier payments as a percentage of total LTCH PPS standard Federal payment rate payment. We received several comments on the proposed annual update to the LTCH PPS standard Federal payment rate which we have summarized and responded to in sections IX.C. of the preamble to this final rule. We also received several comments on the proposed fixed-loss amount for high-cost outlier cases which we have summarized and responded to in section V.D.3. of the Addendum to this final rule. Based on the finalized payment rates and factors in this final rule, we now project a 3.0 percent increase in payments to LTCH PPS standard Federal payment rate cases for FY 2026 (as compared to our projection of 2.2 percent in the proposed rule). This increase in our projected percentage change in payments is partia to LTCH PPS standard Federal payment rate cases for FY 2026 (as compared to our projection of 2.2 percent in the proposed rule). This increase in our projected percentage change in payments is partially being driven by an increase to the annual update for FY 2026 based on the updated data available for this final rule. The final annual update factor of 2.7 percent is 0.1 percentage point higher than the proposed annual update factor. As discussed in section IX.C.2. of the preamble to this final rule, we believe this LTCH market basket increase appropriately reflects the input price growth that LTCHs will incur providing medical services in FY 2026. The increase in our projected percentage change in payments is also partially being driven by a downward revision in this final rule to our estimate of FY 2025 high cost outlier payments to LTCH PPS standard Federal payment rate cases. In this final rule, after incorporating into our payment model more recent data, as discussed in section V.D.3. of the Addendum to this final rule, we now estimate that high cost outlier payments for LTCH PPS standard Federal payment rate cases will increase payments by approximately 0.4 percentage point .D.3. of the Addendum to this final rule, we now estimate that high cost outlier payments for LTCH PPS standard Federal payment rate cases will increase payments by approximately 0.4 percentage point (rather than decrease payments by approximately 0.3 percentage points as projected in the proposed rule based on the best data available at that time). As we discuss in detail throughout this final rule, based on the best available data, we believe that the provisions of this final rule relating to the LTCH PPS, which are projected to result in an overall increase in estimated aggregate LTCH PPS payments (for both LTCH PPS standard Federal payment rate cases and site neutral payment rate cases), and the resulting LTCH PPS payment amounts will result in appropriate Medicare payments that are consistent with the statute. 2. Impact on Rural Hospitals For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of an urban area and has fewer than 100 beds. As shown in Table IV, we are projecting a 3.0 percent increase in estimated payments for LTCH PPS standard Federal payment rate cases for LTCHs located in a rural area. This increase r than 100 beds. As shown in Table IV, we are projecting a 3.0 percent increase in estimated payments for LTCH PPS standard Federal payment rate cases for LTCHs located in a rural area. This increase is primarily due to the combination of the 2.7 percent annual update to the LTCH PPS standard Federal payment rate for FY 2026, the changes to the area wage level adjustment, and estimated changes in outlier payments. This estimated impact is based on the FY 2024 data for the 17 rural LTCHs (out of 327 LTCHs) that were used for the impact analyses shown in Table IV. 3. Anticipated Effects of the LTCH PPS Payment Rate Changes and Policy Changes a. Budgetary Impact Section 123(a)(1) of the BBRA requires that the PPS developed for LTCHs ‘‘maintain budget neutrality.’’ We believe that the statute’s mandate for budget neutrality applies only to the first year of the implementation of the LTCH PPS (that is, FY 2003). Therefore, in calculating the FY 2003 standard Federal payment rate under § 412.523(d)(2), we set total estimated payments for FY 2003 under the LTCH PPS so that estimated aggregate payments under the LTCH PPS were estimated to equal the amount that would have been paid if the L .523(d)(2), we set total estimated payments for FY 2003 under the LTCH PPS so that estimated aggregate payments under the LTCH PPS were estimated to equal the amount that would have been paid if the LTCH PPS had not been implemented. Section 1886(m)(6)(A) of the Act establishes a dual rate LTCH PPS payment structure with two distinct payment rates for LTCH discharges beginning in FY 2016. Under this statutory change, LTCH discharges that meet the patient-level criteria for exclusion from the site neutral payment rate (that is, LTCH PPS standard Federal payment rate cases) are paid based on the LTCH PPS standard Federal payment rate. LTCH discharges paid at the site neutral payment rate are generally paid the lower of the IPPS comparable per diem amount, reduced by 4.6 percent for FYs 2018 through 2026, including any applicable high-cost outlier (HCO) payments, or 100 percent of the estimated cost of the case, reduced by 4.6 percent. As discussed in section I.J.1. of this appendix, we project an increase in aggregate LTCH PPS payments in FY 2026 of approximately $83 million. This estimated increase in payments reflects the projected increase in payments to LTCH PPS standard Federal roject an increase in aggregate LTCH PPS payments in FY 2026 of approximately $83 million. This estimated increase in payments reflects the projected increase in payments to LTCH PPS standard Federal payment rate cases of approximately $73 million and the projected increase in payments to site neutral payment rate cases of approximately $10 million under the dual rate LTCH PPS payment rate structure required by the statute beginning in FY 2016. Consistent with prior years, Table IV only reflects changes in LTCH PPS payments for LTCH PPS standard Federal payment rate cases and, unless otherwise noted, the remaining discussion in section I.J.3. of this appendix refers only to the impact on LTCH PPS payments for LTCH PPS standard Federal payment rate cases. In the following section, we present our provider impact analysis for the changes that affect LTCH PPS payments for LTCH PPS standard Federal payment rate cases. b. Impact on Providers The basic methodology for determining a per discharge payment for LTCH PPS standard Federal payment rate cases is currently set forth under §§ 412.515 through 412.533 and 412.535. In addition to adjusting the LTCH PPS standard Federal payment rate by rge payment for LTCH PPS standard Federal payment rate cases is currently set forth under §§ 412.515 through 412.533 and 412.535. In addition to adjusting the LTCH PPS standard Federal payment rate by the MS–LTC–DRG relative weight, we make adjustments to account for area wage levels and SSOs. LTCHs located in Alaska and Hawaii also have their payments adjusted by a COLA. Under our application of the dual rate LTCH PPS payment structure, the LTCH PPS standard Federal payment rate is generally only used to determine payments for LTCH PPS standard Federal payment rate cases (that is, those LTCH PPS cases that meet the statutory criteria to be excluded from the site neutral payment rate). LTCH discharges that do not meet the patient-level criteria for exclusion are paid the site neutral payment rate, which we are calculating as the lower of the IPPS comparable per diem amount as determined under § 412.529(d)(4), reduced by 4.6 percent for FYs 2018 through 2026, including any applicable outlier payments, or 100 percent of the estimated cost of the case as determined under existing § 412.529(d)(2). In addition, when certain thresholds are met, LTCHs also receive HCO payments for both LT tlier payments, or 100 percent of the estimated cost of the case as determined under existing § 412.529(d)(2). In addition, when certain thresholds are met, LTCHs also receive HCO payments for both LTCH PPS standard Federal payment rate cases and site neutral payment rate cases that are paid at the IPPS comparable per diem amount. To understand the impact of the changes to the LTCH PPS payments for LTCH PPS standard Federal payment rate cases presented in this final rule on different categories of LTCHs for FY 2026, it is necessary to estimate payments per discharge for FY 2025 using the rates, factors, and the policies established in the FY 2025 IPPS/ LTCH PPS final rule and estimate payments per discharge for FY 2026 using the rates, factors, and the policies in this final rule (as discussed in section IX. of the preamble of this final rule and section V. of the Addendum to this final rule). As discussed elsewhere in this final rule, these estimates are based on the best available LTCH claims data and other factors, such as the application of inflation factors to estimate costs for HCO cases in each year. The resulting analyses can then be used to compare how our policies applica CH claims data and other factors, such as the application of inflation factors to estimate costs for HCO cases in each year. The resulting analyses can then be used to compare how our policies applicable to LTCH PPS standard Federal payment rate cases affect different groups of LTCHs. For the following analysis, we group hospitals based on characteristics provided in the OSCAR data, cost report data in HCRIS, and PSF data. Hospital groups included the following: • Location: large urban/other urban/rural. • Ownership control. • Census region. • Bed size. c. Calculation of LTCH PPS Payments for LTCH PPS Standard Federal Payment Rate Cases For purposes of this impact analysis, to estimate the per discharge payment effects of our policies on payments for LTCH PPS standard Federal payment rate cases, we VerDate Sep 2014 00:36 Aug 02, 2025 Jkt 265001 PO 00000 Frm 00764 Fmt 4701 Sfmt 4700 E:\FR\FM\04AUR2.SGM 04AUR2 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k Federal Register / Vol. 90, No. 147 / Monday, August 4, 2025 / Rules and Regulations 37299 simulated FY 2025 and FY 2026 payments on a case-by-case basis using historical LTCH claims from the FY 2024 MedPAR fil gister / Vol. 90, No. 147 / Monday, August 4, 2025 / Rules and Regulations 37299 simulated FY 2025 and FY 2026 payments on a case-by-case basis using historical LTCH claims from the FY 2024 MedPAR files that met or would have met the criteria to be paid at the LTCH PPS standard Federal payment rate if the statutory patient-level criteria had been in effect at the time of discharge for all cases in the FY 2024 MedPAR files. For modeling FY 2025 LTCH PPS payments, we used the FY 2025 standard Federal payment rate of $49,383.26 (or $48,424.36 for LTCHs that failed to submit quality data as required under the requirements of the LTCH QRP). Similarly, for modeling payments based on the FY 2026 LTCH PPS standard Federal payment rate, we used the FY 2026 standard Federal payment rate of $50,824.51 (or $49,834.74 for LTCHs that failed to submit quality data as required under the requirements of the LTCH QRP). In each case, we applied the applicable adjustments for area wage levels and the COLA for LTCHs located in Alaska and Hawaii. Specifically, for modeling FY 2025 LTCH PPS payments, we used the current FY 2025 labor-related share (72.8 percent), the wage index values established in the for LTCHs located in Alaska and Hawaii. Specifically, for modeling FY 2025 LTCH PPS payments, we used the current FY 2025 labor-related share (72.8 percent), the wage index values established in the Tables 12A and 12B listed in the Addendum to the FY 2025 IPPS/LTCH PPS final rule (which are available via the internet on the CMS website), the FY 2025 HCO fixed-loss amount for LTCH PPS standard Federal payment rate cases of $77,048 (as reflected in the FY 2025 IPPS/ LTCH PPS final rule), and the FY 2025 COLA factors (shown in the table in section V.C. of the Addendum to that final rule) to adjust the FY 2025 nonlabor-related share (27.2 percent) for LTCHs located in Alaska and Hawaii. Similarly, for modeling FY 2026 LTCH PPS payments, we used the FY 2026 LTCH PPS labor-related share (72.9 percent), the FY 2026 wage index values from Tables 12A and 12B listed in section VI. of the Addendum to this final rule (which are available via the internet on the CMS website), the FY 2026 HCO fixed-loss amount for LTCH PPS standard Federal payment rate cases of $78,936 (as discussed in section V.D.3. of the Addendum to this final rule), and the FY 2026 COLA factors (shown in the table in sectio -loss amount for LTCH PPS standard Federal payment rate cases of $78,936 (as discussed in section V.D.3. of the Addendum to this final rule), and the FY 2026 COLA factors (shown in the table in section V.C. of the Addendum to this final rule) to adjust the FY 2026 nonlabor- related share (27.1 percent) for LTCHs located in Alaska and Hawaii. We note that in modeling payments for HCO cases for LTCH PPS standard Federal payment rate cases, we inflated charges reported on the FY 2024 claims by the charge inflation factors in section V.D.3.b. of the Addendum to this final rule. We also note that in modeling payments for HCO cases for LTCH PPS standard Federal payment rate cases, we estimated the cost of each case by multiplying the inflated charges by the adjusted CCRs that we determined using our methodology described in section V.D.3.b. of the Addendum to this final rule. The impacts that follow reflect the estimated ‘‘losses’’ or ‘‘gains’’ among the various classifications of LTCHs from FY 2025 to FY 2026 based on the payment rates and policy changes applicable to LTCH PPS standard Federal payment rate cases presented in this final rule. Table IV illustrates the estimated aggregate FY 2025 to FY 2026 based on the payment rates and policy changes applicable to LTCH PPS standard Federal payment rate cases presented in this final rule. Table IV illustrates the estimated aggregate impact of the change in LTCH PPS payments for LTCH PPS standard Federal payment rate cases among various classifications of LTCHs. (As discussed previously, these impacts do not include LTCH PPS site neutral payment rate cases.) • The first column, LTCH Classification, identifies the type of LTCH. • The second column lists the number of LTCHs of each classification type. • The third column identifies the number of LTCH cases expected to meet the LTCH PPS standard Federal payment rate criteria. • The fourth column shows the estimated FY 2025 payment per discharge for LTCH cases expected to meet the LTCH PPS standard Federal payment rate criteria (as described previously). • The fifth column shows the estimated FY 2026 payment per discharge for LTCH cases expected to meet the LTCH PPS standard Federal payment rate criteria (as described previously). • The sixth column shows the percentage change in estimated payments per discharge for LTCH cases expected to meet the LTCH PPS standard Fed rd Federal payment rate criteria (as described previously). • The sixth column shows the percentage change in estimated payments per discharge for LTCH cases expected to meet the LTCH PPS standard Federal payment rate criteria from FY 2025 to FY 2026 due to the annual update to the standard Federal rate (as discussed in section V.A.2. of the Addendum to this final rule). • The seventh column shows the percentage change in estimated payments per discharge for LTCH PPS standard Federal payment rate cases from FY 2025 to FY 2026 due to the changes to the area wage level adjustment (that is, the updated hospital wage data and the labor-related share) and the application of the corresponding budget neutrality factor (as discussed in section V.B.6. of the Addendum to this final rule). • The eighth column shows the percentage change in estimated payments per discharge for LTCH PPS standard Federal payment rate cases from FY 2025 (Column 4) to FY 2026 (Column 5) due to all changes. TABLE IV—IMPACT OF PAYMENT RATE AND POLICY CHANGES TO LTCH PPS PAYMENTS FOR LTCH PPS STANDARD FEDERAL PAYMENT RATE CASES FOR FY 2026 [Estimated FY 2025 payments compared to estimated FY 2026 payments] LTCH Class PACT OF PAYMENT RATE AND POLICY CHANGES TO LTCH PPS PAYMENTS FOR LTCH PPS STANDARD FEDERAL PAYMENT RATE CASES FOR FY 2026 [Estimated FY 2025 payments compared to estimated FY 2026 payments] LTCH Classification No. of LTCHS Number of LTCH PPS Standard payment rate cases Average FY 2025 LTCH PPS payment per standard payment rate Average FY 2026 LTCH PPS payment per standard payment rate 1 Change Due to change to the annual update to the standard federal rate 2 Percent change due to changes to area wage ad- justment with wage budget neutrality 3 Percent change due to all standard payment rate Changes 4 (1) (2) (3) (4) (5) (6) (7) (8) ALL PROVIDERS .......................................... BY LOCATION: RURAL ................................................... URBAN ................................................... BY OWNERSHIP TYPE: VOLUNTARY ......................................... PROPRIETARY ..................................... GOVERNMENT ..................................... BY REGION: NEW ENGLAND .................................... MIDDLE ATLANTIC ............................... SOUTH ATLANTIC ................................ EAST NORTH CENTRAL ...................... EAST SO GION: NEW ENGLAND .................................... MIDDLE ATLANTIC ............................... SOUTH ATLANTIC ................................ EAST NORTH CENTRAL ...................... EAST SOUTH CENTRAL ...................... WEST NORTH CENTRAL ..................... WEST SOUTH CENTRAL ..................... MOUNTAIN ............................................ PACIFIC ................................................. BY BED SIZE: BEDS: 0–24 ........................................... BEDS: 25–49 ......................................... BEDS: 50–74 ......................................... BEDS: 75–124 ....................................... 327 17 310 53 266 8 10 20 60 46 32 21 90 25 23 37 153 75 42 43,513 55,243 56,921 1,343 42,170 5,032 37,937 544 1,334 3,018 9,465 5,490 3,288 2,369 10,627 2,143 5,779 2,272 16,905 10,868 8,179 43,770 55,608 59,674 54,408 72,473 49,914 63,843 53,164 56,164 48,779 51,090 49,756 56,880 69,371 54,222 49,188 56,321 63,707 45,084 57,298 62,211 55,959 75,072 51,487 66,684 54,968 58,382 50,813 53,305 50,513 58,407 71,080 55,441 50,704 58,181 65,674 2.6 2.6 2.6 2.5 2.6 2.6 2.7 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.5 2.6 2.6 2.6 2.6 0.0 ¥0.1 0.0 0.5 ¥0.1 959 75,072 51,487 66,684 54,968 58,382 50,813 53,305 50,513 58,407 71,080 55,441 50,704 58,181 65,674 2.6 2.6 2.6 2.5 2.6 2.6 2.7 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.5 2.6 2.6 2.6 2.6 0.0 ¥0.1 0.0 0.5 ¥0.1 ¥0.8 0.8 0.5 0.5 0.3 0.7 1.0 ¥0.7 0.0 ¥0.9 ¥0.3 0.4 0.1 ¥0.3 3.0 3.0 3.0 4.3 2.9 3.6 3.2 4.5 3.4 3.9 4.2 4.3 1.5 2.7 2.5 2.2 3.1 3.3 3.1 VerDate Sep 2014 00:36 Aug 02, 2025 Jkt 265001 PO 00000 Frm 00765 Fmt 4701 Sfmt 4700 E:\FR\FM\04AUR2.SGM 04AUR2 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k 37300 Federal Register / Vol. 90, No. 147 / Monday, August 4, 2025 / Rules and Regulations TABLE IV—IMPACT OF PAYMENT RATE AND POLICY CHANGES TO LTCH PPS PAYMENTS FOR LTCH PPS STANDARD FEDERAL PAYMENT RATE CASES FOR FY 2026—Continued [Estimated FY 2025 payments compared to estimated FY 2026 payments] LTCH Classification No. of LTCHS Number of LTCH PPS Standard payment rate cases Average FY 2025 LTCH PPS payment per standard payment rate Average FY 2026 LTCH PPS payment per standard payment rate 1 Change Due to change to the annual update to the standard federal rate 2 Percent change due to changes to area wage ad- justment with wage budget neutrality 3 Percent change due to ard payment rate 1 Change Due to change to the annual update to the standard federal rate 2 Percent change due to changes to area wage ad- justment with wage budget neutrality 3 Percent change due to all standard payment rate Changes 4 (1) (2) (3) (4) (5) (6) (7) (8) BEDS: 125+ ........................................... 20 5,289 59,727 61,304 2.6 ¥0.5 2.6 1 Estimated FY 2026 LTCH PPS payments for LTCH PPS standard Federal payment rate criteria based on the payment rate and factor changes applicable to such cases presented in the preamble of and the Addendum to this final rule. 2 Percent change in estimated payments per discharge for LTCH PPS standard Federal payment rate cases from FY 2025 to FY 2026 due to the annual update to the LTCH PPS standard Federal payment rate. 3 Percent change in estimated payments per discharge for LTCH PPS standard Federal payment rate cases from FY 2025 to FY 2026 due to the changes to the area wage level adjustment under § 412.525(c) (that is, the updated hospital wage data and the labor-related share) with budget neutrality. 4 Percent change in estimated payments per discharge for LTCH PPS standard Federal payment rate cases from FY 2025 (shown in ed hospital wage data and the labor-related share) with budget neutrality. 4 Percent change in estimated payments per discharge for LTCH PPS standard Federal payment rate cases from FY 2025 (shown in Column 4) to FY 2026 (shown in Column 5), due to all of the changes to the rates and factors applicable to such cases presented in the preamble and the Addendum to this final rule. We note that this column, which shows the percent change in estimated payments per discharge due to all changes, does not equal the sum of the percent changes in estimated payments per discharge due to the annual update to the LTCH PPS standard Federal payment rate (Column 6) and due to the changes to the area wage level ad- justment with budget neutrality (Column 7) due to the effect of estimated changes in estimated payments to aggregate HCO payments for LTCH PPS standard Fed- eral payment rate cases (as discussed in this impact analysis), as well as other interactive effects that cannot be isolated. d. Results Based on the FY 2024 LTCH cases (from 327 LTCHs) that were used for the analyses in this final rule, we have prepared the following summary of the impact (as shown in Table IV) of the LTCH PPS payme s Based on the FY 2024 LTCH cases (from 327 LTCHs) that were used for the analyses in this final rule, we have prepared the following summary of the impact (as shown in Table IV) of the LTCH PPS payment rate and policy changes for LTCH PPS standard Federal payment rate cases presented in this final rule. The impact analysis in Table IV shows that estimated payments per discharge for LTCH PPS standard Federal payment rate cases are projected to increase 3.0 percent, on average, for all LTCHs from FY 2025 to FY 2026 as a result of the payment rate and policy changes applicable to LTCH PPS standard Federal payment rate cases presented in this final rule. This estimated 3.0 percent increase in LTCH PPS payments per discharge was determined by comparing estimated FY 2026 LTCH PPS payments (using the payment rates and factors discussed in this final rule) to estimated FY 2025 LTCH PPS payments for LTCH discharges which will be LTCH PPS standard Federal payment rate cases if the dual rate LTCH PPS payment structure was or had been in effect at the time of the discharge (as described in section I.J.3. of this appendix). As stated previously, we are finalizing an annual update to the LTCH P H PPS payment structure was or had been in effect at the time of the discharge (as described in section I.J.3. of this appendix). As stated previously, we are finalizing an annual update to the LTCH PPS standard Federal payment rate for FY 2026 of 2.7 percent. For LTCHs that fail to submit quality data under the requirements of the LTCH QRP, as required by section 1886(m)(5)(C) of the Act, a 2.0 percentage point reduction is applied to the annual update to the LTCH PPS standard Federal payment rate. Consistent with § 412.523(d)(4), we also are applying a budget neutrality factor for changes to the area wage level adjustment of 1.0021275 (discussed in section V.B.6. of the Addendum to this final rule), based on the best available data at this time, to ensure that any changes to the area wage level adjustment will not result in any change (increase or decrease) in estimated aggregate LTCH PPS standard Federal payment rate payments. As we also explained earlier in this section of the rule, for most categories of LTCHs (as shown in Table IV, Column 6), the estimated payment increase due to the 2.7 percent annual update to the LTCH PPS standard Federal payment rate is projected to resul , for most categories of LTCHs (as shown in Table IV, Column 6), the estimated payment increase due to the 2.7 percent annual update to the LTCH PPS standard Federal payment rate is projected to result in approximately a 2.6 percent increase in estimated payments per discharge for LTCH PPS standard Federal payment rate cases for all LTCHs from FY 2025 to FY 2026. We note our estimate of the changes in payments due to the update to the LTCH PPS standard Federal payment rate also includes estimated payments for SSO cases, a portion of which are not affected by the annual update to the LTCH PPS standard Federal payment rate, as well as the reduction that is applied to the annual update for LTCHs that do not submit data under the requirements of the LTCH QRP. (1) Location Based on the most recent available data, the vast majority of LTCHs are located in urban areas. Only approximately 5 percent of the LTCHs are identified as being located in a rural area, and approximately 3 percent of all LTCH PPS standard Federal payment rate cases are expected to be treated in these rural hospitals. The impact analysis presented in Table IV shows that the average percent increase in estimated paymen LTCH PPS standard Federal payment rate cases are expected to be treated in these rural hospitals. The impact analysis presented in Table IV shows that the average percent increase in estimated payments per discharge for LTCH PPS standard Federal payment rate cases from FY 2025 to FY 2026 is 3.0 percent for LTCHs located in both urban and rural areas. (2) Ownership Control LTCHs are grouped into three categories based on ownership control type: voluntary, proprietary, and government. Based on the best available data, approximately 16 percent of LTCHs are identified as voluntary (Table IV). The majority (approximately 81 percent) of LTCHs are identified as proprietary, while government owned and operated LTCHs represent approximately 3 percent of LTCHs. Based on ownership type, proprietary LTCHs are expected to experience an increase in payments to LTCH PPS standard Federal payment rate cases of 2.9 percent. Voluntary LTCHs are expected to experience an increase in payments to LTCH PPS standard Federal payment rate cases from FY 2025 to FY 2026 of 4.3 percent. Government owned and operated LTCHs are expected to experience an increase in payments to LTCH PPS standard Federal payment standard Federal payment rate cases from FY 2025 to FY 2026 of 4.3 percent. Government owned and operated LTCHs are expected to experience an increase in payments to LTCH PPS standard Federal payment rate cases from FY 2025 to FY 2026 of 3.6 percent. (3) Census Region The comparisons by region show that the changes in estimated payments per discharge for LTCH PPS standard Federal payment rate cases from FY 2025 to FY 2026 are projected an increase from 1.5 percent in the West South Central region to 4.5 percent in the Middle Atlantic region. These regional variations are primarily due to the changes to the area wage adjustment and estimated changes in outlier payments. (4) Bed Size LTCHs are grouped into five categories based on bed size: 0–24 beds; 25–49 beds; 50–74 beds; 75–124 beds; and greater than 125 beds. We project that LTCHs with 50–74 beds will experience the largest increase in payments with 3.3 percent. The remaining bed size categories are projected to experience an increase in payments in the range of 2.2 to 3.1 percent. 4. Effect on the Medicare Program As stated previously, we project that the provisions of this final rule will result in an increase in estimated agg se in payments in the range of 2.2 to 3.1 percent. 4. Effect on the Medicare Program As stated previously, we project that the provisions of this final rule will result in an increase in estimated aggregate LTCH PPS payments to LTCH PPS standard Federal payment rate cases in FY 2026 relative to FY 2025 of approximately $73 million (or approximately 3.0 percent) for the 329 LTCHs in our database. Although, as stated previously, the hospital-level impacts do not include LTCH PPS site neutral payment rate cases, we estimate that the provisions of this final rule will result in an increase in estimated aggregate LTCH PPS payments to site neutral payment rate cases in FY 2026 relative to FY 2025 of approximately $10 million (or approximately 10.0 percent) for the 329 LTCHs in our database. (As noted previously, we estimate payments to site neutral payment rate cases in FY 2026 will represent approximately 4.1 percent of total estimated FY 2026 LTCH PPS payments.) Therefore, we project that the provisions of VerDate Sep 2014 00:36 Aug 02, 2025 Jkt 265001 PO 00000 Frm 00766 Fmt 4701 Sfmt 4700 E:\FR\FM\04AUR2.SGM 04AUR2 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k Fe the provisions of VerDate Sep 2014 00:36 Aug 02, 2025 Jkt 265001 PO 00000 Frm 00766 Fmt 4701 Sfmt 4700 E:\FR\FM\04AUR2.SGM 04AUR2 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k Federal Register / Vol. 90, No. 147 / Monday, August 4, 2025 / Rules and Regulations 37301 this final rule will result in an increase in estimated aggregate LTCH PPS payments for all LTCH cases in FY 2026 relative to FY 2025 of approximately $83 million (or approximately 3.3 percent) for the 329 LTCHs in our database. 5. Effect on Medicare Beneficiaries Under the LTCH PPS, hospitals receive payment based on the average resources consumed by patients for each diagnosis. We do not expect any changes in the quality of care or access to services for Medicare beneficiaries as a result of this final rule, but we continue to expect that paying prospectively for LTCH services will enhance the efficiency of the Medicare program. As discussed previously, we do not expect the continued implementation of the site neutral payment system to have a negative impact on access to or quality of care, as demonstrated in areas where there is little or no LTCH presence, general short-term acute care hospitals f the site neutral payment system to have a negative impact on access to or quality of care, as demonstrated in areas where there is little or no LTCH presence, general short-term acute care hospitals are effectively providing treatment for the same types of patients that are treated in LTCHs. K. Effects of Requirements for the Hospital Inpatient Quality Reporting (IQR) Program In sections X.C.3., X.C.4, and X.C.7. of the preamble of this final rule, we discuss the finalized requirements for hospitals reporting quality data under the Hospital IQR Program to receive the full annual percentage increase for the FY 2026 payment determination and subsequent years. In this final rule, we are: (1) modifying the Hospital 30-Day, All-Cause, Risk- Standardized Mortality Rate (RSMR) Following Acute Ischemic Stroke Hospitalization claims-based measure, beginning with the FY 2027 payment determination, associated with a July 1, 2023—June 30, 2025 performance period; (2) modifying the Hospital-Level, Risk- Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) claims-based measure beginning with the FY 2027 payment deter , Risk- Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) claims-based measure beginning with the FY 2027 payment determination, associated with the April 1, 2023—March 31, 2025 performance period; (3) modifying the reporting requirements of the Hybrid Hospital-Wide Readmission (HWR) measure beginning with the FY 2028 payment determination, associated with a July 1, 2025—June 30, 2026, performance period; (4) modifying the reporting requirements of the Hybrid Hospital-Wide Mortality (HWM) measure beginning with the FY 2028 payment determination, associated with a July 1, 2025—June 30, 2026, performance period; (5) removing the Hospital Commitment to Health Equity measure beginning with the CY 2024 reporting period/FY 2026 payment determination; (6) removing the COVID–19 Vaccination Coverage among Healthcare Personnel (HCP) measure beginning with the CY 2024 reporting period/FY 2026 payment determination; (7) removing the Screening for Social Drivers of Health measure beginning with the CY 2024 reporting period/FY 2026 payment determination; and (8) removing the Screen Positive Rate for Social Drivers o 7) removing the Screening for Social Drivers of Health measure beginning with the CY 2024 reporting period/FY 2026 payment determination; and (8) removing the Screen Positive Rate for Social Drivers of Health measure beginning with the CY 2024 reporting period/FY 2026 payment determination. As shown in the summary tables in section XIII.B.4.h. of the preamble of this final rule, we estimate a decrease of 627,027 hours at a savings of $16,116,129 in information collection burden associated with the finalized policies compared to the currently approved information collection burden estimates under OMB control number 0938– 1022 (expiration date January 31, 2026). We also estimate a decrease of between 24,400 hours at a savings of $1,378,600 and 27,450 hours at a savings of $1,608,570 in information collection burden associated with the finalized policies compared to the currently approved information collection burden estimates and under OMB control number 0920–1317 (expiration date January 31, 2028). In section X.C.7. of the preamble of this final rule, we are modifying reporting requirements of the Hybrid HWR and HWM measures beginning with the FY 2028 payment determination. This mo ry 31, 2028). In section X.C.7. of the preamble of this final rule, we are modifying reporting requirements of the Hybrid HWR and HWM measures beginning with the FY 2028 payment determination. This modification will lower the submission thresholds for both the Hybrid HWR and HWM measures to allow for up to two missing laboratory results and up to two missing vital signs, reduce the core clinical data elements (CCDEs) submission requirement to 70 percent or more of discharges, and reduce the submission requirement of linking variables to 70 percent or more of discharges. While we are unable to quantify the associated impact, we believe these modifications will result in reducing the overall administrative burden required by hospitals to report these measures. Regarding the remaining proposals, we do not believe any of these proposals will result in any additional economic impact beyond those discussed in section XIII.B.4. of the preamble of this final rule (Collection of Information). Historically, 100 hospitals, on average, that participate in the Hospital IQR Program do not receive the full annual percentage increase in any fiscal year due to the failure to meet all requirements o istorically, 100 hospitals, on average, that participate in the Hospital IQR Program do not receive the full annual percentage increase in any fiscal year due to the failure to meet all requirements of the Hospital IQR Program. We anticipate that the number of hospitals not receiving the full annual percentage increase will be approximately the same as in past years based on review of previous performance. We received no comments on our assumptions regarding these effects. L. Effects of New Requirements for the PPS- Exempt Cancer Hospital Quality Reporting (PCHQR) Program In section X.D. of the preamble of this final rule, we discuss finalized requirements for PPS-exempt cancer hospitals (PCHs) reporting quality data under the PCH Quality Reporting (PCHQR) Program. The PCHQR Program is authorized under section 1866(k) of the Act. There is no financial impact to PCH Medicare reimbursement if a PCH does not submit data. In this final rule, we are: (1) removing the Hospital Commitment to Health Equity measure beginning with the FY 2026 program year; (2) removing the Screening for Social Drivers of Health measure beginning with the FY 2026 program year; and (3) removing the Screen Posi Health Equity measure beginning with the FY 2026 program year; (2) removing the Screening for Social Drivers of Health measure beginning with the FY 2026 program year; and (3) removing the Screen Positive Rate for Social Drivers of Health measure beginning with the FY 2026 program year. We are also modifying the public reporting requirements to allow for public reporting of the PCHQR Program on the Care Compare tool on Medicare.gov or a successor website in addition to current publication in the Provider Data Catalog. As shown in the summary tables in section XIII.B.5.f. of the preamble of this final rule, we estimate a decrease of 107 hours at a savings of $2,921 in information collection burden associated with the finalized policies compared to the currently approved information collection burden estimates under OMB control number 0938–1175 (expiration date November 30, 2027). We do not believe any of these policies will result in any additional economic impact beyond those discussed in section XIII.B.5. of the preamble of this final rule (Collection of Information). We received no comments on our assumptions regarding these effects. M. Effects of Requirements for the Long-Term C in section XIII.B.5. of the preamble of this final rule (Collection of Information). We received no comments on our assumptions regarding these effects. M. Effects of Requirements for the Long-Term Care Hospital Quality Reporting Program (LTCH QRP) In section X.E.3. of this final rule, we are finalizing our proposal to modify reporting requirements for the COVID–19 Vaccine: Percent of Patients/Residents Who are Up to Date measure to exclude patients who have expired in the LTCH beginning on October 1, 2026, for the FY 2028 LTCH QRP. In section X.E.4. of this final rule, we are finalizing our proposal to remove four standardized patient assessment data elements collected under the SDOH category from the LTCH QRP beginning with the FY 2028 LTCH QRP. Additionally, we are finalizing our proposal to amend our reconsideration policy and process as described in section X.E.5 of the preamble of this proposed rule. Finally, in sections X.E.6 through X.E.8. of the proposed rule, we sought public comment on several Requests for Information (RFIs), specifically: (1) future measure concepts for the LTCH QRP; (2) revisions to the data submission deadlines for assessment data collected for the L c comment on several Requests for Information (RFIs), specifically: (1) future measure concepts for the LTCH QRP; (2) revisions to the data submission deadlines for assessment data collected for the LTCH QRP; and (3) advancing digital quality measurement (dQM) in the LTCH QRP. The effect of these proposals for the LTCH QRP would be an overall decrease in burden for LTCHs participating in the LTCH QRP. For the FY 2026 LTCH QRP, we estimate an increase in burden related to the proposal to amend the reconsideration request policy and process, as described in section X.E.4. of the preamble of this final rule. For LTCHs that seek to file an extension to file a request for reconsideration of a noncompliance determination, we estimate that this form will take LTCHs approximately 15 minutes to complete. We believe that this data would be entered by medical records specialists. However, LTCHs determine the staffing resources necessary. For the purposes of calculating the costs we obtained median hourly wages from the U.S. Bureau of Labor Statistics’ (BLS) May 2023 National Occupational Employment and Wage Estimates.2 To account for overhead and fringe benefits, we have doubled the hourly wa n hourly wages from the U.S. Bureau of Labor Statistics’ (BLS) May 2023 National Occupational Employment and Wage Estimates.2 To account for overhead and fringe benefits, we have doubled the hourly wage. These amounts are detailed in Table I.M.–01. VerDate Sep 2014 00:36 Aug 02, 2025 Jkt 265001 PO 00000 Frm 00767 Fmt 4701 Sfmt 4700 E:\FR\FM\04AUR2.SGM 04AUR2 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k 37302 Federal Register / Vol. 90, No. 147 / Monday, August 4, 2025 / Rules and Regulations TABLE I.M.–01—U.S. BUREAU OF LABOR AND STATISTICS’ MAY 2023 NATIONAL OCCUPATIONAL EMPLOYMENT AND WAGE ESTIMATE Occupational title Occupation code Median hourly wage ($/hr) Other indirect costs and fringe benefits ($/hr) Adjustes hour- ly wage ($/hr) Medical Records Specialist ............................................................................. 29–2072 $23.45 $23.45 $49.60 We estimate that the collection of this form will result in an additional 15 minutes, or 0.25 hours, per form. Based on the number of reconsiderations requests we have received in the previous 3 years, we estimate an average of 16 forms per year, for an additional 4 hours per year (0.25 hours × urs, per form. Based on the number of reconsiderations requests we have received in the previous 3 years, we estimate an average of 16 forms per year, for an additional 4 hours per year (0.25 hours × 16 forms per year) for all LTCHs. Given an estimated $46.90 hourly wage, we estimate an increase of $187.60 (4 hours × $46.90) for all LTCHs annually or $0.57 per LTCHs that submit reconsiderations. For the FY 2028 LTCH QRP, as shown in summary table XII.B–09 in section XII.B.6. of this final rule, we estimate a total information collection burden decrease for 330 eligible LTCHs of 7.98 hours per LTCH, or 2,633.51 hours for all LTCHs, for a total cost decrease of approximately ¥$180,016.80, or $545.51 per LTCH annually associated with our proposed policies and updated burden estimates for the FY 2028 program year compared to our currently approved information collection burden estimates. We refer readers to section XII.B.6. of this final rule, where CMS has provided an estimate of the burden and cost to LTCHs, and note that it will be included in a revised information collection request for 0938–1163. We have summarized the comments we received about modifying reporting requirements fo en and cost to LTCHs, and note that it will be included in a revised information collection request for 0938–1163. We have summarized the comments we received about modifying reporting requirements for the Patient/Resident COVID–19 Vaccination Measure in section X.E.3. of this final rule, removing four standardized patient assessment data elements collected under the SDOH category in section X.E.4. of this final rule, and amending the reconsideration policy and process in X.E.5. of this final rule, and provided responses. We did not receive comments specific to the estimates. After consideration of the public comments, we are finalizing these proposals without modification. N. Effects of Requirements Regarding the Medicare Promoting Interoperability Program In section X.F. of the preamble of this final rule, we discuss finalized requirements for eligible hospitals and critical access hospitals (CAHs) to report objectives and measures and electronic Clinical Quality Measures (eCQMs) under the Medicare Promoting Interoperability Program. In this final rule, we are: (1) adopting a new optional bonus measure under the Public Health and Clinical Data Exchange objective for health inform er the Medicare Promoting Interoperability Program. In this final rule, we are: (1) adopting a new optional bonus measure under the Public Health and Clinical Data Exchange objective for health information exchange to a public health agency (PHA) that occurs using the Trusted Exchange Framework and Common Agreement (TEFCA), and where the eligible hospital or CAH meets certain additional requirements, beginning with the electronic health record (EHR) reporting period in CY 2026; (2) modifying the Safety Assurance Factors for Electronic Health Record Resilience (SAFER) Guides measure by requiring eligible hospitals and CAHs to attest ‘‘yes’’ to completing an annual self- assessment using the SAFER Guides published in January 2025 beginning with the EHR reporting period in CY 2026; (3) modifying the Security Risk Analysis measure by adding a requirement for eligible hospitals and CAHs to attest ‘‘yes’’ to having conducted security risk management as required by the HIPAA Security Rule beginning with the EHR reporting period in CY 2026; and (4) defining the EHR reporting period in CY 2026 and subsequent years as a minimum of any continuous 180-day period within that calendar year for e inning with the EHR reporting period in CY 2026; and (4) defining the EHR reporting period in CY 2026 and subsequent years as a minimum of any continuous 180-day period within that calendar year for eligible hospitals and CAHs participating in the Medicare Promoting Interoperability Program and making corresponding revisions at 42 CFR 495.4. As discussed in section XIII.B.7. of the preamble of this final rule, we estimate no change in information collection burden associated with our proposed policies and updated burden estimates for the EHR reporting period in CY 2026 and future years compared to our currently approved information collection burden estimates. We refer readers to section XIII.B.7. of the preamble of this final rule (Collection of Information) for a detailed discussion of the calculations estimating the changes to the information collection burden for submitting data to the Medicare Promoting Interoperability Program. In section X.F.5. of the preamble of this final rule, we are adopting a new optional bonus measure under the Public Health and Clinical Data Exchange objective for health information exchange to a PHA that occurs using TEFCA, and where the eligible hos , we are adopting a new optional bonus measure under the Public Health and Clinical Data Exchange objective for health information exchange to a PHA that occurs using TEFCA, and where the eligible hospital or CAH meets certain additional requirements, beginning with the EHR reporting period in CY 2026. For eligible hospitals and CAHs that already report health information to a PHA using TEFCA, there will be no additional economic impacts if they elect to voluntarily attest to this optional bonus measure. For eligible hospitals and CAHs that are currently using another means for reporting data to a PHA and desire to attest to this optional bonus measure, there will be some non-recurring costs associated with the transition to set up and technically validate the functioning of the information exchange. In addition, eligible hospitals and CAHs may also incur some recurring costs associated with TEFCA connectivity depending on the nature of their agreement with the health IT vendors or other entities through which they participate in TEFCA. However, because each eligible hospital, CAH, and health IT vendor or other entity is unique and we lack sufficient insight into the individual dec er entities through which they participate in TEFCA. However, because each eligible hospital, CAH, and health IT vendor or other entity is unique and we lack sufficient insight into the individual decisions of each, the extent of these costs is difficult to quantify. In section X.F.4. of the preamble of this final rule, we are modifying the SAFER Guides measure by requiring eligible hospitals and CAHs to attest ‘‘yes’’ to completing an annual self-assessment using the SAFER Guides that ASTP published in January 2025 beginning with the EHR reporting period in CY 2026. We do not believe this provision results in any additional economic impacts beyond those previously discussed in the FY 2022 and FY 2024 IPPS/LTCH PPS final rules (86 FR 45609 and 88 FR 59432 through 59433, respectively). In section X.F.3. of the preamble of this final rule, we are modifying the Security Risk Analysis measure to require eligible hospitals and CAHs to attest ‘‘yes’’ to having conducted security risk management as required by the HIPAA Security Rule at 45 CFR 164.308(a)(1)(ii)(B) beginning with the EHR reporting period in CY 2026. While we proposed to require eligible hospitals and CAHs to attest ‘‘yes’’ ent as required by the HIPAA Security Rule at 45 CFR 164.308(a)(1)(ii)(B) beginning with the EHR reporting period in CY 2026. While we proposed to require eligible hospitals and CAHs to attest ‘‘yes’’ to having conducted security risk management, the costs associated with performing security risk management required by the HIPAA Security Rule are currently approved under OMB control number 0945–0003 (expiration date July 31, 2027). We do not believe this provision results in any additional economic impacts. We do not believe the remaining provision results in any additional economic impact beyond those discussed in section XIII.B.7. of the preamble of this final rule. We received no comments on our assumptions regarding these effects. O. Alternatives Considered This final rule contains a range of policies. It also provides descriptions of the statutory provisions that are addressed, identifies the policies, and presents rationales for our decisions and, where relevant, alternatives that were considered. 1. Alternatives Considered to the LTCH QRP Reporting Requirements Regarding the proposal to remove item O0350, Patient’s COVID–19 vaccination is up to date, on the LCDS with respect t were considered. 1. Alternatives Considered to the LTCH QRP Reporting Requirements Regarding the proposal to remove item O0350, Patient’s COVID–19 vaccination is up to date, on the LCDS with respect to patients who have expired in the LTCH, we believe this is responsive to LTCHs concerns and will help reduce assessment collection burden. We considered the alternative of continuing to collect this item with respect to patients who have expired in the LTCH VerDate Sep 2014 00:36 Aug 02, 2025 Jkt 265001 PO 00000 Frm 00768 Fmt 4701 Sfmt 4700 E:\FR\FM\04AUR2.SGM 04AUR2 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k Federal Register / Vol. 90, No. 147 / Monday, August 4, 2025 / Rules and Regulations 37303 but given the concerns from LTCHs and other interested parties about data collection challenges and increased provider burden in collecting immunization data, we believe maintaining this item is unwarranted. Regarding our proposal to remove four SDOH standardized patient assessment data elements, we considered keeping these items but decided not to because of the burden associated with these items at this time. Regarding the proposal to amend the process by which ent assessment data elements, we considered keeping these items but decided not to because of the burden associated with these items at this time. Regarding the proposal to amend the process by which an LTCH may request an extension to file a reconsideration request if the LTCH was affected by an extraordinary circumstance beyond the control of the LTCH, we considered the alternative of leaving the policy language unchanged. However, we found it important to clarify the definition of ‘‘extraordinary’’ and the process for requesting an extension to file a reconsideration request, we believe these proposals are responsive to providers’ feedback. 2. Alternatives Considered for the Transforming Episode Accountability Model In section XI.A. of the preamble of this final rule, we discuss the mandatory episode- based payment model called the Transforming Episode Accountability Model (TEAM). TEAM is designed to improve beneficiary care through financial accountability for episodes categories that begin with one of the following procedures: coronary artery bypass graft, lower extremity joint replacement, major bowel procedure, surgical hip/femur fracture treatment, and spinal fusion. TEAM w hat begin with one of the following procedures: coronary artery bypass graft, lower extremity joint replacement, major bowel procedure, surgical hip/femur fracture treatment, and spinal fusion. TEAM will test whether financial accountability for these episode categories reduces Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries. We anticipate that TEAM would benefit Medicare beneficiaries through improving the coordination of items and services paid for through Medicare FFS payments, encouraging provider investment in health care infrastructure and redesigned care processes, and incentivizing higher value care across the inpatient and post-acute care settings for the episode. Throughout this final rule, we have identified our proposed policies and alternatives that we have considered and provided information as to the effects of these alternatives and the rationale for each of the proposed policies. For example, we considered requiring new acute care hospitals that open in a mandatory core- based statistical areas (CBSA) to immediately participate in TEAM. However, we are concerned that requiring immediate participation while they are w acute care hospitals that open in a mandatory core- based statistical areas (CBSA) to immediately participate in TEAM. However, we are concerned that requiring immediate participation while they are establishing their clinical and operational practices could make it challenging for new acute care hospitals to participate in the model. We also considered multiple approaches to a low volume hospital policy, as discussed in section XI.A.2.c.(8). of the preamble of this final rule. While we have not proposed a low volume hospital policy, we recognize including a low volume hospital policy in TEAM would have a financial impact to TEAM’s ability to reduce Medicare expenditures. This is because all the options considered give some financial protection to low volume hospitals. We assessed the financial impact to TEAM by modeling the option that would result in the most cost to Medicare, specifically the option that would waive downside financial risk at the episode category level for TEAM participants that did not initiate at least 31 episodes in the baseline period. Using 2023 as a performance year and 2019–2021 as a baseline period, we simulated reconciliation results for the hospitals rticipants that did not initiate at least 31 episodes in the baseline period. Using 2023 as a performance year and 2019–2021 as a baseline period, we simulated reconciliation results for the hospitals required to participate in TEAM. We found that applying a low volume policy where downside risk was waived for approximately 1.75% of the episodes in the model resulted in approximately $10.7 million in repayment amounts being waived. We also found that $5.8 million of the $10.7 million in repayment amounts were associated with safety net hospitals, that are already eligible to have downside risk waived if they choose to participate in Track 1 of the model. We note that our Medicare savings estimates from the FY 2025 IPPS/ LTCH PPS final rule (89 FR 70026), that estimated a $481 million savings to Medicare, already assumed TEAM participants that are considered safety net hospitals, as defined at § 512.505, would have downside risk waived for the first three performance years of the model. Therefore, we anticipate the inclusion of a potential low volume hospital policy in TEAM would slightly reduce Medicare savings but would still yield overall positive savings to Medicare. We solicite Therefore, we anticipate the inclusion of a potential low volume hospital policy in TEAM would slightly reduce Medicare savings but would still yield overall positive savings to Medicare. We solicited and welcomed comments on our proposals, on the alternatives we have identified, and on other alternatives that we should consider. In each section of the final rule that we received comments on alternatives considered we have addressed them accordingly, including the policy for low volume hospitals. P. Overall Conclusion 1. Acute Care Hospitals Acute care hospitals are estimated to experience an increase of approximately $5.0 billion in FY 2026, including operating, capital, and the effects of: (1) new technology add-on payment changes; (2) the changes to estimated uncompensated care payments; and (3) the statutory expiration of the MDH program and the temporary changes to the low-volume hospital payment adjustment on October 1, 2025. The estimated change in operating payments and uncompensated care payments is approximately $4.97 billion (discussed in sections I.F. of this Appendix). The estimated change in capital payments is approximately $0.25 billion (discussed in section I.I. o ensated care payments is approximately $4.97 billion (discussed in sections I.F. of this Appendix). The estimated change in capital payments is approximately $0.25 billion (discussed in section I.I. of this Appendix). The estimated change in the combined effects of other changes including new technology add-on payment changes and the statutory expiration of the temporary changes to the low-volume hospital payment adjustment on October 1, 2025, is approximately ¥$0.18 billion as discussed in sections I.F. and I.G. of the Appendix of this final rule. Totals may differ from the sum of the components due to rounding. Table I. of section I.F. of the Appendix of this final rule also demonstrates the estimated redistributional impacts of the FY 2026 changes on IPPS payments relative to FY 2025. We estimate that hospitals will experience a 3.2 percent increase in capital payments per case, as shown in Table III of section I.I. of this Appendix. We project that there will be an approximately $251 million increase in capital payments in FY 2026 compared to FY 2025. The discussions presented in the previous pages, in combination with the remainder of this final rule, constitute a regulatory i 51 million increase in capital payments in FY 2026 compared to FY 2025. The discussions presented in the previous pages, in combination with the remainder of this final rule, constitute a regulatory impact analysis. 2. LTCHs Overall, LTCHs are projected to experience an increase in estimated payments in FY 2026. In the impact analysis, we are using the rates, factors, and policies presented in this final rule based on the best available claims and CCR data to estimate the change in payments under the LTCH PPS for FY 2026. Accordingly, based on the best available data for the 329 LTCHs included in our analysis, we estimate that overall FY 2026 LTCH PPS payments would increase approximately $83 million relative to FY 2025, primarily due to the annual update to the LTCH PPS standard Federal rate partially offset by an estimated decrease in high-cost outlier payments. Q. Regulatory Review Cost Estimation If regulations impose administrative costs on private entities, such as the time needed to read and interpret a rule, we should estimate the cost associated with regulatory review. Due to the uncertainty involved with accurately quantifying the number of entities that would review the d to read and interpret a rule, we should estimate the cost associated with regulatory review. Due to the uncertainty involved with accurately quantifying the number of entities that would review the final rule, we assumed that the total number of timely pieces of correspondence on this year’s proposed rule would be the number of reviewers of the final rule. We acknowledge that this assumption may understate or overstate the costs of reviewing the rule. It is possible that not all commenters reviewed this year’s rule in detail, and it is also possible that some reviewers chose not to comment on the proposed rule. For these reasons, we believe that the number of past commenters would be a fair estimate of the number of reviewers of the final rule. We recognize that different types of entities are in many cases affected by mutually exclusive sections of the rule. Thus, for the purposes of our estimate we assume that each reviewer read approximately 50 percent of the proposed rule. Finally, in our estimates, we have used the 5,409 number of timely pieces of correspondence on the FY 2026 IPPS/LTCH PPS proposed rule as our estimate for the number of reviewers of the final rule. We conti y, in our estimates, we have used the 5,409 number of timely pieces of correspondence on the FY 2026 IPPS/LTCH PPS proposed rule as our estimate for the number of reviewers of the final rule. We continue to acknowledge the uncertainty involved with using this number, but we believe it is a fair estimate due to the variety of entities affected and the likelihood that some of them choose to rely (in full or in part) on press releases, newsletters, fact sheets, or other sources rather than the comprehensive review of preamble and regulatory text. Using the wage information from the BLS for medical and health service managers (Code 11–9111), we estimate that the cost of reviewing the final rule is $132.44 per hour, including overhead and fringe benefits (https://www.bls.gov/oes/current/oes_ nat.htm). Assuming an average reading VerDate Sep 2014 00:36 Aug 02, 2025 Jkt 265001 PO 00000 Frm 00769 Fmt 4701 Sfmt 4700 E:\FR\FM\04AUR2.SGM 04AUR2 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k 37304 Federal Register / Vol. 90, No. 147 / Monday, August 4, 2025 / Rules and Regulations speed, we estimate that it would take approximately 24.56 hours for the staff to review half d n o m m a h k 37304 Federal Register / Vol. 90, No. 147 / Monday, August 4, 2025 / Rules and Regulations speed, we estimate that it would take approximately 24.56 hours for the staff to review half of this final rule. For each IPPS hospital or LTCH that reviews this final rule, the estimated cost is $3,252.73 (24.56 hours × $132.44). Therefore, we estimate that the total cost of reviewing this final rule is $17,594,017 ($3,252.73 × 5,409 reviewers). II. Accounting Statements and Tables A. Acute Care Hospitals As required by OMB Circular A–4 (available at https://www.reginfo.gov/public/ jsp/Utilities/a-4.pdf), in Table V. of this Appendix, we have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this final rule as they relate to acute care hospitals. This table provides our best estimate of the change in Medicare payments to providers as a result of the changes to the IPPS presented in this final rule. All expenditures are classified as transfers to Medicare providers. As shown in Table V. of the Appendix of this final rule, the net costs to the Federal Government associated with the policies in this final rule are e re classified as transfers to Medicare providers. As shown in Table V. of the Appendix of this final rule, the net costs to the Federal Government associated with the policies in this final rule are estimated at $5.0 billion. TABLE V—ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED EX- PENDITURES UNDER IPPS THE FROM FY 2025 TO FY 2026 Category Trannsfers Annualized Monetized $5.0 billion. Transfers. From Whom to Whom Federal Government to IPPS Medicare Providers B. LTCHs As discussed in section I.J. of the Appendix of this final rule, the impact analysis of the payment rates and factors presented in this final rule under the LTCH PPS is projected to result in an increase in estimated aggregate LTCH PPS payments in FY 2026 relative to FY 2025 of approximately $83 million based on the data for 329 LTCHs in our database that are subject to payment under the LTCH PPS. Therefore, as required by OMB Circular A–4 (available at https:// www.reginfo.gov/public/jsp/Utilities/a-4.pdf), in Table VI. of the Appendix of this final rule, we have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this final rule as they relate LTCHs. VI. of the Appendix of this final rule, we have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this final rule as they relate LTCHs. Table VI. of this Appendix provides our best estimate of the estimated change in Medicare payments under the LTCH PPS as a result of the payment rates and factors and other provisions presented in this final rule based on the data for the 329 LTCHs in our database. All expenditures are classified as transfers to Medicare providers (that is, LTCHs). As shown in Table VI. of the Appendix of this final rule, the net cost to the Federal Government associated with the policies for LTCHs in this final rule are estimated at $83 million. TABLE VI—ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED EX- PENDITURES FROM THE FY 2025 LTCH PPS TO THE FY 2026 LTCH PPS Category Transfers Annualized Monetized $83 million. Transfers. From Whom to Whom Federal Government to LTCH Medicare Providers. C. HTI–2 We estimate that the total annual cost to developers of certified health IT for this final rule for the first year after it is finalized (including one-time costs), based on the cost estimates outlined estimate that the total annual cost to developers of certified health IT for this final rule for the first year after it is finalized (including one-time costs), based on the cost estimates outlined previously and throughout, would result in $50.3 million. The total undiscounted cost over a 10-year period to developers for this final rule (starting in year two), based on cost estimates outlined previously, would result in $177.6 million. We estimate the total costs to developers over a 10-year period for this final rule to be $228 million. We estimate the total annual benefit across all entities for progress toward interoperability (progress initiated by adoption of the criteria and standards set forth in this final rule, then implemented with intermediate activities that connect such adoption with the generation of benefits) beginning in 2027, when the associated policies are required to be implemented and expected benefits to be realized, would be on average $1.0 billion. We estimate the total benefits across all entities to be $19.2 billion. This benefits estimate is not comparable with the quantification of costs (totaling $228 million) because the cost of some intermediate ac e the total benefits across all entities to be $19.2 billion. This benefits estimate is not comparable with the quantification of costs (totaling $228 million) because the cost of some intermediate activities has not been estimated and the cost of other intermediate activities has been attributed to other regulatory provisions, such as the ones finalized by CMS at 89 FR 8758. TABLE VII—E.O. 12866 SUMMARY TABLE (IN $ MILLIONS, 2024 DOLLARS): HTI Primary (3%) Primary (7%) Present Value of Quantified Costs .............................................................................................................. Annualized Quantified Costs ....................................................................................................................... $210,331,976.62 24,657,324.17 $190,350,533.75 27,101,633.64 III. Regulatory Flexibility Act (RFA) Analysis The RFA requires agencies to analyze options for regulatory relief of small entities. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small government jurisdictions. We estimate that most hospitals and most other providers and suppliers are small entities as that term is used i include small businesses, nonprofit organizations, and small government jurisdictions. We estimate that most hospitals and most other providers and suppliers are small entities as that term is used in the RFA. The great majority of hospitals and most other health care providers and suppliers are small entities, either by being nonprofit organizations or by meeting the SBA definition of a small business (having revenues of less than $8.0 million to $41.5 million in any 1 year). (For details on the latest standards for health care providers, we refer readers to page 38 of the Table of Small Business Size Standards for NAIC 622 found on the SBA website at https://www.sba.gov/ sites/default/files/files/Size_Standards_ Table.pdf.) For purposes of the RFA, all hospitals and other providers and suppliers are considered to be small entities. Because all hospitals are considered to be small entities for purposes of the RFA, the hospital impacts described in this final rule are impacts on small entities. Individuals and States are not included in the definition of a small entity. MACs are not considered to be small entities because they do not meet the SBA definition of a small business. HH entities. Individuals and States are not included in the definition of a small entity. MACs are not considered to be small entities because they do not meet the SBA definition of a small business. HHS’s practice in interpreting the RFA is to consider effects economically ‘‘significant’’ if greater than 5 percent of providers reach a threshold of 3 to 5 percent or more of total revenue or total costs. We believe that the provisions of this final rule relating to IPPS hospitals would have an economically significant impact on small entities as explained in this Appendix. Therefore, the Secretary has certified that this final rule is expected to have a significant economic impact on a substantial number of small entities. For example, the majority of the 3,033 IPPS hospitals included in the impact analysis shown in ‘‘Table I.—Impact Analysis of Changes to the IPPS for Operating Costs for FY 2026,’’ on average are expected to see increases in the range of 4.3 percent, primarily due to the hospital rate update and uncompensated care payments, as discussed in section I.F. of the Appendix of this final rule. On average, the rate update for these hospitals is estimated to be 2.5 percent a hospital rate update and uncompensated care payments, as discussed in section I.F. of the Appendix of this final rule. On average, the rate update for these hospitals is estimated to be 2.5 percent and VerDate Sep 2014 00:36 Aug 02, 2025 Jkt 265001 PO 00000 Frm 00770 Fmt 4701 Sfmt 4700 E:\FR\FM\04AUR2.SGM 04AUR2 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k Federal Register / Vol. 90, No. 147 / Monday, August 4, 2025 / Rules and Regulations 37305 uncompensated care payments are estimated to increase payments in FY 2026 by 1.7 percent for all hospitals. The 327 LTCH PPS hospitals included in the impact analysis shown in ‘‘Table IV: Impact of Payment Rate and Policy Changes to LTCH PPS Payments for LTCH PPS Standard Federal Payment Rate Cases for FY 2026 (Estimated FY 2025 Payments Compared to Estimated FY 2026 Payments)’’ on average are expected to see an increase of approximately 3.0 percent, primarily due to the annual standard Federal rate update for FY 2026 (2.7 percent) and a projected 0.4 percent increase in high cost outlier payments as a percentage of total LTCH PPS standard Federal payment rate payments, as discussed in section I.J. of the Appendix of .7 percent) and a projected 0.4 percent increase in high cost outlier payments as a percentage of total LTCH PPS standard Federal payment rate payments, as discussed in section I.J. of the Appendix of this final rule. This final rule contains a range of policies. It provides descriptions of the statutory provisions that are addressed, identifies the finalized policies, and presents rationales for our decisions and, where relevant, alternatives that were considered. All alternatives considered apply to hospitals considered small businesses. The analyses discussed in this Appendix and throughout the preamble of this final rule constitutes our regulatory flexibility analysis. We sought public comments on our estimates and analysis of the impact of our policies on small entities. IV. Impact on Small Rural Hospitals Section 1102(b) of the Act requires us to prepare a regulatory impact analysis for any proposed or final rule that may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. With the exception of hospitals located in certain New England counties, for purposes of sec al number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. With the exception of hospitals located in certain New England counties, for purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of an urban area and has fewer than 100 beds. Section 601(g) of the Social Security Amendments of 1983 (Pub. L. 98–21) designated hospitals in certain New England counties as belonging to the adjacent urban area. Thus, for purposes of the IPPS and the LTCH PPS, we continue to classify these hospitals as urban hospitals. As shown in Table I. in section I.F. of the Appendix of this final rule, rural IPPS hospitals with 0–49 beds (313 hospitals) are expected to experience an increase in payments from FY 2025 to FY 2026 of 3.0 percent and rural IPPS hospitals with 50–99 beds (180 hospitals) are expected to experience an increase in payments from FY 2025 to FY 2026 of 1.7 percent. These changes are primarily driven by the hospital rate update and the increase in estimated uncompensated care payment offset by the statutory expiration of the MDH program and the budget neutral changes to the MS–DRGs rimarily driven by the hospital rate update and the increase in estimated uncompensated care payment offset by the statutory expiration of the MDH program and the budget neutral changes to the MS–DRGs and relative weights. We refer readers to Table I. in section I.F. of the Appendix of this final rule for additional information on the quantitative effects of the policy changes under the IPPS for operating costs. All rural LTCHs (17 hospitals) shown in Table IV. in section I.J. of the Appendix of this final rule have less than 100 beds. These hospitals are expected to experience an increase in payments from FY 2025 to FY 2026 of 3.0 percent. This increase is primarily due to the combination of the 2.7 percent annual update to the LTCH PPS standard Federal payment rate for FY 2026, the changes to the area wage level adjustment, and estimated changes in outlier payments as discussed in section I.J. of the Appendix of this final rule. V. Unfunded Mandates Reform Act Analysis Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104–4) also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of $10 the Unfunded Mandates Reform Act of 1995 (Pub. L. 104–4) also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of $100 million in 1995 dollars, updated annually for inflation. In 2025, that threshold is approximately $187 million. This final rule would not mandate any requirements that meet the threshold for State, local, or Tribal governments, nor would it affect private sector costs. VI. Executive Order 13132 Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts state law, or otherwise has federalism implications. This final rule would not have a substantial direct effect on State or local governments, preempt states, or otherwise have a federalism implication. VII. Executive Order 13175 Executive Order 13175 directs agencies to consult with Tribal officials prior to the formal promulgation of regulations having Tribal implications. Section 1880(a) of the Act states that a hospital of the Indian Health Service, whether o s to consult with Tribal officials prior to the formal promulgation of regulations having Tribal implications. Section 1880(a) of the Act states that a hospital of the Indian Health Service, whether operated by such Service or by an Indian Tribe or Tribal organization, is eligible for Medicare payments so long as it meets all of the conditions and requirements for such payments which are applicable generally to hospitals. Consistent with section 1880(a) of the Act, this final rule contains general provisions also applicable to hospitals and facilities operated by the Indian Health Service or Tribes or Tribal organizations under the Indian Self- Determination and Education Assistance Act. We continue to engage in consultations with Tribal officials on IPPS issues of interest. We use input received from these consultations, as well as the comments on the proposed rule, to inform our rulemaking. VIII. Executive Order 14192 Executive Order 14192, titled ‘‘Unleashing Prosperity Through Deregulation,’’ was issued on January 31, 2025, and requires that ‘‘any new incremental costs associated with new regulations shall, to the extent permitted by law, be offset by the elimination of existin gulation,’’ was issued on January 31, 2025, and requires that ‘‘any new incremental costs associated with new regulations shall, to the extent permitted by law, be offset by the elimination of existing costs associated with at least 10 prior regulations. IX. Executive Order 12866 In accordance with the provisions of Executive Order 12866, the Office of Management and Budget reviewed this final rule. Appendix B: Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services I. Background Section 1886(e)(4)(A) of the Act requires that the Secretary, taking into consideration the recommendations of MedPAC, recommend update factors for inpatient hospital services for each fiscal year that take into account the amounts necessary for the efficient and effective delivery of medically appropriate and necessary care of high quality. Under section 1886(e)(5) of the Act, we are required to publish update factors recommended by the Secretary in the proposed and final IPPS rules. Accordingly, this Appendix provides the recommendations for the update factors for the IPPS national standardized amount, the hospital-specific rate for SCHs and MDHs, and the rate d final IPPS rules. Accordingly, this Appendix provides the recommendations for the update factors for the IPPS national standardized amount, the hospital-specific rate for SCHs and MDHs, and the rate-of-increase limits for certain hospitals excluded from the IPPS, as well as LTCHs. In prior years, we made a recommendation in the IPPS proposed rule and final rule for the update factors for the payment rates for IRFs and IPFs. However, for FY 2026, consistent with our approach for FY 2025, we are including the Secretary’s recommendation for the update factors for IRFs and IPFs in separate Federal Register documents at the time that we announce the annual updates for IRFs and IPFs. We also discuss our response to MedPAC’s recommended update factors for inpatient hospital services. II. Inpatient Hospital Update for FY 2026 A. FY 2026 Inpatient Hospital Update As discussed in section VI.B. of the preamble to this final rule, for FY 2026, consistent with section 1886(b)(3)(B) of the Act, as amended by sections 3401(a) and 10319(a) of the Affordable Care Act, we are setting the applicable percentage increase by applying the following adjustments in the following sequence. Specifically, t amended by sections 3401(a) and 10319(a) of the Affordable Care Act, we are setting the applicable percentage increase by applying the following adjustments in the following sequence. Specifically, the applicable percentage increase under the IPPS is equal to the rate-of-increase in the hospital market basket for IPPS hospitals in all areas, subject to a reduction of one-quarter of the applicable percentage increase (prior to the application of other statutory adjustments; also referred to as the market basket percentage increase or rate-of-increase (with no adjustments)) for hospitals that fail to submit quality information under rules established by the Secretary in accordance with section 1886(b)(3)(B)(viii) of the Act and a reduction of three-quarters of the applicable percentage increase (prior to the application of other statutory adjustments; also referred to as the market basket percentage increase or rate-of-increase (with no adjustments)) for hospitals not considered to be meaningful electronic health record (EHR) users in accordance with section 1886(b)(3)(B)(ix) of the Act, and then an adjustment based on changes in economy-wide productivity (the productivity adjustmen eaningful electronic health record (EHR) users in accordance with section 1886(b)(3)(B)(ix) of the Act, and then an adjustment based on changes in economy-wide productivity (the productivity adjustment). Section 1886(b)(3)(B)(xi) of the Act, as added by section 3401(a) of the Affordable Care Act, states that application of the productivity adjustment may result in the applicable percentage increase being less than zero. VerDate Sep 2014 00:36 Aug 02, 2025 Jkt 265001 PO 00000 Frm 00771 Fmt 4701 Sfmt 4700 E:\FR\FM\04AUR2.SGM 04AUR2 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k 37306 Federal Register / Vol. 90, No. 147 / Monday, August 4, 2025 / Rules and Regulations We note that, in compliance with section 404 of the MMA, in this final rule, we are replacing the 2018-based IPPS operating and capital market baskets with the rebased and revised 2023-based IPPS operating and capital market baskets beginning in FY 2026. In the FY 2026 IPPS/LTCH PPS proposed rule, in accordance with section 1886(b)(3)(B) of the Act, we proposed to base the proposed FY 2026 market basket update used to determine the applicable percentage increase for the IPPS on IGI’s fourth quarter 2 ordance with section 1886(b)(3)(B) of the Act, we proposed to base the proposed FY 2026 market basket update used to determine the applicable percentage increase for the IPPS on IGI’s fourth quarter 2024 forecast of the proposed 2023-based IPPS market basket rate-of-increase with historical data through third quarter 2024, which was estimated to be 3.2 percent. In accordance with section 1886(b)(3)(B) of the Act, as amended by section 3401(a) of the Affordable Care Act, in section VI.B. of the preamble of the FY 2026 IPPS/LTCH PPS proposed rule, based on IGI’s fourth quarter 2024 forecast, we proposed a productivity adjustment of 0.8 percentage point for FY 2026. We also proposed that if more recent data subsequently became available, we would use such data, if appropriate, to determine the FY 2026 market basket update and productivity adjustment for the FY 2026 IPPS/LTCH PPS final rule. In the FY2026 IPPS/LTCH proposed rule, based on IGI’s fourth quarter 2024 forecast of the proposed 2023-based IPPS market basket percentage increase and the productivity adjustment, depending on whether a hospital submits quality data under the rules established in accordance with section 1886(b)(3 2023-based IPPS market basket percentage increase and the productivity adjustment, depending on whether a hospital submits quality data under the rules established in accordance with section 1886(b)(3)(B)(viii) of the Act (hereafter referred to as a hospital that submits quality data) and is a meaningful EHR user under section 1886(b)(3)(B)(ix) of the Act (hereafter referred to as a hospital that is a meaningful EHR user), we presented four possible applicable percentage increases that could be applied to the standardized amount. In accordance with section 1886(b)(3)(B) of the Act, as amended by section 3401(a) of the Affordable Care Act, we are establishing the applicable percentages increase for the FY 2026 updates based on IGI’s second quarter 2025 forecast of the 2023-based IPPS market basket percentage increase of 3.3 percent and the productivity adjustment of 0.7 percentage point, as discussed in section VI.B of the preamble of this final rule, depending on whether a hospital submits quality data under the rules established in accordance with section 1886(b)(3)(B)(viii) of the Act and is a meaningful EHR user under section 1886(b)(3)(B)(ix) of the Act, as shown in the table t mits quality data under the rules established in accordance with section 1886(b)(3)(B)(viii) of the Act and is a meaningful EHR user under section 1886(b)(3)(B)(ix) of the Act, as shown in the table that follows. FY 2026 for Failure IPPS Market Basket Rate-of-Increase ............................................................. to Submit Quality Data under Section Adjustment 1886(b)(3)(B)(viii) of the Act ......................................................................... Adjustment for Failure to be a Meaningful EHR User under Section 1886(b)(3)(B)(ix) of the Act .......................................................................... Productivity Adjustment under Section 1886(b)(3)(B)(xi) of the Act ............... ......... Applicable Percentage Increase Applied to Standardized Amount Hospital sub- mitted quality data and is a meaningful EHR user Hospital sub- mitted quality data and is not a meaningful EHR user Hospital did not submit quality data and is a meaningful EHR user Hospital did not submit quality data and is not a meaningful EHR user 3.3 0.0 0.0 ¥0.7 2.6 3.3 0.0 ¥2.475 ¥0.7 0.125 3.3 ¥0.825 0.0 ¥0.7 1.775 3.3 ¥0.825 ¥2.475 ¥0.7 ¥0.7 B. FY 2026 SCH Update Sec ser Hospital did not submit quality data and is not a meaningful EHR user 3.3 0.0 0.0 ¥0.7 2.6 3.3 0.0 ¥2.475 ¥0.7 0.125 3.3 ¥0.825 0.0 ¥0.7 1.775 3.3 ¥0.825 ¥2.475 ¥0.7 ¥0.7 B. FY 2026 SCH Update Section 1886(b)(3)(B)(iv) of the Act provides that the applicable percentage increase in the hospital-specific rate for SCHs and MDHs equals the applicable percentage increase set forth in section 1886(b)(3)(B)(i) of the Act (that is, the same update factor as for all other hospitals subject to the IPPS). Therefore, the update to the hospital-specific rates for SCHs and MDHs is also subject to section 1886(b)(3)(B)(i) of the Act, as amended by sections 3401(a) and 10319(a) of the Affordable Care Act. As discussed in section VI.F. of the preamble of this final rule, section 2202 of the Full-Year Continuing Appropriations and Extensions Act, 2025 extended the MDH program through FY 2025. Therefore, under current law, the MDH program will expire for discharges on or after October 1, 2025. We note that if the MDH program were to be extended by law into FY 2026, the updates to the hospital-specific rates for SCHs as described in this section would also apply to the hospital-specific rates for e that if the MDH program were to be extended by law into FY 2026, the updates to the hospital-specific rates for SCHs as described in this section would also apply to the hospital-specific rates for MDHs for FY 2026. We refer readers to section V.E. of the preamble of this final rule for further discussion of the MDH program. As previously stated, the update to the hospital specific rate for SCHs is subject to section 1886(b)(3)(B)(i) of the Act, as amended by sections 3401(a) and 10319(a) of the Affordable Care Act. Accordingly, depending on whether a hospital submits quality data and is a meaningful EHR user, we are establishing the same four possible applicable percentage increases in the previous table for the hospital-specific rate applicable to SCHs. C. FY 2026 Puerto Rico Hospital Update Because Puerto Rico hospitals are no longer paid with a Puerto Rico-specific standardized amount under the amendments to section 1886(d)(9)(E) of the Act, there is no longer a need for us to make an update to the Puerto Rico standardized amount. Hospitals in Puerto Rico are now paid 100 percent of the national standardized amount and, therefore, are subject to the same update to the nationa ke an update to the Puerto Rico standardized amount. Hospitals in Puerto Rico are now paid 100 percent of the national standardized amount and, therefore, are subject to the same update to the national standardized amount discussed under section VI.B.1. of the preamble of this final rule. In addition, as discussed in section VI.B.2. of the preamble of this final rule, section 602 of Public Law 114–113 amended section 1886(n)(6)(B) of the Act to specify that subsection (d) Puerto Rico hospitals are eligible for incentive payments for the meaningful use of certified EHR technology, effective beginning FY 2016. In addition, section 1886(n)(6)(B) of the Act was amended to specify that the adjustments to the applicable percentage increase under section 1886(b)(3)(B)(ix) of the Act apply to subsection (d) Puerto Rico hospitals that are not meaningful EHR users, effective beginning FY 2022. Section 1886(b)(3)(B)(ix) of the Act in conjunction with section 602(d) of Public Law 114–113 requires that for FY 2024 and subsequent fiscal years, any subsection (d) Puerto Rico hospital that is not a meaningful EHR user as defined in section 1886(n)(3) of the Act and not subject to an exception unde that for FY 2024 and subsequent fiscal years, any subsection (d) Puerto Rico hospital that is not a meaningful EHR user as defined in section 1886(n)(3) of the Act and not subject to an exception under section 1886(b)(3)(B)(ix) of the Act will have a reduction of three-quarters of the applicable percentage increase (prior to the application of other statutory adjustments). Based on IGI’s fourth quarter 2024 forecast of the proposed 2023-based IPPS market basket update with historical data through third quarter 2024, in the FY 2026 IPPS/ LTCH PPS proposed rule, in accordance with section 1886(b)(3)(B) of the Act, as previously discussed, for Puerto Rico hospitals, we proposed an IPPS market basket increase of 3.2 percent and a productivity adjustment of 0.8 percentage point. Therefore, for FY 2026, depending on whether a Puerto Rico hospital is a meaningful EHR user, we stated that there are two possible applicable percentage increases that can be applied to the standardized amount. Based on these data, we proposed the following applicable percentage increases to the standardized amount for FY 2026 for Puerto Rico hospitals: • For a Puerto Rico hospital that is a meaningful EHR user ed on these data, we proposed the following applicable percentage increases to the standardized amount for FY 2026 for Puerto Rico hospitals: • For a Puerto Rico hospital that is a meaningful EHR user, we proposed an applicable percentage increase to the operating standardized amount of 2.4 percent (that is, the FY 2026 estimate of the proposed IPPS market basket rate-of-increase of 3.2 percent less an adjustment of 0.8 percentage point for the proposed productivity adjustment). • For a Puerto Rico hospital that is not a meaningful EHR user, we proposed an applicable percentage increase to the operating standardized amount of 0.0 percent (that is, the FY 2026 estimate of the proposed market basket rate-of-increase of 3.2 percent, less an adjustment of 2.4 percentage point (the proposed IPPS market basket rate-of- increase of 3.2 percent × 0.75 for failure to be a meaningful EHR user), and less an VerDate Sep 2014 00:36 Aug 02, 2025 Jkt 265001 PO 00000 Frm 00772 Fmt 4701 Sfmt 4700 E:\FR\FM\04AUR2.SGM 04AUR2 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k Federal Register / Vol. 90, No. 147 / Monday, August 4, 2025 / Rules and Regulations 37307 adjustment of 0.8 p \FM\04AUR2.SGM 04AUR2 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k Federal Register / Vol. 90, No. 147 / Monday, August 4, 2025 / Rules and Regulations 37307 adjustment of 0.8 percentage point for the proposed productivity adjustment). As noted previously, we proposed that if more recent data subsequently became available, we would use such data, if appropriate, to determine the FY 2026 market basket percentage increase and the productivity adjustment for the FY 2026 IPPS/LTCH PPS final rule. As discussed in section VI.B.1. of the preamble of this final rule, based on more recent data available for this FY 2026 IPPS/ LTCH PPS final rule, we estimate that the FY 2026 market basket update used to determine the applicable percentage increase for the IPPS is 3.3 percent less a productivity adjustment of 0.7 percentage point. Therefore, in accordance with section 1886(b)(3)(B) of the Act, for this final rule, for Puerto Rico hospitals the more recent update of the market basket rate-of-increase is 3.3 percent reduced by a productivity adjustment of 0.7 percentage point. For FY 2026, depending on whether a Puerto Rico hospital is a meaningful EHR user, there are tw ket basket rate-of-increase is 3.3 percent reduced by a productivity adjustment of 0.7 percentage point. For FY 2026, depending on whether a Puerto Rico hospital is a meaningful EHR user, there are two possible applicable percentage increases that can be applied to the standardized amount. Based on these data, we determined the following applicable percentage increases to the standardized amount for FY 2026 for Puerto Rico hospitals: • For a Puerto Rico hospital that is a meaningful EHR user, an applicable percentage increase to the FY 2026 operating standardized amount of 2.6 percent (that is, the FY 2026 estimate of the market basket rate-of-increase of 3.3 percent reduced by 0.7 percentage point for the productivity adjustment). • For a Puerto Rico hospital that is not a meaningful EHR user, an applicable percentage increase to the operating standardized amount of 0.125 percent (that is, the FY 2026 estimate of the market basket rate-of-increase of 3.3 percent, less an adjustment of 2.475 percentage point (the market basket rate-of-increase of 3.3 percent × 0.75 for failure to be a meaningful EHR user), and reduced by 0.7 percentage point for the productivity adjustment). D. Upd 2.475 percentage point (the market basket rate-of-increase of 3.3 percent × 0.75 for failure to be a meaningful EHR user), and reduced by 0.7 percentage point for the productivity adjustment). D. Update for Hospitals Excluded From the IPPS for FY 2026 Section 1886(b)(3)(B)(ii) of the Act is used for purposes of determining the percentage increase in the rate-of-increase limits for children’s hospitals, cancer hospitals, and hospitals located outside the 50 States, the District of Columbia, and Puerto Rico (that is, short-term acute care hospitals located in the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and America Samoa). Section 1886(b)(3)(B)(ii) of the Act sets the rate-of-increase limits equal to the market basket percentage increase. In accordance with § 403.752(a) of the regulations, religious nonmedical health care institutions (RNHCIs) are paid under the provisions of § 413.40, which also use section 1886(b)(3)(B)(ii) of the Act to update the percentage increase in the rate-of-increase limits. Currently, children’s hospitals, PPS- excluded cancer hospitals, RNHCIs, and short-term acute care hospitals located in the U.S. Virgin Islands, Guam, the Northern Mari in the rate-of-increase limits. Currently, children’s hospitals, PPS- excluded cancer hospitals, RNHCIs, and short-term acute care hospitals located in the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa are among the remaining types of hospitals still paid under the reasonable cost methodology, subject to the rate-of-increase limits. In addition, in accordance with § 412.526(c)(3) of the regulations, extended neoplastic disease care hospitals (described in § 412.22(i) of the regulations) also are subject to the rate-of-increase limits. As discussed in section VI. of the preamble of this final rule, we are finalizing to use the percentage increase in the 2023-based IPPS operating market basket to update the target amounts for children’s hospitals, PPS-excluded cancer hospitals, RNHCIs, short-term acute care hospitals located in the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa, and extended neoplastic disease care hospitals for FY 2026 and subsequent fiscal years. Accordingly, for FY 2026, the rate-of-increase percentage to be applied to the target amount for these children’s hospitals, cancer hospitals, RNHCIs, extended neo FY 2026 and subsequent fiscal years. Accordingly, for FY 2026, the rate-of-increase percentage to be applied to the target amount for these children’s hospitals, cancer hospitals, RNHCIs, extended neoplastic disease care hospitals, and short-term acute care hospitals located in the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa is the FY 2026 percentage increase in the 2023-based IPPS operating market basket. For this final rule, the current estimate of the IPPS operating market basket percentage increase for FY 2026 is 3.3 percent. E. Update for LTCHs for FY 2026 Section 123 of Public Law 106–113, as amended by section 307(b) of Public Law 106–554 (and codified at section 1886(m)(1) of the Act), provides the statutory authority for updating payment rates under the LTCH PPS. As discussed in section V.A. of the Addendum to this final rule, we are updating the LTCH PPS standard Federal payment rate for FY 2026 by 2.7 percent, consistent with section 1886(m)(3) of the Act which provides that any annual update be reduced by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II) of the Act (that is, the productivity adjustment). Furthermore, ) of the Act which provides that any annual update be reduced by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II) of the Act (that is, the productivity adjustment). Furthermore, in accordance with the LTCH QRP under section 1886(m)(5) of the Act, we are reducing the annual update to the LTCH PPS standard Federal rate by 2.0 percentage points for failure of a LTCH to submit the required quality data. Accordingly, we are establishing an update factor of 1.027 in determining the LTCH PPS standard Federal rate for FY 2026. For LTCHs that fail to submit quality data for FY 2026, we are establishing an annual update to the LTCH PPS standard Federal rate of 0.7 percent (that is, the annual market basket update for FY 2026 of 2.7 percent less 2.0 percentage points for failure to submit the required quality data in accordance with section 1886(m)(5)(C) of the Act and our rules) by applying an update factor of 1.007 in determining the LTCH PPS standard Federal rate for FY 2026. (We note that, as discussed in section IX.C. of the preamble of this final rule, the update to the LTCH PPS standard Federal payment rate of 2.7 percent for FY 2026 does not reflect any budget ne 026. (We note that, as discussed in section IX.C. of the preamble of this final rule, the update to the LTCH PPS standard Federal payment rate of 2.7 percent for FY 2026 does not reflect any budget neutrality factors.) III. Secretary’s Recommendations MedPAC is recommending inpatient hospital rates be updated by the amount specified in current law plus 1.0 percent. MedPAC’s rationale for this update recommendation is described in more detail in this section. As previously stated, section 1886(e)(4)(A) of the Act requires that the Secretary, taking into consideration the recommendations of MedPAC, recommend update factors for inpatient hospital services for each fiscal year that take into account the amounts necessary for the efficient and effective delivery of medically appropriate and necessary care of high quality. Consistent with current law, depending on whether a hospital submits quality data and is a meaningful EHR user, we are recommending the four applicable percentage increases to the standardized amount listed in the table under section II. of this Appendix. We are recommending that the same applicable percentage increases apply to SCHs. In addition to making a recommenda s to the standardized amount listed in the table under section II. of this Appendix. We are recommending that the same applicable percentage increases apply to SCHs. In addition to making a recommendation for IPPS hospitals, in accordance with section 1886(e)(4)(A) of the Act, we are recommending update factors for certain other types of hospitals excluded from the IPPS. Consistent with our policies for these facilities, we are recommending an update to the target amounts for children’s hospitals, cancer hospitals, RNHCIs, short-term acute care hospitals located in the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa and extended neoplastic disease care hospitals of 3.3 percent. For FY 2026, consistent with policy set forth in section IX.C. of the preamble of this final rule, for LTCHs that submit quality data, we are recommending an update of 2.7 percent to the LTCH PPS standard Federal rate. For LTCHs that fail to submit quality data for FY 2026, we are recommending an annual update to the LTCH PPS standard Federal rate of 0.7 percent. IV. MedPAC Recommendation for Assessing Payment Adequacy and Updating Payments in Traditional Medicare In its March 202 ommending an annual update to the LTCH PPS standard Federal rate of 0.7 percent. IV. MedPAC Recommendation for Assessing Payment Adequacy and Updating Payments in Traditional Medicare In its March 2025 Report to Congress, MedPAC assessed the adequacy of current payments and costs, and the relationship between payments and an appropriate cost base. MedPAC recommended an update to the hospital inpatient rates by the amount specified in current law plus 1.0 percent. MedPAC anticipates that their recommendation to update the IPPS payment rate by the amount specified under current law plus 1.0 percent in 2026 would generally be adequate to maintain beneficiaries’ access to hospital inpatient and outpatient care and keep IPPS payment rates close to, if somewhat below, the cost of delivering high- quality care efficiently. MedPAC stated that their recommended update to IPPS and OPPS payment rates of current law plus 1.0 percent may not be sufficient to ensure the financial viability of some Medicare safety-net hospitals with a poor payer mix. MedPAC recommends redistributing the current Medicare safety-net payments (disproportionate share hospital and uncompensated care payments) using th edicare safety-net hospitals with a poor payer mix. MedPAC recommends redistributing the current Medicare safety-net payments (disproportionate share hospital and uncompensated care payments) using the MedPAC-developed Medicare Safety-Net Index (MSNI) for hospitals. In addition, MedPAC recommends adding $4 billion to this MSNI pool of funds to help maintain the VerDate Sep 2014 00:36 Aug 02, 2025 Jkt 265001 PO 00000 Frm 00773 Fmt 4701 Sfmt 4700 E:\FR\FM\04AUR2.SGM 04AUR2 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k 37308 Federal Register / Vol. 90, No. 147 / Monday, August 4, 2025 / Rules and Regulations financial viability of Medicare safety-net hospitals and recommended to Congress transitional approaches for a MSNI policy. We refer readers to the March 2025 MedPAC report, which is available for download at https://www.medpac.gov/ document-type/report/. We look forward to working with Congress on these matters. We are establishing an applicable percentage increase for FY 2026 of 2.6 percent as described in section 1886(b)(3)(B) of the Act, provided the hospital submits quality data and is a meaningful EHR user consistent with these statutory requirements. W ase for FY 2026 of 2.6 percent as described in section 1886(b)(3)(B) of the Act, provided the hospital submits quality data and is a meaningful EHR user consistent with these statutory requirements. We note that, because the operating and capital payments in the IPPS remain separate, we are continuing to use separate updates for operating and capital payments in the IPPS. The update to the capital rate is discussed in section III. of the Addendum to this final rule. We note that section 1886(d)(5)(F) of the Act provides for additional Medicare payment adjustments, called Medicare disproportionate share hospital (DSH) payments, for subsection (d) hospitals that serve a significantly disproportionate number of low-income patients. Section 1886(r) of the Act provides that, for FY 2014 and each subsequent fiscal year, the Secretary shall pay each such subsection (d) hospital that is eligible for Medicare DSH payments an empirically justified DSH payment equal to 25 percent of the Medicare DSH adjustment they would have received under section 1886(d)(5)(F) of the Act if subsection (r) did not apply. The remaining amount, equal to an estimate of 75 percent of what otherwise would have be DSH adjustment they would have received under section 1886(d)(5)(F) of the Act if subsection (r) did not apply. The remaining amount, equal to an estimate of 75 percent of what otherwise would have been paid as Medicare DSH payments if subsection (r) of the Act did not apply, reduced to reflect changes in the percentage of individuals who are uninsured, is available to make additional payments to each hospital that qualifies for Medicare DSH payments and has uncompensated care. These additional payments are called uncompensated care payments. We refer readers to section V. of the preamble of this final rule for further discussion of Medicare DSH and uncompensated care payments. [FR Doc. 2025–14681 Filed 7–31–25; 4:15 pm] BILLING CODE 4120–01–P 2 S E L U R h t i w D O R P 4 4 1 S 7 W 9 K S D n o d n o m m a h k VerDate Sep 2014 00:36 Aug 02, 2025 Jkt 265001 PO 00000 Frm 00774 Fmt 4701 Sfmt 9990 E:\FR\FM\04AUR2.SGM 04AUR2