Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs; Overall Hospital Quality Star Ratings; and Hospital Price Transparency bed in the TiC GitHub schemas for the ‘‘In-Network File,’’ ‘‘Out-Of-Network Allowed Amount File,’’ and the optional ‘‘Provider Reference File,’’ most group health plans and health insurance issuers must post pricing information, and such pricing information must be associated with a provider’s NPI to ensure that consumers have reliable data and can make informed healthcare purchasing decisions.297 We believe that aligning the NPI across the HPT and TiC MRFs would support improved cross- comparison among hospital data and health plan data, providing users of both MRFs further context about hospital standard charges. We believe this proposal would increase data researchers’ ability to automate research as they would be better able to match on a common hospital numeric unique identifier across multiple datasets. Additionally, inclusion of the NPI(s) in the MRF could enable the development of products that combine price, claims, and quality data to stimulate additional hospital price competition. Including identifiers used for financial transactions (like the Type 2 NPI(s)) in the MRF would also make it easier for key participants in price negotiations (for example, employers and payer tition. Including identifiers used for financial transactions (like the Type 2 NPI(s)) in the MRF would also make it easier for key participants in price negotiations (for example, employers and payers) to programmatically identify hospitals in their internal financial databases, such as claims databases, enabling them to better conduct in-depth payment and volume analyses to support contract negotiations and potentially reduce healthcare costs for consumers. A standard identifier could also help CMS, 296 https://www.whitehouse.gov/presidential- actions/2025/02/making-america-healthy-again-by- empowering-patients-with-clear-accurate-and- actionable-healthcare-pricing-information/. 297 https://github.com/CMSgov/price- transparency-guide. researchers, and innovators reduce dependence on manual processes for identifying a hospital and hospital locations and increase opportunities for automated processes. We specifically propose to require, beginning January 1, 2026, that hospitals report, in a newly created general data element in the MRF, any Type 2 NPI(s) that has a primary taxonomy code starting with ‘28’ (indicating hospital) or ‘27’ (indicating hospital unit) and that is active a in a newly created general data element in the MRF, any Type 2 NPI(s) that has a primary taxonomy code starting with ‘28’ (indicating hospital) or ‘27’ (indicating hospital unit) and that is active as of the date of the most recent update to the standard charge information. We propose to limit the Type 2 NPI(s) that hospitals would report to only those that meet this taxonomy criteria, because while hospitals may have more NPIs beyond these criteria for other departments or units, these taxonomy codes limit the number of NPIs to only those indicating hospital or hospital unit. In the case that hospitals have more than one NPI that meet the proposed criteria above, we propose that hospitals would be required to report in the general data element all active Type 2 NPIs meeting the criteria. Should the proposal be finalized as proposed, we would include additional technical instructions in the CMS data dictionary and JSON schema in the Hospital Price Transparency—Data Dictionary GitHub Repository available at https:// github.com/CMSgov/hospital-price- transparency. We seek comment on our proposal and any additional taxonomy codes that would be necessary or helpful to consider. We con epository available at https:// github.com/CMSgov/hospital-price- transparency. We seek comment on our proposal and any additional taxonomy codes that would be necessary or helpful to consider. We considered, as an alternative, that should a hospital have multiple NPIs, it would be required to report only one NPI. With this alternative, MRF users could crosswalk the NPI to identify additional NPIs. A review of the publicly available January 2025 data from PECOS, the online Medicare enrollment system, found that only approximately 10 percent of hospital enrollment applications reported multiple NPIs.298 This data was cross- walked with NPPES data to find the provider taxonomy code (a 10-digit code that designates classification or specialization), whether the NPI was still active in the system, and whether an NPI was classified as an organization subpart. The majority of reported NPIs for applications with multiple NPIs were active. Some applications reported as many as 27 NPIs with a hospital or hospital unit taxonomy. However, the median number of NPIs with a hospital 298 CMS Hospital Enrollments and Hospital Additional NPIs datasets https://data.cms.gov/ provider-characteristics/ ospital or hospital unit taxonomy. However, the median number of NPIs with a hospital 298 CMS Hospital Enrollments and Hospital Additional NPIs datasets https://data.cms.gov/ provider-characteristics/hospitals-and-other- facilities/hospital-enrollments. VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00327 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 33802 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules or hospital unit taxonomy was 2 and the average number of NPIs with a hospital or hospital unit taxonomy was 1.9. For this reason, we believe that requiring hospitals to include NPIs that meet our proposed criteria would not pose a significant burden or, for most hospitals, significantly increase the amount of data stored in the MRFs. We also considered proposing to require that hospitals include in the MRF a Place of Service code and the Taxpayer Identification Number (TIN), as the TiC final rule also requires them. Place of Service Codes are used on professional claims to indicate the setting where an item or service was rendered. Because the HPT requirements alr (TIN), as the TiC final rule also requires them. Place of Service Codes are used on professional claims to indicate the setting where an item or service was rendered. Because the HPT requirements already require hospitals to indicate the setting of the item or service in the MRF, we do not believe the Place of Service Codes would provide any additional information that is not already included in the MRF. Similarly, we do not believe there would be a benefit to requiring hospitals to encode their TIN within the MRF; rather, we believe that would be duplicative since the HPT MRF naming convention already requires the EIN (typically a hospital’s TIN), thus innovators and researchers could extract it from the naming convention. We also considered proposing to require that hospitals include other identifiers in their MRF, such as the CMS Certification Number (CCN). CCNs are assigned by CMS and used to identify health care facilities participating in the Medicare Part A and Medicaid programs.299 300 Hospitals primarily have assigned CCNs as entities, but CCNs can also be used to identify specific hospital locations or units, especially when those units operate under the same organizatio s.299 300 Hospitals primarily have assigned CCNs as entities, but CCNs can also be used to identify specific hospital locations or units, especially when those units operate under the same organizational umbrella but at different sites. CCNs do not change when hospital ownership changes, but hospital mergers, acquisitions, and consolidations can result in CCN changes. We elected not to propose to require that hospitals encode CCNs because CCNs are limited to Medicare- or Medicaid-participating hospitals, while the HPT regulations apply to all hospitals in the United States (with exceptions listed at § 180.30(b)), and, also, the inclusion of CCNs would not align with the TiC provider identifier requirements. We seek comment on our proposal, as well as any additional, or alternative, taxonomy codes that commenters 299 https://www.cms.gov/files/document/provider- enrollment-certification-roadmap.pdf. 300 https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/ pim83c10.pdf. believe would be necessary or helpful to consider. We also seek comment on other standard identifiers that may be useful in providing needed context and streamlining the alignment of price transpar f. believe would be necessary or helpful to consider. We also seek comment on other standard identifiers that may be useful in providing needed context and streamlining the alignment of price transparency data. C. Proposal To Improve and Enhance Enforcement 1. Background In the CY 2020 HPT final rule (84 FR 65524), we established actions that would address hospital noncompliance with the requirements under §§ 180.50 and 180.60, which may include issuing a written warning notice, requesting a CAP, and imposing CMPs on noncompliant hospitals and publicizing these penalties on a CMS website. In the CY 2022 OPPS/ASC final rule with comment period (86 FR 63941), we increased the amount of CMP to which a hospital could be subject to a minimum total penalty of $300/day that applies to smaller hospitals with a bed count of 30 or fewer, and a penalty of $10/bed/day for hospitals with a bed count greater than 30, not to exceed a maximum daily dollar amount of $5,500. In the CY 2024 OPPS/ASC final rule with comment period (88 FR 82113), we finalized several improvements to our enforcement process by updating our methods to assess hospital compliance, requiring hospitals to acknowledge receipt l rule with comment period (88 FR 82113), we finalized several improvements to our enforcement process by updating our methods to assess hospital compliance, requiring hospitals to acknowledge receipt of warning notices, working with health system officials to address noncompliance issues in one or more hospitals that are part of a health system, and publicizing more information about CMS enforcement activities related to individual hospital compliance. We also finalized revisions to § 180.70(a)(2) to add activities that CMS may use to monitor and assess for compliance. Specifically, we revised § 180.70(a)(2)(iii) to indicate that we may conduct an audit and comprehensive compliance review of a hospital’s standard charge information posted on a publicly available website. We stated that we believed that provision was necessary to clarify the methods we may use to determine a hospital’s compliance with HPT requirements. In addition, we added new provisions at § 180.70(a)(2)(iv)–(v), to require, upon our request, an authorized hospital official to submit to CMS a certification as to the accuracy and completeness of the standard charge information posted in the MRF, and to require sub require, upon our request, an authorized hospital official to submit to CMS a certification as to the accuracy and completeness of the standard charge information posted in the MRF, and to require submission of additional documentation as may be necessary to determine hospital compliance. Further, we finalized at § 180.70(b)(1) a requirement that a hospital submit an acknowledgement of receipt of a warning notice in the form and manner, and by the deadline, specified in the notice of violation issued by CMS to the hospital (88 FR 82117, 82185), which requirement we thought was necessary to provide an appropriate compliance contact earlier in the enforcement process. We also, in the CY 2024 OPPS/ASC final rule with comment period (88 FR 82119, 82185), finalized at § 180.70(d) that CMS may publicize on its website information related to CMS’ assessment of a hospital’s compliance; any compliance action(s) taken against a hospital, the status of such compliance action(s), or the outcome of such compliance action(s); and notifications sent to health system leadership. We indicated that, should CMS decide to publicize this information on its website, it would apply uniformly to all hospi such compliance action(s); and notifications sent to health system leadership. We indicated that, should CMS decide to publicize this information on its website, it would apply uniformly to all hospitals. We further noted that, similar to other such assessments, the information we make public would only be relevant as of the date indicated and should not be taken to suggest any ongoing state of compliance or noncompliance. We stated that we believed such information: (1) would improve the public’s understanding of CMS’ enforcement process by allowing interested parties to view compliance actions and determinations made by CMS, increasing transparency; (2) might reduce repetitive complaints to CMS regarding a hospital’s compliance assessment; 301 and (3) might increase the likelihood that hospitals would more quickly come into compliance due to public scrutiny. We are aware that there are still instances of egregious violations of the HPT requirements, such as failure to post an MRF or a shoppable services file. Over a 3-year period, as shown in Table 91, violations related to not having posted an MRF and/or a shoppable service file accounted for nearly 20 percent of all enforcemen a shoppable services file. Over a 3-year period, as shown in Table 91, violations related to not having posted an MRF and/or a shoppable service file accounted for nearly 20 percent of all enforcement actions (including warning notices, CAP request letters, and all other).302 In a fact sheet, ‘‘Hospital Price Transparency Enforcement Updates’’ (https://www.cms.gov/newsroom/fact- sheets/hospital-price-transparency- enforcement-updates), that we posted on April 26, 2023, we provided updates 301 Information on enforcement actions as a result of CMS’ assessment of a hospital’s compliance with the HPT regulations may be found here https:// data.cms.gov/provider-characteristics/hospitals- and-other-facilities/hospital-price-transparency- enforcement-activities-and-outcomes. 302 Data is gathered from the CMS Hospital Price Transparency database and encompasses compliance actions from August 29, 2022, through March 10, 2025. VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00328 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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. 135 / Thursday, July 17, 2025 / Proposed Rules 3 t 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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. 135 / Thursday, July 17, 2025 / Proposed Rules 33803 we have implemented regarding our enforcement process, including streamlining the process to no longer issue a warning notice to a hospital that has not posted an MRF or shoppable services list/price estimator tool. This was intended to incentivize hospitals to more quickly comply with our HPT requirements, and especially the basic HPT requirements to post an MRF and a consumer-friendly display of shoppable services. Consistent with Executive Order 14221, we continue to believe that it is critically important that all hospitals subject to the HPT regulations be compliant with them. As CMS identifies hospitals without an MRF and/or shoppable services file, we will continue to prioritize those cases for immediate compliance by sending them a CAP request letter. 2. Civil Money Penalties: Waiver of Hearing, Automatic Reduction of Penalty Amount In prior HPT rulemaking,303 we issued regulations that established processes to enforce the HPT requirements, including issuance of CMPs when Waiver of Hearing, Automatic Reduction of Penalty Amount In prior HPT rulemaking,303 we issued regulations that established processes to enforce the HPT requirements, including issuance of CMPs when a noncompliant hospital fails to respond to our request to submit a corrective action plan (CAP) or comply with the requirements of the CAP (§ 180.90(a)). The HPT regulations set forth the criteria we use to determine the CMP amount (§ 180.90(c)) and permit hospitals to appeal a CMP imposed by us within 30 days of issuance of the notice of imposition of a CMP (§§ 180.100 and 180.110). As of May 2025, we have issued CMP notices to 27 hospitals, 20 of which have exercised their right to appeal the CMP to an administrative law judge (ALJ).304 Hospitals may elect to mount an appeal for many reasons, including disagreeing with our assessment of the law or facts underlying our determination, seeking to protect their reputation and/or avoid other civil or state regulatory actions, or other reasons. We are aware that some other CMS enforcement programs offer entities subject to CMPs the ability to waive appeal rights in exchange for a 35 303 The CY 2020 HPT final rule, CY 2022 OPPS/ ASC final s. We are aware that some other CMS enforcement programs offer entities subject to CMPs the ability to waive appeal rights in exchange for a 35 303 The CY 2020 HPT final rule, CY 2022 OPPS/ ASC final rule, and CY 2024 OPPS/ASC final rule with comment period. 304 CMS (2025, June) Enforcement Actions. https://www.cms.gov/priorities/key-initiatives/ hospital-price-transparency/enforcement-actions. percent discount in the amount of the CMP owed.305 For example, in the FY 2024 Skilled Nursing Facility Prospective Payment System final rule (88 FR 53200, 53326), we discussed our experience over the years with the CMP reduction pertaining to LTC facilities. We noted there how, between CYs 2016 and 2022 (but for CY 2017 that was not referenced), around 80 percent of LTC facilities submitted waivers, with the figure rising to 91 percent in CY 2021 but retreating to 81 percent in CY 2022, while also a considerable percentage of the remaining facilities did not submit a waiver but also not did not contest the penalty and its basis. Most significantly, throughout the period only between 2 to 6 percent of facilities availed themselves of the full hearing process. Given respondents’ widespread in contest the penalty and its basis. Most significantly, throughout the period only between 2 to 6 percent of facilities availed themselves of the full hearing process. Given respondents’ widespread invocation of the LTC facility enforcement appeal waiver provision, we considered whether offering hospitals the opportunity to receive a reduced penalty—in some circumstances, and in exchange for their acknowledging their HPT noncompliance—could expedite timely payment of CMPs. Among our considerations, we believe that hospitals that might elect such a waiver opportunity pursuant to such a proposal would be demonstrating their acceptance of responsibility for HPT 305 See, for example, 42 CFR 488.1245(c)(2)(ii) (Hospice); 42 CFR 488.845(c)(2)(ii) (Home Health Agency); 42 CFR 488.436(b) (Long-Term Care (LTC) Facility). noncompliance, and, concomitantly, their corresponding commitment to timely achieving future compliance, which would be key to helping us achieve our overarching HPT goal of ensuring this information, in compliant form, is accessible to healthcare consumers. We therefore propose at new § 180.90(c)(4), and subject to the exceptions discussed below, that the amount of a CMP w suring this information, in compliant form, is accessible to healthcare consumers. We therefore propose at new § 180.90(c)(4), and subject to the exceptions discussed below, that the amount of a CMP would be reduced by 35 percent should a hospital submit to CMS a written notice requesting to waive its right to a hearing under § 180.100 within 30 calendar days of the date of the notice of imposition of the CMP. We also propose that if a hospital waives its right to appeal a CMP and receives a 35 percent reduction in accordance with § 180.90(c)(4), the hospital: (1) would not be eligible to receive a 35 percent reduction under § 180.90(c)(4) on any CMPs issued under § 180.90(f) that result from the same instance(s) of noncompliance (that is, continuing violations); and (2) would waive its right to appeal CMPs for any such continuing violations. As discussed above, and if our proposal is finalized as proposed, in waiving its right to appeal and receiving a 35 percent reduction with respect to the initial CMP, we believe a hospital would be demonstrating acceptance of responsibility for HPT noncompliance and a commitment to achieving future compliance; as such, we do not believe it wou t to the initial CMP, we believe a hospital would be demonstrating acceptance of responsibility for HPT noncompliance and a commitment to achieving future compliance; as such, we do not believe it would be necessary or appropriate to VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00329 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00330 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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. 135 / Thursday, July 17, 2025 / Proposed Rules 33805 section 1886(d)(4)(C)(i) of the Act requires that the weighting factors be adjusted at least annually to reflect changes in treatment patterns, technology, and other factors which may change the relative use of hospital resources. In this proposed rule, we propose for cost reporting periods ending on or after January 1, 2026, to collect on the Medicare cost report the median payer- specific negotiated charge that the hospital has negotiated with all of its MAOs, by MS–DRG. We propose to utilize this da ter January 1, 2026, to collect on the Medicare cost report the median payer- specific negotiated charge that the hospital has negotiated with all of its MAOs, by MS–DRG. We propose to utilize this data within a proposed methodology for calculating the IPPS MS–DRG relative weights to reflect relative market-based pricing, effective in FY 2029. This proposal reflects certain modifications to the policy as finalized in the FY 2021 IPPS/LTCH PPS final rule (85 FR 58873 through 58892), as discussed further in section XX.C. of this proposed rule. As stated previously, we continue to believe there is a need for Medicare to reduce its reliance on the hospital chargemaster and develop market-based approaches to payment under the Medicare FFS system. We discuss in further detail in this section our evaluation and reconsideration of the usefulness and appropriateness of market-based data for ratesetting purposes since the FY 2022 IPPS/LTCH PPS final rule. As discussed in greater detail in section XX.C.2. of this proposed rule, this proposal provides instruction on how hospitals would calculate the median of the payer-specific negotiated charges for an MS–DRG using data from the machine- read n XX.C.2. of this proposed rule, this proposal provides instruction on how hospitals would calculate the median of the payer-specific negotiated charges for an MS–DRG using data from the machine- readable file (MRF) that hospitals are required to disclose under the hospital price transparency regulations at 45 CFR part 180. This proposal also addresses circumstances when hospitals use something other than MS–DRGs as a basis for reporting under those hospital price transparency requirements. As described further in section XX.C.2. of this proposed rule, we specifically propose that for the purposes of reporting the data on the cost report, hospitals would report the median of the payer-specific negotiated charges for an MS–DRG that the hospital has disclosed for all of its MAOs on the most recent version of the MRF that the hospital is required to disclose under 45 CFR 180.40(a). If the hospital disclosed the payer-specific negotiated charge for an MS–DRG as a dollar amount, the hospital would use the dollar amount disclosed on its MRF under 45 CFR 180.50(b)(2)(ii)(C) in determining the median of the payer-specific negotiated charges to be reported on its Medicare cost report, as di l would use the dollar amount disclosed on its MRF under 45 CFR 180.50(b)(2)(ii)(C) in determining the median of the payer-specific negotiated charges to be reported on its Medicare cost report, as discussed further in section XX.C.2. If the hospital disclosed the payer-specific negotiated charge as a percentage or algorithm on the MRF, we propose that the hospital would instead use the proposed ‘‘median allowed amount’’ (as proposed in section XIX. of this proposed rule) to calculate the median of the payer-specific negotiated charges.307 The hospital would then report the median payer-specific negotiated charge on its Medicare cost report, as also discussed further in section XX.C.2. of this proposed rule. We believe this proposed approach of utilizing data required for disclosure on the MRF under 45 CFR 180.50(b)(2)(ii)(C) in determining the median of the payer-specific negotiated charges would help streamline requirements for hospitals and result in less administrative burden overall because hospitals would already be required to calculate and disclose these data in compliance with the hospital price transparency requirements. For additional details on hospital price transparen ll because hospitals would already be required to calculate and disclose these data in compliance with the hospital price transparency requirements. For additional details on hospital price transparency requirements, including MRF requirements and the proposed modifications to the hospital price transparency requirements, we refer readers to section XIX. of this proposed rule and https://www.cms.gov/ priorities/key-initiatives/hospital-price- transparency/hospitals. As described in greater detail in section XX.C. of this proposed rule, the median payer-specific negotiated charges as reported on the Medicare cost report would be used in a proposed market-based methodology to calculate IPPS MS–DRG relative weights beginning in FY 2029 to reflect the relative hospital resources used to provide inpatient services to patients. The use of the median payer-specific negotiated charges would replace the current use of gross charges that are reflected on a hospital’s chargemaster and cost information from Medicare cost reports for the development of the IPPS MS–DRG relative weights. B. Factors Considered As discussed in the FY 2021 IPPS/ LTCH PPS final rule (85 FR 58873 through 58892), to re ation from Medicare cost reports for the development of the IPPS MS–DRG relative weights. B. Factors Considered As discussed in the FY 2021 IPPS/ LTCH PPS final rule (85 FR 58873 through 58892), to reduce the Medicare program’s reliance on the hospital chargemaster and to support the development of a market-based approach to payment under the Medicare FFS system, we finalized our proposal to require that hospitals report certain market-based payment rate 307 As discussed further in section XX.C.2. of this proposed rule, if CMS does not finalize to amend 45 CFR 180.50(b)(2)(ii)(C), hospitals would use the ‘‘estimated allowed amount’’ as required under the current hospital price transparency regulations for purposes of calculating the median payer-specific negotiated charge that is reported on the cost report. information on their Medicare cost report for cost reporting periods ending on or after January 1, 2021. In that same rulemaking, we also adopted a market- based MS–DRG relative weight methodology using that information. In the FY 2022 IPPS/LTCH PPS final rule (86 FR 45319), we repealed both the collection of market-based rate information on the Medicare cost report and the mar ight methodology using that information. In the FY 2022 IPPS/LTCH PPS final rule (86 FR 45319), we repealed both the collection of market-based rate information on the Medicare cost report and the market-based MS–DRG relative weight methodology and stated that we would continue to evaluate and consider the usefulness and appropriateness of market-based data for ratesetting purposes. As noted in the FY 2022 IPPS/LTCH PPS rulemaking, we have continued to consider the use of market-based rate information for purposes of the IPPS relative weight methodology, including for the reasons discussed in the FY 2021 IPPS/LTCH PPS final rule (85 FR 58874 through 58875) regarding reducing the Medicare program’s reliance on the hospital chargemaster and supporting the development of a market-based approach to payment under the Medicare FFS system, as well as additional factors since the repeal of the prior policies. For example, in the FY 2021 IPPS/ LTCH PPS proposed rule we described research that chargemasters are usually highly inflated and that these inflated charges have been used to secure higher payments from Medicare and private payers (85 FR 32790). We indicated that some hospitals’ char hargemasters are usually highly inflated and that these inflated charges have been used to secure higher payments from Medicare and private payers (85 FR 32790). We indicated that some hospitals’ charges do not reflect market rates. Hospital bills that are generated off these chargemaster rates can be inherently unreasonable when judged against prevailing market rates. We stated that recognizing that chargemaster (gross) rates rarely reflect true market costs, we believed that by reducing our reliance on the hospital chargemaster we could adjust Medicare payment rates so that they reflect the relative market value for inpatient items and services. As part of our efforts since the FY 2022 repeal, we have examined more recent research on hospital chargemasters, which is generally consistent with the discussion in the FY 2021 rulemaking regarding whether hospital chargemasters reflect true market costs. Recent research by Linde and Egede 308 concluded that higher chargemaster markups are associated with higher hospital profitability. They delineated four potential causal pathways that may connect chargemaster markups to hospital profitability. First, chargemaster prices 308 Linde S, E associated with higher hospital profitability. They delineated four potential causal pathways that may connect chargemaster markups to hospital profitability. First, chargemaster prices 308 Linde S, Egede LE. Do Chargemaster Prices Matter?: An Examination of Acute Care Hospital Profitability. Med Care. 2022 Aug 1;60(8):623–630. VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00331 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 33806 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules are commonly billed to uninsured patients and therefore may increase profits via higher payments (or payment settlements) with uninsured patients. Second, higher chargemasters may yield higher payments from insured individuals that seek care out-of- network, or who receive care at in- network facilities but are cared for by out-of-network providers. Third, chargemaster prices do in many cases serve as reference prices for the contractual payments between private insurers and hospitals. As such, higher chargemaster prices may yield increased profits by increasing payments from private payors erve as reference prices for the contractual payments between private insurers and hospitals. As such, higher chargemaster prices may yield increased profits by increasing payments from private payors. Fourth, higher chargemaster prices may allow hospitals to increase the cost-saving value of liabilities that end up being written off as bad debt, and therefore increased hospital profits. We have also continued to consider the available research comparing Medicare, MAO, and commercial payment rates since the repeal. As discussed in the FY 2021 IPPS/LTCH PPS final rule (85 FR 58874 through 58877), we reviewed available literature to compare Medicare FFS and MAO payment rates and how those MAO rates may reflect the relative hospital resources used within an MS–DRG differently than our current cost-based methodology. As discussed in the FY 2021 rulemaking, Berenson et al.309 surveyed senior hospital and health plan executives and found that MA plans nominally pay only 100 to 105 percent of traditional Medicare rates and, in real economic terms, possibly less. Respondents broadly identified three primary reasons for near payment equivalence: • Statutory and regulatory provisions that li traditional Medicare rates and, in real economic terms, possibly less. Respondents broadly identified three primary reasons for near payment equivalence: • Statutory and regulatory provisions that limit out-of-network payments to traditional Medicare rates, • De facto budget constraints that MA plans face because of the need to compete with traditional Medicare and other MA plans, and • A market equilibrium that permits relatively lower MA rates as long as commercial rates remain well above the traditional Medicare rates. As also discussed in the FY 2021 rulemaking, Baker et al.310 used data from Medicare and the Health Care Cost Institute (HCCI) to identify the prices paid for hospital services by FFS 309 Berenson RA, Sunshine JH, Helms D, Lawton E. Why Medicare Advantage plans pay hospitals traditional Medicare prices. Health Aff (Millwood). 2015;34(8):1289–1295. 310 Baker LC, Bundorf MK, Devlin AM, Kessler DP. Medicare Advantage plans pay less than traditional Medicare pays. Health Aff (Millwood). 2016;35(8):1444–1451. Medicare, MA plans, and commercial insurers in 2009 and 2012. They calculated the average price per admission, and its trend over time, in each of the three type Aff (Millwood). 2016;35(8):1444–1451. Medicare, MA plans, and commercial insurers in 2009 and 2012. They calculated the average price per admission, and its trend over time, in each of the three types of insurance for fixed baskets of hospital admissions across metropolitan areas. After accounting for differences in hospital networks, geographic areas, and case- mix between MA and FFS Medicare, they found that MA plans paid 5.6 percent less for hospital services compared to FFS Medicare. For the time period studied, the authors suggest that at least one channel through which MA plans paid lower prices was by obtaining greater discounts on types of FFS Medicare admissions that were known to have very short lengths-of- stay. They also found that the rates paid by commercial plans were much higher than those of either MA or FFS Medicare, and that this differential was growing. At least some of this difference they indicated came from the much higher prices that commercial plans paid for certain service lines. Maeda and Nelson 311 also analyzed data from the HCCI in their research. They compared the hospital prices paid by MA organizations and commercial plans with Medicare FFS prices certain service lines. Maeda and Nelson 311 also analyzed data from the HCCI in their research. They compared the hospital prices paid by MA organizations and commercial plans with Medicare FFS prices using 2013 claims from the HCCI. The HCCI claims were used to calculate hospital prices for private insurers, and Medicare’s payment rules were used to estimate Medicare FFS prices. The authors focused on stays at acute care hospitals in metropolitan statistical areas (MSAs). They found MA prices to be roughly equal to Medicare FFS prices, on average, but commercial prices were 89 percent higher than FFS prices. In addition, commercial prices varied greatly across and within MSAs, but MA prices varied much less. Although they noted that they used slightly different methods to calculate Medicare FFS prices, the authors considered their results generally consistent with the Baker et al. study findings in that hospital payments by MA plans were much more similar to Medicare FFS levels than they were to commercial payment levels. In their study, Maeda and Nelson also examined whether the ratio of MA prices to FFS prices varied across DRGs to assess whether there were certain DRGs for whic hey were to commercial payment levels. In their study, Maeda and Nelson also examined whether the ratio of MA prices to FFS prices varied across DRGs to assess whether there were certain DRGs for which MA plans tended to pay more or less than FFS. They ranked the ratio of MA prices to FFS prices and adjusted for outlier payments. The 311 Maeda JLK, Nelson L. How Do the Hospital Prices Paid by Medicare Advantage Plans and Commercial Plans Compare with Medicare Fee-for- Service Prices? The Journal of Health Care Organization, Provision, and Financing. 2018;55(1– 8). authors found that ‘‘there were some DRGs where the average MA price was much higher than FFS and there were some DRGs where the average MA price was a bit lower than FFS.’’ For example, for the time period in question, on average, MA plans paid 129 percent more than FFS for rehabilitation stays (DRG 945), 33 percent more for depressive neuroses (DRG 881), and 27 percent more for stays related to psychoses (DRG 885). But MA plans paid an average of 9 percent less than FFS for stays related to pathological fractures (DRG 542) and wound debridement and skin graft (DRG 464) (see Online Appendix Table 5 from their study). The lans paid an average of 9 percent less than FFS for stays related to pathological fractures (DRG 542) and wound debridement and skin graft (DRG 464) (see Online Appendix Table 5 from their study). The authors state these results suggest that there may be certain services where MA plans pay more than FFS possibly because the FFS rates for those services are too low, but that there may be other services where MA plans pay less than FFS possibly because the FFS rates for those DRGs are too high (Maeda, Nelson, 2018 p. 5). In addition to this research discussed in the FY 2021 rulemaking, we have also considered more recent research comparing Medicare FFS rates, MAO rates, and rates of other commercial payers, some of which used data that was made public under the provisions of the Hospital Price Transparency regulations. Meiselbach et al.312 used 2022 price information disclosed by hospitals to examine the ratio of commercial-to-MA prices negotiated by the same insurer and found that median prices were two to three times higher for commercial plans than MA plans in the same hospital for the same service. They attributed the relatively lower MA prices to the same reasons outlined by Ber n prices were two to three times higher for commercial plans than MA plans in the same hospital for the same service. They attributed the relatively lower MA prices to the same reasons outlined by Berenson et al. Based on price transparency data from 22 dyads of large hospitals and insurers, Randall and Duffy 313 found that, for a market basket of inpatient services, prices for health insurance exchange plans were 143.3 percent of those for MA organizations and about 89 percent of those for commercial group insurance plans. This more recent research does not directly address the relationship between payer-specific charges negotiated between hospitals and MAOs and Medicare IPPS payment rates, but it is generally consistent in other respects to the earlier research we cited in the FY 312 Meiselbach MK, Wang Y, Xu Jianhui, Bai G, Anderson GF. Hospital Prices for Commercial Plans Are Twice Those For Medicare Advantage Plans When Negotiated By The Same Insurer. Health Aff. 2023;42(8):1110–1118. 313 Randall S, Duffy EL. Insurers Negotiate Lower Hospital Prices for HIX Than for Commercial Groups. The American Journal of Managed Care. 2022;28(9): e347–e350. VerDate Sep 2014 22:23 Jul 16, 2 118. 313 Randall S, Duffy EL. Insurers Negotiate Lower Hospital Prices for HIX Than for Commercial Groups. The American Journal of Managed Care. 2022;28(9): e347–e350. VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00332 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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. 135 / Thursday, July 17, 2025 / Proposed Rules 33807 2021 IPPS/LTCH PPS final rule (85 FR 58876 through 58877) indicating that hospital payments by MAOs are much more similar to Medicare FFS levels than they are to commercial payment levels. We continue to believe that payer-specific charges negotiated between hospitals and MAOs and Medicare IPPS payment rates are generally well-correlated. In the FY 2022 IPPS/LTCH PPS final rule we indicated that we agreed with commenters that we needed to further consider the questions raised by commenters regarding the ability of the payer-specific charges negotiated between hospitals and MAOs to represent market-based pricing given the relationship between Medicare FFS and MAO rates. After considering this issue further since the FY 2022 rulemaking, we do not beli etween hospitals and MAOs to represent market-based pricing given the relationship between Medicare FFS and MAO rates. After considering this issue further since the FY 2022 rulemaking, we do not believe that the current general correlation between the two precludes the ability of this data over time to reflect market-based pricing for at least some services. As discussed in the FY 2021 IPPS/LTCH PPS final rule (85 FR 58883), MA rates to MA contracted inpatient hospitals are not required to be the same as (or based on) Medicare FFS rates; the Medicare statute only requires MAOs to pay FFS rates to a health care provider for services furnished to an MA enrollee when the MAO does not have a contract with the health care provider. We believe that to the extent hospitals and MAOs over time negotiate different relative relationships for some services than the relationships that exist under the IPPS, this information adds value to the IPPS and should be incorporated. For example, in the FY 2021 IPPS final rule we stated that we believe the rates that hospitals negotiate with MAOs capture the relative resource use to provide services to patients in order to maximize profits (or, in the ca 021 IPPS final rule we stated that we believe the rates that hospitals negotiate with MAOs capture the relative resource use to provide services to patients in order to maximize profits (or, in the case of not- for-profit hospitals, net income), subject to market constraints and conditions (supply and demand, community benefit requirements, etc.). Therefore, we stated we believed that payer- specific negotiated charges provide greater insight into the resource use of a hospital (85 FR 58886). After further consideration, recognizing that there is currently general correlation between the Medicare FFS and MAO rates, we believe that the ability of the payer specific negotiated charges to provide these insights over time still holds true. Another factor that we considered in our current proposal is the experience hospitals have gained through the process of disclosing the payer-specific negotiated charge information for the purpose of the hospital price transparency requirements. In calculating the median payer-specific negotiated charges to be reported on the Medicare cost report for use in the proposed market-based relative weight methodology, hospitals would use the same payer-spec lating the median payer-specific negotiated charges to be reported on the Medicare cost report for use in the proposed market-based relative weight methodology, hospitals would use the same payer-specific negotiated charge information that hospitals are required to disclose under the requirements (45 CFR 180.40(a)) that we initially finalized in the Hospital Price Transparency final rule (84 FR 65524), beginning January 1, 2021. Over the last four years, hospitals have become increasingly familiar with the hospital price transparency requirements and procedures necessary to disclose payer- specific negotiated charges. CMS has also taken enforcement actions against hospitals that have failed to comply with the price transparency requirements.314 We believe that this increased familiarity, experience, and enforcement has improved the data integrity of this information, simplified the initial administrative burden in disclosing this data, and means that this data is now more robust for Medicare ratesetting purposes than it was when we repealed the prior market-based policies. An additional factor we considered was the ending of the COVID–19 public health emergency (PHE). To the extent dicare ratesetting purposes than it was when we repealed the prior market-based policies. An additional factor we considered was the ending of the COVID–19 public health emergency (PHE). To the extent commenters previously raised concerns regarding the need for additional flexibilities as hospitals continue to recover from the COVID–19 PHE, as summarized in the FY 2022 IPPS/LTCH final rule (86 FR 45319), the COVID–19 PHE expired on May 11, 2023. Taking into account these factors, we propose to require that hospitals report on the Medicare cost report the median payer-specific negotiated charge that the hospital has negotiated with all of its MAO payers, by MS–DRG, effective for cost reporting periods ending on or after January 1, 2026, and to use this data in a new market-based MS–DRG relative weight methodology, beginning in FY 2029. If finalized, we would intend to make our analysis of this market-based data available for public review prior to the proposed effective date of this market- based relative weight methodology in FY 2029, including the estimated potential payment impact on the MS– DRG relative weights. As under the current methodology, the impact of any MS–DRG relative ket- based relative weight methodology in FY 2029, including the estimated potential payment impact on the MS– DRG relative weights. As under the current methodology, the impact of any MS–DRG relative weight changes on an individual hospital would depend on the mix of services provided by that particular hospital. 314 For example, see https://www.cms.gov/ priorities/key-initiatives/hospital-price- transparency/enforcement-actions. C. Market-Based MS–DRG Relative Weight Estimation 1. Overview Section 1886(d)(4)(A) of the Act states that the Secretary shall establish a classification of inpatient hospital discharges by diagnosis-related groups and a methodology for classifying specific hospital discharges within these groups. Section 1886(d)(4)(B) of the Act states that for each such diagnosis- related group the Secretary shall assign an appropriate weighting factor which reflects the relative hospital resources used with respect to discharges classified within that group compared to discharges classified within other groups. For the reasons previously discussed, we believe the use of median payer-specific negotiated charge data for a hospital’s MAOs, to be collected on the Medicare charges classified within other groups. For the reasons previously discussed, we believe the use of median payer-specific negotiated charge data for a hospital’s MAOs, to be collected on the Medicare cost report, may support the development of an appropriate market-based approach to payment under the Medicare FFS system by incorporating such data into the estimation of the relative hospital resources used with respect to discharges classified within a single MS–DRG compared to discharges classified within other MS–DRGs, as required by statute. As discussed, since the FY 2022 IPPS/ LTCH PPS final rule, we have continued to evaluate and consider the usefulness and appropriateness of market-based data for ratesetting purposes. Based on this review, we believe it would be appropriate to propose the use of hospitals’ median payer-specific negotiated charges for MAOs, to be collected on the Medicare cost report as described previously, within a proposed new methodology for calculating the MS–DRG relative weights to reflect a more market-based approach, using our authority under sections 1886(d)(4)(A), 1886(d)(4)(B), and 1886(d)(4)(C) of the Act. 2. Proposed Market-Based Data Collection I –DRG relative weights to reflect a more market-based approach, using our authority under sections 1886(d)(4)(A), 1886(d)(4)(B), and 1886(d)(4)(C) of the Act. 2. Proposed Market-Based Data Collection In order to support the development of a relative market-based payment methodology under the IPPS, we propose to collect market-based payment rate data on the Medicare cost report for cost reporting periods ending on or after January 1, 2026. This proposed data collection is similar to the market-based data collection as finalized in the FY 2021 IPPS/LTCH PPS final rule (85 FR 558873 through 58892), with additional modifications to use the payer-specific negotiated charges from the hospital’s most recent MRF published prior to the submission of its cost report, to reflect proposed VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00333 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 33808 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules revisions to the hospital price transparency regulations at 45 CFR 180, and to better address when the payer- specific negotiated charge is Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules revisions to the hospital price transparency regulations at 45 CFR 180, and to better address when the payer- specific negotiated charge is based on a percentage or algorithm, in response to previous concerns (85 FR 58884). Specifically, we propose that hospitals would report on their cost report the median of the payer-specific negotiated charges that the hospital negotiated with its MAOs, by MS–DRG, beginning with cost reporting periods ending on or after January 1, 2026. Sections 1815(a) and 1833(e) of the Act provide that no Medicare payments will be made to a provider unless it has furnished the information, as may be requested by the Secretary, to determine the amount of payments due to the provider under the Medicare program. We require that providers follow reasonable cost principles under section 1861(v)(1)(A) of the Act when completing the Medicare cost report. Under the regulations at 42 CFR 413.20 and 413.24, we define adequate cost data and require cost reports from providers on an annual basis. As previously discussed, the collection of this market-based data on the Medicare cost report would allow for the ad fine adequate cost data and require cost reports from providers on an annual basis. As previously discussed, the collection of this market-based data on the Medicare cost report would allow for the adoption of a market-based strategy to determine the appropriate weighting factors to reflect the relative hospital resources used with respect to hospital discharges, as required under sections 1886(d)(4)(B) and 1886(d)(4)(C) of the Act. As discussed in the FY 2021 IPPS/ LTCH PPS final rule (85 FR 58877), Medicare certified providers, such as Medicare certified hospitals, are required to submit an annual cost report to their Medicare Administrative Contractor (MAC). The Medicare cost report contains provider information such as facility characteristics, cost and charges by cost center, in total and for Medicare, Medicare settlement data, and financial statement data. The cost report must be submitted in a standard (ASCII) electronic cost report (ECR) format. CMS maintains the cost report data in the Healthcare Cost Report Information System (HCRIS) data set. The HCRIS data supports our payment policymaking, congressional studies, legislative health care reimbursement initiatives, Medica ta in the Healthcare Cost Report Information System (HCRIS) data set. The HCRIS data supports our payment policymaking, congressional studies, legislative health care reimbursement initiatives, Medicare profit margin analysis, and relative weight updates. As such, data from hospital cost reports beginning on or after May 1, 2010 is reflected on the HCRIS dataset, and available for public access and use. If we were to finalize this proposal to collect the proposed market-based information (specifically, the median payer-specific negotiated charges negotiated between a hospital and all its MAOs, by MS–DRG) on the cost report, this data would become publicly accessible on the HCRIS dataset in a de- identified manner and would be usable for analysis by third parties. The data would, by definition, be de-identified since we propose that the hospital calculate the median rate (that is, the specific rate that is negotiated between a hospital and a specific MAO for an MS–DRG would not be reported and need to be de-identified). For more information or to obtain HCRIS data we refer readers to https://www.cms.gov/ data-research/statistics-trends-and- reports/cost-reports/cost-reports-fiscal- ted and need to be de-identified). For more information or to obtain HCRIS data we refer readers to https://www.cms.gov/ data-research/statistics-trends-and- reports/cost-reports/cost-reports-fiscal- year. We propose that the hospital would determine the weighted median of the payer-specific negotiated charges that the hospital negotiated with its MAOs, by MS–DRG, as follows: Step 1. Using the hospital’s most recent MRF as of the hospital’s cost report filing date identify the following information: (a) each MAO payer- specific negotiated charge under 45 CFR 180.50(b)(2)(ii) that the hospital has negotiated with its MAOs for inpatient items or services (for example, discharges), and (b) the code under 45 CFR 180.50(b)(2)(iv)(A) for each payer- specific negotiated charge. If the payer- specific negotiated charge is based on a percentage or algorithm, the hospital would identify and substitute the dollar amount in the MRF required under 45 CFR 180.50(b)(2)(ii)(C) for the percentage or algorithm. Exclude any payer-specific negotiated charges that represent capitated payment. Step 2. For the cost reporting period, sum the number of inpatient discharges for each MAO for each MS–DRG. Exc gorithm. Exclude any payer-specific negotiated charges that represent capitated payment. Step 2. For the cost reporting period, sum the number of inpatient discharges for each MAO for each MS–DRG. Exclude inpatient discharges where payment was made on a capitated basis. Step 3. For each MS–DRG, list each MAO payer-specific negotiated charge (from Step 1) the number of times as there were inpatient discharges that occurred during the cost reporting period for that MAO (from Step 2). Step 4. For each MS–DRG, compute the median 315 of the MAO payer- specific negotiated charge in the list from Step 3. To compute the median, using the list in Step 3, order the list in Step 3 from the lowest MAO payer- specific negotiated charge to the highest; if the list contains an odd number of charges the median is the middle value in the list, or if the list contains an even number of charges the median is the mean of the two middle values. For each MS–DRG, this median is the weighted median MAO payer-specific negotiated charge for that MS–DRG. As we discussed in the FY 2021 rulemaking, we recognize that the payer-specific negotiated charges negotiated between MAOs and hospitals may in some cases b specific negotiated charge for that MS–DRG. As we discussed in the FY 2021 rulemaking, we recognize that the payer-specific negotiated charges negotiated between MAOs and hospitals may in some cases be based on a system other than MS–DRGs. If there are codes identified in (b) of Step 1 that are not MS–DRG codes, or discharges in Step 2 that are not classified to MS–DRGs, the hospital would crosswalk those codes or classify those discharges to MS–DRGs. Hospitals can utilize the CMS GROUPER and associated definitions manual for this purpose. Hospitals have access to the publicly available version of the CMS Grouper used to group ICD– 10 diagnosis and procedure codes to MS–DRGs.316 This software and associated definitions manual can be used to crosswalk the code(s) in the MRF or classify the discharge to an MS– DRG code. We note that, in section XIX. of this proposed rule, we propose to amend the regulations at 45 CFR 180 as they relate to a standard charge that is based on a percentage or algorithm. Specifically, we propose in section XIX. of this proposed rule, that, beginning January 1, 2026, hospitals would be required to report a new data element, the ‘‘median allowed amount,’’ i r algorithm. Specifically, we propose in section XIX. of this proposed rule, that, beginning January 1, 2026, hospitals would be required to report a new data element, the ‘‘median allowed amount,’’ instead of the ‘‘estimated allowed amount’’ reported at present, and that the median allowed amount would be defined as the median of the total allowed amount that the hospital has historically received from a third-party payer (including MAOs) for an item or service. We also propose in section XIX. of this rule that if a payer- specific negotiated charge is based on a percentage or algorithm, the hospital’s MRF would have to describe the percentage or algorithm that determines the dollar amount for the item or service and the hospital would have to calculate and encode the median allowed amount in dollars for that item or service. We propose in section XIX. of this rule that, to calculate the ‘median allowed amount,’ hospitals would be required to use electronic remittance advice transaction data, and that the dollar amount would reflect no longer than a 12-month time period prior to the posting of the most recent MRF. We refer readers to section XIX. in this proposed rule for more inf on data, and that the dollar amount would reflect no longer than a 12-month time period prior to the posting of the most recent MRF. We refer readers to section XIX. in this proposed rule for more information regarding the specific proposal. Accordingly, the dollar amount in the MRF required under 45 CFR 180.50(b)(2)(ii)(C) for the percentage or algorithm in Step 1 would be the 315 The middle number; found by ordering all data points and selecting the one in the middle (or if there are two middle numbers, taking the mean of those two numbers). 316 https://www.cms.gov/medicare/payment/ prospective-payment-systems/acute-inpatient-pps/ ms-drg-classifications-and-software. VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00334 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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. 135 / Thursday, July 17, 2025 / Proposed Rules 33809 ‘‘median allowed amount’’ if this proposed amendment is finalized. If CMS does not finalize changes to 45 CFR 180.50(b)(2)(ii)(C), the dollar amount would be the ‘‘estimated allowed amount’’ under the current regulations. A simplified example for th ent is finalized. If CMS does not finalize changes to 45 CFR 180.50(b)(2)(ii)(C), the dollar amount would be the ‘‘estimated allowed amount’’ under the current regulations. A simplified example for the purpose of illustrating this process is as follows: For its cost reporting period ending on September 30, 2026, a hospital had MAO payer-specific negotiated charges for MS–DRG 123 for five MAOs: MA1, MA2, MA3, MA4, and MA5. The hospital filed its cost report on February 28, 2027. The hospital made available to the public its MRF on January 1, 2027. This MRF did not contain MAO payer- specific negotiated charges for MA5 because the hospital stopped contracting with MA5 and began contracting with a new MAO, MA6. Step 1. The hospital identified the following MAO payer-specific negotiated charge information for MS– DRG 123 from its January 1, 2027 MRF: •MA1: $7,400 •MA2: $7,200 •MA3: $7,500 •MA4: $7,300 (algorithm-based) •MA6: $7,400 Note, as the payer-specific negotiated charge for MA4 was based on an algorithm, the hospital substituted the dollar amount in the MRF required under 45 CFR 180.50(b)(2)(ii)(C) for the algorithm. Step 2. The hospital summed the number of inpatient discharges based on an algorithm, the hospital substituted the dollar amount in the MRF required under 45 CFR 180.50(b)(2)(ii)(C) for the algorithm. Step 2. The hospital summed the number of inpatient discharges that occurred during the cost report period ending September 30, 2026, for each MAO for MS–DRG 123. •MA1: 2 discharges •MA2: 1 discharge •MA3: 1 discharge •MA4: 3 discharges •MA5: 2 discharges Step 3. The hospital listed each MAO payer-specific negotiated charge (from Step 1) the number of times as there were inpatient discharges that occurred during the cost reporting period for that MAO (from Step 2). •MA1: $7,400, $7,400 •MA2: $7,200 •MA3: $7,500 •MA4: $7,300, $7,300, $7,300 For example, the $7,400 MA1 charge from Step 1 was listed two times because there were two discharges for MS–DRG 123 that occurred during the cost report period ending September 30, 2026, for MA1; the MRF charge of $7,200 for MA2 was listed once because there was one discharge; the MRF charge of $7,500 for MA3 was listed once because there was one discharge; the MRF charge of $7,300 for MA4 was listed three times because there were three discharges, there is no MRF charge for MA5 as the hospital no longer contr listed once because there was one discharge; the MRF charge of $7,300 for MA4 was listed three times because there were three discharges, there is no MRF charge for MA5 as the hospital no longer contracted with that MAO, and the MRF charge of $7,400 for MA6 was not listed as there were no discharges during the cost reporting period for that MAO. Step 4. The median charge for MS– DRG 123 is $7,300 because that is the median of the charges in the list from Step 3.317 (Note that if the list had contained an even number of charges, the median would have been the mean of the two middle numbers).318 •$7,200—MA2 •$7,300—MA4 •$7,300—MA4 •$7,300—MA4 •$7,400—MA1 •$7,400—MA1 •$7,500—MA3 For purposes of this calculation, we propose to define the term ‘‘payer- specific negotiated charge’’ as the charge that a hospital has negotiated with a MAO for an item or service. We propose to use this definition of payer-specific negotiated charge because it would capture the charges that are negotiated between hospitals and MAOs and be able to provide the data needed to support the use of market-based information for payment purposes within the MS–DRG relative weight calculation. For consistency, the defi n hospitals and MAOs and be able to provide the data needed to support the use of market-based information for payment purposes within the MS–DRG relative weight calculation. For consistency, the definition of ‘‘payer-specific negotiated charge’’ that we propose here is the same as the definition at 45 CFR 180.20 for purposes of our requirements for hospitals to make their standard charges available to the public. We also propose to define ‘‘items and services’’ as all items and services, including individual items and services and service packages, that could be provided by a hospital to a patient in connection with an inpatient admission for which the hospital has established a standard charge.319 (With respect to service packages, we note that an MS–DRG, as established by CMS under the MS–DRG 317 Ordering the payer-specific negotiated charges from Step 3 from lowest to highest as {$7,200, $7,300, $7,300, $7,300, $7,400, $7,400, $7,500} the median, or middle, charge in that list is the fourth charge of $7,300. 318 For example, if the list had been {$7,300, $7,300, $7,400, $7,500} the median would have been $7,350, the mean of $7,300 and $7,400 (the two middle values are the secon he fourth charge of $7,300. 318 For example, if the list had been {$7,300, $7,300, $7,400, $7,500} the median would have been $7,350, the mean of $7,300 and $7,400 (the two middle values are the second and third charges of $7,300 and $7,400.) 319 Our proposed definition here of ‘‘items and services’’ is the same as the definition at 45 CFR 180.20, but for the examples included there and omitting the reference to outpatient department visits, as here we would not require hospitals to calculate the median of their payer-specific negotiated charges for items and services provided in the hospital outpatient setting. classification system, is a type of service package consisting of items and services based on patient diagnosis and other characteristics.) We propose this definition of ‘‘items and services’’ because we believe it captures the types of items and services, including service packages, that a hospital would use to calculate and report the median payer- specific negotiated charge for each MS– DRG to support the use of market-based rate information by MS–DRG within the MS–DRG relative weight calculation. For purposes of this calculation, an MAO is defined as in 42 CFR 422.2 and for each MS– DRG to support the use of market-based rate information by MS–DRG within the MS–DRG relative weight calculation. For purposes of this calculation, an MAO is defined as in 42 CFR 422.2 and means a public or private entity organized and licensed by a State as a risk-bearing entity (with the exception of provider-sponsored organizations receiving waivers) that is certified by CMS as meeting the MA contract requirements. We note that these proposed definitions are the same as those finalized in the FY 2021 IPPS/ LTCH PPS final rule. As finalized in the FY 2021 IPPS/ LTCH PPS final rule (85 FR 58888), we propose that subsection (d) hospitals in the 50 states and DC, as defined at section 1886(d)(1)(B) of the Act, and subsection (d) Puerto Rico hospitals, as defined under section 1886(d)(9)(A) of the Act, would be required to report the median payer-specific negotiated charge information. We note that hospitals that do not negotiate payment rates and only receive non-negotiated payments for service would be exempted from this proposed data collection. Examples of subsection (d) hospitals that only receive non-negotiated payment rates include hospitals operated by an Indian H payments for service would be exempted from this proposed data collection. Examples of subsection (d) hospitals that only receive non-negotiated payment rates include hospitals operated by an Indian Health Program as defined in section 4(12) of the Indian Health Care Improvement Act or federally owned and operated facilities. We note that this proposed data collection requirement would apply to a smaller subset of hospitals as compared to the public reporting requirements under the hospital price transparency regulations. We recognize that Critical Access Hospitals (CAHs) may, in some instances, negotiate payment rates; however, because CAHs are not subsection (d) hospitals and are not paid on the basis of MS–DRGs, CAHs would not be subject to this proposed data collection requirement. We also note that rural emergency hospitals would not be subject to this proposed data collection requirement given that they do not provide inpatient services. On March 12, 2025, CMS announced the intention to end the Maryland Total VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00335 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P h t i w D O R P 4 4 1 S 7 W 9 K S D n tion to end the Maryland Total VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00335 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 33810 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules Cost of Care Model.320 We propose that hospitals in Maryland, which are currently paid under the Maryland Total Cost of Care Model, would be exempted from this data collection requirement during the performance period of that Model. Following the end of the performance period of the Maryland Total Cost of Care Model, Maryland hospitals would no longer be exempt from this data collection requirement. Further instructions for the reporting of this proposed market-based data collection requirement on the Medicare cost report will be discussed in a forthcoming new Information Collection Request, which is currently under development. We believe that the administrative burden for this proposal is reduced by utilizing data that hospitals would disclose under existing and proposed hospital price transparency requirements relative to if hospitals did not already have this data compiled. Pleas is reduced by utilizing data that hospitals would disclose under existing and proposed hospital price transparency requirements relative to if hospitals did not already have this data compiled. Please refer to section XXII.E. of this proposed rule where we discuss the estimated burden for hospitals as a result of this proposed policy. We also propose to amend 42 CFR 413.20(d)(3) to reflect this proposed requirement. Specifically, we propose to amend § 413.20(d)(3) to require hospitals to report the median payer- specific negotiated charge by MS–DRG for MAOs on the Medicare cost report. We propose to capture this proposed data collection requirement in regulation at § 413.20(d)(3)(i)(B). This proposed requirement would be effective for cost reporting periods ending on or after January 1, 2026. 3. Proposed Market Based MS–DRG Relative Weight Methodology As previously discussed, we propose a new market-based methodology for estimating the MS–DRG relative weights, beginning in FY 2029. We note that this proposed market-based MS– DRG relative weight methodology would be the same market-based MS– DRG relative weight methodology that was initially adopted in the FY 2021 IPPS/LTCH PPS fin note that this proposed market-based MS– DRG relative weight methodology would be the same market-based MS– DRG relative weight methodology that was initially adopted in the FY 2021 IPPS/LTCH PPS final rule (85 FR 58879 through 58881). Specifically, we propose to implement a methodology for calculating the MS–DRG relative weights using the median payer-specific negotiated charge for MAOs for each MS–DRG, as described in this section and reported on the cost report. For the reasons discussed in section XX.B. of this proposed rule, based on our further review, we believe that using the median payer-specific negotiated charge 320 https://www.cms.gov/priorities/innovation/ innovation-models/md-tccm. for MAOs within the MS–DRG relative weight calculation would allow for a more market-based approach to determining Medicare FFS reimbursement. Below is a description of the steps for a proposed MS–DRG relative weight methodology change using the payer- specific negotiated charge data. We refer readers to the FY 2021 IPPS/LTCH PPS final rule (85 FR 58880 through 58881) for additional discussion of the finalized methodology which we are reproposing. • Step One: Standardize the Median Payer-S readers to the FY 2021 IPPS/LTCH PPS final rule (85 FR 58880 through 58881) for additional discussion of the finalized methodology which we are reproposing. • Step One: Standardize the Median Payer-Specific Negotiated Charges: In order to make the median payer-specific negotiated charges from the cost reports more comparable among hospitals, we would standardize the median payer- specific negotiated charges reported on the cost report by removing the effects of differences in area wage levels, and cost-of living adjustments for hospital claims from Alaska and Hawaii, in the same manner as under the current MS– DRG relative weight calculation for those effects. • Step Two: Create a Single Weighted Average Standardized Median MAO Payer-Specific Negotiated Charge by MS–DRG Across Hospitals: For each MS–DRG, we would create a single weighted average across hospitals of the standardized median payer-specific negotiated charges. We would weight the standardized payer-specific negotiated charge for each MS–DRG for each hospital using that hospital’s Medicare transfer-adjusted case count for that MS–DRG, with transfer adjusted case counts calculated the same way as under the current MS–DR rge for each MS–DRG for each hospital using that hospital’s Medicare transfer-adjusted case count for that MS–DRG, with transfer adjusted case counts calculated the same way as under the current MS–DRG relative weight methodology. We note that, as discussed in the FY 2025 IPPS/LTCH PPS final rule (89 FR 69109), the current MS–DRG relative weight methodology does not include MA cases as discharges for Medicare beneficiaries enrolled in a MA managed care plan are excluded from the relative weight methodology. We believe that using the Medicare transfer-adjusted case counts would be a reasonable approach to combining the data across hospitals because it would reflect relative volume and transfer activity (that is, larger hospitals responsible for more discharges would be weighted more heavily in the calculation, hospitals that transfer more often would be weighted less heavily). • Step Three: Create a Single National Weighted Average Standardized MAO Payer-Specific Negotiated Charge Across all MS–DRGs: We would create a single national weighted average across MS–DRGs of the results of Step Two, where the weights are the national Medicare transfer adjusted case counts by MS– DRG. • Ste s all MS–DRGs: We would create a single national weighted average across MS–DRGs of the results of Step Two, where the weights are the national Medicare transfer adjusted case counts by MS– DRG. • Step Four: Calculate the Market- based Relative Weights: For each MS– DRG, the market-based relative weight would be calculated as the ratio of the single weighted average standardized median MAO payer-specific negotiated charge for that MS–DRG across hospitals from Step Two to the single national weighted average standardized median MAO payer-specific negotiated charge across all MS–DRGs from Step Three. • Step Five: Normalize the Market- based Relative Weights: We note that as under the current cost-based MS–DRG relative weight methodology, the market-based relative weights would be normalized by an adjustment factor so that the average case weight after recalibration would be equal to the average case weight before recalibration. As under the current cost-based relative weight estimation methodology, the normalization adjustment is intended to help ensure that recalibration by itself neither increases nor decreases total payments under the IPPS, as required by section 1886(d)(4)(C)(iii ethodology, the normalization adjustment is intended to help ensure that recalibration by itself neither increases nor decreases total payments under the IPPS, as required by section 1886(d)(4)(C)(iii) of the Act. We believe initially there would be minimal impacts to the relative weights calculated under this proposed market based MS–DRG relative weight methodology (which would utilize the median payer-specific negotiated charge data negotiated between hospitals and their MAOs) beginning in FY 2029, given the relationship between the MAO rates and Medicare FFS rates (as evidenced by feedback from commenters as discussed in the FY 2021 IPPS/LTCH PPS final rule and the results of our literature review). If finalized, we would expect, for some period of time following implementation of this proposed market-based MS–DRG relative weight methodology, to continue to estimate and publicly provide, for informational purposes, the MS–DRG relative weights as calculated using our current cost- based estimation methodology. In addition, similar to our discussion in the FY 2021 IPPS/LTCH PPS final rule (85 FR 58886 through 58887), if finalized, we would intend to provide additional opportunity sed estimation methodology. In addition, similar to our discussion in the FY 2021 IPPS/LTCH PPS final rule (85 FR 58886 through 58887), if finalized, we would intend to provide additional opportunity for the public to review the MAO median payer-specific negotiated charge data received prior to the utilization of this data in the market- based MS–DRG relative weight methodology beginning in FY 2029. We continue to believe this would allow for additional discussions, public review, and conversation about utilizing this market-based data in the MS–DRG relative weight methodology. We seek comment on all elements of this proposed market-based data VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00336 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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. 135 / Thursday, July 17, 2025 / Proposed Rules 33811 collection for cost reporting periods ending on or after January 1, 2026, and market-based methodology for estimating the MS–DRG relative weights beginning in FY 2029. We also seek comments on potential unintended consequences of this proposal, if any, including special cons nd market-based methodology for estimating the MS–DRG relative weights beginning in FY 2029. We also seek comments on potential unintended consequences of this proposal, if any, including special considerations if needed to mitigate those potential consequences for certain hospitals. We also seek comment on how these or other market-based strategies could be utilized in additional Medicare FFS payment systems and the benefits of these market-based approaches. XI. Graduate Medical Education Accreditation A. Executive Order 14279 Executive Order 14279 (April 23, 2025), entitled ‘‘Reforming Accreditation to Strengthen Higher Education,’’ directs the Attorney General, in consultation with the Secretary of Health and Human Services, to ‘‘investigate and take appropriate action to terminate unlawful discrimination by American medical schools or graduate medical education entities that is advanced by the Liaison Committee on Medical Education or the Accreditation Council for Graduate Medical Education or other accreditors of graduate medical education, including unlawful ‘diversity, equity, and inclusion’ requirements under the guise of accreditation standards.’’ 321 The Executive Order f Education or other accreditors of graduate medical education, including unlawful ‘diversity, equity, and inclusion’ requirements under the guise of accreditation standards.’’ 321 The Executive Order further directs that standards for training doctors should focus solely on providing the highest quality care, and should not require or encourage educational institutions to discriminate unlawfully on the basis of race. The Accreditation Council for Graduate Medical Education (‘ACGME’) is the primary organization in the United States that currently conducts accreditation for Graduate Medical Education (‘GME’) Programs. While ACGME accreditation is a voluntary process, programs that are not accredited by the ACGME generally do not receive Medicare funding from CMS for Direct Graduate Medical Education (DGME) and Indirect Medical Education (IME). Additionally, if the ACGME withdraws accreditation, residents generally must receive assistance to continue their education from other ACGME-accredited programs.322 321 90 FR 17529. https://www.federalregister.gov/ documents/2025/04/28/2025-07376/reforming- accreditation-to-strengthen-higher-education. 322 https://www.acgme.org/about/acgme- freq ited programs.322 321 90 FR 17529. https://www.federalregister.gov/ documents/2025/04/28/2025-07376/reforming- accreditation-to-strengthen-higher-education. 322 https://www.acgme.org/about/acgme- frequently-asked-questions/. For a number of years, the ACGME has identified ‘diversity, equity, and inclusion’ as a primary value of the organization and a central component of its vision for graduate medical education.323 The ACGME’s Common Program Requirements require that institutions ‘‘must engage in practices that focus on mission-driven, ongoing, systematic recruitment and retention of a diverse and inclusive workforce of residents, fellows (if present), faculty members, senior administrative staff members,’’ and that organizations’ ‘‘programs implement, policies and procedures related to recruitment and retention of individuals underrepresented in medicine and medical leadership.’’ 324 In practice, many such diversity, equity, and inclusion programs unlawfully discriminate against Americans on the basis of race. In Students for Fair Admissions v. President and Fellows of Harvard College (2023), the U.S. Supreme Court held that race-based admissions policies, even when focused on th icans on the basis of race. In Students for Fair Admissions v. President and Fellows of Harvard College (2023), the U.S. Supreme Court held that race-based admissions policies, even when focused on the goal of diversity, violate the Equal Protection Clause of the Fourteenth Amendment unless they satisfy strict scrutiny.325 While the ruling applies specifically to admissions decisions at institutions of higher education, its broader reasoning— especially the requirement that any use of race be narrowly tailored to a compelling interest—strongly suggests that race-conscious elements in Diversity, Equity, and Inclusion (DEI) initiatives in federally funded education programs are generally impermissible. These programs raise particular concerns in the medical context, where patients and the larger society have a compelling need for medical education to be focused primarily on excellence and delivering the best possible care to patients. B. Definition of ‘‘Approved Medical Residency Programs’’ Section 1886(h) of the Act, as added by section 9202 of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (Pub. L. 99–272), and as currently implemented in CMS regulations at 42 C s’’ Section 1886(h) of the Act, as added by section 9202 of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (Pub. L. 99–272), and as currently implemented in CMS regulations at 42 CFR 413.75 through 413.83, establishes a methodology for 323 ACGME, Policies and Procedures, February 2, 2025. https://www.acgme.org/globalassets/pdfs/ab_ acgmepoliciesprocedures.pdf. 324 ACGME, Guide to the Common Program Requirements, March 2024, https://www.acgme.org/ globalassets/pdfs/guide-to-the-common-program- requirements-residency.pdf?utm_ source=chatgpt.com. 325 Students for Fair Admissions, Inc. v. President and Fellows of Harvard College, June 2023. https:// www.supremecourt.gov/opinions/22pdf/20-1199_ hgdj.pdf. determining payments to hospitals for the direct costs of approved graduate medical education (GME) programs. Section 1886(h)(2) of the Act sets forth a methodology for the determination of a hospital-specific base-period per resident amount (PRA) that is calculated by dividing a hospital’s allowable direct costs of GME in a base period by its number of full-time equivalent (FTE) residents in the base period. In general, Medicare direct GME payments are calculated by ividing a hospital’s allowable direct costs of GME in a base period by its number of full-time equivalent (FTE) residents in the base period. In general, Medicare direct GME payments are calculated by multiplying the hospital’s updated PRA by the weighted number of FTE residents working in all areas of the hospital complex (and at non- provider sites, when applicable), and the hospital’s Medicare share of total inpatient days. Section 1886(d)(5)(B) of the Act provides for a payment adjustment known as the indirect medical education (IME) adjustment under the IPPS for hospitals that have residents in an approved GME program, to account for the higher indirect patient care costs of teaching hospitals relative to nonteaching hospitals. The regulations regarding the calculation of this additional payment are located at 42 CFR 412.105. The hospital’s IME adjustment applied to the DRG payments is calculated based on the ratio of the hospital’s number of FTE residents training in either the inpatient or outpatient departments of the IPPS hospital (and, for discharges occurring on or after October 1, 1997, at nonprovider sites, when applicable) to the number of inpatient hospital beds. Hos npatient or outpatient departments of the IPPS hospital (and, for discharges occurring on or after October 1, 1997, at nonprovider sites, when applicable) to the number of inpatient hospital beds. Hospitals may receive direct GME and IME payments for residents in ‘‘approved medical residency training programs.’’ Section 1886(h)(5)(A) of the Act defines an ‘‘approved medical residency training program’’ as ‘‘a residency or other postgraduate medical training program participation in which may be counted toward certification in a specialty or subspecialty and includes formal postgraduate training programs in geriatric medicine approved by the Secretary.’’ The regulations at § 413.75(b) define an ‘‘approved medical residency program’’ for purposes of direct GME payment as a program that meets one of four criteria: (1) is approved by one of the national organizations specified in the regulations at § 415.152; (2) may count towards certification of the participant in a specialty or subspecialty listed in the current edition of certain publications specified in the regulations; (3) is approved by the ACGME as a fellowship program in geriatric medicine; or (4) is a program that would be a alty listed in the current edition of certain publications specified in the regulations; (3) is approved by the ACGME as a fellowship program in geriatric medicine; or (4) is a program that would be accredited except for the accrediting agency’s reliance upon an VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00337 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 33812 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules accreditation standard that involves induced abortions, regardless of whether the standard provides exceptions or exemptions. The regulations at § 412.105(f)(1)(i) define an ‘‘approved teaching program’’ similarly for purposes of IME payment. The regulations at § 415.152 define an ‘‘approved graduate medical education program’’ as a residency program approved by one of the following national organizations (or their predecessors): The Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), the Commission on Dental Accreditation (CODA) of the American Dental Association, and the Council on Podiatric Medical E Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), the Commission on Dental Accreditation (CODA) of the American Dental Association, and the Council on Podiatric Medical Education (CPME) of the American Podiatric Medical Association. Thus, in general, under §§ 413.75(b) and 412.105(f)(1)(i), an ‘‘approved’’ program can be a program that is accredited by one of these national organizations, or one that leads toward board certification by the American Board of Medical Specialties (ABMS). The statute gives CMS authority to specify additional criteria for approved GME programs. Therefore, to ensure that accreditation for approved medical residency programs is in compliance with applicable laws related to race- based admission policies and to improve the accreditation process, the agency proposes that accreditors may not require as part of accreditation, or otherwise encourage institutions to put in place, diversity, equity, and inclusion programs that encourage unlawful discrimination on the basis of race or other violations of Federal law. The effective date of this proposal would be January 1, 2026. Additionally, we note that the Secretary may recognize o unlawful discrimination on the basis of race or other violations of Federal law. The effective date of this proposal would be January 1, 2026. Additionally, we note that the Secretary may recognize other organizations that meet or exceed Medicare’s requirements as accreditors to increase the potential for competition in the accreditation space and improve the quality of the accreditation process. This proposal is intended to ensure that accreditors of academic medical institutions are focused on the mission of ensuring excellence in graduate medical education, of improving the potential for competition in the accreditation space, and of eliminating unlawful and discriminatory DEI programs. We welcome commenters’ feedback on this proposal. XXII. Collection of Information Requirements Under the Paperwork Reduction Act of 1995, we are required to provide 60- day notice in the Federal Register and solicit public comment before a collection of information requirement is submitted to the Office of Management and Budget (OMB) for review and approval. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction A fice of Management and Budget (OMB) for review and approval. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 requires that we solicit comment on the following issues: • The need for the information collection and its usefulness in carrying out the proper functions of our agency. • The accuracy of our estimate of the information collection burden. • The quality, utility, and clarity of the information to be collected. • Recommendations to minimize the information collection burden on the affected public, including automated collection techniques. We are soliciting public comment on each of these issues for the following sections of this document that contain information collection requirements (ICRs): A. ICRs for the Hospital Outpatient Quality Reporting (OQR) Program 1. Background In sections XIV. and XV. of this proposed rule, we discuss the proposed requirements for the Hospital OQR Program. The Hospital OQR Program is generally aligned with the CMS quality reporting program for hospital inpatient services known as the Hospital Inpatient Quality Reporting (IQR) Program. We refer Program. The Hospital OQR Program is generally aligned with the CMS quality reporting program for hospital inpatient services known as the Hospital Inpatient Quality Reporting (IQR) Program. We refer readers to the CY 2025 OPPS/ASC final rule with comment period (89 FR 94522 through 94530) for detailed discussions of the previously finalized Hospital OQR Program ICRs which are currently approved under OMB control number 0938–1109 (expiration date January 31, 2026). In this proposed rule, we propose to: (1) remove the COVID–19 Vaccination Coverage Among Healthcare Personnel (HCP) measure beginning with the CY 2024 reporting period/CY 2026 payment determination; (2) remove the Hospital Commitment to Health Equity (HCHE) measure beginning with the CY 2025 reporting period/CY 2027 payment determination; (3) remove the Screening for Social Drivers of Health (SDOH) measure beginning with the CY 2025 reporting period; (4) remove the Screen Positive Rate for SDOH measure beginning with the CY 2025 reporting period; (5) modify the Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Hospital Level—Outpatient) eCQM (Excessive Radiation eCQM) 2025 reporting period; (5) modify the Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Hospital Level—Outpatient) eCQM (Excessive Radiation eCQM) from mandatory reporting beginning with the CY 2027 reporting period to continue voluntary reporting in the CY 2027 reporting period and subsequent years; (6) adopt the Emergency Care Access & Timeliness electronic clinical quality measure (eCQM) with voluntary reporting for the CY 2027 reporting period, followed by mandatory reporting beginning with the CY 2028 reporting period/CY 2030 payment determination; (7) remove the Median Time from Emergency Department (ED) Arrival to ED Departure for Discharged ED Patients measure beginning with the CY 2028 reporting period/CY 2030 payment determination; and (8) remove the Left Without Being Seen (LWBS) measure beginning with the CY 2028 reporting period/CY 2030 payment determination. In section XIV.D. of this proposed rule, we also propose to update our Extraordinary Circumstances Exception (ECE) Policy for the Hospital OQR Program. This proposed update would explicitly include extensions as a type of extraordinary circumstances relief opti pdate our Extraordinary Circumstances Exception (ECE) Policy for the Hospital OQR Program. This proposed update would explicitly include extensions as a type of extraordinary circumstances relief option, in addition to exceptions. Because the process for requesting or granting an ECE would remain the same as the current ECE process, these updates would not affect burden associated with the submission of the ECE form. In the CY 2025 OPPS/ASC final rule with comment period, we calculated reporting burden estimates for the Hospital OQR Program by utilizing the Bureau of Labor Statistics (BLS) mean hourly wage rate for Medical Records Specialists (89 FR 94522 through 94523). Specifically, we used the industry-specific wage for Medical Records Specialists working in ‘‘general medical and surgical hospitals,’’ as this categorization aligns the closest with the Hospital OQR Program care setting. The most recent data from BLS’ May 2024 National Occupational Employment and Wage Estimates reflects a median hourly wage of $27.53 per hour for Medical Records Specialists working in ‘‘general medical and surgical hospitals’’ (SOC 29–2072).326 We calculated the cost of overhead, including fringe ts a median hourly wage of $27.53 per hour for Medical Records Specialists working in ‘‘general medical and surgical hospitals’’ (SOC 29–2072).326 We calculated the cost of overhead, including fringe benefits, at 100 percent of the median hourly wage, consistent with previous years. This is a rough adjustment, both because fringe benefits and overhead costs vary significantly by employer and methods of estimating these costs vary widely in the literature. Nonetheless, we believe that doubling the hourly wage rate ($27.53 × 2 = $55.06) to estimate total cost burden is reasonably accurate. Accordingly, unless otherwise specified, 326 U.S. Bureau of Labor Statistics. (2025). Occupational Outlook Handbook, Medical Records Specialists. Available at: https://data.bls.gov/oes/#/ industry/622100. Accessed: April 8, 2025. VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00338 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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. 135 / Thursday, July 17, 2025 / Proposed Rules 33813 we calculate cost burden to hospitals using a wage plus benefits estimate of $55.06 per hour throughou o m m a h k Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules 33813 we calculate cost burden to hospitals using a wage plus benefits estimate of $55.06 per hour throughout the discussion in this section of this proposed rule for the Hospital OQR Program. In the CY 2025 OPPS/ASC final rule with comment period, our burden estimates assumed that approximately 3,200 hospital outpatient departments (HOPDs) would report data to the Hospital OQR Program (89 FR 94523). For this proposed rule, based on the most recent available data from the CY 2024 Hospital OQR Program payment determination, we estimate that 3,200 HOPDs would report data to the Hospital OQR Program for the CY 2026 reporting period/CY 2028 payment determination and future years. 2. Information Collection Burden Estimate for the Proposed Removal of the COVID–19 Vaccination Coverage Among HCP Measure Beginning With CY 2024 Reporting Period/CY 2026 Payment Determination As discussed in section XIV.C.1. of this proposed rule, we propose to remove the COVID–19 Vaccination Coverage Among HCP measure beginning with the CY 2024 reporting period/CY 2026 payment determination. The information collection . of this proposed rule, we propose to remove the COVID–19 Vaccination Coverage Among HCP measure beginning with the CY 2024 reporting period/CY 2026 payment determination. The information collection burden associated with this measure is currently approved under OMB control number 0920–1317. To report this measure, HOPDs have the option to manually enter data directly into the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) web-based application or by uploading a CSV file. CDC estimates that each HOPD requires between 40 minutes (0.67 hours) to upload a CSV file and 45 minutes (0.75 hours) monthly to enter the data manually. CDC assumes that manual data entry would be completed by a Microbiologist with a wage rate of $58.60/hour and uploading of a CSV file would be completed by an Information Technologist with a wage rate of $56.50/ hour. Therefore, we estimate that this proposal would result in a decrease in burden of between 25,600 hours (0.67 hours × 12 months × 3,200 HOPDs) at a savings of $1,446,400 (25,600 hours × $56.50/hour) and 28,800 hours (0.75 hours × 12 months × 3,200 HOPDs) at a savings of $1,687,680 (28,800 hours × $58.60/h .67 hours × 12 months × 3,200 HOPDs) at a savings of $1,446,400 (25,600 hours × $56.50/hour) and 28,800 hours (0.75 hours × 12 months × 3,200 HOPDs) at a savings of $1,687,680 (28,800 hours × $58.60/hour) annually across all 3,200 HOPDs under OMB control number 0920–1317. 3. Information Collection Burden Estimate for the Proposed Removal of the HCHE Measure Beginning With the CY 2025 Reporting Period/CY 2027 Payment Determination As discussed in section XIV.C.2. of this proposed rule, we propose to remove the HCHE measure beginning with the CY 2025 reporting period/CY 2027 payment determination. The information collection burden associated with this measure is currently approved under OMB control number 0938–1109. The currently approved information collection burden estimate for this measure assumes HOPDs spend approximately 10 minutes (0.167 hours) annually to report measure data. Therefore, for all participating HOPDs, we estimate removal of this measure would decrease burden by approximately 533 hours (0.167 hours × 3,200 HOPDs) at a savings of $29,347 (533 hours × $55.06/ hour). 4. Information Collection Burden Estimate for the Proposed Removal of the Screening for SDOH Measure oximately 533 hours (0.167 hours × 3,200 HOPDs) at a savings of $29,347 (533 hours × $55.06/ hour). 4. Information Collection Burden Estimate for the Proposed Removal of the Screening for SDOH Measure Beginning With the CY 2025 Reporting Period In section XIV.C.3. of this proposed rule, we propose to remove the Screening for SDOH measure beginning with the CY 2025 reporting period. There are two components to this measure: patient screening for five health related social needs domains and hospital submission of aggregated hospital-level measure data. We have previously estimated each patient requires 2 minutes (0.033 hours) to complete the screening and each hospital requires 10 minutes (0.167 hours) annually to report this measure. We determine the cost for patients (or their representative) to complete the screening using a post-tax wage of $25.63/hour based on assumptions from the report ‘‘Valuing Time in U.S. Department of Health and Human Services Regulatory Impact Analyses: Conceptual Framework and Best Practices,’’ which identifies an approach for valuing time when individuals undertake administrative and other tasks on their own time.327 To derive the costs for patients (or ptual Framework and Best Practices,’’ which identifies an approach for valuing time when individuals undertake administrative and other tasks on their own time.327 To derive the costs for patients (or their representatives), a measurement of the usual weekly earnings of wage and salary workers of $1,192 is divided by 40 hours to calculate an hourly pre-tax wage rate of $29.80/hour.328 This rate is adjusted downwards by an estimate of the effective tax rate for median income households of about 14 percent calculated by comparing pre- and post- tax income,329 resulting in the post-tax hourly wage rate of $25.63/hour. Unlike our State and private sector wage adjustments, we are not adjusting beneficiary wages for fringe benefits and other indirect costs because the individuals’ activities, if any, would occur outside the scope of their employment. Under OMB control number 0938– 1109, we estimate 206,325,645 HOPD visits annually that will result in screening once the measure becomes mandatory. Therefore, for all participating HOPDs, we estimate removal of this measure would decrease burden for voluntary reporting for the CY 2025 reporting period by approximately 1,719,380 hours for 51, ory. Therefore, for all participating HOPDs, we estimate removal of this measure would decrease burden for voluntary reporting for the CY 2025 reporting period by approximately 1,719,380 hours for 51,581,411 patients (0.033 hours × 206,325,645 patients × 50 percent response rate × 50 percent of HOPDs) at a savings of $44,067,709 (1,719,380 hours × $25.63/hour). For mandatory reporting beginning with the CY 2026 reporting period, we estimate a decrease in burden of 6,877,522 hours (206,325,645 patients × 0.033 hours per patient) at a savings of $176,270,889 (6,877,522 hours × $25.63/hour). With regard to measure reporting, we estimate a decrease in burden of 267 hours (3,200 HOPDs × 50 percent of HOPDs × 0.167 hours per HOPD) at a savings of $14,701 (267 hours × $55.06/hour) for voluntary reporting for the CY 2025 reporting period and 533 hours annually (0.167 hours × 3,200 HOPDs) at a savings of $29,347 (533 hours × $55.06/hour) for mandatory reporting beginning with the CY 2026 reporting period. 5. Information Collection Burden Estimate for the Proposed Removal of the Screen Positive Rate for SDOH Measure Beginning With the CY 2025 Reporting Period In section XIV.C.3. of this prop ing period. 5. Information Collection Burden Estimate for the Proposed Removal of the Screen Positive Rate for SDOH Measure Beginning With the CY 2025 Reporting Period In section XIV.C.3. of this proposed rule, we propose to remove the Screen Positive Rate for SDOH measure beginning with the CY 2025 reporting period. For this measure, HOPDs are required to report on an annual basis the number of patients who screen positive 327 Office of the Assistant Secretary for Planning and Evaluation. (2017). Valuing Time in U.S. Department of Health and Human Services Regulatory Impact Analyses: Conceptual Framework and Best Practices. Available at https:// aspe.hhs.gov/reports/valuing-time-us-department- health-human-services-regulatory-impact-analyses- conceptual-framework. Accessed: June 24, 2025. 328 Bureau of Labor and Statistics. (2025). Usual Weekly Earnings of Wage and Salary Workers, Fourth Quarter 2025. Available at https:// www.bls.gov/news.release/pdf/wkyeng.pdf. Accessed: March 3, 2025. 329 Guzman, G. & Kollatr, M. (2024). Income in the United States: 2023. Available at https:// www2.census.gov/library/publications/2024/demo/ p60-282.pdf. Accessed: June 24, 2025. VerDate Sep 2014 25. 329 Guzman, G. & Kollatr, M. (2024). Income in the United States: 2023. Available at https:// www2.census.gov/library/publications/2024/demo/ p60-282.pdf. Accessed: June 24, 2025. VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00339 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 33814 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules for one or more of the five SDOH domains divided by the total number of patients screened (reported as five separate rates). We previously estimated each HOPD requires 10 minutes (0.167 hours) annually to report this measure. Therefore, we estimate removal of this measure would decrease burden by 267 hours (3,200 HOPDs × 50 percent of HOPDs × 0.167 hours per HOPD) at a savings of $14,701 (267 hours × $55.06/ hour) for voluntary reporting for the CY 2025 reporting period and 533 hours annually (0.167 hours × 3,200 HOPDs) at a savings of $29,347 (533 hours × $55.06/hour) for mandatory reporting beginning with the CY 2026 reporting period. 6. Information Collection Burden Estimate for the Proposed Adoption of the Emergency Care Access & 29,347 (533 hours × $55.06/hour) for mandatory reporting beginning with the CY 2026 reporting period. 6. Information Collection Burden Estimate for the Proposed Adoption of the Emergency Care Access & Timeliness eCQM With Voluntary Reporting for the CY 2027 Reporting Period, Followed by Mandatory Reporting Beginning With the CY 2028 Reporting Period/CY 2030 Payment Determination As discussed in section XV.B.1. of this proposed rule, we propose to adopt the Emergency Care Access & Timeliness eCQM beginning with voluntary reporting for the CY 2027 reporting period, followed by mandatory reporting beginning with the CY 2028 reporting period/CY 2030 payment determination. Similar to the information collection burden for the Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) and Excessive Radiation Dose or Inadequate Image Quality for Diagnostic CT in Adults eCQMs currently approved under OMB control number 0938–1109, we assume a Medical Records Specialist would require 10 minutes (0.167 hours) to submit the data required per quarter for each HOPD or 40 minutes (0.67 hours; 10 minutes × 4 quarters) annually. For voluntary reporting for the CY 2027 reporting per quire 10 minutes (0.167 hours) to submit the data required per quarter for each HOPD or 40 minutes (0.67 hours; 10 minutes × 4 quarters) annually. For voluntary reporting for the CY 2027 reporting period, HOPDs would be able to voluntarily submit at least one quarter and up to four quarters of data. For estimation purposes, similar to the assumptions previously used for the STEMI and Excessive Radiation Dose or Inadequate Image Quality for Diagnostic CT in Adults eCQMs, we estimate 20 percent of HOPDs would voluntarily report one quarter of data for the measure in the CY 2027 reporting period, with 100 percent of HOPDs reporting the measure as required in subsequent years (86 FR 63962 and 63963, and 88 FR 82134). For voluntary reporting for the CY 2027 reporting period, we estimate an annual burden for voluntarily participating HOPDs of 107 hours (3,200 HOPDs × 20 percent × 0.167 hours × 1 quarter) at a cost of $5,891 (107 hours × $55.06/hour). Beginning with the CY 2028 reporting period, we estimate the annual burden for all participating HOPDs to be 2,133 hours (0.67 hours × 3,200 HOPDs) at a cost of $117,443 (2,133 hours × $55.06/ hour). With respect to any costs/burdens unrelat od, we estimate the annual burden for all participating HOPDs to be 2,133 hours (0.67 hours × 3,200 HOPDs) at a cost of $117,443 (2,133 hours × $55.06/ hour). With respect to any costs/burdens unrelated to data submission, we refer readers to the Regulatory Impact Analysis in section XXV. of this proposed rule. 7. Information Collection Burden Estimate for the Proposed Removal of the Median Time From ED Arrival to ED Departure for Discharged ED Patients Measure Beginning With the CY 2028 Reporting Period/CY 2030 Payment Determination number 0938–1109. The currently approved information collection burden estimate for this measure assumes HOPDs spend approximately 10 minutes (0.167 hours) annually to report measure data. Therefore, for all participating HOPDs, we estimate removal of this measure would decrease burden by approximately 533 hours (0.167 hours × 3,200 HOPDs) at a savings of $29,347 (533 hours × $55.06/ hour). 9. Information Collection Burden Estimate for the Proposal To Modify the Excessive Radiation eCQM From Mandatory Reporting Beginning With the CY 2027 Reporting Period To Continue Voluntary Reporting in the CY 2027 Reporting Period and Subsequent Years As discussed i fy the Excessive Radiation eCQM From Mandatory Reporting Beginning With the CY 2027 Reporting Period To Continue Voluntary Reporting in the CY 2027 Reporting Period and Subsequent Years As discussed in section XV.B.2. of As discussed in section XV.B.3. of this proposed rule, we propose to remove the Median Time from ED Arrival to ED Departure for Discharged ED Patients measure beginning with the CY 2028 reporting period/CY 2030 payment determination, when reporting for the Emergency Care Access & Timeliness eCQM is proposed to become mandatory. The information collection burden associated with this measure is currently approved under OMB control number 0938–1109. The currently approved information collection burden estimate for this measure assumes an average of 289 cases are reported annually per HOPD, and HOPDs require approximately 2.9 minutes (0.049 hours) per case to perform the necessary chart abstraction and report measure data. Therefore, we estimate removal of this measure would decrease burden by approximately 14.2 hours (0.049 hours × 289 cases) at a savings of $782 per HOPD (14.2 hours × $55.06/hour). Therefore, for all participating HOPDs, we estimate a decrease in ann ld decrease burden by approximately 14.2 hours (0.049 hours × 289 cases) at a savings of $782 per HOPD (14.2 hours × $55.06/hour). Therefore, for all participating HOPDs, we estimate a decrease in annual burden of 45,440 hours (14.2 hours per HOPD × 3,200 HOPDs) at a savings of $2,501,926 (45,440 hours × $55.06/hour). 8. Information Collection Burden Estimate for the Proposed Removal of the Left Without Being Seen Measure Beginning With the CY 2028 Reporting Period/CY 2030 Payment Determination As discussed in section XV.B.2. of this proposed rule, we propose to remove the Left Without Being Seen measure beginning with the CY 2028 reporting period/CY 2030 payment determination, when reporting for the Emergency Care Access & Timeliness eCQM is proposed to become mandatory. The information collection burden associated with this measure is currently approved under OMB control this proposed rule, we propose to modify the reporting requirements for the Excessive Radiation eCQM by maintaining voluntary reporting instead of mandatory reporting of the measure, beginning with the CY 2027 reporting period. The information collection burden associated with this measure is currently approved u g voluntary reporting instead of mandatory reporting of the measure, beginning with the CY 2027 reporting period. The information collection burden associated with this measure is currently approved under OMB control number 0938–1109 and estimates HOPDs spend approximately 10 minutes (0.167 hours) per quarter annually to report measure data. In the CY 2024 OPPS/ASC final rule, where we adopted the Excessive Radiation eCQM beginning with voluntary reporting in the CY 2026 reporting period, we estimated that 20 percent of hospitals would voluntarily report one quarter of data for the measure and 100 percent of hospitals would report data for the measure once mandatory reporting began with the CY 2027 reporting period/CY 2029 payment determination. We also finalized to gradually increase the number of quarters of data hospitals would be required to report on the measure starting with two self-selected quarters for the CY 2027 reporting period/CY 2029 payment determination, and all four quarters for the CY 2028 reporting period/CY 2030 payment determination (88 FR 82134). Because 80 percent of HOPDs would no longer be required to report this measure under the proposed modification to e arters for the CY 2028 reporting period/CY 2030 payment determination (88 FR 82134). Because 80 percent of HOPDs would no longer be required to report this measure under the proposed modification to extend voluntary reporting beginning with the CY 2027 reporting period, we estimate the revised data submission burden would be 107 hours (3,200 HOPDs × 20 percent × 0.167 hours × 1 quarter) at a cost of $5,891 (107 hours × $55.06/hour) annually. This updated burden estimate is a decrease of 960 hours [(3,200 HOPDs × 0.167 hours × 2 quarters) ¥ VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00340 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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. 135 / Thursday, July 17, 2025 / Proposed Rules 33815 (3,200 HOPDs × 20 percent × 0.167 hours × 1 quarter)] at a savings of $52,858 (960 hours × $55.06) for the CY 2027 reporting period, and a decrease of 2,027 hours [(3,200 HOPDs × 20 percent × 0.167 hours × 3 quarters) + (3,200 HOPDs × 80 percent × 0.167 hours × 4 quarters)] at a savings of $111,607 (2,027 hours × $55.06/hour) annually beginning with the CY 2028 reporting period. percent × 0.167 hours × 3 quarters) + (3,200 HOPDs × 80 percent × 0.167 hours × 4 quarters)] at a savings of $111,607 (2,027 hours × $55.06/hour) annually beginning with the CY 2028 reporting period. In addition, for this measure as described under OMB control number 0938–1109, participating HOPDs must follow the process for running their chosen vendor’s translation software prior to sending data to its EHR for measure calculation and reporting. We estimate participating HOPDs spend approximately 15 minutes (0.25 hours) annually to conduct these activities prior to data submission. Therefore, for all participating HOPDs, we estimate removal of this measure would decrease annual burden associated with these activities by approximately 640 hours (0.25 hours × 80 percent × 3,200 HOPDs) at a savings of $35,238 (640 hours × $55.06/hour) beginning with the CY 2027 reporting period. 10. Summary of Proposed Information Collection Burden Estimates for the Hospital OQR Program Tables 92 through 96 summarizes the information collection burden changes under OMB control number 0938–1109 (expiration date January 1, 2026). We estimate that the proposals in this proposed rule would result in a de 96 summarizes the information collection burden changes under OMB control number 0938–1109 (expiration date January 1, 2026). We estimate that the proposals in this proposed rule would result in a decrease in information collection burden of 6,924,988 hours at a savings of $178,884,367 annually for all 3,200 program-eligible HOPDs from the CY 2025 reporting period/CY 2027 payment determination through the CY 2028 reporting period/CY 2030 payment determination. We also estimate that the proposals in this proposed rule would result in a decrease in information collection burden of between 25,600 hours at a savings of $1,446,400 and 28,800 hours at a savings of $1,687,680 under OMB control number 0920–1317. We will submit the revised information collection estimates to OMB for approval under OMB control number 0938–1109. With respect to any costs/ burdens unrelated to data submission, we refer readers to the Regulatory Impact Analysis (section XXVI.A. of this proposed rule). We invite public comments on the information collection requirements and whether our estimated burden is a reasonable estimate. BILLING CODE 4120–01–P 2 S L A S O P O R P h t i w D O R P 4 4 1 S 7 W 9 K S D n o d blic comments on the information collection requirements and whether our estimated burden is a reasonable estimate. BILLING CODE 4120–01–P 2 S L A S O P O R P 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 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00341 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00342 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00343 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00344 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00345 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00346 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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. 135 / Thursday, July 17, 2025 / Proposed Rules 33821 we refer readers to the Regulatory Impact Analysis in section XXVI. of this proposed r 9 K S D n o d n o m m a h k Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules 33821 we refer readers to the Regulatory Impact Analysis in section XXVI. of this proposed rule). We invite public comments on the information collection requirements and whether our estimated burden is a reasonable estimate. BILLING CODE 4120–01–P 2 S L A S O P O R P 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 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00347 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00348 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00349 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00350 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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. 135 / Thursday, July 17, 2025 / Proposed Rules 33825 hour). Beginning with the mandatory reporting for the CY 2026 reporting period, we estim K S D n o d n o m m a h k Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules 33825 hour). Beginning with the mandatory reporting for the CY 2026 reporting period, we estimate a decrease in burden of approximately 729,045 hours for 21,871,350 patients (4,765 patients × 4,590 ASCs × 0.033 hours per patient) at a savings of $18,685,423 (729,045 hours × $25.63/hour). With regard to measure reporting, we estimate the removal of this measure would decrease burden for voluntary reporting for the CY 2025 reporting period by 383 hours (4,590 ASCs × 50 percent of ASCs × 0.167 hours per ASC) at a savings of $21,088 (383 hours × $55.06/hour) and 765 hours annually (0.167 hours × 4,590 ASCs) at a savings of $42,121 (765 hours × $55.06/hour) for mandatory reporting beginning with the CY 2026 reporting period. 5. Information Collection Burden Estimate for the Proposed Removal of the Screen Positive Rate for SDOH Measure Beginning With the CY 2025 Reporting Period In section XIV.C.3. of this proposed rule, we propose to remove the Screen Positive Rate for SDOH measure beginning with the CY 2025 reporting period. For this measure, ASCs are required to report on an annua on XIV.C.3. of this proposed rule, we propose to remove the Screen Positive Rate for SDOH measure beginning with the CY 2025 reporting period. For this measure, ASCs are required to report on an annual basis the number of patients who screen positive for one or more of the five SDOH domains divided by the total number of patients screened (reported as five separate rates). We previously estimated each ASC requires 10 minutes (0.167 hours) annually to report this measure. Therefore, consistent with the burden estimates for this measure under OMB control number 0938–1270, we estimate the removal of this measure would decrease burden for voluntary reporting for the CY 2025 reporting period by 383 hours (4,590 ASCs × 50 percent of ASCs × 0.167 hours per ASC) at a savings of $21,088 (383 hours × $55.06/hour) and 765 hours annually (0.167 hours × 4,590 ASCs) at a savings of $42,121 (765 hours × $55.06/hour) for mandatory reporting beginning with the CY 2026 reporting period. 6. Information Collection Burden for the Proposed Adoption of the Information Transfer PRO–PM Beginning With Voluntary Reporting for the CY 2027 and CY 2028 Reporting Periods Followed by Mandatory Reporting Beginning ollection Burden for the Proposed Adoption of the Information Transfer PRO–PM Beginning With Voluntary Reporting for the CY 2027 and CY 2028 Reporting Periods Followed by Mandatory Reporting Beginning With the CY 2029 Reporting Period/CY 2031 Payment Determination As discussed in section XVII.B.1. of this proposed rule, we propose to adopt the Information Transfer PRO–PM with voluntary reporting for the CY 2027 and CY 2028 reporting periods followed by mandatory reporting beginning with the CY 2029 reporting period/CY 2031 payment determination. In the CY 2025 OPPS/ASC final rule with comment period, we finalized a similar measure for the Hospital OQR Program (89 FR 94406 through 94413) and discussed our estimates for information collection burden (89 FR 94525); the associated information collection burden is approved under OMB control number 0938–1109 (expiration date January 31, 2026). The Information Transfer PRO–PM would use patient reported outcome (PRO) data regarding recovery instructions, collected by ASCs through a nine-item survey instrument administered to patients post- operatively. The modes of PRO data collection can include completion of the post-operative surveys el structions, collected by ASCs through a nine-item survey instrument administered to patients post- operatively. The modes of PRO data collection can include completion of the post-operative surveys electronically. In section XVII.C.1.b, we propose that, for ASCs that anticipate receiving more than 200 completed surveys, these ASCs would have the option to either: (1) survey and report data on their entire eligible Information Transfer PRO–PM patient population, or (2) randomly sample their eligible Information Transfer PRO–PM patient population to collect and report data from 200 completed surveys. As submission rates among facilities may vary, we conservatively estimate that, for voluntary reporting for the CY 2027 and CY 2028 reporting periods, 50 percent of ASCs (or their third-party vendors) would obtain responses from 30 percent of patients and, beginning with mandatory reporting for the CY 2029 reporting period, ASCs (or their third- party vendors) would obtain responses from 30 percent of patients. To provide an estimate of patient volume for the purposes of calculating the information collection burden associated with this measure, we utilized data derived from the ASC Qual percent of patients. To provide an estimate of patient volume for the purposes of calculating the information collection burden associated with this measure, we utilized data derived from the ASC Quality Collaborative (ASCQC) related to ASC patient fall benchmarking data as this metric applies to all patients rather than a subset. Since we expect that ASCs reporting data to the ASCQC will tend to be larger facilities with larger patient populations than non-reporting ASCs, we conservatively estimate that each year approximately 22,326,000 patients (10,433,448 admissions 338 ÷ 2,145 ASCs reporting) × 4,590 ASCs) with an average of 4,864 patients per ASC (22,326,000 admissions ÷ 4,590 ASCs) would be eligible to be screened annually when reporting on the measure becomes mandatory. We determine the cost for patients (or their representative) undertaking administrative and other tasks, such as filling out a survey or intake form, using a post-tax wage of $25.63/hr based on the report ‘‘Valuing Time in U.S. Department of Health and Human Services Regulatory Impact Analyses: Conceptual Framework and Best Practices,’’ which identifies the approach for valuing time when individuals undertak ing Time in U.S. Department of Health and Human Services Regulatory Impact Analyses: Conceptual Framework and Best Practices,’’ which identifies the approach for valuing time when individuals undertake activities on their own time.339 To derive the costs for patients (or their representatives), a measurement of the usual weekly earnings of wage and salary workers of $1,192 is divided by 40 hours to calculate an hourly pre-tax wage rate of $29.80/hr.340 This rate is adjusted downwards by an estimate of the effective tax rate for median income households of about 14 percent calculated by comparing pre- and post- tax income,341 resulting in the post-tax hourly wage rate of $25.63/hr. Unlike our State and private sector wage adjustments, we are not adjusting beneficiary wages for fringe benefits and other indirect costs because the individuals’ activities, if any, would occur outside the scope of their employment. We estimate each patient would require an average of 5 minutes (0.083 hours) to complete the survey. For voluntary reporting for the CY 2027 and CY 2028 reporting periods, we estimate a total burden for patients of 279,075 hours (22,326,000 patients × 30 percent response rate to complete the survey. For voluntary reporting for the CY 2027 and CY 2028 reporting periods, we estimate a total burden for patients of 279,075 hours (22,326,000 patients × 30 percent response rate × 50 percent of ASCs × 0.083 hours per patient surveyed) at a cost of $7,152,692 (279,075 hours × $25.63/hour). For mandatory reporting beginning with the CY 2029 reporting period, we estimate an annual total burden for patients of 558,150 hours (22,326,000 patients × 30 percent response rate × 0.083 hours per patient) at a cost of $14,305,385 (558,150 hours × $25.63/hour) or $3,117 per ASC ($14,305,385 ÷ 4,590 ASCs). Measure data would be submitted via the HQR system annually. Similar to the currently approved burden estimate for 339 Office of the Assistant Secretary for Planning and Evaluation. (2017). Valuing Time in U.S. Department of Health and Human Services Regulatory Impact Analyses: Conceptual Framework and Best Practices. Available at https:// aspe.hhs.gov/reports/valuing-time-us-department- health-human-services-regulatory-impact-analyses- conceptual-framework. Accessed: June, 24, 2025. 340 Bureau of Labor and Statistics. (2025). Usual Weekly Earnings of Wage and Salary Wor s-department- health-human-services-regulatory-impact-analyses- conceptual-framework. Accessed: June, 24, 2025. 340 Bureau of Labor and Statistics. (2025). Usual Weekly Earnings of Wage and Salary Workers, Fourth Quarter 2025. Available at https:// www.bls.gov/news.release/pdf/wkyeng.pdf. Accessed: March 3, 2025. 338 ASC Quality Collaboration. ASC Quality Collaboration Quality Report. Available at https:// ascquality.org/benchmarking/. Accessed: March 3, 2025. 341 Guzman, G. & Kollatr, M. (2024). Income in the United States: 2023. Available at https:// www2.census.gov/library/publications/2024/demo/ p60-282.pdf. Accessed: June, 24, 2025. VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00351 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 33826 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules other web-based measures reported via the HQR system for the ASCQR Program, we estimate a burden of 10 minutes (0.167 hours) per ASC to report measure data. For voluntary reporting for the CY 2027 and CY 2028 reporting periods, we estimate an annual burden for participating ASCs o timate a burden of 10 minutes (0.167 hours) per ASC to report measure data. For voluntary reporting for the CY 2027 and CY 2028 reporting periods, we estimate an annual burden for participating ASCs of 383 hours (4,590 HOPDs × 50 percent of ASCs × 0.167 hours) at a cost of $21,088 (383 hours × $55.06/hour). For mandatory reporting beginning with the CY 2029 reporting period, we estimate an annual burden for all ASCs of 765 hours (4,590 ASCs × 0.167 hours) at a cost of $42,121 (765 hours × $55.06/hour). 7. Summary of Information Collection Burden Estimates for the ASCQR Program Tables 100 through 104 summarizes the information collection burden changes for under OMB control number 0938–1270 (expiration date July 31, 2027). We estimate that the proposals in this proposed rule would result in an overall decrease in information collection burden of 172,425 hours at a savings of $4,464,280 annually for all 4,590 program-eligible ASCs from the CY 2025 reporting period/CY 2027 payment determination through the CY 2029 reporting period/CY 2031 payment determination. We also estimate that the proposals in this proposed rule would result in a decrease in information collection burden of betw nation through the CY 2029 reporting period/CY 2031 payment determination. We also estimate that the proposals in this proposed rule would result in a decrease in information collection burden of between 36,720 hours at a savings of $2,074,680 and 41,310 hours at a savings of $2,420,766 under OMB control number 0920–1317. We will submit the revised information collection estimates to OMB for approval under OMB control number 0938–1270. With respect to any costs/ burdens unrelated to data submission, we refer readers to the Regulatory Impact Analysis (section XXVI.A. of this proposed rule). We invite public comments on the information collection requirements and whether our estimated burden is a reasonable estimate. BILLING CODE 4120–01–P 2 S L A S O P O R P 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 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00352 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00353 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00354 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00354 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00355 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00356 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00357 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 33832 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules Further instructions for the reporting and complying with this proposed market-based data collection requirement on the Medicare cost report will be discussed in a forthcoming ICR request. F. ICRs for Medicare OPPS Drug Acquisition Cost Survey a. Background In section V.C. of this proposed rule, we discuss our intent to conduct a survey of hospitals’ drug acquisition costs. Section 1833(t)(14)(A)(iii) of the Act required the Secretary to set payment rates for specified covered outpatient drugs (SCODs) 342 beginning in 2006 at the amount the Secret drug acquisition costs. Section 1833(t)(14)(A)(iii) of the Act required the Secretary to set payment rates for specified covered outpatient drugs (SCODs) 342 beginning in 2006 at the amount the Secretary determined to be the average acquisition cost for the drug for that year, at least when certain hospital acquisition cost survey data is available. To collect the cost survey data for the Secretary to use for 2006 payment rates, section 1833(t)(14)(D)(i)(I) of the Act required the Comptroller General of the United States to conduct a survey in each of 2004 and 2005 to determine the hospital acquisition cost for each SCOD. To inform payment rates in later years, section 1833(t)(14)(D)(ii) requires the Secretary periodically to conduct surveys of hospital acquisition costs for each SCOD. The GAO conducted the required surveys in 2004 and 2005, and, in reporting the results in 2006, recommended that the Secretary thereafter validate, ‘‘on an occasional basis—possibly every 5 or 10 years— average sales price (ASP)data that manufacturers report to CMS for developing SCOD payment rates.’’ 343 CMS has not, however, conducted its own survey of the acquisition costs for each SCOD for all ho average sales price (ASP)data that manufacturers report to CMS for developing SCOD payment rates.’’ 343 CMS has not, however, conducted its own survey of the acquisition costs for each SCOD for all hospitals paid under the OPPS. Accordingly, under section 1833(t)(14)(D)(ii) of the Act, we will be conducting a survey, with the survey submission window opening by early CY 2026, of the acquisition costs for each separately payable drug acquired by all hospitals paid under the OPPS. We intend for the survey to be completed in time for the survey results to be used to inform policy making beginning with the CY 2027 OPPS/ASC proposed rule. Additionally, on April 18, 2025, President Trump signed Executive Order (E.O.) 14273, ‘‘Lowering Drug Prices by Once Again Putting Americans First.’’ 344 Section 5 of the E.O., ‘‘Appropriately Accounting for Acquisition Costs of Drugs in Medicare,’’ directs the Secretary of HHS to publish in the Federal Register a plan to conduct a survey under section 1833(t)(14)(D)(ii) of the Act so he can determine the hospital acquisition cost for covered outpatient drugs at hospital outpatient departments. 342 For the definition of a SCOD, see section 1833(t)(14)( 3(t)(14)(D)(ii) of the Act so he can determine the hospital acquisition cost for covered outpatient drugs at hospital outpatient departments. 342 For the definition of a SCOD, see section 1833(t)(14)(B) of the Act at https://www.ssa.gov/OP_ Home/ssact/title18/1833.htm. 343 https://www.gao.gov/assets/gao-06-372.pdf. 344 https://www.govinfo.gov/content/pkg/FR- 2025-04-18/pdf/2025-06837.pdf. b. OPPS Drug Acquisition Cost Survey Description and Burden Calculation From January 1, 2026, through March 31, 2026, we intend to survey hospitals paid under the OPPS for their drug acquisition costs, including for SCODs, and drugs and biologicals CMS historically treats as SCODs. The survey is designed to impose the least amount of burden on hospitals as possible while ensuring we capture the required data to inform payment rates as required by statute. As part of this data collection, we will survey hospitals only about drugs that are separately paid under the OPPS and will ask hospitals to report the total acquisition cost, net of all rebates and discounts, of each drug by National Drug Code (NDC) purchased during the 1-year timeframe of July 1, 2024, through June 30, 2025. We are asking hospi the total acquisition cost, net of all rebates and discounts, of each drug by National Drug Code (NDC) purchased during the 1-year timeframe of July 1, 2024, through June 30, 2025. We are asking hospitals to incorporate all rebates and discounts in their acquisition cost for each NDC, including discounts directly applicable to an individual NDC, but also those discounts that are not necessarily linked to a single NDC, but could be a discount linked to a certain invoice, or discounts linked to purchases made over a certain time period, such as prompt pay discounts, wholesaler discounts, or other discounts. We understand that certain discounts may depend on whether an eligible patient receives the drug. That is true, for example, for drugs acquired through the 340B program. We are therefore asking for hospitals to separately list their acquisition costs for drug NDCs acquired through the 340B program and those drug NDCs acquired VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00358 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 > H P G H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00359 Fmt 00358 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 > H P G H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00359 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00360 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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. 135 / Thursday, July 17, 2025 / Proposed Rules 33835 final rule, but we will no longer account for this one-time burden moving forward. Additionally, we finalized an estimated ongoing annual national burden of 383,292 hours (54 hours × 7,098 hospitals) and an annual national cost of $32,370,571 dollars ($4,560.52 per respondent × 7,098 hospitals), which represented a $10,698,069 ($32,370,571¥$21,672,502) increase over our previous estimated ongoing national annual burden for subsequent years for hospitals to update their standard charge information in the CMS standard template and conform to the data dictionary. We still believe these hourly estimates are accurate estimates of the ongoing annual burden for hospitals to update the rge information in the CMS standard template and conform to the data dictionary. We still believe these hourly estimates are accurate estimates of the ongoing annual burden for hospitals to update their standard charge information in the CMS standard template and conform to the data dictionary. In this proposed rule, we are updating the number of hospitals estimated to be subject to the HPT requirements, providing updated estimates for hospitals to implement new proposed data elements, and updating wage rates for the annual ongoing estimates. For this proposed rule, we updated the number of hospitals estimated to be subject to the HPT requirements using the same methodology as we did in the CY 2024 OPPS/ASC final rule. There were 8,340 hospitals most recently identified in the HIFLD hospital dataset. We subtracted 374 hospitals HIFLD identified as ‘‘closed’’ as well as hospitals that are deemed under the regulation to have met requirements which included 352 Federally owned non-military and military hospitals, and 198 state, local, and district run forensic hospitals. We therefore estimate that, for this proposed rule, 7,416 hospitals would meet the HPT regulation’s definition of ‘ y and military hospitals, and 198 state, local, and district run forensic hospitals. We therefore estimate that, for this proposed rule, 7,416 hospitals would meet the HPT regulation’s definition of ‘‘hospital’’ at 45 CFR 180.2. We estimated the hourly cost for each labor category used in this analysis by referencing the Bureau of Labor Statistics report on Occupational Employment and Wages (May 2024).347 We included labor categories for General and Operations Managers, Business Operations Specialists, and Network and Computer Systems Administrators for this proposed rule as we believe these labor categories are associated with the one-time and annual burden related to the implementation of hospital price transparency policies. (See Table 108.) As discussed in section XIX. of this proposed rule, the ‘‘estimated allowed amount’’ (defined at § 180.20) means the average dollar amount that the hospital has historically received from a third- party payer for an item or service. While we believe that the estimated allowed amount provides useful additional context and enhances transparency and comparability of hospital standard charges, we acknowledge that these average dollar amounts do ieve that the estimated allowed amount provides useful additional context and enhances transparency and comparability of hospital standard charges, we acknowledge that these average dollar amounts do not necessarily apply to any particular individual, nor do they necessarily represent the actual dollar amount an individual would pay for an item or service. Therefore, we propose to require hospitals to report four new data elements when the standard charge is based on a percentage or algorithm—the median allowed amount (which would replace the estimated allowed amount data element), the tenth percentile allowed amount, the ninetieth percentile allowed amount, and the count of allowed amounts. We also propose to require that hospitals use electronic data interchange (EDI) 835 electronic remittance advice (ERA) transaction data to calculate and encode these values, and we propose to require that hospitals abide by specific instructions regarding the methodology, including the lookback period, that should be used to calculate the median, tenth and ninetieth percentile allowed amounts. We believe that the median, tenth and ninetieth percentile allowed amounts would provide greater conte iod, that should be used to calculate the median, tenth and ninetieth percentile allowed amounts. We believe that the median, tenth and ninetieth percentile allowed amounts would provide greater context and clarity with respect to the payer- specific negotiated charge, would be a better consumer benchmark than the estimated allowed amount, and better enable price estimator tools to develop and estimate an individual’s personalized out-of-pocket cost, enabling MRF users to more easily compare such standard charges across hospitals. We also propose that beginning January 1, 2026, hospitals must attest in their MRF that they have included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file, and the hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer- specific negotiated charges that cannot be expressed as a dollar amount in the MRF, or are not knowable in advance, the hospital would attest that the payer- specific negotiated charge is based on a contractual algorithm, percentage or for be expressed as a dollar amount in the MRF, or are not knowable in advance, the hospital would attest that the payer- specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but 347 U.S. Bureau of Labor Statistics, May 2024 National Occupational Employment and Wage Estimates United States, Occupational Employment and Wage Statistics. Accessed at https:// www.bls.gov/oes/tables.htm. VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00361 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00362 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 > H P G H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00363 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 33838 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules system for one additional ye SGM 17JYP2 2 S L A S O P O R P 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 33838 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules system for one additional year (through CY 2026). The ASC impacts discussed below reflect our application of the hospital market basket update for CY 2026. In addition, this proposed rule is necessary to make policy changes under rural emergency hospitals (REHs), ASCs reporting data under the Hospital OQR, REHQR, and ASCQR Programs, respectively. The primary objective of these quality reporting programs is to promote higher quality, more efficient health care for Medicare beneficiaries by collection and reporting on quality-of- care metrics. This information is made available to consumers, both to empower Medicare beneficiaries and inform decision making, as well as to incentivize healthcare facilities to make continued improvements. This rule is also necessary to modify the methodology for the Overall Hospital Quality Star Ratings to emphasize and align the importance of patient safety across CMS programs. The Overall Hospital Quality Star Ratings information is publicly available. Also, this proposed rule is ne ty Star Ratings to emphasize and align the importance of patient safety across CMS programs. The Overall Hospital Quality Star Ratings information is publicly available. Also, this proposed rule is necessary to enhance clarity and standardization in hospital disclosure of standard charges. The Hospital Price Transparency regulations requiring public release of hospital standard charge information are a necessary and important first step in ensuring transparency in prices of healthcare services for consumers. B. Overall Impact of Provisions of This Proposed Rule We have examined the impacts of this rule as required by Executive Order 12866, ‘‘Regulatory Planning and Review’’; Executive Order 13132, ‘‘Federalism’’; Executive Order 13563, ‘‘Improving Regulation and Regulatory Review’’; Executive Order 14192, ‘‘Unleashing Prosperity Through Deregulation’’; the Regulatory Flexibility Act (RFA) (Pub. L. 96–354); section 1102(b) of the Social Security Act; and section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104–4). Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to sele ates Reform Act of 1995 (Pub. L. 104–4). Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select those regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety, and other advantages; distributive impacts; and equity).). Section 3(f) of Executive Order 12866 defines a ‘‘significant regulatory action’’ as any regulatory action that is likely to result in a rule that may: (1) have an annual effect on the economy of $100 million or more or adversely affect in a material way the economy, a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or State, local, or tribal governments or communities; (2) create a serious inconsistency or otherwise interfere with an action taken or planned by another agency; (3) materially alter the budgetary impact of entitlements, grants, user fees, or loan programs or the rights and obligations of recipients thereof; or (4) raise novel legal or policy issues arising out of legal mandates, or the President’s priorities. A regulatory impact analysi r loan programs or the rights and obligations of recipients thereof; or (4) raise novel legal or policy issues arising out of legal mandates, or the President’s priorities. A regulatory impact analysis (RIA) must be prepared for a regulatory action that is significant under section 3(f)(1) of E.O. 12866. Based on our estimates, the Office of Management and Budget’s (OMB) Office of Information and Regulatory Affairs (OIRA) has determined this rulemaking is significant per section 3(f)(1). Accordingly, we have prepared a Regulatory Impact Analysis that to the best of our ability presents the costs and benefits of the rulemaking. Therefore, OMB has reviewed these proposed regulations, and the Departments have provided the following assessment of their impact. We estimate that the total increase in Federal Government expenditures under the OPPS for CY 2026, compared to CY 2025, due to the changes to the OPPS in this proposed rule, would be approximately $1.61 billion. Taking into account our estimated changes in enrollment, utilization, and case-mix for CY 2026 we estimate that the OPPS expenditures, including beneficiary cost-sharing, for CY 2026 would be approximately $100.0 billion, ur estimated changes in enrollment, utilization, and case-mix for CY 2026 we estimate that the OPPS expenditures, including beneficiary cost-sharing, for CY 2026 would be approximately $100.0 billion, which is approximately $8.1 billion higher than estimated OPPS expenditures in CY 2025. Table 112 of this proposed rule displays the distributional impact of the CY 2026 changes in OPPS payment to various groups of hospitals and for CMHCs. We note that under our proposed CY 2026 policy, drugs and biologicals are generally paid at ASP plus 6 percent, WAC plus 6 percent, or 95 percent of AWP, as applicable. We estimate that the proposed update to the conversion factor will increase total OPPS payments by 2.4 percent in CY 2026. The proposed changes to the APC relative payment weights, the proposed changes to the wage indexes, the proposed continuation of a payment adjustment for rural SCHs, including EACHs, and the proposed payment adjustment for cancer hospitals would not increase total OPPS payments because these changes to the OPPS are budget neutral. However, these updates would change the distribution of payments within the budget neutral system. We estimate that the total change i PS payments because these changes to the OPPS are budget neutral. However, these updates would change the distribution of payments within the budget neutral system. We estimate that the total change in payments between CY 2025 and CY 2026, considering all budget- neutral payment adjustments, changes in estimated total outlier payments, the application of the frontier State wage adjustment, the proposed payment adjustment for drug administration services furnished at excepted off campus PBDs, in addition to the application of the OPD fee schedule increase factor after all adjustments required by sections 1833(t)(3)(F), 1833(t)(3)(G), and 1833(t)(17) of the Act will increase total estimated OPPS payments by 1.9 percent. We note that, as previously discussed in section V.B.7 of this proposed rule, we propose to reduce payments for non-drug items and services for hospitals for whom the annual reduction to payment amounts under § 419.32(b)(1)(iv)(B)(12) applies by 2 percentage points in CY 2026. We estimate that this proposed reduction would reduce OPPS spending by $1.1 billion in CY 2026. We estimate the total increase (from changes to the ASC provisions in this proposed rule, as well 2026. We estimate that this proposed reduction would reduce OPPS spending by $1.1 billion in CY 2026. We estimate the total increase (from changes to the ASC provisions in this proposed rule, as well as from enrollment, utilization, and case-mix changes) in Medicare expenditures (not including beneficiary cost-sharing) under the ASC payment system for CY 2026 compared to CY 2025, to be approximately $480 million. Tables 113 and 114 of this proposed rule display the redistributive impact of the CY 2026 changes regarding ASC payments, grouped by specialty area and then grouped by procedures with the greatest ASC expenditures, respectively. C. Detailed Economic Analyses 1. Estimated Effects of OPPS Changes in This Proposed Rule With Comment Period a. Limitations of Our Analysis The distributional impacts presented here are the projected effects of the proposed CY 2026 policy changes on various hospital groups. We post our hospital-specific estimated payments for CY 2026 on the CMS website with the other supporting documentation for this proposed rule. To view the hospital- specific estimates, we refer readers to the CMS website at https:// www.cms.gov/medicare/payment/ prospective-pay with the other supporting documentation for this proposed rule. To view the hospital- specific estimates, we refer readers to the CMS website at https:// www.cms.gov/medicare/payment/ prospective-payment-systems/hospital- outpatient. On the website, select ‘‘Regulations and Notices’’ from the left side of the page and then select ‘‘CMS– 1834–P’’ from the list of regulations and notices. The hospital-specific file layout and the hospital-specific file are listed VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00364 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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. 135 / Thursday, July 17, 2025 / Proposed Rules 33839 with the other supporting documentation for this proposed rule. We show hospital-specific data only for hospitals whose claims were used for modeling the impacts shown in Table 112 of this proposed rule. We do not show hospital-specific impacts for hospitals whose claims we were unable to use. We refer readers to section II.A. of this proposed rule for a discussion of the hospitals whose claims we do not use for ratesetting or impact purposes. We estimate hose claims we were unable to use. We refer readers to section II.A. of this proposed rule for a discussion of the hospitals whose claims we do not use for ratesetting or impact purposes. We estimate the effects of the individual policy changes by estimating payments per service, while holding all other payment policies constant. We use the best data available but do not attempt to predict behavioral responses to our policy changes in order to isolate the effects associated with specific policies or updates, but any policy that changes payment could have a behavioral response. In addition, we have not made any adjustments for future changes in variables, such as service volume, service-mix, or number of encounters. b. Estimated Effects of the Proposal To Control Unnecessary Increases in the Volume of Outpatient Services Furnished in Excepted Off-Campus Provider Based Departments (PBDs) In section X.A. of this proposed rule, we discuss our CY 2026 proposal to control for unnecessary increases in the volume of outpatient services by paying for drug administration services furnished at an off-campus PBD at an amount equal to the site-specific PFS payment rate for nonexcepted items and reases in the volume of outpatient services by paying for drug administration services furnished at an off-campus PBD at an amount equal to the site-specific PFS payment rate for nonexcepted items and services furnished by a nonexcepted off- campus PBD (the PFS payment rate). Specifically, we propose to pay for HCPCS codes billed with modifier ‘‘PO’’ and assigned to and paid through drug administration APCs 5691 through 5694 at an amount equal to the site-specific PFS payment rate for nonexcepted items and services furnished by a nonexcepted off-campus PBD (the PFS payment rate). For a discussion of the PFS relativity adjuster that used to pay for all drug administration services provided at all off-campus PBDs, we refer readers to the CY 2018 PFS final rule with comment period discussion (82 FR 53023 through 53024), as well as the CY 2019 PFS proposed rule. To develop an estimated impact of this proposal, we began with CY 2024 outpatient claims data used, for claim lines with HCPCS codes assigned for payment through drug administration APCs 5691 through 5694 that contained modifier ‘‘PO’’ because the presence of this modifier indicates that such claims were billed for services fur des assigned for payment through drug administration APCs 5691 through 5694 that contained modifier ‘‘PO’’ because the presence of this modifier indicates that such claims were billed for services furnished by an off-campus department of a hospital paid under the OPPS. We then simulated payment for the remaining claim lines as if they were paid at the PFS- equivalent rate, removing a portion of the payment associated with rural Sole Community Hospitals based on our proposed exception for those hospitals. An estimate of the proposed policy that includes the effects of estimated changes in enrollment, utilization, and case-mix based on the FY 2026 Mid- Session review budget approximates the estimated decrease in total payments at $280 million, with Medicare OPPS payments decreasing by $210 million and beneficiary copayments decreasing by $70 million in CY 2026. This estimate is utilized for the accounting statement displayed in Table 115 of this proposed rule because the impact of this proposed CY 2026 policy, which is not budget neutral, is combined with the impact of the OPD update, which is also not budget neutral, to estimate changes in Medicare spending under the OPPS as a resul roposed CY 2026 policy, which is not budget neutral, is combined with the impact of the OPD update, which is also not budget neutral, to estimate changes in Medicare spending under the OPPS as a result of the changes proposed in this rule. We note our estimates may differ from the actual effect of the proposed policy due to offsetting factors, such as changes in provider behavior. We note that by removing this payment differential that may influence site-of-service decision- making, we anticipate an associated decrease in the volume of drug administration services provided in the excepted off-campus PBD setting. We remind readers that this estimate could change in the final rule based on a number of factors such as the availability of updated data, changes in the final payment policy, and/or the method of assessing the payment impact in the final rule. As discussed in more detail in section X.A. of this proposed rule, we are seeking public comment on both our proposed payment policy for drug administration services furnished at off-campus provider-based departments as well as how to apply methods for controlling overutilization of services more broadly. 2 S L A S O P O R P h t i w r drug administration services furnished at off-campus provider-based departments as well as how to apply methods for controlling overutilization of services more broadly. 2 S L A S O P O R P 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 c. Estimated Effects of OPPS Changes on Hospitals Table 112 shows the estimated impact of the proposed rule on hospitals. Historically, the first line of the impact table, which estimates the change in payments to all facilities, has always included cancer and children’s hospitals, which are held harmless to their pre-Balanced Budget Act (BBA) amount. We also include CMHCs in the first line that includes all providers. We include a second line for all hospitals, excluding permanently held harmless hospitals and CMHCs. We present separate impacts for CMHCs in Table 112, and we discuss them separately below, because CMHCs VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00365 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00366 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 14 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00366 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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. 135 / Thursday, July 17, 2025 / Proposed Rules 33841 0.4 percent overall. Major teaching hospitals would experience an estimated decrease of 0.1 percent. Column 3: Wage Indexes and the Effect of the Provider Adjustments Column 3 demonstrates the combined budget neutral impact of the APC recalibration, the updates for the wage indexes with the FY 2026 IPPS post- reclassification wage indexes, the rural adjustment, the frontier adjustment, and the cancer hospital payment adjustment. We modeled the independent effect of the budget neutrality adjustments and the OPD fee schedule increase factor by using the relative payment weights and wage indexes for each year and using a CY 2025 conversion factor that included the OPD fee schedule increase and a budget neutrality adjustment for differences in wage indexes. Column 3 reflects the independent effects of the updated wage indexes, including the application of budget neutrality for the rural floor policy on a nationwide basis, as well a ences in wage indexes. Column 3 reflects the independent effects of the updated wage indexes, including the application of budget neutrality for the rural floor policy on a nationwide basis, as well as the proposed CY 2026 changes in wage index policy, discussed in section II.C. of this proposed rule. We did not model a budget neutrality adjustment for the rural adjustment for SCHs because we propose to continue the rural payment adjustment of 7.1 percent to rural SCHs for CY 2026, as described in section II.E. of this proposed rule. We modeled a budget neutrality adjustment for the proposed cancer hospital payment adjustment because the proposed payment-to-cost ratio target for the cancer hospital payment adjustment in CY 2025 is 0.87, which is the same PCR target adopted in the CY 2025 OPPS/ ASC final rule with comment period (89 FR 93979). We note that, in accordance with section 16002 of the 21st Century Cures Act, we propose to apply a budget neutrality factor calculated as if the cancer hospital adjustment target payment-to-cost ratio was 0.88, not the 0.87 target payment-to-cost ratio we propose in section II.F. of this proposed rule with comment period. We modeled the indep cancer hospital adjustment target payment-to-cost ratio was 0.88, not the 0.87 target payment-to-cost ratio we propose in section II.F. of this proposed rule with comment period. We modeled the independent effect of updating the wage indexes by varying only the wage indexes, holding APC relative payment weights, service-mix, and the rural adjustment constant and using the CY 2026 scaled weights and a CY 2025 conversion factor that included a budget neutrality adjustment for the effect of the changes to the wage indexes between CY 2025 and CY 2026. Column 4: All Budget Neutrality Changes Combined With the Market Basket Update Column 4 demonstrates the combined impact of all the proposed changes previously described and the update to the conversion factor of 2.4 percent. Overall, these changes would increase payments to urban hospitals by 2.6 percent and to rural hospitals by 2.5 percent. Rural sole community hospitals would receive an estimated increase of 2.7 percent while other rural hospitals would receive an estimated increase of 2.1 percent. Column 5—Proposed Off-Campus PBD Drug Administration Payment Policy Column 5 displays the estimated effect of our proposed CY 2026 policy hospitals would receive an estimated increase of 2.1 percent. Column 5—Proposed Off-Campus PBD Drug Administration Payment Policy Column 5 displays the estimated effect of our proposed CY 2026 policy to pay for drug administration services assigned to APCs 5691 through 5694 when billed with modifier ‘‘PO’’ at a PFS-equivalent rate. We note that the numbers provided in this column isolate the estimated effect of this proposed policy adjustment relative to the numerator of Column 4. Therefore, the numbers reported in Column 5 show how much of the difference between the estimates in Column 4 and the estimates in Column 6 are a result of the proposed off-campus PBD visits policy. Column 6: All Changes With Outlier— Proposed CY 2026 Update Column 6 depicts the full impact of the proposed CY 2026 policies on each hospital group by including the effect of all changes for CY 2026 and comparing them to all estimated payments in CY 2025. Column 6 shows the combined budget neutral effects of Columns 2 and 3; the effect of the proposed off-campus provider-based department drug administration policy; the OPD fee schedule increase; the impact of estimated OPPS outlier payments, as discussed in umns 2 and 3; the effect of the proposed off-campus provider-based department drug administration policy; the OPD fee schedule increase; the impact of estimated OPPS outlier payments, as discussed in section II.G of proposed rule; the Hospital OQR Program payment reduction for the small number of hospitals in our impact model that failed to meet the reporting requirements (discussed in section XV. of this proposed rule); and other rule adjustments to the CY 2026 OPPS payments. Of those hospitals that failed to meet the Hospital OQR Program reporting requirements for the full CY 2025 update (and assumed, for modeling purposes, to be the same number for CY 2026), we included 79 hospitals in our model because they had both CY 2024 claims data and recent cost report data. We estimate that the cumulative effect of all changes for CY 2026 would increase payments to all facilities by 1.9 percent for CY 2026. We modeled the independent effect of all changes in Column 6 using the final relative payment weights for CY 2025 and the proposed relative payment weights for CY 2026. We used the final conversion factor for CY 2025 of $89.169 and a CY 2026 conversion factor of $91.747 discussed in s payment weights for CY 2025 and the proposed relative payment weights for CY 2026. We used the final conversion factor for CY 2025 of $89.169 and a CY 2026 conversion factor of $91.747 discussed in section II.B. of this proposed rule. Column 6 contains simulated outlier payments for each year. We used the 1- year charge inflation factor used in the FY 2026 IPPS/LTCH PPS final rule (90 FR 18434) of 5.4 percent (1.05440) to increase charges on the CY 2024 claims, and we used the overall CCR in the April 2025 Outpatient Provider-Specific File (OPSF) to estimate outlier payments for CY 2025. Using the CY 2024 claims and a 5.4 percent charge inflation factor, we currently estimate that outlier payments for CY 2025, using a multiple threshold of 1.75 and a fixed-dollar threshold of $7,750, would be approximately 0.92 percent of total payments. The estimated current outlier payments of 0.92 percent are incorporated in the comparison in Column 5. We used the same set of claims and a charge inflation factor of 11.2 percent (1.1118) and the CCRs in the April 2025 OPSF, with an adjustment of 0.970113 (90 FR 18435), to reflect relative changes in cost and charge inflation between CY 2025 and flation factor of 11.2 percent (1.1118) and the CCRs in the April 2025 OPSF, with an adjustment of 0.970113 (90 FR 18435), to reflect relative changes in cost and charge inflation between CY 2025 and CY 2026, to model the proposed CY 2026 outliers at 1.0 percent of estimated total payments using a multiple threshold of 1.75 and a fixed dollar threshold of $6,450. The charge inflation and CCR inflation factors are discussed in detail in the FY 2026 IPPS/ LTCH PPS proposed rule (90 FR 18434 through 18435). Overall, we estimate that facilities would experience an increase of 1.9 percent under this proposed rule in CY 2026 relative to total spending in CY 2025. This projected increase (shown in Column 6) of Table 112 of this proposed rule reflects the proposed 2.4 percent OPD fee schedule increase factor, adding the 0.08 difference in estimated outlier payments between CY 2025 (0.92 percent) and CY 2026 (1.0 percent), minus 0.22 percent for the change in the pass-through payment estimate between CY 2025 and CY 2026. We estimate that the combined effect of all changes for CY 2026 would increase payments to urban hospitals by 2.0 percent. Overall, we estimate that rural hospitals would e etween CY 2025 and CY 2026. We estimate that the combined effect of all changes for CY 2026 would increase payments to urban hospitals by 2.0 percent. Overall, we estimate that rural hospitals would experience a 2.0 percent increase as a result of the combined effects of all the changes for CY 2026. Among hospitals, by teaching status, we estimate that the impacts resulting from the combined effects of all changes include an increase of 1.7 percent for major teaching hospitals and an increase of 2.2 percent for nonteaching hospitals. Minor teaching hospitals would experience an estimated increase of 2.2 percent. VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00367 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 33842 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules In our analysis, we also have categorized hospitals by type of ownership. Based on this analysis, we estimate that voluntary hospitals would experience an increase of 2.0 percent, proprietary hospitals would experience an increase of 2.6 percent, and governmental hospitals would experience an increase of 2 te that voluntary hospitals would experience an increase of 2.0 percent, proprietary hospitals would experience an increase of 2.6 percent, and governmental hospitals would experience an increase of 2.0 percent. Reduction for Providers Subject to the 340B Remedy Offset In column 7 we have included additional information to account for estimated changes in the CY 2026 OPPS for providers subject to the 340B Remedy Offset. BILLING CODE 4120–01–P 2 S L A S O P O R P 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 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00368 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules 33843 2 S L A S O P O R P 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 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00369 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00370 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00371 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00372 Fmt 4701 17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00371 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00372 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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. 135 / Thursday, July 17, 2025 / Proposed Rules 33847 with the applicable fiscal year, year, cost reporting period, or other annual period). For ASCs that fail to meet their quality reporting requirements, the CY 2026 payment determinations would be based on the application of a 2.0 percentage point reduction to the hospital market basket update for CY 2026. We calculated the proposed CY 2026 ASC conversion factor by adjusting the CY 2025 ASC conversion factor by 0.9999 to account for changes in the pre- floor and pre-reclassified hospital wage indexes between CY 2025 and CY 2026, which includes our policy to limit wage index declines of greater than 5 percent, and by applying the CY 2026 hospital market basket update factor of 2.4 percent (which is equal to the proposed inpatient hospital market basket percentage increase of 3.2 percent reduc han 5 percent, and by applying the CY 2026 hospital market basket update factor of 2.4 percent (which is equal to the proposed inpatient hospital market basket percentage increase of 3.2 percent reduced by a proposed productivity adjustment of 0.8 percentage point). The proposed CY 2026 ASC conversion factor is $56.207 for ASCs that successfully meet the quality reporting requirements. a. Limitations of Our Analysis Presented here are the projected effects of the proposed changes for CY 2026 on Medicare payment to ASCs. A key limitation of our analysis is our inability to predict changes in ASC service-mix between CY 2024 and CY 2026 with precision. We believe the net effect on Medicare expenditures resulting from the proposed CY 2026 changes would be small in the aggregate for all ASCs. However, such changes may have differential effects across surgical specialty groups, as ASCs continue to adjust to the payment rates based on the policies of the revised ASC payment system. We are unable to accurately project such changes at a disaggregated level. Clearly, individual ASCs would experience changes in payment that differ from the aggregated estimated impacts presented below. b. Esti ble to accurately project such changes at a disaggregated level. Clearly, individual ASCs would experience changes in payment that differ from the aggregated estimated impacts presented below. b. Estimated Effects of ASC Payment System Policies on ASCs Some ASCs are multispecialty facilities that perform a wide range of surgical procedures from excision of lesions to hernia repair to cataract extraction; others focus on a single specialty and perform only a limited range of surgical procedures, such as ophthalmology, digestive system, or orthopedic procedures. The combined effect of the proposed update to the payments on an individual ASC would depend on a number of factors, including, but not limited to, the mix of services the ASC provides, the volume of specific services provided by the ASC, the percentage of its patients who are Medicare beneficiaries, and the extent to which an ASC provides different services in the coming year. The following discussion includes tables that display estimates of the impact of the proposed CY 2026 updates to the ASC payment system on Medicare payments to ASCs, assuming the same mix of services, as reflected in our CY 2024 claims data. Table 113 y estimates of the impact of the proposed CY 2026 updates to the ASC payment system on Medicare payments to ASCs, assuming the same mix of services, as reflected in our CY 2024 claims data. Table 113 depicts the estimated aggregate percent change in payment by surgical specialty or ancillary items and services group by comparing estimated CY 2025 payments to estimated CY 2026 payments, and Table 114 shows a comparison of estimated CY 2025 payments to estimated CY 2026 payments for items and procedures that we estimate would receive the most Medicare payment in CY 2025. In Table 113, we have aggregated the surgical HCPCS codes by specialty group, grouped all HCPCS codes for covered ancillary items and services into a single group, and then estimated the effect on aggregated payment for surgical specialty and ancillary items and services groups. The groups are sorted for display in descending order by estimated Medicare program payment to ASCs. The following is an explanation of the information presented in Table 113. • Column 1—Surgical Specialty or Ancillary Items and Services Group indicates the surgical specialty into which ASC procedures are grouped and the ancillary items and s rmation presented in Table 113. • Column 1—Surgical Specialty or Ancillary Items and Services Group indicates the surgical specialty into which ASC procedures are grouped and the ancillary items and services group, which includes all HCPCS codes for covered ancillary items and services. To group surgical procedures by surgical specialty, we used the CPT code range definitions and Level II HCPCS codes and Category III CPT codes, as appropriate, to account for all surgical procedures to which the Medicare program payments are attributed. • Column 2—Estimated CY 2025 ASC Payments were calculated using CY 2024 ASC utilization data (the most recent full year of ASC utilization) and CY 2025 ASC payment rates. The surgical specialty groups are displayed in descending order based on estimated CY 2025 ASC payments. • Column 3—Estimated CY 2026 Percent Change is the aggregate percentage increase or decrease in Medicare program payment to ASCs for each surgical specialty or ancillary items and services group that is attributable to proposed updates to ASC payment rates for CY 2026 compared to CY 2025. As shown in Table 113, for the six specialty groups that account for the most ASC utilizatio rvices group that is attributable to proposed updates to ASC payment rates for CY 2026 compared to CY 2025. As shown in Table 113, for the six specialty groups that account for the most ASC utilization and spending, we estimate that the proposed update to ASC payment rates for CY 2026 would result in a 2 decrease in aggregate payment amounts for eye and ocular adnexa procedures, a 1 percent increase in aggregate payment amounts for musculoskeletal system procedures, a 3 percent increase in aggregate payment amounts for nervous system procedures, a 3 percent increase in aggregate payment amounts for digestive system procedures, a 12 percent increase in aggregate payment amounts for cardiovascular system procedures, and an 18 percent increase in aggregate payment amounts for genitourinary system procedures. We note that these changes can be a result of different factors, including updated data, payment weight changes, and changes in policy. In general, spending in each of these categories of services is increasing due to the 2.4 percent payment rate update. After the payment rate update is accounted for, aggregate payment increases or decreases for a category of services can be highe s of services is increasing due to the 2.4 percent payment rate update. After the payment rate update is accounted for, aggregate payment increases or decreases for a category of services can be higher or lower than a 2.4 percent increase, depending on if payment weights in the OPPS APCs that correspond to the applicable services increased or decreased or if the most recent data show an increase or a decrease in the volume of services performed in an ASC for a category. For example, we estimate a 2 percent decrease in eye surgical procedure payments. The decrease in expenditures for eye surgical procedures is largely a result of a relative decline in the OPPS relative weights for the Level 1 Intraocular Procedures APC which is attributable to the relative decline in hospital geometric mean costs for procedures assigned to this APC. The large increase in cardiovascular and genitourinary procedures is a result of higher APC level assignment in the OPPS of newer peripheral vascular procedures and prostate biopsy procedure codes compared to prior vascular and prostate biopsy procedure codes. For estimated changes for selected procedures, we refer readers to Table 113. BILLING CODE 4120 ures and prostate biopsy procedure codes compared to prior vascular and prostate biopsy procedure codes. For estimated changes for selected procedures, we refer readers to Table 113. BILLING CODE 4120–01–P VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00373 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 33848 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules BILLING CODE 4120–01–C Table 114 shows the estimated impact of the updates to the revised ASC payment system on aggregate ASC payments for selected surgical procedures during CY 2026. The table displays 30 of the procedures receiving the greatest estimated CY 2025 aggregate Medicare payments to ASCs. The HCPCS codes are sorted in descending order by estimated CY 2025 program payment. • Column 1–CPT/HCPCS code. • Column 2–Short Descriptor of the HCPCS code. • Column 3–Estimated CY 2025 ASC Payments were calculated using CY 2024 ASC utilization (the most recent full year of ASC utilization) and the CY 2025 ASC payment rates. The estimated CY 2025 payments are expressed in millions of dollars. • Column 4–Estimated ing CY 2024 ASC utilization (the most recent full year of ASC utilization) and the CY 2025 ASC payment rates. The estimated CY 2025 payments are expressed in millions of dollars. • Column 4–Estimated CY 2026 Percent Change reflects the percent differences between the estimated ASC payment for CY 2025 and the estimated payment for CY 2026 based on the proposed update. 2 S L A S O P O R P 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 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00374 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00375 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00376 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 / > H P G H P G H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00377 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 33852 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Pr 00377 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 33852 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules associated with our proposals for the CY 2027 reporting period/CY 2029 program determination and subsequent years compared to our currently approved information collection burden estimates under OMB control number 0938–1454 (expiration date April 30, 2027). In section XVI.B.1. of this proposed rule, we proposed to adopt the Emergency Care Access & Timeliness eCQM. Similar to the effects associated with the STEMI eCQM finalized for the Hospital OQR Program in the CY 2022 OPPS/ASC final rule with comment period (86 FR 63984 and 63985), we believe that costs associated with adoption of eCQMs are multifaceted and include not only the burden associated with reporting but also the costs associated with implementing and maintaining program requirements, such as maintaining measure specifications in REHs’ EHR systems for the eCQMs used in the REHQR Program. Because REHs would have the option to report the Emergency Care Access & Timeliness eCQM or the more burdensome Median Time f ecifications in REHs’ EHR systems for the eCQMs used in the REHQR Program. Because REHs would have the option to report the Emergency Care Access & Timeliness eCQM or the more burdensome Median Time for Discharged ED Patients measure, we believe REHs would be positively impacted by the decreased effort required to report the Emergency Care Access & Timeliness eCQM in the long- term following initial implementation in the EHR. Regarding the remaining proposals, we do not believe these proposals would result in any additional economic impact beyond those discussed in section ‘‘XXII.B. Collection of Information’’ of this proposed rule. 5. Effects of Proposed Changes in Requirements for the Ambulatory Surgical Center Quality Reporting (ASCQR) Program a. Background We refer readers to the CY 2025 OPPS/ASC final rule with comment period (89 FR 94563) for the previously estimated effects of changes to the ASCQR Program for the CY 2025 reporting period and subsequent years. Based on the most recent analysis of the CY 2025 payment determination data, we found that, of the 6,012 ambulatory surgical centers (ASCs) that were actively billing Medicare, 4,271 were required to participate in the ecent analysis of the CY 2025 payment determination data, we found that, of the 6,012 ambulatory surgical centers (ASCs) that were actively billing Medicare, 4,271 were required to participate in the ASCQR Program. Of the 1,741 ASCs not required to participate in the program, 319 ASCs did so and met full requirements. On this basis, we estimate that 4,590 ASCs (4,271 + 319) will submit data for the ASCQR Program for the CY 2026 reporting period and subsequent years unless otherwise noted. We note that this estimate is an increase of 115 ASCs from our estimate of 4,475 provided in the CY 2025 OPPS/ ASC final rule with comment period (89 FR 94563) due to more recent data analysis regarding numbers of eligible ASCs. b. Impact of CY 2025 OPPS/ASC Proposed Rule Policies In this proposed rule, we propose (1) to remove the COVID–19 Vaccination Coverage Among HCP Measure beginning with the CY 2024 reporting period/CY 2026 payment determination; (2) to remove the Facility Commitment to Health Equity (FCHE) measure beginning with the CY 2025 reporting period/CY 2027 payment determination; (3) to remove the Screening for SDOH measure beginning with the CY 2025 reporting period/CY 2027 payment quity (FCHE) measure beginning with the CY 2025 reporting period/CY 2027 payment determination; (3) to remove the Screening for SDOH measure beginning with the CY 2025 reporting period/CY 2027 payment determination; (4) to remove the Screen Positive Rate for SDOH measure beginning with the CY 2025 reporting period/CY 2027 payment determination; and (5) to adopt the Patient Understanding of Key Information Related to Recovery After a Facility- Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance (Information Transfer PRO–PM) measure beginning with voluntary reporting for the CY 2027 and CY 2028 reporting periods followed by mandatory reporting beginning with the CY 2029 reporting period/CY 2031 payment determination. In section XVII.D. of this proposed rule, we also propose to update our ECE policy for the ASCQR Program. This proposed update would explicitly include extensions as a type of extraordinary circumstances relief option, in addition to exceptions. Because the process for requesting or granting an ECE would remain the same as the current ECE process, these updates would not affect burden associated with the submission of the ECE form. We refer Because the process for requesting or granting an ECE would remain the same as the current ECE process, these updates would not affect burden associated with the submission of the ECE form. We refer readers to section ‘‘XXII.C. Collection of Information’’ of this proposed rule for a detailed discussion of the calculations estimating the changes to the information collection and reporting burden for proposed data requirements under the ASCQR Program for the estimated 4,590 program-eligible ASCs. As shown in summary tables in section XXII.C.7., we estimate a total information collection and reporting burden decrease of 172,425 hours at a cost of $4,464,280 annually associated with our proposals for the CY 2029 reporting period/CY 2031 payment determination and subsequent years compared to our currently approved information collection burden estimates under OMB control number 0938–1270 (expiration date July 31, 2027) We also estimate a decrease of between 36,720 hours at a savings of $2,074,680 and 41,310 hours at a savings of $2,420,766 in information collection burden associated with the proposal to remove the COVID–19 Vaccination Among HCP measure compared to the currently approve 074,680 and 41,310 hours at a savings of $2,420,766 in information collection burden associated with the proposal to remove the COVID–19 Vaccination Among HCP measure compared to the currently approved information collection burden estimates and under OMB control number 0920–1317 (expiration date January 31, 2028). In section XVII.B.1. of this proposed rule, we proposed to adopt the Information Transfer PRO–PM. Similar to the effects associated with the Information Transfer PRO–PM finalized for the Hospital OQR Program in the CY 2025 OPPS/ASC final rule with comment period (89 FR 94562), for ASCs that are not currently collecting these data and elect to begin doing so as a result of this measure there would be some costs associated with changes in workflow and information systems to collect the data. The extent of these costs is difficult to quantify as ASCs may utilize different modes of data collection (collected by facilities or authorized third-party vendors post- discharge through a web-based survey instrument, distributed electronically) and have differing response rates influencing data volume. While we assume the majority of ASCs would report data for this measure directly a web-based survey instrument, distributed electronically) and have differing response rates influencing data volume. While we assume the majority of ASCs would report data for this measure directly to CMS, we assume some ASCs may elect to submit measure data via a third-party survey vendor, for which there are associated costs. Under OMB control number 0938–1240 for the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey (expiration date November 30, 2026), an estimate of approximately $4,000 per hospital is used to account for these costs. Communication interventions have been associated with increased adherence to treatment regimen and improved patient satisfaction, which are positively related to better health outcomes, such as reduced hospital readmission, mortality, morbidity, or improved quality of life, as well as potentially reducing complaints and malpractice claims.348 Additional research indicates enhanced readability of discharge instructions is associated with a decrease in the proportion of patients calling after hospital discharge, a decrease in the proportion of hospital readmissions per 100 patients 348 Bec y of discharge instructions is associated with a decrease in the proportion of patients calling after hospital discharge, a decrease in the proportion of hospital readmissions per 100 patients 348 Becker C, Zumbrunn S, Beck K, et al. (2021). Interventions to Improve Communication at Hospital Discharge and Rates of Readmission: A Systematic Review and Meta-analysis. JAMA Netw Open. 4(8):e2119346. doi:10.1001/ jamanetworkopen.2021.19346. VerDate Sep 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00378 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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. 135 / Thursday, July 17, 2025 / Proposed Rules 33853 discharged, and a decrease in the proportion of patients calling and readmissions for poor pain control.349 Therefore, while we are unable to quantify the benefits associated with the measure, we believe the potential improvements in post-operative recovery, patient satisfaction, and quality of life outweigh the estimated burden for patients of $10,389 per ASC. Regarding the remaining proposals, we do not believe these proposals would result in any additional economic impact beyond ality of life outweigh the estimated burden for patients of $10,389 per ASC. Regarding the remaining proposals, we do not believe these proposals would result in any additional economic impact beyond those discussed in section ‘‘XII.C. Collection of Information’’ of this proposed rule. 6. Effects of Requirements for the Overall Hospital Quality Star Ratings a. Background In section XVIII. Overall Hospital Quality Star Rating Modification to Emphasize the Safety of Care Measure Group of this proposed rule, we discussed our proposal as it relates to the Overall Hospital Quality Star Rating methodology. The Overall Hospital Quality Star Rating uses measures that are publicly reported on the provider comparison tool on Medicare.gov (https://www.medicare.gov/care- compare/) under the public reporting authority of each individual hospital program furnishing measure data. The burden associated with measures included in the Overall Hospital Quality Star Rating, including forms used to request withholding of publicly reported measure data and the Overall Hospital Quality Star Rating (for CAHs), is already captured in respective hospital programs’ burden estimates and represents no increased withholding of publicly reported measure data and the Overall Hospital Quality Star Rating (for CAHs), is already captured in respective hospital programs’ burden estimates and represents no increased information collection burden to hospitals. b. Impact of CY 2026 OPPS/ASC Proposed Rule Policies In this CY 2026 OPPS/ASC proposed rule, we are using the most recent data from the Bureau of Labor Statistics, which reflects a median hourly wage of $24.16 per hour for a Medical Records and Health Information Technician professional.350 We calculate the cost of overhead, including fringe benefits, at 100 percent of the hourly wage estimate, consistent with the previous year. This is necessarily a rough adjustment, both because fringe benefits and overhead costs vary significantly from employer- to-employer and because methods of estimating these costs vary widely from study-to-study. Therefore, we believe that doubling the hourly wage rate ($24.16 × 2 = $48.32) to estimate total cost is a reasonably accurate estimation method. Accordingly, we calculate the cost burden to hospitals using a wage plus benefits estimate of $48.32 per hour. We estimate that the non- information collection bur asonably accurate estimation method. Accordingly, we calculate the cost burden to hospitals using a wage plus benefits estimate of $48.32 per hour. We estimate that the non- information collection burden associated with all non-Veterans Health Administration (VHA) hospitals reviewing their Overall Hospital Quality Star Rating preview report prior to public reporting to be 2 hours per hospital, which includes time to review the report and ask any questions about the calculation necessary to increase comprehension. Estimating that approximately 4,600 hospitals would receive an Overall Hospital Quality Star Rating hospital specific report (HSR), regardless of if they meet the reporting thresholds to be assigned a star rating, we estimate the overall non- information collection burden to be $444,544 annually ($48.32 × 2 hours per preview report × once per year × 4,600 hospitals). For CAHs specifically, which are included in the estimate above, we estimate that 1,300 CAHs would be eligible for an Overall Hospital Quality Star Rating, which represents a burden of $125,632 annually (1,300 CAHs × 2 hours per preview report × once per year × $48.32). Within this rule, for CY 2026 Overall Ho for an Overall Hospital Quality Star Rating, which represents a burden of $125,632 annually (1,300 CAHs × 2 hours per preview report × once per year × $48.32). Within this rule, for CY 2026 Overall Hospital Quality Star Rating and subsequent years, we propose to make the following two-stage methodological updates to emphasize the importance of the Safety of Care measure group to the Overall Hospital Quality Star Rating methodology: (1) implement a 4-star cap 349 Choudhry AJ, Younis M, Ray-Zack MD, et al. (2019). Enhanced readability of discharge summaries decreases provider telephone calls and patient readmissions in the posthospital setting. Surgery. 165(4):789–794. https://doi.org/10.1016/ j.surg.2018.10.014. 350 Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Medical Records Specialists, at https://www.bls.gov/ooh/ healthcare/medical-records-and-health- information-technicians.htm. for poor performance in the Safety of Care measure group (lowest performing quartile) for the 2026 Star Rating, and (2) implement a blanket 1-star reduction for poor performance in the Safety of Care measure group (lowest performing quartile) for the 2027 Star Rati performing quartile) for the 2026 Star Rating, and (2) implement a blanket 1-star reduction for poor performance in the Safety of Care measure group (lowest performing quartile) for the 2027 Star Rating and thereafter. To simulate the impact of the proposed Overall Hospital Quality Star Rating methodology, we used the July 2024 refresh of the Overall Hospital Quality Star Rating (the most recent publicly released results as of the writing of this proposal) to describe the overall distribution and reclassification of the Overall Hospital Quality Star Rating across different types of hospitals. The proposed update to the Overall Hospital Quality Star Rating methodology in CY 2026 that will limit hospitals in the lowest quartile of Safety of Care (based on at least three measure scores) to a maximum of 4 out of 5 stars (Stage 1 methodological change) would have resulted in 14 (0.30 percent) hospitals receiving a lower Overall Hospital Quality Star Rating in the July 2024 simulation. While the proposed update to the Overall Hospital Quality Star Rating methodology beginning in CY 2027 that will reduce the Overall Hospital Quality Star Rating of any hospital in the lowest quartile of Sa the proposed update to the Overall Hospital Quality Star Rating methodology beginning in CY 2027 that will reduce the Overall Hospital Quality Star Rating of any hospital in the lowest quartile of Safety of Care (based on at least three measure scores) by 1 star, to a minimum 1-star rating (Stage 2 methodological change) would have resulted in 459 (9.90 percent) hospitals receiving a lower Overall Hospital Quality Star Rating. Utilizing the Stage 1 methodology update, fewer hospitals would have received a different Overall Hospital Quality Star Rating and changes in the Overall Hospital Quality Star Rating are less easily attributed to specific hospital characteristics, as very few hospitals of any type would be affected. In contrast, the Stage 2 methodological update resulted in teaching hospitals, non- safety-net hospitals, VHA hospitals, non-CAHs, large hospitals (100+ beds), and non-specialty hospitals being more likely to receive a lower Overall Hospital Quality Star Rating in the July 2024 simulation. (Table 118). BILLING CODE 4120–01–P 2 S L A S O P O R P 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 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 0037 e July 2024 simulation. (Table 118). BILLING CODE 4120–01–P 2 S L A S O P O R P 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 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00379 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 33854 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules 2 S L A S O P O R P 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 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00380 Fmt 4701 Sfmt 4725 E:\FR\FM\17JYP2.SGM 17JYP2 / > H P G 2014 22:23 Jul 16, 2025 Jkt 265001 PO 00000 Frm 00381 Fmt 4701 Sfmt 4702 E:\FR\FM\17JYP2.SGM 17JYP2 2 S L A S O P O R P 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 33856 Federal Register / Vol. 90, No. 135 / Thursday, July 17, 2025 / Proposed Rules the annual burden of the HPT regulations would be 54 hours per hospital with a cost of $4,560.52 per hospital, resulting in a total national annual burden of 383,292 hours and $32,370,571 (88 FR 82171). As described in section ‘‘XXII. Collection of Information’’ of this proposed rule, we still believe these hourly estimates are accurate estimates of the ongoing annual burden for hospitals to update their scribed in section ‘‘XXII. Collection of Information’’ of this proposed rule, we still believe these hourly estimates are accurate estimates of the ongoing annual burden for hospitals to update their standard charge information in the CMS standard template and conform to the data dictionary. For this proposed rule, we updated the number of hospitals estimated to be subject to the HPT requirements using the same methodology as we did in the CY 2024 OPPS/ASC final rule with comment period. There were 8,340 hospitals most recently identified in the HIFLD hospital dataset. We subtracted 374 hospitals HIFLD identified as ‘‘closed’’ as well as hospitals that are deemed under the regulation to have met requirements which included 352 Federally owned non-military and military hospitals, and 198 state, local, and district run forensic hospitals. We therefore estimate that, for this proposed rule, 7,416 hospitals would meet the HPT regulation’s definition of ‘‘hospital’’ at 45 CFR 180.20, increasing the national annual burden to 400,464 hours and $36,519,350.40. We estimate that hospitals will incur an additional one-time cost to update their processes and systems to (1) identify and collect