CMS Releases Fiscal Year 2027 IPPS and LTCH Final Rule

The Centers for Medicare & Medicaid Services (CMS) on July 31, 2026, released the fiscal year (FY) 2027 final rule for the Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) Prospective Payment System. The final rule updates Medicare payment rates and policies for inpatient hospital services, revises graduate medical education (GME) policies, updates quality program requirements and finalizes a broad range of additional policy changes affecting hospital reimbursement, value-based care models and program integrity.

The rule was published in the Federal Register on August 4, 2026, and regulations are effective October 1, 2026. CMS also issued a fact sheet and press release accompanying the rule.

Key Takeaways

• CMS finalized a 2.3 percent payment increase for hospitals that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful users of electronic health records, reflecting a projected 3.2 percent market basket update reduced by a 0.9 percentage point productivity adjustment. CMS estimates that the finalized IPPS payment and policy changes will increase payments to hospitals by approximately $2.1 billion in FY 2027. CMS separately estimates additional payments for cases involving new medical technologies, bringing the combined estimated increase to approximately $2.9 billion.
• CMS finalized nationwide expansion of the Comprehensive Care for Joint Replacement (CJR-X) Model but delayed mandatory participation until January 1, 2028, rather than October 1, 2027, in response to stakeholder concerns regarding implementation readiness. The model will become the first nationwide mandatory episode-based payment model for nearly all IPPS hospitals.
• CMS finalized several important refinements to the Transforming Episode Accountability Model (TEAM), including expanding eligible spinal fusion episodes, aligning attribution and quality measurement methodologies with other CMS programs, updating target price methodologies and modifying normalization factors to better reflect current spending patterns.
• CMS finalized several new Medicare Severity Diagnosis Related Groups (MS-DRGs), including:
  • extensive and complex spinal fusion (MS-DRGs 523-525)
  • hip and knee procedures involving periprosthetic joint infection (MS-DRGs 403-404)
  • cardiac pacemaker revision and replacement (MS-DRGs 210-211)
• CMS finalized significant changes to the New Technology Add-on Payment (NTAP) program. Beginning with FY 2028 applications, CMS will eliminate the alternative NTAP pathway available for U.S. Food and Drug Administration Breakthrough Devices and Qualified Infectious Disease Products (QIDPs), requiring all applicants to satisfy the traditional statutory eligibility criteria. CMS approved 19 new technologies for FY 2027 – three under the traditional pathway and 16 under the alternative pathway – and continued NTAP eligibility for 41 existing technologies.
• CMS substantially modified and delayed its proposed non-renal organ acquisition reconciliation policies. Rather than imposing standardized charges based solely on historical costs, CMS will allow Independent Organ Procurement Organizations (IOPOs) and Histocompatibility Laboratories (HCLs) to submit documented prospective estimates for Medicare contractor review, with implementation delayed until cost-reporting periods beginning on or after October 1, 2028.

Key Aspects of the FY 27 IPPS Final Rule

IPPS Payment Update

CMS finalized a 2.3 percent increase in operating payment rates for acute care hospitals that successfully report quality data and are meaningful users of electronic health records (EHRs). This update reflects a projected 3.2 percent market basket increase, reduced by a 0.9 percentage point productivity adjustment, as required under the Affordable Care Act. The productivity adjustment increased from the proposed 0.8 percentage point reduction based primarily on updated Bureau of Labor Statistics historical productivity data. Hospitals that fail to submit quality data but are meaningful EHR users will receive a 1.5 percent update; hospitals that submit quality data but are not meaningful EHR users will receive a minus-0.1 percent update, and hospitals that meet neither requirement will receive a minus-0.9 percent update.

CMS estimates these changes will result in an overall increase of approximately $2.9 billion in federal fiscal year (FFY) 2027 payments to acute care hospitals (with roughly $2.1 billion attributable to operating payments).

LTCH Payment

For FY 2027, CMS finalizes a 2.3 percent update to the LTCH PPS standard Federal payment rate based on a 3.2 percent market basket increase reduced by a 0.9 percentage point productivity adjustment, consistent with Affordable Care Act requirements. LTCHs that fail to submit required data under the LTCH Quality Reporting Program (QRP) will receive a reduced update of 0.3 percent (a two percentage point penalty). CMS continues to use the 2022-based LTCH market basket, adopted in FY 2025, to reflect LTCH-specific cost structures.

CMS also finalizes continued application of applicable budget-neutrality adjustments, including the area wage-level budget-neutrality factor. The finalized rates apply to LTCH PPS payments for FY 2027.

Disproportionate Share Hospital and Uncompensated Care Payments

Hospitals that qualify for Medicare Disproportionate Share Hospital (DSH) payments receive two separate payments:

• a DSH payment equal to 25 percent of the amount they would otherwise receive under Section 1886(d)(5)(F) of the Social Security Act
• an uncompensated care (UC) payment, calculated using three statutory factors:
  • Factor 1 – 75 percent of the amount that would otherwise be paid under Section 1886(d)(5)(F) of the Act
  • Factor 2 – one minus the percent change in the percentage of individuals who are uninsured
  • Factor 3 – the hospital's share of uncompensated care relative to all DSH hospitals

CMS finalizes updated calculations for Factors 1 and 2 and maintains its established methodology for Factor 3, using more recent data than was available for the proposed rule.

• Factor 1 – finalized at $11.82 billion for FY 2027
• Factor 2 – finalized at 67.14 percent for FY 2027
• Factor 3 – CMS finalizes the use of the three most recent years of audited cost report data (FY 2021, FY 2022 and FY 2023) to calculate each hospital's uncompensated care share while retaining the same methodology used for FY 2025 and FY 2026

Low-Volume Hospital and Medicate-Dependent Hospital (MDH) Program Changes

For the first three months of FFY 2027, hospitals will continue to qualify for the enhanced low-volume hospital payment adjustment if they have fewer than 3,800 discharges and are located more than 15 road miles from another subsection (d) hospital. Beginning January 1, 2027, however, the temporary statutory expansion expires and the more restrictive permanent eligibility criteria will take effect, limiting eligibility to hospitals with fewer than 200 discharges that are located more than 25 road miles from another subsection (d) hospital.

As a result of this change, CMS was required to establish an empirically justified payment adjustment for hospitals that continue to qualify under the permanent criteria. In the final rule, CMS finalized a 25 percent low-volume hospital payment adjustment for the January 1 through September 30, 2027 period.

CMS also confirmed that the MDH Program will expire after December 31, 2026, consistent with the Consolidated Appropriations Act of 2026. Absent further congressional action, hospitals that previously qualified for MDH status will be paid solely under the federal inpatient prospective payment system rate beginning January 1, 2027.

Wage Index Policy Changes

The wage index reflects the relative wage levels of hospitals within a geographic area compared to the national average. CMS determines each hospital's labor market area using Core-Based Statistical Areas (CBSAs) established by the Office of Management and Budget (OMB). For FY 2027, CMS finalizes its annual wage index updates using wage data from the FY 2023 cost reporting period and continues several budget-neutral wage index policies.

Key finalized wage index policies include:

• Discontinuation of the Low-Wage Index Policy. Under the FY 2020 IPPS/LTCH PPS Final Rule, CMS established a temporary policy to address wage index disparities affecting low-wage hospitals, many of which are located in rural areas, which was found unlawful by the U.S. District Court for the District of Columbia Circuit. Consistent with its FY 2026 approach, CMS finalizes a narrow, budget-neutral transitional exception for FY 2027 for hospitals that benefited from the FY 2024 low-wage index policy and are significantly affected by its discontinuation. Eligible hospitals will receive a transitional payment adjustment if their FY 2027 wage index falls below 85.73 percent of their FY 2024 wage index after application of the 5 percent cap policy. CMS also finalizes a comparable budget-neutral adjustment under the capital IPPS to mitigate the impact of the policy change. The associated budget neutrality adjustment is 0.999777.
• Permanent 5 Percent Cap Policy. Finalized in the FY 2023 IPPS/LTCH PPS Final Rule, this permanent policy limits annual decreases in a hospital's wage index to no more than 5 percent from the prior fiscal year. For FY 2027, the associated budget neutrality adjustment is 0.999379.
• Rural Floor. Established under the Balanced Budget Act of 1997, the rural floor ensures that an urban hospital's wage index cannot be lower than the rural wage index for its state. For FY 2027, the associated budget neutrality adjustment is 0.985465.
• Medicare Geographic Classification Review Board reclassifications. Established under the Omnibus Budget Reconciliation Act of 1989, this policy allows hospitals to apply for reclassification to a higher wage index area. For FY 2027, the associated budget neutrality adjustment is 0.949363.

Revision of Provider-Based Location Criteria Regulations Applicable to Off-Campus Facilities or Organizations

Current law identifies the types of facilities that qualify as "providers of services" but does not explicitly define the term "provider-based." In practice, CMS distinguishes between freestanding facilities and those operating as part of a "main provider," where multiple locations are treated as a single entity for Medicare payment and coverage purposes. CMS has established criteria at 42 C.F.R. § 413.65 to determine eligibility for provider-based status.

To qualify, a facility must satisfy the "same patient population" requirement by demonstrating that either 1) at least 75 percent of its patients reside in the same ZIP codes as at least 75 percent of the main provider's patients or 2) at least 75 percent of its patients who require services furnished by the main provider receive those services from that provider. These criteria must be met over the preceding 12 months and on an ongoing basis.

Citing concerns that certain inpatient facilities may receive unintended payment advantages, for FY 2027, CMS finalizes its proposal to limit the second pathway to outpatient facilities and organizations. As a result, off-campus inpatient facilities may no longer rely on the referral-based test to satisfy the "same patient population" requirement for provider-based status and instead must meet the geographic ZIP code test. CMS states the change is intended to preserve the original purpose of the referral-based exception while reducing the potential for unintended payment advantages for certain inpatient facilities.

GME and Program Oversight

Hospitals may receive direct graduate medical education (GME) and indirect medical education (IME) payments for residents training in "approved medical residency programs."

CMS finalized, as proposed, a policy to establish additional nondiscrimination requirements for approved medical residency programs, nursing and allied health education (NAHE) programs, and NAHE accrediting organizations. Effective October 1, 2026, these programs and organizations may not discriminate, or promote or encourage discrimination, based on race, color, national origin, sex, age, disability or religion.

CMS consolidates the applicable GME- and NAHE-related nondiscrimination requirements under a new 42 C.F.R. 413.84. CMS directs programs to the U.S. Attorney General's guidance regarding potentially unlawful policies and proxies and advises programs to review their selection criteria for compliance.

Criteria to Determine a "New" Medical Residency Programs

CMS also revises the criteria for determining whether a residency program qualifies as "new" for purposes of establishing additional direct GME and IME full-time equivalent (FTE) resident caps. Starting October 1, 2026, for medical residency training programs starting to train residents or programs still in the five-year cap building period, "in addition to receiving initial accreditation by the appropriate accrediting body, for a residency program to be considered new, at least 90 percent of the individual resident trainees (not FTEs) must not have previous experience training in another program in the same specialty." In addition, CMS will "no longer consider the previous employment of the faculty or program director in determining whether a residency program is genuinely new for cap-building purposes."

Allowable NAHE Direct and Indirect Costs

For cost reporting periods beginning on or after October 1, 2026, hospitals must deduct tuition and other program revenue from NAHE direct costs before allocating overhead. Hospitals must then use the Worksheet B-1 reconciliation column to restore the deducted revenue to the accumulated cost statistic solely for purposes of allocating indirect costs.

CMS further clarifies that allowable NAHE overhead is limited to costs incurred by the provider that are directly attributable to, and proportionately benefit, the approved educational activity. While CMS did not finalize its proposal to require mandatory componentization of general service cost centers, hospitals must continue to use appropriate cost allocation methodologies to ensure unrelated overhead is not assigned to NAHE cost centers. CMS also clarifies that personnel costs must be appropriately apportioned between educational and patient care activities when employees perform both functions.

MS-DRG Updates

CMS finalized several changes to the MS-DRG classification system for FY 2027, including the creation of new MS-DRGs for extensive and complex spinal fusion procedures (MS-DRGs 523-525), hip and knee procedures involving periprosthetic joint infection (MS-DRGs 403-404), and cardiac pacemaker revision and replacement procedures (MS-DRGs 210-211). CMS also finalized the deletion and consolidation of several existing MS-DRGs to better reflect current clinical practice and resource utilization.

Housing Instability Z-Code Severity Levels

CMS finalized its proposal to reclassify 10 ICD-10-CM diagnosis codes describing homelessness, inadequate housing, and housing instability from Complication or Comorbidity (CC) to NonCC, effective FY 2027. CMS explained that updated claims data no longer supported continued CC designation for these codes under its long-standing severity-level methodology and concluded that the revised classification more accurately reflects the relative resource use associated with these diagnoses.

NTAP

The NTAP program was established to ensure that the MS-DRG payment system does not create a disincentive for hospitals to provide new, costly technologies and services to Medicare patients.

Under the traditional NTAP pathway, CMS finalizes its proposal to continue NTAPs for 41 technologies. CMS' long-standing practice was to treat a technology as "new" for purposes of NTAP eligibility for two to three years after data become available reflecting the inpatient hospital code assigned to the new technology. For technologies first approved before FY 2025, CMS uses the midpoint of the upcoming fiscal year (April 1) to determine whether the technology's newness period has expired. For technologies first approved in FY 2025 or later, CMS extends NTAP eligibility for an additional year when the three-year anniversary of the product's U.S. market entry falls on or after October 1 of that fiscal year

CMS is discontinuing NTAPs for 13 technologies that no longer qualify as "new" for FY 2027 because their three-year anniversary of market entry occurs before April 1, 2027 (or, for one technology first approved in FY 2026, before October 1, 2026).

CMS is approving 19 new NTAP applications for FY 2027. Of those, CMS is approving three technologies under the traditional pathway.

CMS also finalizes that any documented delay in commercial availability may extend a technology's newness period only until the NTAP becomes effective. If the technology is still unavailable at that time, the newness period begins on September 30 before the NTAP start date.

Applicants Considered for Alternative Pathways for FY 2027 and Removal of Alternative Pathways Beginning FY 2028

CMS considered and approved 16 applications under the alternative pathways, all of which received the Breakthrough Device designation. CMS did not consider any applications with QIDP designation or the Limited Population Pathway for Antibacterial and Antifungal Drugs pathway.

Beginning with FY 2028 applications, CMS eliminates the NTAP alternative pathways and generally requires all applicants to meet the standard eligibility criteria, including substantial clinical improvement, unless grandfathered. Under this change, all future NTAP applicants must demonstrate that the technology meets all standard eligibility requirements, including substantial clinical improvement, unless eligible for a limited grandfathering transition. Technologies already approved under the alternative pathway, including the 16 technologies approved in this final rule, remain eligible for continued NTAP under the alternative pathway for as long as they otherwise satisfy continuation requirements.

Mandatory Expansion of the CJR-X Model

The original Comprehensive Care for Joint Replacement (CJR) Model operated from April 2016 through December 2024 as a mandatory, episode-based bundled payment model for hip and knee replacements in selected geographic areas. Participating hospitals were accountable for the quality and cost of care during the inpatient stay and for 90 days following discharge.

CMS finalized nationwide expansion of the model through the CJR-X Model but delayed mandatory participation until January 1, 2028, rather than the proposed October 1, 2027, in response to stakeholder concerns regarding implementation readiness. The model will become the first nationwide mandatory episode-based payment model for most acute care hospitals paid under the IPPS.

CJR-X will apply to lower-extremity joint replacement episodes, including qualifying hip, knee and ankle replacement procedures performed in both inpatient and hospital outpatient settings. Episodes will include related Medicare Parts A and B services furnished during the anchor hospitalization or outpatient procedure and throughout the 90-day post-discharge period. CMS will compare actual episode spending against hospital-specific target prices, with participating hospitals eligible to receive reconciliation payments or required to repay Medicare based on their financial and quality performance. CMS estimates that CJR-X will save the Medicare program approximately $736 million over the next five years.

TEAM

TEAM is a mandatory, five-year, episode-based payment model for selected hospitals that runs from January 1, 2026, through December 31, 2030. The model is intended to improve care coordination, quality and cost efficiency across five surgical episodes: Coronary Artery Bypass Graft (CABG), Lower Extremity Joint Replacement (LEJR), Major Bowel Procedure, Surgical Hip/Femur Fracture Treatment (SHFFT) and Spinal Fusion.

CMS finalized several refinements to TEAM for FY 2027, including:

• Spinal Fusion Episode Category. Adds three MS-DRGs to better reflect patient acuity and resource use for certain spinal fusion procedures.
• Episode Attribution. Excludes TEAM participants from the CJR-X Model to avoid overlapping mandatory episode payment models and preserve distinct episode attribution methodologies.
• Measurement Performance Periods. Aligns two hospital-harm quality measures with the Hospital IQR Program's one-year reporting period and the International Society for Traditional, Complementary & Integrative Medicine Research measure with its existing two-year rolling performance period.
• Composite Quality Score (CQS) Baseline Methodology. Adopts a concurrent CQS baseline methodology beginning in Performance Year 1.
• Ambulatory Payment Classifications (APC) and MS-DRG Update Factors. Incorporates annual APC and MS-DRG update factors into TEAM's target price methodology to better reflect current Medicare payment rates and spending patterns.
• Prospective Normalization Factors. Beginning in Performance Year 2, CMS will calculate prospective normalization factors by episode type and region using baseline episode data and apply risk-adjustment coefficients across the baseline period to improve the accuracy of target prices.

Collectively, according to CMS, these refinements are intended to improve the accuracy of target prices, better align TEAM with other CMS quality and payment programs and ensure episode benchmarks more closely reflect current clinical practice and Medicare spending. CMS estimates TEAM will save the Medicare program approximately $368 million over its five performance years.

Through RFIs, CMS sought feedback on potential TEAM expansions, including model design, financial accountability, episode construction, quality measurement and voluntary participation by physician-owned hospitals. CMS intends to propose allowing physician-owned hospitals outside mandatory CBSAs to participate in future rulemaking.

Organ Acquisition and Reasonable Cost Policies

CMS finalized a significant package of reforms to Medicare reasonable cost reimbursement policies affecting IOPOs and HCLs reimbursed on a reasonable cost basis. Though the agency retained the approach of aligning reimbursement more closely with Medicare reasonable cost principles, it made several notable modifications in response to stakeholder feedback.

Most significantly, CMS delayed implementation of the new non-renal organ acquisition reconciliation methodology by an additional year, making the policies effective for cost reporting periods beginning on or after October 1, 2028. Under the final rule, rather than establishing standardized non-renal Standard Acquisition Charges and HCL testing rates based solely on historical costs, IOPOs and HCLs will submit reasonable, documented estimates of their anticipated organ-specific acquisition charges and testing rates to their Medicare contractors for review and approval.

The final rule also provides greater flexibility for addressing overpayments and underpayments during the cost reporting year by allowing Medicare contractors – or IOPOs and HCLs – to initiate interim rate adjustments when appropriate. If approved, contractors may issue lump-sum payments to reconcile significant differences between interim reimbursement and allowable costs before annual cost report settlement.

In addition, CMS finalized its proposal to reconcile non-renal organ acquisition costs using an organ-specific Medicare ratio modeled after the existing kidney acquisition methodology and codified the CMS Administrator's discretionary authority to review reimbursement appeals involving IOPOs and HCLs.

Beyond organ acquisition, the final rule clarifies the prudent buyer principle, allowable outreach and public education activities, professional education costs, travel and meal expenses, and the treatment of nonallowable costs such as entertainment and alcohol. CMS also codified existing overhead cost allocation requirements.

Expanding the Birthing-Friendly Hospital Designation: CMS issued an RFI seeking stakeholder feedback on potential expansion of the Birthing-Friendly Hospital Designation, which currently recognizes hospitals that demonstrate a commitment to improving maternal health through participation in quality improvement initiatives. CMS stated that it intends to evolve the designation beyond its current structural measure by incorporating hospital performance on the Cesarean Birth and Severe Obstetric Complications electronic clinical quality measures (eCQMs). The agency also sought comment on a proposed composite scoring methodology, peer grouping based on delivery volume, differential weighting of maternal outcome measures and replacing the current binary designation with a tiered recognition framework. CMS noted that these changes are intended to provide a more meaningful assessment of maternal care quality, improve transparency for patients and better recognize high-performing hospitals while accounting for differences in hospital size and obstetric volume. CMS did not finalize any changes and indicated that stakeholder feedback would inform future rulemaking.

Adoption of Health Information Technology (IT) Standards

The Office of the National Coordinator for Health Information Technology (ONC) partnered with CMS to finalize a series of health IT standards and specifications that were originally included in the 2026 CMS Interoperability Standards and Prior Authorization for Drugs proposed rule (CMS-0062-P). According to ONC, the standards support the interoperability of FHIR Application Programming Interfaces for electronic prior authorization transactions, exchange of administrative and clinical data between payers and providers, sharing payer drug formularies and sharing information about payer provider directories. Furthermore, ONC finalized replacing previously adopted versions of the updated standards on the effective date of the FY 2027 IPPS final rule, which is Oct. 1, 2026.

Quality Program Updates

CMS finalized updates to several hospital quality programs, including the Hospital IQR Program, Hospital Value-Based Purchasing (VBP) Program, Medicare Promoting Interoperability Program, PPS-Exempt Cancer Hospital (PCH) Quality Reporting Program and Hospital Readmissions Reduction Program (HRRP). For hospitals participating in the Hospital IQR Program, CMS finalized three new measures: 1) the Excess Days in Acute Care After Hospitalization for Diabetes measure beginning with the FY 2029 payment determination, 2) the Advance Care Planning eCQM beginning with the FY 2030 payment determination and 3) the Hospital Harm – Postoperative Venous Thromboembolism eCQM beginning with the FY 2030 payment determination. Hospitals that fail to meet IQR reporting requirements remain subject to a two percentage point reduction to their annual payment update.

CMS also finalized five modified mortality measures under the Hospital IQR Program beginning with the FY 2028 payment determination, with corresponding modifications to the Hospital VBP Program beginning with the FY 2032 program year. These measures address 30-day, all-cause, risk-standardized mortality following hospitalization for acute myocardial infarction, heart failure, pneumonia, chronic obstructive pulmonary disease and CABG surgery. The modified measures expand the applicable patient cohort to include Medicare Advantage beneficiaries and shorten the performance period from three years to two.

For the Medicare Promoting Interoperability Program, CMS finalized revisions to the definition of certified electronic health record technology to align with updates to the ONC Health IT Certification Program, including the removal of references to four certification criteria effective January 1, 2027. CMS also finalized several additional changes, including removal of certain ONC attestations beginning with the CY 2026 EHR reporting period, removal of the two Electronic Referral Loops measures beginning in CY 2029, modification of the Electronic Prior Authorization measure to make it an optional bonus measure for CY 2027 and required beginning in CY 2028, adoption of the Unique Device Identifiers for Implantable Medical Devices measure beginning in CY 2027 and changes to several eCQMs to align with the Hospital IQR Program.

For the PCH Quality Reporting Program, CMS finalized adoption of the Advance Care Planning and Malnutrition Care Score eCQMs beginning with the FY 2030 program year, as well as removal of the COVID-19 Vaccination Coverage Among Healthcare Personnel measure beginning with FY 2028. CMS also finalized associated eCQM reporting and submission requirements for PCHs.

Finally, for the HRRP, CMS finalized adoption of the Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate Following Sepsis Hospitalization measure. CMS will provide early performance information beginning with the FY 2028 program year, with the measure affecting payment beginning with the FY 2030 program year.

LTCH Quality Reporting Program

CMS finalized several changes to the LTCH QRP. LTCHs that fail to submit required quality data will continue to receive a two percentage point reduction to their annual payment update, resulting in an update of 0.3 percent for FFY 2027.

Beginning with the FFY 2028 LTCH QRP, CMS will remove both the COVID-19 Vaccination Coverage Among Healthcare Personnel measure and COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date measure. CMS also finalized changes intended to reduce the lag between data collection and public reporting. Beginning with the FFY 2029 LTCH QRP, LTCHs will be required to submit LTCH Continuity Assessment Record and Evaluation assessment data and Centers for Disease Control and Prevention National Healthcare Safety Network data by the 15th day of the second month following the end of each calendar quarter, replacing the current 4.5-month submission window.

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