Becker’s Hospital Review has published an article detailing the myriad policy changes to be implemented in 2026 that will impact hospitals and other medical providers. Among the most significant policy changes are:
- The expiration of the enhanced subsidies under the Affordable Care Act that allowed households earning more than 400% of the federal poverty level to qualify for subsidies and capping benchmark plan premiums at 8.5% of income. As a result, approximately 4.8 million people are expected to lose coverage, meaning more uninsured patients will be seeking treatment. The consequences of the expiration of the subsidies could result in a decrease in total economic output of $57 billion and a decline of 130,000 healthcare jobs.
- The end of the 5% increase in the Federal Medical Assistance Percentage (FMAP) paid to reimburse states for the federal share of Medicaid expenditures, which was intended to incentivize states to expand Medicaid coverage under the Affordable Care Act.
- An increase of 2.6% to hospitals meeting quality reporting requirements for outpatient procedures under Medicare’s Hospital Outpatient Prospective Payment System.
- The phasing out of Medicare’s inpatient only list over three years, while simultaneously expanding the list of procedures covered at ambulatory surgical centers. These changes are expected to result in a significant increase in surgeries performed in outpatient settings.
- A 2.5% increase in the Medicare Physician Fee Schedule conversion factor, bringing the conversion factor to $33.57 for physicians participating in advanced alternative payment models and $33.40 for non-participating providers.
- A reduction in the timeframes for Medicare Advantage plans to respond to prior authorization requests to within 72 hours for expedited requests and within seven calendar days for standard requests. Medicare Advantage plans will also be required to provide specific reasons for denying prior authorization requests and to publicly report prior authorization metrics.
- An expanded definition of “organizational determination” to specifically include Medicare Advantage plans decisions made during a member’s care, rather than just before or after. This rule change is intended to ensure that adverse decisions affecting ongoing care are subject to the Medicare appeal process.
- A reduction in prices for the ten drugs included in the first round of Medicare negotiated drug prices.
Many of these changes will make it more important than ever that healthcare providers track and appeal improper denials and downcodes by health insurance companies.
The attorneys at Whatley Kallas, LLP will continue to analyze how these policy changes impact medical providers throughout the year. The Becker’s Hospital Review article is linked here.