CMS Administrator Mehmet Oz, MD, has moved quickly to advance President Donald Trump’s “Make America Healthy Again” agenda in 2025. The push comes after President Trump this summer signed the One Big Beautiful Bill Act, a sweeping package of reforms targeting Medicaid, Medicare and the ACA marketplace.
From plans to close a Medicaid funding “loophole” to probing hospitals over gender care for minors and clamping down on states using federal Medicaid funds to treat undocumented migrants, here are 20 key actions CMS has taken since Dr. Oz was confirmed as administrator:
Editor’s note: This is an updated version of an article originally printed in July 2025. This is not an exhaustive list.
1. CMS plans to add prior authorization for some traditional fee-for-service Medicare services as part of its newly launched Wasteful and Inappropriate Service Reduction model. The agency said it will work with companies specializing in AI and machine learning to test ways to improve and expedite prior authorization for services including epidural steroid injections, cervical fusion, arthroscopy for knee osteoarthritis and skin and tissue substitutes. The news came one week after the wider insurance industry announced reforms that aim to reduce and streamline prior authorization processes across commercial, Medicare Advantage and managed Medicaid plans.
2. CMS finalized a rule shortening the open enrollment period on the ACA exchange and tightening eligibility verification. The changes will lower individual premiums by about 5% on average and save about $12 billion in 2026 by reducing improper enrollments, according to CMS. The agency estimated as many as 5 million people may have improperly enrolled in ACA plans “enabled by weakened verification process and expanded premium subsidies.”
“CMS is restoring integrity to ACA Exchanges by cracking down on fraud, protecting American taxpayer dollars, and ensuring coverage is there for those who truly need it,” Dr. Oz said in a news release. “This is about putting patients first, stopping exploitation of the system, and realigning the program with the values of personal responsibility and fiscal discipline.”
3. CMS aims to close what it describes as a Medicaid tax “loophole” that some states have used to increase federal payments while limiting their own financial contributions. CMS said the proposal is intended to ensure federal Medicaid dollars support “vulnerable populations” rather than other state programs, including coverage for undocumented immigrants. The rule would:
- Ban states from taxing Medicaid business at higher rates than non-Medicaid business
- Prevent the use of ambiguous language to obscure Medicaid-specific taxes
- Continue statistical testing while introducing additional safeguards to deter system manipulation; and
- Implement a phased transition timeline based on the duration of existing waivers.
“States are gaming the system — creating complex tax schemes that shift their responsibility to invest in Medicaid and rob federal taxpayers,” Dr. Oz said. “This proposed rule stops the shell game and ensures federal Medicaid dollars go where they’re needed most — to pay for health care for vulnerable Americans who rely on this program, not to plug state budget holes or bankroll benefits for noncitizens.”
4. The agency is ramping up oversight to prevent states from “misusing” Medicaid funds to cover care for undocumented immigrants. While federal Medicaid dollars are generally limited to emergency services for “noncitizens with unsatisfactory immigration status” who meet specific eligibility criteria, CMS argues that some states have expanded benefits beyond what is permitted — shifting additional costs to federal taxpayers.
“Medicaid is not, and cannot be, a backdoor pathway to subsidize open borders,” Dr. Oz said. “States have a duty to uphold the law and protect taxpayer funds. We are putting them on notice — CMS will not allow federal dollars to be diverted to cover those who are not lawfully eligible.”
5. CMS finalized its Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System rule for 2026, phasing out Medicare’s inpatient-only list over three years. The agency will remove 285 procedures — largely musculoskeletal — from the inpatient-only list and add 289 procedures to the ASC covered procedures list in 2026, while allowing payment in hospital outpatient departments when clinically appropriate. CMS also continued certain two-midnight policy-related medical review exemptions for procedures removed from the inpatient-only list and increased outpatient payment rates by 2.6% for hospitals that meet quality-reporting requirements.
For 2026, CMS will apply the hospital market basket update to ASC payment rates and continue studying the migration of outpatient procedures, an effort extended during the COVID-19 public health emergency. The rule also aligns payment rates for certain services delivered in hospital outpatient departments and off-campus facilities to advance site-neutral payments and reduce higher patient copays based solely on care location.
Ashley Thompson, senior vice president of public policy analysis and development for the American Hospital Association, said the policies ignore the complex needs of hospital outpatient department patients and widen financial strain. “The AHA is disappointed that CMS has finalized cuts to hospital and health system services, including those in rural and underserved communities,” Ms. Thompson said in a Nov. 21 statement. “Combined with its continued inadequate market basket updates, the agency is exacerbating the challenging financial pressures under which hospitals are operating to serve their patients and communities.”
6. CMS on July 31 finalized its fiscal year 2026 Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System rule, setting a 2.6% Medicare payment increase for acute care hospitals and a 2.7% increase for long-term care hospitals.
CMS also revised the IPPS operating and capital market baskets to a 2023 base year, set the national labor-related share at 66% and finalized plans to end the low wage index hospital policy, replacing it with a narrow, budget-neutral transitional exception for affected hospitals in 2026.
The final rule also includes updates to the Transforming Episode Accountability Model, a five-year mandatory program beginning Jan. 1, 2026, that requires selected hospitals to manage costs and quality for certain surgical episodes through 30 days post-discharge. Changes to the model include incorporating patient-reported outcomes, refining target pricing and expanding post-acute care access through a broader skilled nursing facility waiver.
7. CMS’ final rule for 2026 Medicare payments under the physician fee schedule establishes two separate conversion factors for reimbursement. The agency will apply one conversion factor for qualified practitioners participating in advanced alternative-payment models and another for non-QP clinicians. Under the final rule, the QP conversion factor will rise 3.77% to $33.57, while the non-QP conversion factor will increase 3.26% to $33.40. CMS said the updates reflect statutory increases of 0.75% for QPs and 0.25% for non-QPs, a one-year 2.5% boost required by the OBBBA, and a 0.49% adjustment tied to finalized changes in work relative value units for certain services.
8. CMS finalized multiple changes to the Medicare Shared Savings Program under the physician fee schedule rule, including limiting how long ACOs can remain in one-sided risk under the BASIC track to five performance years during an ACO’s first agreement period beginning in 2027. The change is intended to accelerate movement into two-sided risk models and strengthen accountability.
The agency also increased flexibility around the program’s 5,000-beneficiary minimum requirement starting in 2027 and removed the health equity adjustment from ACO quality scores beginning in performance year 2026, among other quality and reporting updates.
9. CMS on June 3 withdrew a 2022 guidance issued under the Biden administration that reinforced hospitals’ obligations to provide emergency abortion care under the Emergency Medical Treatment and Labor Act.. The move effectively removes federal protections for clinicians who offer such care in states where abortion is restricted or banned.
The original guidance, issued in July 2022 shortly after the Supreme Court overturned Roe V. Wade, clarified that clinicians treating pregnant patients in emergency departments — including providing abortions — were protected under EMTALA, regardless of conflicting state laws. Enacted in 1986, EMTALA requires Medicare-participating hospitals to provide appropriate emergency care to all patients.
Although the guidance has been withdrawn, CMS said it will continue to enforce EMTALA in cases where the health of a pregnant woman or her unborn child is at risk.
10. CMS proposed two new payment models to curb Medicare drug spending by tying reimbursement to international price benchmarks: the Guiding and Reducing Drug Spending model, or GUARD, for Medicare Part D and the Global Benchmarking for Part B Drugs model, or GLOBE, for Medicare Part B drugs. Under the proposals, Medicare payments for certain high-expenditure drugs would be benchmarked against prices paid in economically comparable countries, an approach CMS said is designed to lower inflated domestic costs, improve access to critical medications and reduce financial strain on beneficiaries.
11. CMS plans to open applications in 2026 for the Advancing Chronic Care with Effective, Scalable Solutions model, or ACCESS, to test whether linking recurring payments to outcomes expands the use of digital tools for chronic disease management. CMS said the model will include tracks focused on cardiometabolic risk, cardio-kidney-metabolic disease, chronic pain and behavioral health conditions.
12. CMS announced the voluntary Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth model, or BALANCE, focused on GLP-1 drugs. CMS said the model would negotiate reduced prices with manufacturers for state Medicaid programs and Medicare Part D plans and pair drug access with no-cost lifestyle support programs. CMS said weight-loss coverage would begin in May 2026 for Medicaid and January 2027 for Medicare Part D, with a bridge program enabling earlier Part D access. CMS asked interested participants to respond by Jan. 8, 2026. The initiative follows the White House’s recent agreements with Eli Lilly and Novo Nordisk to apply most-favored-nation pricing to drugs used to treat obesity, diabetes and related conditions.
13. The agency will launch its long-term enhanced accountable care organization design model, or LEAD, at the end of 2026, after the conclusion of the ACO Realizing Equity, Access, and Community Health model, or REACH. The initiative builds on CMS’ broader goal of placing all traditional Medicare beneficiaries in an accountable care relationship by 2030 and is intended to expand participation beyond the current ACO REACH program. CMS said LEAD is intended to be more inclusive of smaller, rural and independent practices and to improve risk adjustment and benchmarking for high-needs patients.
14. CMS on Dec. 15 published 24 quality and efficiency measures under consideration for adoption across Medicare programs as part of its pre-rulemaking process. The agency uses the process to gather stakeholder input before proposing measures in future rules, with public comments open through Jan. 6.
Of the 24 measures, eight are currently in use but include substantial specification changes, while two are being considered for expansion into additional Medicare programs. Most measures rely exclusively on digital data sources, aligning with CMS’ interoperability goals, and focus heavily on chronic conditions, patient safety, person-centered care and care coordination. The hospital inpatient quality reporting program and the hospital value-based purchasing program account for the largest number of measures resubmitted due to specification updates.
15. CMS is investigating an undisclosed number of hospitals that provide gender-confirming care to minors. In a May 28 letter to “select hospitals,” Dr. Oz said CMS is seeking details on informed consent practices, clinical guidelines, documentation of adverse outcomes and financial information tied to such care.
“These are irreversible, high-risk procedures being conducted on vulnerable children, often at taxpayer expense,” Dr. Oz said. “Hospitals accepting federal funds are expected to meet rigorous quality standards and uphold the highest level of stewardship when it comes to public resources — we will not turn a blind eye to procedures that lack a solid foundation of evidence and may result in lifelong harm.”
16. CMS issued updated hospital price transparency guidance requiring hospitals to publicly post actual prices — not estimates — for items and services. CMS also proposed updates to insurer and health plan transparency requirements, including reorganizing and simplifying data files, reducing reporting frequency from monthly to quarterly and strengthening consumer-facing price comparison tools. The proposal would also update disclosures under the No Surprises Act.
17. CMS on April 4 published its final rule for Medicare Advantage and Part D in 2026. While the final rule solidifies several changes — including measures to streamline prior authorization, tighten oversight of supplemental benefits and codify provisions from the Inflation Reduction Act — CMS stopped short of addressing two of the most closely watched issues: expanding coverage for GLP-1s under Medicare and Medicaid, and regulating the use of AI in prior authorization. Those decisions have been deferred to future rulemaking.
18. CMS on Nov. 25 released its proposed rule for the 2027 Medicare Advantage and Part D programs, outlining changes to how star ratings are calculated, new enrollment flexibilities and the rollback of several Biden-era health equity requirements. Under the proposal, CMS would not implement the Excellent Health Outcomes for All reward, previously known as the Health Equity Index, which was finalized under the Biden administration and scheduled to begin with the 2027 star ratings.
The agency also proposes eliminating 12 star ratings measures it says are largely administrative or show little performance variation among plans, a shift that would increase the relative weight of Healthcare Effectiveness Data and Information Set (HEDIS) measures and Consumer Assessment of Healthcare Providers & Systems (CAHPS) scores. CMS additionally proposes adding a new Medicare Advantage depression screening and follow-up measure beginning with the 2027 measurement year and the 2029 ratings.
19. CMS plans to increase payments to MA plans by more than $25 billion in 2026. MA plans can expect a payment increase of 5.03% in 2026, more than double what the Biden administration proposed. The agency will continue the final year of the phase-in of risk-adjustment changes, shifting MA’s diagnosing coding from ICD-9 to ICD-10 and remove certain codes from the hierarchical condition categories model.
20. CMS plans to audit every MA plan annually as part of what it calls an “aggressive” effort to strengthen oversight and address potential overpayments. The agency currently audits about 60 plans each year but intends to expand that to all 500-plus MA plans moving forward.
In addition to the expanded audit scope, CMS said it will intensify efforts to recover uncollected overpayments from previous audits and complete outstanding reviews from 2018 through 2024. The last major recovery effort targeted plan year 2007. To support this initiative, CMS plans to grow its team of medical coders from 40 to approximately 2,000 by Sept. 1 and will deploy “enhanced technology” to streamline the review of medical records.
“While the administration values the work that Medicare Advantage plans do, it is time CMS faithfully executes its duty to audit these plans and ensure they are billing the government accurately for the coverage they provide to Medicare patients,” Dr. Oz said.
