CMS has advanced a range of coverage, payment and program integrity changes under President Donald Trump’s administration, including several major policies that have taken shape throughout 2026.
The agency’s actions span Medicare and Medicaid payment reforms, ACA marketplace oversight, prior authorization, fraud enforcement and new value-based care models.
Here are 20 key CMS actions for hospital and health system leaders to know:
Editor’s note: This is not an exhaustive list.
1. Cracking down on ACA marketplace enrollment fraud
On Sept. 22, CMS said it had canceled about 315,000 unauthorized ACA Marketplace enrollments covering more than 760,000 people. It’s a move the agency expects to return about $2.2 billion in taxpayer-funded subsidies. CMS has also established an anti-fraud coordination group and placed a temporary moratorium on new registration for the 2027 plan year for agents and brokers without an active 2026 exchange agreement.
2. Eyeing Medicare payment cuts for more than 1,100 lab codes
CMS revealed in late September that it is preparing to reset Medicare laboratory payments in 2027 after new private-payer data showed Medicare pays significantly more than commercial insurers for many tests. CMS said preliminary rates are about 16% lower on average than 2026 Medicare rates. The agency estimates the new rates could save about $1 billion annually. More than 1,100 laboratory codes could see lower rates, though annual cuts would be capped at 15% from 2027 to 2029.
3. Expanding the ACCESS model
CMS said in mid-September it will add four condition tracks to its Advancing Chronic Care with Effective, Scalable Solutions model April 1, 2027: heart failure, chronic obstructive pulmonary disease, substance use disorders and tobacco cessation. The ACCESS model connects Medicare payments with measurable patient health improvements and currently has 160 participating organizations.
4. Barring 11 medical suppliers from future Medicare Advantage payments
CMS barred 11 durable medical equipment supply companies with focuses on durable medical equipment, prosthetics, orthotics and supplies in early September from receiving future Medicare Advantage Parts C and D payments. This comes after the agency found more than $3.4 billion in suspected fraudulent billing in 2025 and 2026. The agency alleged the suppliers engaged in practices including billing for equipment for deceased beneficiaries and equipment beneficiaries did not request or receive.
5. Increasing scrutiny of Medicare Advantage payments
Federal scrutiny of Medicare Advantage risk-adjustment practices has intensified. Two Justice Department settlements involving The Villages Health System in late August and Kaiser Permanente in January totaled nearly $1.1 billion and centered on allegations that involved diagnosis coding practices that can increase health plan payments.
CMS said separately in late August that its enforcement efforts had blocked more than $1.6 billion in potentially improper Medicare laboratory payments throughout President Trump’s administration.
6. Proposing a Medicaid provider tax overhaul
CMS proposed sweeping changes to Medicaid provider tax policy in late July that the agency estimated would reduce federal spending by $246 billion from 2026 through 2035. The proposed changes would replace the longstanding 6% federal threshold with state- and provider-specific limits, phase down allowable taxes in Medicaid expansion states and strengthen federal oversight.
The American Hospital Association urged CMS in late September to reconsider aspects of the proposal. AHA argued that the changes could strain state Medicaid financing and hospital resources.
7. Implementing Medicaid work requirements
CMS published an interim final rule in early June that detailed how states will implement Medicaid work requirements. The rule creates the operational framework states will use to administer the requirements. What’s in: a phased approach to verification, a federal eligibility tool, a two-part medical frailty exemption, a broader short-term hardship exception, a $1.52 billion price tag for system upgrades and new state reporting duties. What’s out: lock-out and waiting periods and managed care plans as compliance verifiers.
Hospitals have warned the policy could cause eligible patients to lose coverage and increase uncompensated care.
8. Capping certain state Medicaid payments
CMS proposed a rule in late May that would cap certain Medicaid state-directed and fee-for-service payments, more closely aligning them with Medicare rates. CMS estimated the proposal would reduce Medicaid spending by more than $775 billion over a decade, including $510 billion in federal savings.
9. Finalizing an ACA marketplace overhaul
In mid-May, CMS finalized several changes to the ACA marketplace for 2027 that affect plan design, eligibility verification and federal subsidies. Included in the changes, CMS eliminated the requirement that insurers on the federal exchange offer standardized plan options and removed the cap on the number of non-standardized plans they can offer.
10. Accelerating electronic prior authorization
CMS selected 29 healthcare organizations, including health systems, EHR developers, physician practices, networks and digital health developers, in early May to participate in its Electronic Prior Authorization Acceleration initiative prior to federal requirements taking effect in 2027. In early April, the agency had proposed the extension of prior authorization requirements to drugs, including electronic prior authorization requirements and shorter decision timeframes.
Meanwhile, the American Medical Association urged CMS in late September to maintain its electronic prior authorization deadline.
11. Requiring states to audit Medicaid providers
CMS said in late April that it would require all states to submit plans that detail how they will verify whether providers are legitimate, licensed and delivering care under Medicaid. The effort is focused particularly on areas the agency considers at high-risk for fraud.
12. Proposing a mandatory nationwide joint replacement model
CMS proposed in early April the first mandatory, nationwide, episode-based payment model as part of its fiscal year 2027 Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System proposed rule.
The Comprehensive Care for Joint Replacement Model would be expanded into a mandatory nationwide program known as CJR-X. The proposed rule also included a 2.4% Medicare payment increase for acute care and long-term care hospitals.
13. Launching a GLP-1 coverage model
CMS launched a GLP-1 coverage model in late December 2025 to help expand access to weight loss drugs through participating Medicaid programs and Medicare Part D plans while pairing coverage with lifestyle support.
14. Launching a new accountable care model
CMS revealed plans in mid-December 2025 to launch a long-term enhanced accountable care organization design, or LEAD, model at the end of 2026 after the conclusion of the ACO realizing equity, access, and community health model. The LEAD model is designed to include smaller, rural and independent practices and will offer two voluntary risk-sharing options.
15. Expanding site-neutral payments and phasing out the inpatient-only list
CMS finalized its 2026 hospital outpatient rule in late November 2025. The rule expanded site-neutral payments and began a three-year phaseout of Medicare’s inpatient-only list. In 2026, 285 mostly musculoskeletal procedures are being removed from the inpatient-only list, with 289 procedures being added to the ASC covered procedures list. CMS also finalized a 2.6% outpatient payment increase for hospitals that meet quality reporting requirements.
16. Establishing two physician conversion factors
In early November 2025, CMS’ 2026 physician fee schedule created separate Medicare conversion factors for clinicians who participated in qualifying advanced alternative-payment models and those who did not. The QP-conversion factor increased 3.77% to $33.57, while the non-QP factor increased 3.26% to $33.40.
17. Updating the TEAM model
CMS finalized changes in late July 2025 to the TEAM model as part of its fiscal 2026 inpatient payment rule. TEAM is a five-year mandatory model, which kicked off Jan. 1, 2026. It requires selected hospitals to manage costs and quality for certain surgical episodes through 30 days after discharge.
18. Withdrawing Biden-era EMTALA guidance on emergency abortion care
In early June, 2025, CMS withdrew 2022 guidance under the Biden administration that had reinforced hospitals’ obligations to offer emergency abortion care under the Emergency Medical Treatment and Labor Act when necessary to stabilize a patient. The withdrawal did not repeal EMTALA itself, with cases being enforced where the health of a pregnant woman or her unborn child is at risk.
19. Increasing scrutiny of states’ Medicaid spending on undocumented immigrants
CMS said in late May 2025 it would increase federal oversight of state Medicaid spending to locate potentially improper federal spending on healthcare for undocumented immigrants. The agency said efforts would include reviews of state Medicaid spending reports, examinations of financial management systems in certain states and evaluations of eligibility rules.
20. Tightening hospital price transparency requirements
In late May 2025, CMS updated its hospital price transparency guidance after an executive order from President Trump in late February 2025 that aimed to boost healthcare price transparency. The agency directed hospitals to post actual prices of items and services rather than estimates in their machine-readable files whenever a dollar amount can be calculated.
