CMS & CMMI Updates

Key Actions:

CMS activity over the last 30 days shows a Trump administration push on price transparency, drug payment reform, rural capacity, Stars, and claims-payment controls. CMS finalized the Transparency in Coverage Final Rules — CMS-9882-F to make pricing and coverage data easier to find, compare, and report, paired with a press release on the same policy direction (fact sheet; press release). CMS also finalized a new mandatory drug payment model for Original Medicare Part B, aimed at lowering beneficiary drug prices; this is the most consequential CMMI-type payment action in the packet and will affect providers billing Part B drugs once operational details are fully implemented (CMS press release).

On Medicare Advantage, CMS released the 2027 Medicare Advantage and Part D Star Ratings, setting the quality-payment and bonus landscape for MA and PDP contracts (fact sheet). CMS also issued FAQs on the Medicare Improvement Fund Premium Rebate, signaling continued beneficiary-premium affordability activity in Medicare (FAQ).

CMS issued multiple transmittals tightening operations and payment accuracy: R13995CP / CR 14682 updates compliance and payment accuracy for physician services in skilled nursing facilities, effective April 5, 2027 (R13995CP); R13997OTN / CR 14622 revises edits to prevent overpayment for long-term hospice stays, effective April 5, 2027 (R13997OTN); R13996OTN establishes a Home Health Reason Code 19963 edit for missing Notices of Admission, effective April 5, 2027 (R13996OTN); and CMS updated home health grouper and consolidated billing HCPCS enforcement through R13974CP / CR 14631 and R13988CP / CR 14639 (R13974CP; R13988CP).

CMS also announced targeted rural investments: $37.7M in Louisiana, $209M in Iowa, $17M+ in North Carolina, $7.2M in South Dakota, and nearly $55M in Alabama for rural workforce, emergency care, maternal telehealth, behavioral health, cancer prevention, and ambulance-based telemedicine (Louisiana; Iowa; North Carolina; South Dakota; Alabama).

Implications for VBC Stakeholders:

MA plans need to model revenue exposure from the 2027 Star Ratings and align quality-improvement investments with measures that drive bonus payments, rebates, and bid strategy. The Transparency in Coverage rule increases competitive pressure on payer-provider contracting: plans, ACOs, and health systems should expect more scrutiny of negotiated rates, machine-readable files, and consumer-facing cost tools.

ACO REACH, MSSP ACOs, oncology groups, rheumatology practices, hospital outpatient departments, and infusion-heavy physician groups should evaluate the mandatory Part B drug payment model for margin effects, care redesign opportunities, and beneficiary cost-sharing implications. Organizations in two-sided risk arrangements may benefit if drug spending trends fall, but providers dependent on buy-and-bill spread may face downside.

Home health, hospice, SNF, and post-acute networks face a tightening claims environment. Missing home health Notices of Admission, long-stay hospice billing patterns, SNF physician-service billing, and home health consolidated billing edits will require front-end revenue-cycle fixes before 2027 implementation. ACOs and MA plans should treat these edits as network-management signals: preferred post-acute partners with clean billing