One notable change is a three-month delay in the start date, from Oct. 1, 2027, to Jan. 1, 2028. Performance periods will run on a standard calendar-year basis.

Key provisions that remain unchanged include the following.

• The model continues to apply to hospitals paid under the Inpatient PPS and OPPS, excluding hospitals located in Maryland and hospitals participating in the Transforming Episode Accountability Model.
• Hospitals will be held accountable for Medicare spending and quality of care for patients from the inpatient admission or outpatient procedure through 90 days after discharge.
• The model includes inpatient hip, knee and ankle replacements and reattachments under MS-DRGs 469, 470, 521 and 522, as well as outpatient hip and knee procedures under HCPCS codes 27130 and 27447.

Hospitals should use the additional time before implementation to evaluate episode spending, strengthen post-acute care partnerships and identify opportunities to improve quality performance. The Missouri Hospital Association will continue to monitor CMS guidance and share additional resources as implementation approaches.

The new model will require 340B providers to send a claim to participating manufacturers for purchases of 340B drugs included as selected pilot program drugs. Then the manufacturer will issue rebates to the 340B provider. When a claim is filed, manufacturers will not be permitted to deny a rebate based on suspected instances of diversion, duplicate discounts between 340B and Medicaid, eligible issues with the provider or insufficient purchases of a drug at full price. Such issues remain subject to agency review, manufacturer audits and 340B Administrative Dispute Resolution processes.

IPPS

• Includes market basket increase of 2.3% (3.2% less 0.9% productivity adjustment)
• Estimates a net IPPS payment increase of $2.1 billion, up from $1.4 billion as proposed
• Finalizes new policy requiring that approved medical residency training programs not discriminate, or promote or encourage discrimination, on the basis of race, color, national origin, gender, age, disability or religion
• Updates IPPS quality reporting program
• Updates Medicare Promoting Interoperability Program
• Updates Medicare mandatory pay-for-program
• Expands the current mandatory CJR model into a new mandatory model, known as CJR-X
  • Most hospitals paid under the IPPS would be mandatory participants except hospitals participating in the Transforming Episode Accountability Model (TEAM) or those hospitals not paid under both the IPPS and Outpatient PPS

LTCH PPS

• Includes market basket increase of 2.3% (3.2% less 0.9% productivity adjustment)
• Estimates a net LTCH PPS payment increase of $54 million, a decrease from the proposed $55 million
• Updates LTCH quality reporting program

MHA soon will publish an issue brief with additional details.

MHD also is requesting input on proposed changes to the Personal Care Provider Manual regarding the Bureau of Special Health Care Needs’ Medically Complex Children and Youth Program. Comments are due to MO HealthNet by noon Thursday, Aug. 6.

Emergency rules 13 CSR 70-3.300 and 13 CSR 70-3.310 rescind language regarding removal of complementary health and alternative therapies for chronic pain management and chiropractic services as MO HealthNet covered services.

Emergency rule 13 CSR 70-15.015 removes the definition of state-deemed critical access hospitals and updates the language related to the stop-loss payment, which will allow for annual adjustments. It also adds language recognizing the governor’s budget withholds on psychiatric adjustment payments and clarifies Graduate Medical Education payments are to be made to in-state hospitals.

Emergency rule 13 CSR 70-15.160 updates all documents incorporated by reference and used to create the outpatient simplified fee schedule, and updates the language for the outpatient rate adjustment.

As proposed, new indirect hold harmless thresholds for health care-related taxes would generally be based on taxes that were enacted and imposed as of July 4, 2025. The Missouri Hospital Association published an issue brief with additional information. Comments about the proposed rule are due Monday, Sept. 21.

Gov. Mike Kehoe recently signed HB 2372, a wide-ranging health care bill that includes a new signage requirement for Missouri hospitals. Starting Friday, Aug. 28, hospitals must prominently display printed signage in the waiting rooms of their emergency departments and labor and delivery departments, outlining the legal penalties for assaulting health care professionals.

To support compliance, the Missouri Hospital Association has developed ready-to-use signage featuring the required statutory language, along with added context noting that the wording and display requirement stem from legislation enacted in 2026. Member hospitals can download this signage now to print and install before the Aug. 28 deadline.

MHA also offers a broader library of customizable print and digital safety signage — available in English and Spanish — through its Healing Happens Here initiative. Explore the full collection of additional resources to reinforce a safe care environment.

Among the updates to the refreshed site, health care staff who work with nursing homes or other long-term care facilities will notice a fresh look and a new central hub. The Nursing Homes and Other Long-Term Care page now gathers all related resources in one place, including:

• Preadmission Screening and Resident Review (PASRR) — access the online Level I/Level of Care applications

• CNA, CMT, LIMA and Insulin Registry

• Licensing and Certification

• LTC Blog

Website visitors are encouraged to update any saved bookmarks, so they don't lose access to these resources.

• Skilled nursing facilities
• Intermediate care facilities
• Residential care facilities
• Assisted living facilities

For these LTC facilities, DRL will limit consultative plan review to new construction and/or major renovations that require Certificate of Need approval through the Health Facilities Review Committee.

For all other facility types, including hospitals, inpatient hospice, ambulatory surgery centers and adult day care programs, DRL life safety code staff will provide technical assistance regarding life safety code regulatory requirements, if requested.

For non-LTC facilities that had plans submitted before July 1, DRL staff will contact them to determine if they would like the plan review and consultation to continue through completion of the pending projects. 

For questions regarding this change, contact the Physical Environment Emergency Preparedness Unit (PEEP) at (573) 526-3415.

Physician Fee Schedule

• After accounting for the expiration of a 2.5% CY 2026 payment increase under the One Big Beautiful Bill Act, the proposed CY 2027 qualifying Alternative Payment Model conversion factor of $33.17 represents a projected decrease of 40 cents or 1.19% from the current conversion factor of $33.57.
• The proposed nonqualifying APM conversion factor of $32.84 represents a projected decrease of 56 cents or 1.68% from the current conversion factor of $33.40.
• Evaluation and management services that occur during a global period would be reimbursed at 100% for the most expensive services and at 50% for all other services.
• The methodology used to calculate practice expense Relative Value Units would move away from older specialty-specific data to a mixture of input data and a “PE stabilizer” designed to minimize volatility in RVU values.
• Diabetes services now would be included as preventive services for Rural Health Clinics to align such payments with those in Federally Qualified Health Centers and physician offices.

Medicare Shared Savings Program

• Shared savings for Basic track Level E would be raised from 50% to 60%.
• Maximum weight used for calculating regional adjustments under the Enhanced track would be reduced from 50% to 35%.
• The prior savings adjustment scaling factor would increase from 50% to 75% to reduce the so-called “ratchet effect” for Accountable Care Organizations.

Comments are due by Monday, Sept. 14. The Missouri Hospital Association published an issue brief with additional information.

Designed to generate savings while maintaining quality of care, the CJR-X model would include both inpatient and outpatient settings and hold hospitals financially accountable for a full 90 days after discharge. 

In response to an increased number of inquiries, the Missouri Hospital Association developed the CJR-X Model Summary to provide hospitals with an overview of who would be affected, how the model would work, the reasons for the proposed expansion and MHA’s recommendations to CMS. 

Claims without the 340B indicator or modifier will pay at the standard MO HealthNet pharmacy hierarchy. Claims for drugs that are non-preferred on the PDL and claims for drugs not part of the PDL would still be able to utilize 340B stock.

The full PDL list as of June 25 can be found in an Excel sheet or a searchable database. Please note that the PDL list is “proprietary of the State of Missouri, MO HealthNet Division. All information is deemed reliable as of the date of the document, but not guaranteed.”

The proposed regulation language change can be found below.

MO HealthNet Regulation 13 CSR 70-20.075 – 340B Drug Pricing Program

Full regulation can be found here.

Proposed Regulation Change:

(6) MHD may carve-out certain medications and categories of medications from 340B participation for MHD reimbursement. Medications subject to the carve-out will be reimbursed according to 13 CSR 70-20.070. The following medications and categories of medications are carved-out of reimbursement through the 340B program:

(A) (Drugs approved by the FDA for the treatment of obesity) All preferred agents on the Preferred Drug List (PDL) on the date of service; and

(B) Cell and gene therapies

OPPS

• Increases the OPPS payment rates by 2.4%, based on a 3.2% market basket update, less a 0.8% productivity adjustment
• Reduces off-campus provider-based department payments for imaging without contrast services. CMS estimates this will “reduce Medicare Part B expenditures by approximately $260 million in the first year, including approximately $190 million in Part B savings and $70 million in reduced beneficiary premiums.”
• Updates payment rates for drugs purchased under the 340B Drug Pricing Program to better reflect what hospitals pay for such drugs. “This proposal would save Original Medicare a collective estimated $4.55 billion in drug expenditures, for total reduced drugs spending of approximately $5.7 billion in 2027 alone.”
• Continues phasing out the inpatient-only list over a three-year period beginning with the elimination of 638 procedures
• Issues request for information about strengthening hospital price transparency rules
• Updates the Medicare payment rates for Intensive Outpatient Program services and Partial Hospitalization Program services
• Revises the Hospital Outpatient Quality Reporting Program
• Proposes requiring prior authorization for eight additional botulinum toxin injection codes

ASC

• Increases ASC rates by 2.4%, based on the IPPS market basket increase of 3.8%, less the 0.8% productivity adjustment
• Updates the ASC Quality Reporting Program

Comments are due by Monday, Aug. 31. The Missouri Hospital Association published an issue brief with additional information.

CMS also is proposing changes to the provider enrollment system, the HH Quality Reporting Program, expansion to the HH value-based purchasing program and changes to the durable medical equipment program. Comments about the proposed rule will be due by 4 p.m. Monday, Aug. 31. The Missouri Hospital Association published an issue brief with additional details.

Among other provisions, the final rule:

• Phases out traditional “look-back” validation surveys and adopts direct observation validation surveys in which state survey agencies accompany AO surveyors to evaluate their performance.
• Prohibits AOs from giving hospitals or other facilities any advance notice of a survey or identifying survey “blackout” dates.
• Requires AOs to align their minimum standards with Medicare CoPs and provide a crosswalk demonstrating that alignment.
• Restricts certain AO consulting services in the 12 months before an accreditation survey.
• Requires AOs to adopt conflict-of-interest policies for surveyors and other staff.
• Requires terminated providers to demonstrate compliance through a state agency survey before CMS will approve a new Medicare participation agreement.

The final rule’s policies take effect June 16, 2027.

The Medicaid community engagement requirements were enacted in Public Law 119-21, which was signed into law by President Donald J. Trump on July 4, 2025. States are required to implement these requirements by Jan. 1, 2027.

At its core, the survey is a statewide data engine. It captures the realities of hospital operations — from service lines and staffing to financial pressures and emerging technologies. What makes this survey truly valuable is what happens next: MHA transforms this information into advocacy that shapes Missouri’s health care landscape.

Turning Data Into Action

The Annual Licensing Survey gives MHA staff a comprehensive view of the challenges and opportunities facing Missouri hospitals. Your survey responses provide verified, statewide data that strengthens MHA’s advocacy efforts to shape reimbursement, regulatory policy and care delivery across Missouri in several critical ways:

• Legislative credibility — Lawmakers rely on accurate, statewide information to make decisions. The survey equips MHA with clear, evidence-based insights on issues like workforce shortages, behavioral health capacity and financial strain.
• Policy development — Trends identified in the survey help shape MHA’s policy priorities and guide recommendations to state leaders.
• Resource allocation — DHSS and other state partners use the data to understand utilization, capacity and community needs.
• Supporting materials — The survey powers MHA’s legislative guide, community investment reports and issue briefs that lawmakers depend on throughout the session.

Strengthening Missouri’s Voice Nationally

Because the survey is conducted in partnership with the American Hospital Association, Missouri’s data also contributes to national reporting and advocacy efforts. That means:

• Missouri hospitals are accurately represented in federal policy discussions.
• National ranking and reports reflect the true scope of care delivered in our state.
• Missouri's needs are visible in national debates on reimbursement, regulation and workforce.

 Strong data gives Missouri a strong voice at the national level.

Reducing Burden, Increasing Impact

One of the most important advocacy wins built into this process is efficiency. By consolidating data collection into a single annual survey, MHA reduces the number of requests hospitals receive throughout the year — from us, from DHSS and from AHA.

That means hospitals spend less time reporting and more time caring for patients. And because the data is standardized and comprehensive, it eliminates duplication and ensures every partner — state, federal, association — is working from the same trusted information.

Why This Matters for Missouri

Missouri’s hospitals are essential to the health and economic stability of its communities. To advocate effectively on their behalf, MHA needs more than anecdotes — we need a complete accurate picture of the hospital landscape. The Annual Licensing Survey provides MHA with the information necessary to help:

• protect hospital funding
• support workforce initiatives
• strengthen behavioral health services and resources
• improve access in rural communities
• guide regulatory modernization
• ensure Missouri remains competitive nationally

The Annual Licensing Survey may have started as a regulatory requirement, but its true value lies in what it makes possible: a stronger, more informed, more effective advocacy voice for Missouri hospitals. Your participation does more than meet a mandate — it ensures Missouri hospitals speak with a unified, data‑driven voice. That voice is essential to protecting funding, advancing shared policy priorities and strengthening access to care for communities across the state. 

The 2026 Missouri Pharmacy Law Review Virtual Program scheduled from 11 a.m. to 1 p.m. Thursday, July 9, will focus on Missouri regulatory changes, legislative updates, compliance trends, medication safety, technician activities, investigations and expanded pharmacist scope of practice.

Additionally, Sterile Compounding and Nuclear Pharmacy Rules Revisions Webinars will be held from noon to 1 p.m. July 14, July 17 and July 28, during the Lunch with the Chief Inspector series. These three webinars will review the upcoming rule revisions affecting the following.

• 20 CSR 2220-2.200 Sterile Compounding
• 20 CSR 2220-2.500 Nuclear Pharmacy — Minimum Standards for Operation

 The board will incorporate USP Chapters 797 and 825 into these revisions that take effect Thursday, July 30. A copy of both revised rules will be available Tuesday, June 30, in the Code of State Regulations.

This position will be responsible for the oversight of the division's regulatory duties on behalf of the Centers for Medicare & Medicaid Services as well as state licensure of applicable health care facilities. The position serves as a subject matter expert, leading a team of regulatory managers while also providing guidance as needed to the regulated industry and stakeholders in all aspects of their regulatory responsibilities.

The final rule would hold AOs accountable to the same Medicare standards of state survey agencies, ensure AOs remain independent reviewers, prevent AO conflicts of interest, improve AO performance, and improve consistency and standardization in surveys. The Missouri Hospital Association published an issue brief with additional details.

“When understood and used effectively, cost report data can reveal service line performance, identify reimbursement opportunities and risks, and show how much cost incurred is nonreimbursable or nonallowable,” said Andrew Wheeler, vice president of federal advocacy and finance for the Missouri Hospital Association.

At its core, the Medicare cost report is how the Centers for Medicare & Medicaid Services evaluates hospitals, according to Wheeler. Each year, hospitals are required to submit a cost report after the close of their fiscal year, typically within five months. It is filed electronically with their Medicare Administrative Contractor, which reviews and audits the submission on behalf of CMS.

What does a cost report include?

Cost reports provide a comprehensive view of an organization’s costs, operations and patient mix. The report captures a wide range of information, including the following.

• utilization statistics (including days and discharges) across Medicare, Medicaid and other payers
• patient revenue and expenses
• wage data, including salary and benefits
• departmental costs and charges
• graduate medical education information
• bad debt and uncompensated care data
• capital costs and depreciation
• overhead allocations and statistics
• physician allowable and nonallowable costs

Within the report, certain sections cover critical data.

• Worksheet S-3: Medicare utilization
• Worksheet E series: final reimbursement calculations
• Worksheet S-10: uncompensated care and charity care reporting
• Worksheet A, A-6 and A-8: cost center expenses and adjustments
• Worksheet C: cost-to-charge ratios
• Graduate Medical Education and Indirect Medical Education worksheets
• Worksheet S-3 Parts II, III and IV: wage data used to establish the hospital wage index
• Worksheet G series: hospital financial statement information

Why is a cost report important?

The Medicare cost report is a powerful tool for hospital leaders.

Cost reports help leaders benchmark against peer hospitals, track trends in uncompensated care, evaluate eligibility for various payment programs, and inform advocacy and policy discussions. These reports also offer insight into labor and wage competitiveness and support more informed capital improvement planning decisions.

Additionally, the importance of cost reports extends beyond individual hospitals, Wheeler said.

“Aggregated cost report data help demonstrate the financial realities hospitals face across Missouri, including workforce pressures, uncompensated care burdens and rural access challenges,” he said. “These reports also help support fair wage index calculations and provide data used in state and federal policy development.”

MHA and its data company, the Hospital Industry Data Institute, publish Medicare cost report comparisons annually and share supporting reports used for the Medicare wage index determinations based on CMS wage index reporting and review deadlines.

Where does the data come from?

While finance departments typically lead the process of developing these reports, it requires coordinated input from across an organization, Wheeler said. Revenue cycle and patient financial services teams provide billing and payer data. HR contributes wage and benefits information, while clinical departments supply utilization statistics.

To ensure the cost reports are accurate, hospitals typically use the following.

• accounting and general ledger reports
• patient accounting and billing systems
• payroll and HR systems
• Medicare remittance advice and claims data
• fixed asset systems
• data from electronic medical/health records and other sources

“Although the Medicare cost report is straightforward, optimizing each worksheet and dataset is extremely complex and challenging due to a number of reasons,” Wheeler said.

Hospitals must navigate frequent Medicare policy changes, and there is increasing scrutiny around worksheet S-10 and wage index data. Gathering and coordinating data from across multiple systems as well as departments can be difficult, too. Maintaining consistency between audited financial statements and reported costs also can be a challenge.

Wheeler noted there is a persistent misconception that the Medicare cost report is becoming less relevant and may no longer be used. In reality, the data that cost reports contain continue to drive payment policy, regulatory decisions and more.

Hospital leaders who invest time in understanding their cost report gain a clearer view of their organization’s financial performance and strategic position, Wheeler said.

CMS is reminding electronic health record vendors to implement application programming interfaces between patients and insurers, providers and insurers and payer to payers by Jan. 1, 2027. Also included is a requirement to develop a provider directory API. CMS is accepting comments until Monday, June 15.

MO HealthNet also is developing a two-year comprehensive provider revalidation strategy within the next 30 days. This follows an April 21 announcement from CMS on provider integrity. MO HealthNet released additional information on provider revalidation on May 5.

1. Respond to Records Requests: If you receive a written request from CoventBridge for medical records relating to sampled claims, you are required to respond within the timeframe specified in the request. Timely submission is essential to avoid compliance issues. 

2. Legal Compliance: Under the Deficit Reduction Act and other applicable federal and state laws, providers are legally obligated to furnish the requested medical records. Records may be released under HIPAA for Health Oversight Activities authorized by law under 45 CFR 164.512(d). Failure to comply may result in administrative actions as outlined in 13 CSR 70-3.030. 

3. Staff Awareness: Please ensure your administrative staff is aware and understands that correspondence from CoventBridge is official and requires prompt attention. 

CMS released the guidance in response to questions from stakeholders about NATCEP/CEP requirements, including fees for nurse aides, instructor qualifications, general supervision, settings for training sites, competency evaluation procedures, and the use of remote technology as a means of direct observation for training and evaluation.

The purpose of this guidance is to clarify NATCEP/CEP requirements, assist states in streamlining NATCEP/CEP program approvals and expand the capacity for nurse aide trainees by improving access and flexibility for training and testing requirements.

More detailed information can be found in this CMS memo.

The scam involves fraudulent documents claiming a provider’s license has been suspended for illegal drug trafficking and requesting payment of a government security bond via wire transfer.

The documents falsely include official-looking letterhead, seals and stamps from the U.S. Department of Justice and the Missouri Division of Professional Registration Central Investigations Unit. The documents also make fraudulent use of DCI Director Angela Nelson’s signature.

Any unexpected notice of license suspension or a request for payment should be treated as suspicious. Remember the following.

• If any provider receives an unexpected communication regarding license suspension due to drug trafficking or otherwise, stop immediately.
• Do not submit payment in response to any suspicious communications or requests.
• If there is any doubt about the legitimacy of a document or other communication, contact the board at healingarts@pr.mo.gov.

In addition, CMS is seeking comments on ways to streamline the step therapy process using technology and data sharing, such as the Payer-to-Payer API. Comments are due 60 days after the date of publication in the Federal Register. MHA will soon publish an issue brief with additional details.

Claims without the 340B indicator or modifier will pay at the standard MO HealthNet pharmacy hierarchy. Claims for drugs that are non-preferred on the PDL and claims for drugs not part of the PDL would still be able to utilize 340B stock.

The full PDL list as of March 20 can be found here. MO HealthNet plans on issuing updated PDL lists in April and July to help hospitals prepare for the change. Please note that the PDL list is “proprietary of the State of Missouri, MO HealthNet Division. All information is deemed reliable as of the date of the document, but not guaranteed.”

The proposed regulation language change can be found below.

MO HealthNet Regulation 13 CSR 70-20.075 – 340B Drug Pricing Program

Full regulation can be found here.

Proposed Regulation Change:

(6) MHD may carve-out certain medications and categories of medications from 340B participation for MHD reimbursement. Medications subject to the carve-out will be reimbursed according to 13 CSR 70-20.070. The following medications and categories of medications are carved-out of reimbursement through the 340B program:

(A) (Drugs approved by the FDA for the treatment of obesity) All preferred agents on the Preferred Drug List (PDL) on the date of service; and

(B) Cell and gene therapies

Applications for reimbursement can be submitted between Wednesday, April 1, and Thursday, April 30. DMH’s letter, attestation form and fillable Excel document can be found on the department’s website.

The changes appear in TJC’s Environment of Care Standard EC.02.03.03, EP 3, for ambulatory care organizations, assisted living communities, nursing care centers, behavioral health care and human services organizations, and home care organizations. The revisions also apply to hospitals and critical access hospitals, according to Physical Environment Standard PE.03.01.01, EP 3.

Questions can be directed to your TJC account representative or TJC’s Department of Standards and Survey Methods.

CMS also is requesting stakeholder input on additional ways the agency can prevent fraud that will be used to develop possible future rulemaking under CMS’ Comprehensive Regulations to Uncover Suspicious Healthcare Initiative. Comments must be received within 30 days after publication in the Federal Register.

In 2025, HRSA opened a 340B rebate model to certain manufacturers who volunteered as participants. HRSA later paused implementation due to litigation. Through the release of this request, “HRSA is undertaking a methodical and deliberate approach to assess whether implementing a potential 340B Rebate Model Pilot Program [is] consistent with its statutory authority."

Comments on this notice are due no later than Thursday, March 19.

The rule would strengthen regulations on marketing practices, mandate a standard eligibility application, restore certain aspects of network adequacy authority back to the states using state-based exchanges, revise special enrollment periods and change the user fees charged to participating insurers. 

CMS is accepting comments on the proposed rule through Friday, March 13. MHA published an issue brief with additional information.

The financial implications include effects of the CY 2026 updates to the market basket, the productivity reduction mandated by the Affordable Care Act, the patient-driven grouping model, the permanent behavior assumption adjustment and changes to the wage index. The estimated effect of the final home health rule will decrease payments in Missouri by 1.04%, or $210,300. 

CMS is working to build on lessons learned during the COVID-19 public health emergency by “exploring ways to reduce reliance on foreign-made medical supplies and enhance the nation’s readiness for future emergencies while supporting American workers and manufacturers.” CMS is seeking comments about the following.

• useful alternatives to self-attestation on the Medicare cost report used to obtain designation approval
• definition of “domestic” for PPE and essential medicines
• criteria for determining a sufficient supply of PPE and essential medicines
• barriers hospitals may face
• considerations for phasing in the policy over time

Comments from the public must be received within 60 days after the date of publication in the Federal Register.

The extension allows DEA-registered practitioners to continue prescribing Schedule II through V controlled substances via audio-video telemedicine and Schedule III through V narcotic-controlled medications to treat opioid use disorder via audio-only encounters without first conducting an in-person medical evaluation, according to a DEA news release.

The extension is intended to prevent in-person care backlogs, ensure continuity of care — particularly for rural and underserved patients — and allow “time to finalize and implement regulations that balance access to care with the necessary safeguards against drug diversion,” the agencies said.

On Jan. 17, 2025, the DEA and HHS published two final rules — “Expansion of Buprenorphine Treatment via Telemedicine Encounter” and “Continuity of Care via Telemedicine for Veterans Affairs Patients” — which took effect Dec. 31, 2025. These rules, along with this fourth temporary extension, established three distinct frameworks for telemedicine prescribing.

Learn more about this extension from the Federal Register.