Lexology November 12, 2025
On October 31, CMS finalized the CY 2026 Medicare Physician Fee Schedule (PFS) rule (CMS-1832-F), effective January 1, 2026. While primarily directed at Medicare providers, the rule’s changes have clear downstream effects for payors and private insurers that benchmark to Medicare or align commercial policies with federal payment logic. Key themes are higher baseline rates, a stronger push toward value-based care via dual conversion factors, permanent telehealth flexibilities (including virtual supervision), expanded behavioral health integration, and a cost-containment overhaul for skin substitutes.
Rates and Conversion Factors
Beginning in 2026, Medicare will use two conversion factors: $33.57 for qualifying alternative payment model (APM) participants (up 3.77%) and $33.40 for non‑qualifying APM participants (up 3.26%). These increases — reflecting statutory updates and...
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