August 15, 2025 – Jacksonville, FL
Every fall, CMS sets the direction for the year ahead with the Medicare Physician Fee Schedule (PFS). While it’s often seen as a technical update to reimbursement rates, the rule is much more than that. It signals Medicare’s priorities, its expectations for providers, and the pace of change toward value-based care.
The proposed 2026 rule blends targeted adjustments with strategic shifts. It opens more pathways for participation in advanced models, makes certain pandemic-era flexibilities permanent, and refines how quality is measured. Some changes reduce barriers, others raise the bar, but all point toward a faster transition to integrated, accountable care.
The Medicare Shared Savings Program remains a cornerstone for value-based care participation. The proposal would give more providers an entry point by applying the 5,000-beneficiary threshold only in the third benchmark year. Smaller or newer ACOs could join earlier, start learning the program, and grow toward the threshold.
But this wider doorway comes with a shorter runway. The maximum time an ACO can remain in upside-only arrangements would drop from seven years to five. That means organizations will need to build the infrastructure for two-sided risk, like care coordination, data analytics, and clinical integration, more quickly than before.
Healthcare ownership and affiliation changes don’t wait for an annual roster update. CMS is proposing to require certain Changes in Ownership (CHOW) to be reported mid-year, specifically when the surviving TIN has no Medicare billing history.
The aim is to:
This shift brings operational demands, meaning ACOs will need processes and oversight systems that can identify and document changes as they happen, not months later.
To continue the shift theme, CMS is signaling a narrower focus on quality reporting. Two measures would be removed from the APP Plus set: the health equity adjustment and the Social Drivers of Health screening measure. For some, this streamlines reporting; for others, it reduces recognition of equity-related initiatives. It’s a reminder that quality metrics will continue to evolve and that adaptability in reporting is as important as adaptability in care delivery.
Additionally, in the Quality Payment Program (QPP), CMS is proposing Qualifying APM Participant determinations at both the entity and individual level, creating new pathways for specialists and multi-specialty providers to participate. At the same time, the MIPS performance threshold would remain at 75 points through 2030, offering rare stability in an otherwise shifting program. Expanded MIPS Value Pathways would further align measures with clinical practice.
CMS is introducing the Ambulatory Specialty Model (ASM), set to launch in 2027, which will bring mandatory two-sided risk to select specialists in targeted regions, underscoring CMS’s intention to embed value-based principles beyond primary care. Meanwhile, many telehealth flexibilities introduced during the pandemic, for instance, expanded covered services, removal of certain visit limits, and ongoing allowance for direct supervision via telehealth, are set to become permanent, enhancing access and continuity of care.
Taken together, the CY 2026 proposals create both opportunity and urgency. Medicare is lowering some barriers to participation while compressing the time providers have to prepare for risk. It’s embedding flexibility in care delivery while streamlining quality reporting.
For providers, the best response is to use this lead time to strengthen infrastructure, refine reporting capabilities, and prepare for the realities of two-sided risk.
At Wellbox, we help providers navigate exactly these kinds of transitions. We support care delivery models that improve outcomes, close gaps, and ease the operational lift of program participation. With the right strategy in place now, you can step confidently into 2026 and beyond.
Learn more about how Wellbox helps providers extend their reach, ease operational burden, and improve outcomes without adding more to their plates. Discover care management support at wellboxhealth.com
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