CMS isn’t just tweaking ASC policies in 2026; it’s remolding the financial and regulatory foundation of outpatient surgery. From a major expansion of procedures allowed in the setting to the phaseout of the Medicare inpatient-only list and rollout of AI-supported prior authorization, the agency’s latest moves signal a faster, more complex shift of care out of hospitals.
Together, these five decisions will influence where surgery happens, how it’s paid for, and what new oversight ASCs will face in the coming years.
1. CMS finalized a 573-code expansion to the ASC Covered Procedures List for 2026: In November, CMS finalized its 2026 Hospital Outpatient Prospective Payment System and ASC Payment System rule, adding 573 codes to the ASC Covered Procedures List.
The move marked a significant advocacy win for the Ambulatory Surgery Center Association, particularly for spine and cardiovascular procedures. ASCA leaders told Becker’s that the expansion followed years of collaboration with specialty groups, including the American College of Cardiology and Heart Rhythm Society, and relied heavily on Medicare-specific safety data demonstrating that these procedures can be performed safely in ASCs.
2. CMS is eliminating the Medicare inpatient-only list — a structural shift in site-of-service policy: The phaseout will take place over next three years, ending a longstanding policy that required certain complex procedures to be performed in inpatient hospital settings.
The move removes a blanket inpatient safeguard and gives physicians broader discretion over where care is delivered. While CMS says the change will increase flexibility, lower costs and accelerate outpatient migration, a Jan. 14 JAMA Surgery article warned it could outpace system readiness and raised concerns about safety oversight, payer behavior and algorithm-driven denials. Meanwhile, some ASC leaders called the shift a “fundamental redefinition” of surgical care delivery.
3. CMS finalized a 2.6% ASC payment increase and addressed cardiac reimbursement calculations: In the 2026 OPPS/ASC Final Rule, CMS updated ASC payment rates by 2.6% using the hospital market basket methodology.
The ASC conversion factor will be $56.322, compared with $91.415 for hospital outpatient departments, and CMS signaled it plans to continue using the hospital market basket update this year while monitoring its impact. CMS also corrected a calculation error affecting cardiac procedures; instead of a 4.7% cut, reimbursement for those services will increase 3.4% over 2025 rates.
4. CMS’ WISeR pilot will introduce AI-supported prior authorization in select states: CMS launched its Wasteful and Inappropriate Service Reduction model on Jan.1 in Arizona, Washington, New Jersey, Texas, Ohio and Oklahoma, requiring providers, including ASCs, to follow new prior authorization protocols for certain services.
CMS contractors will use a combination of AI tools and clinical review to assess requests, aligned with existing Medicare coverage standards. The initial services subject to review include electrical nerve stimulator implants, certain epidural steroid injections, percutaneous vertebral augmentation and image-guided lumbar decompression. CMS also plans to pilot a mid-2026 “gold carding” exemption for clinicians with high approval rates, though the model has drawn congressional scrutiny over AI use and potential access concerns.
5. Federal drug price negotiations are expanding under CMS authority: Beginning Jan. 1, CMS-negotiated prices took effect for 10 of the nation’s most expensive drugs under the Inflation Reduction Act.
Lawmakers also introduced legislation Nov. 20 that would expand annual negotiations to 50 medications and extend the program beyond Medicare to private insurers. The proposal would also reverse a provision in the One Big Beautiful Bill Act that exempts certain rare-disease drugs from negotiation. While the program currently applies to Medicare, expanded negotiations could have downstream implications for outpatient cost structures, pharmaceutical contracting and overall reimbursement dynamics across ASC service lines.
