Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals (IPPS) and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year (FY) 2026 Rates; Changes to the FY 2025 IPPS Rates Due to Court Decision; Requirements for Quality Programs; and Other Policy Changes; Health Data, Technology, and Interoperability: Electronic Prescribing, Real-Time Prescription Benefit and Electronic Prior Authorization

This table summarizes the newly modified and previously finalized Hospital IQR Program measure set for the FY 2029 payment determination and for subsequent years:

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BILLING CODE 4120-01-C 7. Updates to the Form, Manner, and Timing of Hospital IQR Program Data Submission

In the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18342 through 18344), we proposed changes to our reporting and submission requirements for eCQMs and hybrid measures. We provide more details on these proposals in the subsequent sections.

We did not propose changes to the following requirements, and we have therefore omitted the following subsections from the Form, Manner, and Timing of Quality Data Submission section: procedural requirements; data submission requirements for chart-abstracted measures; sampling and case thresholds for chart-abstracted measures; HCAHPS Survey administration and submission requirements; data submission requirements for structural measures; data submission and reporting requirements for CDC NHSN measures; and data submission and reporting requirements for Patient-Reported Outcome-Based Performance Measures (PRO-PMs). We refer readers to the QualityNet website at: https://qualitynet.cms.gov/inpatient/iqr (or other successor CMS designated websites) for more details on the Hospital IQR Program data submission and procedural requirements. a. Background

Sections 1886(b)(3)(B)(viii)(I) and (b)(3)(B)(viii)(II) of the Act state that the applicable percentage increase for FY 2015 and each subsequent year shall be reduced by one-quarter of such applicable percentage increase (determined without regard to sections 1886(b)(3)(B)(ix), (xi), or (xii) of the Act) for any subsection (d) hospital that does not submit data required to be submitted on measures specified by the Secretary in a form and manner and at a time specified by the Secretary. To participate successfully in the Hospital IQR Program, hospitals must comply with the specific procedural, data collection, submission, and validation requirements that we specify for the program. b. Maintenance of Technical Specifications for Quality Measures

Section 412.140(c)(1) of title 42 of the CFR generally requires that a subsection (d) hospital participating in the Hospital IQR Program must submit to CMS data on measures selected under section 1886(b)(3)(B)(viii) of the Act in a form and manner, and at a time, specified by CMS. The data submission requirements, specifications manual, measure methodology reports, and submission deadlines are posted on the QualityNet website at: https://qualitynet.cms.gov (or other successor CMS designated websites). The CMS Annual Update for the Hospital Quality Reporting Programs (Annual Update) contains the technical specifications for eCQMs. The Annual Update also contains updated measure specifications for the year prior to the reporting period. For example, for the CY 2025 reporting period/FY 2027 payment determination, hospitals are collecting and will submit eCQM data using the May 2024 Annual Update and any applicable addenda. The Annual Update and implementation guidance documents are available on the Electronic Clinical Quality Improvement (eCQI) Resource Center website at: https://ecqi.healthit.gov/.

Hospitals must register and submit quality data as described at 42 CFR 412.140(a). See 45 CFR parts 160 and 164, subparts A, C, and E. c. Modification to the Reporting of the Hybrid Hospital-Wide All-Cause Readmission (HWR) and Hybrid Hospital-Wide All-Cause Risk Standardized Mortality (HWM) Measures (1) Background

The Hospital IQR Program previously adopted two hybrid measures: (1) the Hybrid HWR measure; and (2) the Hybrid HWM measure. Hybrid measures use more than one data source for measure calculation. Specifically, the Hybrid HWR and Hybrid HWM measures are calculated using core clinical data elements (CCDEs), linking variables, and claims data (80 FR 49698). CCDEs are a set of clinical variables derived from EHRs that can be used to risk adjust hospital outcome measures (80 FR 49699). Linking variables are administrative data that can be used to link or merge the CCDEs and claims data for measure calculation (80 FR 49701). These measures are designed to enhance risk adjustment of claims-based outcome measures by utilizing patient clinical data captured in EHRs (80 FR 49698).

Hospitals are currently required to report CCDEs (both vital signs and laboratory test results) on 90 percent of discharges and to submit four linking variables on 95 percent of discharges for both the Hybrid HWR and Hybrid HWM measures in a given reporting period beginning with mandatory reporting for the FY 2028 payment determination (89 FR 94495 through 94499). Hospitals must report 13 CCDEs (six vital signs and seven laboratory test results) for the Hybrid HWR measure and 10 CCDEs (four vital signs and six laboratory test results) for the Hybrid HWM measure. (2) Decrease of the Hybrid Measures CCDE and Linking Variable Submission Thresholds Beginning With the FY 2028 Payment Determination

As a part of measure maintenance, we routinely monitor hospital performance

on the Hospital IQR Program measures. The results of 2024 voluntary reporting for both the Hybrid HWR and Hybrid HWM measures indicated that three-fourths of the participating hospitals that submitted measure data during this voluntary period did not meet submission thresholds of 90 percent of discharges for the CCDEs and 95 percent of discharges for the linking variables. It is therefore likely that an even larger percentage of hospitals would not have met the current hybrid measure CCDE and linking variable submission thresholds if they had been required to report them during the July 1, 2022 through June 30, 2023 performance period. The hospitals that participated in voluntary reporting of these data consisted mostly of large, non-rural, non-critical access, and non-safety net hospitals.

In the CY 2025 OPPS/ASC final rule, we summarized feedback received on the reporting of the Hybrid HWR and Hybrid HWM measures (89 FR 94495 through 94499). Several commenters described challenges meeting the 90 percent thresholds for CCDEs and the 95 percent thresholds for linking variables and recommended reducing the required threshold percentages. A few commenters specifically recommended lowering the threshold for reporting laboratory results, which are included in the CCDEs. While lowering the thresholds would have been out-of-scope for the CY 2025 OPPS/ASC final rule, we stated our intent to propose lowering the thresholds in future rulemaking.

Based on the feedback from commenters and our analysis of the results from the voluntary reporting for both the Hybrid HWR and Hybrid HWM measures, we considered whether lowering the thresholds for CCDE and linking variables would increase the number of hospitals that were able to successfully report the hybrid measures without significantly decreasing reliability. The results of an internal analysis indicated that for both the Hybrid HWR and Hybrid HWM measures, allowing (1) fewer CCDEs to be submitted--up to two missing lab values and up to two missing vital signs--combined with (2) lowering the percentage of discharges meeting the CCDE lab values and vital signs threshold to 70 percent of discharges, significantly improves hospitals' ability to meet the measure reporting thresholds.\344\ The same effect was observed for linking variables when lowering the threshold to 70 percent of discharges. While we established the current 90 and 95 percent thresholds for CCDEs and linking variables, respectively, based on initial measure testing to encourage data completeness, our recent analysis shows that these lower thresholds still demonstrate good reliability for measure calculation, while increasing the number of hospitals that were able to successfully report the hybrid measures.345 346 347

\344\ CMS. Internal Analysis. September 2024.

\345\ CMS. Internal Analysis. September 2024.

\346\ Battelle--Partnership for Quality Measurement. Hybrid Hospital-Wide Readmission (HWR) Measure with Claims and Electronic Health Record Data. Available at: https://p4qm.org/measures/2879e.

\347\ Battelle--Partnership for Quality Measurement. Hybrid Hospital[hyphen]Wide (All[hyphen]Condition, All[hyphen]Procedure) Risk[hyphen]Standardized Mortality Measure with Claims and Electronic Health Record Data. Available at: https://p4qm.org/measures/3502e.

Therefore, in the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18343 through 18344), we proposed to reduce the submission thresholds for both CCDE and linking variables to at least 70 percent of discharges for both the Hybrid HWR and Hybrid HWM measures. We selected the threshold of 70 percent to ensure successful submission for as many hospitals as possible, while still maintaining statistical validity.\348\ We also proposed (90 FR 18343 through 18344) to lower the number of required CCDE data elements for both the Hybrid HWR and Hybrid HWM measures to allow for up to two missing laboratory results and up to two missing vital signs. A hospital that submits CCDE and linking variable data for less than 70 percent of applicable patient discharges or that submits CCDE data with more than two missing laboratory results or more than two missing vital signs under either hybrid measure would not satisfy the measure's Hospital IQR Program requirements and would receive a one-fourth reduction to its Annual Payment Update (APU) for the applicable fiscal year.

\348\ CMS Internal Analysis. September 2024.

We invited public comment on our proposals to reduce the number of required CCDEs, to allow up to two missing lab values and two missing vital signs, and to lower the required percentage of discharges meeting the CCDE and linking variable thresholds to 70 percent of discharges for the Hybrid HWR and Hybrid HWM measures beginning with the FY 2028 payment determination, which has a performance period of July 1, 2025, through June 30, 2026.

Comment: Many commenters stated support for CMS's proposal to reduce the data completeness thresholds for CCDEs and linking variables from 90 and 95 to 70 percent, as well as to allow up to two missing lab values and two missing vital signs. Many commenters noted that these changes would significantly reduce the reporting burden on hospitals, increase feasibility for compliance, improve participation rates, and provide CMS with more data to evaluate hospitals' reporting performance.

A few commenters emphasized that the proposed reductions acknowledge data capture workflows and real-world challenges, such as technical limitations in EHR systems and operational barriers, while others noted that the reduced threshold would assist in the transition to incorporating more granular clinical data into quality measurement. A commenter supported maintaining the first mandatory reporting year of July 1, 2025-June 30, 2026 as this provides hospitals with the stability and predictability needed for successful implementation while recognizing the substantial investments many organizations have already made in the reporting of hybrid measures. A few commenters expressed support for the overall philosophy behind the hybrid measures as they provide a more comprehensive perspective on readmissions and mortality.

Response: We thank commenters for their support.

Comment: A few commenters urged CMS to provide transparency regarding the rationale for the 70 percent threshold.

Response: We conducted an internal analysis examining hospital's ability reach different reporting thresholds based on voluntary reporting data and selected the threshold of 70 percent to ensure successful submission for as many hospitals as possible, while still maintaining statistical validity.\349\ Internal results demonstrate that comparing admissions with and without CCDEs have similar outcome rates and similar claims-based risk variable prevalences. As such, a threshold of 70 percent maximizes hospitals' ability to meet the threshold, while maintaining scientific rigor. We note that the hybrid measures utilize CCDE for risk adjustment, based on stakeholder feedback that the claims-only measures did not adequately account for clinical risk factors.

\349\ CMS Internal Analysis. September 2024.

Comment: A few commenters requested clarification on the application of the missing data allowance and whether the allowance of up to two missing clinical data elements and two missing linking variables applies per patient on an individual

basis, or if it must be the same elements missing across all patients for the allowance to apply.

Response: We wish to clarify that the allowance of missing data applies to CCDEs only, specifically up to two missing lab values and two missing vital signs. This missing data allowance applies per patient on an individual basis. We refer readers to the eCQI Resource Center for more details on the measure specifications.350 351

\350\ eCQI Resource Center. May 2025. Core Clinical Data Elements for the Hybrid Hospital-Wide Readmission Measure with Claims and Electronic Health Record Data--HWR. Available at: https://ecqi.healthit.gov/ecqm/hosp-inpt/2026/cms0529v6?qt-tabs_measure=specifications-and-data-elements.

\351\ eCQI Resource Center. May 2025. Core Clinical Data Elements for the Hybrid Hospital-Wide All-Condition All-Procedure Risk-Standardized Mortality Measure--HWM. Available at: https://ecqi.healthit.gov/ecqm/hosp-inpt/2026/cms0844v6?qt-tabs_measure=specifications-and-data-elements.

Comment: A commenter requested clarification on whether the reporting period of July 1, 2024 through June 30, 2025 included the addition of MA patients as finalized in the FY 2024 IPPS/LTCH PPS final rule.

Response: We wish to clarify that the July 1, 2024 through June 30, 2025 performance period impacting the FY 2027 payment determination did include MA patients as finalized in the FY 2024 IPPS/LTCH PPS final rule (88 FR 59161 through 59168). We refer readers to the eCQI Resource Center for more details on the 2024 reporting period measure specifications.352 353

\352\ eCQI Resource Center. May 2025. Hybrid HWR Measure Information. Available at: https://ecqi.healthit.gov/ecqm/hosp-inpt/2024/cms0529v4.

\353\ eCQI Resource Center. May 2025. Hybrid HWM Measure Information. Available at: https://ecqi.healthit.gov/ecqm/hosp-inpt/2024/cms0844v4.

Comment: A few commenters recommended CMS lower the threshold even further, such as 60 percent, to alleviate reporting burdens and encourage broader participation. A commenter recommended allowing an additional missing lab value for a total of three to better align with clinical workflows. A commenter urged CMS to eliminate the linking variable and CCDE threshold requirements altogether.

Response: We thank the commenters for their recommendations. We selected the 70 percent threshold and the allowance of two missing lab values and two missing vital signs to maintain statistical validity, while providing opportunity for more successful submissions for more hospitals, based on the results of an internal analysis. Results show that the majority of hospitals can meet the 70 percent threshold, which was selected to retain the integrity of the data for statistical calculation amongst missing data.\354\

\354\ Jakobsen, J.C., Gluud, C., Wetterslev, J. et al. When and how should multiple imputation be used for handling missing data in randomised clinical trials--a practical guide with flowcharts. BMC Med Res Methodol 17, 162 (2017). https://doi.org/10.1186/s12874-017-0442-1

Comment: Commenters urged CMS to continue monitoring hospital experiences with reporting on these measures by reviewing performance data, particularly under the new proposed thresholds, and work with hospitals and stakeholders to refine the measure specifications and adjust voluntary reporting as necessary. A commenter noted that the internal analysis performed by CMS suggested an improved ability to meet the proposed measure reporting thresholds but emphasized that hospitals participating in voluntary reporting are likely those with more resources. A few commenters specifically suggested examining the impacts of the thresholds on small and rural hospitals and urged CMS to consider the lack of bed availability at skilled nursing facilities.

Response: We remain committed to monitoring hospital experiences on reporting the hybrid measures, particularly for small and rural hospitals and for hospitals/facilities with fewer resources, and working with stakeholders toward future measure refinement and improvement.

Comment: Many commenters raised concerns about the feasibility of mandatory reporting for the Hybrid Hospital-Wide Readmission (HWR) and Mortality (HWM) measures. Many commenters emphasized the need for CMS to address multiple technical and data processing issues before transitioning to mandatory reporting. A few commenters urged CMS to conduct further analysis and testing to ensure the measures are clinically valid and equitable before making them mandatory, particularly under the new reporting thresholds. Many commenters recommended extending voluntary reporting for at least one or two additional years to allow hospitals to address operational challenges, refine workflows, and ensure accurate data submission.

Response: We appreciate the commenters raising their concerns about mandatory reporting. In the CY 2025 OPPS/ASC final rule (89 FR 94495 through 94499), we addressed several technical and data processing issues in response to feedback we received from hospitals from the 2024 Voluntary Reporting period. After conducting an internal analysis on hospitals' submission data from this reporting period, we extended voluntary reporting for an additional two years to allow hospitals more time to address any technical issues, with mandatory reporting beginning with the FY 2028 payment determination (89 FR 94499). We refer readers to the CY 2025 OPPS/ASC final rule (89 FR 94495 through 94499) for further details and a discussion surrounding the challenges faced by hospitals, as well as our corresponding updates to the measures.

Our proposal to lower the thresholds to 70 percent and allow up to two missing lab values and two missing vital signs will provide hospitals with even greater flexibility to continue to address operational challenges and refine workflows as mandatory reporting approaches. We remain committed to monitoring hospitals' ability to report on these measures and will work with stakeholders to make any necessary measure refinements in the future.

Comment: A few commenters highlighted delays and inaccuracies regarding the calculation of CCDE values in the CMS feedback reports. A commenter acknowledged the “Update to Hospital-Specific Reports for Hybrid HWR and HWM Measures” that CMS released on June 2, 2025, but expressed concern that they would not receive the corrected results until well after the next filing deadline.

Response: As we stated in our Update to Hospital-Specific Reports for Hybrid HWR and HWM Measures,\355\ there was an issue impacting the reports released on May 14, 2025 that marked CCDE values as missing for excluded patients even though they were correctly submitted. This resulted in incorrect percentages of successfully linked vital signs and lab test results to be calculated and displayed on the Hospital- Specific Reports. We would like to notify commenters that as of June 9, 2025, the updated Hospital-Specific Reports with the corrected CCDE values and percentages are now available on the Measure Details Dashboard in the Hospital Quality Reporting (HQR) System.\356\

\355\ CMS. June 2025. Update to Hospital-Specific Reports for Hybrid HWR and HWM Measures. Available at: https://www.qualityreportingcenter.com/globalassets/listserves/2025/iqr/2025-57-ip_listserve_update-to-hsrs-for-hybrid-hwr-and-hwm-measures_06022025_vfinal-508.pdf.

\356\ eCQI Resource Center. (June 2025). Updated Hospital- Specific Reports for Hybrid HWR and HWM Measures Now Available. Available at: https://ecqi.healthit.gov/updated-hospital-specific-reports-hybrid-hwr-and-hwm-measures-now-available.

Comment: A few commenters suggested that CMS provide more robust support, such as more comprehensible hospital-specific reports, technical

guidance, and dedicated office hours for questions.

Response: We wish to note there are several additional ways for hospitals and EHR vendors to receive technical assistance to support implementation of these measures, which include CCSQ Support Central \357\ and ONC JIRA.\358\ Additional resources about the hybrid measures, including fact sheets, frequently asked questions, and webinar recordings, are available on our QualityNet website at: https://qualitynet.cms.gov/inpatient/measures/hybrid/resources. We will continue to identify opportunities to improve our responsiveness and the quality of available technical assistance.

\357\ Available at: https://cmsqualitysupport.servicenowservices.com/ccsq_support_central.

\358\ Available at: https://oncprojectracking.healthit.gov/olp/.

Comment: A few commenters noted a lack of transparency regarding the discussion surrounding challenges and outcomes experienced by hospitals during the voluntary submission period for discharges in 2024 Voluntary Reporting. A commenter requested public release of this information before making reporting mandatory to allow hospitals the chance to learn from the data that resulted from this reporting period.

Response: We received feedback directly from hospitals via email and help desk questions, in addition to soliciting public comment on the CY 2025 OPPS/ASC proposed rule (89 FR 59502) regarding challenges faced by hospitals when reporting on these measures. We refer the commenter to the CY 2025 OPPS/ASC final rule (89 FR 94495 through 94499) for further details and a discussion surrounding the challenges faced by hospitals, as well as our corresponding updates to the measures. In addition, we will continue to provide hospital-specific reports to allow hospitals to learn from the data resulting from the prior reporting period.

Comment: A few commenters suggested that, if CMS retains the hybrid measures as mandatory for FY 2028, CMS should remove any completeness thresholds, until it can perform a thorough analysis of submissions during the voluntary period. A commenter recommended that CMS maintain the mandatory reporting requirement, while postponing the requirement to meet the data completeness thresholds until reporting and measure definition issues with the inclusion of MA patients are resolved. A few commenters suggested postponing mandatory reporting until hospitals achieve a threshold of 90 percent, as commenters were concerned with the validity of a 70 percent threshold. A commenter recommended CMS allow hospitals to submit data using the 70 percent threshold for internal feedback and data analysis only but avoid any payment update penalties or publicly reporting these results until data completeness improves significantly.

Response: We thank the commenters for their recommendations. Based on our internal analysis, we concluded that a 70 percent threshold significantly improves hospitals' ability to meet the reporting requirements while still maintaining statistical validity. At this time, we are requiring mandatory reporting beginning with the FY 2028 payment determination as hospitals were already given an extended voluntary reporting period to properly adjust to reporting on these measures in the CY 2025 OPPS/ASC Final Rule (89 FR 94499). Mandatory reporting will provide CMS with a larger data set, especially with the 70 percent thresholds, that will be useful to analyze hospital performance and ensure all patients are being provided quality care. We remain committed to monitoring hospitals' ability to report on these measures and intend to raise these thresholds accordingly as hospital performance improves.

Comment: Several commenters expressed concerns about the inclusion of MA patients in the measure cohorts, noting challenges with capturing Medicare Beneficiary Identifiers (MBIs) for MA patients, as these identifiers are often incomplete or missing due to third-party data integration issues or format variability in claims documentation. A few commenters recommended that CMS monitor the impact of MA inclusion on data completeness and consider temporary exclusions or adjustments where MA data completeness is lower. Additionally, a few commenters suggested stratifying performance data by coverage type to ensure fair assessment and providing technical guidance to improve MBI capture rates. A commenter urged CMS to provide hospitals with feedback reports for at least the first reporting period in which MA patients are included, before the inclusion of MA patients becomes mandatory.

Response: We thank commenters for their feedback regarding reporting MBIs for MA patients and acknowledge these challenges. We note that the inclusion of MA patients was finalized in the FY 2024 IPPS/LTCH PPS final rule beginning with the FY 2027 payment determination (88 FR 59161 through 59168) which corresponds to the performance period of July 1, 2024 through June 30, 2025. We subsequently made the submission of CCDE and linking variable requirements for this reporting period voluntary per the CY 2025 OPPS/ ASC final rule (89 FR 94499).

We expanded the measure cohort to include MA patients because MA beneficiary enrollment has been rapidly increasing as a share of overall beneficiaries. As of March 2025, 51 percent of Medicare beneficiaries--or 35.1 million people--were enrolled in MA plans.\359\ The Congressional Budget Office estimates that by 2034, 64 percent of beneficiaries will be covered by MA plans. MA coverage also varies across counties and states with lower enrollment in rural states.\360\ Including MA beneficiaries in hospital outcome measures will help ensure that hospital quality is measured across all Medicare beneficiaries.361 362

\359\ Centers for Medicare & Medicaid Services. (2025). Medicare Enrollment Dashboard. Available at: https://data.cms.gov/tools/medicare-enrollment-dashboard. Accessed: July 11, 2025.

\360\ Freed M, Biniek JF, Damico A, Neuman T. Medicare Advantage in 2024: Enrollment Update and Key Trends. Kaiser Family Foundation. Accessed July 11, 2025. Available at: https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-enrollment-update-and-key-trends/.

\361\ Ochieng N and Biniek JF. Beneficiary Experience, Affordability, Utilization, and Quality in Medicare Advantage and Traditional Medicare: A Review of the Literature. Accessed July 11, 2025. Available at: https://www.kff.org/medicare/report/beneficiary-experience-affordability-utilization-and-quality-in-medicare-advantage-and-traditional-medicare-a-review-of-the-literature/.

\362\ Medicare Payment Advisory Commission. The Medicare Advantage program: Status Report and mandated report on dual- eligible special needs plans. Accessed July 11, 2025. Available at: https://www.medpac.gov/wp-content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_Ch12_SEC.pdf.

As July 1, 2024 through June 30, 2025 is the first performance period in which MA patients were included, we will examine the data submitted by hospitals and evaluate the need for measure adjustments to ensure successful submission of MBIs. In addition, we will include MA data in the feedback reports for admissions July 1, 2024 through June 30, 2025 performance period to allow hospitals to address any reporting issues.

Comment: Several commenters highlighted technical and operational barriers to meeting the reporting requirements for hybrid measures. A few commenters noted challenges with capturing specific clinical data elements, such as vital signs and lab values, due to variability in EHR systems and coding standards. Commenters highlighted specific

examples such as “first heart rate” being marked as missing due to hospitals recording the first measurement as a “pulse” and the inability to submit platelets due to a different unit (femtoliter) being used. A few commenters emphasized the complexity and specificity required of the linking variables, and stated it leaves no margin for error.

A few commenters also noted that the narrow 24-hour lookback period for CCDE collection may exclude relevant clinical data, particularly for transfer patients and patients with extended emergency department or observation stays as these tests are often performed at the originating facility or during the ED/observation period and may not be repeated within the 24-hour window. A commenter expressed their desire for patients under observation status to have their lab values extracted within 24 hours before inpatient status to avoid redundant labs being drawn when a patient is transferred. Another commenter proposed extending the lookback period to 48 hours prior to admission.

Response: We thank the commenters for their feedback regarding technical and operational barriers to meeting reporting requirements for the hybrid measures. We refer readers to the CY 2025 OPPS/ASC final rule (89 FR 94495 through 94499) in which many of these issues were raised by commenters and discussed in more detail.

We recognize that variability in EHR systems and coding standards, such as the documentation of heart rate, present challenges with capturing CCDEs. However, our approach to CCDEs allows hospitals to map codes and is not specific to any particular EHR system, meaning that all hospitals should be able to successfully capture and submit CCDEs. Additionally, by lowering the reporting thresholds, particularly the allowance of up to two missing lab values and two missing vital signs, we provide hospitals with more flexibility regarding these potential technical challenges. Specific to concerns that platelets counted as “missing” in performance reports, we note that beginning with July 1, 2023, through June 20, 2024 performance period data, associated with FY 2026 payment determination, platelet laboratory test values with the unit of femtoliter (fL) were accepted.

Regarding concerns about the current timing requirements for CCDEs, we have made updates to address these points. Specifically, we extended the anchor timestamp requirement for CCDEs to increase flexibility regarding data collection. We refer readers to the eCQI Resource Center for more details on the measure specifications.363 364 We will continue to work with stakeholders and monitor hospital feedback to address any technical and operational issues with reporting on the hybrid measures.

\363\ eCQI Resource Center. May 2025. Core Clinical Data Elements for the Hybrid Hospital-Wide Readmission Measure with Claims and Electronic Health Record Data--HWR. Available at: https://ecqi.healthit.gov/ecqm/hosp-inpt/2026/cms0529v6?qt-tabs_measure=specifications-and-data-elements.

\364\ eCQI Resource Center. May 2025. Core Clinical Data Elements for the Hybrid Hospital-Wide All-Condition All-Procedure Risk-Standardized Mortality Measure--HWM. Available at: https://ecqi.healthit.gov/ecqm/hosp-inpt/2026/cms0844v6?qt-tabs_measure=specifications-and-data-elements.

Comment: A few commenters raised broader concerns about the validity and impact of the hybrid measures. A few commenters questioned whether the measures accurately reflect patient care and outcomes, particularly given challenges with data completeness and linking variables.

Response: The hybrid measures are designed to provide a more comprehensive assessment of patient care and outcomes by combining administrative claims data with clinical data extracted from EHRs, allowing us to account for important clinical variables that are not available in claims data alone. By incorporating these additional data points, hybrid measures aim to improve risk adjustment and provide a more detailed understanding of hospital performance, ultimately supporting efforts to improve patient care. We will continue working with stakeholders and monitoring hospitals' experiences with reporting on these measures.

Comment: A few commenters raised concerns about the potential unintended consequences of readmission measures as a whole, such as increased mortality rates and disproportionate penalties for hospitals serving low-income populations.

Response: We acknowledge commenters' concerns about readmission measures. The Hybrid HWM measure was developed as a balancing measure to the Hybrid HWR measure to decrease the potential unintended consequence of increasing mortality due to reducing readmissions. We note that since the implementation of the condition-specific mortality and readmission measures, there has been a reduction in readmission rates, without an accompanying increase in mortality.\365\ Additionally, the hybrid measures aim to improve upon existing readmission measures by incorporating clinical data that better accounts for patient complexity and social risk factors. This enhanced risk adjustment aims to ensure a more comprehensive evaluation of hospital performance, particularly for hospitals serving low-income populations.

\365\ Ko, D., Khera, R., Lau, G. et al. Readmission and Mortality After Hospitalization for Myocardial Infarction and Heart Failure. JACC. 2020 Feb, 75 (7) 736-746. https://doi.org/10.1016/j.jacc.2019.12.026.

Comment: A commenter urged CMS to remove the hybrid measures altogether until standardized EHR interoperability and infrastructure are universally available, and they shared that these measures present a disproportionate burden on hospitals with little clinical value due to costly manual abstraction of certain data elements and unfairly penalize smaller resource-constrained hospitals. Another commenter emphasized the burden of reporting this measure and urged CMS to simplify the measure requirements due to the complexity and labor costs associated with implementation that take away from direct patient care, especially during ongoing workforce shortages.

Response: We thank the commenters for their input. While we recognize that standardized EHR interoperability is not yet universally available, the hybrid measures are an important step toward leveraging clinical data to improve quality measurement. The hybrid measures utilize EHR data for risk adjustment, based on stakeholder feedback that the claims-only measures did not adequately account for clinical risk factors.

We acknowledge the concerns about the reporting burden associated with hybrid measures, particularly with ongoing workforce shortages. The hybrid measures are designed to leverage data that hospitals are already collecting as part of routine clinical care, which should help minimize additional workload. We have already taken steps to reduce manual abstraction by promoting the use of automated data extraction from EHRs and will continue working with stakeholders to refine the measures as necessary.

After consideration of the public comments we received, we are finalizing our proposal to decrease the hybrid measures CCDE and linking variable submission thresholds beginning with the FY 2028 payment determination. 8. Hospital IQR Program Extraordinary Circumstances Exception (ECE) Policy a. Background

Under our current Extraordinary Circumstances Exception (ECE)

regulations, we have granted exceptions with respect to quality data reporting requirements in the event of extraordinary circumstances beyond the control of a hospital (42 CFR 412.140(c)(2)). An exception may be granted for extraordinary circumstances including, but not limited to, natural disasters or systemic problems with data collection systems.\366\ We refer readers to 42 CFR 412.140(c)(2) for our current ECE regulations, as well as the FY 2012 IPPS/LTCH PPS final rule (76 FR 51651), FY 2014 IPPS/LTCH PPS final rule (78 FR 50836), and FY 2015 IPPS/LTCH PPS final rule (79 FR 50277) for further background and details of our ECE policy. We also refer readers to the QualityNet website for the specific requirements for submission of an ECE request in the Hospital IQR Program.\367\

\366\ Centers for Medicare & Medicaid Services (CMS) Quality Program Extraordinary Circumstances Exceptions (ECE) Request Form. (2025). QualityNet. Available at: https://qualitynet.cms.gov/files/677e843f50ed8df7419f60e1?filename=HQR_ECE_Req_Form_CY_2025.pdf.

\367\ https://qualitynet.cms.gov/inpatient/iqr/participation#tab3.

Our ECE policy provides flexibility for Hospital IQR Program participants to ensure continuity of quality care delivery and measure reporting in the event of an extraordinary circumstance. For instance, we recognize that, in circumstances where a full exception is not applicable, it is beneficial for a hospital to report data later than the reporting deadline. Delayed reporting authorized under our ECE policy allows temporary relief for a hospital experiencing an extraordinary circumstance while preserving the benefits of data reporting, such as transparency and informed decision-making for beneficiaries and providers alike. Accordingly, we proposed to update our regulations to specify that an ECE could take the form of an extension of time for a hospital to comply with a data reporting requirement if CMS determines that this type of relief would be appropriate under the circumstances. b. Update to the Extraordinary Circumstances Exception (ECE) Policy for the Hospital IQR Program

In the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18344), we proposed to update the current ECE policy codified at 42 CFR 412.140(c)(2) to include extensions of time as a form of relief and to further clarify the policy. Specifically, at proposed Sec. 412.140(c)(2)(i), we proposed that CMS may grant an ECE with respect to reporting requirements in the event of an extraordinary circumstance-- defined as an event beyond the control of a hospital (for example a natural or man-made disaster such as a hurricane, tornado, earthquake, terrorist attack, or bombing)--that affected the ability of the hospital to comply with one or more applicable reporting requirements with respect to a fiscal year.

We proposed (90 FR 18344) that the steps for requesting or granting an ECE would remain the same as the current ECE process, detailed by CMS at the QualityNet website or a successor website.\368\ At proposed Sec. 412.140(c)(2)(ii)(A), we proposed that a hospital may request an ECE within 30 calendar days of the date that the extraordinary circumstance occurred. Our current policy allows a request within 90 days; however, this change would align the Hospital IQR policy with CMS systems implementation requirements across all quality reporting programs. Under this proposed codified policy, we clarified that CMS retains the authority to grant an ECE as a form of relief at any time after the extraordinary circumstance has occurred. At proposed Sec. 412.140(c)(2)(ii)(B), we proposed that CMS would notify the requestor with a decision in writing. In the event that CMS grants an ECE to the hospital, the written decision will specify whether the hospital is exempted from one or more reporting requirements or whether CMS has granted the hospital an extension of time to comply with one or more reporting requirements.

\368\ https://qualitynet.cms.gov/inpatient/iqr/participation#tab3.

Additionally, at Sec. 412.140(c)(2)(iii), we proposed that CMS may grant an ECE to one or more hospitals that have not requested an ECE if CMS determines that: a systemic problem with a CMS data collection system directly impacted the ability of the hospital to comply with a quality data reporting requirement, or that an extraordinary circumstance has affected an entire region or locale. As is the case under our current policy, any ECE granted will specify whether the affected hospitals are exempted from one or more reporting requirements or whether CMS has granted the hospitals an extension of time to comply with one or more reporting requirements.

This updated ECE policy would provide further reporting flexibility for hospitals and clarify the ECE process.

We invited public comment on our proposals.

Comment: Many commenters expressed support for CMS' proposal to update and codify the ECE policy across hospital quality reporting programs. Commenters appreciated CMS' efforts to codify its authority to grant reporting deadline extensions or exceptions in response to extraordinary circumstances, recognizing this flexibility as critical for hospitals facing natural disasters or other emergencies. Commenters also noted that codifying updates to the ECE policy would provide hospitals with greater clarity and consistency in navigating quality reporting requirements during extraordinary events. A few commenters specifically supported the proposal to update and codify CMS' ability to grant ECEs to hospitals even if those hospitals have not requested an exception. A commenter supported the proposal to allow hospitals 30 days to submit an ECE request.

Response: We thank the commenters for their support.

Comment: Several commenters urged CMS to explicitly include cyberattacks as qualifying extraordinary circumstances under the ECE policy. Commenters emphasized that cyberattacks are increasingly frequent in the healthcare industry and can debilitate data systems for extended periods, disrupting hospitals' data collection and reporting. A few commenters highlighted the burden associated with reverting to manual documentation practices during cyberattacks and the challenges of later integrating this data into electronic systems. A commenter urged CMS to provide additional clarification on its process for approving ECE requests related to cyberattacks, including publicly posting any supplemental documentation that would aid in requesting an ECE.

Response: We thank commenters for their recommendations. We note that extraordinary circumstances are not limited to the examples provided in Sec. 412.140(c)(2). We have received and accepted multiple ECE requests due to cyberattacks across reporting programs. We recommend that hospitals submit an ECE request anytime an event beyond the control of a hospital affects the ability of the hospital to comply with one or more reporting requirements with respect to a fiscal year, regardless of whether it was included in the examples provided in the CFR language. We note that QualityNet provides the ECE Request Form, ECE Information and Resources document, and ECE Quick Reference document, all of which are updated as necessary. We will continue to update these documents to provide updated information, resources, and references.\369\

\369\ We refer readers to the Hospital IQR Program ECE web page, available at: https://qualitynet.cms.gov/inpatient/iqr/participation#tab3 for reference materials.

Comment: Several commenters, while supporting this proposal, cautioned CMS to avoid defaulting to extensions in cases where broader relief is warranted, and ensure reporting extensions are not disproportionately utilized in place of exceptions. Commenters also urged CMS to recognize that a mere extension is not always sufficient, as the reliability and integrity of data collected during extraordinary events may be compromised. A few commenters urged CMS to provide details on how the determination of an exception versus an extension will be made to ensure transparency. A commenter noted this transparency will allow hospitals to better prepare for response times and required resources based on whether they are likely to receive an exemption or an extension.

Response: We appreciate commenters' concerns regarding the use of extensions for ECE requests. We note that we do not intend to replace exemptions with extensions and acknowledge that extensions are not always appropriate or technically possible. The determination of an exception versus an extension will be approved on a case-by-case basis based on the specifics of the circumstance affecting the hospital.

Comment: A commenter supported the inclusion of the Severe Sepsis and Septic Shock Management Bundle (SEP-1) measure within the ECE process and recommended that newly mandated measures, such as the Hospital-Level Total Hip Arthroplasty/Total Knee Arthroplasty Patient- Reported Outcome-Based Performance measure (THA/TKA PRO-PM), be incorporated into the ECE policy annually.

Response: We note that this policy is inclusive of any measures within the program, regardless of when the measure was adopted.

Comment: Several commenters did not support the reduced timeframe for hospitals to request an ECE from the current 90-day period to 30 days following an extraordinary circumstance. Commenters stated that the proposed 30-day window is insufficient for hospitals to respond to a crisis, assess the impact on data collection and systems, and submit a request for an exception. Commenters highlighted examples, such as severe flooding and ransomware attacks, where hospitals were fully engaged in patient care and operational recovery, leaving little capacity to prioritize administrative tasks like ECE requests. A few commenters expressed concern that the reduced timeframe encourages hospitals to divert critical staff at a time they are needed most and would force them to prioritize paperwork over patient care, undermining the goals of the CMS quality reporting and value programs. A commenter requested that CMS review past ECE submissions to assess the feasibility for hospitals to meet a 30-day response deadline and disclose its justification for the readjustment.

Several commenters urged CMS to retain the current 90-day window, which they stated provides a more reasonable timeframe for hospitals to recover and assess the impact of extraordinary events. A commenter suggested a compromise of 60 days to provide hospitals with more flexibility while still encouraging timely notification to CMS. The commenter also urged CMS to retain discretion to accept late requests in extraordinary circumstances, such as if communication lines are down for an extended period, to ensure that hospitals are not unfairly punished for failing to report data during a crisis.

Response: We appreciate commenters' concern regarding the reduced timeframe for hospitals to submit an ECE request. We recognize that hospitals may not have the ability to assess the impact on quality data submissions and complete the necessary paperwork within 30 days of the extraordinary circumstance. Due to concerns regarding hospitals' ability to complete the ECE request within 30 days of the extraordinary circumstance, we are modifying the timeframe to allow for 60 days to submit an ECE request. We believe this timeframe will provide sufficient time for hospitals to assess the impact on quality reporting without disrupting operational and care needs.

After consideration of the public comments, we will finalize our ECE proposals as proposed, except for the proposed 30-day deadline. In lieu of the 30-day deadline, we will finalize an ECE deadline of 60 days following an extraordinary circumstance. We are making conforming amendments to our regulation text (at Sec. 412.140(c)(2)(ii)(A)) to reflect this policy change.

The PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program, authorized by section 1866(k) of the Act, applies to hospitals described in section 1886(d)(1)(B)(v) of the Act (referred to as “PPS- Exempt Cancer Hospitals” or “PCHs”). We refer readers to the FY 2013 IPPS/LTCH PPS final rule (77 FR 53555 through 53567) for a general overview of the PCHQR Program. We also refer readers to 42 CFR 412.24 for codified PCHQR Program requirements. 2. PCHQR Program Measures a. Removal of the Hospital Commitment to Health Equity Measure Beginning With CY 2024 Reporting Period/FY 2026 Program Year and for Subsequent Years

We refer readers to the FY 2024 IPPS/LTCH PPS final rule (88 FR 59204 through 59210) where we adopted the Hospital Commitment to Health Equity (hereinafter referred to as HCHE) measure into the PCHQR Program. In the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18344 through 18345), we proposed to remove the HCHE measure beginning with the CY 2024 reporting period/FY 2026 program year due to the costs associated with achieving a high score on the measure outweighing the benefit of its continued use in the program. When adopted, we intended the collection of data described in the five domains of this measure to provide hospital leadership with meaningful and actionable health data to drive quality improvements to eliminate health disparities. Based on feedback received from hospitals as well as a re-focus on clinical outcome measures, for which the HCHE measure, as a structural measure, does not directly measure clinical outcomes, the burden of collecting this measure may outweigh the benefits. Removal of this measure would alleviate an estimated annual burden of approximately 2 hours, at a cost of $90, across all PCHs (88 FR 59317).

One of the goals of the PCHQR Program is to move forward in the least burdensome manner possible, while maintaining a parsimonious set of the most meaningful quality measures and continuing to incentivize improvement in the quality of care provided to patients. Removing this measure from the PCHQR Program is an effective way to accomplish this goal. Our priority is a re-focus on measurable clinical outcomes as well as identifying quality measures on topics of prevention and well- being. It may be costly for hospitals to continue reporting on the HCHE measure, and removal of this measure would make room in the program's measure set to enhance the program's focus on measurable clinical outcomes. We acknowledge that some hospitals may have expended resources to implement some or all of the activities described in the HCHE measure

attestation statements in order to be able to attest “yes” for measure reporting purposes, however, hospitals that had already implemented such activities prior to adoption of the measure would have been able to attest “yes” without expending similar resources.

We stated that if the proposed removal is finalized, any HCHE measure data received by CMS would not be used for public reporting purposes.

We invited public comments on our proposal to remove the HCHE measure from the PCHQR Program beginning with the CY 2024 reporting period/FY 2026 program year.

We received many general comments regarding our proposed removal of the HCHE measure. We focus here on comments specific to removing this measure from the PCHQR Program. For our responses to general comments, we refer readers to our responses in the Hospital IQR Program section of this final rule (section X.C.4.a.).

Comment: A commenter expressed concern regarding removal of the HCHE measure, stating that public reporting on hospital performance fosters transparency and helps patients make informed decisions about where to seek care, which is especially important for patients with complex conditions such as cancer.

Response: We thank the commenter for sharing this concern. We are removing these measures from the PCHQR Program to reduce the burden incurred by patients and providers for screening, data storage, and data reporting. We note that the other quality measures in the PCHQR Program continue to be publicly reported to allow patients to make informed decisions about their care.

Comment: A commenter recommended that CMS consider ways that health equity can be integrated into cancer-specific outcome, patient experience, or quality-of-life measures.

Response: We thank this commenter for this recommendation and will consider this input in future measure development. PCHs may use a range of strategies to ensure positive outcomes for their patients and we encourage PCHs to pursue strategies that support efficient and high- quality care for all patients.

After consideration of the public comments we received, we are finalizing the removal of the HCHE measure as proposed. b. Removal of Two Social Drivers of Health Measures Beginning With CY 2024 Reporting Period/FY 2026 Program Year and for Subsequent Years

In the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18345), we proposed to remove two social drivers of health (SDOH) process measures from the PCHQR Program beginning with the CY 2024 reporting period/FY 2026 program year:

Screening for Social Drivers of Health measure (adopted in the FY 2024 IPPS/LTCH PPS final rule (88 FR 59210 through 59219)); and

Screen Positive Rate for Social Drivers of Health measure (adopted in the FY 2024 IPPS/LTCH PPS final rule (88 FR 59219 through 59222)).

We proposed to remove the SDOH measures beginning with the CY 2024 reporting period/FY 2026 program year under removal Factor 8, the costs associated with the measure outweigh the benefit of its continued use in the program (90 FR 18345). We have previously heard from some hospitals concerned with the costs and resources associated with screening patients via manual processes, manually storing such data, training hospital staff, and altering workflows for these measures. As stated in section XIII.B.5.d of the proposed rule, removal of Screening for Social Drivers of Health measure would alleviate an estimated annual burden for hospitals and patients of 29 hours, at a cost of $773 for 6 PCHs for the FY 2026 program year and 103 hours, at a cost of $2,699, across all PCHs for the FY 2027 program year (90 FR 18411). Also, as stated in section XIII.B.5.e. of the proposed rule, removal of Screen Positive Rate for Social Drivers of Health measure would alleviate an estimated annual burden of 1 hour, at a cost of $55 for 6 PCHs for the FY 2026 program year and 2 hours, at a cost of $111, across all PCHs for the FY 2027 program year (90 FR 18411).\370\ Further, we noted that these measures document an administrative process and report aggregate level results, and do not shed light on the extent to which providers are ultimately connecting patients with resources or services and whether patients are benefiting from these screenings (90 FR 18345). We stated that the costs of the use of these measures in the PCHQR Program outweigh the benefits to beneficiaries and providers at this time. Removal of these measures would alleviate the burden on hospitals to manually screen each patient and submit data each reporting cycle, allowing hospitals to focus resources on measurable clinical outcomes. This will also remove the patient burden associated with repeated SDOH screenings across multiple healthcare facilities. We acknowledge that some hospitals may have expended resources to implement SDOH screenings, however, hospitals that had already implemented such screenings prior to adoption of the measures would not have expended similar resources. The objectives of the PCHQR Program continue to incentivize the improvement of care quality and health outcomes for all patients through transparency and use of appropriate quality measures.

\370\ We note that in the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18345) we state that “In the FY 2023 and FY 2024 IPPS/LTCH PPS final rules, we estimated a total annual burden of 101 hours across all PCHs at a cost of $2,092 to screen all patients in accordance with measure specifications for Screening for Social Drivers of Health measure (88 FR 59317 through 59318). . For Screen Positive Rate for Social Drivers of Health measure, we estimated a total annual burden of 2 hours across all PCHs at a cost of $90 (88 FR 59318).” We have updated the burden in this final rule to more accurately reflect the estimated impact.

We stated in the proposed rule (90 FR 18345), that, if finalized, any SDOH measure data received by CMS would not be used for public reporting purposes.

We invited public comment on our proposal to remove the SDOH measures from the PCHQR Program beginning with the CY 2024 reporting period/FY 2026 program year.

We received many general comments regarding our proposed removal of the SDOH measures. We focus here on comments specific to removing these measures from the PCHQR Program. For our responses to general comments we refer readers to our responses in the Hospital IQR Program section of this final rule (section X.C.4.c.).

Comment: A few commenters recommended that CMS consider how social risk factors can be integrated into future outcome, patient experience, or quality-of-life measures specific to cancer treatment. A commenter stated that patients with cancer are at increased risk for financial distress, which can impact their quality of life, mental health, and satisfaction with social activities and relationships. The commenter emphasized the importance of addressing social needs as part of broader efforts to improve health and well-being, particularly for vulnerable populations like cancer patients.

Response: We appreciate commenters' concerns regarding the role SDOH can have on patient outcomes and will consider this risk in development of future measures. We expect PCHQR Program participants to continue to provide appropriate, high-quality care to all their patients. We agree that

addressing social needs is an important effort in improving health and well-being for patients, particularly for vulnerable populations like patients with cancer, and that healthcare outcomes may be different for those experiencing financial distress. Hospitals may find ways to address these concerns in their workflow, including connecting patients with community resources that would address patients' needs and provide appropriate referrals, because they recognize the importance of these items. The removal of this requirement should not preclude hospitals from collecting and using this information. Hospitals will still be able to screen patients for SDOH related concerns, but they will not be required to report on these screenings or results.

After consideration of the public comments we received, we are finalizing the removal of the two SDOH measures as proposed. c. Summary of Adopted PCHQR Program Measures for the CY 2026 Reporting Period/FY 2028 Program Year and Subsequent Years

Table X.D.-01 summarizes the finalized measures for the PCHQR Program measure set beginning with the CY 2026 reporting period/FY 2028 program year. BILLING CODE 4120-01-P [GRAPHIC] [TIFF OMITTED] TR04AU25.278

Under section 1866(k)(4) of the Act, the Secretary must establish procedures for making data submitted under the PCHQR Program available to the public. a. Summary of Previously Finalized Public Display Policies for the PCHQR Program

Table X.D.-02 summarizes our current public display requirements for the PCHQR Program measures. The measure performance data are made publicly available on a CMS website, which is currently the Provider Data Catalog, available at: https://data.cms.gov/provider-data/. [GRAPHIC] [TIFF OMITTED] TR04AU25.279

BILLING CODE 4120-01-C b. Public Reporting of PCHQR Data on Both the Provider Data Catalog and Compare Tool Website or Successor Websites

In FY 2022 IPPS/LTCH PPS final rule, we codified at 42 CFR 412.24(f) that data submitted by PCHs under the PCHQR Program are to be made publicly available on the Provider Data Catalog website (https://data.cms.gov/provider-data/) and that PCHs have an opportunity to review their data prior to publication during a preview period via the Hospital Quality Reporting (HQR) system (https://hqr.cms.gov/hqrng/login) with timelines for review published on the QualityNet website (https://qualitynet.cms.gov) and applicable listservs (86 FR 45435 through 45437; 86 FR 45518 through 45519). In the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18347), we proposed to modify the public reporting requirements of the PCHQR Program to enable us to publicly report PCHQR data on both the Provider Data Catalog and the Compare tool (https://www.medicare.gov/care-compare/) or their successor websites. We also proposed to make corresponding changes to the regulation text at Sec. 412.24(f).

In 2020, CMS launched the Provider Data Catalog and the Compare tool websites to replace previous CMS

healthcare comparison tools including Hospital Compare. Both the Provider Data Catalog and the Compare tool are valuable tools that allow patients, caregivers and families, providers, and other interested parties to find and compare information about the quality of care at participating PCHs and hospitals, respectively.

The Provider Data Catalog allows for downloading, exploration, and analysis of performance data. However, the Compare tool displays performance data in a format that is more user-friendly and more easily understood by consumers than the Provider Data Catalog. Data displayed on the Provider Data Catalog is a valuable resource that allows consumers, providers, and researchers to conduct analyses and compare quality of care delivery among PCHs. However, displaying data submitted by PCHs under the PCHQR Program in a more user-friendly format and making data more widely available would support consumer engagement and promote greater transparency. The Compare tool already includes quality measure information about hospitals participating in the Hospital Inpatient Quality Reporting Program, Hospital Outpatient Quality Reporting Program, Hospital-Acquired Condition Reduction Program, Hospital Readmissions Reduction Program, Inpatient Psychiatric Facility Quality Reporting Program, and Medicare Promoting Interoperability Program.

Therefore, to support greater data transparency and consumer engagement and to align with the other hospital quality programs, we proposed to modify the public reporting requirements of the PCHQR Program to enable us to publicly report data from the PCHQR Program on both the Provider Data Catalog and the Compare tool (https://www.medicare.gov/care-compare) or their successor websites. We also proposed corresponding changes to the regulation text at Sec. 412.24(f) replacing references to “Provider Data Catalog” with “CMS websites”.

We invited public comments on our proposal to publicly report PCHQR data on both the Provider Data Catalog and Compare tool or successor websites.

Comment: Several commenters supported the proposal to publicly report data from the PCHQR Program on the Compare tool in addition to the Provider Data Catalog. A few of these commenters noted that data displayed on the Compare website would be more user friendly, thus promoting interpretability and transparency. Additionally, a few commenters highlighted that presenting quality-of-care metrics in a more accessible format on the Compare website would empower patients, families, and referring providers to make well-informed decisions about where to seek intensive cancer care. A commenter noted that choosing a cancer care provider is a critical decision and patients should have easy access to quality-of-care data to support care decisions.

Response: We thank commenters for their support. We agree that publishing data on the Compare website will increase interpretability and transparency, which is critical for consumer engagement.

Comment: A commenter stated that PCHQR data should only be compared between hospitals in the PCHQR Program to maintain data validity and accuracy.

Response: We thank this commenter for their support and recommendation. We proposed to publish data on the Compare tool, in addition to the Provider Data Catalog, to allow consumers to more readily compare quality of care delivery among PCHs. We will consider how best to display the data so that consumers can readily understand and compare data between PCHs.

Comment: A commenter recommended that CMS re-engage stakeholders before making the PCHQR data using the updated 2022 NHSN rebaseline publicly available.

Response: We will consider this commenter's recommendation to re- engage stakeholders before making data using the updated 2022 NHSN baseline publicly available, however, we reiterate that PCHs have an opportunity to review their data prior to publication during a preview period via the Hospital Quality Reporting (HQR) system.

After consideration of the public comments received, we are finalizing our proposal to publicly report PCHQR data on both the Provider Data Catalog and the Compare tool or their successor websites. 4. Codification of Updates to the Extraordinary Circumstances Exception Policy for the PCHQR Program a. Background

Under our current Extraordinary Circumstances Exception (ECE) regulations, we have granted exceptions with respect to quality data reporting requirements in the event of extraordinary circumstances beyond the control of the PCH (42 CFR 412.24(e)). An exception may be granted for extraordinary circumstances including, but not limited to, natural disasters or systemic problems with data collection systems.\371\ We refer readers to 42 CFR 412.24(e) for our current ECE regulations, as well as FY 2014 IPPS/LTCH PPS final rule (78 FR 50848); FY 2018 IPPS/LTCH PPS final rule (82 FR 38424 through 38425); and FY 2019 IPPS/LTCH PPS final rule (83 FR 41623 through 41624) for further background and details of our ECE policy. We also refer readers to the QualityNet website for the specific requirements for submission of an ECE request in the PCHQR Program.\372\

\371\ Centers for Medicare & Medicaid Services (CMS) Quality Program Extraordinary Circumstances Exceptions (ECE) Request Form. (2025). QualityNet. Available at: https://qualitynet.cms.gov/files/677e843f50ed8df7419f60e1?filename=HQR_ECE_Req_Form_CY_2025.pdf.

\372\ CMS QualityNet. Available at: https://qualitynet.cms.gov/pch/pchqr/participation#tab2.

Our ECE policy provides flexibility for PCHs to ensure continuity of quality care delivery and measure reporting in the event of an extraordinary circumstance. For instance, we recognize that in circumstances where a full exception is not applicable, it is beneficial for a PCH to report data later than the reporting deadline. Delayed reporting authorized under our ECE policy allows temporary relief for a PCH experiencing an extraordinary circumstance while preserving data reporting such as transparency and informed decision- making for beneficiaries and providers alike. Accordingly, in the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18347 through 18348), we proposed to update our regulations to specify that an ECE could take the form of an extension of time for a PCH to comply with a data reporting requirement if CMS determines that this type of relief would be appropriate under the circumstances. b. Update to the Extraordinary Circumstances Exception (ECE) Policy for the PCHQR Program

In the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18348), we proposed to update the current ECE policy codified at 42 CFR 412.24(e) to include extensions of time as a form of relief and to further clarify the policy. Specifically, at Sec. 412.24(e)(1), we proposed that CMS may grant an ECE with respect to reporting requirements in the event of an extraordinary circumstance--defined as an event beyond the control of a PCH (for example a natural or man-made disaster such as a hurricane, tornado, earthquake, terrorist attack, or bombing)--that affected the ability of the PCH to comply with one or more

applicable reporting requirements with respect to a fiscal year.

We proposed that the process for requesting or granting an ECE would remain the same as the current ECE process, detailed by CMS at the QualityNet website or a successor website.\373\ At Sec. 412.24(e)(2)(i), we proposed that a PCH may request an ECE within 30 calendar days of the date that the extraordinary circumstance occurred. Our current policy allows a request within 90 days; however, this proposed change would align the PCHQR policy with CMS systems implementation requirements across all quality reporting programs. Under this proposed codified policy, we clarify that CMS retains the authority to grant an ECE as a form of relief at any time after the extraordinary circumstance has occurred. At Sec. 412.24(e)(2)(ii), we proposed that CMS notify the requestor with a decision in writing, via email. In the event that CMS grants an ECE to the PCH, the written decision will specify whether the PCH is exempted from one or more reporting requirements or whether CMS has granted the PCH an extension of time to comply with one or more reporting requirements.

\373\ https://qualitynet.cms.gov/inpatient/iqr/participation#tab3.

Additionally, at Sec. 412.24(e)(3), we proposed that CMS may grant an ECE to one or more PCHs that have not requested an ECE if CMS determines that: a systemic problem with CMS data collection systems directly impacted the ability of the PCH to comply with a data submission; or that an extraordinary circumstance has affected an entire region or locale. As is the case under our current policy, any ECE granted will specify whether the affected PCHs are exempted from one or more reporting requirements or whether CMS has granted the PCHs an extension of time to comply with one or more reporting requirements. At Sec. 412.24(e)(4), we proposed that CMS may grant or deny an ECE based on the evaluation of the extraordinary circumstance including, but not limited to, whether the extraordinary circumstance occurred beyond the control of the PCH and affected the PCH's ability to meet data reporting requirements by the specified deadlines. We proposed that CMS will notify the PCH of a denial of an ECE in writing via email to be codified at Sec. 412.24(e)(5).

This proposed ECE policy would provide further reporting flexibility for PCHs and clarify the ECE process.

We invited public comment on our proposal to update the ECE policy for the PCHQR Program with corresponding updates to regulatory text at Sec. 412.24(e).

We received many general comments regarding our ECE-related proposals. We did not receive any comments specific to these updates for the PCHQR Program. For our responses to general comments we refer readers to our responses in the Hospital IQR Program section of this final rule (section X.C.8.). As discussed in section X.C.8 of this final rule in response to commenter concerns, we recognize that hospitals may not have the ability to assess the impact on quality data submissions and complete the necessary paperwork within 30 days of the extraordinary circumstance. Due to concerns regarding PCHs' ability to complete the ECE request within 30 days of the extraordinary circumstance and a commenter suggestion to increase to a 60-day deadline, we are modifying the timeframe to allow for 60 days to submit an ECE request. We believe this timeframe will provide sufficient time for PCHs to assess the impact on quality reporting without disrupting operational and care needs.

After consideration of the public comments, we will finalize our ECE proposals as proposed, except for the proposed 30-day deadline. In lieu of the 30-day deadline, we will finalize an ECE deadline of 60 days following an extraordinary circumstance. We are making conforming amendments to our regulation text (at Sec. 412.24(e)) to reflect this policy change.

The Long-Term Care Hospital Quality Reporting Program (LTCH QRP) is authorized by section 1886(m)(5) of the Act, and it applies to all hospitals certified by Medicare as Long-Term Care Hospitals (LTCHs). Section 1886(m)(5)(C) of the Act requires LTCHs to submit to the Secretary quality measure data specified under section 1886(m)(5)(D) in a form and manner, and at a time, specified by the Secretary. In addition, section 1886(m)(5)(F) of the Act requires LTCHs to submit data on quality measures under section 1899B(c)(1) of the Act, resource use or other measures under section 1899B(d)(1) of the Act, and standardized patient assessment data required under section 1899B(b)(1) of the Act. LTCHs must submit the data required under section 1886(m)(5)(F) of the Act in the form and manner, and at the time, specified by the Secretary. Section 1886(m)(5)(A) of the Act requires the Secretary to reduce by 2 percentage points the annual update to the LTCH PPS standard Federal rate for discharges for an LTCH during a fiscal year (FY)--if the LTCH has not submitted data to the Secretary in accordance with the LTCH QRP requirements specified for that FY. Section 1890A of the Act requires that the Secretary establish and follow a pre-rulemaking process, in coordination with the consensus- based entity (CBE) with a contract under section 1890(a) of the Act, to solicit input from certain groups regarding the selection of quality and efficiency measures for the LTCH QRP. We have codified our program requirements in our regulations at 42 CFR 412.560.

In this final rule, we finalize our proposal to modify reporting requirements for the COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date measure to exclude patients who have expired in the LTCH by removing an item on the LTCH Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) as described in section X.E.3. of this final rule. We also finalize our proposal to remove four items previously adopted as standardized patient assessment data elements under the social determinants of health (SDOH) category beginning with the FY 2028 LTCH QRP: one item for Living Situation, two items for Food, and one item for Utilities. Next, we finalize our proposal to amend our reconsideration policy and process as described in section X.E.4. of this final rule. Finally, we provide summaries of the public comments received in response to several requests for information (RFIs), specifically on: (1) future measure concepts for the LTCH QRP as described in section X.E.5 of this final rule; (2) revisions to the data submission deadlines for assessment data collected for the LTCH QRP as described in section X.E.6. of this final rule; and (3) advancing digital quality measurement (dQM) in the LTCH QRP as described in section X.E.7. of this final rule. 2. General Considerations Used for the Selection of Measures for the LTCH QRP--Quality Measures Currently Adopted for the LTCH QRP

For a detailed discussion of the considerations we use for the selection of LTCH QRP quality, resource use, and other measures, we refer readers to the FY 2016 Inpatient Prospective Payment System (IPPS)/LTCH PPS final rule (80 FR 49728). The LTCH QRP currently has 18 adopted measures, which are set out in Table X.E.-01. We did not propose to adopt any new measures for the LTCH QRP.

For a discussion of the factors we use to evaluate whether a measure should be removed from the LTCH QRP, we refer readers to the FY 2019 IPPS/LTCH PPS final rule (83 FR 41624 through 41634) and to the regulations at Sec. 412.560(b)(3). BILLING CODE 4120-01-P [GRAPHIC] [TIFF OMITTED] TR04AU25.280

BILLING CODE 4120-01-C 3. Modification of Reporting Requirements for COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date Measure Beginning With the FY 2028 LTCH QRP

In the FY 2024 IPPS/LTCH PPS Final Rule (88 FR 59243 through 59250), we finalized the COVID-19 Vaccine: Percent of Patients/ Residents Who Are Up to Date (Patient/Resident COVID-19 Vaccine) measure for the LTCH QRP beginning with the FY 2026 LTCH QRP. LTCHs collect and report data for this measure on the LTCH Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS), the LTCH patient assessment instrument (88 FR 59247 and 59253). We added the Patient/Resident COVID-19 Vaccine item (O0350) on the LCDS discharge assessments (Planned Discharge, Unplanned Discharge, and Expired) for LTCHs to collect data on this measure for patients being discharged from the LTCH and who expire during their stay (88 FR 59253). We finalized that LTCHs must begin collecting data using the LCDS for this measure with patients discharged on October 1, 2024, for the FY 2026 LTCH QRP (88 FR 59247 and 59253).

Since the Patient/Resident COVID-19 Vaccine measure was adopted for the LTCH QRP and LTCHs began collecting data for this measure on October 1, 2024, LTCHs and other interested parties have expressed concerns about challenges and increased provider burden in collecting immunization data.\374\ They have specifically noted

challenges in identifying a patient's vaccination status once they have expired. We agree that collecting information regarding an expired patient's vaccination status is challenging because it may be difficult to interview the patient's family or other caregivers to ascertain the patient's vaccination status if it is not known during the expired assessment window (that is, no later than 5 days after the patient's date of death).\375\ In addition, we agree that collecting this data creates unnecessary burden for LTCHs because this information is no longer actionable for LTCHs, since they can no longer help an expired patient stay up to date with regard to COVID-19 vaccinations. Removing the requirement to report this item when a patient expires in an LTCH will allow CMS to be responsive to LTCHs and reduce assessment collection burden.

\374\ Standing Technical Expert Panel for the Development, Evaluation, and Maintenance of Post-Acute Care (PAC) and Hospice Quality Reporting Program (QRP) Measurement Sets Summary Report December 15, 2023, https://www.cms.gov/files/document/december-2023-pac-and-hospice-cross-setting-tep-summary-report.pdf-1.

\375\ Chapter 2, Overview. LCDS Manual accessed in the Downloads section of: https://www.cms.gov/medicare/quality/long-term-care-hospital/ltch-care-data-set-ltch-qrp-manual.

We proposed to modify the reporting requirements for the Patient/ Resident COVID-19 Vaccine measure in the LTCH QRP to exclude patients who have expired in the LTCH beginning with the FY 2028 LTCH QRP. Specifically, we proposed that, beginning with patients admitted on or after October 1, 2026, LTCHs would no longer be required to submit the Patient/Resident COVID-19 Vaccine item (O0350) on the LCDS with respect to patients who have expired in the LTCH. We also proposed to remove the COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to item (O0350) from future LCDS forms that LTCHs use for expired patients. The remaining LCDS forms used for Planned Discharge and Unplanned Discharge would continue to include the Patient/Resident COVID-19 Vaccine item (O0350) for purposes of collecting and reporting data on the Patient/ Resident COVID-19 Vaccine measure.

We invited public comment on our proposal to modify reporting requirements for the Patient/Resident COVID-19 Vaccine measure in the LTCH QRP to exclude patients who have expired in the LTCH beginning with the FY 2028 LTCH QRP. A summary of comments received and our responses follow.

Comment: Several commenters supported CMS's proposal to modify reporting requirements for the Patient/Resident COVID-19 Vaccine measure, citing support for reducing the administrative burden in the LTCH QRP. A few commenters agreed that it was challenging to obtain vaccination status after a patient expires, and the information was no longer actionable. Another commenter appreciated CMS's consideration of the burden associated with LCDS collection and support this proposal.

Response: We thank commenters for their support. CMS continually looks for opportunities to work with LTCHs in order to balance data collection requirements and quality care delivered to the patient.

Comment: A commenter supported the modification of reporting requirements and recommended that CMS implement this change sooner.

Response: We appreciate the commenter's support. We recognize that with regard to patients who expire in a LTCH, assessing for and collecting information on COVID-19 vaccination status is challenging and burdensome. We plan to remove this item from the expired LCDS assessment beginning on October 1, 2026, but since it is not technically feasible to remove this item earlier, we are making submission for data on Patient/Resident COVID-19 Vaccine item (O0350) for expired patients optional for discharges on or after October 1, 2025.

Comment: A commenter supported the removal of this measure from the LTCH QRP, citing the end of the public health emergency, high vaccination rates, and the diminishing relevance of the measure for LTCHs.

Response: We wish to clarify that we did not propose to remove the Patient/Resident COVID-19 Vaccine measure, but to modify reporting requirements to exclude patients who have expired in the LTCH.

After consideration of the public comments, we are finalizing our proposal to modify reporting requirements for the Patient/Resident COVID-19 Vaccine measure in the LTCH QRP to exclude patients who have expired in the LTCH beginning with the FY 2028 LTCH QRP. 4. Removal of Four Standardized Patient Assessment Data Elements Beginning With the FY 2028 LTCH QRP

We refer readers to the FY 2025 IPPS/LTCH PPS final rule (89 FR 69582 through 69593) where we finalized the adoption of four items as standardized patient assessment data elements under the social determinants of health (SDOH) category from the LTCH CARE Data Set \376\ (LCDS): one item for Living Situation (R0310); two items for Food (R0320A and R0320B); and one item for Utilities (R0330). As finalized in the FY 2025 IPPS/LTCH PPS final rule, LTCHs would be required to report these items using the LCDS beginning with patients discharged on or after October 1, 2026, through December 31, 2026, for purposes of the FY 2028 LTCH QRP and each program year after (89 FR 69597 and 69598).

\376\ The LTCH CARE Data Set is CMS's required assessment instrument used by LTCHs to collect certain data from patients upon their admission and discharge from the LTCH. See section 1899B of the Act, which requires LTCHs to use Post-Acute Care (PAC) assessment instruments for collecting and submitting to CMS certain standardized patient assessment data as part of PAC quality reporting programs, including the LTCH QRP.

In the proposed rule, we proposed to remove these four standardized patient assessment items under the SDOH category from the LCDS as we acknowledge the burden associated with these items at this time. Further, as it is also standard evidence-based practice to assess and address these items in LTCHs, we would like to change the focus of CMS's data collection at this time. We continuously look for ways to balance the need for data collections regarding quality care and burden that such data collections may have on LTCH providers. One goal we have is to facilitate improved health care delivery by requiring different systems and software applications to communicate and exchange data. Therefore, we would like to work towards the workflow for these items being part of a low burden interoperable electronic system. The focus will turn towards how the data and associated recommendations can improve care coordination, efficiency, reduction in errors and improved patient experience. As health information technology (IT) advances and interoperability of data becomes more standardized, the burden to collect and share clinical data on these and other relevant patient information will become less burdensome allowing for better outcomes for LTCH patients and their families. The objectives of the LTCH QRP continue to be the improvement of care, quality, and health outcomes for all patients through transparency and quality measurement, while not imposing undue burden on essential health providers.

Under our proposal, LTCHs would not be required to collect and submit Living Situation (R0310), Food (R0320A and R0320B), and Utilities (R0330) items using the LCDS beginning with patients discharged on or after October 1, 2026, removing the required collection and reporting of these items that we previously finalized. Under this proposal, these items would not be

necessary to meet LTCH QRP requirements to avoid a 2 percent payment reduction beginning with the FY 2028 LTCH QRP. In the proposed rule, we calculated that removing these items from the data collection for the FY 2028 LTCH QRP would keep the 330 LTCHs from incurring 2,601 hours of administrative burden at a cost of $182,330.10 (or $552.52 per LTCH) at this time (90 FR 18350). We refer readers to section XIII.B.6. of this final rule for more details on this estimated burden reduction.

We invited public comment on our proposal to remove these four standardized patient assessment data elements collected under the SDOH category from the LTCH QRP beginning with the FY 2028 LTCH QRP. A summary of comments received and our responses follow.

Comment: Several commenters supported our proposal, citing the burden of data collection. These commenters stated that the items can be time-consuming and detract from direct patient care. A few commenters state that removal of these items will help providers focus their resources on other areas of importance, address quality issues that matter most to patients, and allow LTCH staff to spend more time caring for patients. Two commenters acknowledged that CMS must work towards a balance of provider burden and data collection efforts for quality, ensuring data adds value to its program and advances health care. Another commenter stated support for the removal of the four SDOH items, stating that this will not impact quality of care in LTCHs while noting that the items overlap with existing assessments or other health initiatives.

Response: We thank commenters for their support for our proposal to remove these four SDOH items from the standardized patient assessment data elements collected and submitted using the LCDS. We continue to monitor the LTCH QRP data collection requirements to look for ways to reduce administrative burden, where appropriate, while maintaining a high standard of quality care. We agree that removing these items at this time will alleviate some of the burden on LTCH providers associated with LTCH QRP data collection and submission requirements. We intend to align the LTCH QRP more closely with CMS's overarching goal for improved health care delivery through health IT advances and low-burden interoperable electronic systems. As we stated in the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18350), we plan to refocus efforts on how data elements can improve care coordination, efficiency, reduction in errors, and patient experience.

We appreciate commenters' recognition of having an appropriate balance of burden and value in quality measurement programs, such as the LTCH QRP. By streamlining the number of data elements required for reporting, LTCHs and their staff can focus efforts and resources to address the quality issues that matter most to their patients. As stated in section X.E.6 of this rule, we solicited comment on measurement concepts that address resident well-being while more appropriately reflecting factors that are within practitioners' and facilities' scope of care or where practitioners can provide actionable advice that will help reduce the prevalence of chronic diseases, including nutrition, increased adherence to expected daily thresholds for physical activity, minimization of chronic stressors, and improvements in mental health.

Comment: A commenter supported these items becoming voluntary beginning October 1, 2025, and phased out of the LTCH QRP altogether by FY 2028.

Response: We wish to clarify that these items were finalized to be collected beginning with patients discharged on or after October 1, 2026, and were never intended to be voluntary. They do not appear on the current version of the LTCH Care Data Set (LCDS, Version 5.1). We did not propose to modify these four SDOH items to be optional items on the LCDS that LTCHs could voluntarily report. Because we are finalizing our proposal to remove these items as proposed, they will not be added to the next version of the LCDS.

Comment: Many commenters were opposed to CMS's proposal to remove the four SDOH items from the LCDS and urged CMS to reconsider the proposal. These commenters stated that this data adds value to LTCHs, who serve some of the most vulnerable patients in the health care continuum. The commenters stated certain literature on how screening for SDOH improves health outcomes and how this information results in a more holistic approach to patient care and discharge planning which facilitates proactive approaches to reduce risks. A few of these commenters stated that removal of these items would leave remaining measures to focus too exclusively on diagnosed conditions at the expense of whole-person care. A few commenters stated these SDOH items were particularly important in caring for patients with complex or chronic conditions including geriatric patients. These commenters also stated that identification and subsequent support of patients' social needs decreased healthcare expenditures, readmissions, inpatient stays, and emergency department visits resulting in both health and financial benefits.

Response: We appreciate commenters' concerns and feedback regarding the importance of collecting these SDOH items from LTCH patients and acknowledge the value that commenters ascribe to the collection of this information for discharge planning and patient care, especially for the LTCH patient population. We also acknowledge feedback from commenters that healthcare outcomes may be different for those experiencing unstable housing, food insecurity or challenges paying utilities.

However, in reviewing the data collection and reporting requirements for the FY 2027 LTCH QRP, we determined that these SDOH items should be removed from the LCDS prior to the start of data collection and submission. We have re-evaluated the value of adding these SDOH items to the LCDS for the purposes of the LTCH QRP against their burden at this time. We considered that LTCHs have not yet begun to report these data, we do not currently have a use for these items in the LTCH QRP, and, these SDOH items are not clinical items related to direct patient care. We also have refocused our efforts on modernization of health care and health care systems. We continuously review and reassess the balance of data collection and LTCH provider burden for the LTCH QRP, and at this time, determined these SDOH items should be removed prior to implementation.

The objectives of the LTCH QRP continue to be the improvement of care and health outcomes for all patients through transparency and quality measurement, while balancing burden on LTCHs and their staff. As outlined in our request for information in the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18353 and 18354), we are refocusing our efforts to advance the digital quality measurement transition to include ways for data elements, such as those related to SDOH, to be collected as part of a low-burden interoperable electronic system. Given these administrative goals and efforts to reduce burden for LTCHs, we do not believe that the collection of these SDOH items via the LCDS assessment outweighs the cost and burden of collecting them at this time.

At this time, we believe that halting the implementation of the four SDOH items prior to their being added to the LCDS on October 1, 2026 removes the

burden these data collection requirements and submission would impose on LTCHs before most training activities, data collection, reviews of the guidance manuals, and other implementation tasks have occurred.

Comment: A few commenters noted standardized items on the LCDS improve consistency and the exchangeability of information and further support LTCH providers in administering a comprehensive plan of care in accordance with CMS's regulation. A commenter urged CMS to retain the SDOH items until a more efficient electronic health record (EHR) data collection framework was in place. A few commenters stated that the cost and burden does not meaningfully outweigh the value of collecting this information, which includes being able to more accurately measure the quality of care in LTCHs by determining whether the influence of poor outcomes is through factors outside the influence of the facility. These commenters added that assessing SDOH for patients improves coordination between facilities and community care providers ensuring that Medicare dollars are spent efficiently and facilitating high quality care across settings.

Response: We acknowledge the value that commenters ascribe to the collection of this information for discharge planning and care coordination, and commenters' experiences with improving outcomes and facilitating high quality care through improved coordination between providers. We agree with the commenters that the exchangeability of information is important for a comprehensive plan of care. CMS intends to work towards the workflow and data exchange for items being part of a less burdensome interoperable electronic system. We appreciate the commenter's suggestion to retain the items until a more efficient health IT infrastructure and data collection framework is in place. However, all data collection requirements have inherent burden associated with collection and we strive to balance that burden with the value of measuring the quality of care that patients receive. Data collection for these four SDOH items would be burdensome on LTCHs and there is no current or planned use for the data in the LTCH QRP at this time. As we have stated, LTCHs can continue to collect this information to inform discharge planning but, for the purposes of the LTCH QRP, we are finalizing our proposal to remove these four items from the LCDS before implementation begins. This means that LTCHs would not need to submit this information to meet requirements of the LTCH QRP. With the alleviation of this data collection requirement, LTCHs could redistribute their resources toward efforts to improve or enhance clinical care, health IT, or other areas as determined by the LTCH.

Comment: A commenter stated CMS provided extensive support and rationale for adopting these four items in the FY 2025 IPPS/LTCH PPS final rule, developing a policy that was well-vetted and examined in detail. This commenter stated that CMS has not provided any reasoning or explanation in our proposal in the FY 2026 IPPS/LTCH PPS proposed rule as to why these are no longer important or how circumstances have changed to necessitate their removal.

Response: We reiterate that, in the proposed rule, we explained that the removal of these items is a result of CMS's focus on balancing the need for data collections regarding quality care and the burden of these data collection on LTCHs and their staff (90 FR 18350). We would also like to reiterate that LTCHs and their staff independently may determine to screen their patients for factors that may affect their clinical decision-making, even in the absence of a reporting requirement. We did not intend to suggest with our proposal to remove these items from LTCH QRP requirements that LTCHs should cease collecting this or similar information for other purposes, such as the LTCH's patient-specific assessment of needs in developing a discharge plan as required by 42 CFR 483.43. Rather, we are removing these four SDOH items from the LCDS to reduce the burden of data collection and submission for the LTCH QRP. Reducing the burden of LTCH QRP requirements would enable LTCHs and their staff to focus their efforts on clinical decision making by preserving clinicians' flexibility to address social risk factors in other ways that are tailored to the needs of and make the most sense for their patient populations.

We understand implementation efforts to collect and submit any data elements for the purposes of meeting LTCH QRP requirements is inherently burdensome for LTCHs and their staff, particularly adopting and implementing new data elements since they involve adjustments to health IT systems and EHRs, workflows, and staff trainings. We are always reviewing and reassessing this balance of data collection and LTCH provider burden for the LTCH QRP.

For these four SDOH items, we reconsidered the value of their collection and submission to CMS for the purposes of the LTCH QRP against their burden at this time. We specifically considered that these items are not clinical in nature. While they reflect certain aspects of a patient's health that may inform clinical decisions, they are not factors within the scope of care an LTCH and its staff provides. Furthermore, if maintained on the LCDS, there is currently no use for these items in risk adjustment models, reporting of LTCH measure results, or the development of new quality measures. We proposed removal of these four SDOH items from the LCDS because LTCHs have not started data collection for these items yet, we are not utilizing the information for any purpose at this time, and there is an agency-wide refocusing on modernization of health care and health care systems and on engaging LTCHs and their staff with these health IT efforts. We are working towards developing less burdensome data collection methods as we believe leveraging technological advances and data modernizations can streamline standardization of the LCDS in ways that support interoperable patient data and reduce time spent collecting this data by LTCHs and their staff. We strive to collaborate with LTCH providers in these efforts as exhibited in our request for information on advancing digital quality measurement (dQM) in the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18353 and 18354). This collaboration includes reducing the burden of paperwork for participating in the LTCH QRP, where possible, to support LTCH providers in moving towards health data technology and interoperability that promotes spending more time with patients. LTCHs are welcome to continue collecting this information to inform care coordination and discharge planning.

Comment: Many commenters stated that the SDOH items provide important insights into housing, food, and utility insecurity, which affect patient outcomes and that removing these SDOH items is counter to national efforts aimed at improving health outcomes, including current CMS agency goals related to the development of patient nutrition, physical activity, and well-being measures. The commenters stated that the SDOH items could be utilized to support the Make America Healthy Again initiative's core mission of a more efficient, prevention-focused health care system through the treatment of expensive complications that could be prevented through early identification of risks.

A few commenters encouraged CMS to specifically retain the items related to nutrition. These commenters stated that

nutritional risk is often linked to readmissions and overall health outcomes, especially for patients in rural and underserved areas. They also felt addressing food insecurity can reduce preventable healthcare cost, adding an estimated $53 billion annually, and disproportionately affects individuals with or at risk for diet-related diseases, such as patients with diabetes.

Response: We disagree but understand why LTCH providers believe that removal of these items is counter to our national efforts aimed at improving health outcomes. In response to comments about the agency's goals related to nutrition and well-being, we do not believe these four SDOH items are the only foundational items needed for future measure development related to nutrition. As we finalized in the FY 2025 IPPS final rule (89 FR 69585 and 69586), the two Food items (R0320A and R0320B) assess one particular aspect of nutrition: food availability and food security. These items do not encompass other relevant, meaningful information to improve patients' health outcomes, including healthy nutrition, sleep, and physical activity levels. In addition, there are other existing data elements on the LCDS that could support the development of measure concepts we are considering in the future. For example, the LCDS includes other nutrition items in Section I and K. To reiterate, at this time, we are removing these SDOH items to refocus efforts and resources towards a less burdensome interoperable system for LTCHs participating in the LTCH QRP and existing LCDS items, such as the standardized patient assessment data elements in Section K that were finalized in the FY 2020 IPPS final rule (84 FR 42564 through 42568), provide a foundation for building out nutrition measures.

We would also like to note that CMS is currently considering other ways to measure nutrition in our RFI on potential future measures in the LTCH QRP. In the proposed rule (90 FR 18352 and 18353), we stated that preventable care, including assessment of an individual's nutritional status, plays a vital role by proactively addressing factors that may lead to poor nutritional status or related health issues. These efforts not only support optimal nutrition but also work to prevent conditions that could otherwise hinder an individual's health and nutritional needs. With regard to well-being, we are soliciting comment on ways to improve patient well-being across the Medicare programs and we remain committed to identifying the needs of patients and supporting LTCHs in addressing those risks in a way that best accounts for patients' clinical circumstances with minimal burden. We also remain committed to supporting LTCHs and their staff in addressing health risks and needs of at-risk populations such as those experiencing challenges with maintaining healthy nutrition and physical activity levels and managing or improving chronic stressors, mental health concerns, and chronic diseases.

Comment: A few commenters were concerned that many healthcare facilities across the country have already made substantial investments to incorporate the screening of these SDOH items into setting up systems, electronic health records, and workflows. These commenters stated that this would amount to more than ongoing implementation costs, and that hospitals and other settings expecting to report these items have already expended the necessary resources to set up their systems and referral programs. These commenters stated that removing these SDOH items does not reduce their prior investments and may result in additional resources to rework their systems. A few other commenters stated that many healthcare organizations have already invested in incorporating SDOH screening into their admissions processes and care coordination workflows.

Response: We acknowledge the commenters' concerns and understand the time and resources that LTCHs may have spent anticipating the requirement to collect these items as part of the LTCH QRP. Since the inception and initial development of the LTCH QRP, interested parties have requested we provide draft specifications for the upcoming release of the revised LCDS as early as possible. We have been responsive to this request and aim to provide as much information as possible when that information is available. However, we would like to emphasize that the information released consists of draft LCDS data specifications, not final specifications, and that the LCDS data specifications cannot be finalized until CMS policies are finalized after the final rule is released.

We also note that the time and resources spent to build technical infrastructure accounts for only a portion of the overall cost we considered, which also includes training activities, continuous data collection, reviews of the guidance manuals, and other implementation tasks. Collecting these SDOH items is not a one-time task but an ongoing requirement for every LTCH patient admitted to the facility. As a result, we believe removing these items before data collection begins will still save LTCHs and their staff time, money, and resources.

After consideration of the public comments, we are finalizing our proposal to remove four standardized patient assessment data elements collected under the SDOH category (one item for Living Situation (R0310); two items for Food (R0320A and R0320B); and one item for Utilities (R0330)) from the LTCH QRP beginning with the FY 2028 LTCH QRP without modification. 5. Proposals To Amend the Reconsideration Request Policy and Process a. Background

In the FY 2014 IPPS/LTCH PPS final rule (78 FR 50885 through 50887), we finalized the LTCH QRP reconsiderations policy and process whereby an LTCH may request reconsideration of an initial determination that the LTCH did not comply with the LTCH QRP reporting requirements, warranting CMS reducing the LTCH's annual payment update by 2 percent for the applicable fiscal year as required by section 1886(m)(5)(A) of the Act. In that rule, we stated that the LTCH may file a request for reconsideration if they believe that the finding of non-compliance is erroneous, or if they were non-compliant, they have a valid and justifiable excuse for this non-compliance (78 FR 50886). We further stated that, after we review the request for reconsideration, we may reverse our initial finding of non-compliance if: (1) the LTCH provides proof of compliance with all requirements during the reporting period; or (2) the LTCH provides adequate proof of a valid or justifiable excuse for non-compliance if the LTCH was not able to comply with requirements during the reporting period (78 FR 50886). Finally, we stated that we will uphold an initial finding of non-compliance if the LTCH cannot show any justification for non-compliance (78 FR 50886).

In the FY 2015 IPPS/LTCH PPS final rule (79 FR 50317 and 50318), we finalized amendments to the LTCH QRP reconsideration policy and process. Specifically, we stated that each LTCH would receive a notification of noncompliance with LTCH QRP requirements if we determine it had not correctly submitted data with respect to the applicable fiscal year (79 FR 50317). Then, the LTCH would have 30 days from the date of our initial notification of noncompliance to submit a request for reconsideration via email. We also

provided that, in very limited circumstances, we may grant a request by an LTCH to extend the deadline to submit its reconsideration request, so long as the LTCH requested the extension and demonstrated that extenuating circumstances existed that prevented it filing a reconsideration request by the 30-day deadline (79 FR 50317). Finally, we provided that, as part of its reconsideration request, the LTCH must submit all supporting documentation and evidence demonstrating: (1) full compliance with all LTCH QRP reporting requirements during the reporting period; or (2) extenuating circumstances that affected noncompliance if the LTCH was not able to comply with the requirements during the reporting period (79 FR 50317). We stated that we would not review any reconsideration request that fails to provide the necessary documentation and evidence along with the request (79 FR 50317).

In the FY 2016 IPPS/LTCH PPS final rule (80 FR 49755 and 49770), we codified the reconsideration policy and process for the LTCH QRP at Sec. 412.560(d). In subsequent rulemakings, we have amended our reconsideration policy and process at Sec. 412.560(d) for minor clarifications and technical updates (FY 2017 IPPS/LTCH PPS final rule (81 FR 57230 and 57231); FY 2019 IPPS/LTCH PPS final rule (83 FR 41633 and 41634; 83 FR 41705); and FY 2020 IPPS/LTCH PPS final rule (84 FR 42588 and 42615)). As codified, our regulation at Sec. 412.560(d) addresses how we send our written notification of noncompliance to an LTCH, the process for an LTCH to request reconsideration, what information an LTCH must include with its reconsideration request (for example, documentation that demonstrates the LTCH's compliance with LTCH QRP requirements), and how we notify the LTCH of our final decision regarding its reconsideration request.

We have become aware there are inconsistencies in our preamble and regulation text regarding LTCH requests for reconsideration. On this basis, in this final rule, we seek to clarify these areas. b. Proposal To Allow LTCHs To Request an Extension To File a Request for Reconsideration

As noted previously, in the FY 2015 IPPS/LTCH PPS final rule (79 FR 50317 and 50318), we provided that, in very limited circumstances, we may grant a request by an LTCH to extend the deadline to submit its reconsideration request, so long as the LTCH requested the extension and demonstrated that extenuating circumstances existed that prevented it filing a reconsideration request by the 30-day deadline (79 FR 50317). We did not codify this policy--permitting LTCHs to request an extension to file their reconsideration request--in our regulation text at Sec. 412.560(d). In implementing this finalized policy, we have noted two areas where further clarity would be beneficial to LTCHs.

First, we have not clearly defined or explained the term “extenuating circumstances,” as used in our reconsideration policy. In contrast, we use the term “extraordinary circumstances” in our Extraordinary Circumstance Exception and Extension (ECE) policy, as codified at Sec. 412.560(c). We did explain “extraordinary circumstances” in detail when we originally finalized this ECE policy in FY 2014 IPPS/LTCH PPS final rule (78 FR 50883).

On this basis, we proposed to remove the term “extenuating circumstances” as used currently in our reconsideration policy and replace it with “extraordinary circumstances.” Specifically, we proposed that an LTCH may request, and CMS may grant, an extension to file a reconsideration request if the LTCH was affected by extraordinary circumstances beyond the control of the LTCH (for example, a natural or man-made disaster). By modifying the basis by which an LTCH may request an extension to file a reconsideration request in this manner, we also proposed to incorporate our prior explanation regarding the meaning of the term extraordinary circumstances, as set forth in the FY 2014 IPPS/LTCH PPS final rule (78 FR 50883 through 50885) as part of our Extraordinary Circumstance Exception and Extension (ECE) Policy.

Second, we have noted some areas in our policy where LTCHs may benefit from clearly demarcated deadlines. Although we believe an LTCH would have an interest in asking for an extension to file a reconsideration request prior to the deadline, our policy currently does not specify a deadline for an LTCH to submit its request for such extension (79 FR 50317). Our policy also provides that, to support such request, the LTCH must demonstrate that extenuating circumstances existed that prevented filing the reconsideration request by the 30-day deadline (79 FR 50317). However, we have not specified a temporal relationship between when the extenuating circumstances occurred and the reconsideration request deadline. We believe LTCHs may benefit from further specificity regarding these requirements for submitting a request to extend the deadline to file a reconsideration request.

On this basis, we proposed to amend our reconsideration policy as codified at Sec. 412.560(d) to permit LTCHs to request, and CMS to grant, an extension to file a request for reconsideration of a noncompliance determination if, during the period to request a reconsideration as set forth in Sec. 412.560(d)(2), the LTCH was affected by an extraordinary circumstance beyond the control of the LTCH (for example, a natural or man-made disaster). We proposed that the LTCH must submit its request for an extension to file a reconsideration request to CMS via email no later than 30 calendar days from the date of the written notification of noncompliance. We proposed that the LTCH's extension request, submitted to CMS, must contain the following information: (1) the CCN for the LTCH; (2) the business name of the LTCH; (3) the business address of the LTCH; (4) certain contact information for the LTCH's chief executive officer or designated personnel; (5) a statement of the reason for the request for the extension; and (6) evidence of the impact of the extraordinary circumstances, including, for example, photographs, newspaper articles, and other media. We proposed to codify this process at Sec. 412.560(d)(4).

We further proposed that CMS will notify the LTCH in writing of its final decision regarding its request for an extension to file a reconsideration of noncompliance request via an email from CMS. We proposed to notify the LTCH in writing via email because this will allow for more expedient correspondence with the LTCH, given the 30-day reconsideration timeframe. We proposed to codify this process at Sec. 412.560(d)(5).

We note that we proposed similar modifications across all post- acute care setting quality reporting programs to more closely align the reconsideration processes.

We invited comment on these proposals to amend the LTCH QRP reconsideration policy to permit LTCHs to requests an extension to file a reconsideration request and to codify this proposed policy and process at Sec. 412.560(d)(4) and (5).

The following is a summary of the public comments received and our responses:

Comment: Several commenters supported the proposed revisions, particularly the efforts to address inconsistencies in the reconsideration policy. Several of these commenters appreciated CMS's recognition that extraordinary circumstances, such as disasters, can prevent timely filing of

reconsideration requests. A commenter encouraged CMS to consider adopting similar policies across its other quality and value-based programs.

Response: We thank commenters for their support.

Comment: A commenter supported CMS's proposal to allow an extension of time to submit a request for reconsideration but opposed shortening the timeframe for submitting an ECE request from 90 days to 30 days following an extraordinary event, stating that a 30-day window is simply too short for hospitals that are in the midst of responding to a disaster.

Response: We appreciate the commenter's concerns and recommendations, though we find aspects of the comments to be unclear. We interpret the commenter to mean that they believed our proposed 30- day deadline would apply to the exception and extension (ECE) process for data submission, rather than the ability to request an extension due to extraordinary circumstances during the reconsideration process following a determination of noncompliance.

We wish to clarify the proposed policies do not modify either the deadline for submitting an ECE request during the reporting period, or the deadline for submitting a reconsideration request, but specifically address an LTCH's ability to submit a request for an extension to submit the reconsideration request. This policy establishes that providers impacted by an extraordinary circumstance within the reconsideration time frame will have 30 days to request an extension to file their reconsideration request after receipt of the CMS initial notice of noncompliance for a given fiscal year annual payment update. LTCHs still have 90 days to submit an exception and extension request from the time of an extraordinary event, and 30 days from the initial notification of noncompliance to submit a request for reconsideration. Because our current policy does not specify a deadline for an LTCH to submit its request for such an extension (79 FR 50317) during the reconsideration period, we are providing a clear timeframe of 30 days for this process.

Comment: Several commenters opposed CMS's proposal to remove the “extenuating circumstances” standard from the LTCH QRP reconsideration policy. They stated that this standard was established in the FY 2015 IPPS/LTCH PPS Final Rule and has been upheld by federal courts (79 FR 50317). Commenters urged CMS to reaffirm and codify this standard in regulation as a valid and independent basis for reversing a payment penalty, separate from demonstrating full compliance. Another commenter emphasized that “extenuating” and “extraordinary” circumstances are not synonymous.

Response: We appreciate commenters' feedback and recognize the historical use of the term “extenuating circumstances” in prior rulemaking and administrative decisions. However, as noted in the proposed rule, CMS identified inconsistencies between regulatory text and preamble language and is using this rulemaking to clarify and align the LTCH QRP reconsideration policy with other post-acute care quality reporting programs. The intent of this clarification is to promote consistency, not to reduce flexibility. Moving forward, CMS will use the single term “extraordinary circumstances,” defined as circumstances beyond the LTCH's control, to standardize the basis for reconsideration. We believe this approach enhances transparency and improves alignment across quality reporting programs.

In response to the commenter who stated that “extenuating” and “extraordinary” circumstances are not synonymous, we agree with this distinction and proposed using “extraordinary circumstances” to establish a clear, program-wide definition that reflects events beyond a provider's control. This approach aligns with policies used in other CMS quality reporting programs. CMS remains committed to reviewing documentation requesting an extension to file a reconsideration request on a case-by-case basis and will continue to consider all relevant evidence demonstrating that circumstances outside of the LTCH's control impacted their ability to file a reconsideration request within the 30- day deadline.

After consideration of the public comments, we are finalizing our proposal to amend the LTCH QRP reconsideration policy to permit LTCHs to requests an extension to file a reconsideration request and to codify this proposed policy and process at Sec. 412.560(d)(4) and (d)(5). c. Update to the Bases on Which CMS Can Grant a Reconsideration Request

As discussed previously, in the FY 2014 IPPS/LTCH PPS final rule, we stated that, after we review an LTCH's request for reconsideration, we may reverse our initial finding of non-compliance if: (1) the LTCH provides proof of compliance with all requirements during the reporting period; or (2) the LTCH provides adequate proof of a valid or justifiable excuse for non-compliance if the LTCH was not able to comply with requirements during the reporting period (78 FR 50886). We also stated that we will uphold an initial finding of non-compliance if the LTCH cannot show any justification for non-compliance (78 FR 50886).

In the FY 2015 IPPS/LTCH PPS final rule (79 FR 50317 and 50318), we reiterated this position, and provided that, as part of its reconsideration request, the LTCH must submit all supporting documentation and evidence demonstrating: (1) full compliance with all LTCH QRP reporting requirements during the reporting period; or (2) extenuating circumstances that affected noncompliance if the LTCH was not able to comply with the requirements during the reporting period (79 FR 50317). We stated that we would not review any reconsideration request that fails to provide the necessary documentation and evidence along with the request (79 FR 50317).

As previously discussed, we codified our reconsideration policy at Sec. 412.560(d) in the FY 2016 IPPS/LTCH PPS final rule (80 FR 49755 and 49770). Our regulation at Sec. 412.560(d)(2)(vii) requires that an LTCH's request for reconsideration include accompanying documentation that demonstrates the LTCH's compliance with the LTCH QRP requirements. Then, we will notify the LTCH in writing regarding our final decision on its reconsideration request (Sec. 412.560(d)(3)). We believe it would be beneficial for LTCHs if we codify our specific bases for granting a reconsideration request in our regulation at Sec. 412.560(d).

On these bases, we proposed to modify our reconsideration policy to provide that we will grant a timely request for reconsideration, and reverse an initial finding of non-compliance, only if CMS determines that the long-term care hospital was in full compliance with the LTCH QRP requirements for the applicable program year. We would consider full compliance with the LTCH QRP requirements to include CMS granting an exception or extension to LTCH QRP reporting requirements under our ECE policy at Sec. 412.560(c). However, to demonstrate full compliance with our ECE policy, the LTCH would need to comply with our ECE policy's requirements, including the specific scope of the exception or extension as granted by CMS.

We proposed to revise Sec. 412.560(d)(3) to codify this modified policy in our regulation. The remainder of the text at Sec. 412.560(d)(3) would remain the same, subject to minor technical amendments.

We noted that we considered proposing similar modifications across all post-acute care setting quality reporting programs to more closely align the reconsideration processes.

We invited comment on these proposals to amend the bases by which we grant a reconsideration request under the LTCH QRP reconsideration policy and to codify this proposed policy at Sec. 412.560(d)(3).

The following is a summary of the public comments received and our responses:

Comment: Commenters requested that CMS continue to allow LTCHs to raise extraordinary circumstances during the reconsideration appeal process. These commenters also requested that CMS reverse a payment penalty during the reconsideration process if an LTCH provides evidence of extraordinary circumstances that prevented timely submission of data, even if the LTCH did not previously submit an exception request to CMS.

Response: We appreciate commenters' input on the reconsideration process. We clarify that LTCHs will be considered compliant if an exception or extension request (ECE) was submitted and approved under Sec. 412.560(c). However, in order to be considered compliant, the ECE must have been both submitted and approved prior to the reconsideration request.

LTCHs may not submit an ECE as a basis for requesting reconsideration in response to a notice of noncompliance. The ECE process requires that requests be submitted within 90 calendar days of the extraordinary circumstance event, as outlined in the current policy. During the 30-day reconsideration period, providers may also request an extension to file the reconsideration if they experienced extraordinary circumstances that prevented timely submission of the reconsideration request.

Comment: Commenters had concerns about the change in terminology from “extraordinary” to “extenuating” and circumstances. They cited legal definitions to demonstrate that extenuating circumstances involve a reduction in culpability, whereas extraordinary circumstances imply highly unusual events. They expressed concern that removing “extenuating circumstances” narrows the scope of acceptable reasons for reconsideration and removes an avenue for more subjective, contextual review.

Response: We interpret these comments to mean that commenters are opposed to the use of “extraordinary circumstances” as a basis for reconsideration of a notice of noncompliance. We wish to clarify that we are proposing to permit LTCHs to request extensions to file reconsideration requests based on extraordinary circumstances in section E.5.b. We are also proposing in section E.5.c to update the bases by which we grant a reconsideration request. Specifically, we would only reverse an initial finding of non-compliance if CMS determines that the LTCH was in full compliance with the LTCH QRP requirements for the applicable program year. We would not consider an LTCH's assertion of “extraordinary circumstances” as a new basis for overturning a noncompliance finding during the reconsideration process. While full compliance with the LTCH QRP requirements may include CMS granting an exception or extension to LTCH QRP reporting requirements under our ECE policy at Sec. 412.560(c), we wish to reiterate that the LTCH would need to comply with our ECE policy's requirements, including compliance with the specific scope of the exception or extension as granted by CMS. After consideration of the public comments, we are finalizing our proposal to amend the bases by which we grant a reconsideration request under the LTCH QRP reconsideration policy and to codify this proposed policy. 6. LTCH QRP Measure Concepts Under Consideration for Future Years-- Request for Information (RFI): Interoperability, Well-Being, Nutrition & Delirium

In the proposed rule, we sought input on the importance, relevance, appropriateness, and applicability of each of the quality measure concepts under consideration listed in Table X.E.-02 for future years in the LTCH QRP. In the FY 2025 LTCH PPS proposed rule (89 FR 36350 through 36351), we included a request for information (RFI) on a set of principles for selecting and prioritizing LTCH QRP measures, identifying measurement gaps, and suitable measures for filling these gaps. We refer readers to the FY 2025 LTCH PPS final rule (89 FR 69594 and 69596) for a summary of the public comments we received in response to the RFI.

We sought input on four concepts for future measures for the LTCH QRP. We refer readers to the FY 2026 IPPS/LTCH PPS proposed rule (90 FR 18352 and 18353) for a description of each of the quality measure concepts under consideration for this RFI. [GRAPHIC] [TIFF OMITTED] TR04AU25.281

We received several public comments with feedback on these measure concepts. The following is a summary of the comments we received. a. Interoperability

Comment: A few commenters supported the interoperability measure. A commenter recommended CMS to consider a phased approach with financial incentives. Another commenter stated that they would be supportive of the interoperability measure in the LTCH QRP if CMS provided funding for implementation upgrades that are needed to achieve interoperability.

A commenter opposed the measure, saying that LTCH staff responsible for quality reporting are not trained to evaluate the level of readiness for interoperable data exchange. The commenter also noted that CMS has not financially supported information technology systems.