Becker's Hospital Review

7 CFO / FINANCE CMS under Dr. Oz: 12 key actions By Alan Condon C MS Administrator Mehmet Oz, MD, is charting an ambitious path to reshape federal healthcare policy in line with President Donald Trump's "Make America Healthy Again" agenda. His vision comes as President Trump on July 4 signed e One Big Beautiful Bill Act, a sweeping package of reforms targeting Medicaid, Medicare, and the ACA marketplace. From plans to close a Medicaid funding "loophole" to probing hospitals over gender care for minors and clamping down on states using federal Medicaid funds to treat undocumented migrants, here are 12 key actions CMS has taken since Dr. Oz was confirmed as administrator: 1. CMS plans to add prior authorization for some traditional fee-for- service Medicare services as part of its newly launched Wasteful and Inappropriate Service Reduction model. e agency will partner with companies specializing in AI and machine learning to test ways to provide an improved and expedited prior authorization process for traditional Medicare services including epidural steroid injections for pain management, cervical fusion, arthroscopy for knee osteoarthritis, and skin and tissue substitutes. e news came one week aer the wider insurance industry announced reforms that aim to reduce and streamline prior authorization processes across commercial, Medicare Advantage and managed Medicaid plans. 2. CMS is enacting a final rule that will shorten the open enrollment period on the ACA exchange and create stricter eligibility verifications for enrollees. e changes will lower individual premiums by about 5% on average, and save around $12 billion in 2026 by clamping down on improper enrollments, according to the agency, which estimates as many as 5 million people may have improperly enrolled in ACA plans "enabled by weakened verification process and expanded premium subsidies." "CMS is restoring integrity to ACA Exchanges by cracking down on fraud, protecting American taxpayer dollars, and ensuring coverage is there for those who truly need it," Dr. Oz said. "is is about putting patients first, stopping exploitation of the system, and realigning the program with the values of personal responsibility and fiscal discipline." 3. CMS proposed a rule to close what it describes as a Medicaid tax "loophole" that some states have used to increase federal payments while limiting their own financial contributions. e proposed rule aims to ensure that federal Medicaid dollars are used to support vulnerable populations rather than being redirected to fund other state programs, including healthcare coverage for undocumented immigrants. "States are gaming the system — creating complex tax schemes that shi their responsibility to invest in Medicaid and rob federal taxpayers," Dr. Oz said. "is proposed rule stops the shell game and ensures federal Medicaid dollars go where they're needed most — to pay for health care for vulnerable Americans who rely on this program, not to plug state budget holes or bankroll benefits for noncitizens." 4. CMS is ramping up federal oversight to prevent states from "misusing" Medicaid funds to cover care for undocumented immigrants. While federal Medicaid dollars are generally limited to emergency services for "noncitizens with unsatisfactory immigration status" who meet specific eligibility criteria, CMS argues that some states have expanded benefits beyond what is permitted — shiing additional costs to federal taxpayers. "Medicaid is not, and cannot be, a backdoor pathway to subsidize open borders," Dr. Oz said. "States have a duty to uphold the law and protect taxpayer funds. We are putting them on notice — CMS will not allow federal dollars to be diverted to cover those who are not lawfully eligible." 5. CMS on June 3 withdrew a 2022 guidance issued under the Biden administration that reinforced hospitals' obligations to provide emergency abortion care under the Emergency Medical Treatment and Labor Act. e move effectively removes federal protections for clinicians who offer such care in states where abortion is restricted or banned. e original guidance, issued in July 2022 shortly aer the Supreme Court overturned Roe V. Wade, clarified that clinicians treating pregnant patients in emergency departments — including providing abortions — were protected under EMTALA, regardless of conflicting state laws. Enacted in 1986, EMTALA requires Medicare-participating hospitals to provide appropriate emergency care to all patients. Although the guidance has been withdrawn, CMS said it will continue to enforce EMTALA in cases where the health of a pregnant woman or her unborn child is at risk. 6. CMS is investigating an undisclosed number of hospitals that provide gender-confirming care to minors. In a letter sent May 28 to "select hospitals," Dr. Oz outlined concerns about clinical standards and potential financial incentives associated with treatments such as puberty blockers, cross-sex hormones and sex trait modification surgeries. CMS is requesting that hospitals respond within 30 days with detailed information on informed consent practices for pediatric patients, updates to clinical guidelines, documentation of adverse outcomes, and financial data — including facility- and provider-level revenue and profit related to such care. "ese are irreversible, high-risk procedures being conducted on vulnerable children, oen at taxpayer expense," Dr. Oz said. "Hospitals accepting federal funds are expected to meet rigorous quality standards and uphold the highest level of stewardship when it comes to public resources — we will not turn a blind eye to procedures that lack a solid foundation of evidence and may result in lifelong harm." 7. On May 22, CMS issued updated price transparency requiring hospitals to publicly post actual prices for items and services — not estimates. e update follows an executive order from President Trump aimed at increasing transparency in healthcare pricing. Under the revised rules, hospitals must display payer-specific standard charges as dollar amounts in their machine-readable files whenever those amounts can be calculated. is includes negotiated rates for individual services, base rates for bundled service packages, and dollar amounts derived from percentage-based fee schedules. CMS also directed hospitals to stop using placeholder codes — specifically "999999999" — in the "estimated allowed amount" field of machine-readable files. Instead, hospitals must input actual dollar values, using electronic remittance data from the prior 12 months to calculate those estimates. e agency is soliciting public feedback

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