CMS 2026 Proposed Reimbursement Changes: What They Mean for Your Practice
The Centers for Medicare & Medicaid Services (CMS) has released the 2026 Proposed Physician Fee Schedule (PFS). The signal is unmistakable: revenue based on office-only, fee-for-service (FFS) encounters keeps tightening, while reimbursements for care-between-visits, which includes activities like virtual care, chronic care management, behavioral health integration, and prevention, keep expanding (effective on/after January 1, 2026, if finalized). This is less a temporary tweak and more a continued realignment of Medicare payment toward services that measurably improve outcomes and reduce avoidable cost. While many practices may feel uneasy about yet another year of downward payment pressure on office visits, the proposals also create new opportunities, if practices are willing to pivot.
CMS’s 2026 reimbursement changes reflect its broader strategy: reducing long-term healthcare costs by incentivizing proactive care delivered between visits. This includes new CPT codes for virtual services, expanded reimbursements for chronic care and behavioral health, and reinforced coverage for preventive services. Practices that adapt quickly will benefit from stronger, more sustainable revenue streams; those that don’t will feel the squeeze of deeper FFS cuts.
2026 Physician Fee Schedule Cuts: Why Traditional Models Work Less and Less
For the past several years, every new CMS’s proposed fee schedule brings more reductions to traditional office-based services, usually hidden behind a modest fee increase that doesn't keep up with inflation. For 2026, this trend continues: under the proposal, CMS applies an “efficiency adjustment” of -2.5% to the work RVU and intra-service time of non-time-based codes. Time-based services are exempted: this includes care management, behavioral health integration, and services on the Medicare Telehealth List. Overall, practices will benefit from a proposed 3.8% increase in reimbursements in 2026, although the proposed bump in rates is not enough to make up for the 2025 cuts and inflation rates. In plain terms, visit-centric revenue is pressured; longitudinal, time-based care retains relative strength.
- Primary and specialty visits reimbursed under FFS will face deeper cuts, albeit only effected by rising infaltion, further eroding margins for practices that rely heavily on in-person visits.
- CMS’s aim is to discourage reliance on episodic care and instead shift resources to services that promote better outcomes and lower total cost of care.
- Practices serving largely Medicare patients in rural or underserved areas will feel the sharpest impact if they fail to diversify revenue streams.
This is not simply about lower payments: it’s about the sustainability of business models. Practices built solely around scheduled visits are increasingly fragile. To remain financially viable, practices must integrate virtual care, chronic care management, and preventive programs into their day-to-day operations.
What’s driving the squeeze
Several factors are guiding the changes in the CMS proposed fee schedule for 2026:
- Budget neutrality: New/expanded benefits are offset elsewhere. The conversion-factor math continues to nudge value away from volume-only visits.
- Relativity drift: Ongoing revaluations tilt toward services with population impact and measurable outcomes.
- Policy priorities: CMS continues to prioritize coordination, prevention, and access, especially in rural and underserved settings where travel distance, specialist scarcity, and chronic disease burden are highest.
What it means operationally? A practice built around in-person E/Ms will feel thinner margins unless it rebalances its code mix. The office visit is becoming less of the endpoint, and more of a gateway into reimbursable longitudinal services focused on promoting better outcomes. Especially in rural/frontier counties, where missed visits and travel barriers are common, leaving reimbursable non-visit work un-billed is no longer a viable business model for the long-term.
Virtual Care Expansion: More CPT Codes, Easier Adoption
The 2026 proposal further lowers barriers to adoption for practices and patients who don’t yet produce daily device data or who are just getting started with remote care.
CMS is proposing four new CPT codes for remote patient care in 2026, designed to make adoption easier for practices and patients:
- Two new device-supply codes for patients who log 2–15 readings per 30 days, recognizing that even intermittent monitoring has clinical value.
- Two new time-based codes for 10–19 minutes of monitoring per month, lowering the threshold for reimbursable engagement.
These updates reflect CMS’s acknowledgment that virtual care is not one-size-fits-all: by lowering the bar, CMS is giving practices tools to expand enrollment, engage more patients, and bill appropriately for meaningful monitoring. This can be valuable, for example, with rural and older patient populations, where daily readings may be less realistic.
This matters, as it creates more "real-world" flexibility: older patients, those with dexterity or digital literacy challenges, and many rural residents with limited broadband can still qualify for reimbursable monitoring; offers a better fit to behavior, with code selection can match actual engagement levels instead of forcing “daily or nothing.”; and, it creates the premises for a faster ramp, with lower thresholds making it easier to scale virtual offerings beyond small, highly adherent cohorts.
Remote Patient Monitoring (RPM) & Remote Therapeutic Monitoring (RTM): Stronger Than Ever
The proposed 2026 updates virtually confirm that Remote Patient Monitoring (RPM) is now a permanent reimbursable service. Practices can prescribe RPM for eligible patients on a **long-term basis**, cementing its role in chronic disease management. Key points to note:
- RPM permanence. No longer limited to short-term conditions, RPM can support long-term management of hypertension, heart failure, COPD, and diabetes. In other words, RPM is no longer framed as a short episode-only tool. RPM for eligible chronic patients remains appropriate on a continuing basis when medically necessary;
- Lower reporting threshold : The reported 2–15 readings and 10–19 minutes codes would widen eligibility and align coding with real engagement.
- RTM growth. CMS continues to support Remote Therapeutic Monitoring (RTM), expanding billing opportunities for musculoskeletal, respiratory, and therapy-related interventions.
- Compliance warning. CMS has explicitly cautioned against fraudulent use of non-FDA approved consumer devices (e.g., consumer fitness trackers). Only medical-grade, FDA-cleared devices qualify. Furthermore, auditable data pipelines must be maintained.
- Expense-based reimbursement declines. CMS plans to lower expense-based RPM rates in 2026. Practices should scale adoption now while margins are still favorable.
For rural practices, RPM/RTM adoption is particularly powerful, allowing providers to track patients who live far from clinics, reduce avoidable hospitalizations, and deliver proactive interventions.
Chronic Care Management (CCM) vs. Advanced Primary Care Management (APCM): The Revenue Gap Widens
CMS’s 2026 proposals reaffirm that Chronic Care Management (CCM) remains one of the most profitable reimbursable services for outpatient practices. Time-based care management categories (e.g., CCM) are exempt from the –2.5% efficiency adjustment, while many visit-based services are not. With concurrent billing with TCM already operational from 2025, CCM remains a highly reliable monthly revenue engine for multi-morbid panels in 2026:
- Higher reimbursement thresholds make CCM an even stronger revenue anchor.
- Positive 2025 updates, like concurrent billing with Transitional Care Management (TCM), carry forward.
- Compared to Advanced Primary Care Management (APCM), CCM offers more stable and higher revenue opportunities in 2026.
For practices, this means CCM should be a central pillar of their financial strategy. Patients with multiple chronic conditions are abundant in rural and underserved populations, and CCM programs can both improve outcomes and provide consistent monthly revenue. APCM, while useful, is still a weaker option financially.
Why CCM often outperforms APCM on net margin
- Predictable PMPM tied to work you’re already doing (medication reconciliation, care planning, outreach).
- Scales with complexity via add-on time codes.
- Maps cleanly onto RN/MA workflows and team-based care, especially valuable for rural panels with limited specialty access.
Behavioral Health Integration (BHI): Expanded Opportunities
CMS is doubling down on its commitment to behavioral health in 2026. The proposal introduces:
- Optional BHI/CoCM add-on G-codes under APCM and extends related options to FQHCs/RHCs, reinforcing financing for behavioral health in safety-net settings.
- Expanded coverage for digital mental health treatment devices to ADHD, reflecting CMS’s recognition of growing behavioral health needs.
- Expanded list of personnel eligible to deliver Community Health Integration (CHI) and Principal Illness Navigation (PIN).
- Lower requirements for the initial visit, making it easier to initiate services.
- Unbundling for FQHCs and RHCs, allowing rural clinics to bill separately for BHI.
These changes create significant new opportunities for practices to expand behavioral health offerings, integrate services into primary care, and meet rising demand in both rural and urban areas.
Remember: treat these as proposed details pending final rule text. However, these proposed changes could be particularly valuable as rural communities face long waits and long drives for behavioral care. Integrating BHI into primary care creates access, improves follow-through, and supports sustainable billing within the medical home.
Preventive Care Reimbursements: The Future of Primary Care
Preventive care continues to be the centerpiece of CMS’s long-term cost-control strategy. The proposed rule and Quality Payment Program materials point to continued measure updates/MVPs and policy refinements (e.g., TEFCA-related incentives, suppression policy). Rather than anchoring on a fixed count of “new measures,” the bigger story is that CMS keeps tying more of your payment opportunity to chronic disease control, risk factor management, and interoperability, areas that depend on proactive, between-visit care. The 2026 proposals:
- expand Coverage for nutrition counseling and chronic condition management.
- Introduce Five new MIPS measures targeting chronic conditions like hypertension and diabetes.
- Bring more emphasis on preventive visits as gateways to / activation points for CCM, RPM, and behavioral health services.
The key takeaway is that preventive care will be more than a clinical priority, it will be a financial cornerstone for practices, and practices that build workflows around preventive services will strengthen patient outcomes while maximizing reimbursement. Standing orders and protocolized outreach can be used to maintain adherence across large rural panels with transportation challenges.
How Practices Can Benefit From CMS 2026 Changes
The winners will be those who operationalize the proposal, turning policy into a scheduled, measured, and sustainable workflow. CMS’s 2026 proposals may seem daunting, but they also open doors to new revenue opportunities. Practices can benefit by:
1. Auditing billing models. Identify reliance on FFS and rebalance toward CCM, RPM, BHI, and preventive services.
2. Expanding virtual care infrastructure. Adopt platforms that integrate monitoring, telehealth, and compliance workflows.
3. Maximizing CCM enrollment. Fully capture eligible chronic care patients and ensure concurrent billing with TCM.
4. Integrating behavioral health. Onboard new eligible personnel and expand screenings to capture reimbursable services.
5. Leveraging FQHC/RHC opportunities. Train staff on new BHI and CTBS codes.
6. Using preventive care strategically. Position preventive visits as springboards for care management programs.
The key here is that practices that adapt will not only offset revenue losses from FFS cuts but also unlock new, sustainable revenue streams aligned with CMS’s long-term vision.
These proposed changes and the several points made by CMS on the importance of "how" the services are implemented, also intrinsically highlight how there is a clear advantage from implementing these changes on a robust digital and operational platform, for example:
- Compliance and integrity: FDA-cleared devices only, consent logging, precise time capture, audit trails.
- Efficiency: Unified queue for CCM/RPM/RTM/BHI; templated care plans; cellular provisioning for low-connectivity areas.
- Measurement: Real-time dashboards by code family and clinician; payer-mix visibility; QPP measure tracking.
In summary, the 2026 CMS proposal accelerates a long-running trend: revenue follows care-between-visits. Office-only FFS models will continue to erode; longitudinal, virtual, and preventive care will continue to compound. Practices that pivot now expanding CCM, RPM/RTM, BHI, and prevention will do more than replace lost FFS dollars: they’ll improve economics and run a sturdier, more patient-centered business, especially in rural communities where access and adherence are hardest.
Book a demo with Lara Health to see how our leading platform can help you operationalize the 2026 rule, unifying CCM/RPM/RTM/BHI workflows, automating documentation and time capture, provisioning FDA-cleared cellular devices for rural patients, and giving leaders the metrics they need to grow the right lines of business.
FAQs
Is RPM now permanent?
CMS continues coverage for RPM as an ongoing PFS service and proposes additional remote-monitoring policy updates for 2026. Treat any “permanence” framing as continued coverage, subject to annual rulemaking.
What new codes are proposed for 2026?
Legal/industry analyses describe four new RPM/RTM codes (two device-supply codes at 2-15 readings per 30 days, and two time-based codes at 10-19 minutes per month). Verify against the Federal Register text when available.
Will RPM economics worsen?
CMS proposes using OPPS data to inform rate setting for some remote monitoring services; some analyses predict downward pressure on expense components. Monitor the final rule for specifics.
Why is CCM so profitable relative to APCM?
Time-based care management is exempt from the proposed -2.5% adjustment; CCM also benefits from concurrent TCM, add-on time codes, and clean integration into RN/MA workflows.
What’s new for behavioral health?
The proposal introduces APCM add-on G-codes for BHI/CoCM and extends related options to FQHCs/RHCs; several summaries note potential clarifications for CHI/PIN personnel. Confirm details at finalization.
Other articles you might find interesting
The $50 Billion Rural Health Transformation Program: What Providers Can Do Before Nov. 5, 2025
Improving Population Health with CCM
Integrating CCM and RPM for Better Outcomes
How to Choose the Best CCM Platform: Key Factors to Consider
Sources
CMS - Calendar Year (CY) 2026 Medicare Physician Fee Schedule (PFS) Proposed Rule (CMS-1832-P) Fact Sheet (web). 2025.
DLA Piper - CMS proposes new behavioral health integration add-on codes for APCM. 2025.
CMS QPP - 2026 QPP Proposed Policies: Fact Sheet/Policy Comparison. 2025.
