CMS finalizes 2027 dialysis rule: base rate $297.52, payments up 2.7%, low-volume attestations due Dec. 31

CMS on October 28 issued the final calendar year 2027 payment rule for outpatient dialysis, CMS-1846-F, and gave a large group of mid-sized dialysis facilities a deadline they did not have before: December 31, 2026, to attest that they qualify for Medicare’s low-volume payment adjustment (LVPA) [1, 2]. The rule appeared in the Federal Register on October 30 and takes effect January 1 [2].

What changed

The 2027 ESRD Prospective Payment System (PPS) base rate is $297.52 per treatment, up $15.81 from $281.71 [1]. CMS projects total Medicare payments to dialysis facilities rise about 2.7% next year, with hospital-based and freestanding facilities each at 2.7% [1, 2]. Medicare expects to pay $7.0 billion to roughly 7,600 facilities under the ESRD PPS in 2027 [1].

The rate is built in four steps. CMS adds $12.85 to the 2026 rate for phosphate binders, applies a wage index budget neutrality factor of 1.00260 and a factor of 0.98864 for changes to the low-volume, pediatric and home training adjustments, then applies a 1.9% market basket update [1, 2]. That 1.9% is a 2.9% market basket increase less a 1.0 percentage point productivity adjustment [2].

How did the final rule change from the June proposal?

CMS’s June proposal had set the base rate at $299.55, with a 1.6% update and a $15.96 binder add-on [2]. The final base rate is lower even though the update rose to 1.9%. The reason is the binder amount. CMS recalculated it with claims through June 30, 2026, about fifteen months of data instead of nine, and with newer average sales price (ASP) data. The per-treatment average fell to $12.98, and after a 1% outlier reduction the add-on came to $12.85 [2].

The home training add-on was finalized at $138.00, based on 2.66 hours of registered nurse time at an updated $51.88 an hour [2]. The six-tier LVPA was finalized as proposed, with a recalculated budget neutrality factor of 0.98901 [2].

Who it affects

Freestanding and hospital-based facilities are both paid under the new rate [1]. CMS’s impact estimates spread widely by type: from a 2.9% decrease for regional chain facilities to a 9.6% increase for facilities furnishing 4,000 to 4,999 treatments a year [2].

Mid-sized facilities. The LVPA threshold doubles from 4,000 to 8,000 treatments, and the number of tiers goes from two to six [1]. Eligibility requires being under the threshold in each of the three prior cost reporting years, and the three-year median sets the tier [2]. Treatments at other facilities under common ownership and within 5 road miles count toward the total, and a week of peritoneal dialysis counts as three hemodialysis treatments [2].

Facilities in low-wage areas. The labor-related share, the part of the base rate adjusted by the local wage index, rises from 55.2% to 63.5% [2]. CMS says a facility at the 0.600 wage index floor would lose 4.3% of payment from that change alone, and most facilities with higher wage index values would see less effect [2].

Home and pediatric programs. The training add-on rises from $95.60 to $138.00 and can be paid during the onset period, the first 120 days of dialysis [1, 2]. The temporary 30% pediatric add-on ends December 31, 2026. It is replaced by new pediatric case-mix adjusters and by letting pediatric treatments draw the LVPA [1, 2].

Facilities treating AKI patients. The AKI rate equals the base rate, $297.52. Because binder payment now sits in that rate, facilities are expected to furnish medically necessary binders to AKI patients [1, 2].

What it means for your practice

Start with the base rate arithmetic. On 10,000 treatments, the $15.81 increase works out to $158,100 a year before case mix, wage index and outliers. Most of that is binder money that used to arrive through the transitional drug add-on payment adjustment (TDAPA). CMS estimates about $410 million in 2026 TDAPA payments for DefenCath, Vafseo and phosphate binders ends, offset by the binder base-rate increase and about $260 million in post-TDAPA add-on payments in 2027 [2].

Outlier thresholds climb steeply. The adult fixed dollar loss amount goes from $14.80 to $90.60 and the adult Medicare allowable payment from $23.68 to $41.83 [1]. Your high-cost cases need to run much further over expected cost before outlier money flows. CMS links the jump mainly to new drugs that become outlier services in 2027 and projects the change lowers payments by about 1.6% [1, 2].

The post-TDAPA add-ons now change every quarter. For the first quarter of 2027 they are $8.3220 per treatment for DefenCath, $0.9970 for Vafseo and $0.0793 for Korsuva, which drops out after that quarter. Later amounts come through change requests [2].

If your facility sits between 4,000 and 8,000 treatments, the LVPA is the largest single item. CMS’s own analysis found facilities under 8,000 treatments tend to have costs above payments, while higher-volume facilities pay part of the cost through a base rate about 1.1% (roughly $3) lower [1, 2]. CMS also notes that eligible facilities do not all attest, and those that do not attest do not get the adjustment [2].

On quality, starting with payment year 2029 the Hypercalcemia reporting measure is replaced by a Hyperphosphatemia clinical measure, and the medication reconciliation and COVID-19 healthcare personnel vaccination measures are removed [1, 2]. With no reporting measures left, CMS drops the Reporting Measure Domain and shifts its weight to the Care Coordination and Clinical Care domains [1].

When is the 2027 low-volume attestation deadline?

December 31, 2026. The usual deadline under 42 CFR 413.232(e) is November 1, which gives Medicare Administrative Contractors (MACs) 60 days to verify a claim of eligibility [2]. CMS moved the 2027 deadline after commenters asked for a later attestation date or for pushing the policy to 2028, and points to similar extensions for 2015, 2016 and 2021 [2].

What to do now

• Pull treatment counts for your last three cost reporting years, including facilities under common ownership within 5 road miles, and find your median [2].
• If you were under 8,000 in each year, send a written attestation to your MAC by December 31, 2026 [1, 2].
• Update your 2027 revenue model with $297.52, the 63.5% labor-related share, the new outlier thresholds and quarterly post-TDAPA amounts [1, 2].
• Set up binder supply for AKI patients before January 1 [1].
• If you run a home program, schedule training billing for patients in their first 120 days [2].

The policy fight

Section 153 of the Medicare Improvements for Patients and Providers Act of 2008 requires a payment adjustment for “low-volume facilities (as defined by the Secretary)” whose costs exceed other facilities’ [4]. Many commenters on the proposal pointed out that no statute requires the LVPA to be budget neutral, and asked CMS to fund the expansion outside the base rate [2]. Some asked CMS to drop the rural adjustment to offset it, and a few noted that some high-volume urban facilities treat medically complex patients [2]. CMS answered that “budget neutrality is appropriate for this proposal,” because low-volume costs were built into the base rate when the system began in 2011 [2].

On the overall update, most commenters said the proposed 1.6% was insufficient given inflation and workforce shortages, and several noted that only $1.88 of the proposed $17.84 increase came from outside the binder add-on [2]. CMS said the higher final update addresses some of those concerns [2]. Some commenters asked for a phase-in of the labor-related share increase. CMS declined, saying a phase-in would shortchange facilities whose costs the higher share fits better [2].

The Medicare Payment Advisory Commission took the other side in March. It found a 4.5% fee-for-service Medicare margin for dialysis facilities in 2024, projected 4% for 2026, and voted 17 to 0 that Congress should “eliminate the update to the 2026 base payment rate” for 2027 [3]. CMS applied the 1.9% update, which it describes as required by section 1881(b)(14)(F) of the Social Security Act [2].