The Proposed Rule Season That Matters Most
CMS releases the Calendar Year 2027 Hospital Outpatient Prospective Payment System proposed rule every summer. For 340B hospitals, this document has become the single most consequential annual policy release.
Since the Supreme Court’s 2022 decision in AHA v. Becerra, CMS has been rebuilding its approach to 340B drug reimbursement. The Drug Acquisition Cost Survey launched in July 2026. The CY 2027 proposed rule will be the first to potentially incorporate survey data into payment rate calculations.
If CMS proposes reducing 340B drug reimbursement based on acquisition cost data, the comment period becomes a critical window for hospitals to respond with data, legal arguments, and impact analyses.
What to Watch For
Three provisions in the CY 2027 OPPS proposed rule will determine the near-term trajectory of 340B reimbursement.
First, the drug payment methodology. CMS currently pays for separately payable drugs at ASP+6% regardless of whether the hospital purchased the drug at 340B prices. If the proposed rule introduces a tiered payment methodology, with lower rates for 340B-acquired drugs, it would directly reduce the financial benefit of program participation.
Second, the survey data methodology. How CMS calculates “acquisition cost” from the survey data will determine the magnitude of any payment change. If CMS uses average 340B ceiling prices, the reduction will be smaller than if it uses the lowest reported acquisition costs.
Third, the budget neutrality adjustment. Under OPPS rules, payment reductions in one area must be offset by increases elsewhere. If CMS reduces 340B drug payments, the redistribution methodology matters. Will non-340B hospitals see increased payments? Will the savings be redirected within the drug payment system?
Preparing Your Comment Letter
The comment period is your formal opportunity to influence the final rule. Effective comment letters share several characteristics.
They’re data-driven. CMS responds to empirical evidence, not advocacy rhetoric. Quantify the impact of the proposed changes on your hospital’s finances, your uncompensated care funding, and your ability to serve your patient population.
They’re specific. Address the exact provisions you want changed and propose alternative approaches. A letter that says “this will harm safety-net hospitals” is less useful than one that says “the proposed acquisition cost methodology should be modified to exclude sub-ceiling prices because they don’t represent the prevailing market price for 340B-eligible entities.”
They’re timely. The comment period typically runs 60 days. Don’t wait until the last week. Early comments allow your voice to be part of the internal deliberation process at CMS.
Scenario Planning for Financial Impact
While the proposed rule is still forthcoming, hospitals can begin scenario planning now using their Drug Acquisition Cost Survey submissions as a starting point.
Model three scenarios. A base case where CMS maintains current ASP+6% reimbursement. A moderate case where CMS reduces 340B drug reimbursement to ASP minus a modest percentage. An aggressive case where CMS moves to acquisition-cost-based reimbursement.
For each scenario, calculate the revenue impact on your Medicare outpatient drug program, the downstream effect on 340B savings available for patient care, and the operational changes needed to maintain financial viability.
Hospitals that have completed this analysis before the proposed rule is released will be positioned to respond quickly with data-driven comments and to begin implementation planning without delay.
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