On October 31, CMS finalized the CY 2026 Medicare Physician Fee Schedule (PFS) rule (CMS-1832-F), effective January 1, 2026. While primarily directed at Medicare providers, the rule’s changes have clear downstream effects for payors and private insurers that benchmark to Medicare or align commercial policies with federal payment logic. Key themes are higher baseline rates, a stronger push toward value-based care via dual conversion factors, permanent telehealth flexibilities (including virtual supervision), expanded behavioral health integration, and a cost-containment overhaul for skin substitutes.

Rates and Conversion Factors

Beginning in 2026, Medicare will use two conversion factors: $33.57 for qualifying alternative payment model (APM) participants (up 3.77%) and $33.40 for non‑qualifying APM participants (up 3.26%). These increases — reflecting statutory updates and routine PFS adjustments — will likely ripple into commercial contracts that reference PFS, affecting unit costs, network reimbursement strategies, actuarial projections, and medical loss ratios.

Telehealth Permanence and Virtual Supervision

CMS is permanently removing frequency limits for certain telehealth visits and allowing “virtual” direct supervision via real-time audio-video for applicable incident-to services, diagnostic tests, and pulmonary/cardiac rehab, with teaching physicians permitted to be virtually present when services are furnished virtually. This expands reimbursable virtual services and raises expectations for telehealth parity across private plans, prompting updates to coding, prior authorization, and digital health benefit designs — particularly for behavioral health and chronic care management.

Behavioral Health Integration and Whole‑Person Care

CMS is reinforcing integrated care by creating optional add-on codes that allow Behavioral Health Integration (BHI) or Collaborative Care Model (CoCM) services to be layered onto Advanced Primary Care Management (APCM) base codes. CMS also expands digital mental health treatment to include ADHD devices. Payors should anticipate increased demand for integrated behavioral health reimbursement and consider aligning coverage criteria and care management programs to support collaborative, whole-person care.

Skin Substitutes: Cost Containment Signal

CMS is moving skin substitute payment from product-specific, ASP-based rates to incident-to supplies paid when used with covered application procedures in physician offices and hospital outpatient departments, with products grouped by FDA regulatory status. For 2026, CMS set a single cross-category rate (~$127.28) and indicated future differentiation. This bundling approach is a clear precedent for rationalizing high-spend product categories, providing payors a policy basis to revisit product pricing, renegotiate rates, tighten coverage criteria, and strengthen utilization management in wound care.

Implications for Payors and Private Insurers

  • Value‑based care momentum: The two‑tiered conversion factor reinforces CMS’s push toward risk‑bearing, value‑based models. Expect commercial insurers to mirror aspects of APM differentiation in network design, contracting strategies, and performance incentives.
  • Rate benchmarking: Overall Medicare rate increases will flow through to commercial agreements pegged to PFS, influencing fee schedules, actuarial projections, and medical loss ratios.
  • Virtual care parity: Permanent telehealth flexibilities (including virtual supervision) elevate expectations for commercial coverage parity and may necessitate updates to telehealth coding, prior authorization, and benefit designs, particularly for behavioral health and chronic disease programs.
  • Integrated behavioral health: New integration and collaborative care add‑ons underscore federal support for whole‑person care. Commercial plans should prepare for more integrated billing and clinical workflows and consider benefit alignment that facilitates primary‑care‑based behavioral health.
  • Product payment reform: The skin substitute overhaul signals a broader appetite for bundling and product rationalization. Insurers can leverage this precedent to advance similar cost‑discipline approaches in commercial policies.

Bottom Line
The CY 2026 PFS final rule continues the convergence between Medicare and private sector payment logic — advancing virtual care, reinforcing value‑based incentives, and tightening high‑cost product reimbursement. For payors and private insurers, the rule offers both a blueprint and an imperative: update reimbursement and benefit policies to reflect permanent telehealth flexibilities, support integrated behavioral health, and adopt cost‑disciplined approaches for high‑spend product categories, while preparing for rate increases to ripple through Medicare‑benchmarked contracts.