The Protecting Access to Medicare Act (PAMA) reformed the Medicare Clinical Laboratory Fee Schedule (CLFS) by establishing a single national fee schedule based on private-market data from applicable laboratories serving Medicare beneficiaries, including hospital outreach, independent and physician-office laboratories.
The Consolidated Appropriations Act of 2026, signed into law Feb. 3, 2026, included several updates to PAMA:
- Delays CLFS rate reductions of up to 15% through Dec. 31, 2026.
- Updates the private payer data that the Centers for Medicare & Medicaid Services (CMS) will use to establish 2027 CLFS rates by shifting the data collection period to Jan. 1 through June 30, 2025, from the same period in 2019.
- Establishes a new data reporting period of May 1 through July 31, 2026, for applicable laboratories, to allow CMS to calculate CLFS rates that take effect Jan. 1, 2027.
A hospital outreach laboratory is defined as an applicable laboratory if it:
- Furnishes laboratory tests to nonpatients rather than admitted inpatients or registered outpatients of the hospital.
- Bills Medicare Part B laboratory services furnished to nonpatients using Form CMS-1450 Type of Bill 14X.
- Meets or exceeds the low expenditure threshold by receiving at least $12,500 in Medicare CLFS revenues during the six-month data collection period.
Members are encouraged to monitor the CMS CLFS reporting website for updated resources, including frequently asked questions, the required Excel reporting template and the list of test codes for which laboratories must report private payer rates and volumes. Members may also reference the recent letter from CMS.
Members with questions should contact the MHA health finance team.
