AAFP summary of 2026 proposed MPFS outlines payment boost, other potential wins

The summary breaks down the increase to both conversion factors this way:

• For both CFs, 2.5% of the increase is attributable to H.R. 1.

• A statutorily required update of .75% for the APM CF and 0.25% to the non-APM CF.

• An additional .55% increase necessary to account for proposed changes in RVUs for some services (meaning a positive budget-neutrality adjustment).

CMS estimates that the impact on total allowed charges by family physicians will be a net-positive 3% in 2026, factoring in proposed updates to practice-expense methodology and efficiency adjustments. However, the impact of these updates will vary depending on whether a family physician practices in a facility-based setting (hospital outpatient departments, ambulatory surgical centers, skilled nursing facilities, inpatient hospitals, etc.) or a non-facility, such as a physician-owned clinic. CMS predicts that total payments for services provided by family physicians in facility settings may be reduced by 9%, while total payments to physicians in non-facility settings, will increase by 6%. According to CMS’ analysis, approximately $1 billion was billed by facility-based family physicians in 2024 (the most recent year complete data are available) and $4.36 billion by family physicians in non-facility settings, suggesting that the majority of payments to family physicians would increase.

The division between facility and non-facility payments stems from a new policy CMS proposes, centered on more accurately capturing indirect costs (rent, administration and other overhead not attributed to a specific service) for practitioners in office-based settings compared with facility settings. If the proposal is finalized, CMS will adjust its methodology to better recognize the true cost of doing business for physician-owned practices, something for which the Academy has advocated.

CMS also proposes to start applying an efficiency adjustment to non-time-based codes. In a potential win for family physicians, these adjustments would exclude codes frequently billed by primary care practices, such as E/M, care management and behavioral health services. The proposed efficiency adjustment, which would mostly affect surgical specialties, radiology and pathology, would reduce overall payment by 1%, contributing to a positive .55% budget-neutrality adjustment to both of the proposed 2026 conversion factors. Over time, this would improve the valuation of services for most family physicians: The conversion factors would increase (while procedural codes are adjusted downward), but the E/M RVU values would not.

Both the new practice expense methodology and efficiency adjustment proposals "take a meaningful step forward in acknowledging what the AAFP has long championed: that existing Medicare payment undervalues primary care services," said David Tully, the AAFP's vice president of Government Relations. "However, the complexity of the policies warrants a thorough review. The AAFP will closely examine both the short- and long-term impacts on family physicians to ensure that our policy recommendations to CMS reflect the best interests of our members and support sustainable, high-quality primary care delivery."

Add-on codes

The rule would allow G2211 to be billed as an add-on code with home or residence E/M services—answering the Academy’s payment advocacy.

Emphasizing behavioral health care, the 2026 MPFS also proposes

• optional add-on codes for behavioral health integration (BHI) services that can be billed concurrently with APCM codes by removing the time requirements of the existing BHI and collaborative care management services,

• expanded payment for digital mental health technology devices (HCPCS codes G0552, G0553, G0445) to include those for ADHD and

• an expansion of the types of visits that can initiate community health integration (CHI) services to include CPT 90791 (psychiatric diagnostic evaluation) and Health Behavior Assessment and Intervention (HBAI) codes.

Telehealth flexibilities

The 2026 MPFS proposes adjustments to telehealth policies affecting family physicians.

It would adopt a definition of direct supervision allowing “immediate availability” of the supervising practitioner to include using audio/video real-time communications technology—though not, as the AAFP has advocated, audio-only—for an expanded set of services.

It also would end a flexibility, established during the COVID public health emergency, that allowed teaching physicians to have a virtual presence for purposes of billing for services furnished involving residents in all teaching settings through Dec. 31, 2025. Instead, CMS would again require teaching physicians to be in person with their residents in all teaching settings.

However, a rural telehealth exception, established in the 2021 MPFS, would continue to let teaching physicians at rural residency training sites (those located outside federal metropolitan statistical areas) use audio/video real-time communications technology to fulfill the presence requirement if they maintain active, real-time observation and participation in the service.

Coding changes

The proposed rule would delete HCPCS code G0136, which covers social determinants of health (SDOH) risk assessments; CMS indicates that this is because the code’s resource costs are already captured in existing services such as E/M visits. G0136 likewise would be eliminated from the Medicare Telehealth Services list and from the list of optional elements of the annual wellness visit.

CMS further proposed replacing the term “social determinants of health” with “upstream driver(s)” in CHI code descriptors, positing that the latter would be more comprehensive. Other code revisions for similar services based on the new terminology would include services furnished by rural health centers, federally qualified rural health centers and opioid treatment programs.

Quality Payment Program (QPP)

The proposed rule removes from the family medicine specialty set several Merit-based Incentive Payment System (MIPS) Clinical Quality Measures (CQM) in 2026:

• Non-Recommended Cervical Cancer Screening in Adolescent Females,

• Screening for SDOH,

• Connection to Community Service Provider-HRSN screening and

• Adult COVID-19 Vaccination Status.

A proposed new Ambulatory Specialty Model would test whether adjusting payment for specialists results in enhanced quality of care and reduced costs through more effective upstream management of chronic conditions. This model, which would run Jan. 1, 2027, through Dec. 31, 2031, would center on care provided by select specialists to beneficiaries with heart failure and lower-back pain. Family medicine is not among the specialties identified as participants, though the program would include incentives for patients to have a regular source of primary care.

The rule proposes six new MIPS Value Pathways (MVPs) and revisions to all 21 existing MVPs and maintains the same performance threshold (75 points).

CMS also proposes changes to each performance category but no wholesale changes to the program itself, the Academy’s summary notes.

Medicare Shared Savings Program (MSSP)

The rule would reduce from seven to five the number of years an MSSP accountable care organization (ACO) can participate in a one-sided model of the BASIC track under the ACO’s first agreement period. The “health equity adjustment” applied to the ACO’s quality score would be removed, beginning in 2025, in favor of a  “population adjustment.” The rule also would change the APM Payment Pathway Plus quality measure set to align with other quality measure changes proposed elsewhere in the rule, including removal of its measure related to screening for SDOH.

Read the Academy’s full executive summary for details of proposed work and practice expense values for specific codes and other key points.

What’s next?

The AAFP continues to review the proposed rule ahead of providing comments to CMS before the Sept. 12 deadline. The final rule will be released around Nov. 1, and will take effect on Jan. 1, 2026, except where specified otherwise in the final rule. The AAFP also continues to call for permanent Medicare payment reforms, including annual inflationary updates.