CMS increases the dialysis base rate and changes low-volume, home-training and quality policies for 2027

What changed

CMS finalized the calendar year (CY) 2027 End-Stage Renal Disease (ESRD) Prospective Payment System rule, setting the unadjusted bundled payment base rate at $297.52 per treatment, up from $281.71 in 2026. The retained rule states that the regulations take effect January 1, 2027; later corrections and current legal status remain to be verified. The base rate is a starting point: patient and facility adjustments, geographic wages, applicable training and outlier payments, and other payment rules mean that a particular facility's payment may differ. CMS estimates that Medicare ESRD PPS payments across facilities will rise 2.7% in CY 2027 compared with estimated 2026 payments; that aggregate projection is not a guarantee of the same increase for each provider or of an increase in all-payer revenue.

The $15.81 base-rate increase includes $12.85 for phosphate binders as CMS completes their incorporation into the bundle. CMS applies a 1.00260 wage-index budget-neutrality factor, a combined 0.98864 factor for low-volume, pediatric and training changes, and a 1.9% productivity-adjusted market-basket update. The 1.9% update is the 2.9% market-basket increase less a 1.0 percentage-point productivity adjustment. The resulting calculation is (($281.71 + $12.85) × 1.00260 × 0.98864) × 1.019 = $297.52. The binder addition becomes part of the base rate and is subject to annual PPS updates; CMS states it is not separately repriced each year based on binder prices or utilization.

Low-volume eligibility and the near-term deadline. CMS expands the low-volume payment adjustment (LVPA) to six tiers for eligible facilities furnishing fewer than 8,000 treatments, with larger factors at lower volumes. The final factors range from 1.368 for 0–2,999 treatments to 1.050 for 7,000–7,999 treatments. The rule's eligibility text requires fewer than 8,000 total treatments in each of the three preceding cost-reporting years, subject to specified aggregation and exceptions; the fact sheet describes the tier using median treatments over those years. Eligibility and tier selection are therefore separate checks, and volume alone does not establish eligibility. For payment year 2027, an eligible facility seeking the adjustment must provide its attestation by December 31, 2026.

Pediatric and home dialysis. The temporary pediatric ESRD add-on ends December 31, 2026. CMS revises pediatric case-mix adjusters and extends LVPA to pediatric treatments at facilities meeting the applicable requirements, including a pediatric exception to the common-ownership aggregation rule. Facility-specific eligibility for that exception depends on the rule's applicable conditions. CMS also increases the home and self-dialysis training add-on from $95.60 to $138.00, permits it during the ESRD onset period, and reduces the onset factor from 1.327 to 1.311 to account for overlap. These payment changes are budget neutral; a facility should model its own patient mix rather than assume that every component increases its net payment.

Acute kidney injury is included. For dialysis furnished by ESRD facilities to beneficiaries with acute kidney injury (AKI), CMS sets the CY 2027 base payment at $297.52 before the applicable geographic adjustment and applies the $138 training add-on where applicable. Starting in CY 2027, ESRD facilities must furnish medically necessary phosphate binders to AKI beneficiaries receiving renal dialysis services under the facility's direct care. CMS also explains that the existing ESRD facility conditions for coverage apply to AKI patients using home modalities, including training and backup dialysis support; sending a patient to an emergency department or discharging them to find another provider does not itself satisfy that backup-support obligation.

Quality measurement starts before the payment year. Beginning with payment year (PY) 2029, CMS replaces the hypercalcemia reporting measure with an adult chronic hyperphosphatemia clinical measure; removes the medication reconciliation and healthcare-personnel COVID-19 vaccination reporting measures from the ESRD Quality Incentive Program (QIP); updates the National Healthcare Safety Network bloodstream-infection measure; and changes the domain and measure weights. Removing those measures from the QIP does not by itself eliminate other clinical, documentation, infection-control or regulatory obligations. CMS discusses a possible patient life-goals measure in response to a request for information; it did not adopt that measure in this rule.

In its discussion of the proposal, CMS described monthly EQRS reporting during CY 2027 for PY 2029; final operational reporting specifications and deadlines still need verification. The hyperphosphatemia measure uses a six-month rolling average of pre-dialysis phosphorus values, using the first reported value in the current month and up to five preceding consecutive months. Among the measure's criteria, it excludes patients with fewer than 91 days of ESRD treatment and includes a patient for a facility only when the patient remains there for the full reporting month and preceding five months; other nutritional exclusions also apply. In that proposal discussion, CMS's example for January 2027 uses August 2026 through January 2027 values, making historical data availability relevant before the new performance period starts. Verify the final technical specifications and reporting schedule before implementing a local workflow.

Why it matters

The Medicare ESRD PPS aggregate estimate is not a facility-specific payment guarantee. Eligibility for the low-volume adjustment and its tier are separate checks, and the PY 2029 quality measure depends on historical data and facility continuity. The final technical specifications and operational guidance remain to be checked.

Suggested action

Suggested operational actions, not additional legal duties. Revenue-cycle and finance teams should model the rate and geographic adjustment against actual treatment mix; separately assess LVPA eligibility, ownership aggregation, cost-report history and tier, and prepare the attestation before the specified deadline if seeking payment. Pharmacy, clinical and contracting teams should assess binder procurement, supply and transitions for eligible ESRD and AKI patients. Home-dialysis leaders should review training capacity, billing configuration and backup-support arrangements. Quality and laboratory teams should map the first pre-dialysis monthly phosphorus value into EQRS workflows, check continuity and exclusions, and validate the historical data needed for the rolling measure. Track CMS and Medicare Administrative Contractor implementation guidance, and confirm that any existing requirements remain in force before discontinuing a prior QIP reporting process. These are proposed planning steps, not a claim that CMS mandated each local action.

Sources

• CMS-1846-F, CY 2027 ESRD PPS final rule public-inspection PDF, Centers for Medicare & Medicaid Services. | Published Federal Register rule

• Calendar Year (CY) 2027 ESRD PPS Final Rule (CMS-1846-F), Centers for Medicare & Medicaid Services; source date 2026-10-28.