CMS Proposes Dropping the Obstetric Training and Quality Rules Hospitals Must Meet on Jan. 1
CMS would remove four 2024 hospital rules it once costed at about $3 billion over 10 years and reopen anesthetist supervision. Comments are due Jan. 9.
Idea in Brief
The News
CMS's proposed CARE rule, CMS-3484-P, publishes Nov. 10 and would remove hospital training requirements on emergency readiness, patient transfers and obstetric care, plus obstetric-specific quality rules.
What Changes
Hospitals offering obstetrics would instead need documented consent and written policies for birth tissue collection or release. CMS also asks whether to keep physician supervision of nurse anesthetists.
The Deadline
The obstetric requirements still take effect Jan. 1, 2027, while the proposal is pending. Comments are due 60 days after publication, Jan. 9, 2027.
The Centers for Medicare and Medicaid Services has proposed removing four hospital requirements it finalized in November 2024, including the obstetric staff training and obstetric quality rules hospitals were due to meet on Jan. 1, 2027.
The proposal, titled Cutting Administrative Requirements for Excellence in Patient Care and filed as CMS-3484-P, went on public inspection at the Federal Register on Nov. 5 and is scheduled for formal publication on Nov. 10. Comments are due 60 days after publication, which on that schedule is Jan. 9, 2027. CMS estimates the full package would save about $320 million a year across hospitals, nursing homes, critical access hospitals and other facilities.
For physicians, three parts matter most: the obstetric rollback, a new birth tissue consent standard that takes the place of one of the rules being removed, and a request for comment on whether Medicare should keep requiring physician supervision of nurse anesthetists.
Which requirements would go?
All four hospital provisions came from the calendar year 2025 outpatient payment rule, which created the first Medicare conditions of participation specific to obstetric services. Two have applied since July 1, 2025. Two have not yet taken effect. In each case the proposed rule quotes CMS's own 2024 estimate of what compliance would cost. We pulled those figures from the rule text and added them up.
Our tally of the four provisions, with CMS's 2024 ten-year cost estimates as quoted in the proposal:
Emergency services readiness staff training (annual; in effect since July 1, 2025): $1.73 billion and 16.4 million staff hours.
Annual training on patient transfer protocols (in effect since July 1, 2025): $862 million and 5.1 million staff hours.
Obstetric services staff training (initial plus every two years; due Jan. 1, 2027): $242 million and 1.8 million staff hours.
Obstetric quality assessment and performance improvement requirements, including data stratified by subpopulation, an annual maternal health disparities project and use of maternal mortality review committee findings (due Jan. 1, 2027): $188 million and 1.1 million staff hours.
The four total about $3.02 billion over 10 years in CMS's original estimates. The new proposal's own impact analysis puts savings for hospitals at $123.2 million a year, or $1.23 billion over a decade, plus $16.6 million a year for critical access hospitals. The two sets of figures use different methods, and the proposal does not reconcile them. Read closely, the transfer-training section also labels its "more than $862 million" figure as the cost of "emergency services readiness staff training," the same label the next section attaches to the separate $1.73 billion estimate. Commenters may want CMS to clarify which figure belongs to which requirement.
The written transfer policies and the core obstetric conditions of participation stay. What goes is the federal mandate to train on them and to run obstetric-specific quality projects.
Why does CMS say it is reversing course?
CMS says comments to its 2025 deregulation request for information, from groups including "physician organizations, medical associations, and rural health advocates," argued the requirements were costly for small and rural hospitals and could push some to close labor and delivery units. The agency writes that it "originally disagreed" with similar comments in 2024 and has "since refined" its view. It now finds that the general hospital quality program, accreditation standards, board certification, state licensing and EMTALA together cover the same ground.
The proposal cites the North Carolina Rural Health Research Program's financial distress index, which it says puts 86 rural hospitals in the highest risk category and 329 more in the next tier. It also states that hospitals would still have to meet all the other obstetric conditions on organization, staffing, delivery of care and emergency preparedness.
Timing is awkward. CMS acknowledges the rule is unlikely to be final before Jan. 1, 2027, when the obstetric training and quality requirements take effect. It says it would ask surveyors to "focus on those CoPs that are not potentially subject to imminent revision" in the meantime. That is a request to surveyors, not a delay of the effective date, and accrediting organizations may set their own expectations.
Clinical Pearls
- CMS estimates the full proposal would save about $320 million a year, including $123.2 million a year for hospitals.
- By our tally of CMS's 2024 estimates, the four hospital requirements it would remove were costed at about $3.02 billion over 10 years.
- The emergency readiness and transfer-protocol training requirements have applied since July 1, 2025; the obstetric training and quality requirements take effect Jan. 1, 2027.
- CMS says it would ask surveyors to focus on conditions not subject to imminent revision, but it does not delay the effective date.
- The proposed birth tissue standard covers cord blood, cord tissue, placenta, amniotic membrane and amniotic fluid.
- Governors of 26 states and Guam have opted out of Medicare's physician supervision requirement for nurse anesthetists.
What is the new birth tissue standard?
The proposal replaces the obstetric training text at section 482.59(c) with a new standard on birth tissue. Hospitals and critical access hospitals that offer obstetric services and take part in any collection, storage, donation, banking, transfer or release of birth tissue would have to obtain and document informed consent first. They would also need written policies letting patients ask to keep or receive birth tissue, with instructions for safe handling.
The definition is broad: cord blood, cord tissue, placenta, amniotic membrane, amniotic fluid "and other tissues or biological materials associated with live childbirth." CMS notes that including amniotic fluid departs from the Food and Drug Administration's tissue definitions. It estimates a one-time cost of $19.2 million to write the policies, a figure that by our arithmetic assumes about 3,130 hospitals and critical access hospitals at $6,128 each, including eight hours of an obstetrician-gynecologist's time.
What does the anesthesia request ask?
CMS is asking whether to keep, revise or change the rule that a physician must supervise a certified registered nurse anesthetist in hospitals, critical access hospitals, rural emergency hospitals and surgery centers. The rule text notes that governors of 26 states and Guam have opted out since the 2001 exemption process began. This section is a request for information, not a proposal. Anesthesiologists, surgeons and the hospitals that employ them should expect it to draw heavy comment, as the 1997 and 2001 rulemakings on the same question did, with more than 20,000 and 28,500 comments respectively, according to CMS.
The package also seeks comment on the role of physician assistants and nurse practitioners in nursing home care and on barriers facing new transplant programs.
What should physicians and practices do now?
Obstetric and emergency department leaders should not stop training already in place: the two 2025 requirements remain in force until a final rule removes them, and the obstetric requirements still take legal effect Jan. 1. Departments planning birth tissue programs, or that already release placentas to families, should read the proposed consent standard now, since it would apply to any hospital that facilitates release. Anesthesia groups in the 24 states that have not opted out have the most at stake in the supervision question. The comment docket is CMS-2026-3631 at Regulations.gov, and last week's outpatient payment final rule and physician fee schedule set the payment side of the same Jan. 1 calendar.
Reported, fact-checked and edited by The Script Pad's editorial staff. See How we use AI.
This article is for professional education and does not replace clinical judgment. Treatment decisions should be based on the individual patient and current guidelines.
