Header: PAMA Cycle Delayed to 2027, With New Base Year 2025
Background
PAMA is legislation passed in 2014, one part of which planned for the Clinical Laboratory Fee Schedule to be repriced every 3 years, based on surveys of payor prices in the insured marketplace. However, the triennial process only happened once - when payments from 2016 were surveyed in 2017 to set a new fee schedule in 2018. The survey has been delayed annually since 2020. This means 2019 data was frozen from 2020 reporting, and frozen from 2021 reporting, 2022 reporting, etc.
What's New
On February 3, 2026, the new budget bill gave new PAMA benchmarkets (Section 6226). The next reporting period will be in >>> May-June-July 2026, reporting data from 1H2025, to reset a new triennial schedule for 2027, 2028, 2029.
The base year has been updated from 2019 to 2025. This means hundreds of "new" PLA codes (from 2019 to 2025) will get repriced in the "next" (rather than second-next) PAMA cycle.
Only labs paid over $12500 from Medicare in 1H2025 need report.
There are some quirks (see Nerd Notes below).
The New Future
The plan would be, for data from 2028 to be reported in 2029 for a new schedule in 2030, 2031, 2032.
For More
See news at ACLA. ACLA continues to seek a larger-scale legislative fix, currently as legislation titled "RESULTS."
Nerd Notes - Take a Deep Breath
By March 2026, CMS will release a list of reported lab codes, which will be all lab codes active during 1H2025 (For example, codes coming active on or after July 1, 2025, will not be surveyed).
The first PAMA survey in 2017 included about 5 administrative MAAA codes and about 15 Category I MAAA codes (81501 etc), but no PLA codes.
It's massively different today. This survey will include over 500 PLA codes, up to but not including those starting on and after July 1, 2025.
Only labs with $12500 in Medicare payments in 1H2025 are reporting labs.
In the weeds. If a lab had a PLA code in 1H2025, but it got less than $12500 Medicare payments (and possibly 0) such a code will fall outside the PAMA rate setting survey. So regulation says that CMS is supposed to crosswalk or gapfill it. CMS would do that "crosswalk or gapfill on code lacking PAMA data" in the rapid time window between the reporting period (through July 31, 2026) and the start of 2027.
The easiest way for CMS to maneuver this period would be to have the (potentially several hundred PLA codes) with no CMS reporting, simply crosswalked by fiat to their current price (set by crosswalk or gapfill from 2018 to 2025). However, CMS could review the several hundred codes with no PAMA data on a one-by-one gapfill basis or some novel crosswalk (seems infeasable).
0551U was the last code to be made effective on April 1, 2025, and therefore "effective" during 1H2025 (at least during one quarter (Q2) of 1H2025). 0530U was the last code to be made effective on January 1, 2025, and thus active during the entire half-year of 1H2025.
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81479
Remember that PAMA does not set prices for 81479, so it won't collect data on this code. But 81479 is $600M a year in CY2024, a substantial part of all MoPath spending. Here's the most recent breakdown, for CY2023 (CY2024 to release around May-June 2026).
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One criterion for reporting lab data is being paid more than $12500 in 1H2025. While exactly data isn't public, for back-of-the-envelope, you can look up lab payments for 2023 and count how many labs were paid more than $25000 in part B CLFS in all of CY2023, which would approximate the results for 1H CY 2025 $12500.
