Federal
CMS proposes 2027 Medicare Fee Schedule; comments due September 11
The Centers for Medicare & Medicaid Services (CMS) released a draft Medicare Physician Fee Schedule with a proposed effective date of January 1, 2027. Although the schedule would not directly affect workers’ compensation, several state fee schedules are based on Medicare reimbursement rates. Public comments may be submitted to CMS through September 11, 2026. Additional information about the proposed fee schedule and instructions for submitting comments are available on the CMS website: CY 2027 Medicare Physician Fee Schedule Proposed Rule.
House considers managed-care reform for injured federal workers
In Congress, the House of Representatives is considering a bill that would require injured federal workers to receive medical treatment through managed-care networks. The bill (HR 9869) would also direct the Department of Labor to establish treatment protocols for injured federal workers based on the best practices of the healthcare industry and direct the head of each federal agency to contract with a managed care network to treat injured workers. Networks would be required to "make reasonable attempts to provide" the contracted services, a requirement that would include maintaining "a sufficient number of providers" without reasonable proximity to the employing agency's jobsites. The bill (Actions - H.R.9869 - 119th Congress (2025-2026): FECA Modernization and Cost Containment Act of 2026 | Congress.gov | Library of Congress) was referred to the House Committee on Education and the Workforce in July.
Arizona proposes $300 cap on prescription topical reimbursements
The Industrial Commission of Arizona (ICA) continues to refine proposed changes to its workers’ compensation pharmacy fee schedule for prescription topical medications.
Under the current proposal, the ICA would cap reimbursement at the lesser of the existing fee-schedule amount or $300 for a 30-day supply, prorated as applicable, plus a $7.00 dispensing fee. The proposal would also require medical documentation to support continued use of any prescription topical that exceeds $300.
Stakeholders who wish to provide feedback and comments to the ICA should email myketa.coker@azica.gov. The current proposed language is available on the ICA website: 2027 Proposal of AZ WC Pharmaceutical Fee Schedule.
Colorado schedules hearing on workers’ compensation rule changes
The Colorado Division of Workers’ Compensation has scheduled a hearing for proposed changes to Rules 16 (Utilization Review Standards) and 18 (Medical Fee Schedule) on August 27, 2026, at 10 a.m. MT. The public may testify during the hearing and submit written comments by email to amy.kingston@state.co.us prior to the hearing.
The proposed Rule 18 Medical Fee Schedule changes include several pharmacy-related revisions:
- Drug prior authorization: Adds prior authorization controls for combination topical agents and patches.
- Compounded drugs: Revises existing language from “Prescription-Strength Topical Compounds” to “Non-Sterile Compounded Drugs” to allow reimbursement only when a compounded drug is medically indicated.
- Topical analgesics / OTC products: Clarifies that, for combination topical agents or patches containing ingredients available in lower-cost prescription or OTC products, reimbursement is limited to the lowest-cost therapeutically equivalent option unless prior authorization is obtained.
- Physician dispensing: Adds billing instructions for physician-dispensed or other non-pharmacy-dispensed drugs, directing providers to bill using CPT 99070 along with the applicable NDC or another drug identifier.
Related materials for both rules (including change lists) are available through the Division’s hearing notice here: Workers' Compensation Proposed and Adopted Rules | Department of Labor & Employment.
Illinois enacts major changes to workers’ compensation utilization review
Illinois Gov. J.B. Pritzker recently signed House Bill 5228 (Illinois General Assembly - Bill Status of HB5228), which significantly revises current UR requirements. Among other provisions, the bill creates new standards for utilization review and medical examinations when determining the necessity of workers' compensation treatment requests.
Current law requires that medical-necessity determinations be made by healthcare professionals. Under the new requirements, adverse determinations are to be rendered by physicians when the services are recommended or provided by a physician. The reviewing physician must hold a valid, unrestricted U.S. license and a current certification by a relevant recognized American medical specialty board.
The bill also establishes new confidentiality requirements for UR programs. Patient-specific information obtained during the review process must remain confidential under applicable state and federal law. The information may be shared only with specified individuals, including the employee, the employee's designee and healthcare provider, or others authorized by law to receive it.
Louisiana enacts workers’ compensation reform on medical care and billing
Louisiana Senate Bill 408 SB408, an expansive workers’ compensation reform bill recently signed into law by the Governor Jeff Landry, includes provisions that will affect the delivery of medical and pharmacy care both immediately and in the future. Among its many provisions, the bill updates existing fee schedules, establishes new requirements for medical EDI reporting and medical eBilling, as well as provides for creation of a new medical fee schedule (as seen below):
Effective as of August 1, 2026:
- New fee schedule for implants, original manufacturers invoice or authorized distributor invoice amount paid, plus 20%
- State WC agency shall render a decision on any medical fee dispute no later than 15 business days from date of submittal.
- Any request for authorization of office visits, diagnostic testing, chiropractic treatment of 12 office visits or less or physical therapy of 12 office visits or less is considered authorized and approved by payor if the request has not been specifically denied within five business days.
Effective January 1, 2027, Medical EDI Reporting:
- Office of Workers’ Compensation Administration (WCA) shall adopt and implement a medical bill payment electronic submission portal for workers’ compensation.
- All workers’ compensation payers shall submit to the WCA specified medical and pharmacy bill(s) paid claims data.Kentucky updates 2026 physician fee schedule
Effective July 1, 2027, Medical eBilling:
- WCA shall adopt and implement an electronic medical bill payment requirement, which includes utilization of specific billing forms/formats as well as specific EOR/EOB remittance forms/formats.
- All workers’ compensation claims for medical services rendered shall be submitted to a workers’ compensation payor in electronic format.
- Within 5 days for receipt of an electronic medical bill, a WC payor (or their agent) shall determine if the claim is accepted and respond to the provider accordingly.
Effective July 1, 2029, New Medical Fee Schedule:
- No later than January 1, 2029, the WCA shall adopt and subsequently implement a new medical fee schedule, rules, regulations, manuals and reimbursement methodologies for all medical services, items, devices and medications.Michigan proposal would limit practitioner-dispensed drug reimbursement
Ohio BWC revises workers’ compensation drug formulary
On August 1, 2026, the Ohio Bureau of Workers’ Compensation (BWC) revised its drug formulary and first fill list, effective. The revisions include medication additions and removals, updated coverage requirements, and additional first fill medications.
These requirements apply to state fund claims administered by the BWC and its PBM. Self-insured employers and their PBMs may adopt the BWC formulary and first fill list at their discretion.
More information on the revised drug formulary and first fill list can be found on the state register website: https://www.registerofohio.state.oh.us/rules/search/details/379713 and here https://www.registerofohio.state.oh.us/rules/search/details/379714.
Texas proposes ODG-based return-to-work guidelines
The Texas Division of Workers’ Compensation (DWC) is accepting public comments on a proposal to amend Section 137.10 of Title 28 of the Texas Administrative Code concerning return-to-work guidelines.
The proposed amendments require insurance carriers, health care providers, and employers to use the disability-duration values in the current edition of the Official Disability Guidelines (ODG) when evaluating expected or average return-to-work time frames.
Stakeholders can learn more and submit feedback to the DWC on DWC's website.