New Requirements in Conditions of Participation: Discharge planning

Effective July 1, a subtle but significant expansion for the Centers for Medicare & Medicaid Services (CMS) added new requirements to 42 CFR § 482.43 regarding transfer protocols. Originally mentioned back in November 2024 as part of the CY 2025 Outpatient Prospective Payment System (OPPS) Final Rule, CMS announced the finalization of new requirements in conjunction with the maternal healthcare news briefs.

However, likely during the political change of offices, an interesting proactive statement was added to the Conditions of Participation (CoP) regulations that require acute-care hospitals to develop and implement written transfer protocols.

The finalized regulation, outlined in § 482.43(c), mandates that all acute-care hospitals have written policies and procedures governing intra-hospital and inter-hospital transfers. These include the following:

• Transfers from the emergency department to inpatient admission;
• Transfers between units within the same hospital; and
• Transfers between different hospitals for higher levels of care or specialized services.

While the transfer of patients between hospital units or facilities has long been a routine operational function, CMS is now moving to standardize and elevate the practice as a core compliance obligation, focused on improving patient safety, care transitions, and timely access to appropriate levels of care. This rule codifies what many hospitals already do, transferring patients from the ED to hospitalized patient units, between units, and to other facilities. But now, these processes must be formally documented in written policy, implemented organization-wide, and supported with annual training for designated staff.

Hospitals are also required to conduct annual training for relevant staff on these transfer protocols. Notably, CMS leaves flexibility for hospitals to determine which staff are included, allowing adaptation based on organizational structure and resources.

However, given the unique ties of this additional standard with obstetrics, consideration should be given to hospital admissions and transfers in and out of the mother-baby unit. For hospitals to ensure appropriate compliance, it makes sense to audit and formalize existing transfer policies.

Consider review of the existing annual training provided to applicable clinical staff to meet the requirements for providing information regarding transfer protocols.

In reviewing the original guidance and comments in the CY 2025 OPPS ruling as to what led to this change, CMS cited the need to reduce delays, ensure continuity, and protect patients in particularly vulnerable populations, such as pregnant and postpartum individuals. Federal Register :: Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs, Including the Hospital Inpatient Quality Reporting Program; Health and Safety Standards for Obstetrical Services in Hospitals and Critical Access Hospitals; Prior Authorization; Requests for Information; Medicaid and CHIP Continuous Eligibility; Medicaid Clinic Services Four Walls Exceptions; Individuals Currently or Formerly in Custody of Penal Authorities; Revision to Medicare Special Enrollment Period for Formerly Incarcerated Individuals; and All-Inclusive Rate Add-On Payment for High-Cost Drugs Provided by Indian Health Service and Tribal Facilities