The 2026 Medicare Physician Schedule Final Rule includes several distinct policy changes in which the Centers for Medicare & Medicaid Services (CMS) modifies how it uses or pays for services related to social-risk drivers and the social determinants of health (SDoH), by either eliminating these terms altogether or reframing them under different terminology. Below are the principal changes.
For Community Health Integration (CHI) services listed under HCPCS code G0019, CMS is replacing the descriptor phrase “social determinants of health” with the term “upstream driver(s).” The rule states that this term is “more comprehensive and includes a variety of factors that can impact the health of Medicare beneficiaries, such as smoking, poor nutrition, low physical activity, substance misuse, or potential dietary, behavioral, medical, and environmental drivers.”
In addition, CMS removed the term of an unmet SDoH need from the initiating visit descriptor requirement, to allow for a broader list of eligible initiating services for which CHI can be applied.
In the policies surrounding the Medicare Shared Savings Program (MSSP), CMS finalized the removal of Quality ID 487, “Screening for Social Drivers of Health,” from the APP Plus quality measure set for 2025 and beyond. The ruling explains that MSSP Accountable Care Organizations (ACOs) will no longer report that measure as part of the required quality set.
While strictly speaking of a terminology change for SDoH, the rule removes the health equity adjustment applied to an ACO’s quality score beginning in 2026, and revises related terminology by renaming the benchmark adjustment as the “population adjustment.” This change is described in the rule to be part of a broader recalibration of how CMS handles social risk/health-equity in ACO quality and payment.
In the proposed rule, CMS proposed to delete HCPCS code G0136 – “Administration of a standardized, evidence-based SDOH risk assessment,” on the basis that the resource costs are already captured in existing evaluation and management (E&M) and behavioral health services. However, in the Final Rule, CMS ultimately did not delete G0136, but revised the descriptor instead. The new descriptor shifts the focus from SDoH risk assessment to “administration of a standardized, evidence-based assessment of physical activity and nutrition, 5-15 minutes, not more often than every 6 months.” At the time of this publication, there is no specific recommended screening tool to use in place of the prior Health-Related Social Needs (HRSN) tool.
Entities that had structured workflows around “SDoH risk assessments” should start to revise terminology, documentation templates, care-coordination services, and quality-improvement frameworks to align with “upstream driver(s)” language. Although this is a CMS change in terminology, internal organizational considerations must remain on how populations will be managed, given the known risk factors of housing, transportation, food, and utilities impact, in light of how they are so often felt “upstream” in the health and well-being of our patients.
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