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Medicare’s hospital wage index has a rule, since 1997, that no urban hospital may be paid below its state’s rural hospitals — the “rural floor.” It was written to protect rural America. What follows is what two islands did with it, and what it did to them.

The island that played

In 2008, the only hospital on Nantucket, Massachusetts — newly merged into the Partners health system — converted from a Critical Access Hospital (whose wages don’t count) into an ordinary Medicare hospital (whose wages do). It thereby became the only rural hospital in Massachusetts, and its island wages became, by law, the wage floor for every urban hospital in the state. By 2022 that floor stood at 1.28 — built, in MedPAC’s words, “solely” on this one hospital’s data — raising nearly every hospital in Massachusetts, “in some instances over 35 percent.” By FY2027 the floor stands at 1.3071 — high enough to bind even Boston, whose final wage index is exactly 1.3071 — and the island payroll underneath it averages $78.99 an hour, 5.2 times the $15.17 behind rural Puerto Rico’s floor. The annual transfer to the state’s other hospitals was estimated at $256–367 million per year, paid by every other hospital in the country. Twenty-one states organized against it. The courts reviewed it. It stands. Sources: MedPAC, Report to Congress, June 2023, ch. 9; HHS-OIG audit A-01-15-00502; Boston Globe reporting, 2013; FY2027 IPPS final rule, Tables 2–3 (CCN 220177).

The formula that lifts every hospital in Massachusetts on the payroll of one small island is the same formula waiting for Puerto Rico. The day Vieques opens a certified hospital, the island’s real wages go to work for every hospital in Puerto Rico — automatically, legally, with no new law and nobody’s permission.

The proof of how much force that formula carries is on the federal record. When federal auditors examined the Nantucket hospital’s wage data (HHS-OIG, A-01-15-00502, March 2017), they found reporting errors of about 7.3% had moved an estimated $133.6 million to 55 other Massachusetts hospitals in a single year — nothing illegal, nothing recovered (“CMS has no mechanism to recover overpayments or remedy underpayments resulting from inaccurate wage data”), the bill quietly absorbed by hospitals in the rest of the country under ACA §3141. That is the scale of what one island’s payroll commands under this statute. Massachusetts has been collecting on it for fifteen years. Puerto Rico’s claim to the very same machinery is one certified hospital away — and this time the numbers would be real, working for the island that has been paying into everyone else’s floor.

The island that couldn’t

Vieques, Puerto Rico is also rural under Medicare’s definition — it sits in no metropolitan or micropolitan area at all. It has had no hospital since Hurricane María destroyed its health center in 2017. In January 2020, a 13-year-old girl, Jaideliz Moreno Ventura, died there of a flu-like illness amid a failed transfer off-island; FEMA obligated reconstruction money roughly two weeks later. The replacement — an $85 million emergency and ambulatory center — was delivered to the Department of Health in December 2025 and, as of mid-2026, awaits its formal opening. It is licensed as a diagnostic and treatment center, not a hospital; its wage data counts toward nothing. Sources: NBC News, Jan. 2021; San Juan Daily Star, Dec. 2025; El Vocero, Jul. 2026. Links verified Sept. 1, 2026.

A floor made of our own floor

Puerto Rico does have a rural floor — the statute requires one. In years with no rural hospital wage data, CMS computes it as the average of Puerto Rico’s own urban areas (FY2008 final rule, 72 FR 47323). Read that again: the island’s wage floor is the average of the island’s wage indexes. A floor made of the thing it is supposed to hold up. For FY2027, the rural Puerto Rico wage index stands at 0.2511 — below every urban area on the island, and roughly one-fifth of Nantucket’s handiwork. Source: FY2027 IPPS final rule (91 FR 49570), Table 3; Addendum, rural floor methodology.

We pay for the privilege

The rural floor is budget-neutral nationally: every hospital’s wage index is shaved by a uniform factor to fund the floors the rule produces — 0.973976 in FY2026, a 2.6% cut. Puerto Rico’s hospitals, at wage indexes of 0.33–0.37, absorb that cut in full. Which is to say: the lowest-paid hospitals in the United States help finance the Massachusetts rural floor every year. No legislature has organized about this. Source: FY2026 IPPS final rule (90 FR 36536), Addendum II.A.4.

The all-urban island with twelve rural municipios

Since FY2025, twelve Puerto Rico municipios are rural for Medicare — including Vieques and Culebra. Puerto Rico nonetheless qualifies for the federal “all-urban state” floor (0.3278 in FY2027), because the island’s two hospitals located in rural municipios are both legally deemed urban through reclassification, leaving no hospital “classified as rural.” The island is all-urban because its rural hospitals have paperwork saying otherwise. This is currently Puerto Rico’s best wage-index protection. Sources: 42 CFR 412.64(h)(5)(ii); FY2027 Imputed State Floors PUF; FY2027 Tables 2–3.

The politest sentence in the Federal Register

The temporary policy that had roughly doubled Puerto Rico’s wage indexes was struck down by the D.C. Circuit in 2024. The replacement transition steps the indexes down 5% a year — and absent action the step-down does not end on October 1, 2027: each year’s wage-index decrease stays capped at 5% (42 CFR §412.64(h)(7)), so inpatient payments grind down roughly 2% every October for about eight more years until they settle ≈15.5% below the protected level. Asked to extend the transition, CMS answered: “we may consider this in future rulemaking.” On the rule where that consideration will happen, 982 public comments were filed. Puerto Rico institutions filed four. Sources: Bridgeport Hosp. v. Becerra, 108 F.4th 882 (D.C. Cir. 2024); 91 FR 49570; docket CMS-2026-1256; 42 CFR §412.64(h)(7).

The punchline is optional

Here is the part that isn’t cynical. The Nantucket rules are still the rules — the courts have forced CMS to honor rural wage data in the floor (Citrus HMA v. Becerra, D.D.C. 2022) — and Puerto Rico already holds both keys. First, Vieques needs no law and no petition. The municipio lies outside every metropolitan and micropolitan area, so the moment the Susana Centeno facility is licensed and Medicare-certified as a hospital it is a rural hospital automatically, by geography — the same sentence of the statute that made Nantucket’s hospital rural (SSA §1886(d)(2)(D), 42 U.S.C. §1395ww). Second, the strategy is Vieques — deliberately. Federal regulation does give urban hospitals doors into rural status (42 CFR §412.103(a)), and by CMS’s own FY2027 wage table the island’s four highest payrolls — ASEM ($31.77/hour), the Cardiovascular Center, the Comprehensive Cancer Center, and Hospital Universitario — are public institutions whose wages compute to ≈0.42–0.50. But this console does not lead with that route, for two reasons. The optics: a hospital in metropolitan San Juan arguing it is “rural” hands critics the very manipulation story this page documents. And the math: the protected wage level the island is stepping down from (≈0.5259) corresponds to $31.78/hour — almost exactly ASEM’s payroll — so a reclassified floor of 0.42–0.50 mostly duplicates protection the island still has while the 5%-a-year step-down plays out. Vieques needs zero petitions and one licensure decision: the cheaper strategy on every axis, and the honest one — real rural wages from a genuinely rural island. Source: FY2027 Table 2, Average Hourly Wage column.

What it takes — the checklist

Path A — the Vieques hospital (rural automatically; its own wage data counts ≈4 years after certification, the same lag Nantucket rode 2008→2011):

1. License it as a hospital. The Susana Centeno facility is licensed today as a diagnostic and treatment center (CDT); the Departamento de Salud must license it as a hospital with inpatient beds. This is the only government act required — a licensure decision, not legislation.
2. Enroll in Medicare as a hospital (Form CMS-855A through the Part A MAC, First Coast Service Options for Puerto Rico). CMS provider enrollment.
3. Pass the certification survey against the hospital Conditions of Participation (42 CFR Part 482), via the State survey agency or a CMS-approved accreditor, and receive a CCN. Certify as an IPPS hospital, not a Critical Access Hospital — CAH wages are excluded from the wage index; converting out of CAH status is precisely how Nantucket started the clock in 2008.
4. From the day the CCN issues, it is a rural IPPS hospital by geography — Vieques sits outside every CBSA — with no petition, law, or reclassification.
5. File its first Medicare cost report (Form CMS-2552-10); its wages enter the wage index ≈four fiscal years later — the FY2031 option.

What to pay — the target is arithmetic, not aspiration. A wage index is the area’s occupational-mix-adjusted average hourly wage divided by the national average — $60.43 in FY2027, derived two independent ways from CMS’s own Table 3 ($78.99 ÷ 1.3071 = $15.17 ÷ 0.2511 = $60.43). That $60.43 is the effective divisor implied by the published indexes: the raw national average hourly wage in the FY2027 final rule is $58.83, and published indexes carry a budget-neutrality adjustment of ≈0.9736 ($58.83 ÷ 0.9736 = $60.43; Nantucket’s provider-specific ratio $78.99/$58.83 = 1.3426 becomes the published 1.3071 the same way). Both of Puerto Rico’s areas sit exactly at this pure ratio — across all 511 CBSAs in Table 3, the implied divisor tops out at 60.43–60.44, and PR is at the top — so dividing a target payroll by $60.43 converts it directly into a published index. So the Vieques hospital’s payroll converts directly: $25.40/hour computes a wage index of ≈0.42; $30.25 ≈ 0.50; $36.25 ≈ 0.60. The right target is backed into from the payment level Puerto Rico wants — the geographic adjustment that flows through hospital payments and, about a calendar year later via the AGA repricing, into the MA benchmarks (FY2031 wage index → CY2032 benchmarks) — not picked from a wage survey.

Path B — urban reclassification under §412.103: considered, and set aside. The doors exist — rural referral center (§412.96), sole community hospital (§412.92), state designation — and the four Centro Médico payrolls ($24.02–$31.77/hour) qualify arithmetically. This campaign does not lead with them, for the two reasons above: the optics of a metropolitan San Juan hospital claiming rural status, and the math — a ≈0.42–0.50 floor mostly duplicates the protection the island still holds while the 5%-a-year step-down plays out, so the gain arrives in the out-years, which is exactly when Vieques’s real wage data arrives anyway. One certified hospital on Vieques does the work with no petitions at all.

What the campaign itself needs, then: one licensure decision by Salud for Vieques, an operator and a survey date; comments in the FY2028 rulemaking asking CMS to hold the transition while those wages ripen; and an island that files more than four comments in the rulemaking that decides this. Sources: 42 CFR Part 482; 42 CFR §§412.92, 412.96, 412.103; FY2027 Table 2; the lag from Nantucket’s own record (converted 2008, floor moved Oct. 1, 2011 — MedPAC 2011 letter, June 2023 ch. 9).

Nantucket needed one hospital and a merger — nothing else. Vieques needs exactly as much: a certified hospital. The day it opens its doors as one, the statute counts its wages automatically — no law, no waiver, no permission. The difference between the two islands was never the ocean — it was who had a hospital on the field.

The mechanics, the sequencing cautions, and the calendar live one tab over, in FY2028 Watch. This page exists so nobody mistakes the current arrangement for an accident of nature. It is an arrangement. Arrangements can be rearranged.

Puerto Rico, with a stabilized benchmark structure, should not be viewed as a distressed Medicare Advantage market in need of rescue. The evidence supports the opposite conclusion: Puerto Rico already represents one of the strongest real-world demonstrations of what CMS is working to achieve nationally through Medicare Advantage — and, with a stabilized benchmark, it can stand as the national benchmark for the program.

The central paradox

Puerto Rico has achieved near-universal Medicare Advantage participation — approximately 96.2% MA penetration (MA enrollees as a share of Parts A+B beneficiaries, May 2026) versus roughly 55.5% on the mainland — while simultaneously delivering elite quality under CMS's own Star Ratings system. Under the 2026 CMS Star Ratings, three of Puerto Rico's four largest Medicare Advantage contracts earned the highest possible 5-Star designation — including MCS Classicare (H5577), the single largest 5-Star Medicare Advantage contract in the United States. In all, approximately 99.1% of Puerto Rico MA beneficiaries are enrolled in plans rated 4.5 Stars or higher — a concentration of quality unmatched in most mainland markets.

Puerto Rico produces these outcomes while operating at among the lowest benchmark payment levels in the nation. For CY2027, Puerto Rico's average Medicare Advantage benchmark is approximately $778 PMPM, against approximately $1,313 PMPM on the mainland — roughly 59 cents for every dollar paid in the continental United States — and against $967 PMPM in the US Virgin Islands, an adjacent territory operating under the same Medicare statute — roughly 80 cents for every dollar paid next door.

The market producing some of the strongest quality outcomes, the highest beneficiary participation, and the most consistent high-performance enrollment in the country is funded at among the lowest benchmark levels in the country.

The issue is not performance

The federal policy question is not whether Puerto Rico's Medicare Advantage system works. The data already shows that it does. Nor is the question whether Puerto Rico requires a bailout or special treatment. Puerto Rico is already producing many of the precise outcomes CMS seeks nationally:

• exceptionally high Medicare Advantage participation;
• consistent enrollment in elite-rated plans;
• strong quality and compliance performance;
• large-scale, population-level chronic disease management; and
• efficient care delivery under materially constrained funding.

The actual question is whether CMS intends to stabilize and preserve this model before prolonged structural underpayment erodes the financial conditions necessary to sustain it.

The drug-utilization data makes the efficiency concrete: the funds are not absorbed — they are converted into care. Puerto Rico's Medicare Advantage members fill roughly 19% more prescriptions per year than the national average at roughly 15% lower gross drug cost per enrollee — about $63 per prescription versus $89 nationally (CY2023, CMS Program Statistics), a pattern that holds every year since 2020. Medication adherence — precisely what CMS Star Ratings reward — is where the dollars go, delivered at the lowest unit cost in the nation.

The risk-score counterargument — answered with the audit record

Puerto Rico’s average Part C risk score is high — 1.53 vs 1.38 for the states (CY2024 plan payment file, Rates tab) — and a critic will read that as coding intensity. Three verifiable facts frame the honest answer. First, the validation regime is national, and Puerto Rico is inside it. CMS’s RADV audits test whether diagnoses submitted for payment are supported in the enrollee’s medical record; the 2023 final rule (88 FR 6643) authorizes extrapolated recoveries beginning with payment year 2018 with no FFS adjuster, and in May 2025 CMS moved from auditing ~60 contracts a year to every eligible MA contract annually, targeting the PY2018–2024 backlog by 2026. Second, PR contracts already appear in the published audit record — a Humana Puerto Rico plan was among the 90 PY2011–2013 RADV audits released in 2022, and HHS-OIG’s 2024 audit of MMM Healthcare (H4003) found 108 of 688 sampled diagnosis groups unsupported and recommended a $165,312 enrollee-level refund, consistent with the rule’s pre-2018 policy. Third, coding intensity is a nationwide phenomenon, not a Puerto Rico one — MedPAC estimated MA risk scores roughly 16% above an FFS-equivalent nationally for 2025, an estimate its March 2026 report revised downward under the v28 model phase-in. One caveat carried openly: in September 2025 a federal district court vacated the 2023 rule on procedural grounds (Humana v. Becerra, N.D. Tex.); CMS has appealed to the Fifth Circuit and continues the expanded audits and enrollee-level recoveries while extrapolation is litigated. The defensible claim is therefore not that Puerto Rico’s scores are proven clean — it is that they sit inside the same medical-record validation machinery as every mainland contract, while the island’s dual-heavy demographics (Duals tab) and measured chronic-condition prevalence (Circularity tab) supply documented clinical reasons for above-average acuity.

[19] 88 FR 6643 (Feb 1, 2023) · CMS press release, May 21, 2025 · HHS-OIG A-04-20-07090 (Aug 2024) · KFF Health News (Nov 2022) · MedPAC March 2025 Report to the Congress, ch. 11 · Humana v. Becerra (N.D. Tex., Sept 25, 2025), appeal pending. Full verification register [19], Circularity tab.

The policy position: benchmark parity with the US Virgin Islands

Apply to Puerto Rico the same benchmark treatment CMS already applies to the US Virgin Islands.

This is the position, stated in full. It is not a request for mainland rates. It is not a request for any special adjustment, demonstration, or carve-out. It is the application of an existing CMS payment level to a directly comparable jurisdiction: adjacent geography, identical Medicare statute, identical program rules, and a shared regional health-care economy. The US Virgin Islands benchmark — $967 PMPM for CY2027 — is what CMS already pays in a Caribbean US territory under its own rate machinery. Puerto Rico's benchmark of $778 PMPM sits $189 PMPM below it. The discretion to close that gap is documented in CMS's own rate documents, twice over. First: the statute ranks benchmark quartiles only for counties in “the 50 States and the District of Columbia” (§1853(n)(2)), so every territory county's applicable percentage is assigned by administrative decision — “For the territories, CMS assigns an applicable percentage to each territory county based on where the territory county rate falls in the quartiles established for the 50 States and the District of Columbia” (CY2027 Advance Notice, Attachment II). Second: CMS has adjusted Puerto Rico's own FFS inputs by discretion every year since the CY2017 Rate Announcement — computing PR rates from beneficiaries with both Parts A and B and correcting for the nationwide propensity of zero-claims beneficiaries. The authority is not hypothetical; CMS exercises it annually.

The comparison removes every confounder typically raised in benchmark debates. Both jurisdictions are US territories. Both operate under the same statutory framework. Both serve Caribbean populations through the same federal program. CMS’s own Geographic Variation file prices their care within 2.4% of each other — $6,437 versus $6,597 per FFS beneficiary (actual dollars, 2024) — while the benchmarks sit 19.5% apart. Yet the lower-paid market — Puerto Rico — demonstrably outperforms the higher-paid one, and every state in the program, on penetration, Star Ratings, and drug-cost efficiency. No payment-policy rationale has been articulated that justifies a $189 PMPM differential between two adjacent territories under the same statute, in which the lower rate is assigned to the stronger performer. Absent such a rationale, benchmark parity with the US Virgin Islands is the defensible floor — the narrowest correction available, anchored entirely in CMS's own precedent.

This framing also defines the burden of proof. The question before CMS is not whether Puerto Rico merits an increase; it is whether the agency can defend treating Puerto Rico worse than the jurisdiction next door. If $967 is the right benchmark for the US Virgin Islands, the agency must articulate the basis on which $778 is right for Puerto Rico. CMS has faced a version of this question before: in the CY2018 Rate Announcement it declined a proposal to use the USVI rate as a proxy for Puerto Rico, maintaining that Puerto Rico's own FFS data was sufficient to set accurate rates. That defense is precisely what this console tests — the measurement base behind it, now roughly 4% of Puerto Rico's Medicare-eligible population and shrinking, is the circularity documented throughout. The data in this console indicates no such basis exists.

Puerto Rico as a national benchmark

Puerto Rico should be viewed not as a peripheral exception within Medicare Advantage policy, but as a potential national benchmark for how a mature, high-performing MA ecosystem functions when beneficiaries overwhelmingly participate in coordinated care and remain concentrated in highly rated plans. With a stabilized benchmark methodology, Puerto Rico can serve as a national showcase demonstrating that high enrollment, elite quality, strong compliance, and lower overall Medicare spending can coexist within a properly aligned MA system.

Why stabilization matters

Puerto Rico's performance has been achieved despite severe benchmark compression — not because that compression is sustainable. Over time, the current benchmark structure creates pressures that are increasingly difficult to absorb: margin compression, reduced provider reimbursement flexibility, physician-migration and specialist-access risk, workforce recruitment challenges, and diminished reserve and investment capacity. These pressures do not produce immediate collapse; they gradually weaken the financial and operational flexibility required to sustain elite performance. The objective now is to ensure the benchmark methodology does not undermine the long-term sustainability of a proven success.

The strategic choice

In a truly performance-based Medicare Advantage system, Puerto Rico would not rank near the bottom of the benchmark structure. It would stand as one of the clearest national demonstrations of how Medicare Advantage can simultaneously improve quality, increase participation, maintain compliance, and manage costs at scale. The choice facing federal policymakers is therefore not whether to rescue a failing market. It is whether to:

• extend the benchmark standard CMS already applies to the US Virgin Islands, stabilizing one of the most efficient, highest-performing Medicare Advantage markets in the country and letting it serve as the national benchmark; or
• allow continued structural benchmark compression to gradually weaken the very model CMS is working to build nationwide.

The evidence strongly supports the first approach.

Puerto Rico’s hospitals carry the lowest Medicare area wage index in the nation — and the temporary protection that has cushioned them since the courts struck down CMS’s low-wage-index policy is in its final approved year. What CMS decides in the FY2028 rule determines whether that slide stops — or keeps compounding at the capped 5% a year (42 CFR §412.64(h)(7)) toward a cumulative ≈15.5% inpatient payment cut — and, through the ratebook’s claim-repricing machinery, what happens to every municipio’s Medicare Advantage benchmark from CY2029 forward.

The verified position, FY2027

• Official wage indexes: San Juan–Bayamón–Caguas 0.3500, Guayama 0.3654, Ponce 0.3303, with Aguadilla, Arecibo and Mayagüez held at 0.3278 by the statutory imputed floor (ARPA §9831). The lowest area anywhere else in the nation is rural Mississippi at 0.7112. Source: FY2027 IPPS final rule (CMS-1849-F, 91 FR 49570, Aug. 4, 2026), Table 3.
• What hospitals are actually paid on is a post-Bridgeport transitional exception — a payment-equivalent wage index of ≈0.5259 (85.74% of FY2024), declining 5% per year. All 55 hospitals carrying an FY2027 transition value are in Puerto Rico. Source: 91 FR 49570; FY2027 Table 2.
• If nothing replaces the protection, Medicare inpatient payments to the island’s 52 IPPS hospitals settle ≈15.5% lower (the payment multiplier (0.62×WI+0.38) evaluated at 0.35 versus 0.5259) — reached not in one day but in 5%-a-year wage-index steps (42 CFR §412.64(h)(7)): a payment cut of roughly 2% compounding every October 1 for about eight years. Computation from the statutory 62% labor-related share, 42 U.S.C. 1395ww(d)(3)(E)(ii).
• The political front is moving. On February 25, 2026, eighteen Members of Congress led by Rep. Pablo José Hernández asked HHS and CMS, in comments on the CY2027 MA Advance Notice, to set a minimum AGA factor of 0.70 for Puerto Rico under SSA §1876(a)(4) — noting benchmarks ≈41% below the national average, 674,000 seniors, and 94% MA enrollment (the letter). And on August 5, 2026, the Governor welcomed the fourteen-Member Murphy letter carrying the same ask into the 2028 rate cycle — featured in the callout at the top of this tab. An AGA of 0.70 would sit above every one of Puerto Rico’s 78 municipios today (CY2027 Rate Calculation Data: median 0.504, highest 0.650). The full five-document record — both congressional letters, the Governor’s formal comment, the healthcare community’s MOU, and the Puerto Rico Republican Party’s letter — is collected in The paper trail below, each linked to its primary source.
• The wage arithmetic underneath: Puerto Rico hospital average hourly wages run $14.37–$31.77 against a ≈$60 national average. The four highest-wage hospitals on the island are the public institutions of Centro Médico — ASEM ($31.77), Centro Cardiovascular ($26.10), Centro Comprensivo del Cáncer ($24.03), Hospital Universitario ($24.02). Source: FY2027 Table 2, Average Hourly Wage FY2027 column.
• Because CMS reprices all five historical claims years to current wage indexes when building the MA ratebook, the wage-index outcome of FY2028 reaches municipio benchmarks in the CY2029 ratebook (January 1, 2029) — all at once, no phase-in. Source: CY2027 Advance Notice (Jan. 26, 2026), repricing methodology.

The two requests before CMS

• Extend the transitional payment exception into FY2028 and subsequent years. CMS wrote in the FY2027 final rule that it “may consider this in future rulemaking” after commenters asked for exactly this, “particularly in Puerto Rico.” The American Hospital Association has separately urged that the transition be non-budget-neutral (AHA comments, June 9, 2026).
• Hold the rural floor computation harmless. Commit that the rural Puerto Rico wage index used for the BBA 1997 §4410 floor is never computed below the contiguous-average methodology of the FY2008 final rule (72 FR 47323).

The public calendar

• Sept 1 (annual) — MGCRB reclassification applications due, 13 months before the fiscal year.
• Dec 31, 2026 — Medicare-Dependent Hospital program and low-volume adjustment expire absent congressional extension (CAA 2026 §§6201–6202).
• ~Late Jan 2027 — CY2028 MA Advance Notice; FY2028 preliminary wage index file.
• ~April 2027 — FY2028 IPPS proposed rule display; §412.103 reclassification approvals must land within 60 days of display to count in the FY2028 wage index; ~60-day public comment period follows. On the FY2027 rule, only 4 of 982 comments came from Puerto Rico institutions (docket CMS-2026-1256).
• ~Aug 1, 2027 — FY2028 final rule. Oct 1, 2027 — FY2028 begins. Jan 1, 2029 — CY2029 benchmarks carry the outcome.

The legislative track runs in parallel: H.R. 8109 (119th Cong.) would codify the low-wage-index policy — restoring a ≈0.60 wage index permanently — and CMS has stated that a cost-of-living adjustment for the territories “would require legislation.” (91 FR 49570.)

This page tracks a live rulemaking cycle and is updated as CMS publishes; figures above are frozen to the FY2027 final rule vintage of August 4, 2026.