What does the tax reform change for hospitals?
Brazil's consumption tax reform swaps five taxes for two. The CBS (Contribuição sobre Bens e Serviços, a federal goods and services contribution) replaces PIS and Cofins. The IBS (Imposto sobre Bens e Serviços, a state and municipal goods and services tax) replaces ICMS (state VAT) and ISS (municipal services tax). The constitutional basis is Emenda Constitucional 132/2023 (Constitutional Amendment 132/2023), and the rules are in Lei Complementar 214/2025 (Complementary Law 214/2025) [1][2].
For a hospital, the change runs through three parts of the revenue cycle: the amount on the invoice and the claim, the contract with the health plan (operadora), and when cash comes in. That is why the topic connects to revenue cycle KPIs: margin by health plan, days to payment and final claim denials may read differently during the transition.
Complementary Law 214/2025 has already been amended. Complementary Law 227/2026, of January 13, 2026, created the IBS Management Committee (Comitê Gestor do IBS, CGIBS), the public body that runs the tax, and changed provisions of Law 214 [3]. Always read the law in its current consolidated text.
This guide describes the law and its practical effect. It is not tax advice: classification, calculation and credits should be validated with the hospital's tax team or advisors.
The transition calendar, 2026 to 2033
The transition is set in the Transitional Constitutional Provisions Act (ADCT), added by Constitutional Amendment 132/2023, arts. 125 to 129 [1].
| Year | What happens | Legal basis [1] | Practical effect for the hospital |
|---|---|---|---|
| 2026 | Test year: CBS at 0.9% and state IBS at 0.1%; payment waived for taxpayers that meet reporting obligations [2] | ADCT, art. 125 · LC 214, art. 348 | Invoices with IBS and CBS fields; billing system and service registry updated |
| 2027 | PIS and Cofins abolished; CBS starts being charged | ADCT, art. 126 | First year with real effect on price and cash |
| 2027 and 2028 | IBS at 0.05% state and 0.05% municipal; CBS reduced by 0.1 percentage point | ADCT, art. 127 | CBS coexists with ICMS and ISS |
| 2029 to 2032 | ICMS and ISS charged at 9/10 (2029), 8/10 (2030), 7/10 (2031) and 6/10 (2032) of their rates; tax benefits reduced in the same proportion | ADCT, art. 128 | Two tax logics in the same billing |
| 2033 | ICMS and ISS abolished | ADCT, art. 129 | New system fully in place |
Reference rates for the CBS and IBS will be set by Senate resolution: the CBS rate from 2027 to 2035 and the IBS rate from 2029 to 2035 (Complementary Law 214/2025, art. 18) [2]. Until then, any simulation with a final percentage is an estimate.
What is the 60% reduction for health services?
The 60% reduction means an eligible health service pays 40% of the rate that would otherwise apply, not a 60% rate. Constitutional Amendment 132/2023 allowed the complementary law to create this differentiated regime for health services [1]. Complementary Law 214/2025 sets the reduction in arts. 128 and 130 [2].
Article 130 reduces IBS and CBS rates by 60% for “os serviços de saúde relacionados no Anexo III” (the health services listed in Annex III), each with its code in the NBS (Nomenclatura Brasileira de Serviços, Brazil's services classification) [2]. Annex III has 30 items. Those most relevant to hospitals are:
| Annex III item | Service | NBS |
|---|---|---|
| 1 | Surgical services | 1.2301.11.00 |
| 2 | Gynecological and obstetric services | 1.2301.12.00 |
| 4 | Intensive Care Unit services | 1.2301.14.00 |
| 5 | Emergency care services | 1.2301.15.00 |
| 6 | Hospital services not classified elsewhere | 1.2301.19.00 |
| 7 | General medical services | 1.2301.21.00 |
| 8 | Specialized medical services | 1.2301.22.00 |
| 10 | Nursing services | 1.2301.91.00 |
| 12 | Laboratory services | 1.2301.93.00 |
| 13 | Diagnostic imaging services | 1.2301.94.00 |
Source: Complementary Law 214/2025, Annex III [2][5].
In practice, the reduction applies per service, not per facility. Revenue that is not a listed health service, such as parking or space rental, does not get the reduction. That requires separating revenue in billing and assigning each service the correct NBS code.
Nonprofit hospitals and tax-immune entities have their own treatment, which this guide does not cover.
Unpaid denied claims are left out of the tax base
The sole paragraph of art. 130 of Complementary Law 214/2025 says the IBS and CBS tax base of health services excludes “os valores glosados pela auditoria médica dos planos de assistência à saúde e não pagos” (amounts denied by health plan medical audit and not paid) [2]. It is the reform rule most closely tied to day-to-day billing.
The text has two conditions: the origin (a denial by the health plan's medical audit) and the outcome (the amount was not paid). If the denial is reversed on appeal and the amount is paid, it no longer qualifies. In practice, the hospital must show, claim by claim, what was billed, what was denied, why, and what was paid after appeal.
Volume makes this control relevant. At hospitals belonging to Anahp (Associação Nacional de Hospitais Privados, Brazil's national association of private hospitals), initial denial was 15.93% of amounts receivable from health plans in 2025, and 1.72% of gross health plan revenue became a final loss [4]. Without tracking the reason and outcome of each claim denial, the hospital loses the proof that the amount went unpaid. The reason is coded in the claim analysis statement of the TISS standard (the mandatory data-exchange standard set by ANS, Brazil's National Supplementary Health Agency), which helps build the audit trail.
How the exclusion will appear on the tax document depends on regulations and technical notes from the Federal Revenue Service and the CGIBS. The hospital should validate the procedure with its tax team.
How does the reform affect pricing, contracts and cash?
The reform affects the claim at three points, and each has a KPI to track.
Pricing and contracts. IBS and CBS are charged on top of the price, shown separately, and generate credits on purchases along the chain [2]. That changes how price tables and bundles are built. Under Law 9,656/1998 (art. 17-A, § 3), contracts with health plans are adjusted annually [6]. ANS Resolução Normativa 503/2022 (Normative Resolution 503/2022) requires contracts to set out prices and adjustments [7]. It is worth checking whether the contract says who absorbs a change in tax burden. The guide RN 503/2022: what the payer contract must say covers these clauses.
Cash. Complementary Law 214/2025 provides for collection at payment settlement (split payment): part of the amount paid is set aside at the moment of payment and sent to the tax authority (art. 32) [2]. For the hospital, the net amount received may already arrive without the tax, which requires adjusting receivables reconciliation. The start date of this mechanism for health plan payments to hospitals should be tracked with the tax team.
Billing. The service invoice carries IBS and CBS fields since 2026, and the service registry needs the NBS classification [2].
| Area | What changes | KPI to track | Who to involve |
|---|---|---|---|
| Service registry | Each service with an NBS code and its Annex III item | Share of revenue from services with the reduction | Billing and tax |
| Claim denials | Denied and unpaid amounts excluded from the base | Final denials by reason and by health plan | Billing and claims review |
| Contracts | Price, bundles and adjustments under the new tax burden | Margin by health plan before and after the transition | Commercial and legal |
| Cash | Tax set aside at payment settlement | Days to payment and net amount received | Treasury |
| Ancillary revenue | No 60% reduction | Non-care revenue tracked separately | Controllership |
What we see in operations
At Accrua, the part of Brazil's tax reform that touches the revenue cycle most is the sole paragraph of art. 130 of LC 214/2025: unpaid denials are excluded from the IBS and CBS tax base. To use that rule, the hospital has to prove, claim by claim, what was denied, what was appealed and what in fact went unpaid.
Accrua OS reconciles each remittance statement with the claim submitted and records the outcome of each denial: paid, upheld or under appeal. Every action, by an agent or a person, is logged in an audit trail with its source. Accepting a denial is a person's decision, and that decision is documented.
In the test year, the work is in the service catalog and the tax invoice, which change inside the HIS/ERP the hospital already uses. In contracts with health plans, we check whether there is a clause on changes in tax burden, because prices and adjustments are still set by the contract.
Where to start
- Map revenue by type of service and flag which items are in Annex III of Complementary Law 214/2025.
- Review the service registry in the system, with each item's NBS code, together with the tax team.
- Track every denial to its outcome, with reason, appeal and amount paid, to support the tax-base exclusion.
- List health plan contracts and check how they handle price adjustments and changes in tax burden.
- Follow Federal Revenue Service and CGIBS rules every quarter with the tax team, and log what changes in billing.