News
- CMS Announces $50 Billion in Awards to Strengthen Rural Health in All 50 States
- CMS Announces Establishment of the Office of Rural Health Transformation
- New CMS LEAD Model Aims to Expand Access to Accountable Care, Improve Health Outcomes
- CMS Proposed Model Test Would Lower Certain Medicare Part B Prescription Drugs
- CMS Proposed Model Test Would Lower Drugs Costs for Medicare Part D
- CMS BALANCE Model Aims to Expand Access to GLP-1 Medications for People with Medicare Part D & Medicaid
- Transparency in Coverage Proposed Rule
- Final Local Coverage Determinations for Certain Skin Substitutes Withdrawn
- Physicians & Non-Physicians: Comment on Medicare Enrollment Application by February 17
- Hospitals: Submit Data for OPPS Drug Acquisition Cost Survey by March 31
- Hospitals: Apply for Additional Residency Positions by March 31
- Medicare-Funded Physician Residency Positions Awarded
- Health Professional Shortage Area: CY 2026 Bonus Payments
- Ambulance Fee Schedule: CY 2026 Inflation Factor
- Doctors & Clinicians: CY 2023 Performance Information
- Information for Critical Access Hospitals
Claims, Pricers & Codes
- ICD-10-PCS: CMS Announces 80 New Codes, Effective April 1
- Medicare Part B Drug Pricing Files & Revisions: January Update
- National Correct Coding Initiative: January Update
- Updated ICD-10 Medicare Severity Diagnosis-Related Group Version 43.1
Events
MLN Matters® Articles
- Cardiac Contractility Modulation for Heart Failure
- Chimeric Antigen Receptor T-Cell Therapy Billing Instructions: Medicare Claims Processing Manual Update
- DMEPOS Fee Schedule: CY 2026 Update
- ESRD & Acute Kidney Injury Dialysis: CY 2026 Update
- National Coverage Determination 20.40: Renal Denervation for Uncontrolled Hypertension
- Laboratory National Coverage Determination Edit Software: January 2026 Update
- Payment for Medicare Part B Preventive Vaccines & Their Administration for Rural Health Clinics & Federally Qualified Health Centers – Revised
Publications & Multimedia
News
CMS Announces $50 Billion in Awards to Strengthen Rural Health in All 50 States
CMS announced that all 50 states will receive awards under the Rural Health Transformation (RHT) Program, a $50 billion initiative established under President Trump’s Working Families Tax Cuts legislation (Public Law 119-21) to strengthen and modernize health care in rural communities across the country. In 2026, states will receive first-year awards from CMS averaging $200 million within a range of $147 million to $281 million. This unprecedented federal investment will help states expand access to care in rural communities, strengthen the rural health workforce, modernize rural facilities and technology, and support innovative models that bring high-quality, dependable care closer to home.
More Information:
CMS Announces Establishment of the Office of Rural Health Transformation
CMS announced the establishment of the Office of Rural Health Transformation (ORHT) within the Center for Medicaid and CHIP Services (CMCS). Following the creation of the Rural Health Transformation (RHT) Program earlier this year under President Trump’s Working Families Tax Cut legislation (Public Law 119-21), CMS has been carrying out this work and has now formally established ORHT within its organizational structure. The office will continue overseeing the RHT Program—a historic, $50 billion initiative to strengthen rural health systems and expand sustainable access to care nationwide.
Read the full press release.
New CMS LEAD Model Aims to Expand Access to Accountable Care, Improve Health Outcomes
What’s New
The Long-term Enhanced ACO Design (LEAD) Model is the Innovation Center’s next Accountable Care Organization (ACO) model that will focus on reaching more health care providers who have not joined ACOs, with a 10-year pathway to sustainable benchmarks, flexible population-based payments to support team-based care, integrated support for patients with complex care needs, and new waivers and flexibilities to attract beneficiaries and promote preventive care and healthy living.
Why It Matters
LEAD’s improved benchmarking methodology and other design features will support smaller, independent, or rural-based practices and those who serve patients with more complex challenges that have faced financial and administrative obstacles to being in ACOs previously.
What to Expect
LEAD is a 10-year model that will begin January 1, 2027; ACOs can apply to participate in LEAD by responding to a Request for Applications, which will become available beginning in Spring 2026.
More Information:
- LEAD Model webpage
- CMS Innovation Center Strategic Direction
- Value-Based Care Spotlight
- Innovation Insights
CMS Proposed Model Test Would Lower Certain Medicare Part B Prescription Drugs
What’s New
CMS announces the newly proposed Global Benchmark for Efficient Drug Pricing (GLOBE) Model that would lower costs of drugs covered by Medicare Part B.
Why It Matters
GLOBE would make high-cost Part B drugs more accessible for people with Medicare by reducing their cost sharing for select eligible Part B GLOBE drugs and alleviating financial strain on Medicare and for American taxpayers.
What to Expect
CMS is seeking public comment on GLOBE by February 23, 2026; see the proposed rule.
More Information:
- GLOBE Model webpage
- Press release
- CMS Innovation Center Strategic Direction
- Value-Based Care Spotlight
- Innovation Insights
CMS Proposed Model Test Would Lower Drugs Costs for Medicare Part D
What’s New
CMS announces the newly proposed Guarding U.S. Medicare Against Rising Drug Costs (GUARD) Model that would lower net costs of certain prescription drugs covered by Medicare Part D to reflect prices paid in economically comparable countries.
Why It Matters
GUARD would help make critical prescriptions more accessible for people with Medicare Part D, better enabling them to follow their prescribed care for optimal health outcomes, and alleviating financial strain on Medicare.
What to Expect
CMS is seeking public comment on GUARD by February 23, 2026; see the proposed rule.
More Information:
- GUARD Model webpage
- Press release
- CMS Innovation Center Strategic Direction
- Value-Based Care Spotlight
- Innovation Insights
CMS BALANCE Model Aims to Expand Access to GLP-1 Medications for People with Medicare Part D & Medicaid
What’s New
Under the BALANCE Model, CMS negotiates drug pricing with manufacturers of GLP-1 medications on behalf of state Medicaid agencies and Medicare Part D plans to enable people to improve their long-term health, potentially preventing chronic disease and disability.
Why It Matters
GLP-1 drugs are a promising tool to help people with weight loss and improve their overall health, but access to these drugs is uneven because coverage under Medicare and Medicaid is limited.
What to Expect
CMS is issuing a Request for Applications, soliciting drug manufacturers to participate in negotiations. BALANCE will launch in Medicaid in 2026 as participating states can join the model on rolling basis, from May – December. The Balance Model is anticipated to start in Medicare Part D in January 2027. Prior to the launch of the BALANCE Model, CMS plans to implement a separate Medicare GLP-1 payment demonstration beginning July 2026 that will serve as a short-term bridge to the BALANCE Model.
More Information:
- BALANCE Model webpage
- CMS Innovation Center Strategic Direction
- Value-Based Care Spotlight
- Innovation Insights
Transparency in Coverage Proposed Rule
Consistent with the President’s Executive Order 14221, “Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information,” on December 19, 2025, CMS, in partnership with the Department of Labor and the Department of the Treasury jointly proposed changes to the payer price transparency regulations to improve the accessibility of pricing disclosures to participants, beneficiaries, and enrollees, and the standardization and reliability of the public pricing disclosures from non-grandfathered group health plans and health insurance issuers offering non-grandfathered group and individual health insurance coverage.
More Information:
Final Local Coverage Determinations for Certain Skin Substitutes Withdrawn
Effective immediately, CMS A/B Medicare Administrative Contractors are withdrawing the Local Coverage Determinations for Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers that were scheduled to become effective on January 1, 2026.
Read the full fact sheet.
Physicians & Non-Physicians: Comment on Medicare Enrollment Application by February 17
CMS requests your comments on the Medicare Enrollment Application for Physician and Non-Physician Practitioners (Form CMS-855I) by February 17. Visit the PRA Listing webpage to get the supporting statement and related forms.
Hospitals: Submit Data for OPPS Drug Acquisition Cost Survey by March 31
The Outpatient Prospective Payment System (OPPS) Drug Acquisition Cost Survey (ODACS) is live. Hospitals paid under OPPS must submit their drug acquisition cost data to CMS by March 31 at 11:59 pm ET.
More Information:
- Visit the ODACS webpage to get official guidance on the survey
- Contact OPPSDrugSurvey@cms.hhs.gov with questions
Hospitals: Apply for Additional Residency Positions by March 31
Apply for additional residency positions under section 126 of the Consolidated Appropriations Act, 2021 by March 31, 2026. Visit the Direct Graduate Medical Education webpage for information on Round 5:
Medicare-Funded Physician Residency Positions Awarded
CMS awarded partially Medicare-funded residency slots to enhance the health care workforce and fund additional positions in hospitals serving underserved communities:
- 200 slots under Round 4 of section 126 of the Consolidated Appropriations Act, 2021 (ZIP) (fourth 200 of 1,000)
- 200 slots under section 4122 of the Consolidated Appropriations Act, 2023 (ZIP)
These graduate medical education residency slot awards will help address access to care challenges and workforce shortages in the highest need areas. Visit the Direct Graduate Medical Education webpage for more information.
Health Professional Shortage Area: CY 2026 Bonus Payments
See ZIP Codes designated as Health Professional Shortage Areas in 2026 that are eligible for a Medicare Physician Bonus:
See the instruction to your Medicare Administrative Contractor (PDF).
Ambulance Fee Schedule: CY 2026 Inflation Factor
The CY 2026 Ambulance Inflation Factor is 2.0%.
More Information:
Doctors & Clinicians: CY 2023 Performance Information
CMS added CY 2023 Quality Payment Program performance information to the Provider Data Catalog and the clinician and group profile pages on the Medicare.gov compare tool. Visit the Care Compare: Doctors and Clinicians Initiative webpage for more information.
Information for Critical Access Hospitals
The critical access hospital (CAH) bills for facility and professional outpatient services only when physicians or practitioners reassign their billing rights to the CAH.
Learn how CAHs can prevent Fiscal Intermediary Shared System reason codes 31006 and 31007 (indicating that providers don’t have a reassignment on file in PECOS) claim denials:
- CAHs must submit the reassignment application through PECOS or the paper Form CMS-855I
- Starting on January 2, 2026, we’ll return to provider (RTP) CAH claims for professional services if a reassignment isn’t in PECOS
More Information:
- Information for Critical Access Hospitals (PDF) booklet
- Editing for Duplicate Processing for Practitioner Professional Services and CAH Professional Services (PDF) Medicare Administrative Contractor instruction
- Medicare Part B Overpaid and Beneficiaries Incurred Cost-Share Overcharges of Over $1 Million for the Same Professional Services Office of the Inspector General report
Claims, Pricers & Codes
ICD-10-PCS: CMS Announces 80 New Codes, Effective April 1
Visit the ICD-10 webpage to get April 2026 procedure code update files. Use these codes for discharges and patient encounters occurring from April 1 – September 30, 2026.
Medicare Part B Drug Pricing Files & Revisions: January Update
Learn about quarterly updates to the following average sales price and not otherwise classified pricing files:
- January 2026
- October 2025
- July 2025
- April 2025
- January 2025
See the instruction to your Medicare Administrative Contractor (PDF).
National Correct Coding Initiative: January Update
Get the National Correct Coding Initiative (NCCI) first quarter edit files, effective January 1, 2026, on these Medicare NCCI webpages:
Updated ICD-10 Medicare Severity Diagnosis-Related Group Version 43.1
See Medicare Severity Diagnosis-Related Group (MS-DRG) Classifications and Software webpage for:
- Updated ICD-10 MS-DRG grouper software, Version 43.1
- ICD-10 MS-DRG Definitions Manual
- Definitions of Medicare Code Edits
See the instruction to your Medicare Administrative Contractor (PDF).
Events
2026 CMS Burden Reduction Conference – February 25
Wednesday, February 25 from 9 am – 1 pm ET
Register to attend in-person at the Hubert H. Humphrey Building in Washington, DC or virtually. In-person attendance is limited due to space.
This hybrid conference convenes leadership from the federal government, health provider organizations, and patient advocates to focus on opportunities across the health care enterprise to reduce administrative burden and strengthen access to quality care, improving the health care experience for clinicians and patients.
MLN Matters® Articles
Cardiac Contractility Modulation for Heart Failure
Learn about national coverage for cardiac contractility modulation (PDF):
- Criteria
- Coverage with evidence development study criteria
- Claims processing requirements
Chimeric Antigen Receptor T-Cell Therapy Billing Instructions: Medicare Claims Processing Manual Update
Learn about billing instruction updates and payment requirement scenarios (PDF):
- CMS will adjust the payment for claims that group to Medicare Severity Diagnosis-Related Group (MS-DRG) 018 when:
- The case involves a clinical trial for CAR T-cell therapy
- There’s expanded access use of CAR T-cell therapy or another immunotherapy product
- You don’t purchase the CAR T-cell therapy product in the usual manner, such as obtaining it at no cost
- We won’t apply a payment adjustment to claims that group to MS-DRG 018 when the case involves a clinical trial of a different product
DMEPOS Fee Schedule: CY 2026 Update
Learn about the updated payment policies (PDF), effective January 1, 2026:
- Fees for new codes
- Annual covered item fee updates
ESRD & Acute Kidney Injury Dialysis: CY 2026 Update
Learn about updates (PDF) to the ESRD Prospective Payment System and Acute Kidney Injury dialysis payment, effective January 1, 2026:
- Base rate, labor-related share, and wage index
- Outlier and rural adjustment transition policies
- Transitional drug add-on payment adjustment (TDAPA) and post-TDAPA add-on payment adjustment amounts
National Coverage Determination 20.40: Renal Denervation for Uncontrolled Hypertension
Learn about national coverage for renal denervation (PDF):
- Criteria
- Coverage with evidence development study criteria
- Claims processing requirements
Laboratory National Coverage Determination Edit Software: January 2026 Update
Learn about National Coverage Determinations with added ICD-10-CM codes (PDF).
Payment for Medicare Part B Preventive Vaccines & Their Administration for Rural Health Clinics & Federally Qualified Health Centers – Revised
Learn what’s changed (PDF):
- Added links to additional manual updates
- Clarified reimbursement after cost reporting
Publications & Multimedia
Medicare Provider Enrollment – Revised
CMS updated the enrollment fee amount for 2026.
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