News
- Delaware: New Funding to Support Early Career Physicians
- Maryland: $16M for Rural Healthcare Workforce Training & Retention
- Montana: New Funding to Expand Rural EMS & Bring More Care Directly to Patients
- New Hampshire: $11M to Strengthen Rural EMS & Expand Mobile Healthcare
- Ohio: $92M to Coordinate Rural Hospital Networks, Improve Maternal Care & Expand Medical Services
- Texas: $78M for Rural Healthcare Workforce, Chronic Disease Prevention & Facility Upgrades
- CMS Proposes Reforms to Strengthen Transparency & Affordability in Medicare Advantage and Part D
- Qualified Medicare Beneficiary: Changes to Cost Sharing Requirements Upon Loss of Medicaid Enrollment due to Working Families Tax Cut Legislation
- Clinical Laboratory Fee Schedule: Submit Comments & Reconsideration Requests by November 19
- Inpatient Rehabilitation Facility Initial Interdisciplinary Team Meeting Requirement: Enforcement Discretion
- Short-Term Acute Care Hospitals: Download Your Q2 FY 2026 PEPPER
- Help Detect Breast Cancer Early
Compliance
Claims, Pricers & Codes
MLN Matters® Articles
- Ambulatory Surgical Center Payment System: October 2026 Update
- Inpatient Rehabilitation Facility Services: Medicare Benefit Policy Manual Updates
News
Delaware: New Funding to Support Early Career Physicians
This federal investment will award housing and assistance to help future physicians train and practice in rural communities, ensuring Delawareans get the care they need close to home.
The Trump Administration announced over $1 million in Rural Health Transformation Program funding to help recruit and retain physicians serving communities in rural Delaware. This investment will support medical students and physicians in residency training, reduce the financial burden of clinical training, and encourage more physicians to build their careers while expanding quality care access to rural communities across Delaware.
Read the full press release.
Maryland: $16M for Rural Healthcare Workforce Training & Retention
This federal investment will prepare Marylanders for healthcare careers and help rural communities recruit and retain nurses, physicians, dentists, and other providers.
The Trump Administration announced $16.4 million in Rural Health Transformation Program funding to address critical healthcare workforce shortages and improve access to care. This investment will support projects ready for rapid deployment that train new healthcare workers, expand apprenticeships, and help rural communities recruit and retain skilled professionals across Maryland.
Read the full press release.
Montana: New Funding to Expand Rural EMS & Bring More Care Directly to Patients
This federal investment will give rural emergency medical teams the tools to provide in-home care, manage chronic conditions, and help Montanans avoid unnecessary emergency visits.
The Trump Administration announced $3.63 million in Rural Health Transformation Program funding to expand community integrated health services across rural Montana. This investment will help rural emergency medical services (EMS) agencies deliver more care directly to patients and connect them to vital resources, keeping high-quality care close to home for Montanans.
Read the full press release.
New Hampshire: $11M to Strengthen Rural EMS & Expand Mobile Healthcare
This federal investment will create and expand mobile health programs, connect emergency medical service (EMS) agencies with rural hospitals, and bring more care directly to patients across New Hampshire.
The Trump Administration announced more than $11 million in Rural Health Transformation Program funding to strengthen EMS and expand Mobile Integrated Health across rural New Hampshire. This investment will support Mobile Integrated Health programs that bring healthcare services directly into rural communities, while helping EMS agencies respond to rising demand and workforce pressures.
Read the full press release.
Ohio: $92M to Coordinate Rural Hospital Networks, Improve Maternal Care & Expand Medical Services
This federal investment will connect rural providers and bring MRI, behavioral health, and maternal care closer to patients across Ohio.
The Trump Administration announced $92 million in Rural Health Transformation Program funding to help rural providers connect patients to coordinated, high-quality care and bring essential health services closer to home for Ohioans. This investment will support coordinated care networks, strengthen maternal health services, and upgrade equipment and facilities at 22 rural hospitals across Ohio.
Read the full press release.
Texas: $78M for Rural Healthcare Workforce, Chronic Disease Prevention & Facility Upgrades
These investments will support the rural health workforce, modernize aging equipment, and advance chronic disease prevention to keep quality care within reach for rural Texans.
The Trump Administration announced $78 million in Rural Health Transformation Program funding to 216 rural healthcare providers through the Rural Texas Strong initiative to strengthen healthcare across rural Texas communities. This investment will support chronic disease prevention and improved health outcomes, rural healthcare workforce recruitment and retention, and medical equipment and facility improvements to expand access to state-of-the-art care across Texas.
Read the full press release.
CMS Proposes Reforms to Strengthen Transparency & Affordability in Medicare Advantage and Part D
CMS issued a proposed rule that would improve the accuracy of provider directories for Medicare Advantage plans, establish transparency and compensation requirements for Pharmacy Benefit Managers, and deliver enhanced cost-saving protections for low-income Medicare beneficiaries.
More information:
Qualified Medicare Beneficiary: Changes to Cost Sharing Requirements Upon Loss of Medicaid Enrollment due to Working Families Tax Cut Legislation
If a dually eligible individual’s loss of Medicaid coverage includes removal from the Qualified Medicare Beneficiary (QMB) eligibility group, the individual will no longer be eligible for the cost sharing protections required for QMBs. Additionally, loss of Medicaid coverage due to section 1903(v)(5) of the Social Security Act (the Act) would affect Medicaid coverage as the secondary payer.
Before billing or assessing cost sharing, providers should verify:
- Current Medicaid eligibility status
- Current QMB eligibility status
- Applicable coverage
Original Medicare providers and suppliers can identify Medicaid eligibility in the HIPAA Eligibility Transaction System (HETS) (see Checking Medicare Eligibility (PDF)), while Medicare Advantage Organizations inform their providers regarding any applicable enrollee billing protections.
For more information:
- Medicare Enrollment, Disenrollment, and Cost Sharing Requirements Upon Implementation of section 1903(v)(5) of the Social Security Act for Dually Eligible Individual’s Loss of Medicaid Coverage memo:
- Go to the HPMS webpage
- Select the Memos icon at the top left
- Prohibition on Billing QMBs (PDF) fact sheet
Working Families Tax Cut Legislation: Implementing Sections 71109 & 71201
Starting October 1, 2026, section 1903(v)(5) of the Act, as added by section 71109 of Public Law (P.L.) 119-21, which CMS refers to as the Working Families Tax Cut (WFTC) legislation, generally limits, with some exceptions, federal financial participation for Medicaid to noncitizens who are:
- Lawful permanent residents (LPRs) or green card holders
- Cuban/Haitian entrants
- Compacts of Free Association (COFA) migrants
See the April 8, 2026, State Health Official letter for more information.
Section 71201 of the WFTC also limits Medicare entitlement and enrollment to the same categories of noncitizens. Terminations for Medicare based on the new entitlement and enrollment categories will occur after implementation of section 71109. See the CY 2027 Medicare Physician Fee Schedule proposed rule for more information.
Clinical Laboratory Fee Schedule: Submit Comments & Reconsideration Requests by November 19
Get the latest payment information on the Clinical Laboratory Fee Schedule (CLFS) and find out how to submit comments on the CY 2027 preliminary determination for codes with no applicable information (ZIP) by November 19 to CLFS_Annual_Public_Meeting@cms.hhs.gov.
Visit the CLFS Annual Public Meetings webpage for more information on the annual rate setting process.
Inpatient Rehabilitation Facility Initial Interdisciplinary Team Meeting Requirement: Enforcement Discretion
Starting October 1, 2026, an initial interdisciplinary team (IDT) meeting at an inpatient rehabilitation facility (IRF) must occur on or before Day 4 (with the patient’s admission date counted as Day 1) in order to:
- Implement appropriate treatment services
- Establish or review the patient's stated rehabilitation goals
- Identify any problems that could impede goals
In response to stakeholder feedback, CMS is exercising enforcement discretion from October 1, 2026 – March 31, 2027. For IRF admissions during this period, Medicare Administrative Contractors shouldn’t deny or non-affirm a claim based solely on the timing of the initial IDT meeting if an IDT meeting occurs at least once per week throughout the duration of the patient's stay. IRFs must meet all other coverage and documentation requirements.
IRFs should use this enforcement discretion period to implement processes to comply with the 4-day requirement.
Short-Term Acute Care Hospitals: Download Your Q2 FY 2026 PEPPER
CMS released the second quarter FY 2026 Program for Evaluating Payment Patterns Electronic Report (PEPPER) for short-term acute care hospitals. Your PEPPER helps you review your billing data to make sure claims are accurate. Use it to:
- Spot billing patterns that may need review or improvement
- Identify areas that may need closer monitoring or internal audits
- Find services that may be under-coded or over-coded
- Track trends like longer patient stays
How to Get Your PEPPER
Authorized officials (AOs), access managers (AMs), and staff end users (SEUs) can download their organization’s report from the PEPPER Portal.
How to become an SEU:
- Sign in to the CMS Identity & Access (I&A) Management System using your existing NPPES or PECOS credentials.
- Request the PEPPER business function for your organization. The Comparative Billing Report business function is also available and you can request it at the same time.
- Your AO or AM must approve your request.
More Information:
- Visit the Training & Resources webpage for more information about the release and User Guide
- See the I&A Quick Reference Guide and FAQs: Step-by-step instructions for AOs and AMs
- Contact the External User Services Help Desk
Help Detect Breast Cancer Early
Breast cancer is the second most common cancer among women in the United States (see CDC). During National Breast Cancer Awareness Month, talk with your patients about the best screening options for them to help detect breast cancer early.
Medicare covers mammography screening and clinical breast exam during screening pelvic exam. Find out when your patient is eligible for their next screening (PDF).
More Information:
- Preventive Services webpage
- Screening Pap Tests & Pelvic Exams (PDF) booklet
- CDC Breast Cancer webpage
- Mammogram information for your patients
Compliance
Parenteral Nutrition: Prevent Claim Denials
In 2024, the improper payment rate for parenteral nutrition was 33%, with a projected improper payment amount of $81.9 million. Learn how to bill correctly for these services. Review the Parenteral Nutrition provider compliance tip for more information, including:
- Billing codes
- Denial reasons and how to prevent them
- Refill and documentation requirements
Claims, Pricers & Codes
ITVISMA® Cell Gene Therapy Drug: Get Billing Guidance
Medicare pays for the cell gene therapy drug, ITVISMA, for claims from providers in physician offices with dates of service on or after July 1, 2026.
Billing instructions:
- Use HCPCS code J3405 (onasemnogene abeparvovec-brve, per treatment) and Place of Service code 11
- Submit multiple claims and append:
- LU modifier (fractionated billing)
- 76 modifier (repeat service or payment by the same physician or other qualified healthcare professional)
- Include fractionated units in your claims. You must bill in 0.1 increments. For example, if J3405 is $2,729,937.922:
- The payment amount will be split out in 30 claims
- Submit 28 claims with 0.1 unit and a charge of $90,997.93
- Submit 2 additional claims with 0.1 unit and a charge of $90,997.94
MLN Matters® Articles
Ambulatory Surgical Center Payment System: October 2026 Update
Learn about new HCPCS codes, revised code descriptors, and payment indicator changes (PDF) for:
- Surgical procedures
- Drugs, biologicals, and radiopharmaceuticals
- Skin substitute products
- Non-opioid treatments for pain relief
Inpatient Rehabilitation Facility Services: Medicare Benefit Policy Manual Updates
Learn about updates (PDF), including requirements for:
- Documentation
- Therapy timing
- Initial interdisciplinary team meeting
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