The following is the latest health policy news from the federal government for December 12-18.  Some of the language used below is taken directly from government documents.

Congress

In a 216-211 vote yesterday, the House passed the Lower Health Care Premiums for All Americans Act, a Republican package aimed at addressing multiple health care policies.  The legislation includes provisions for employee tax-advantaged benefits like HSAs and FSAs, cost-sharing reductions (CSR) subsidies, and increased transparency requirements for pharmacy benefit managers (PBMs).  It notably did not include an extension of the enhanced Affordable Care Act premium tax credits that many of the party’s moderate members sought to include.  See the full bill text here and the Rules Committee report here.  The measure now moves to the Senate, where it is unlikely to garner the support needed for enactment.

With no Affordable Care Act amendment in the bill, House members Brian Fitzpatrick (R-PA), Mike Lawler (R-NY), Bob Bresnahan (R-PA), and Ryan Mackenzie (R-PA) signed onto Democratic leader Hakeem Jeffries’ (D-NY) discharge petition (a parliamentary procedure for bringing a bill out of committee and to the floor for consideration without a report from the committee) for a clean three-year extension of the enhanced Affordable Care Act premium tax credits.  With the support of those four moderate Republicans, the discharge petition gained the 218 signatures needed to bring the Democratic bill onto the House floor for a vote.  Speaker Mike Johnson (R-LA) will not schedule a vote on the legislation until January, well after the December 31 deadline for the enhanced Affordable Care Act premium subsidies.

Congress will reconvene on January 6 to resume discussions about appropriations and the expiring January 30 continuing resolution (CR).  Senators are considering a five-bill minibus that would provide funding for Labor, Health and Human Services, Education, and Related Agencies.  Lawmakers also will need to address the health care extenders funded by the CR that are set to lapse, including the delay of Medicaid DSH cuts, telehealth, the Acute Hospital Care at Home program, and the low-volume hospital adjustment program.

New CMS Models
  • On December 1, CMS and its Center for Medicare and Medicaid Innovation introduced their new ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) Model, which seeks to give original Medicare providers and patients access to high-value, technology-supported care options to better prevent and manage chronic disease.  At the time the program and its July 1 launch date were announced, CMS said it would invite expressions of interest in participating in the voluntary program in the near future.  Now, CMS has posted a form for interested providers to convey that interest; find that form here and learn more about the program on the ACCESS Model web page.
  • CMS and its Center for Medicare and Medicaid Innovation have announced the launch of the new “Make America Healthy Again:  Enhancing Lifestyle and Evaluating Value-based Approaches Through Evidence Model” (MAHA ELEVATE) to address the increase in the prevalence of chronic diseases.  The model will provide approximately $100 million to fund three-year cooperative agreements for up to 30 proposals that seek to promote health and prevention for original Medicare beneficiaries.  Participants will be required to use evidence-based, whole-person care approaches, including functional or lifestyle medicine interventions currently not covered by original Medicare.  These approaches are intended to support, not replace, the care people with Medicare receive.  MAHA ELEVATE also will gather and evaluate new data on cost and quality to inform future interventions promoting healthy lifestyle behaviors and ultimately reduce spending in original Medicare.  CMS will release a Notice of Funding Opportunity (NOFO) in early 2026 for the first cohort and the voluntary model will launch on September 1, 2026.  Learn more from the MAHA ELEVATE web page, which includes additional information about the model’s approach and its underlying rationale; the model’s objectives; eligible applicants (including hospitals, health systems, academic organizations, Federally Qualified Health Centers, Rural Health Clinics, state and local governments, and others); an FAQ; and a link to the MAHA ELEVATE listserv.
  • CMS has announced the launch of a new Long-term Enhanced ACO Design Model (LEAD) that will focus on reaching more health care providers who have not joined other ACOs.  Lead will use improved benchmarking and other design features to support smaller, independent, and rural-based practices and those who serve patients with more complex challenges and who have faced financial and administrative obstacles to participating in other CMS ACOs.  LEAD will offer a predictable window without rebasing and a pathway toward sustainable long-term benchmarks and savings and will focus on better coordinating care for high-need patients, such as those dually eligible for Medicare and Medicaid, and those who are homebound or home limited.  LEAD will be a ten-year voluntary model that will begin on January 1, 2027.  CMS will release a request for applications to participate in the program in March.  Learn more about LEAD Model from this CMS announcement and the LEAD Model web page, which offers more information about the program’s design, goals, and anticipated manner of operating and an FAQ.
Centers for Medicare & Medicaid Services
  • CMS has posted preview versions of two proposed regulations addressing gender-affirming care:
    • Medicaid Program: Prohibition on Federal Medicaid and Children’s Health Insurance Program Funding for Sex-Rejecting Procedures Furnished to Children.  This proposed rule would require that a state Medicaid plan provide that the Medicaid agency will not make payment under the plan for gender-affirming procedures (referred to as “sex-rejecting procedures” in the proposed rules) for children under 18 and prohibit the use of federal Medicaid dollars to fund gender-affirming procedures for individuals under the age of 18.  In addition, it would require that a separate State Children’s Health Insurance Program (CHIP) plan must provide that the CHIP agency will not make payment under the plan for gender-affirming procedures for children under 19 and prohibit the use of federal CHIP dollars to fund gender-affirming procedures for individuals under the age of 19.  The deadline for stakeholders to submit written comments is 60 days after the proposed rule’s official publication, which is scheduled for December 19.
    • Medicare and Medicaid Programs: Hospital Condition of Participation:  Prohibiting Sex Rejecting Procedures for Children.  This proposed rule would revise the requirements that Medicare and Medicaid-certified hospitals must meet to participate in the Medicare and Medicaid programs.  These changes reflect HHS’s review of recent information on the safety and efficacy of gender-affirming procedures on children.  The revisions to the requirements would prohibit hospitals from performing gender-affirming procedures on children.  The deadline for stakeholders to submit written comments is 60 days after the proposed rule’s official publication, which is scheduled for December 19.

Learn more about the proposed regulations from this HHS news release.

  • CMS has unveiled 24 measures for which it proposes collecting quality and efficiency data from health care providers for various Medicare programs.  The release, billed annually as “Measures Under Consideration,” includes measures that address digital data, health outcomes, chronic diseases, and quality measures, some of which specifically pursue greater alignment with HHS’s “Make America Healthy Again” (MAHA) initiative.  Some of the measures are already in use but would be modified or used for different or additional purposes.  Learn more about this undertaking from this CMS announcement; this CMS overview of the Measures Under Consideration; and this review of the process for developing, proposing, adopting, and implementing new measures.  The deadline for stakeholders to submit comments on the proposed measures is January 6.
  • The Medicare Administrative Contractors (MACs) will issue updated Final Local Coverage Determinations (LCDs) for skin substitute grafts/cellular and tissue-based products for the treatment of diabetic foot ulcers and venous leg ulcers that will take effect on January 1.  The LCDs will provide access to multiple evidence-based skin substitute products for Medicare beneficiaries with diabetic foot ulcers and venous leg ulcers and will only apply to those indications and will not affect payment for these products for other uses.  The LCDs also will describe frequency and utilization limits.  Learn more about this development and find a list of the covered products and their codes from this CMS news release.
  • CMS has issued an FAQ on the use of funds in segregated accounts by Qualified Health Plan issuers in the individual market under section 1303 of the Affordable Care Act.  The key point addressed in the FAQ is that those plans may not use these federal funds for abortion services.  Learn more from this CMS FAQ.
  • CMS has posted a bulletin presenting ICD-10 and other coding revisions to National Coverage Determinations.  Find the bulletin here and a complete list of the codes here.  The new codes take effect on April 1.
  • CMS has posted a bulletin summarizing the calendar year 2026 update of the Medicare home health prospective payment system.  Find that bulletin here.  The changes it presents take effect on January 1.
  • CMS has posted updated HCPCS codes for skilled nursing facilities in 2026.  Find Part A code changes here and Part B code changes here.  The updated codes take effect on January 1.
  • CMS has sent a memo to all Medicare Advantage organizations, Section 1876 cost plans, and health care prepayment plans informing them that in advance of its intention to begin collecting data related to all Medicare Advantage plan initial coverage decisions and plan processed appeals in 2027, it is seeking volunteers for a voluntary pilot among such plans in 2026.  In the memo CMS outlines how the data collection program will work, including the data elements it will collect.  Interested plans have until January 9 to inform CMS of their interest in participating in this pilot.  Learn more from this CMS memo.
  • CMS has added the following items to its Quality Payment Program resource library.  (Note:  clicking these links may give a prompt to download a file that may be a zip file.)
The White House

The White House has issued an executive order calling for establishing a single national framework for artificial intelligence regulation.  The order seeks to use federal authority and funding mechanisms to push states to align with national policy by establishing an AI Litigation Task Force in the Justice Department to challenge state AI laws; calling for potential funding restrictions for states that enact AI laws the administration deems “onerous;” calling on the Commerce Department to evaluate state AI laws that conflict with federal policy; calling on the Federal Communications Commission and Federal Trade Commission to consider standards and guidance that would preempt state rules; and calling for legislation to establish a uniform federal AI framework that also would preempt state laws.  Some of these activities could potentially conflict with or contradict how the states regulate health care and health care providers.  Learn more from this executive order and an accompanying White House fact sheet.

Department of Health and Human Services
  • HHS has added Duchenne muscular dystrophy and metachromatic leukodystrophy to the Recommended Uniform Screening Panel (RUSP) for newborns.  Learn more from this HHS news release.
  • HHS’s Office of the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP) has posted a commentary examining the similarities and differences between the Trusted Exchange Framework and Common Agreement™ (TEFCA™) and CMS-Aligned Networks, describing how they relate to one another and their respective roles in accelerating interoperability.  Find the post here.
HHS/Office of the Inspector General
  • HHS’s Office of the Inspector General (OIG) has issued a favorable opinion regarding certain discount structures that a pharmaceutical manufacturer offers on certain vaccines.  Find that OIG opinion here.
  • The OIG has issued a report describing trends in dual-eligible enrollees’ access to prescription drugs under Medicare Part D from 2011 through 2025.  Find that report here.
  • Some selected health centers received duplicate reimbursement from HHS’s Health Resources and Services Administration (HRSA) for COVID-19 testing services, the OIG found in a recent audit.  Learn more about what the OIG learned and the steps it recommended to address this problem from this OIG report.
Medicaid State Plan Amendments

CMS has approved the following state plan amendments for Medicaid and CHIP programs.

  • To Nevada, updating the payment methodology for the state’s Enhanced Rates for Practitioner Services Delivered in a Teaching Environment program.
  • To Nevada, establishing a payment methodology for vagus nerve stimulation therapy devices.
  • To Ohio, increasing the personal needs allowance for institutionalized individuals and Aid to Families with Dependent Children (AFDC)-related children and adults.
  • To Ohio, removing the September 30, 2025 sunset date for the medication-assisted treatment benefit, making that benefit permanent under the Medicaid state plan.
  • To Iowa, updating nursing facility per diem rates using 2024 cost report data under the state plan under Title XIX of the Social Security Act medical assistance program.
  • To Iowa, increasing reimbursement rates for 1915(i) state plan home- and community-based habilitation and supported employment habilitation services.
  • To Iowa, permitting bachelor-level practitioners for functional family therapy and multisystemic therapy.
  • To Montana, updating the reimbursement fee schedule for psychiatric residential treatment facility services for state FY 2026.
  • To Montana, increasing the professional dispensing fee to $17.52 for pharmacies with an annual prescription volume between 0 and 39,999 prescriptions; $15.17 for pharmacies with an annual prescription volume between 40,000 and 69,999; and $12.83 for pharmacies with an annual prescription volume greater than or equal to 70,000.
  • To Montana, implementing the mandatory exception to the Medicaid clinic services “four walls” requirement for Indian Health Service and Tribal clinics.
  • To Montana, increasing the monetary limit for dental services provided to members aged 21 and over, aligning with the provider rate increase appropriated by the Montana legislature and ensuring that the quantity of services a member can receive remains unaffected by the provider rate increase.
  • To Massachusetts, updating the methods and standards used by the state for payment for substance use disorder clinic services.
  • To Massachusetts, updating the methods and standards used by the state for payment for mental health centers.
  • To Idaho, discontinuing contracting and reimbursing as part of the Healthy Connections Value Care program through value care organizations and the Healthy Connections primary care case management program.
  • To Louisiana, to allow a beneficiary to request disenrollment from a managed care organization without cause up to two times in a calendar year.
  • To Louisiana, amending provisions governing non-emergency medical transportation to permit transportation network companies to provide non-emergency medical transportation through the Medicaid program.
  • To Pennsylvania, continuing the funding of inpatient disproportionate share hospital (DSH), outpatient supplemental, direct medical education payments, and certain DSH and supplemental payments for new hospitals.
  • To Wisconsin, providing mandatory coverage in accordance with section 1902(a)(84)(D) of the Social Security Act for eligible juveniles who incarcerated in a public institution post-adjudication of charges.
  • To New Jersey, covering and reimbursing for over-the-counter COVID-19 test kits when recommended and prescribed by a physician or other licensed practitioner.
  • , implementing supportive visitation services.
  • To New Jersey, establishing per diem add-on rate updates to the process for setting add-on rates for nursing facilities.
  • To Delaware, providing for mandatory coverage for eligible juveniles who are incarcerated in a public institution post-adjudication of charges.
  • To Michigan, providing targeted case management for eligible juveniles who are within 30 days of their scheduled date of release from a public institution following adjudication.
  • To Michigan, updating Attachment 3.1-A of the Medicaid state plan for clinic services with the required state plan amendment template.
  • To Rhode Island, providing additional clarity regarding billing practices for community health workers and outlining service limitations to ensure alignment with program goals.
  • To the District of Columbia, removing individuals under age 65 with income over 133 percent of the federal poverty level from the Section 1932(a) managed care state plan amendment.
  • To Vermont, affirming compliance with the mandatory exception to the Medicaid clinic services benefit “four walls” requirement for Indian Health Service and Tribal Clinics.
  • To Connecticut, continuing coverage and reimbursement for over-the-counter COVID-19 tests.
  • To Washington, updating home- and community-based services personal care services rates.
HHS Newsletters, Reports, and Videos
  • CMS – MLN Connects – December 18
  • CMS – Medicare Diabetes Prevention Program (MDPP) Bulletin – December
  • Agency for Healthcare Research and Quality – AHRQ News Now – December 16
  • CDC – Mortality and Morbidity Weekly Report – “Effectiveness of 2024–2025 COVID-19 Vaccines in Children in the United States – VISION, August 29, 2024–September 2, 2025” – December 11
  • HHS – The ASPR/TRACIE Express – December 2025
  • Health Resources and Services Administration (HRSA) – Office for the Advancement of Telehealth Announcements – December 18
Centers for Disease Control and Prevention (CDC)

The CDC has adopted individual-based decision-making for hepatitis B immunization for parents deciding whether to give the hepatitis B vaccine, including the birth dose, to infants born to women who test negative for the virus.  For those infants not receiving the birth dose, the CDC suggests that the initial dose be administered no earlier than two months of age.  Learn more from this HHS news release and an accompanying fact sheet.

Congressional Research Service

The Congressional Research Service has prepared a document that provides information on all of Medicare’s fee-for-service payment systems.  The document compiles the payment systems, their main portals on CMS’s web site, the typical rulemaking schedule, statutory and regulatory requirements, and the most recently issued proposed rules, public comments, final rules, and subsequent corrections.  It also includes embedded links to the applicable resources.  Learn more from the Congressional Research Service report “Finding Medicare Fee-For-Service (FFS) Payment System Rules: Schedules and Resources.”

Stakeholder Events

CMS – PEPPER Webinar – January 6

CMS will hold a webinar to provide guidance on recent changes the agency made to its Program for Evaluating Payment Patterns Electronic Report (PEPPER) for short-term acute-care hospitals and to review the reports it published this month.  The webinar will be held on Tuesday, January 6 at 1:00 (eastern).  Go here for additional information about the webinar and to register to participate.

MedPAC – Commissioners Meeting – January 15-16

MedPAC’s commissioners will hold their next public meeting virtually on Thursday, January 15 and Friday, January 16.  An agenda and participation information are not yet available but when they are they will be posted here.

MACPAC – Commissioners Meeting – January 29-30

MACPAC’s commissioners will hold their next public meeting virtually on Thursday, January 29 and Friday, January 30.  An agenda and participation information are not yet available but when they are they will be posted here.

HHS/Office of the Assistant Secretary for Technology Policy – ASTP Annual Meeting – February 11-12, 2026

HHS’s Office of the Assistant Secretary for Technology Policy will hold its annual meeting in Washington, DC on February 11-12, 2026.  The meeting will include in-person education and plenary sessions and networking opportunities for the health IT community.  The main stage plenary sessions will also be available for viewing online.  ASTP will soon post information on the meeting’s agenda, how to register, and how to reserve a hotel room through ASTP’s room block.  When it does, that information will be posted here.

CMS – 2026 CMS Burden Reduction Conference – February 25

CMS will hold its 2026 Burden Reduction Conference on Wednesday, February 25.  The conference will be held in Washington, D.C., with options for individuals to attend in person or participate virtually.  Learn more from this CMS notice.  Registration information is not available at this time.

CMS – 2026 CMS Quality Conference – March 16-18

CMS will hold its 2026 Quality Conference on Monday, March 16 through Wednesday, March 18 in Baltimore.  The theme of the conference will be “Make America Healthy Again:  Innovating Together for Better Health.”  Interested parties can participate in person or virtually.  Learn more about the conference and how to participate from this CMS announcement.