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The following is the latest health policy news from the federal government for October 30-November 5.  Some of the language used below is taken directly from government documents.

2026 Midterm Elections
  • Democrats regained control of the House and Senate in the 2026 midterm elections.  As of 3:30 p.m. eastern time today, the House is 251-155 and the Senate 54-44, both in favor of Democrats, with the outcome of 29 House races and two Senate races still undecided.  This shift in party control has set the stage for leadership transitions in both chambers.  House and Senate Republicans have scheduled their elections for November 10 and, notably, current Speaker Mike Johnson (R-LA) announced that he will not seek to become House minority leader in the 120th Congress.  House Democrats are expected to complete their leadership elections later in the month; Senate Democrats have not indicated a timeline for theirs.  The election for the new Speaker is scheduled for January 3, 2027, when the new Congress convenes.
  • A continued focus on health care affordability and the growing federal deficit are expected to shape the health care policy agenda in the 120th Congress.  Democrats will be focused on reversing key provisions of the 2025 Reconciliation Act (P.L. 119-21, also called H.R. 1 or the One Big Beautiful Bill Act) and mitigating its impact on access to health care.  Democrats are expected to advance a legislative agenda focused on strengthening traditional Medicare, addressing health care market consolidation and anti-competitive practices, and expanding access to preventive and primary care services.
Congress
  • Congress is scheduled to reconvene on November 9 to complete its remaining business.  Upon its return, one of its priorities will be advancing a government funding package; the current continuing resolution (CR) expires on December 11.
  • Senate Health, Education, Labor and Pensions (HELP) Committee Chairman Bill Cassidy (R-LA) has released a legislative discussion draft for the “Protecting Americans Through Intelligent, Ethical, and Transparent (PATIENT) Artificial Intelligence in Health Care Act.”  The proposal would direct HHS to release AI guidance on patient privacy; clarify when AI-based technology is subject to Food and Drug Administration (FDA) or Office of the National Coordinator for Health Information Technology (ONC) oversight; grant the FDA new reviewing authority; and create a payment pathway to support adoption of AI-based tools.  Stakeholder feedback is due by December 1, 2026.  For more information, see the press release here, the full discussion draft here, and a section-by-section summary here.
CMS Issues Final CY 2027 Medicare Hospital Outpatient Prospective Payment System Rule

Highlights include:

  • A 2.3 percent increase in Medicare payments for hospital outpatient services and ambulatory surgery center services.
  • Offsetting much of this increase, however, is the acceleration of Medicare’s clawback of its recoupment of payments for 340B-acquired drugs between 2018 and 2022 that were struck down by the Supreme Court; this acceleration increases the conversion factor for non-drug services from 0.5 percent to two percent.  This means that 2.3 percent increase will be reduced by two percent.
  • Payments of average sales price minus 28 percent for 340B-acquired drugs.
  • The expansion of Medicare’s site-neutral payment policy by paying the physician fee schedule rate, which is lower than the outpatient rate, for imaging without contrast, including certain bone density scans, x-rays, ultrasounds, CT scans, and MRIs at excepted off-campus provider-based departments.
  • Removal of 637 services from the inpatient-only list, enabling those services to be performed on an outpatient basis.  This reflects CMS’s intention to phase out the inpatient-only list over three years, with these removals part of year two of that process.
  • The addition of eight botulinum injection (botox) codes to those that require prior authorization in hospital outpatient departments.
  • Revisions in the hospital quality star ratings methodology to give greater weight to safety-of–care measure.
  • Updated payments for intensive outpatient programs (IOP) and partial hospitalization programs.
  • Updates to the validation of hospital outpatient quality reporting program data, including the validation of electronic clinical quality measure (eCQM) measures.

Learn more from this CMS news release; an accompanying CMS fact sheet; another CMS fact sheet that focuses on changes in Medicare’s Shared Savings Program; and the 1270-page final rule.  (DeBrunner & Associates’ clients have already received a more detailed analysis of this final regulation.)

CMS Issues Final CY 2027 Medicare Physician Fee Schedule Rule

Highlights include:

  • A 1.89 percent rate decrease for physicians who are qualifying alternative payment model (APM) participants – a conversion factor of $32.9548 – and a 2.3 percent decrease for those who are not, which is a conversion factor of $32.6286.  Much of this cut is the result of the expiration of legislation Congress enacted to temporarily increase Medicare payments to doctors.
  • An increase of 32 percent in base evaluation/management (E/M) rates for providers participating in Shared Savings Programs accountable care organizations (ACOs) and an increase of 16 percent for those who do not and coding changes for such visits.
  • A delay in the sunsetting of the Merit-based Incentive Payment System (MIPS) from the planned 2029 to 2031 and the adoption of three new MIPS Value Pathways.
  • A requirement that 340B entities submit selected claims data for Medicare Part D drugs purchased through that program to the 340B claims data depository beginning on January 1.
  • A reduction of office/outpatient evaluation/management (E/M) visit payments when such visits include a minor procedure performed at the same time as the visit.
  • Introducing a series of incentives to increase ACO participation in Medicare’s Shared Savings Program.
  • Changes in reimbursement for remote patient monitoring, including limiting such monitoring to established patients and a required initiating visit before remote monitoring can be billed.
  • A two-year delay of a proposed ban on third-party monitoring vendors.

Learn more from this CMS news release, an accompanying fact sheet, and this preview version of the 2468-page final rule. (DeBrunner & Associates’ clients will see a more detailed analysis of this final regulation shortly.)

CMS Issues Final CY 2027 Medicare Home Health Prospective Payment System Rule

Highlights include:

  • A rate increase of 2.4 percent but the retention of the 3.0 percent temporary reduction of the system’s base rate to maintain budget neutrality following implementation of the Patient Driven Grouping Model (PDGM).
  • Recalibration of PDGM case-mix weights, low utilization payment adjustment thresholds, impairment levels, and comorbidity adjustment sub-groups.
  • The reduction of OASIS data reporting deadlines from 135 to 45 days.
  • Starting in April of 2027, the addition of specific external infusion pumps and home infusion drugs as Medicare Part B-covered benefits.
  • Enhanced anti-fraud rules that include retroactive revocations for non-compliance and broader authority to deny or revoke Medicare enrollments for providers failing rules after ownership changes.  All enrollment revocations will take effect retroactive to the exact date of non-compliance.
  • A requirement that when home health agencies undergo majority ownership changes they must fully re-enroll as new providers and pass a fresh survey or accreditation.

Learn more from this CMS news release, this CMS fact sheet, and this preview version of the 447-page rule.  Also, HHS’s Office of the Inspector General (OIG) recent updated its FAQ on fraud-related exclusions from Medicare and other federal health care programs; find that updated FAQ here.

Centers for Medicare & Medicaid Services (CMS)
  • New guidance for batching Independent Dispute Resolution (IDR) claims seeks to clarify for certified IDR entities and disputing parties how batched claims will be handled under the federal IDR operations final rule.  This guidance explains how the finalized batching requirements will be operationalized; specifies the permissible CPT code ranges for anesthesiology, radiology, pathology, and laboratory items and services that are considered related to the treatment of a similar condition; explains the definition of a bundled payment arrangement; and provides examples to guide how disputing parties and certified IDR entities should apply the finalized batching and bundled payment provisions.  In particular, the guidance explains that batched items and services must be billed by the same provider, facility, or provider of air ambulance services; that batched items and services must be paid by the same group health plan or health insurance issuer; and batched items and services must be related to the treatment of a similar consideration.  The guidance includes explanations and examples of these and other considerations.  Go here to find the guidance, which was issued by the Department of Health and Human Services, the Department of Labor, the Department of the Treasury, and the Office of Personnel Management.
  • Two IDR entities have been dropped from adjudicating No Surprises Act fee disputes between providers and payers, CMS has announced.  The authorizing agencies – HHS, the Department of Labor, and the Treasury Department –  “… determined that these entities did not meet minimum performance standards and are therefore not eligible for recertification as certified IDR entities.”  Learn more from this CMS notice.
  • CMS finalizes new rules for Organ Procurement Organizations (OPOs) to help more organs reach patients and strengthen accountability for organ procurement organizations (OPOs).  The final rule establishes clear requirements when one organ procurement organization takes over from another and strengthens oversight of unsafe medical practices.  It also provides for enhanced oversight of unsound medical practices; provides clearer guidance on how to identify, investigate, and prevent adverse events; improves documentation on research organs; spells out the circumstances under which CMS may decertify OPOs; and changes how CMS measures transplant performance.  Learn more from this CMS news release, an accompanying fact sheet, and the final rule itself.  At the same time, CMS has updated its 2024 guidance on outcome requirements for initial transplant program approval; find that updated guidance here.
  • CMS is seeking volunteer experts to advise contractors it has hired to analyze nursing home Minimum Data Sets (MDS) and the new MDC Validation Process for CMS quality programs.  Learn more about the work the contractors are doing, the role they envision for their technical experts panels, the background they seek from prospective panel members, and how to participate from this CMS notice (scroll down and click on “Minimum Data Set (MDS) Data Validation Process and Implications for CMS Quality Programs”).  The deadline for submitting nominations is November 30.
  • CMS has added the following items to its Quality Payment Program resource library.  (Note:  clicking some of these links will download a zip file.)
Department of Health and Human Services (HHS)
  • Gender dysphoria will not qualify as a disability under Section 504 of the Rehabilitation Act of 1973 if that dysphoria did not result from physical impairments under a final rule issued by HHS’s Office of Civil Rights.  The rule applies to all programs and activities that receive HHS funding.  Learn more from this HHS news release and the final rule.
  • HHS hopes to improve how AIDS drug assistance programs work with the help of a new AIDS data collection instrument it proposes to develop a foundation for a better approach to the work performed by AIDS drug assistance programs.  HHS’s Health Resources and Services Administration (HRSA has found that AIDS drug assistance programs face increasing operational complexity and believes it lacks comprehensive information about how these programs manage and address emerging challenges and through this data collection hopes to identify best practices, barriers, and opportunities for program improvement.  Likely respondents are staff from state and territorial AIDS drug assistance programs.  Learn more about HRSA’s proposed data collection instrument from this formal notice.  The deadline for submitting comments is December 29.
  • The VA and Department of War have joined the TEFCA Network, according to HHS’s Office of the National Coordinator for Health Information Technology (ONC).  TEFCA, the Trusted Exchange Framework and Common Agreement, is the country’s interoperability network, which seeks to help patients, providers, and public health and federal agencies securely share electronic health information.  Learn more from this ONC news release.
  • Hospitals’ ability to offer patients gift cards to transfer hospitals is the subject of a change in HHS’s Office of the Inspector General’s (OIG) FAQ on “Application of Certain Fraud and Abuse Authorities to Certain Types of Arrangements.”  Find the FAQ here; the change is in question 3.
Rural Health Transformation Program Funding

In the past week CMS announced that it has awarded Rural Health Transformation Program money to the following states:

  • Missouri, $39.7 million to modernize rural health care access across the state
  • West Virginia, $19 million to expand telehealth, specialty care, and the health care workforce across the state

The Office of Rural Health Transformation has written to state officials informing them that the next major round of the program’s funding for each state, which was to be distributed by October 31, will be delayed.  That letter has not been made publicly available.

White House Office of the National Cyber Director

Free cybersecurity protections for rural hospitals are on the way through Project Lifeline 250, six-month joint federal, state, and private-sector initiative involving the White House Office of the National Cyber Director working with the state of South Carolina to strengthen cybersecurity protections at rural hospitals at no cost to participating hospitals.  The pilot program will focus on three major areas:  network defenses, backup technology, and legacy device identification.  Tech companies participating in the program, which will offer free tools, expertise, or hardware, include Cisco, Cyera, Microsoft, Trellix, Zscaler, and Dispel.  Learn more from this news release from the office of the governor of South Carolina.

Medicaid State Plan Amendments

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

  • Florida, updating buy-back provisions for intermediate-care facilities for individuals with developmental disabilities
  • New Jersey, revising the distribution of Graduate Medical Education Supplemental Trauma payments for state FY 2027
  • North Dakota, amending the state plan to increase the personal needs allowance
  • South Dakota, implementing an inflation increase to the health home per member per month and clinical outcome measure payment rates
  • Virginia, indicating that nursing facility value-based program funding is restricted to facilities demonstrating sufficiently high quality of care as determined by the state’s Medicaid department
  • Wyoming, updating the provider-specific Medicare-Equivalent ACR ratios listed in the state plan
Medicaid State Waiver Approvals

CMS has approved state Medicaid waivers for:

  • Alaska, approval of a 1915(c) individualized supports waiver
  • Maine, approval of a 1915(c) waiver for the state’s home- and community-based services for adults with other related conditions waiver
  • Maine, approval of a 1915(c) elderly and adults with disabilities waiver
  • New Hampshire, approval of a 1915(c) waiver for the state’s acquired brain disorder waiver
  • Wisconsin, approval of a 1915(c) waiver for the state’s Children’s Long-Term Support Waiver Program
  • Washington, approval of a 1915(c) community protection waiver
  • Washington, approval of a 1915(c) basic plus waiver
  • Washington, approval of a 1915(c) core waiver
  • Washington, approval of a 1915(c) individual and family services waiver
  • Washington, approval of a 1915(c) children’s intensive in-home behavioral support waiver
Health Policy Newsletters, Reports, and Videos
  • CMS – MLN Connects – November 5
  • CMS – “Short Term Acute Care Hospital (STACH) PEPPER Q2 FY 2026 Release Webinar” – video of October 15 webinar
  • CMS – “Geo AHEAD Technical Specifications Webinar” – October video
  • HHS/Health Resources and Services Administration (HRSA) – “HRSA eNews” – October
  • HHS/Office of the Assistant Secretary for Planning and Evaluation (ASPE) – “Longitudinal Maternal & Infant Health Information for Research FHIR Implementation Guide: Maternal Mental Health Use Case” – October 27 report
  • HHS/Office of the Inspector General (OIG)
Centers for Disease Control and Prevention (CDC)

The CDC’s Advisory Committee on Immunization Practices (ACIP) seeks new members.  The committee consists of up to 19 experts that collectively represent a balanced range of scientific, clinical, and public health expertise relevant to the committee’s mission, including persons knowledgeable about consumer perspectives and/or social and community aspects of immunization programs.  Learn more about the committee and its work and the backgrounds sought from prospective members from this CDC notice.  The deadline for submitting nominations is December 31.

Medicaid and CHIP Payment and Access Commission

MACPAC met last week in Washington, D.C.  During the commission’s deliberations, MACPAC’s staff made the following presentations to the commissioners:

Go here to find MACPAC’s own summary of the meeting.

Stakeholder Events

MedPAC – Commissioners Meeting – November 6

MedPAC’s commissioners are holding their latest public meeting this week.  The second day of the two-day session will be held on Friday, November 6.  Go here to find the meeting’s agenda and for information on how to view a live webcast of the session.

CMS – Healthcare Advisory Committee Public Meeting – November 9

CMS’s Healthcare Advisory Committee will meet to provide recommendations to Secretary Kennedy and CMS Administrator Oz focused on improving Medicare, Medicaid, and the health insurance marketplace and the health care system more broadly in a manner consistent with the executive order “Establishing the President’s Make America Healthy Again Commission.”  The meeting will take place on Monday, November 9, 2026 at 8:30 am (eastern). Go here to find a link to the meeting’s agenda and to the meeting itself.

CMS – Healthcare Common Procedure Coding System (HCPCS) Level II Public Meeting – November 11-12

CMS will hold its second biannual Healthcare Common Procedure Coding System (HCPCS) Level II public meeting of 2026 on Monday, November 2 and Tuesday, November 3 (if necessary) to discuss the CMS preliminary coding, Medicare benefit category, and Medicare payment determinations, if applicable, for new revisions to the HCPCS Level II code set for non-drug and non-biological items and services.  Find the meeting’s agenda and learn more about how to speak at the conference, submit comments, and register to participate either virtually or in person in this CMS announcement.

CMS – Center for Clinical Standards and Quality – Quarterly Stakeholder Webinar – November 17

CMS’s Center for Clinical Standards and Quality will hold its quarterly stakeholder webinar on Tuesday, November 17 at 3:00 (eastern).  During the webinar, agency officials will discuss recent policy efforts and their efforts to improve care and outcomes for beneficiaries in Medicare, Medicaid, and the Marketplace.  Go here to register to participate.

CMS – 2026 CMS National Provider Enrollment Conference – November 18-19

CMS will hold a national provider enrollment conference on Wednesday, November 18 and Thursday, November 19 in Kissimmee, Florida.  The event will provide direct access to the staff responsible for shaping and administering Medicare provider enrollment.  Through keynote presentations, panel discussions, interactive Q&A sessions, and expert-led training, participants will gain insight into enrollment policy, program integrity initiatives, compliance requirements, operationally friendly best practices, and upcoming changes affecting the Medicare provider enrollment landscape.  Learn more from this CMS conference notice.

HHS/Office of the Assistant Secretary for Planning and Evaluation – Physician-Focused Payment Model Technical Advisory Committee Meeting – December 8-9

HHS’s Physician-Focused Payment Model Technical Advisory Committee (PTAC) will hold a public meeting on Tuesday, December 8 and Wednesday, December 9 at 9:00 (eastern).  An agenda has not yet been posted.  Go here to learn more about the meeting and how to participate in person or virtually.

MACPAC – Commissioners Meeting – December 10-11

MACPAC’s commissioners will hold their next public meeting on Thursday, December 10 and Friday, December 11.  An agenda for the meeting and information about how to participate have not yet been posted; when they are, they will be posted here.

HHS/Office of the National Coordinator for Health Information Technology – Annual Conference – February 3-4

HHS’s Office of the National Coordinator for Health Information Technology (ONC) will hold its annual conference on February 3 and 4 in Washington, D.C.  In addition to participating in person, individuals can view livestreams of the session.  Go here for the meeting’s agenda, to register, and for information about accommodations.

 

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