The following is the latest health policy news from the federal government for August 29 – September 4.  Some of the language used below is taken directly from government documents.

Congress

The House and Senate have returned to Washington D.C., where their focus has turned to funding for the federal government, which expires on September 30.  Senior appropriators predict that Congress will pass a continuing resolution (CR) to keep the government open through at least mid-November.  We expect any CR to include a number of health care extenders for programs that also expire after September 30, including for telehealth flexibilities, the Acute Hospital Care at Home program, the Medicare-dependent hospital and low-volume hospital programs, and delays to reductions to Medicaid disproportionate share (Medicaid DSH) allotments to the states.

Rural Health Transformation Program

CMS has updated the web page of the Rural Health Transformation Program with new information about how states will apply for funding from the program.  State applications will be released in mid-September and due by early November, with awards to be decided by the end of the year.  Learn more from the program’s updated web page.  CMS also recently held a webinar about the program; go here to find a video and a transcript of the webinar.

Centers for Medicare & Medicaid Services
  • CMS has announced changes in its Achieving Healthcare Efficiency Through Accountable Design (AHEAD) model.  The AHEAD Model is a state total cost of care model that seeks to drive state and regional health care transformation and multi-payer alignment, with the goals of improving the total health of the population involved, promoting competition and choice, enhancing prevention, and empowering patients.  Under the changes, states must implement at least two policies focused on promoting choice and competition in their health care markets and on prevention, with a new Population Health Accountability Plan focused on preventive care, including chronic disease prevention.  This revised framework will offer risk-bearing Geographic Entities additional tools and enhanced flexibilities to improve health outcomes and reduce spending for their patients while receiving shared payments (or losses) through two-sided risk arrangements.  CMS also is introducing payment reforms for patients with traditional Medicare and establishing new transparency requirements around total cost of care and primary care investment targets.  The program also has been extended through 2035.  Learn more about the AHEAD changes from this CMS announcement and more about the program from the AHEAD model web page.
  • CMS has posted a bulletin about the Transforming Episode Accountability (TEAM) Model that addresses how it will implement the skilled nursing facility Medicare three-day rule waiver.  The bulletin includes detailed information about the criteria CMS will employ to determine whether it will pay for skilled nursing facility or swing bed care without a three-day inpatient stay.  Find that bulletin here.  The policy takes effect on January 1.
  • On December 15, CMS will start a five-year prior authorization demonstration program for certain Medicare-covered services provided in ambulatory surgical centers in California, Florida, Texas, Arizona, Ohio, Tennessee, Pennsylvania, Maryland, Georgia, and New York.  The service categories targeted by the demonstration are blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation procedures.  Providers can submit prior authorization requests beginning on December 1 for dates of service on or after December 15.  Learn more from this CMS announcement.
  • CMS has posted the eCQM specifications for measures proposed for inclusion in the 2027 reporting period for hospitals for outpatient services.  Measures will not be eligible for 2027 reporting unless and until they are proposed and finalized through notice-and-comment rulemaking.  Learn more about the new measures, where to find them, and how to submit questions about them from this notice from the eCQI Resource Center.
  • CMS has updated its Electronic Clinical Quality Improvement (eCQI) Resource Center to identify specific CMS programs and payment models associated with eligible clinician electronic Clinical Quality Measures (eCQMs).  Starting with the 2023 reporting period, these eCQMs are associated with their CMS Reporting Options:  Merit-based Incentive Payment System (MIPS), MIPS Value Pathway (MVP), Primary Care First, Alternative Payment Model (APM) Performance Pathway (APP), and APP Plus (APP+).  Learn more from this notice from the eCQI Resource Center.
  • CMS has hired a contractor to conduct a triennial assessment of the quality and efficiency impact of measures used in Medicare programs.  To assist with that undertaking, that contractor will be convening a technical expert panel – a group of stakeholders and experts – to contribute input on the development of the report, scheduled for release in 2027.  Now, CMS is seeking participants to serve on that panel, and to that end it has published a notice outlining the specific skills and experience it seeks of prospective panel members, an explanation of the time commitment involved, and information on how to apply to participate.  Find that notice here (scroll down and click on “Impact Assessment of CMS Quality Measures – 2027 Impact Assessment Report”).  The deadline for submitting applications is September 12.
Department of Health and Human Services
  • HHS has announced expanded enforcement against health data blocking:  the practice of intentionally interfering with the access, exchange, or use of electronic health information by authorized parties, such as patients, providers, or other health systems.  Learn more about how this action applies to patients, innovators, providers, and health IT developers from this HHS news release; a 2024 video of a presentation about data blocking enforcement from the HHS Office of the Assistant Secretary for Technology Policy; this video from HHS Secretary Kennedy; and this enforcement alert from HHS’s Office of the Inspector General.
  • HHS has announced that it is expanding access to catastrophic health coverage through HHS’s new hardship exemption under new guidance that streamlines access to more affordable catastrophic coverage for consumers who are ineligible for advance payments of the premium tax credit or cost-sharing reductions.  Under this new HHS guidance, consumers may qualify for a hardship exemption to purchase a catastrophic plan on or off the Exchange if they are determined or expect to be ineligible for premium tax credits or cost-sharing reductions based on their projected annual household income.  Consumers may begin applying for such exemptions on November 1.  Learn more about this new policy from this HHS news release and this fact sheet on the hardship exemption guidance for catastrophic coverage.
  • HHS has issued a news release reminding stakeholders about a new regulation – the Health Data, Technology, and Interoperability:  Electronic Prescribing, Real-Time Prescription Benefit and Electronic Prior Authorization final rule, generally referred to in health care circles as the HTI-4 rule – that will give doctors and patients real-time access to prescription drug information.  Among other improvements, the rule will enable consumers to compare drug prices, view out-of-pocket costs, and view prior authorization requirements.  The rule also ensures that providers using certified health IT systems are able to submit prior authorizations electronically, select drugs consistent with a patient’s insurance coverage, and exchange electronic prescription information with pharmacies and insurance plans.  The rule was finalized on July 31 and takes effect on October 1.  Learn more about the rule and its implications for providers and consumers from this HHS news release.
  • Some Medicaid managed care plans made few or no referrals of potential provider fraud, HHS’s Office of the Inspector found in a recent audit.  Learn more about what the OIG found and what it recommends to address this situation from this OIG report.
Medicaid State Plan Amendments

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

  • To the District of Columbia, adding coverage of FDA-approved over-the-counter COVID-19 tests under the state plan.  The district’s initial state plan amendment submission was revised to incorporate the required language in the preventive services benefit instead of the pharmacy benefit.
  • To Louisiana, adding provisions governing the Medicaid purchase plan to increase the income limit and countable resources and to adjust the premium structure accordingly.
  • To New Jersey, revising COVID-19 vaccine administration rates from 100 percent to 50 percent of current Medicare rates.
  • To Utah, making changes to tribal consultation policies.
  • To Nebraska, adding the state’s prenatal plus program to the alternative benefit plan.
  • To Delaware, updating the payment methodology for physician-administered drugs and high investment medications.
  • To Delaware, adding language to the Medicaid state plan regarding lactation counseling services for pregnant and postpartum individuals.
  • To South Dakota, updating supplemental payments for inpatient and nursing facilities.
  • To Wyoming, attesting to the state’s compliance with sections 5121 and 5122 of the Consolidated Appropriations Act, 2023 establishing Medicaid coverage for screening, diagnostic services, and targeted case management for eligible incarcerated individuals under 21 and former foster care youth 18-26 and electing to provide full Medicaid benefits to juveniles pending disposition of charges.
  • To Wyoming, revising the personal needs allowance to authorize a $20 monthly deduction for administrative fees associated with maintaining a Medicaid-compliant Irrevocable Income Trust (Miller Trust).
  • To Texas, implementing rate increases for assisted living, supervised living, and supported home living.
  • To Colorado, increasing hospice provider rates and updating the fee schedule date effective October 11, 2024.
  • To Wisconsin, adding reimbursement for treat-in-place/no transport services.
HHS Newsletters, Reports, and Videos
  • CMS – MLN Connects – September 4
  • CMS – Medicare Shared Savings Program Accountable Care Organizations Performance Year 2024 Financial and Quality Results – fact sheet – August 28
  • HRSA – a video of the August 21 monthly meeting of the board of directors of the Organ Procurement and Transplantation Network
Centers for Disease Control and Prevention (CDC)
  • Nearly 100 people have been sickened in a salmonella outbreak linked to recalled eggs, the CDC has announced.  The outbreak has occurred in 14 states.  Learn more about the outbreak, the states involved, and the sources of the eggs from this CDC news release, which includes information for consumers and businesses.  The CDC also has released a separate food safety alert with additional information for providers; find that alert here.
  • The CDC has published its outlook for the 2025-2026 respiratory disease season.  The agency expects the upcoming fall and winter respiratory disease season to have a similar number of combined peak hospitalizations due to COVID-19, influenza, and RSV as last year.  Learn more from this CDC assessment.
Food and Drug Administration (FDA)

The FDA has introduced new rare disease evidence principles to provide greater speed and predictability in the review of therapies intended to treat rare diseases with very small patient populations with significant unmet medical need and that are driven by a known genetic defect.  Through this new process, sponsors will receive clearer guidance on the types of evidence they can use to demonstrate substantial evidence of effectiveness.  Learn more from this FDA news release.

Medicare Payment Advisory Commission (MedPAC)

MedPAC has submitted comments to CMS in response to CMS’s proposed rule governing how it plans to regulate and pay for Medicare-covered end-stage renal disease care in calendar year 2026.  In its letter, MedPAC endorses CMS’s proposal to increase payments for ESRD services by a net 1.9 percent but opposes the agency’s proposal to introduce a non-contiguous area payment adjustment, suggesting instead that CMS pursue other approaches to addressing the higher labor costs typically found in non-contiguous states and territories.  Find CMS’s comment letter here.

Government Accountability Office (GAO)

The GAO has published a report on behavioral health summarizing federal activities to support crisis response services.  Find that report here.

Stakeholder Events

CMS – Hospital Quality Program Updates in the FY 2026 Inpatient Prospective Payment System Final Rule Webinar – September 10

CMS and its Electronic Clinical Quality Improvement (eCQI) Resource Center will hold a webinar presenting hospital quality program updates in the FY 2026 Medicare inpatient prospective payment system final rule on Wednesday, September 11 at 2:00 (eastern).  The webinar will provide an overview of the FY 2026 final inpatient prospective payment system/long-term care hospital prospective payment system final rule as it affects the Hospital Inpatient Quality Reporting Program, Hospital Value-Based Purchasing Program, PPS-exempt Cancer Hospital Quality Reporting Program, Hospital-Acquired Condition Reduction Program, Medicare Promoting Interoperability Program, and Hospital Readmissions Reduction Program.  Learn more about the webinar and how to participate from this eCQI Resource Center announcement.

CDC – Clinician Update on Measles Cases and Outbreaks in the United States – September 11

The CDC will hold a webinar on Thursday, September 11 at 2:00 (eastern) during which presenters will discuss the current epidemiology of measles in the U.S. and address the most common questions from clinicians about preventing, identifying, and testing for measles.  Presenters also will summarize measles, mumps, and rubella (MMR) vaccination recommendations and considerations.  Learn more about the webinar – the presenters, its objectives, how to obtain continuing education credits, how to participate, and more – from this CDC notice.

MACPAC – Commissioners Meeting – September 18-19

MACPAC’s commissioners will hold their next public meeting virtually on Thursday, September 18 and Friday, September 19.  An agenda and registration information are not yet available but when they are they will be posted here.