Medicare & Medicaid, week of Aug 30, 2026

CMS reports $1.6 billion in Medicare laboratory program integrity actions across revocations, suspensions, recoupments and referrals

What changed

CMS announced on August 28, 2026 that it stopped more than $1.6 billion in potentially improper Medicare laboratory payments. The agency described deploying advanced analytics, including artificial intelligence and machine learning models, against Medicare fee for service claims to flag unusual billing before payment. The $1.6 billion is an aggregate of four different categories rather than a single pool of blocked payments, and CMS states each one differently: $732 million in savings from the revocation of 157 laboratory providers, more than $500 million in potentially fraudulent payments halted through 185 payment suspensions arising from a CMS investigation of 600 laboratories, more than $276 million recouped from 442 identified overpayments already paid out, and $127 million in potentially fraudulent payments prevented as a result of 85 law enforcement referrals. Only the $276 million describes money recovered after it was paid. The remainder combines projected savings from enrollment revocations, payments held under suspension, and payments CMS reports as prevented. CMS uses the words potentially improper and potentially fraudulent throughout the body of the release, while its own headline reads fraudulent, and the release reports no adjudication of fraud behind these amounts. CMS gave three case examples: one individual who enrolled 14 laboratories in Medicare fee for service and billed more than $24 million for services that could not have been rendered, with $12 million currently held by suspension, and two Texas laboratories that began billing at the end of February 2026 and in May 2026 and drew claim denials of $1.2 million and $1.9 million. The release named pathogen detection, high complexity drug testing and genetic testing as the areas of suspicious activity, and it does not direct providers to take any action.

Why it matters

CMS imposed no obligation here, so the value of the announcement is what it says about the instruments in use and how fast they move. Three of the four categories interrupt cash before any appeal: prepayment denial, payment suspension, and enrollment revocation. Each attaches to a billing national provider identifier, so a hospital outreach laboratory, a wholly owned reference laboratory, or a laboratory joint venture can carry the exposure even when the hospital itself is not the target. The named categories, pathogen detection, high complexity drug testing and genetic testing, are where hospital laboratory volume ramps quickly and where medical necessity documentation is thinnest. In the two Texas examples the interval from the start of the billing pattern to denials was a matter of months, which is faster than most internal monitoring cycles. The aggregate itself should be read with care: it mixes projected savings, held payments and actual recoupments, and CMS characterizes the underlying billing as potentially improper rather than as adjudicated fraud.

Response type

Validate

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Revenue Cycle

Affected functions

Compliance, Revenue Cycle, Coding, Clinical Operations, Provider Enrollment, Finance, Legal

First seen

Aug 30, 2026

Last materially changed

Aug 30, 2026

Why it is still here

The September 3 MLN newsletter recirculates the August 28 laboratory announcement. The current CMS release confirms the same four financial categories; retained as a program-integrity signal, without treating recirculation as a new enforcement event.

Recommended actionThis is a self directed review, not an agency requirement, and nothing in the CMS release mandates it. Run a claims level review of the organization's laboratory billing in the three named categories for the last twelve months, look for month over month volume steps, and confirm that an ordering provider relationship and a medical necessity record exist for each sampled claim. Confirm that the enrollment record for every laboratory billing identifier the organization controls, including joint ventures and managed laboratories, is accurate and that someone owns revalidation. Put the result in front of the compliance committee with the volume trend attached.

1. Pull twelve months of laboratory claims in pathogen detection, high complexity drug testing and genetic testing, and chart the monthly volume and dollar trend by billing identifier. Revenue Cycle · due Sep 13, 2026
2. Sample the highest volume test codes and confirm an ordering provider relationship, a signed order, and a medical necessity record for each sampled claim. Compliance · due Sep 27, 2026
3. Inventory every Medicare laboratory billing identifier the organization controls or manages, including joint ventures and managed arrangements, and confirm enrollment data and revalidation ownership. Provider Enrollment · due Sep 27, 2026
4. Confirm the process for receiving and escalating a Medicare payment suspension or revocation notice, including who is notified within one business day and who leads the corrective response. Compliance · due Oct 4, 2026
5. Report the volume trend, the sample error rate, and the enrollment inventory to the compliance committee with a recommendation on prepayment self monitoring. Compliance · due Oct 18, 2026

Permalink: #cms-medicare-laboratory-payment-integrity-actions · Development ID GC-2026-0009

CMS opens the second CY 2027 Medicare Plan Finder benefit and drug-pricing preview through September 11

What changed

CMS scheduled the second CY 2027 Medicare Plan Finder plan-benefit and drug-pricing preview for September 8 at 6:00 a.m. Eastern through September 11 at 11:59 p.m. Eastern. CMS reports that the preview now fixes several display defects, including incorrect Part A cost sharing for zero-dollar D-SNPs, catastrophic cost sharing, prior-authorization and referral labels, transportation benefits, injectable-drug tiers, diabetic-supply coinsurance, skilled-nursing-facility out-of-network labels, Low-Income Subsidy values and excluded-drug catastrophic copays. Plans are encouraged to compare preview data with their HPMS benefit reports and submitted formulary, excluded-drug and pricing files.

Why it matters

The preview is the last short operational window identified in the memo to catch public Medicare Plan Finder display defects before CY 2027 information is released. A plan that assumes a known defect still applies may miss a plan-specific data error, while a plan that checks only the web display without comparing its HPMS and pricing submissions may not identify the source of the discrepancy.

Response type

Validate

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Managed Care

Affected functions

Managed Care, Finance, IT, Compliance

Recommended actionHave Medicare Advantage and Part D owners complete a contract-by-contract spot check before the September 11 close. Compare benefit and drug-pricing displays with the corresponding HPMS reports and submitted formulary, excluded-drug and pricing files, and submit representative comments for any widespread issue rather than duplicating every instance.

1. Compare each CY 2027 plan-benefit preview with its HPMS benefit report and record exceptions, including D-SNP Part A cost sharing and prior-authorization or referral displays. Managed Care · due Sep 10, 2026
2. Compare drug-pricing preview results with submitted formulary, excluded-drug and drug-pricing files, then submit representative CMS comments for each distinct defect before the preview closes at 11:59 p.m. Eastern. Managed Care · due Sep 11, 2026

Permalink: #cms-cy2027-second-plan-benefit-drug-pricing-preview · Development ID GC-2026-0083

CMS opens CY 2027 Medicare Advantage provider-directory preview and sets September 18 attestation deadline

What changed

CMS opened the CY 2027 Medicare Advantage provider-directory preview in HPMS on September 8 and will collect feedback until further notice. Its September 4 technical guide requires local coordinated care plans, regional PPOs, network-based MSAs and network-based PFFS plans with individual coverage to supply current in-network provider and facility data as machine-readable JSON or FHIR-based JSON. CMS will crawl the reported public URLs daily, validate every individual plan and segment, and check that the directory was updated within 30 days. The guide sets September 18 as the target for October 1 production-ready data and as the deadline for a CEO, CFO or COO to attest in HPMS that the information is accurate, complete and truthful. CMS may suppress directory data for a missing attestation, fatal validation errors or data-quality issues above a published threshold.

Why it matters

This converts provider-directory readiness into a public-data, technical-validation and officer-attestation control. Directory content can fail even when individual records are accurate if the index, file format, public access, contract-plan-segment links or HTTP metadata do not meet the guide. A missed attestation or fatal file error can remove the plan's directory data from Medicare Plan Finder at the start of CY 2027 shopping.

Response type

Implement

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Managed Care

Affected functions

Managed Care, Provider Enrollment, IT, Compliance, Executive Leadership

Recommended actionAssign one accountable owner for every affected MA contract. Use the HPMS preview to test representative provider and facility NPIs and all plan segments; validate the public JSON or FHIR index and files from an external network; clear fatal validation findings; and obtain the required CEO, CFO or COO attestation by September 18. Preserve the validation results and sign-off as release evidence.

1. Confirm HPMS preview access for every affected MA contract and test representative practitioner and facility NPIs across all plan and segment combinations. Managed Care · due Sep 11, 2026
2. Validate each public index and constituent JSON or FHIR file from an external network, including syntax, authentication-free access, compression, HTTP headers, file limits and contract-plan-segment relationships. IT · due Sep 14, 2026
3. Review HPMS validation results and correct fatal errors, missing plan segments and stale provider data before the production target. Provider Enrollment · due Sep 16, 2026
4. Route the final evidence to an authorized CEO, CFO or COO and complete the CY 2027 provider-directory attestation in HPMS. Executive Leadership · due Sep 18, 2026

Permalink: #cms-cy2027-ma-provider-directory-preview-attestation · Development ID GC-2026-0084

Noridian finalizes two MolDX coverage policies for California effective October 12 and retires the thrombophilia policy October 11

What changed

September 6 source verification confirms the previously announced dates. Noridian posted on August 27, 2026 that two MolDX local coverage determinations are finalized for Jurisdiction E, which covers California, Hawaii, Nevada and the Pacific territories, effective October 12, 2026. They are L40242, MolDX: Genetic Testing for Hereditary Thrombophilia, and L40222, MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Targeted Therapy in Cancer. The associated billing and coding articles are A60272 and A60239. Separately, Noridian posted that L36155, MolDX: Genetic Testing for Hypercoagulability and Thrombophilia covering Factor V Leiden, Factor II Prothrombin and MTHFR, retires effective October 11, 2026, one day before the replacement policy takes effect.

Why it matters

This is the California Medicare Administrative Contractor changing what it will and will not cover for two families of molecular tests that hospital laboratories and oncology services order regularly. A retirement and a replacement on consecutive days means the coverage basis for a thrombophilia test ordered on October 11 is different from one ordered on October 12, and any order set, laboratory compendium entry, or medical necessity screen built against L36155 stops matching the policy. Non next generation sequencing targeted panels in oncology are the second exposure, since a panel ordered outside the finalized indications becomes a denial rather than a coverage question after the effective date.

Response type

Implement

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal, California, Hawaii, Nevada

Primary owner

Coding

Affected functions

Coding, Revenue Cycle, Clinical Operations, Compliance, Utilization Management, HIM/CDI

First seen

Aug 30, 2026

Last materially changed

Aug 30, 2026

Why it is still here

Noridian still lists October 12 final-policy implementation and October 11 retirement. Current-week updates contain separate proposals, not a postponement of these dates.

Recommended actionRead L40242, L40222 and the billing and coding articles A60272 and A60239 before October 12, 2026. Map the organization current thrombophilia and targeted panel test menu to the finalized indications, update the laboratory compendium, order sets and medical necessity screening logic, and brief the ordering services. Where a test the organization performs or sends out is no longer covered, decide and document the advance beneficiary notice position before the effective date.

1. Obtain L40242, L40222 and billing and coding articles A60272 and A60239, and record the covered indications and coding requirements for each. Coding · due Sep 11, 2026
2. Map the current thrombophilia and non next generation sequencing targeted panel test menu, in house and send out, against the finalized indications and list every test that loses or changes coverage. Clinical Operations · due Sep 25, 2026
3. Update the laboratory compendium, order sets, and medical necessity screening logic so the change takes effect on October 12, 2026 and the retired L36155 basis stops applying on October 11, 2026. IT · due Oct 5, 2026
4. Decide and document the advance beneficiary notice position for tests that become non covered, and brief the ordering services in writing. Revenue Cycle · due Oct 9, 2026
5. Audit a sample of thrombophilia and targeted panel claims in the first four weeks after the effective date and report the denial rate. Compliance · due Nov 13, 2026

Permalink: #noridian-moldx-lcd-finalization-jurisdiction-e · Development ID GC-2026-0011

CMS proposes a new annual Acute Hospital Care at Home reporting requirement, comments close October 26

What changed

CMS published a notice on August 27, 2026 proposing a new information collection, CMS-10971, the Acute Hospital Care at Home Quantity, Intensity, and Mix of Services data collection tool. Participating hospitals would report annually on the number of clinician visits, food services, and pharmacy services provided to patients in the hospital at home setting. CMS estimates roughly 365 responding hospitals, 13,000 total annual responses, and 13,000 hours of reporting burden. The collection stems from the Consolidated Appropriations Act, 2026, which directs CMS to evaluate care quality and service delivery patterns in hospital at home, and the data is intended for congressional reporting. Comments are due October 26, 2026.

Why it matters

For a hospital in the Acute Hospital Care at Home initiative this is a new annual data obligation with three counts that most programs do not capture as structured fields today: clinician visits, food services, and pharmacy services delivered in the home. Whether those counts can be produced from existing documentation, or require a workflow change, is a question to answer during the comment period rather than after the collection is approved. For a hospital considering the waiver, the reporting burden is now part of the business case.

Response type

Comment

Confidence

High

Applies to

Health systems

Jurisdiction

Federal

Primary owner

Clinical Operations

Affected functions

Clinical Operations, Compliance, Quality, HIM/CDI, Finance, Case Management

First seen

Aug 30, 2026

Last materially changed

Aug 30, 2026

Why it is still here

The official CMS collection notice still sets October 26 for comments and describes annual reporting as a proposal. No superseding in-week notice was identified in the Federal Register review.

Recommended actionConfirm whether the organization participates in the Acute Hospital Care at Home initiative. If it does, ask the program owner whether clinician visit, food service, and pharmacy service counts can be produced from current documentation, name a data owner for each of the three counts, and decide by October 26, 2026 whether to comment on the burden estimate.

Permalink: #cms-acute-hospital-care-at-home-qims-data-collection · Development ID GC-2026-0010

Medi-Cal requires quarterly validation of the public fee for service provider directory beginning October 1, 2026, with Provider Portal Transaction Center access at stake

What changed

DHCS published a Medi-Cal provider notice on August 26, 2026 stating that action must be taken to confirm the accuracy of the Public Fee-For-Service Provider Directory quarterly, in accordance with Section 5123 of the Consolidated Appropriations Act, 2023. Beginning October 1, 2026, Provider Portal administrators must complete all of the survey questions in the Provider Portal Directory within 45 days. In each quarter following, providers must update or validate that the provider directory information is accurate within 45 days. Administrators must indicate whether each service location under their organization is accepting new fee for service patients, managed care patients, or both, and must save the directory after reviewing and answering all survey questions. DHCS states that failure to complete the required quarterly updates will result in all users within the organization losing access to the Provider Portal Transaction Center, and that a user who loses access should contact their Provider Portal administrator to update the directory and restore it. The notice states that the 45 day window opens on October 1, 2026 and does not state a calendar end date for it.

Why it matters

The consequence is disproportionate to the task and lands on the wrong people. One administrator failing to answer a survey removes Provider Portal Transaction Center access for every user in the organization, which is an eligibility, claims and transaction outage rather than a directory problem. The obligation recurs every quarter, so it needs a calendared owner and a named backup rather than a one time assignment, and organizations with many service locations have to answer the accepting new patients question accurately for each one, which is a data question the enrollment team may not own today.

Response type

Implement

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

California

Primary owner

Provider Enrollment

Affected functions

Provider Enrollment, Revenue Cycle, Compliance, IT, Patient Access

First seen

Aug 30, 2026

Last materially changed

Aug 30, 2026

Why it is still here

Current DHCS article confirms that quarterly validation begins October 1 with a 45-day completion window. Retained because the start date is within 30 days and portal access depends on completion.

Recommended actionIdentify every Medi-Cal Provider Portal administrator the organization has and confirm each one knows the obligation starts October 1, 2026. Name a primary and a backup owner per organization identifier, and put the validation on a recurring quarterly calendar rather than treating it as a single task. Before the first submission, confirm with patient access and the service line owners whether each service location is in fact accepting new fee for service patients, managed care patients, or neither, so the directory answer matches practice. Confirm the escalation path if Transaction Center access is lost, since restoring it depends on the administrator completing the directory.

1. Inventory every Medi-Cal Provider Portal organization identifier the organization holds and identify the current administrator for each. Provider Enrollment · due Sep 18, 2026
2. Name a primary and a backup administrator per organization identifier and confirm both can reach the Provider Portal Directory survey. Provider Enrollment · due Sep 25, 2026
3. Confirm with patient access and the service line owners, per service location, whether the location is accepting new fee for service patients, managed care patients, or neither. Patient Access · due Oct 9, 2026
4. Complete and save the first directory validation inside the window that opens October 1, 2026, and record the submission date. This target date sits well inside the 45 day window rather than at its end. Provider Enrollment · due Oct 31, 2026
5. Put the validation on a recurring quarterly calendar with the named owners, and confirm the escalation path if Provider Portal Transaction Center access is lost. Revenue Cycle · due Nov 13, 2026

Permalink: #medi-cal-public-fee-for-service-provider-directory-quarterly-validation · Development ID GC-2026-0015

California challenges Medicaid and CHIP funding restrictions scheduled for October 13

What changed

On September 2, California announced a coalition lawsuit challenging the final federal reimbursement restrictions for pediatric gender-affirming care. The final rule specifies October 13 effectiveness, Medicaid beneficiaries under 18 and separate CHIP beneficiaries under 19, with a limited six-month hormone-therapy transition. Filing the lawsuit does not itself stay the rule.

Why it matters

Payment planning requires distinguishing the final rule, California funding policy and any later court order. This draft has not verified a subsequent injunction.

Response type

Assess

Confidence

Moderate

Applies to

Health systems, Provider networks

Jurisdiction

Federal, California

Primary owner

Legal

Affected functions

Legal, Managed Care, Revenue Cycle, Clinical Operations

Recommended actionLegal and Managed Care should verify the docket and DHCS instructions, map affected funding streams and continuity-of-care needs, and prepare contingent billing instructions. Do not change patient care solely on the lawsuit announcement.

1. Verify court orders and current DHCS payment direction before issuing operating instructions. Legal
2. Identify affected claims and continuity-of-care workflows by funding source. Managed Care
3. Prepare billing changes contingent on operative legal requirements. Revenue Cycle

Permalink: #medicaid-chip-gender-affirming-care-litigation · Development ID GC-2026-0022

OIG identifies $587.7 million in Part D payments involving obsolete prescription labeling

What changed

The September 2 audit found ineligible 2021-2023 payments for five drugs after their brand counterparts switched to over-the-counter availability. OIG recommended CMS issue rejection timeframes; CMS concurred.

Why it matters

Obsolete labeling and reference data can leave drug eligibility controls behind regulatory changes. The audit does not itself establish a new universal rejection deadline.

Response type

Assess

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Managed Care

Affected functions

Managed Care, Compliance, Revenue Cycle

Recommended actionPharmacy and Managed Care owners should assess Rx-to-OTC monitoring, reference-file updates and claims review with counsel, and monitor implementing CMS guidance.

Permalink: #oig-partd-otc-labeling-payments · Development ID GC-2026-0023

OIG flags organ acquisition reimbursement and documentation risks

What changed

OIG's September 3 audit estimated $380 million in payments during 2017-2022 for organs not used in Medicare-covered transplants. It separately recommended recovery of $154,210 for unsupported organs. CMS concurred with that recovery recommendation but did not specifically concur or nonconcur on revising guidance.

Why it matters

The estimate is not a blanket recoupment notice. Transplant centers face a documented conflict between CMS guidance and statutory requirements identified by OIG.

Response type

Assess

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Finance

Affected functions

Finance, Clinical Operations, Compliance, Legal

Recommended actionFinance and transplant operations should trace organ counts to disposition and supporting records, consult counsel on the guidance conflict, and monitor MAC instructions before treating the estimate as an organization-specific liability.

Permalink: #oig-organ-acquisition-cost-reimbursement · Development ID GC-2026-0024

Medi-Cal fee-for-service hospices must use the new attestation portal within five days of election

What changed

DHCS made the Medi-Cal hospice attestation portal mandatory September 1. Fee-for-service hospice providers billing DHCS must submit each hospice election attestation within five calendar days. The former Nintex system closed with no transition period.

Why it matters

Late submission can cause claim denial. The FAQ limits this portal to fee-for-service providers; managed care providers follow their plan procedures. The signed DHCS 8052 informed-consent form remains in the medical record and is not submitted through the portal.

Response type

Implement

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

California

Primary owner

Clinical Operations

Affected functions

Clinical Operations, Revenue Cycle, Provider Enrollment, IT, Compliance

Recommended actionConfirm provider-NPI access immediately. Assign admission staff to submit and retain confirmation within five calendar days of each election; check elections since September 1 for missed submissions and contact DHCS about exceptions or access problems.

1. Confirm access for each fee-for-service hospice NPI and identify any admissions awaiting attestation. Provider Enrollment · due Sep 8, 2026
2. Reconcile September elections to portal confirmations, retain informed consent, and escalate missed five-calendar-day submissions to DHCS. Clinical Operations · due Sep 8, 2026
3. Check submission timeliness and associated claim outcomes during the first month; internal review date is not a DHCS extension. Compliance · due Sep 30, 2026

Permalink: #medi-cal-ffs-hospice-attestation-portal · Development ID GC-2026-0032

AB-220 Medi-Cal: subacute care services

What changed

The official text would prohibit a Medi-Cal managed care plan from requiring a subsequent treatment authorization request upon a patient’s return from a bed hold for acute hospitalization. The bill would authorize the department to impose sanctions on Medi-Cal managed care plans for violations of these provisions, as specified. California Legislative Information lists the latest action on September 9, 2026 as: Enrolled and presented to the Governor at 1 p.m. The current official version is 09/03/26 - Enrolled; status and text were reverified on September 10, 2026 after the issue’s August 30 through September 5 coverage window.

Why it matters

Medi-Cal managed care plans and subacute-care providers may need to change treatment-authorization workflows for returns from acute-hospital bed holds, with sanctions possible for noncompliance.

Response type

Monitor

Confidence

Moderate

Applies to

Health systems, Provider networks

Jurisdiction

California

Primary owner

Utilization Management

Affected functions

Utilization Management, Managed Care, Compliance, Legal, Clinical Operations

Recommended actionMonitor the Governor’s action. If enacted, have Utilization Management and Managed Care test return-from-bed-hold authorization workflows, revise plan and provider instructions, and establish evidence that no prohibited subsequent authorization request is imposed.

Permalink: #ab-220-medi-cal-subacute-care-services-gc-2026-0055 · Development ID GC-2026-0055

AB-280 Health care coverage: provider directories

What changed

The official text would require the Department of Managed Health Care to select a central utility and develop uniform provider directory standards requiring a health care service plan to use the designated central utility to collect, manage, and verify the consistency and completeness of their provider directories. The bill would also require health insurers to use the designated central utility and follow the uniform provider directory standards. California Legislative Information lists the latest action on September 4, 2026 as: Enrolled and presented to the Governor at 4 p.m. The current official version is 09/01/26 - Enrolled; status and text were reverified on September 10, 2026 after the issue’s August 30 through September 5 coverage window.

Why it matters

California plans and insurers may need to migrate provider-directory collection and validation to the state-selected central utility and uniform standards.

Response type

Monitor

Confidence

Moderate

Applies to

Health systems, Provider networks

Jurisdiction

California

Primary owner

Managed Care

Affected functions

Managed Care, Provider Enrollment, IT, Compliance, Legal

Recommended actionMonitor the Governor’s action and the state’s selection of a central utility. If enacted, inventory provider-directory feeds and vendors, assign a migration owner, and compare current validation controls with the final uniform standards.

Permalink: #ab-280-health-care-coverage-provider-directories-gc-2026-0056 · Development ID GC-2026-0056

AB-350 Health care coverage: fluoride treatments

What changed

The official text would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2027, that provides coverage for the application of fluoride varnish as a pediatric oral care benefit to provide coverage without cost sharing for the application of fluoride varnish as medically necessary regardless of whether the service is billed as a dental benefit or as a medical benefit, except as specified. This bill would make the application of fluoride or other appropriate fluoride treatment, as defined by the department, a covered benefit under the Medi-Cal program for children under 21 years of age. California Legislative Information lists the latest action on September 3, 2026 as: Enrolled and presented to the Governor at 4 p.m. The current official version is 08/30/26 - Enrolled; status and text were reverified on September 10, 2026 after the issue’s August 30 through September 5 coverage window.

Why it matters

California plans, insurers, Medi-Cal operations, and pediatric providers may need benefit and claims configuration for medically necessary fluoride treatment without cost sharing.

Response type

Monitor

Confidence

Moderate

Applies to

Health systems, Provider networks

Jurisdiction

California

Primary owner

Managed Care

Affected functions

Managed Care, Revenue Cycle, IT, Compliance, Clinical Operations

Recommended actionMonitor the Governor’s action. If enacted, assign Legal and Compliance to confirm organizational applicability, compare the relevant ab-350 health care coverage: fluoride treatments workflow with the final text, and identify any policy, system, contract, training, or documentation changes before the measure becomes operative.

Permalink: #ab-350-health-care-coverage-fluoride-treatments-gc-2026-0057 · Development ID GC-2026-0057

AB-1682 Health care coverage: scalp cooling

What changed

The official text would require a large group health care service plan contract or health insurance policy that is issued, amended, or renewed on and after January 1, 2027, to provide coverage for scalp cooling, when prescribed by a health care provider to reduce the incidence or severity of alopecia before, during, or after chemotherapy in which alopecia-inducing chemotherapeutic agents are used. The bill would define scalp cooling for these purposes. California Legislative Information lists the latest action on September 3, 2026 as: Enrolled and presented to the Governor at 4 p.m. The current official version is 08/30/26 - Enrolled; status and text were reverified on September 10, 2026 after the issue’s August 30 through September 5 coverage window.

Why it matters

Large-group plans and insurers may need benefit, medical-necessity, authorization, and claims configuration for prescribed scalp cooling used with chemotherapy.

Response type

Monitor

Confidence

Moderate

Applies to

Health systems, Provider networks

Jurisdiction

California

Primary owner

Managed Care

Affected functions

Managed Care, Revenue Cycle, IT, Clinical Operations, Compliance

Recommended actionMonitor the Governor’s action. If enacted, assign Legal and Compliance to confirm organizational applicability, compare the relevant ab-1682 health care coverage: scalp cooling workflow with the final text, and identify any policy, system, contract, training, or documentation changes before the measure becomes operative.

Permalink: #ab-1682-health-care-coverage-scalp-cooling-gc-2026-0064 · Development ID GC-2026-0064

AB-1876 Health care coverage: nondiscrimination

What changed

The official text would prohibit a subscriber, enrollee, policyholder, or insured from being excluded from enrollment or participation in, being denied the benefits of, or being subjected to discrimination by, any health care service plan or health insurer licensed in this state, on the basis of race, color, national origin, age, disability, or sex. The bill would define discrimination on the basis of sex for those purposes to include, among other things, sex characteristics, including intersex traits, pregnancy, and gender identity. California Legislative Information lists the latest action on August 31, 2026 as: Enrolled and presented to the Governor at 4 p.m. The current official version is 08/27/26 - Enrolled; status and text were reverified on September 10, 2026 after the issue’s August 30 through September 5 coverage window.

Why it matters

California plans and insurers may need to test enrollment, benefit, claim, and cost-sharing rules for discrimination on the protected bases stated in the bill.

Response type

Monitor

Confidence

Moderate

Applies to

Health systems, Provider networks

Jurisdiction

California

Primary owner

Compliance

Affected functions

Compliance, Legal, Managed Care, IT, Patient Access

Recommended actionMonitor the Governor’s action. If enacted, assign Legal and Compliance to confirm organizational applicability, compare the relevant ab-1876 health care coverage: nondiscrimination workflow with the final text, and identify any policy, system, contract, training, or documentation changes before the measure becomes operative.

Permalink: #ab-1876-health-care-coverage-nondiscrimination-gc-2026-0068 · Development ID GC-2026-0068

AB-2499 Health care coverage: claims payments

What changed

This bill would, commencing May 26, 2028, require a plan or insurer to accept electronic medical records and supporting documentation necessary to process a claim through a standard electronic submission method, as specified, and would prohibit a plan or insurer from denying, pending, or delaying a claim solely because the plan’s or insurer’s systems are unable to accept documentation that otherwise meets the plan’s or insurer’s requirements. The bill would specify that if a state or federal standard is adopted that is specific to file size, number, or other capacity requirements for claims-related supporting documentation submissions, that standard would apply. California Legislative Information lists the latest action on September 4, 2026 as: Enrolled and presented to the Governor at 4 p.m. The current official version is 09/01/26 - Enrolled; status and text were reverified on September 10, 2026 after the issue’s August 30 through September 5 coverage window.

Why it matters

Plans and insurers may need claims-intake capacity for electronic medical records and supporting documents, including controls that prevent delays caused only by system limitations.

Response type

Monitor

Confidence

Moderate

Applies to

Health systems, Provider networks

Jurisdiction

California

Primary owner

Revenue Cycle

Affected functions

Revenue Cycle, IT, Managed Care, Compliance, Finance

Recommended actionMonitor the Governor’s action and any implementing standards. If enacted, have Revenue Cycle and IT inventory claims-document submission channels, test file-size and capacity limits, and plan changes needed before May 26, 2028.

Permalink: #ab-2499-health-care-coverage-claims-payments-gc-2026-0078 · Development ID GC-2026-0078

AB-2571 Reimbursement for pharmacist services

What changed

The official text would additionally require the rate of reimbursement for advanced pharmacist practitioner services to be no less than 85% of the fee schedule for physician services, including MTM pharmacist services. The bill would, subject to, among other things, federal approval, require advanced pharmacist practitioners to be recognized as health care providers at federally qualified health centers and rural health clinics for reimbursement purposes under the Medi-Cal program. California Legislative Information lists the latest action on September 4, 2026 as: Enrolled and presented to the Governor at 4 p.m. The current official version is 09/01/26 - Enrolled; status and text were reverified on September 10, 2026 after the issue’s August 30 through September 5 coverage window.

Why it matters

Medi-Cal, FQHC, rural-health-clinic, plan, insurer, pharmacy, and contracting workflows may need reimbursement and provider-recognition changes for advanced pharmacist practitioners.

Response type

Monitor

Confidence

Moderate

Applies to

Health systems, Provider networks

Jurisdiction

California

Primary owner

Managed Care

Affected functions

Managed Care, Revenue Cycle, Finance, Provider Enrollment, Compliance

Recommended actionMonitor the Governor’s action and required federal approvals. If enacted, have Managed Care and Revenue Cycle identify affected pharmacist contracts, FQHC and rural-health-clinic billing, fee schedules, and medication-therapy-management payment rules.

Permalink: #ab-2571-reimbursement-for-pharmacist-services-gc-2026-0079 · Development ID GC-2026-0079

October Medicare and Medi-Cal claims updates and Noridian service downtime

What changed

CMS highlighted October MPFS and NCCI updates September 3. DHCS separately announced August 31 that updated NCCI edits apply to Medi-Cal claims received on or after October 1. Noridian announced limited portal, IVR and customer-service availability October 2-4. CMS MM14561 retains October 1 effectiveness and October 5 implementation for SNF consolidated billing.

Why it matters

None of these change a compliance obligation on their own, but each lands in a claims or grouper system on a fixed date, and a missed update shows up as a denial or an underpayment rather than as an error message. Two different dates in the same month is the practical risk here: a release plan built only around October 5 misses the laboratory fee schedule and CLIA edits that take effect on October 1. The clinical laboratory fee schedule and CLIA quarterly update matters more than usual this quarter given the CMS laboratory program integrity actions carried as a P1 in this issue.

Response type

Implement

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal, California

Primary owner

Revenue Cycle

Affected functions

Revenue Cycle, IT, Coding, Finance

Recommended actionConfirm with the claims system owner that the October 1, 2026 clinical laboratory fee schedule and CLIA quarterly update and the October 5, 2026 electronic data interchange and physician fee schedule database updates are each scheduled, and confirm with the home health application owner that the version 07.2.26 grouper download is assigned. Ask for written confirmation after each release rather than assuming it applied. The January 4, 2027 items from the same August 27, 2026 transmittal set are tracked separately and need their own owner. For Medi-Cal, use the claim-received date for October NCCI edits. Plan eligibility inquiries and portal-dependent work around October 2-4. Noridian lists January 4 implementation for its SNF summary, while primary CMS MM14561 says October 5; confirm this discrepancy with the MAC before scheduling that release.

Permalink: #october-2026-medicare-claims-processing-updates · Development ID GC-2026-0012

January 2027 Medicare updates: HCPCS quarterly file download instructions and the annual clotting factor furnishing fee, both implementing January 4, 2027

What changed

Two of the transmittals CMS issued on August 27, 2026 implement on January 4, 2027 rather than in October. R13938CP, change request 14586, gives instructions for downloading the Healthcare Common Procedure Coding System files for the January, April, July and October 2027 quarterly releases, with an effective and implementation date of January 4, 2027. R13937CP, change request 14580, is the annual clotting factor furnishing fee update for 2027, also implementing January 4, 2027.

Why it matters

Both items were issued in the same August 27, 2026 batch as the October 2026 claims processing updates but land a full quarter later, which is how a January item gets absorbed into an October release plan and then missed. The HCPCS download instruction governs how the coding files underneath the 2027 quarterly releases are obtained, so an unassigned owner shows up as a stale code file in January rather than as a failure at the time. The clotting factor furnishing fee is a pricing update that reaches reimbursement for hemophilia products directly.

Response type

Implement

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Revenue Cycle

Affected functions

Revenue Cycle, IT, Coding, Finance

First seen

Aug 30, 2026

Last materially changed

Aug 30, 2026

Why it is still here

Current CMS transmittal pages confirm January 4, 2027 implementation for CR14586 and CR14580. Retained for operational planning; the current-week transmittal index revealed no replacement.

Recommended actionName an owner now for each of the two January 4, 2027 items and put them on the January release calendar rather than the October one. For R13938CP, confirm that whoever loads the quarterly HCPCS files has the 2027 download instructions and a scheduled task for each quarterly release. For R13937CP, confirm that the clotting factor furnishing fee is updated in the pricing file for dates of service on and after the implementation date, and that pharmacy and revenue cycle both know when it changes.

Permalink: #january-2027-medicare-hcpcs-file-and-clotting-factor-updates · Development ID GC-2026-0014

Medicare colorectal biomarker coverage: June 8 effective date, January 4 claims implementation

What changed

CMS released MM14581 on September 2 to explain the August 27 transmittals. NCD 210.3 coverage for qualifying non-invasive biomarker screening is effective June 8, 2026; claims-system implementation is January 4, 2027. Coverage is generally once every three years for asymptomatic, average-risk patients aged 45 through 85 who meet the remaining criteria.

Why it matters

Billing and ordering workflows must distinguish the coverage effective date from the later system implementation date. CMS identifies ColoSense code 0421U and waived deductible and coinsurance, subject to the coverage requirements.

Response type

Implement

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Coding

Affected functions

Coding, Revenue Cycle, Clinical Operations, IT, Quality

First seen

Aug 30, 2026

Last materially changed

Aug 30, 2026

Why it is still here

The September 2 educational article and August 31 MCD updates reaffirm the existing coverage decision and January 4 implementation. Retained for implementation planning; no new policy change is inferred from republication.

Recommended actionValidate test eligibility, patient criteria, counseling, and coding against NCD 210.3 and CR14581. Identify affected June 8 onward claims for possible contractor adjustment: MACs will not search for them automatically. Track January 4 system implementation.

Permalink: #ncd-210-3-colorectal-cancer-non-invasive-biomarker-tests · Development ID GC-2026-0013

CMS refreshes hospice telecommunications recertification reporting guidance

What changed

CMS revised MM14495 on September 2 without substantive changes. The underlying requirement starts January 1, 2027, with January 4 system implementation: report qualifying remote recertification encounters using G0679, revenue code 0657 and hospice bill types 81X or 82X.

Why it matters

This is newly tracked guidance in this briefing, not a new September policy. Incorrect claim combinations can cause returns.

Response type

Validate

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Revenue Cycle

Affected functions

Revenue Cycle, Coding, Clinical Operations, IT

Recommended actionRevenue Cycle should validate hospice claim templates and coding with the current instruction, distinguishing the January 1 effective date from January 4 implementation.

Permalink: #hospice-telecommunications-recertification-coding · Development ID GC-2026-0025

CMS opens comment windows on Medicaid quality and Part D application collections

What changed

The September 2 notice seeks comments by October 2 on Money Follows the Person and Medicaid managed care quality collections. The September 1 notice covers retail drug price surveys, Basic Health Program instruments and 2028 Part D contract applications.

Why it matters

These are information-collection proposals. They do not establish a new provider implementation deadline or themselves award a 2028 contract.

Response type

Comment

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Managed Care

Affected functions

Managed Care, Compliance, Finance

Recommended actionManaged Care and Compliance should review the supporting forms for organizational burden and decide whether to comment. Confirm the separate deadline for the September 1 notice before submitting.

Permalink: #cms-pra-medicaid-quality-partd-applications · Development ID GC-2026-0026

CMS explains January Medicare Secondary Payer adjustment-code processing

What changed

CMS released MM14553 on September 4 for CR14553, issued August 21. The instruction changes Part A secondary-payer claim processing effective January 1, 2027, with January 4 implementation; some adjustment codes process automatically and others require review or denial.

Why it matters

Claim adjustments from the primary payer must flow unchanged from the 835 into the secondary 837. Returned claims may need correction and resubmission.

Response type

Validate

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Revenue Cycle

Affected functions

Revenue Cycle, Coding, IT

Recommended actionRevenue Cycle and IT should validate primary-payer adjustment mapping and returned-claim workflows with their MAC before January implementation.

Permalink: #medicare-secondary-payer-adjustment-code-processing · Development ID GC-2026-0031

Noridian opens three proposed MolDX policies for comments through October 11

What changed

An August 31 Noridian notice lists proposed LCDs DL40435 for renal-carcinoma transcriptional biomarkers, DL40427 for hematologic-malignancy next-generation sequencing, and DL40411 for genome-wide copy-number and structural-variant testing in hematologic neoplasms. Comments are open August 27 through October 11.

Why it matters

Affected laboratories and ordering services can review proposed coverage criteria before finalization. Publication for comment does not create a final coverage policy or a current billing change.

Response type

Comment

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal, California, Hawaii, Nevada

Primary owner

Coding

Affected functions

Coding, Clinical Operations, Revenue Cycle, Compliance

Recommended actionCoding and laboratory leaders should review the three proposed LCDs, assess their test menus, and decide whether to submit evidence-based comments by October 11. Keep this proposal separate from the finalized October MolDX changes.

Permalink: #noridian-moldx-proposed-lcds-october-comments · Development ID GC-2026-0033

CMS adjusts September plan payment user fees

What changed

CMS raised the September 2026 Part D coordination-of-benefits collection to 7.4 cents per member and the MA-PD National Medicare Education Campaign rate to 0.029%. PDP NMEC assessments stopped after the annual limit was reached in August.

Why it matters

Health systems or networks with plan operations need to reconcile the September 1 payment against the final annual fee adjustments. The memo places 2024 medical-loss-ratio remittances in the August payment, under code MLR.

Response type

Validate

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Finance

Affected functions

Finance, Managed Care, Compliance

Recommended actionPlan finance teams should compare September remittances with the revised COB and MA-PD NMEC rates, confirm the PDP exception, and investigate variances through the MAPD Help Desk.

Permalink: #september-marx-plan-user-fee-adjustments · Development ID GC-2026-0045