Medicare & Medicaid, October 18, 2026

CMS transmittal 250, issued and effective October 16, restores State Operations Manual Chapter 5 sections 5300.1, 5300.4 and 5320.3 after their accidental deletion in the preceding publication. The restored survey instructions call for review of relevant facility information and standards, ombudsman contact about similar complaints, and an investigation plan. Surveyors must resolve inconsistent evidence and determine whether the facility failed a requirement and whether corrective practice changes achieved compliance.

Past noncompliance requires evidence that the specific requirement was violated after the exit date of the last standard recertification survey and before the current survey, and that the facility had corrected it and was in substantial compliance at the current survey. A nursing home need not submit a plan of correction for that already-corrected deficiency, although surveyors record corrective actions on Form CMS-2567. Written findings must be reported within 10 working days if the individual waives a hearing, the time to request a hearing expires, or a hearing finds abuse, neglect or misappropriation. Recipients include the individual, the current administrator of the incident facility, the administrator of the individual’s current employer if different, applicable licensing authorities and, for nurse aides, the nurse aide registry. The State retains the specified investigation and hearing information.

CMS made proposed rule CMS-4214-P available on public inspection October 16, with formal publication scheduled for October 20. The proposal implements sections 6219, 6220 and 6224 of the already-enacted Consolidated Appropriations Act, 2026. Its posted DATES section requests comments by December 15 at 5 p.m. Eastern Standard Time. For plan years beginning January 1, 2028, the cost-sharing provision would implement a zero copayment for qualifying generic drugs and section 351(k) biological products for full-benefit dual-eligible individuals with income no greater than 100 percent of the federal poverty level. It does not make every drug free for every low-income Part D enrollee.

For specified MA plans, including network-based plans and private fee-for-service plans meeting access standards wholly or partly through provider contracts, proposed directory verification and enrollee protections apply in CY 2028. Verification generally occurs at least every 90 days, while hospitals and specified facility classes receive annual verification. The proposal includes an unable-to-verify flag and removal of nonparticipating providers within five business days after the organization determines nonparticipation. Otherwise-covered out-of-network care listed as in-network when the appointment was made would receive the lesser of in-network or otherwise-applicable cost sharing, with specified evidence, refund and appeal protections. Directory accuracy analysis begins in 2028, with the first annual report due the first Monday of April 2029. Machine-readable public scores and prominent plan display begin in CY 2029. A contemplated low-enrollment waiver is not an adopted exemption from directory duties.

Part D sponsor and PBM contracts would implement the statutory framework from January 1, 2028. Proposed remuneration rules generally limit compensation to qualifying bona fide service fees and specified exceptions, including qualified incentive payments and manufacturer concessions whose full gross economic value reaches the sponsor under the stated conditions. The fee framework addresses flat-dollar amounts, fair market value, actual itemized services and prohibited ties to drug prices, formulary placement or referral value. It preserves specified pharmacy and wholesaler compensation; it is not a blanket prohibition on every pharmacy margin.

Under proposed section 423.2814, annual PBM reports would be due no later than July 1 beginning in 2028 and generally cover the preceding complete plan year. Disgorgement information instead covers June 1 of the preceding calendar year through May 31 of the current year. Annual reporting addresses drug-level spending and reimbursement, affiliate relationships and retained remuneration, with certification, audit and enforcement provisions. Proposed section 423.2812 separately addresses pricing-guarantee transparency. Do not shift the first report to 2029 merely because contract requirements begin in 2028. Separately, proposed CY 2028 marketing and communications policies would start October 1, 2027. These implementing details remain proposed even where the underlying statute already supplies a future duty or date.

Treasury and the IRS published proposed premium tax credit regulations October 15, implementing statutory amendments while proposing detailed eligibility, verification and reconciliation rules. Written comments and hearing outlines are due November 30. A hearing is scheduled December 8 at 10 a.m. Eastern Time but may be canceled if no outlines are received. The proposal distinguishes provisions implementing statutory changes for taxable years after 2025 from later administrative requirements. It does not make every proposed Exchange procedure immediately operative on publication.

Income verification and Exchange failure-to-reconcile coverage-month requirements generally apply to taxable years beginning after December 31, 2027, while the proposal assigns a separate October 15, 2026 plan-year applicability date to its income-only special-enrollment provision. For taxable years after December 31, 2026, a person assessed by an Exchange as ineligible for Medicaid solely for failing the community-engagement requirement would be treated as eligible for minimum essential coverage starting on the later of the first day of the first full month the person otherwise would receive Medicaid benefits, or the first day of the first calendar month after the Exchange assessment or determination, affecting premium tax credit eligibility. The provision stops applying when that sole basis for ineligibility no longer exists. It is not a rule that every Medicaid denial eliminates Marketplace subsidies, and the proposal does not change employer Forms 1095-B or 1095-C reporting.

HHS announced October 14, 2026 that the Secretary had determined the previous day that public health emergencies exist in Florida and Alabama because of Hurricane Isaias. The actual October 13 determination, issued under section 319 of the Public Health Service Act, states that the emergencies have existed since October 6 in Florida and October 7 in Alabama. The signed determination does not print an expiration date. The announcement describes the combination of presidential declarations and the Secretary’s determination as allowing HHS to authorize temporary waivers and modifications for providers and suppliers serving Medicare, Medicaid and CHIP beneficiaries in covered emergency areas.

The announcement also describes ASPR’s deployment and assessment support and use of emPOWER data to identify areas with beneficiaries dependent on electricity-powered medical equipment and essential services. It does not supply the operative text of individual provider waivers or establish that every requirement has been suspended. Specific relief therefore requires checking the applicable waiver instrument, affected location, service dates, conditions and duration before relying on it.

HHS’s October 14, 2026 announcement reports that CMS identified 189,000 people in 2026 who had subsidized Federal Marketplace coverage and either duplicate Medicare, Medicaid or CHIP coverage or a deceased record. CMS says it acted to remove the affected subsidies and projects approximately $1.5 billion in potential taxpayer savings over the next year. Those figures describe reported program-integrity activity and estimated future savings, rather than a recovered-dollar amount or a finding that every affected individual committed fraud. The announcement does not establish a new provider filing deadline.

According to HHS, people flagged for subsidized Marketplace coverage alongside Medicaid or Medicare are contacted and given 30 days to dispute duplicate coverage before subsidies end. After that period they may still appeal or show impending Medicaid or CHIP coverage loss to regain subsidies. For deceased-record matches, the individual or estate is contacted and given 30 days to dispute the record; absent a successful dispute, both the Marketplace subsidy and plan end. These are distinct consequences. The release describes existing data-matching and response processes; it is not a new rule making every duplicate-coverage flag an immediate coverage termination.

DHCS’s October 16 notice establishes new NPI requirements for Medi-Cal long-term-care service dates on or after February 1, 2027. Claim forms, including UB-04, must include both an attending and a referring provider NPI on initial, discharge and transfer claims. An attending NPI is mandatory on every claim, including ongoing claims; the notice does not state that both NPIs are required on every ongoing claim.

The submitted attending and referring identifiers must be 10-digit, valid Type 1 individual NPIs on the National Plan and Provider Enumeration System file for the billed service date. DHCS says claims will be denied if an applicable identifier is missing, invalid, inactive, absent from that file or the wrong NPI type. The notice says revised provider-manual sections will follow in a future Medi-Cal Update; those future sections were not established by this announcement.

DHCS announced on October 16 that the English Notice Regarding Standards for Medi-Cal Eligibility, DHCS 7077, had been revised and posted on its Forms: DHCS 7000 page. The notice explains eligibility provisions to people residing in, or expecting to enter, a long-term-care facility. Providers should begin using the revised English form when English is appropriate; the announcement says threshold-language translations were being prepared and that a future Medi-Cal Update would announce their availability.

The announcement attributes the revision to asset limits reinstated retroactively to January 1, 2026 for most non-MAGI Medi-Cal programs, including LTC. It states a $130,000 limit for one person, increasing by $65,000 for each additional household member up to a household size of ten. It expressly notes that different or higher limits may apply, including under spousal impoverishment protections. This is an October form-update announcement about an earlier policy date, rather than a new October 16 start date for the asset policy.

DHCS’s October 16 notice says DME and clinical-laboratory providers must include a 10-digit ordering-provider NPI on applicable Medi-Cal claim types effective February 1, 2027. The identifier must be an individual Type 1 NPI on NPPES, rather than a group NPI, and valid for the billed service date. DHCS identifies missing, invalid, inactive, absent or wrong-type identifiers as grounds for denial. The notice separately requires the ordering NPI to be actively enrolled as a participating Medi-Cal provider by May 1, 2027.

DME claims for HCPCS E1340, K0739, K0740, V5014, X2996 and X2998 with replacement modifier RP or RB are exempt from the ordering-provider-number requirement described in the notice. Where a referring NPI is also required, both ordering and referring identifiers belong in their respective fields. DHCS points to PAVE for enrollment and says updated manual sections will follow. The February claim-field requirement and May participation requirement are distinct phases; the notice does not move both duties to May.

DHCS announced on October 15 that the Medi-Cal DRG program had updated the Solventum Mapper to version 44.0 for service dates on or after October 1, 2026, incorporating new ICD-10-CM and ICD-10-PCS codes. It warns that claims using new codes for admissions on or after October 1 could have been denied if the payment-system update was incomplete when the claim was submitted. The notice identifies RAD 67 for an unmatched primary/secondary surgical procedure, 9124 for a missing or invalid diagnosis and 9962 when a valid APR-DRG could not be determined, and instructs providers receiving one of these denials to resubmit.

The notice also says present-on-admission indicators should be included to prevent adjudication delays. It describes an Erroneous Payment Correction to reprocess claims with service dates on or after the billing-policy effective date that were appropriately submitted under the article’s guidance but reimbursed incorrectly before the system changes were implemented. Providers may alternatively correct and resubmit previous claims under the manual’s CIF Submission and Timeliness Instructions. The announced correction concerns erroneous reimbursement; it should not replace the separate instruction to resubmit the listed denials.

DHCS posted an October 15 draft proposing to remove the requirement for Behavioral Health Plans and their network providers to administer the Pediatric Symptom Checklist (PSC-35) and submit the corresponding data through the Functional Assessment Screening Tool (FAST) platform. The official 2026 BHIN index requests feedback by November 3, 2026. The three-page file is watermarked DRAFT, identifies itself on the first page as BHIN 26-XXX and leaves the effective date as XXX; its later running headers use different notice numbers. This is a consultation proposal, not an operative repeal or a confirmed date for stopping current assessment and reporting workflows.

The draft links the proposed change to alignment around the Integrated Practice Child and Adolescent Needs and Strengths (IP-CANS) tool. It describes the Early Childhood module as meeting the functional-assessment requirement for children ages zero through five, while further IP-CANS requirements are referenced through notice-number placeholders. It would supersede MHSUDS IN 17-052 and 18-048 only in part. A footnote preserves the option for plans or providers to continue PSC-35 voluntarily to support care, with attention to benefits, burdens and avoiding duplicative assessment and data collection. Those qualifications distinguish removing a mandatory PSC-35/FAST requirement from banning the tool or eliminating the broader functional-assessment process.

DHCS’s official BHIN index lists an October 13 Phase II CANS alignment notice. The linked file’s front page identifies ACL 26-74/BHIN 26-032, and its main policy text sets January 1, 2027 for Phase II changes by DHCS and CDSS. It describes Behavioral Health Plans using IP-CANS for children and youth ages zero through 20, including the Early Childhood module for ages zero through five and the trauma/adverse-childhood-experiences domain across ages. A prior CANS-50 assessment does not require replacement until the next administration cadence is met. Completion is collaborative; a Child and Family Team is required when a child or youth is involved in child welfare or juvenile probation and the assessment is led by a placing agency or by a BHP acting on behalf of a placing agency under a formal agreement, or when High Fidelity Wraparound services are received. A team is recommended rather than universally required in other cases.

The main text describes a transition for administrators who completed another CANS training and/or held active CANS certification before the notice’s effective date. It separately states that administrators who are new to CANS or do not hold current certification must complete the specified training and obtain IP-CANS certification before administration; confirm the applicable transition category before relying on it. Existing eligible administrators may continue during transition but must meet the new training and certification requirements by December 31, 2028, with annual recertification. Behavioral Health Plans are directed to submit reports by March 15 in 2027, 2028 and 2029, including a director/designee attestation, prior-calendar-year training and certification information, noncompliance counts and remediation steps. Shared data-exchange information remains forthcoming. However, the running headers use ACL 26-32 while appendices retain BHIN 26-0XX and October 8 dates; the last rendered page repeats printed Page 13. These unresolved version conflicts mean the timetable must be confirmed against the authoritative issued notice before implementation decisions rely on this file.

The October 16, 2026 California Notice Register publishes the Department of Developmental Services’ denial of Gateway Transportation’s September 1 petition for a regional minimum reimbursement standard for Service Code 875 Transportation Company services. Gateway proposed the greater of the otherwise applicable DDS rate or 90 percent of an upper-tier regional benchmark based on certain Service Code 895 providers in the same regional-center area. DDS rejected that alternative methodology, explaining that the statutory rate-reform framework does not authorize substituting Service Code 895 reimbursement for Service Code 875 rates. The published decision does not adopt the requested floor.

DDS identifies Welfare and Institutions Code section 4519.10 as the existing framework for its Service Code 875 rate methodology and states that rate-reform regulations must be adopted by December 31, 2030. The decision preserves stakeholder participation in that rulemaking and notes a right to request reconsideration within 60 days under Government Code section 11340.7(c). The reproduced letter does not show its issuance date, so the October 16 publication date is not used to calculate a reconsideration deadline. Regional transportation-cost concerns remain a policy issue rather than an approved higher reimbursement entitlement.