Medicare & Medicaid Sweep, November 4, 2026

View the illustration with CMS increases the dialysis base rate and changes low-volume, home-training and quality policies for 2027 →

Scope: The December 31 attestation applies to eligible facilities seeking the 2027 low-volume adjustment. Do not display it as an unconditional deadline; facility-specific pediatric eligibility and final specifications require confirmation.

Summary

CMS set the 2027 Medicare dialysis base rate at $297.52 per treatment and revised low-volume, pediatric, home-training and quality policies. Eligible facilities seeking the 2027 low-volume adjustment face a December 31, 2026 attestation date; individual payment effects depend on facility circumstances.

What changed

CMS finalized the calendar year (CY) 2027 End-Stage Renal Disease (ESRD) Prospective Payment System rule, setting the unadjusted bundled payment base rate at $297.52 per treatment, up from $281.71 in 2026. The retained rule states that the regulations take effect January 1, 2027; later corrections and current legal status remain to be verified. The base rate is a starting point: patient and facility adjustments, geographic wages, applicable training and outlier payments, and other payment rules mean that a particular facility's payment may differ. CMS estimates that Medicare ESRD PPS payments across facilities will rise 2.7% in CY 2027 compared with estimated 2026 payments; that aggregate projection is not a guarantee of the same increase for each provider or of an increase in all-payer revenue.

The $15.81 base-rate increase includes $12.85 for phosphate binders as CMS completes their incorporation into the bundle. CMS applies a 1.00260 wage-index budget-neutrality factor, a combined 0.98864 factor for low-volume, pediatric and training changes, and a 1.9% productivity-adjusted market-basket update. The 1.9% update is the 2.9% market-basket increase less a 1.0 percentage-point productivity adjustment. The resulting calculation is (($281.71 + $12.85) × 1.00260 × 0.98864) × 1.019 = $297.52. The binder addition becomes part of the base rate and is subject to annual PPS updates; CMS states it is not separately repriced each year based on binder prices or utilization.

Low-volume eligibility and the near-term deadline. CMS expands the low-volume payment adjustment (LVPA) to six tiers for eligible facilities furnishing fewer than 8,000 treatments, with larger factors at lower volumes. The final factors range from 1.368 for 0–2,999 treatments to 1.050 for 7,000–7,999 treatments. The rule's eligibility text requires fewer than 8,000 total treatments in each of the three preceding cost-reporting years, subject to specified aggregation and exceptions; the fact sheet describes the tier using median treatments over those years. Eligibility and tier selection are therefore separate checks, and volume alone does not establish eligibility. For payment year 2027, an eligible facility seeking the adjustment must provide its attestation by December 31, 2026.

Pediatric and home dialysis. The temporary pediatric ESRD add-on ends December 31, 2026. CMS revises pediatric case-mix adjusters and extends LVPA to pediatric treatments at facilities meeting the applicable requirements, including a pediatric exception to the common-ownership aggregation rule. Facility-specific eligibility for that exception depends on the rule's applicable conditions. CMS also increases the home and self-dialysis training add-on from $95.60 to $138.00, permits it during the ESRD onset period, and reduces the onset factor from 1.327 to 1.311 to account for overlap. These payment changes are budget neutral; a facility should model its own patient mix rather than assume that every component increases its net payment.

Acute kidney injury is included. For dialysis furnished by ESRD facilities to beneficiaries with acute kidney injury (AKI), CMS sets the CY 2027 base payment at $297.52 before the applicable geographic adjustment and applies the $138 training add-on where applicable. Starting in CY 2027, ESRD facilities must furnish medically necessary phosphate binders to AKI beneficiaries receiving renal dialysis services under the facility's direct care. CMS also explains that the existing ESRD facility conditions for coverage apply to AKI patients using home modalities, including training and backup dialysis support; sending a patient to an emergency department or discharging them to find another provider does not itself satisfy that backup-support obligation.

Quality measurement starts before the payment year. Beginning with payment year (PY) 2029, CMS replaces the hypercalcemia reporting measure with an adult chronic hyperphosphatemia clinical measure; removes the medication reconciliation and healthcare-personnel COVID-19 vaccination reporting measures from the ESRD Quality Incentive Program (QIP); updates the National Healthcare Safety Network bloodstream-infection measure; and changes the domain and measure weights. Removing those measures from the QIP does not by itself eliminate other clinical, documentation, infection-control or regulatory obligations. CMS discusses a possible patient life-goals measure in response to a request for information; it did not adopt that measure in this rule.

In its discussion of the proposal, CMS described monthly EQRS reporting during CY 2027 for PY 2029; final operational reporting specifications and deadlines still need verification. The hyperphosphatemia measure uses a six-month rolling average of pre-dialysis phosphorus values, using the first reported value in the current month and up to five preceding consecutive months. Among the measure's criteria, it excludes patients with fewer than 91 days of ESRD treatment and includes a patient for a facility only when the patient remains there for the full reporting month and preceding five months; other nutritional exclusions also apply. In that proposal discussion, CMS's example for January 2027 uses August 2026 through January 2027 values, making historical data availability relevant before the new performance period starts. Verify the final technical specifications and reporting schedule before implementing a local workflow.

Why it matters

The Medicare ESRD PPS aggregate estimate is not a facility-specific payment guarantee. Eligibility for the low-volume adjustment and its tier are separate checks, and the PY 2029 quality measure depends on historical data and facility continuity. The final technical specifications and operational guidance remain to be checked.

Suggested action

Suggested operational actions, not additional legal duties. Revenue-cycle and finance teams should model the rate and geographic adjustment against actual treatment mix; separately assess LVPA eligibility, ownership aggregation, cost-report history and tier, and prepare the attestation before the specified deadline if seeking payment. Pharmacy, clinical and contracting teams should assess binder procurement, supply and transitions for eligible ESRD and AKI patients. Home-dialysis leaders should review training capacity, billing configuration and backup-support arrangements. Quality and laboratory teams should map the first pre-dialysis monthly phosphorus value into EQRS workflows, check continuity and exclusions, and validate the historical data needed for the rolling measure. Track CMS and Medicare Administrative Contractor implementation guidance, and confirm that any existing requirements remain in force before discontinuing a prior QIP reporting process. These are proposed planning steps, not a claim that CMS mandated each local action.

Sources

• CMS-1846-F, CY 2027 ESRD PPS final rule public-inspection PDF, Centers for Medicare & Medicaid Services. | Published Federal Register rule

• Calendar Year (CY) 2027 ESRD PPS Final Rule (CMS-1846-F), Centers for Medicare & Medicaid Services; source date 2026-10-28.

View the illustration with CMS revises coverage criteria for autologous transplant in multiple myeloma →

Scope: The decision retains specific disease and staging conditions. Intervening prior NCD versions, claims implementation and later status remain open.

Summary

CMS revised national coverage criteria for a single autologous transplant in certain patients with active multiple myeloma, subject to specified disease and staging requirements.

What changed

CMS posted its final reconsideration of the multiple-myeloma provision of national coverage determination 110.23 on October 28, 2026, and states that the revised criteria are effective that day. The decision covers a single autologous stem-cell transplant when the patient has active multiple myeloma under the specified International Myeloma Working Group definition and meets an accepted staging requirement. Active disease requires at least 10% monoclonal bone marrow plasma cells or a biopsy-proven bony or extramedullary plasmacytoma, together with at least one SLiM/CRAB myeloma-defining event.

The staging requirement permits any stage under the International Staging System or its revisions, or stage II or III under the Durie-Salmon system. CMS framed reconsideration around prognostic staging tools and outcomes after autologous transplantation. The decision does not cover every transplant or every myeloma diagnosis automatically. Its appendix separately identifies tandem autologous transplantation for multiple myeloma among nationally non-covered indications. Earlier NCD language and claim-processing instructions require further comparison.

Why it matters

Transplant, oncology, utilization review and revenue-cycle teams may need to align coverage documentation with the revised national language. A staging label alone does not satisfy every criterion; individual clinical suitability and other applicable conditions remain separate questions.

Suggested action

Suggested internal action: clinical and coverage owners should compare the new NCD language with transplant authorization and documentation workflows, identify affected cases and staging evidence, and check CMS and Medicare Administrative Contractor implementation instructions before changing billing or authorization procedures. No new CMS deadline for these planning steps is asserted.

Sources

• Autologous Stem Cell Transplantation for Multiple Myeloma (CAG-00444R2), Decision Memo, Centers for Medicare & Medicaid Services; source date 2026-10-28.

View the illustration with Exchange eligibility verification proposal →

HHS and CMS proposed changes to Exchange eligibility verification, annual redeterminations and enrollment timing in a rule published October 27. The executive summary describes circumstances in which an Exchange generally could not authorize advance premium tax credits and cost-sharing reductions for an otherwise eligible applicant while specified eligibility inconsistencies remain unresolved, subject to a stated family-size special-enrollment exception; other inconsistencies are treated differently. Comments must be received by November 27, 2026, for assured consideration. This is a proposal, not a final rule; the full applicability schedule and all exceptions remain to be reviewed.

The executive summary identifies specified inconsistencies involving citizenship or lawful presence, residence, other minimum essential coverage, household income, family size or eligible noncitizen status. It describes an exception for certain family-size special-enrollment circumstances and different treatment for other data-matching issues; it does not say every inconsistency ends all coverage or assistance.

For annual redetermination of premium tax credit and cost-sharing reduction eligibility, the summary proposes that the enrollee or application filer provide or confirm specified information between August 1 and December 31 of the preceding year, with the Exchange attempting verification. A separate proposed pre-open-enrollment verification period would begin August 1 and end when open enrollment starts; consumers could choose whether to use it. The summary also describes an option to pend plan selection until applicable assistance eligibility is determined, with conditional effective-date and retroactive-enrollment rules.

Why it matters: If finalized, the proposals could affect verification workflows, consumer communications, pending plan selections and the timing of financial assistance. Applicability depends on the final provisions, the Exchange and individual circumstances.

Suggested action: Exchange, issuer and enrollment-assistance teams can compare current verification, notice and escalation processes with the complete proposal, including its definitions, exceptions and applicability dates. These are planning steps, not present implementation duties.

Proposed rule

View the illustration with SNF quality refresh and January preview →

Scope: The October refresh and the earlier preview notice have different dates and purposes; current preview status and final source checks remain open.

CMS says its October skilled nursing facility quality-data refresh is available, with older Medicare Spending Per Beneficiary data remaining in place. CMS had already announced the spending-data delay in July. Separately, an October 15 notice identifies November 14 for review of January 2027 preview reports, subject to CMS's review and data-correction rules.

In its October 28 update, CMS says the SNF Quality Reporting Program refresh is available on Medicare.gov's compare tool and the Provider Data Catalog. Assessment-based measures reflect SNF data from the first through fourth quarters of 2025; other measures use different periods. CMS says the spending measure, based on fourth-quarter 2022 through third-quarter 2024 data, would not update in October because of delayed claims data. It anticipates releasing updated provider scores based on fourth-quarter 2023 through third-quarter 2025 data in the January 2027 refresh. The January release is a stated plan, not an observed completion.

CMS had already described that same delay and planned January update in its July 15 provider-preview notice. The October 28 development is the announced availability of the October refresh and a renewed explanation, not a newly announced delay.

CMS's October 15 entry says January 2027 provider preview reports are available and identifies November 14, 2026 for facilities to review their data. Providers may request CMS review during the preview period if they believe their displayed scores are inaccurate. CMS says assessment updates submitted after the final submission deadline will not appear in the preview reports or on Medicare.gov; corrections it agrees to make appear in a subsequent quarterly release. Facilities should verify the actual report, current deadline, submission deadlines and CMS review procedure rather than assume the preview reopens data submission. No new payment duty or rate is established.

CMS SNF QRP Public Reporting

View the illustration with Reminder: DMEPOS order and prior-authorization lists →

The July 30 notice set October 28, 2026 as the general implementation date for its DMEPOS list updates. It adds 22 specified HCPCS codes to the face-to-face encounter and written-order-before-delivery list and separately adds eight specified codes to the required prior-authorization list. Prior authorization for specified upper-limb orthoses is phased, starting October 28 in California, Florida, Michigan and New York; later phases are January 26 and April 26, 2027. The date’s arrival does not itself establish actual implementation; exact codes, exceptions and later amendments remain open.

Suggested owner and action: DMEPOS suppliers, enrollment and billing teams can check the applicable HCPCS codes, geographic phases, exceptions and current instructions before changing ordering or delivery workflows.

July Federal Register notice

View the illustration with 2027 SNF consolidated-billing update →

On October 26, 2026, CMS issued Transmittal 14003 (CR 14658) for the 2027 annual skilled nursing facility consolidated-billing update. It states a January 1, 2027 effective date and January 4 implementation date, and directs contractors to use the new A/B MAC (A) and (B) SNF coding files for applicable 2027 dates of service. The transmittal alone does not establish individual code changes or actual file postings.

Suggested owner and action: SNF billing and revenue-cycle teams can monitor CMS publication of the applicable 2027 files and compare relevant billing edits with the transmittal; the notice does not itself identify individual code changes.

CMS Transmittal 14003

View the illustration with 2027 physician fee-schedule database instructions →

On October 26, 2026, CMS issued Transmittal 14026 (CR 14618), rescinding and replacing R13960 and consolidating contractor instructions for the January, April, July and October 2027 Medicare Physician Fee Schedule database releases. Contractors must be prepared to retrieve up to three replacement payment datasets per release if corrections are required. For the April, July and October updates, contractors must give providers 30 days’ notice before implementing changes and adjust claims brought to their attention, without searching files to retract payment or retroactively pay already paid claims. This is not a provider filing deadline and does not establish that any replacement files were issued.

Suggested owner and action: Revenue-cycle and contracting teams can track contractor notices and review any corrections relevant to their claims, following the applicable contractor process for claims brought to its attention.

CMS Transmittal 14026

View the illustration with DHCS behavioral-health state plan proposal →

Scope: This reports a proposed amendment and notice, not an approved or operative requirement.

On October 29, 2026, California DHCS issued a revised public notice for proposed Alternative Benefit Plan State Plan Amendment 26-0034. DHCS says the proposal would clarify behavioral health treatment policy, including utilization-management controls, and support program integrity. The revised notice applies only to 26-0034; DHCS says the June 30 notice for Medicaid State Plan Amendment 26-0033 remains unchanged. The notice states a July 1, 2026 proposed effective date subject to CMS approval; it does not establish approval or identify the specific utilization controls.

Suggested owner and action: Behavioral-health policy and contracting teams can monitor CMS’s disposition and obtain the actual amendment and utilization-management provisions before changing contracts or workflows.

DHCS revised public notice

View the illustration with Reminder: Home health QRP reconsideration →

CMS’s October 23 entry says noncompliance notices for agencies determined noncompliant with CY 2027 annual payment update reporting requirements were placed in iQIES My Reports on October 23. An agency receiving a noncompliance letter may request reconsideration by 11:59 p.m. November 23, 2026, following its notice and CMS instructions. The cited page passage does not specify a time zone; the actual notice and instructions should be checked. This is a conditional reminder, not an in-week new announcement or a finding against any named agency.

Suggested owner and action: Home-health quality and reimbursement teams can check iQIES for any notice addressed to their agency and, if a letter was received, assess the stated grounds, deadline and instructions for reconsideration.

CMS home health QRP announcements

View the illustration with CMS publishes Medicaid program-integrity framework →

Scope: CMS says this framework organizes new and existing guidance for states, managed-care plans and law enforcement; it does not itself create new regulatory requirements.

CMS released its Medicaid and CHIP Program Integrity Pillars on October 26, as reported in its October 29 MLN Connects newsletter. The six areas are claims editing and data analytics; provider enrollment; targeted reviews and audits; managed-care oversight; investigations and referrals; and administrative actions. CMS describes a framework for program oversight, not a new universal provider deadline.

Suggested owner and action: Medicaid managed-care, compliance and program-integrity teams can compare the relevant guidance with their existing enrollment, claims review, audit and escalation processes and assess applicability to their roles.

CMS program-integrity framework | October 29 MLN Connects | CMS program-integrity overview

View the illustration with CMS seeks input on future fraud-defense contracts →

CMS’s October 29 MLN Connects newsletter describes a request for information on a proposed approach to Medicare and Medicaid fraud investigations, with a greater CMS role in directing investigations. CMS’s fraud-defense page and the newsletter list November 4, 2026, at 11 a.m. Eastern (16:00 UTC) as the response deadline. That stated deadline has passed. The request is for planning; CMS says it will not award a contract as a result. The underlying SAM notice and amendments remained unreadable during the current check, so no later amendment or extension was verified and detailed instructions remain unverified.

Suggested owner and action: Organizations interested in the contractor model can confirm the current request, amendments and response deadline before deciding whether to respond. Participation is voluntary and does not itself change current investigation requirements.

October 29 MLN Connects | CMS fraud-defense information

On October 29, CMS said California had committed its full fiscal-year 2026 rural-health funding, more than $233 million, to programs across the state. This updates the same funding story as prior finding GC-2026-0329, which reported a $233,639,308.47 first-budget-period award and $219,133,495 put to work through July 31 based on earlier state-reported obligations. The October announcement should not be added to that award as separate new funding or treated as proof of disbursement to particular providers.

Suggested owner and action: Rural-health strategy, finance and compliance teams can compare the current state program and eligibility terms with their organization’s plans and track subsequent reporting; the announcement does not itself establish a provider application or payment.

CMS California announcement | Prior obligated-funds report

Review qualification: The planned expansion is voluntary and prospective; no completed application process or agreement is asserted.

CMS said October 27 that it plans to broaden its voluntary Cell and Gene Therapy Access Model beyond its initial sickle-cell focus. The agency expects to release a request for manufacturer applications in the coming months and describes negotiating outcomes-based agreements on behalf of participating state Medicaid programs.

Applicability and suggested action: State Medicaid, specialty pharmacy and payer contracting teams can monitor the future manufacturer application and participation terms and assess potential relevance; no agreement or coverage expansion for additional therapies is established by the announcement.

CMS Innovation Insight

CMS opened nominations October 30 for a technical expert panel on a developing process to validate nursing homes’ Minimum Data Set information. The agency says nominations close November 30, 2026, and the panel will consider potential effects on quality scoring, payment and public reporting. Nomination is voluntary; no final methodology or new reporting or payment duty is established.

Applicability and suggested action: Nursing-home quality and MDS leaders interested in voluntary participation can review the panel’s nomination requirements and submit by November 30 if they choose; no reporting duty arises from a nomination.

CMS panel listing

View the illustration with Prior-duty update: Noridian A57079 R7 →

Noridian’s October 29 Jurisdiction E Part B notice reports an A57079 revision effective November 1, 2026. It says the Group 1 medical-necessity asterisk explanation specifies diagnosis M72.0 for CPT 20527 and 26341. This R7 notice follows the R6 conformity update described in our October 11 finding; the notice does not determine an individual claim’s medical necessity or payment. The current complete article and earlier R6 table were not reviewed here.

Applicability and suggested action: Affected Jurisdiction E billing and clinical teams can compare the revised notice with the current article and their applicable documentation and medical-necessity rules before changing claim edits.

Noridian R7 notice

View the illustration with Prior-duty update: Noridian A60217 R2 →

Noridian’s October 29 Jurisdiction E notice says revision R2 to billing and coding article A60217 adds 0665U to Group 1 for specified liver-disease biomarker testing, effective October 1, 2026. Noridian cautions that a code’s inclusion does not automatically mean coverage. This is a potential update to the October 11 finding GC-2026-0134; compare the current article and LCD with the earlier version before treating it as a material change. The current complete article, LCD and registry details remain open.

Applicability and suggested action: Affected molecular diagnostics and billing teams can compare the article, associated LCD and any applicable registry requirements before changing workflows; a listed code alone does not establish coverage.

Noridian A60217 notice