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Medicare & Medicaid Sweep, November 8, 2026

Published November 8, 2026Coverage November 1–7, 2026, Pacific

Read this edition’s coverage limitations ↓

Executive triage

This week. CMS released its CY 2027 payment rules. The outpatient rule (published November 6, effective January 1, 2027) sets a 2.3 percent fee schedule increase factor (CMS estimates a 1.7 percent increase in outpatient payments overall, and hospitals that fail the quality reporting requirements are paid on a reduced conversion factor); cuts payment for separately payable 340B-acquired drugs, other than pass-through drugs, vaccines and non-opioid pain relief drugs with status indicator K1, to ASP minus 28 percent at hospitals not exempt from the cut; requires a modifier on every separately paid drug line; raises the 340B remedy offset from 0.5 to 2 percent, except for new providers with a CCN effective January 2, 2018 or later; pays imaging without contrast in the listed payment groups, billed with modifier PO at excepted off-campus departments, at the physician fee schedule equivalent rate (currently 40 percent of the outpatient amount), with rural sole community hospitals exempt; and removes 637 more services from the inpatient only list. The physician fee schedule rule (issued November 4, published November 9, after the window) lowers both conversion factors and adds a claims-data duty for providers and suppliers that are 340B covered entities, for covered Part D drugs billed to Medicare Part D and dispensed under a 340B discount by the entity or its contractors; its facts here come from CMS fact sheets, not the rule text. For California: CMS filed an emergency paperwork request to bring the home health Review Choice Demonstration to the state (providers in demonstration states may choose pre-claim or post-payment review), with comments due November 16, and Medi-Cal members with Unsatisfactory Immigration Status move from managed care to fee-for-service on January 1, 2027; a Medi-Cal clinic notice says Dental Managed Care continues in Los Angeles and Sacramento counties and that Federally Qualified Health Centers and Rural Health Clinics submit dental claims for these members as before. Federal Medicaid guidance and the HPMS memo archive showed nothing new for the window; the HPMS archive had not yet posted the week. Found after the window closed and reported now: CDPH's letter of November 9, 2026 says it will send Medi-Cal revalidation intent letters to health care facilities, and that failure to respond to the intent letter within 35 calendar days results in termination and deactivation from Medi-Cal.

Primary stories

CMS issues CY 2027 Physician Fee Schedule final rule (CMS-1848-F): conversion factors fall, same-day E/M and 0-day global payment cut, new 340B Part D claims repository duty

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View the illustration with CMS issues CY 2027 Physician Fee Schedule final rule (CMS-1848-F): conversion factors fall, same-day E/M and 0-day global payment cut, new 340B Part D claims repository duty →

What changed

On November 4, 2026, CMS released the CY 2027 Physician Fee Schedule (PFS) final rule, effective January 1, 2027; the rule was published in the Federal Register on November 9, 2026. CMS projects the qualifying alternative payment model (APM) conversion factor at $32.95 and the non-qualifying APM conversion factor at $32.63, decreases of 1.83% and 2.31% from CY 2026, after the one-year 2.50% CY 2026 statutory increase lapses. CMS finalized a payment reduction when a separately identifiable office/outpatient evaluation and management (E/M) visit is furnished on the same day as a 0-day global procedure, paying the most expensive service at 100% and the others at 80%, narrower than proposed. The proposal covered a visit furnished by the same physician (or a physician in the same practice) on the same day as a 0-, 10- or 90-day global procedure; the fact sheet says CMS made two significant modifications to it and does not restate the same-physician condition for the final policy. G2211 becomes modifier B1 (16% increase to the E/M code), and a voluntary B2 modifier (32%) is created for practitioners in a Shared Savings Program Accountable Care Organization (ACO) and Participant Providers in a Long-term Enhanced ACO Design (LEAD) Model ACO. The fact sheet says providers and suppliers that are 340B covered entities must submit claim data for covered Part D drugs billed to Medicare Part D and dispensed by the entity or its contractors (such as contract pharmacies) under a 340B discount to the Medicare Part D Claims Data 340B Repository, beginning with claims with dates of service on or after January 1, 2027, with the first quarterly submission deadline moved to September 30, 2027.

Background

Since 1992, Medicare has paid for the services of physicians and other billing professionals under the PFS, and the relative value units applied to each service become payment rates through a conversion factor. Since CY 2026 the statute has required two conversion factors, one for qualifying APM participants and one for physicians and practitioners who are not qualifying participants, and CY 2026 rates carried a one-year 2.50% conversion factor increase that does not continue into CY 2027.

Who this affects

Physicians and practitioners billed under the PFS, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), independent labs paid under the Clinical Laboratory Fee Schedule (CLFS), 340B covered entities that dispense Part D drugs (including through contract pharmacies), Shared Savings Program ACOs.

Why it matters

Inference: professional-fee revenue projections for 2027 need the lower conversion factors; charge masters and coding edits need the B1/B2 modifiers in place of G2211; same-day E/M plus 0-day global billing by the same physician or a physician in the same practice (the condition in the proposal) will pay at 80% for the lesser service; 340B programs need a process and data feed for Part D claims dispensed by the entity or its contract pharmacies starting with January 1, 2027 dates of service; remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) programs that use contracted staff have until January 1, 2029 before the employed-clinical-staff requirement applies.

Required actions

  • Apply CY 2027 PFS payment and coding policies to services on or after 2027-01-01 (rule effective 2027-01-01), except where the rule sets a later start, such as the employed-clinical-staff requirement for remote monitoring services, delayed to January 1, 2029.
  • Providers and suppliers that are 340B covered entities: submit the required claim data for covered Part D drugs billed to Medicare Part D and dispensed by the entity or its contractors under a 340B discount to the Medicare Part D Claims Data 340B Repository, for claims with dates of service on or after 2027-01-01; first quarterly submission for 2027-01-01 to 2027-03-31 dates of service due 2027-09-30.

Recommended action

  • Model 2027 professional revenue at the final conversion factors.
  • Update E/M modifier logic (B1, B2) and same-day 0-day global edits before January claims.
  • Assign a 340B program owner to scope Part D repository data elements against the full rule text and contract-pharmacy data access.
  • ACOs applying for 2027-01-01: decide any track change before the Phase 2 window closes 2026-11-17 at noon ET.

Implementation playbook

  1. Load the CY 2027 conversion factors ($32.95 for qualifying APM participants, $32.63 for others) into the 2027 professional-fee budget and contract models. Owner: Finance and Medical Group Operations. Due: 2026-12-15.
  2. Update charge capture and claim edits for the reduced payment when an office or outpatient E/M visit is billed on the same day as a 0-day global procedure by the same physician or a physician in the same practice (confirm the condition in the rule text), and for modifier B1 in place of G2211 (B2 only for practitioners in a Shared Savings Program ACO and Participant Providers in a LEAD Model ACO). Owner: Revenue Cycle and Coding. Due: 2026-12-31, ahead of the January 1, 2027 effective date.
  3. 340B covered entities: name an owner for submitting Part D claim data to the 340B Repository, confirm the data feed for dates of service from January 1, 2027, and calendar the first quarterly submission. Owner: Pharmacy 340B program and Compliance. Due: process ready 2027-01-01; first submission 2027-09-30 (the fact sheet's date).
  4. Shared Savings Program applicants for a January 1, 2027 start: decide on any track change. Owner: ACO leadership. Due: 2026-11-17, noon Eastern (the fact sheet's window).
  5. Read the published rule (91 FR 70992) for provisions the fact sheets do not cover, and check the points in this entry against the rule text. Owner: Compliance. Due: 2026-12-01.

Scope and timing

Authority status
Final
Responsible owner
Revenue Cycle (professional billing); Pharmacy/340B program for the repository duty
Publication date
2026-11-09 (Federal Register, 91 FR 70992; after the window). CMS fact sheet and press release dated 2026-11-04; placed on public inspection 2026-11-04
Effective date
2027-01-01
Compliance date
2027-09-30: first mandatory quarterly submission to the 340B Repository, covering dates of service in the first quarter of 2027
Implementation date
Requirement for employed clinical staff in remote monitoring services begins with CY 2029
Other dates
Shared Savings Program applicants for a 2027-01-01 start may change track during the Phase 2 window, 2026-11-12 to 2026-11-17 at noon Eastern

Not established

The 2,468-page rule text was not retained (size); every fact comes from the CMS fact sheets plus the Federal Register application programming interface (API) record. Exact 340B Repository data elements, the hospital outpatient interaction with the 0-day global policy, and RHC/FQHC details were not verified in the rule text. The fact sheet's opening line reads 'On 2026' with no day.

Sources

Medicare to pay ASP minus 28 percent for separately payable 340B-acquired drugs at non-exempt hospitals from January 1, 2027 (pass-through drugs, vaccines and non-opioid pain relief drugs excluded); every separately paid OPPS drug line must carry modifier JG, TB or ND

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View the illustration with Medicare to pay ASP minus 28 percent for separately payable 340B-acquired drugs at non-exempt hospitals from January 1, 2027 (pass-through drugs, vaccines and non-opioid pain relief drugs excluded); every separately paid OPPS drug line must carry modifier JG, TB or ND →

What changed

Based on its 2026 drug acquisition cost survey, CMS finalized payment for separately payable 340B-acquired drugs, other than drugs with pass-through payment status, vaccines and non-opioid pain relief drugs with status indicator K1, at average sales price (ASP) minus 28 percent for CY 2027 and subsequent years, choosing its alternative proposal over the proposed ASP minus 33.4 percent; separately payable non-340B drugs are generally still paid at ASP plus 6 percent. The cut is budget neutral within the Hospital Outpatient Prospective Payment System (OPPS), raising non-drug payment rates by an estimated 7.50 percent, and also applies (not budget neutral) to 340B drugs furnished in non-excepted off-campus provider-based departments (PBDs). Rural sole community hospitals (SCHs), children's hospitals and prospective payment system (PPS)-exempt cancer hospitals are exempt, and no add-on payment was adopted. From January 1, 2027, every separately paid OPPS drug claim line must carry JG (a separately payable drug acquired under the 340B Program at a hospital subject to the cut; it triggers the reduction), TB (informational; the rule's summary lists it for 340B-acquired drugs at exempt hospitals and for pass-through and non-opioid pain relief drugs, while the detailed discussion describes TB as marking drugs bought with a 340B discount) or ND (not acquired under 340B; the proposal used placeholder XX). How a pass-through or non-opioid pain relief drug bought without a 340B discount is reported should be confirmed against the rule's final modifier table and CMS claims instructions. CMS estimates OPPS 340B drug payments fall about $4.65 billion and total 340B drug spending about $5.45 billion in CY 2027.

Background

From January 1, 2018 through September 27, 2022, CMS generally paid ASP minus 22.5 percent for certain separately payable drugs acquired through the 340B Program; on June 15, 2022, the Supreme Court held that because HHS had not previously conducted a survey of hospitals' acquisition costs, CMS could not vary the payment rates for outpatient prescription drugs by hospital group. CMS paid 340B-acquired drugs at the statutory default rate (generally ASP plus 6 percent) for CY 2023 through CY 2026, and surveyed hospital drug acquisition costs from January 1 through April 7, 2026.

Who this affects

All hospitals paid under the OPPS, including excepted and non-excepted off-campus provider-based departments, for separately payable drugs. Payment cut applies to 340B covered entity hospitals; rural SCHs, children's hospitals and PPS-exempt cancer hospitals are exempt from the cut and report the informational modifier TB on separately payable drugs bought with a 340B discount (ND on drugs not acquired under 340B). Critical Access Hospitals (CAHs) and Rural Emergency Hospitals (REHs) are outside the OPPS.

Why it matters

This is a claim-level compliance duty for every OPPS hospital, not only 340B participants: non-340B hospitals must append ND to separately paid drug lines from January 1, 2027. Inference: 340B hospitals need line-level split-billing data (340B versus non-340B purchase) in the pharmacy and billing systems by January 1, 2027. Inference: modifier errors could produce overpayments (missing JG) or claim edits; inference: 340B hospitals face a large drug revenue cut partly offset by the 7.50 percent non-drug increase, while non-340B hospitals gain. The rule also amends 42 CFR 427.303(b)(1)(iv) so successor 340B modifiers are used to exclude 340B units from Part B inflation rebates.

Required actions

  • From January 1, 2027, report modifier JG on the same claim line as the drug HCPCS code for 340B-acquired separately payable drugs to which the payment reduction applies (non-exempt OPPS hospitals; the reduction does not reach pass-through drugs, vaccines or non-opioid pain relief drugs with status indicator K1)
  • From January 1, 2027, report modifier TB as the rule's final modifier table directs: the summary lists it for 340B-acquired drugs at rural SCHs, children's hospitals and PPS-exempt cancer hospitals and for pass-through and non-opioid pain relief drugs, and the detailed discussion ties TB to drugs bought with a 340B discount
  • From January 1, 2027, report modifier ND for all separately paid drugs not acquired through the 340B Program (all OPPS hospitals, including excepted and non-excepted off-campus PBDs)

Recommended action

  • Map 340B accumulator or split-billing data to claim lines and test JG/TB/ND logic before January 1, 2027
  • Audit the first months of 2027 drug claims for modifier completeness
  • Model the net effect of the drug cut and the non-drug budget neutrality increase on CY 2027 revenue

Implementation playbook

  1. Confirm the hospital's status under the 340B payment policy (subject to the reduction, or an exempt rural sole community hospital, children's hospital or PPS-exempt cancer hospital), which together with the drug's own status (pass-through, for example) decides between modifiers JG and TB. Owner: Reimbursement. Due: 2026-11-30.
  2. Build and test the claim-line modifier logic so that every separately paid drug line carries JG, TB or ND, using the rule's final modifier table. Owner: Revenue Cycle, Pharmacy and IT. Due: testing complete 2026-12-15; live for dates of service from 2027-01-01 (the rule's date).
  3. Reconcile 340B accumulator and split-billing data so that 340B-acquired drugs are identified correctly at the claim line. Owner: Pharmacy 340B program. Due: 2026-12-15.
  4. Model the effect of ASP minus 28 percent on 340B drug revenue against the estimated 7.50 percent increase to non-drug payments, and update the 2027 budget. Owner: Finance. Due: 2026-12-15.
  5. Check for CMS claims instructions implementing the modifiers. Owner: Compliance. Due: 2026-12-01, then weekly through January 2027.

Scope and timing

Authority status
Final
Responsible owner
Pharmacy / 340B Program (primary); Revenue Cycle; Compliance; Finance
Publication date
2026-11-06
Effective date
2027-01-01
Compliance date
2027-01-01 (modifier reporting on separately paid drug claims)
Other dates
Hospital acquisition cost survey conducted 2026-01-01 through 2026-04-07

Not established

Final modifier table (Table 75 successor) is an image and was not retrieved; modifier descriptors for ND are known only from the placeholder description. Litigation risk not assessed (no court source retrieved). Non-excepted PBD budget neutrality statement is from the proposal text that was finalized as proposed. CMS guidance or a transmittal implementing the modifiers was not searched.

Sources

CMS seeks emergency clearance to expand the home health Review Choice Demonstration to California

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View the illustration with CMS seeks emergency clearance to expand the home health Review Choice Demonstration to California →

What changed

On November 2, CMS published an emergency Paperwork Reduction Act notice for a revision of the CMS-10599 information collection for the Review Choice Demonstration for Home Health Services, stating that approval is essential so the demonstration is expanded to California within the specified timeframe. The notice says the demonstration already operates in Illinois, Ohio, North Carolina, Florida and Texas, and that providers in demonstration states may choose 100 percent pre-claim review or 100 percent post-payment review until they reach a target affirmation or claim approval rate. A November 4 correction removed one sentence from the notice and states that the option referenced in that language is no longer part of the information collection request. Comments are due November 16, 2026, and the correction states the comment period is unchanged.

Background

The Review Choice Demonstration for Home Health Services uses either pre-claim or post-payment review to make sure Medicare payments for home health services are appropriate; CMS has implemented it in Illinois, Ohio, North Carolina, Florida and Texas, with the option to expand to other states in the Palmetto/JM jurisdiction. Under the Paperwork Reduction Act, federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor.

Who this affects

Medicare-certified home health agencies in California, including hospital-based and health-system-owned agencies, and the Medicare contractors that would review their claims.

Why it matters

Inference: if OMB approves the collection and CMS expands the demonstration, California home health agencies would have to choose a review option and submit documentation to the Medicare contractor before or after claims, which affects intake documentation, billing holds and cash flow. Inference: the removed sentence appears to be the one describing the option to skip review and take a 25 percent payment reduction, so that opt-out may not be available in the revised collection; confirm against CMS operational materials. The notice gives no California start date.

Recommended action

  • Home health and revenue-cycle leaders: decide by 2026-11-16 whether to comment on the burden estimates (comments due November 16, 2026).
  • Monitor CMS and the home health Medicare Administrative Contractor (MAC) for the California start date and the choice-selection process; prepare documentation workflows for pre-claim review.
  • Check CMS announcements for the California expansion.

Implementation playbook

  1. Decide whether to comment on the information collection. Owner: Home Health leadership. Due: 2026-11-16 (the notice's date).
  2. Assess documentation readiness for pre-claim review: intake, face-to-face and plan-of-care documentation, and billing holds. Owner: Home Health clinical leadership and Revenue Cycle. Due: 2026-12-15.
  3. Choose a review option when CMS opens selection. Owner: Home Health leadership. Due: when CMS announces it; a CMS page gives billing periods beginning on or after 2027-01-18, pending approval.
  4. Check weekly for CMS and Medicare contractor instructions for California. Owner: Compliance. Due: weekly until the start date is confirmed.

Scope and timing

Authority status
Other (emergency Paperwork Reduction Act information collection notice, with a correction; not a rule)
Responsible owner
Revenue Cycle (home health), with Compliance
Publication date
2026-11-02
Comment deadline
2026-11-16
Other dates
Correction published 2026-11-04 (FR Doc. 2026-22494); California start date not stated

Not established

The notice states no California start date, no MAC and no selection deadline. Which sentence the correction removed is identified by its first and last words only; the match to the 25 percent reduction sentence is an inference from the text. OMB action on the emergency request not checked. govinfo PDFs not retrieved (the full text from the Federal Register application programming interface (API) was used).

Sources

CMS says the home health Review Choice Demonstration expands to California for billing periods from January 18, 2027, pending paperwork approval

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What changed

CMS says it is expanding the Review Choice Demonstration for Home Health Services to California for billing periods beginning on or after January 18, 2027, pending approval of revisions to Paperwork Reduction Act (PRA) package CMS-10599. The posting date of that statement was not established. Read it with the emergency paperwork notice CMS published for the same expansion, reported separately in this edition.

Background

The demonstration uses either pre-claim or post-payment review to make sure Medicare payments for home health services are appropriate. The CMS statement says the California expansion will follow the established processes of the demonstration currently operational in Illinois, Ohio, Texas, North Carolina, Florida, and Oklahoma. CMS's emergency paperwork notice for the same expansion lists Illinois, Ohio, North Carolina, Florida and Texas, without Oklahoma.

Who this affects

California home health agencies, including hospital-based agencies.

Why it matters

Inference: if the expansion goes ahead, California home health agencies (HHAs) would come under the demonstration's review options (pre-claim review or the alternatives) for billing periods beginning on or after January 18, 2027. CMS's statement makes that date conditional on approval of the paperwork package and gives no date by which an agency must choose an option.

Scope and timing

Authority status
Announced
Responsible owner
Home Health / Revenue Cycle
Implementation date
2027-01-18 (billing periods beginning on or after; pending PRA approval)

Not established

Announcement date, operational guide and Palmetto/contractor instructions not retrieved.

Sources

Noridian A57079 R7 (tendon, ligament and ganglion cyst injections) now in effect

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What changed

The R7 revision took effect on November 1, 2026. The CMS Medicare Coverage Database now shows A57079 at revision effective date 11/01/2026, with R7 the latest entry in the revision history; R6 (conformity with Local Coverage Determination (LCD) L40265) also carries a revision effective date of 11/01/2026. The R7 notice's summary of changes carries the instruction to use M72.0 for CPT codes 20527 and 26341; the earlier revision's text was not compared.

Background

Billing and coding article A57079 gives billing and coding guidance to be used with its associated local coverage determination, and applies under Noridian's Part A contract covering all of California as well as its Part B contracts. The R6 revision, effective the same day as R7, made conforming changes reflecting the policy in LCD L40265, Peripheral Nerve Injections and Procedures for Chronic Pain.

Who this affects

Jurisdiction E (California) Part A/B billers of CPT 20527 and 26341.

Why it matters

What 'in effect' means: from its November 1, 2026 effective date, the current article (R7, which also contains the R6 conformity changes) is the version to code against; the article as revised carries the diagnosis-pairing instruction. Inference: a claim edit built on an earlier revision should be checked against R7. The notice does not decide any claim's medical necessity. Inference: claims for these codes with November dates of service that lack the paired diagnosis are exposed to denial.

Recommended 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 (published article).
  • Inference: confirm that claim edits for CPT 20527 and 26341 with dates of service on or after 2026-11-01 reflect R7, and spot-check early November claims.

Scope and timing

Authority status
Effective
Responsible owner
Coding and Revenue Cycle (Jurisdiction E billing); affected: clinical documentation
Publication date
2026-10-29
Effective date
2026-11-01

Not established

LCD L40265 itself not reviewed.

Earlier article: November 4, 2026 edition →

Sources

CY 2027 Home Health PPS final rule (CMS-1844-F) expands the grounds for retroactive Medicare enrollment revocations, across provider types; the printed effective date for those provisions predates the rule

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What changed

On November 4, 2026, CMS issued the CY 2027 Home Health Prospective Payment System (PPS) final rule, published November 9, 2026 at 91 FR 72022. Beyond home health payment, the published rule says it adds grounds for denying or revoking a provider's or supplier's Medicare enrollment and expands the reasons for which CMS can apply a retroactive effective date to a revocation; the CMS fact sheet words this as a policy to make all revocation grounds retroactive and says most of the enrollment provisions apply to all provider types. Home health agencies, hospices and suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) with certain changes in majority ownership must reenroll as new providers. CMS estimates aggregate home health payments increase 2.4% ($415 million) for CY 2027. The published Dates section states that, with the exception of the home health payment and quality provisions and the regulatory changes at 42 CFR 484.245, "these regulations are effective on January 4, 2026", a date before the rule was issued; the Federal Register record listed no correction on November 10, 2026. Until CMS corrects it, the effective date of the enrollment provisions is unresolved.

Background

CMS updates Medicare payment policies for home health agencies every year through this rule. Under current regulations, certain Medicare enrollment revocations take effect prospectively, 30 days after CMS or its contractor mails notice of the revocation, while others take effect retroactively to the date the provider's noncompliance began.

Who this affects

All Medicare-enrolled providers and suppliers (enrollment provisions); hospital-based or affiliated home health agencies, hospices and DMEPOS suppliers; home infusion suppliers.

Why it matters

Inference: once the enrollment provisions take effect (their effective date is unresolved; see the dates line), a revocation of a hospital, practice or affiliated agency could reach back to the date the noncompliance began, raising overpayment exposure; enrollment compliance (revalidations, ownership and managing-employee reporting, license status of owners in other states) becomes more consequential.

Required actions

  • Hospice, home health agency and DMEPOS supplier owners: reenroll as a new provider and undergo a survey or accreditation after certain changes in majority ownership. The date from which this applies is unresolved (see the dates line).

Recommended action

  • Review enrollment records in the Provider Enrollment, Chain, and Ownership System (PECOS) for owners and managing employees, including out-of-state license or program sanctions.
  • Brief compliance and legal on retroactive revocation exposure for affiliated agencies and practices.

Scope and timing

Authority status
Final
Responsible owner
Compliance (provider enrollment); Revenue Cycle
Publication date
2026-11-09 (Federal Register, 91 FR 72022; after the window). CMS fact sheet and press release dated 2026-11-04
Effective date
Home health payment and quality provisions and the 42 CFR 484.245 changes: 2027-01-01. Durable medical equipment (DME) infusion pump benefit expansion: 2027-04-01. All other provisions, including enrollment: the published rule prints January 4, 2026, which predates the rule; unresolved

Not established

The enrollment provisions' regulatory text (42 CFR 424.535 and related sections) was not read line by line; this entry quotes the rule's own summary and the fact sheet. The effective date printed for those provisions cannot be right and the Federal Register record listed no correction when it was retrieved on November 10, 2026. Home health payment details beyond the aggregate estimate were not worked up.

Sources

CMS issues State Operations Manual Transmittal 251: revised CAH rural and distance evaluation guidance, new-hospital re-evaluation, decennial reviews from 2033

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What changed

CMS issued State Operations Manual (Pub. 100-07) Transmittal 251 on November 4, 2026, effective and implemented the same day, revising section 2256A on critical access hospital (CAH) verification criteria. The guidance adds guidance on confirming necessary provider status (including types of evidence the CAH must supply), and directs CMS Locations to review existing CAHs' location and distance compliance when a new acute-care hospital is certified nearby. An affected CAH generally gets one year to reclassify as rural, convert to a hospital or rural emergency hospital, or face termination. Beginning in CY 2033 all existing CAHs will be evaluated every ten years.

Background

Under 42 CFR 485.610, every CAH, including necessary provider CAHs, must be located in a rural area or be treated as rural, and must meet one of three minimum driving-distance requirements: more than a 35-mile drive from any hospital or other CAH; more than a 15-mile drive in mountainous terrain or in areas with only secondary roads; or, for a CAH the State designated as a necessary provider before January 1, 2006, no minimum distance. The State Operations Manual gives two qualifications: the proximity of Indian Health Service (IHS) or Tribal hospitals or CAHs and other hospitals or CAHs to each other is not considered, and a CAH on an island that is entirely surrounded by water, has no other hospital or CAH and is not accessible by any roads is considered to meet the distance requirements.

Who this affects

Critical access hospitals, including necessary provider CAHs, and hospitals considering CAH conversion.

Why it matters

Inference: CAHs that rely on necessary provider designation should confirm they hold documentation of necessary provider designation made before January 1, 2006 and monitor new acute-care hospital certifications within their distance thresholds.

Required actions

  • No new deadline for all CAHs. A CAH that relies on necessary provider status is responsible for supplying evidence of that designation when CMS evaluates its distance status; if CMS cannot confirm the designation, the CAH may send supplementary evidence to the CMS Location within 60 days of the date of the CMS letter saying the distance requirements have not been met.

Recommended action

  • CAHs relying on necessary provider status: assemble the pre-2006 state designation evidence now.
  • Track new acute-care hospital certifications within a 35-mile drive (a 15-mile drive in mountainous terrain or areas with only secondary roads).

Scope and timing

Authority status
Guidance
Responsible owner
Regulatory Compliance (CAH)
Publication date
2026-11-04 (issued)
Effective date
2026-11-04
Implementation date
2026-11-04
Other dates
Decennial evaluations of all existing CAHs begin in CY 2033

Not established

No Quality Safety & Oversight (QSO) memo accompanied it in the QSO memo index (nearest related memo QSO-26-15-CAH, posted 2026-08-21). The Cutting Administrative Requirements for Excellence in Patient Care (CARE) proposed rule (CMS-3484-P) separately proposes CAH distance changes; the interaction was not analyzed.

Sources

Medi-Cal: members with Unsatisfactory Immigration Status move from managed care to fee-for-service on January 1, 2027; clinic billing rules posted

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View the illustration with Medi-Cal: members with Unsatisfactory Immigration Status move from managed care to fee-for-service on January 1, 2027; clinic billing rules posted →

What changed

On November 6, 2026 the Medi-Cal provider site published billing and reimbursement policy for Federally Qualified Health Centers and Rural Health Clinics serving members with Unsatisfactory Immigration Status, who move from Medi-Cal managed care plans to the fee-for-service delivery system effective January 1, 2027. The notice says the transition does not change a member's eligibility, and that members keep full-scope coverage through state funding if they renew on time. From January 1, 2027 these clinics must submit claims directly to the Medi-Cal fiscal intermediary (the notice says there is no change in how they submit dental claims) and will receive the Prospective Payment System rate for eligible visits; claims for a managed care plan differential (wrap) rate for services on or after that date will be denied. Clinics already enrolled in Medi-Cal need no additional enrollment. In the same week the site published a notice of change on Treatment Authorization Requests for these members (November 2) and a fee-for-service provider toolkit for the transition (November 6).

Background

These members have been enrolled in Medi-Cal managed care plans. The notice says federal guidance from CMS states that federal Medicaid funding for emergency services for these members is only available for services actually delivered and cannot be provided through managed care capitation or other risk-based arrangements.

Who this affects

Every Medi-Cal provider that serves members with Unsatisfactory Immigration Status (UIS): hospitals and their clinics, Federally Qualified Health Centers and Rural Health Clinics in particular, and patient access, authorization and billing teams.

Why it matters

Inference: on January 1, 2027 a defined group of patients changes payer path overnight. Clinics must verify each member's eligibility and delivery system assignment, and an October 30 notice (not opened) says providers must follow specific Treatment Authorization Request procedures to transition care already approved by a plan. Inference: authorizations for these members will follow the fee-for-service Treatment Authorization Request process. For clinics, the notice says claims for a managed care plan differential (wrap) rate will be denied for services on or after that date. Inference: hospitals outside the clinic rules are affected through authorizations and claim routing; the hospital-specific notices were not read for this entry.

Required actions

  • Federally Qualified Health Centers and Rural Health Clinics: verify each member's Medi-Cal eligibility and delivery system assignment in the Automated Eligibility Verification System.
  • Federally Qualified Health Centers and Rural Health Clinics: effective January 1, 2027, submit claims for these members, other than dental claims, directly to the Medi-Cal fiscal intermediary; the notice says there is no change in how these clinics submit dental claims. The notice says Medi-Cal policy requires the appropriate billing code set on all claims, including CPT and HCPCS codes on the informational lines, modifiers and valid diagnosis codes.

Recommended action

  • Identify affected members now from eligibility data and flag their accounts for the January 1, 2027 change.
  • Have authorization staff complete the Treatment Authorization Request notice of change training named in the November 2 notice and read the October 30 notice on transitioning services already approved by a plan.
  • Stop wrap-rate claims for these members for dates of service on or after January 1, 2027.
  • Read the provider toolkit and the hospital and inpatient notices on the Medi-Cal provider site, which were not opened for this entry.

Implementation playbook

  1. Read the provider toolkit, the notice of change on Treatment Authorization Requests and any hospital or inpatient notice on the Medi-Cal provider site; for this entry, the clinic policy notice and the November 2 announcement of the notice of change on Treatment Authorization Requests were captured; the notice of change itself (BB400PNC), which needs a learning-portal profile, was not opened. Owner: Revenue Cycle and Compliance. Due: 2026-11-21.
  2. Identify affected members from eligibility data and flag their accounts. Owner: Patient Access. Due: 2026-12-01.
  3. Train authorization staff on the fee-for-service Treatment Authorization Request process for these members. Owner: Authorization. Due: 2026-12-15.
  4. Clinics: route claims other than dental claims to the Medi-Cal fiscal intermediary and stop wrap-rate claims for dates of service from 2027-01-01 (the notice's date). Owner: Clinic Billing. Due: 2027-01-01.

Scope and timing

Authority status
Guidance
Responsible owner
Revenue Cycle; Patient Access; Clinic Operations
Publication date
2026-11-06
Effective date
2027-01-01
Other dates
Related notices published 2026-11-02 (notice of change on Treatment Authorization Requests) and 2026-11-06 (provider toolkit)

Not established

Evidence is rendered-text excerpts read in a browser; the Medi-Cal provider pages could not be fetched directly, so these claims rest on the browser capture alone. The clinic notice was read to 2,800 of 4,582 characters; its annual reconciliation section was not read. The toolkit, the notice of change itself (behind a training-portal profile), the October 30 notice and any hospital-specific notice were not opened.

Sources

CMS finalizes CY 2027 OPPS update: 2.3 percent increase factor, $99.970 conversion factor, $7,150 outlier threshold

Medium priorityNew in this editionRead article →

View the illustration with CMS finalizes CY 2027 OPPS update: 2.3 percent increase factor, $99.970 conversion factor, $7,150 outlier threshold →

What changed

CMS published the CY 2027 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) final rule with comment period on November 6, 2026, effective January 1, 2027. The outpatient department (OPD) fee schedule increase factor is 2.3 percent (3.2 percent market basket less a 0.9 percentage point productivity adjustment); the proposal had been 2.4 percent with a 0.8 point adjustment, and the rule says the change reflects more recent data. The final conversion factor is $99.970; hospitals that fail Hospital Outpatient Quality Reporting (OQR) requirements get a reporting ratio of 0.9804 and a reduced conversion factor of $98.011. The outlier fixed-dollar threshold rises from $6,225 (CY 2026) to $7,150 with the 1.75 multiplier unchanged. CMS estimates total CY 2027 OPPS payments of about $114.4 billion and a net 1.7 percent increase from all finalized policies, with urban hospitals up 2.0 percent, rural hospitals up 5.6 percent, major teaching hospitals down 2.0 percent and government-owned hospitals down 1.1 percent.

Background

When the Medicare law was enacted, payment for hospital outpatient services was based on hospital-specific costs; the OPPS replaced that method and was first implemented for services furnished on or after August 1, 2000. Section 1833(t) of the Social Security Act requires CMS to review and update OPPS payment rates every year.

Who this affects

Hospitals paid under the OPPS (general acute care, children's, cancer hospitals) and community mental health centers (CMHCs). Excluded from the OPPS: critical access hospitals (CAHs), Maryland hospitals under its model, Indian Health Service (IHS) hospitals, rural emergency hospitals (REHs) and hospitals outside the 50 States, DC and Puerto Rico.

Why it matters

Revenue cycle and reimbursement teams need to load the January 2027 OPPS rates (Addenda A and B on cms.gov) and model the combined effect of the 2.3 percent update, the 340B drug payment change and its budget neutrality adjustment, the 340B remedy offset and the imaging site-neutral policy (each reported separately in this edition). Inference: hospitals with high outlier volume may see fewer qualifying cases at the $7,150 threshold. Inference: a California hospital's net change will depend heavily on 340B status, teaching status and ownership, so the facility-specific impact file is the right starting point.

Required actions

  • Hospital OQR Program requirements must be met to avoid the 2.0 percentage point reduction (reduced conversion factor $98.011) for CY 2027 payment

Recommended action

  • Download the CY 2027 final rule Facility Specific Impacts file and Addenda A/B from the CMS-1850-FC page and compare to the CY 2026 baseline before January 1, 2027
  • Update contract-modeling tools that reference Medicare OPPS rates (including Medicare Advantage contracts priced off Original Medicare)
  • Confirm the drug packaging threshold ($135 per day) and diagnostic radiopharmaceutical threshold ($635 per day; one paragraph of the rule calls $665 final, which conflicts with the rule's own computation of $635, so confirm against the addenda) in chargemaster and pharmacy billing logic

Implementation playbook

  1. Load the CY 2027 conversion factor ($99.970) and addenda rates into the 2027 budget and contract models. Owner: Finance. Due: 2026-12-15.
  2. Download the facility-specific impact file and compare it with the internal model. Owner: Reimbursement. Due: 2026-12-01.
  3. Confirm Hospital Outpatient Quality Reporting requirements are met, to avoid the 2.0 percentage point reduction. Owner: Quality. Due: 2026-12-31.
  4. Decide whether to comment on the interim ambulatory payment classification (APC) and status indicator assignments. Owner: Revenue Integrity. Due: 2027-01-04 (the date by which comments are assured consideration).

Scope and timing

Authority status
Final
Responsible owner
Revenue Cycle / Reimbursement (primary); Finance; Pharmacy; Quality
Publication date
2026-11-06 (91 FR 70284); CMS fact sheet and press release dated 2026-11-04
Effective date
2027-01-01
Other dates
Approved by the CMS Administrator 2026-10-29; CMS waived the 60-day Congressional Review Act delay; comments received by 2027-01-04 are assured consideration (final rule with comment period)

Not established

Addenda A/B and the facility-specific impact file were not downloaded, so no California hospital-level figures. The govinfo PDF link is from the Federal Register application programming interface (API) record and was not itself retrieved. The impact text cites both section XXVI and XXVII for the impact analysis; not reconciled.

Sources

340B remedy offset rises from 0.5 percent to 2 percent of the OPPS conversion factor for CY 2027, running to an estimated CY 2031

Medium priorityNew in this editionRead article →

What changed

CMS finalized an increase in the annual reduction to the Hospital Outpatient Prospective Payment System (OPPS) conversion factor for non-drug items and services, used to offset the estimated $7.8 billion in additional non-drug payments made to hospitals from CY 2018 through 2022 as a result of the prior 340B payment policy, from 0.5 percent to 2 percent starting in CY 2027. The rule limits the 0.5 percent reduction to CY 2026 and adds a new paragraph (13) for the 2.0 percent reduction, which continues until reductions reach $7.769 billion, estimated to occur in CY 2031. CMS estimates the offset reduces payments to affected providers by $1.6 billion in CY 2027.

Background

Under the 340B payment policy in effect from CY 2018 through September 27, 2022, lower payments to 340B hospitals for drugs were budget neutralized by corresponding increased payments to all hospitals for non-drug items and services from CY 2018 through CY 2022. To comply with a January 10, 2023 district court remand order, CMS issued the Final Remedy rule on November 8, 2023, made one-time lump sum payments to affected 340B hospitals in early 2024, and set a 0.5 percent annual reduction to the conversion factor for non-drug items and services beginning in CY 2026, which it then estimated would reach $7.8 billion in CY 2041.

Who this affects

OPPS hospitals subject to the 340B remedy offset under 42 CFR 419.32(b)(1)(iv)(B); excludes new providers with a CMS Certification Number (CCN) effective date of January 2, 2018, or later.

Why it matters

Affected hospitals take a larger annual reduction to the non-drug conversion factor over a shorter period: CMS estimates the offset will be complete in CY 2031. Inference: budgets and multi-year forecasts built on the 0.5 percent schedule need revision. Inference: Medicare Advantage contracts priced as a percentage of Original Medicare rates will carry the reduction unless contracts say otherwise; CMS says it does not set MA contract prices.

Recommended action

  • Confirm whether the hospital is subject to the offset (CCN effective date before January 2, 2018) and model the 2 percent reduction through CY 2031
  • Review MA contracts that reference Original Medicare OPPS rates

Scope and timing

Authority status
Final
Responsible owner
Finance / Reimbursement
Publication date
2026-11-06
Effective date
2027-01-01
Other dates
Offset continues until cumulative reductions reach $7.769 billion, estimated CY 2031

Not established

CMS had proposed a 3 percent annual reduction for CY 2027 (proposed reduced conversion factor about $99.015) and finalized 2 percent; a 2 percent reduction was proposed but not finalized for CY 2026. The $98.011 figure for remedy-offset providers appears only in a table image (Table 8) and equals the conversion factor for hospitals that fail Hospital Outpatient Quality Reporting requirements; the rule text gives no separate remedy figure. The rule cites $7.769 billion; the summary and fact sheet say $7.8 billion.

Sources

Imaging without contrast at excepted off-campus PBDs moves to the PFS-equivalent rate on January 1, 2027

Medium priorityNew in this editionRead article →

What changed

Using its volume-control authority under section 1833(t)(2)(F), CMS will pay the site-specific Physician Fee Schedule (PFS)-equivalent rate (currently 40 percent of the Hospital Outpatient Prospective Payment System (OPPS) amount) for imaging without contrast services in ambulatory payment classifications (APCs) 5521 through 5524 and composite APCs 8004, 8005 and 8007 when furnished at excepted off-campus provider-based departments (PBDs) billing modifier PO. The policy is not budget neutral and has no phase-in. Rural sole community hospitals are exempt. CMS estimates a $260 million decrease in CY 2027 payments ($190 million Medicare, $70 million beneficiary copayments).

Background

Under section 603 of the Bipartisan Budget Act of 2015, applicable items and services furnished by certain off-campus outpatient departments of a provider on or after January 1, 2017 are, as a general matter, not paid as covered outpatient department services under the OPPS; in most cases CMS pays these nonexcepted departments under the PFS, at a relativity adjuster of 40 percent of the OPPS amount. Excepted departments bill modifier PO and are generally paid the OPPS rate; in its CY 2019 rule CMS adopted a policy to pay them the PFS-equivalent rate for clinic visits, phased in over 2 years (approximately 70 percent of the OPPS rate in CY 2019, then the full PFS-equivalent rate, 60 percent less than the OPPS rate, from CY 2020), and in CY 2026 it finalized a policy addressing drug administration services at excepted departments.

Who this affects

Hospitals with excepted off-campus provider-based departments that bill imaging without contrast with modifier PO; rural sole community hospitals are exempt.

Why it matters

Hospitals with off-campus imaging centers billed as excepted PBDs should expect lower Medicare payment for certain bone density scans, X-rays, ultrasounds, CT scans and MRIs without contrast in those departments. Inference: affects service-line and site-of-care planning and any MA contracts tied to OPPS rates.

Recommended action

  • Identify excepted off-campus PBD imaging volume billed with modifier PO in APCs 5521-5524 and 8004/8005/8007 and model the CY 2027 reduction
  • Confirm PO and PN modifier accuracy by department

Implementation playbook

  1. List excepted off-campus departments that bill with modifier PO and furnish imaging without contrast in APCs 5521 to 5524 or composite APCs 8004, 8005 and 8007, and confirm whether the hospital is an exempt rural sole community hospital. Owner: Reimbursement. Due: 2026-11-30.
  2. Model the revenue effect of payment at the physician fee schedule equivalent rate (currently 40 percent of the outpatient amount) for those services. Owner: Finance. Due: 2026-12-15.
  3. Update expected-reimbursement tables in the billing system. Owner: Revenue Cycle. Due: 2026-12-31, ahead of the January 1, 2027 effective date.

Scope and timing

Authority status
Final
Responsible owner
Finance / Reimbursement; Imaging service line
Publication date
2026-11-06
Effective date
2027-01-01

Not established

HCPCS-level list is in Addendum B (not retrieved). Press release figure of over $9 billion for CY 2027 to CY 2036 not checked against the rule's 10-year estimate.

Sources

CMS removes 637 more services from the inpatient only list and adds at least 619 procedures (618 in the rule summary, plus CPT 64629) to the ASC covered procedures list for CY 2027

Medium priorityNew in this editionRead article →

What changed

In the second year of a three-year phase-out, CMS finalized removal of 637 services from the inpatient only (IPO) list for CY 2027, from the auditory, digestive, endocrine, female genital, hemic and lymphatic, integumentary, male genital, maternity care and delivery, mediastinum and diaphragm, respiratory and urinary families; 1,438 services had remained on the list. The remaining families, which include the neurological and cardiovascular families and solid organ, intestinal and islet cell transplants, are expected to come off for CY 2028. CMS added 618 of the removed procedures to the ambulatory surgical center (ASC) covered procedures list (CPL) plus CPT 64629 at commenters' request. CMS restated that procedures removed from the IPO list since January 1, 2021, are exempt from site-of-service claim denials, initial medical review contractor referrals to Recovery Audit Contractors (RACs) and RAC patient-status reviews until Medicare claims data for a single calendar year show the procedure performed more than 50 percent of the time on an outpatient basis; CMS also noted that the end of each procedure's exemption would be announced through rulemaking, so the threshold alone does not end it. CMS also restated that MA plans must follow the 2-midnight benchmark.

Background

The IPO list, established with the initial implementation of the outpatient prospective payment system in 2000, names procedures that Medicare pays only when furnished in the inpatient hospital setting under Medicare Part A. CMS finalized a 3-year elimination of the list in its CY 2021 rule, halted it in its CY 2022 rule, and in its CY 2026 rule again finalized elimination over three years, beginning by removing 285 mostly musculoskeletal procedures for CY 2026.

Who this affects

Hospitals (inpatient and outpatient surgery, utilization review, case management), ASCs, surgeons; Medicare Advantage interactions with inpatient admission decisions.

Why it matters

Utilization review and case management need updated procedure lists so the physician's inpatient versus outpatient decision is documented for newly removed procedures. Inference: expect more MA plan pressure toward outpatient status for these procedures; CMS treats MA as out of scope but restates the 2-midnight requirement. Chargemaster and scheduling systems need the new ambulatory payment classification (APC) and status indicator assignments.

Recommended action

  • Download the Final Procedures Removed from the IPO List for CY 2027 and Final Additions to the List of ASC Covered Procedures for CY 2027 public use files and update UR screening tools
  • Brief surgeons and UR staff on the 2-midnight review exemption for removed procedures
  • Track MA denials for inpatient admissions involving newly removed procedures

Implementation playbook

  1. Obtain the code-level list of the 637 services and update inpatient-only edits, scheduling rules and authorization logic. Owner: Revenue Integrity and Utilization Management. Due: 2026-12-31, ahead of the January 1, 2027 effective date.
  2. Brief surgeons, physician advisors and case management on patient-status decisions for the removed procedures under the 2-midnight rule. Owner: Utilization Management. Due: 2026-12-31.
  3. Systems that own ambulatory surgical centers: update the covered procedures list. Owner: ASC Operations. Due: 2026-12-31.
  4. Review Medicare Advantage authorization and status practices against CMS's restatement that plans must follow the 2-midnight benchmark. Owner: Managed Care. Due: 2027-01-31.

Scope and timing

Authority status
Final
Responsible owner
Utilization Review / Case Management (primary); Revenue Cycle; Perioperative Services
Publication date
2026-11-06
Effective date
2027-01-01
Other dates
Remaining IPO services expected to be removed for CY 2028 (third and final phase)

Not established

Code-level IPO and ASC CPL lists not retrieved. ASC CPL removals (for example CPT 0967T) and G0681/G0683 additions noted in the text but not worked up. The 619 in the title is the rule summary's 618 plus CPT 64629; the rule also finalizes adding G0681 and G0683, so this entry does not state a complete total.

Sources

Eight more botulinum toxin injection codes need Medicare OPD prior authorization for dates of service on or after July 1, 2027

Medium priorityNew in this editionRead article →

What changed

CMS finalized adding eight botulinum toxin injection codes to the existing Botulinum Toxin Injections category of the hospital outpatient department (OPD) prior authorization process (42 CFR 419.83), for services on or after July 1, 2027. Table 102 lists CPT 64611, 64616, 64617, 64642, 64644, 64646 and 64647 and HCPCS J0589. CMS cited a 42.8 percent rise in claims for these codes from 2017 to 2024. Bladder injections are not among the added codes. CMS says it intends to provide education and implementation guidance well in advance of the July 1, 2027 effective date.

Background

CMS established the prior authorization process for certain hospital OPD services in its CY 2020 hospital outpatient payment rule; the first service categories, required for service dates on or after July 1, 2020, were blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation. Cervical fusion with disc removal and implanted spinal neurostimulators were added from July 1, 2021, and facet joint interventions from July 1, 2023.

Who this affects

Hospital outpatient departments paid under the Hospital Outpatient Prospective Payment System (OPPS) that furnish the listed chemodenervation services.

Why it matters

Hospital OPDs need prior authorization request workflows for the departments that perform these codes, with requests generally reviewed within 7 calendar days (2 business days for expedited review when a delay could seriously jeopardize the beneficiary's life, health, or ability to regain maximum function). Inference: CMS describes prior authorization as a way to confirm Medicare payment requirements are met before services are furnished and claims are submitted, so OPD claims for these codes without prior authorization on or after July 1, 2027 are at payment risk; the claim consequence is not stated in the rule text read.

Required actions

  • Obtain prior authorization for the eight listed codes for dates of service on or after July 1, 2027 (hospital outpatient departments), unless the provider holds the exemption the process gives qualifying providers that demonstrate a high level of compliance.

Recommended action

  • Inventory OPD volume for the eight codes and assign a prior-authorization owner before Q2 2027
  • Watch for CMS operational guide updates and Medicare Administrative Contractor instructions

Implementation playbook

  1. Identify the departments that perform the eight listed codes and their volumes. Owner: Revenue Cycle with the performing service lines. Due: 2027-03-31.
  2. Build the prior authorization workflow for those codes with the Medicare contractor, using CMS's implementation guidance when it issues. Owner: Patient Access. Due: 2027-06-01.
  3. Go live for dates of service on or after 2027-07-01 (the rule's date). Owner: Patient Access and Revenue Cycle.
  4. Check monthly for CMS education and implementation guidance. Owner: Compliance. Due: monthly until 2027-07-01.

Scope and timing

Authority status
Final
Responsible owner
Revenue Cycle / Patient Access (prior authorization); Clinical departments
Publication date
2026-11-06
Effective date
2027-01-01
Operative date
2027-07-01 (dates of service)
Compliance date
2027-07-01

Not established

J0589 appears only in the Table 102 image (the text names seven CPT codes). Regulatory text of revised 419.83 not read. The rule does not say whether Medicare Advantage plans are affected; not asserted.

Sources

Noridian peripheral nerve injection LCD L40265 and article A60300 take effect November 1; nerve blockade LCD L35456 and article A56034 retired October 31

Medium priorityNew in this editionRead article →

What changed

The Medicare Coverage Database (MCD) lists Noridian Local Coverage Determination (LCD) L40265 (Peripheral Nerve Injections and Procedures for Chronic Pain) and billing article A60300 as effective November 1, 2026, and lists the Noridian Nerve Blockade for Treatment of Chronic Pain and Neuropathy LCD L35456 and article A56034 as retired October 31, 2026. Noridian's JE Part A and Part B update lists posted R1 notices for L40265 and A60300 on October 22, 2026, each stating an effective date of November 1, 2026. The LCD focuses on therapeutic injections or blocks and percutaneous denervation, usually radiofrequency ablation or cryotherapy, for the management of chronic pain, and does not address regional anesthesia, surgical pain, acute pain, and diagnostic injections unless specified; the billing article adds that the related LCD does not apply to botulinum toxins, blocks used to manage pain related to active malignancy refractory to medical management, spasticity treatment, joint impingement syndromes, or pain due to sympathetic neuropathies or neurotomies. Among its utilization parameters, the billing article states that no more than 2 radiofrequency sessions per knee for genicular nerve radiofrequency ablation, and a maximum of 4 occipital nerve blocks for occipital neuralgia, will be reimbursed per rolling 12 months.

Background

Medicare contractors are required to develop and disseminate LCDs, and a billing and coding article such as A60300 contains billing, coding or other guidelines that complement the LCD it supports. Noridian states that L40265 outlines limited coverage and was developed 'to update existing policy to evidence based and incorporate new procedures and literature.'

Who this affects

JE Part A and Part B providers that perform peripheral nerve injections and procedures for chronic pain, including hospital outpatient pain programs.

Why it matters

Inference: pain management and hospital outpatient billing should obtain and assess the new LCD and article, which the Medicare Coverage Database lists as effective 2026-11-01; claims edits, documentation templates and coding built on L35456/A56034 would need review.

Required actions

  • Providers billing Noridian for these procedures: append the KX modifier to the line for initial diagnostic injections, and keep all documentation in the patient's medical record, available to the contractor upon request (billing article A60300).

Recommended action

  • Obtain LCD L40265 and article A60300 and assess them against current billing and documentation for peripheral nerve injections; the Medicare Coverage Database lists both as effective 2026-11-01.
  • Revenue Cycle and Compliance: compare L40265/A60300 coverage and coding with the retired L35456/A56034 and update edits and templates.

Scope and timing

Authority status
Effective
Responsible owner
Revenue Cycle
Publication date
Noridian notices 2026-10-22 (L40265 R1 and A60300 R1)
Effective date
2026-11-01 (L40265; for A60300 this is the revision effective date, and its page shows an original effective date of 2026-10-25)
Other dates
MCD record last updated 2026-10-15 (L40265) and 2026-10-16 (A60300); L35456 and A56034 retirement date 2026-10-31

Not established

The LCD and article texts were read but were not compared with the retired L35456 and A56034; the coverage differences are not established. The MCD application programming interface (API) record names Noridian Part A and Part B without saying JE or JF; the Noridian JE update lists confirm JE for L40265/A60300 but say nothing about the retirement of L35456/A56034.

Sources

Continuing obligations

CY 2027 ESRD PPS final rule: base rate, low-volume attestation and quality changes

High priorityConditional reminderRead article →

What this is

CMS's calendar year (CY) 2027 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) final rule, Federal Register document 2026-22194, was published October 30, 2026 and takes effect January 1, 2027. It sets the unadjusted bundled payment base rate at $297.52 per treatment, up from $281.71 in 2026, and sets the CY 2027 base payment for dialysis furnished by ESRD facilities to beneficiaries with acute kidney injury (AKI) at $297.52 before the applicable geographic adjustment. For payment year 2027, an eligible facility seeking the low-volume payment adjustment (LVPA) must provide its attestation by December 31, 2026, the temporary pediatric ESRD add-on ends that day, and ESRD Quality Incentive Program (QIP) measure changes begin with payment year 2029.

Current status

The Federal Register record for document 2026-22194, retrieved on November 9, 2026 (Pacific time), still shows an effective date of January 1, 2027 and lists no corrections. Final technical specifications for the ESRD Quality Reporting System (EQRS) and any Medicare contractor instructions for the attestation were not checked.

Who this affects

ESRD facilities billing Medicare, including dialysis they furnish to beneficiaries with acute kidney injury (AKI).

Why it matters

CMS estimates that Medicare ESRD PPS payments across facilities will rise 2.7% in CY 2027 compared with estimated 2026 payments, an aggregate projection that is not a guarantee of the same increase for each provider or of an increase in all-payer revenue. Inference: an eligible facility seeking the low-volume adjustment that does not provide its attestation by December 31, 2026 should not expect the 2027 adjustment, so finance must finish eligibility and tier checks well before year end.

Required actions

  • For payment year 2027, an eligible facility seeking the low-volume adjustment must provide its attestation by 2026-12-31 (conditional, not universal).

Recommended action

  • Revenue-cycle and finance: model the rate and geographic adjustment against actual treatment mix; separately assess LVPA eligibility, ownership aggregation, cost-report history and tier; prepare the attestation before the deadline if seeking payment.
  • Pharmacy, clinical and contracting: assess binder procurement, supply and transitions for eligible ESRD and AKI patients.
  • Home-dialysis leaders: review training capacity, billing configuration and backup-support arrangements.
  • Quality and laboratory: map the first pre-dialysis monthly phosphorus value into EQRS workflows, check continuity and exclusions, validate historical data.
  • Track CMS and Medicare Administrative Contractor (MAC) implementation guidance; confirm existing requirements remain before discontinuing a prior QIP reporting process.

Implementation playbook

  1. Decide whether the facility is eligible for the CY 2027 low-volume adjustment and will seek it: check treatment counts, ownership aggregation, cost-report history and tier. Owner: Finance. Due: 2026-11-30.
  2. If seeking the adjustment, prepare the attestation and provide it by the rule's date. Owner: Finance and Revenue Cycle. Due: 2026-12-31 (the date stated for payment year 2027; applies only to an eligible facility seeking the adjustment).
  3. Model the CY 2027 base rate and geographic adjustment against the actual treatment mix and update the 2027 budget. Owner: Finance. Due: 2026-12-15.
  4. Plan for the end of the temporary pediatric add-on. Owner: Finance, with pediatric dialysis leadership. Due: 2026-12-31 (the add-on's end date).
  5. Assess binder procurement, supply and patient transitions for eligible ESRD and AKI patients. Owner: Pharmacy, Clinical Operations and Contracting. Due: 2026-12-15.
  6. Review home dialysis training capacity, billing configuration and backup-support arrangements. Owner: Home Dialysis leadership. Due: 2026-12-15.
  7. Map the first pre-dialysis monthly phosphorus value into the EQRS reporting workflow, check continuity and exclusions, and validate historical data. Owner: Quality and Laboratory. Due: 2026-12-31.
  8. Check for CMS and Medicare contractor implementation guidance, and confirm existing reporting requirements remain before stopping any current quality reporting process. Owner: Compliance. Due: 2026-12-01, then monthly.

Scope and timing

Authority status
Final
Responsible owner
Revenue Cycle and Finance (primary); affected: Pharmacy, Clinical Operations, Contracting, Home Dialysis, Quality, Laboratory
Publication date
2026-10-30
Effective date
2027-01-01
Compliance date
2026-12-31 (low-volume adjustment attestation, eligible facilities seeking the adjustment)
Other dates
Temporary pediatric ESRD add-on ends 2026-12-31; QIP changes begin with payment year 2029

Not established

The playbook's due dates are planning dates set by this briefing, apart from the December 31, 2026 dates stated for the attestation and the pediatric add-on. Final EQRS technical specifications and any Medicare contractor instructions for the attestation were not checked. Quality program changes begin with payment year 2029.

Earlier article: November 4, 2026 edition →

Sources

Hospice election addendum: mandatory since October 1; CMS enforcement discretion on missing or incomplete addenda ends December 31

High priorityConditional reminderRead article →

What this is

In the FY 2027 Hospice Prospective Payment System final rule, CMS made the hospice election statement addendum mandatory for every election on or after October 1, 2026: it must be furnished in writing (paper or electronic) within 5 calendar days of the effective date of the election, any update must be furnished within 3 calendar days of a plan-of-care change, and the condition for payment is met when a valid signed addendum is in the beneficiary's medical record with the hospice. From October 1 to December 31, 2026, CMS is exercising enforcement discretion, under which Medicare Administrative Contractors (MACs) will not deny claims solely because the addendum is missing or incomplete; furnishing the addendum remains required.

Current status

CMS's October 1, 2026 Medicare Learning Network (MLN) Connects newsletter item on the addendum was read again on November 10, 2026 and was unchanged, and the November 5 MLN Connects newsletter carries no change. The FY 2027 hospice final rule text and 42 CFR 418.24(c) were not read again for this edition.

Who this affects

Medicare-certified hospices, including hospice programs operated by hospitals and health systems.

Why it matters

A hospice election without a valid signed addendum in the hospice medical record does not meet the condition for payment. Inference: after December 31 the newsletter's statement that MACs will not deny claims solely for a missing or incomplete addendum no longer applies; the newsletter does not describe post-December claim handling.

Required actions

  • Furnish the addendum in writing (paper or electronic) to every electing beneficiary or representative, with the content required by 42 CFR 418.24(c), within 5 calendar days of the election effective date (elections on and after 2026-10-01).
  • Furnish any addendum update within 3 calendar days of the plan-of-care change.
  • Keep a valid signed addendum in the beneficiary's hospice medical record (condition for payment).

Recommended action

  • Audit October and November elections and correct omissions (Clinical Operations, by 2026-11-20).
  • Add a pre-billing addendum check before the enforcement-discretion window ends (Revenue Cycle, by 2026-12-15).

Implementation playbook

  1. Audit every election since October 1 for an addendum furnished within five calendar days, a valid signature and three-day updates; correct omissions. Owner: Clinical Operations. Due: 2026-11-20 (recommended internal target).
  2. Fix intake and plan-of-care workflow gaps found (electronic health record prompts, tracking report of addendum delivery dates). Owner: Clinical Operations with IT. Due: 2026-12-04 (recommended internal target).
  3. Add a pre-billing check that a valid signed addendum is in the hospice record for each election. Owner: Revenue Cycle. Due: 2026-12-15 (recommended internal target).
  4. Confirm readiness before enforcement discretion ends. Owner: Compliance. Due: 2026-12-31 (the end of enforcement discretion).
  5. Review January claim outcomes and MAC education contacts. Owner: Revenue Cycle. Due: 2027-01-31 (recommended internal target).

Scope and timing

Authority status
Effective
Responsible owner
Clinical Operations (affected: Compliance, Revenue Cycle, IT)
Publication date
2026-10-01 (MLN Connects)
Effective date
2026-10-01 (elections on and after)
Compliance date
Addendum within 5 calendar days of the election effective date; updates within 3 calendar days of a plan-of-care change (rolling)
Other dates
Enforcement-discretion window 2026-10-01 to 2026-12-31

Not established

The FY 2027 hospice final rule text and 42 CFR 418.24(c) were not read again for this edition; the newsletter is the source. Post-December 31 claim handling is not stated by CMS.

Earlier article: October 11, 2026 edition →

Sources

Medi-Cal youth gender-affirming services (APL 26-018): federal reimbursement limit from October 13, 2026 and hormone transition through April 12, 2027

High priorityConditional reminderRead article →

What this is

DHCS All Plan Letter (APL) 26-018, Federal Reimbursement Limitation on Gender-Affirming Care Services for Youth, is listed in the DHCS letter index with the date 09/30/2026. As the October 11 article reported it, the letter limits reimbursement from October 13 for specified gender-affirming surgery, puberty blockers and hormone therapy for Medi-Cal members under 18 and Children's Health Insurance Program (CHIP) members under 19 (services for other medical indications and treatment of complications remain covered when medically necessary), keeps a transition through April 12, 2027 for hormones already being taken as of October 13 (for affected plan members, only under the medical benefit), and requires plans to submit policies, an attestation and copies within 90 calendar days of release, which the article gave as December 29.

Current status

The DHCS letter index, read in a browser on the evening of November 9, 2026 (Pacific time), still lists APL 26-018 with the date 09/30/2026 and an errata attachment. The letter itself was not read for this edition, so the letter details above are the October 11 article's and were not re-verified against the letter; verify them before relying on them. A member page from the Department of Health Care Access and Information (HCAI), published November 5, 2026, says that on October 13, 2026 the federal government stopped paying for some gender affirming care for youth, and that youth already taking gender affirming hormones as of October 13, 2026 can keep getting them through Medi-Cal until April 12, 2027. That page is an official source for those two dates. It does not state the plan submission date.

Who this affects

Medi-Cal managed care plans and their network hospitals and providers serving Medi-Cal members under 18 and CHIP members under 19.

Why it matters

As the October 11 article reported it: plans owe DHCS a submission and owe members notices, and providers face reimbursement limits for the listed services for the affected age groups. Verify the letter, its errata, any later DHCS guidance and any court action before acting on a date in this entry.

Required actions, as the earlier article reported them; not re-verified

  • Medi-Cal managed care plans: submit policies, attestation and copies within 90 calendar days of the September 30 release (2026-12-29).
  • Plans: distribute approved handbook errata and issue individualized adverse-action notices where required, with ten-day advance notice where applicable, appeal rights and continuation information.
  • Plans (medical benefit): continue hormones already being taken as of October 13 through April 12, 2027.

Recommended action

  • Apply service-date controls and exceptions in billing (Revenue Cycle, by 2026-11-20).
  • Do not cancel or redirect care while state-only funding details develop; the October 11 article reported that the APL advises this, and it was not re-verified against the letter.

Implementation playbook

  1. Open APL 26-018, its errata and any later DHCS letter, check for litigation affecting it, and confirm the reimbursement limitation, the transition end date and the plan submission date. Owner: Managed Care and Compliance. Due: 2026-11-17.
  2. If the dates stand as the earlier article reported them, complete the plan policies, attestation and copies for submission. Owner: Managed Care. Due: the date confirmed in step 1 (the earlier article gave 2026-12-29).
  3. Confirm continuity arrangements for members already on hormone therapy. Owner: Medical Management. Due: the date confirmed in step 1 (the earlier article gave 2027-04-12).

Scope and timing

Authority status
Guidance, as the earlier article reported it; current status not verified
Responsible owner
Managed Care (affected: Clinical Operations, Case Management, Revenue Cycle, Legal)
Other dates
2026-12-29: plan policies, attestation and copies due, as the October 11 article reported and not re-verified against the letter; 2027-04-12: youth already taking gender affirming hormones as of 2026-10-13 can keep getting them through Medi-Cal until this date, per HCAI's member page of November 5, 2026 (the October 11 article gave the same date); APL 26-018 released 2026-09-30 as the October 11 article reported; federal payment stopped for some gender affirming care for youth 2026-10-13, per HCAI's member page

Not established

APL 26-018 and its errata were not reopened; for the letter, only the DHCS index entry was read, so the letter's scope and its December 29 plan submission date are as the October 11 article reported them. The October 13, 2026 and April 12, 2027 dates are also stated on the HCAI member page, which was read. The related federal rule is tracked in a separate entry.

Earlier article: October 11, 2026 edition →

Sources

DHCS warns assisted living waiver facilities of denials and reprocessing

High priorityConditional reminderRead article →

What this is

In a notice published October 9, 2026, DHCS said claims for Assisted Living Waiver (ALW) services may be non-payable due to non-compliance with program requirements, that it is reviewing previously paid claims, which may result in the reprocessing of claims that were erroneously paid, and that it will follow up with additional information tailored to specific facilities that have non-payable claims. To prevent claim denials, the notice says facilities must verify ALW eligibility before delivering services and submitting claims, using the approved processes outlined by DHCS and their Care Coordination Agency, fully comply with all ALW standards, policies and contract requirements, submit claims with correct procedure codes and modifiers, consistent with program guidance referenced in ALW program integrity correspondence, and review internal processes for accurate claiming and documentation; it states no agency deadline. First reported in the October 11 edition.

Current status

DHCS's notice, titled "Non-Payment of Inappropriate Claiming for Members Not Enrolled in the ALW Program", was still posted when it was opened in a browser on November 10, 2026 and showed no updated date. Whether DHCS has issued a later notice was not checked, and current status beyond that notice is unverified.

Who this affects

Assisted Living Waiver (ALW) facilities and Care Coordination Agencies billing Medi-Cal; health systems that operate or contract with them (inference).

Why it matters

Per the October 9 notice, the exposure is non-payment of Assisted Living Waiver claims that do not meet program requirements, and possible reprocessing of claims DHCS finds were erroneously paid.

Required actions

  • The October 9 notice says that, to prevent claim denials, facilities must ensure they are verifying Assisted Living Waiver eligibility before delivering services and submitting claims, fully complying with program standards, policies and contract requirements, submitting claims with correct procedure codes and modifiers, and reviewing internal processes for accurate claiming and documentation.

Recommended action

  • Validate eligibility and service evidence before billing; reconcile prior payments and preserve facility-specific correspondence.
  • Send questions to the DHCS ALW claims support channel named in the notice, with the facility name and NPI.

Implementation playbook

  1. Check the Medi-Cal provider news page for any later notice on this subject, since this entry verified only that the October 9 notice is still posted. Owner: Compliance. Due: 2026-11-17.
  2. Match active Assisted Living Waiver members to approved eligibility confirmation and care-coordination records. Owner: Case Management. Due: 2026-11-20.
  3. Sample billed services, modifiers and supporting documentation and correct any non-compliance found. Owner: Revenue Cycle. Due: 2026-11-20.
  4. Reconcile any claims DHCS reprocesses and escalate facility-specific DHCS correspondence. Owner: Finance. Due: 2026-12-04, then monthly.

Scope and timing

Authority status
Announced
Responsible owner
Revenue Cycle (affected: Case Management, Compliance, Finance)
Publication date
2026-10-09
Other dates
No agency deadline stated; DHCS follow-up is facility-specific

Not established

Evidence of the notice is a rendered-text browser capture made on November 10, 2026. Program integrity correspondence the notice refers to was not seen. Any facility-specific follow-up from DHCS is outside public sources. The playbook dates are planning dates set by this briefing.

Earlier article: October 11, 2026 edition →

Sources

DHCS notice (October 9): Medi-Cal clinic institutional claims submitted from October 15 require diagnosis codes

High priorityConditional reminderRead article →

What this is

In a notice published October 9, 2026, DHCS said that for all Medi-Cal claims submitted on or after October 15, 2026, at least one clinically appropriate ICD-10-CM code is required on a UB-04 claim form or the 837I electronic form by Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Indian Health Services (IHS) Memorandum of Agreement (MOA) 638 providers and Tribal FQHCs. The trigger is the claim submission date, not a new date-of-service limit, and the notice says updated provider manual sections will be released in a future Medi-Cal Update. First reported in the October 11 edition.

Current status

DHCS's notice was still posted when it was opened in a browser on November 10, 2026, showed no updated date and still said updated provider manual sections will be released in a future Medi-Cal Update. Whether a later notice or the promised manual update has issued was not checked, and current status beyond that notice is unverified.

Who this affects

FQHCs, RHCs, IHS-MOA 638 providers and Tribal FQHCs submitting UB-04 or 837I claims to Medi-Cal, including hospital-affiliated clinics of those types (inference).

Why it matters

Per the October 9 notice, the requirement applies by claim submission date, from October 15, 2026. Inference: a claim from a listed provider type submitted without a qualifying diagnosis code risks rejection or denial.

Required actions

  • As the October 9, 2026 DHCS notice states it (later notices and the provider manual update not checked): FQHCs, RHCs, IHS-MOA 638 providers and Tribal FQHCs include at least one clinically appropriate ICD-10-CM code on UB-04 and 837I Medi-Cal claims submitted on or after October 15, 2026. Confirm against any later DHCS notice and the updated provider manual sections.

Recommended action

  • Keep the diagnosis edit in affected institutional claim workflows and monitor remittances from October 15.
  • Check whether the promised provider manual update has been released, and review it if so.

Implementation playbook

  1. Check the Medi-Cal provider news page for any later notice on this subject and for the updated provider manual sections, and confirm the requirement still reads as the October 9 notice states it. Owner: Compliance. Due: 2026-11-17.
  2. Until step 1 is done, apply the October 9 notice as written: confirm the affected provider types and UB-04 and 837I claim queues are identified and the diagnosis edit is live. Owner: Revenue Cycle. Due: 2026-11-17.
  3. Confirm claims missing a diagnosis code are stopped internally before submission. Owner: IT. Due: 2026-11-17.
  4. Monitor submissions and remittances, resolve coding exceptions, and reconcile the claim edit to any later notice or manual update. Owner: Coding. Due: 2026-11-20, then monthly.

Scope and timing

Authority status
Requirement as stated in the October 9, 2026 DHCS notice; later notices and the provider manual update not checked
Responsible owner
Revenue Cycle (affected: Coding, IT, Clinical Operations)
Publication date
2026-10-09
Effective date
2026-10-15 (the notice applies the requirement to claims submitted on or after this date)
Other dates
The notice says updated provider manual sections will be released in a future Medi-Cal Update (no date)

Not established

Evidence of the notice is a rendered-text browser capture made on November 10, 2026. Whether the updated provider manual sections have been released is not established. The playbook dates are planning dates set by this briefing.

Earlier article: October 11, 2026 edition →

Sources

Continuing items (78)
ItemPriorityDates still aheadWhat stands behind this rowEarlier article
2027 physician fee-schedule database instructions (Transmittal 14026, CR 14618)Medium priorityJanuary 1, 2027 (effective)
January 4, 2027 (implementation)
April 5, 2027 (implementation)
July 5, 2027 (implementation)
October 4, 2027 (implementation)		An official source was re-read on November 10, 2026November 4, 2026 edition
2027 SNF consolidated-billing update (Transmittal 14003, CR 14658)Medium priorityJanuary 1, 2027 (effective)
January 4, 2027 (implementation)		Partly checked; current status not establishedNovember 4, 2026 edition
Revised NCD criteria for autologous stem cell transplant in multiple myeloma (CAG-00444R2)Medium priorityNone recordedAn official source was re-read on November 10, 2026November 4, 2026 edition
DHCS revised notice for proposed ABP SPA 26-0034 (behavioral health treatment)Medium priorityNone recordedPartly checked; current status not establishedNovember 4, 2026 edition
Exchange pre-eligibility verification proposed rule (comments 2026-11-27)Medium priorityNovember 27, 2026 (comment deadline: for assured consideration)An official source was re-read on November 10, 2026November 4, 2026 edition
California Rural Health Transformation fundingMedium priorityNone recordedPartly checked; current status not establishedNovember 4, 2026 edition
Noridian A60217 R2 (MolDX MASLD/MASH biomarker testing, 0665U)Medium priorityNone recordedPartly checked; current status not establishedNovember 4, 2026 edition
Reminder: DMEPOS face-to-face/written-order and prior-authorization list updatesMedium priorityJanuary 26, 2027: later phase, as the earlier article reported, with actual implementation and later amendments not verified
April 26, 2027: later phase, as the earlier article reported, with actual implementation and later amendments not verified		An official source was re-read on November 10, 2026November 4, 2026 edition
Reminder: Home health QRP reconsideration requestsMedium priorityNovember 23, 2026: 11:59 p.m. deadline for agencies that received a noncompliance letter and choose to request reconsiderationAn official source was re-read on November 10, 2026November 4, 2026 edition
SNF QRP October refresh and January 2027 preview (review date 2026-11-14)Medium priorityNovember 14, 2026: preview review date per the CMS notice of October 15 (a voluntary review request, as the earlier entry recorded it, not re-retrieved)An official source was re-read on November 10, 2026November 4, 2026 edition
DHCS PSC-35 and FAST draft removalMedium priorityNone recordedPartly checked; current status not establishedOctober 18, 2026 edition
CMS-4214-P: Part D PBM, MA directory and dual-eligible cost-sharing proposal (comments 2026-12-15)Medium priorityDecember 15, 2026 (comment deadline: 5 p.m. Eastern Standard Time)
October 1, 2027: proposed start of the CY 2028 marketing policies
January 1, 2028: proposed start of the PBM contract and cost-sharing provisions
July 1, 2028: proposed first annual PBM reporting deadline (reports would be due no later than July 1, beginning in 2028)		An official source was re-read on November 10, 2026October 18, 2026 edition
Treasury/IRS premium tax credit proposed regulationsMedium priorityNovember 30, 2026 (comment deadline)
December 31, 2026: All proposed: the community-engagement provision would apply to taxable years beginning after 2026-12-31
December 31, 2027: All proposed: the income verification and failure-to-reconcile provisions would apply to taxable years beginning after 2027-12-31
December 8, 2026: All proposed: hearing 2026-12-08 at 10 a.m. Eastern, which may be canceled if no outlines are received		Partly checked; current status not establishedOctober 18, 2026 edition
CMS restores SOM Chapter 5 nursing-home complaint investigation and reporting sections (R250SOMA)Medium priorityNone recordedAn official source was re-read on November 10, 2026October 18, 2026 edition
DHCS replacement of the English DHCS 7077 LTC eligibility noticeMedium priorityNone recordedFrom the earlier article; not re-verified for this editionOctober 18, 2026 edition
Medi-Cal long-term care claims: attending and referring NPI requirementsMedium priorityFebruary 1, 2027 (effective: service dates on or after) (as the earlier article reported; not re-verified)Partly checked; current status not establishedOctober 18, 2026 edition
Medi-Cal DME and clinical-laboratory ordering NPI requirementsMedium priorityFebruary 1, 2027 (effective: ordering NPI on claims) (as the earlier article reported; not re-verified)
May 1, 2027 (compliance: ordering NPI actively enrolled as a participating Medi-Cal provider) (as the earlier article reported; not re-verified)		From the earlier article; not re-verified for this editionOctober 18, 2026 edition
Medi-Cal DRG Mapper 44.0 denials and payment correctionMedium priorityNone recordedFrom the earlier article; not re-verified for this editionOctober 18, 2026 edition
DHCS Phase II IP-CANS alignment (ACL 26-74 / BHIN 26-032)Medium priorityJanuary 1, 2027: provisional implementation date (as the earlier article reported; not re-verified)
March 15, 2027: provisional first annual report date, with further reports 2028-03-15 and 2029-03-15 (as the earlier article reported; not re-verified)
March 15, 2028: 2027-03-15: provisional first annual report date, with further reports 2028-03-15 and 2029-03-15 (as the earlier article reported; not re-verified)
March 15, 2029: 2027-03-15: provisional first annual report date, with further reports 2028-03-15 and 2029-03-15 (as the earlier article reported; not re-verified)
December 31, 2028: provisional training and certification date for existing administrators (as the earlier article reported; not re-verified)		From the earlier article; not re-verified for this editionOctober 18, 2026 edition
HHS Hurricane Isaias public health emergencies, Florida and AlabamaMedium priorityNone recordedPartly checked; current status not establishedOctober 18, 2026 edition
CMS Marketplace duplicate-coverage and deceased-enrollee subsidy removalsMedium priorityNone recordedFrom the earlier article; not re-verified for this editionOctober 18, 2026 edition
Medi-Cal fee-for-service provider directory completion and update periodsMedium priorityNone recordedFrom the earlier article; not re-verified for this editionOctober 11, 2026 edition
Federal Medicaid and CHIP funding prohibition for specified youth proceduresMedium priorityNone recordedPartly checked; current status not establishedOctober 11, 2026 edition
AB 280 provider-directory utility and reliance protectionsMedium priorityJuly 1, 2027 (compliance) (as the earlier article reported; not re-verified)
March 1, 2027: Earlier playbook targets: 2027-03-01 (Patient Access workflow mapping), 2027-07-01 (IT testing) (as the earlier article reported; not re-verified)
July 1, 2027: Earlier playbook targets: 2027-03-01 (Patient Access workflow mapping), 2027-07-01 (IT testing) (as the earlier article reported; not re-verified)		From the earlier article; not re-verified for this editionOctober 11, 2026 edition
AB 350 fluoride varnish coverage without cost sharingMedium priorityJanuary 1, 2027: applies to contracts and policies issued, amended or renewed on or after this date, as the earlier article reported, and the statute's own effective date was not separately established
July 1, 2027: DHCS billing guidance due 2027-07-01 (longer-lead) (as the earlier article reported; not re-verified)		From the earlier article; not re-verified for this editionOctober 11, 2026 edition
AB 1682 large-group scalp-cooling coverageMedium priorityJanuary 1, 2027: applies to large-group contracts issued, amended or renewed on or after this date, as the earlier article reported, and the statute's own effective date was not separately establishedFrom the earlier article; not re-verified for this editionOctober 11, 2026 edition
AB 1876 plan and insurer nondiscrimination protectionsMedium priorityJanuary 1, 2027 (effective) (as the earlier article reported; not re-verified)
December 15, 2026: Earlier playbook target 2026-12-15 (Compliance testing) (as the earlier article reported; not re-verified)		From the earlier article; not re-verified for this editionOctober 11, 2026 edition
AB 2499 electronic claim-documentation intake standardMedium priorityMay 26, 2028 (compliance) (as the earlier article reported; not re-verified)
November 15, 2026: Earlier playbook targets: 2026-11-15 (Revenue Cycle inventory), 2027-06-01 (IT) (as the earlier article reported; not re-verified)
June 1, 2027: Earlier playbook targets: 2026-11-15 (Revenue Cycle inventory), 2027-06-01 (IT) (as the earlier article reported; not re-verified)		From the earlier article; not re-verified for this editionOctober 11, 2026 edition
ACCESS model adds heart failure, COPD, substance use disorder, tobacco cessation and MSK follow-on tracksMedium priorityApril 1, 2027 (implementation: new tracks start)An official source was re-read on November 10, 2026October 11, 2026 edition
AB 1126 Medi-Cal other-coverage billing protectionsMedium priorityNone recordedFrom the earlier article; not re-verified for this editionOctober 11, 2026 edition
Ambulatory Specialty Model 2027 performance yearMedium priorityJanuary 1, 2027 (implementation: performance year 2027 begins)Partly checked; current status not establishedOctober 11, 2026 edition
DHCS moves members with unsatisfactory immigration status from managed care to fee-for-serviceMedium priorityDecember 31, 2026 (compliance: managed-care-only providers without FFS enrollment cannot continue caring for affected members after this date) (as the earlier article reported; not re-verified)
January 1, 2027 (implementation) (as the earlier article reported; not re-verified)		From the earlier article; not re-verified for this editionOctober 11, 2026 edition
ACWDL 26-16: asset limits return for Pickle, DAC and DW groupsMedium priorityJanuary 1, 2027 (implementation) (as the earlier article reported; not re-verified)
July 1, 2029: LTC transfer look-back grows to 30 months by 2029-07-01 (longer-lead) (as the earlier article reported; not re-verified)		From the earlier article; not re-verified for this editionOctober 11, 2026 edition
Noridian MolDX billing-article revisions for October 1Medium priorityNone recordedAn official source was re-read on November 10, 2026October 11, 2026 edition
GLOBE model final ruleMedium priorityNovember 30, 2026 (effective)
January 1, 2027: model start with an initial voluntary manufacturer reporting quarter, as the earlier article reported and not re-verified
April 1, 2027: performance period start, as the earlier article reported and not re-verified
March 31, 2032: performance period end, as the earlier article reported and not re-verified		An official source was re-read on November 10, 2026October 11, 2026 edition
IRF FY 2027 rulesMedium priorityNovember 17, 2026 (implementation: R14001BP)An official source was re-read on November 10, 2026October 11, 2026 edition
Home health grouper version 08.0.27 for claim From dates on or after January 1, 2027 (implementation January 4)Medium priorityJanuary 1, 2027 (effective: claim From dates) (as the earlier article reported; not re-verified)
January 4, 2027 (implementation) (as the earlier article reported; not re-verified)		From the earlier article; not re-verified for this editionOctober 11, 2026 edition
January 2027 ASP and ZIP-code instructionsMedium priorityJanuary 1, 2027 (effective: MPFS, per R14026CP)
January 4, 2027 (implementation: MPFS, per R14026CP)
April 5, 2027 (implementation: MPFS quarterly date, per R14026CP)		An official source was re-read on November 10, 2026October 11, 2026 edition
California IRF ownership changes require correct RCD selections and new identifiersMedium priorityNone recordedAn official source was re-read on November 10, 2026October 11, 2026 edition
Medi-Cal updates maintenance dialysis billing for restricted-scope membersMedium priorityNone recordedFrom the earlier article; not re-verified for this editionOctober 11, 2026 edition
RHC and FQHC timeliness waiver for eligible LMFT and psychological associate claimsMedium priorityNovember 29, 2026: waiver submission deadline as the earlier article reported it (an optional waiver, status not verified)From the earlier article; not re-verified for this editionOctober 11, 2026 edition
DOJ corporate fraud directives name healthcare among program-integrity prioritiesMedium priorityNone recordedAn official source was re-read on November 10, 2026October 11, 2026 edition
SB 1049 gives qualifying claim corrections a minimum filing periodMedium priorityJanuary 1, 2027: the date by which the earlier reminders called for workflows to be ready, and the statute's effective and applicability dates were not verifiedFrom the earlier article; not re-verified for this editionOctober 11, 2026 edition
AB 1629 changes noncontracted dental assignment of benefitsMedium priorityJanuary 1, 2027: the date by which the earlier reminders called for workflows to be ready, and the statute's effective and applicability dates were not verifiedFrom the earlier article; not re-verified for this editionOctober 11, 2026 edition
SB 950 adds qualifying dementia treatment coverage protectionsMedium priorityJanuary 1, 2027: applies to contracts or policies issued, amended or renewed from this date, as the earlier article reported, and the statute's own effective date was not separately establishedFrom the earlier article; not re-verified for this editionOctober 11, 2026 edition
AB 1843 limits prior authorization for covered hepatitis C antiviralsMedium priorityJanuary 1, 2027 (effective) (as the earlier article reported; not re-verified)From the earlier article; not re-verified for this editionOctober 11, 2026 edition
AB 1887 sets rare disease drug authorization timingMedium priorityJanuary 1, 2027 (effective) (as the earlier article reported; not re-verified)
January 1, 2027: Contracts or policies issued, amended or renewed from 2027-01-01 (as the earlier article reported; not re-verified)		From the earlier article; not re-verified for this editionOctober 11, 2026 edition
SB 964 creates a qualifying drug dose adjustment request pathwayMedium priorityJanuary 1, 2027 (effective) (as the earlier article reported; not re-verified)From the earlier article; not re-verified for this editionOctober 11, 2026 edition
SB 1094 changes biosimilar substitution and formulary requirementsMedium priorityJanuary 1, 2027: applies to qualifying prescription-drug contracts issued, amended or renewed from this date, as the earlier article reported and not re-verified
January 15, 2027: provider-notice deadline as the earlier article reported it		From the earlier article; not re-verified for this editionOctober 11, 2026 edition
AB 1906 adds qualifying cervical screening home test coverageMedium priorityJanuary 1, 2027 (effective) (as the earlier article reported; not re-verified)From the earlier article; not re-verified for this editionOctober 11, 2026 edition
AB 2348 revises Medi-Cal enhanced care management implementationMedium priorityJanuary 1, 2027 (effective) (as the earlier article reported; not re-verified)
March 31, 2029: DHCS report to the Legislature by 2029-03-31 (state duty, longer-lead) (as the earlier article reported; not re-verified)		From the earlier article; not re-verified for this editionOctober 11, 2026 edition
SB 874 requires BHT employee background checksMedium priorityJuly 1, 2027 (implementation) (as the earlier article reported; not re-verified)
January 1, 2029: DHCS utilization data and policy synopsis by 2029-01-01 (as the earlier article reported; not re-verified)		From the earlier article; not re-verified for this editionOctober 11, 2026 edition
DHCS specifies BHSA service claiming codes for January 2027Medium priorityJanuary 1, 2027 (implementation) (as the earlier article reported; not re-verified)
January 1, 2027: Service dates from 2027-01-01 (as the earlier article reported; not re-verified)		From the earlier article; not re-verified for this editionOctober 11, 2026 edition
HCBS compensation reporting guidance separates 2027 readiness from 2028 reportsMedium priorityJuly 9, 2027 (compliance) (as the earlier article reported; not re-verified)
July 9, 2028 (implementation) (as the earlier article reported; not re-verified)
July 9, 2027: State readiness email to CMS by 2027-07-09 (as the earlier article reported; not re-verified)
July 9, 2028: FFS applicability 2028-07-09 (as the earlier article reported; not re-verified)		From the earlier article; not re-verified for this editionOctober 11, 2026 edition
Medicare SNF place of service utility will reprocess overlapping claims in April 2027Medium priorityApril 1, 2027 (effective)
April 5, 2027 (implementation)		An official source was re-read on November 10, 2026October 11, 2026 edition
DMEPOS Round 2028 registrationMedium priorityDecember 1, 2026: bidder registration opens
January 5, 2027: bid window opens
February 1, 2027: bidder registration closes
February 8, 2027: covered document review date
March 10, 2027: bid window closes
January 1, 2028: start of Round 2028, contracts and single payment amounts in effect		An official source was re-read on November 10, 2026October 11, 2026 edition
Medi-Cal RSV vaccine billing expands age eligibility and modifier rulesMedium priorityNone recordedFrom the earlier article; not re-verified for this editionOctober 11, 2026 edition
Every Woman Counts adds retroactive procedure and diagnosis benefitsMedium priorityNone recordedFrom the earlier article; not re-verified for this editionOctober 11, 2026 edition
Medi-Cal obstetric E/M transition retains CPSP and doula exceptionsMedium priorityJanuary 1, 2027: AMA obstetric coding framework begins 2027-01-01 (as described in the notice) (as the earlier article reported; not re-verified)From the earlier article; not re-verified for this editionOctober 11, 2026 edition
Hospice claim edits gain transfer and ownership-change bypasses in April 2027Medium priorityApril 1, 2027 (effective)
April 5, 2027 (implementation)		An official source was re-read on November 10, 2026October 11, 2026 edition
Home health edit repair addresses purged Notices of Admission in April 2027Medium priorityApril 1, 2027 (effective)
April 5, 2027 (implementation)		An official source was re-read on November 10, 2026October 11, 2026 edition
Home health consolidated billing removes two supply codes in JanuaryMedium priorityJanuary 1, 2027 (effective)
January 4, 2027 (implementation)		An official source was re-read on November 10, 2026October 11, 2026 edition
HETS enrollment email verificationMedium priorityDecember 1, 2026 (compliance)
December 1, 2026: Suspension follows failed delivery on all three of 2026-10-01, 2026-11-01 and 2026-12-01		Partly checked; current status not establishedOctober 11, 2026 edition
Noridian repairs G0260 imaging-code payment edit retroactivelyMedium priorityNone recordedAn official source was re-read on November 10, 2026October 11, 2026 edition
Recuperative care changes: STPHH notices and new-authorization cutoffMedium priorityJanuary 1, 2027 (effective) (as the earlier article reported; not re-verified)
December 1, 2026 (compliance) (as the earlier article reported; not re-verified)
December 31, 2026: UIS-transition STPHH cutoff 2026-12-31 (as the earlier article reported; not re-verified)
January 10, 2027: final monitoring report 2027-01-10 (as the earlier article reported; not re-verified)		From the earlier article; not re-verified for this editionOctober 11, 2026 edition
Temporary network withholds on four county behavioral-health plans (as of the October 5 update)Medium priorityNone recordedFrom the earlier article; not re-verified for this editionOctober 11, 2026 edition
Behavioral-health data sharing needs separate MCP and county implementation phasesMedium priorityJanuary 1, 2027 (implementation) (as the earlier article reported; not re-verified)From the earlier article; not re-verified for this editionOctober 11, 2026 edition
Qualified non-citizen notices and county record updatesMedium priorityDecember 1, 2026 (compliance) (as the earlier article reported; not re-verified)
January 1, 2027 (implementation) (as the earlier article reported; not re-verified)
July 1, 2027: State-funded full-scope coverage through 2027-07-01 per the October 5 newsletter (the July MEDIL gives no end date) (as the earlier article reported; not re-verified)		From the earlier article; not re-verified for this editionOctober 11, 2026 edition
Cell and Gene Therapy Access Model expansionLower priorityNone recordedAn official source was re-read on November 10, 2026November 4, 2026 edition
CMS Medicaid and CHIP Program Integrity PillarsLower priorityNone recordedAn official source was re-read on November 10, 2026November 4, 2026 edition
Nursing-home MDS validation technical expert panel nominations (close 2026-11-30)Lower priorityNovember 30, 2026: Nominations close 2026-11-30 (voluntary)An official source was re-read on November 10, 2026November 4, 2026 edition
DDS denies transportation-rate benchmark petitionLower priorityDecember 31, 2030: rate-reform regulations due by 2030-12-31 (as the earlier article reported; not re-verified)From the earlier article; not re-verified for this editionOctober 18, 2026 edition
OIG $587.7 million Part D OTC-labeling auditLower priorityNone recordedAn official source was re-read on November 10, 2026October 11, 2026 edition
OIG organ-acquisition auditLower priorityNone recordedAn official source was re-read on November 10, 2026October 11, 2026 edition
OIG $72 million MA and Part D payments tied to revoked providersLower priorityNone recordedAn official source was re-read on November 10, 2026October 11, 2026 edition
CMS program-integrity contractor process transmittal R14002PI (implementation 2026-11-27)WatchNovember 27, 2026: implementation date on the retained transmittal listAn official source was re-read on November 10, 2026November 4, 2026 edition
Nov 4 M&M context items (OIG four-state nursing-home spending review, HHVBP appeals guide, Louisiana capitation audit, OIG drug-code mapping, FFE unauthorized enrollment, agent-of-record guidance, subsidy matching notice)WatchNone recordedFrom the earlier article; not re-verified for this editionNovember 4, 2026 edition

No longer carried

Items no longer carried (25)
ItemPriorityDates still aheadWhy it leaves the listEarlier article
Unpaid qualifying APM participants' October 13 billing-information cutoff has passedHigh priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
CMS $1.6 billion laboratory program-integrity announcementMedium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
CMS-10971 Acute Hospital Care at Home data collectionMedium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
Noridian MolDX LCDs L40242 and L40222Medium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
Medi-Cal FFS hospice attestation portalMedium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
GENEROUS Medicaid drug modelMedium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
October EDI front-end edits (R13977, 276/277 attachment)Medium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
Noridian tendon-injection LCD L34218 and article A57079 revisionsMedium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
FY 2027 IPPS and LTCH implementation (R13969 and September 29 correction)Medium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
CY 2027 CLFS preliminary determinationsMedium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
DHCS draft BHIN on psychiatric emergency payment responsibilityMedium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
FY 2027 IPF payment correction and R14000CP teaching-cap clarificationMedium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
Hospice FY 2027 payment tables (R13976CP) and aggregate capMedium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
Medicare primary to FEHBP for specified federal annuitants receiving OWCP benefitsMedium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
Home health certification manual (R13972PI) recognizing allowed practitionersMedium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
Medicare EDI manual update for the TCEDI gateway (R13954CP)Medium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
Acute Hospital Care at Home telehealth coding (POS 21, modifier 95)Medium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
Q2 FY 2026 short-term acute-care PEPPER availabilityMedium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
Refugee medical assistance period corrected to twelve monthsMedium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
SNF FY 2027 correction revises wage-index calculations and burden estimatesMedium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
Noridian October coding updates change FFR, infusion-pump and SAD billingMedium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
October ASC update changes codes, skin substitutes and retroactive pricingMedium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
Recuperative-care pricing feedback period (ended October 16, per the earlier article)Medium priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 11, 2026 edition
CMS request for information on future fraud-defense contracts (deadline passed)Lower priorityNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedNovember 4, 2026 edition
DHCS Justice-Involved Reentry newsletterWatchNone recordedNot carried further in this edition; see the earlier article. Its current status was not re-verifiedOctober 18, 2026 edition

Found after the window closed

CDPH AFL 26-34 (dated November 9): CDPH says it will send Medi-Cal revalidation intent letters to facilities beginning November 9; no response within 35 calendar days means termination from Medi-Cal

High priorityNew in this editionRead article →

What changed

CDPH's All Facilities Letter (AFL) 26-34 is dated November 9, 2026, after this edition's window. It says that beginning November 9, 2026 its License Renewal and Certification Branch will send Medi-Cal revalidation intent letters to each health care facility's physical address and mailing address (if different), based on the current information in CDPH's system of record, asking enrolled providers to revalidate their enrollment or voluntarily withdraw. The letter states that failure to respond to the intent letter within 35 calendar days will result in termination and deactivation from the Medi-Cal program, and cites Title 22 California Code of Regulations section 51000.55(c). After a facility confirms it intends to continue, the branch emails instructions to the licensee's primary contact and the facility administrator at the addresses on file with CDPH. The letter cites the federal requirement that a State Medicaid agency revalidate every provider at least every five years. The letter itself was read on November 10, 2026.

Background

Medi-Cal revalidation is the process in which a provider resubmits and recertifies the accuracy of its Medi-Cal enrollment information, and providers must revalidate to keep their Medi-Cal billing privileges. The letter cites 42 CFR 455.414, under which the State Medicaid agency must revalidate the enrollment of all providers at least every five years, and says DHCS, along with CDPH, is responsible for overseeing revalidation for providers enrolled in Medi-Cal.

Who this affects

All CDPH-licensed health facilities enrolled in Medi-Cal

Why it matters

The AFL does not say whether the 35 days count from the intent letter's date or from its receipt. Inference, for planning only: if the 35 days are counted from the date on the intent letter, a letter dated November 9, 2026 would call for a response by December 14, 2026. The AFL does not say when the count starts, and a facility's letter may carry a later date. Inference: an intent letter that is not routed to the person responsible for Medi-Cal enrollment could go unanswered for 35 calendar days, which the AFL says results in termination and deactivation from Medi-Cal. The AFL says instructions are emailed using the licensee's primary contact and facility administrator email addresses reported to CDPH's Centralized Applications Branch.

Required actions

  • A provider that receives a CDPH Medi-Cal revalidation intent letter: respond within 35 calendar days, by confirming intent to revalidate or by withdrawing. The AFL does not say when the count starts; as a planning assumption, count from the date on the intent letter. The letter says no response results in termination and deactivation from Medi-Cal.

Recommended action

  • Tell mailrooms and administrators at every licensed facility address to route any CDPH intent letter to the Medi-Cal enrollment owner the day it arrives.
  • Confirm the licensee primary contact and facility administrator email addresses, and the mailing address, in CDPH's system of record. The AFL says an email address is updated by an email request from the administrator or the licensee's primary contact, and a mailing address by a Change of Mailing Address application packet to the Centralized Applications Branch.
  • Assemble the revalidation application packet in advance, using the CDPH Medi-Cal Revalidation page the letter points to.

Implementation playbook

  1. Brief mailrooms, administrators and the enrollment owner, and set same-day routing for any CDPH intent letter. Owner: Facility Administration. Due: 2026-11-13.
  2. Confirm or correct the contact emails and mailing address CDPH holds for each licensed facility. Owner: Provider Enrollment. Due: 2026-11-17.
  3. On receipt of an intent letter, respond to CDPH. Owner: Provider Enrollment. Due: within 35 calendar days, counted from the date on the intent letter (the 35 days are CDPH's; counting from the letter's date is a planning assumption, since the AFL does not say when the count starts).
  4. Prepare the revalidation application packet so it can be submitted complete when CDPH sends instructions. Owner: Provider Enrollment and Compliance. Due: 2026-11-30.

Scope and timing

Authority status
Guidance (All Facilities Letter citing 42 CFR 455.414 and Title 22 California Code of Regulations section 51000.55)
Responsible owner
Revenue Cycle (provider enrollment); Compliance; Facility Administration
Compliance date
Response to each facility's intent letter due within 35 calendar days; the letter does not say when the count starts
Implementation date
2026-11-09 (CDPH says intent letters are sent beginning this date)
Other dates
Letter dated 2026-11-09

Not established

Whether DHCS issued a companion notice was not checked. The schedule on which CDPH will mail letters to particular facility types is not stated in the letter. The revalidation page and application forms were not opened.

Sources

CMS corrects the comment docket number for the proposed rule implementing sections 6219, 6220 and 6224 of the Consolidated Appropriations Act, 2026 (CMS-4214-P); December 15 comment date unchanged

Lower priorityUpdated

What changed

A correction published November 9, 2026 fixes a typographical error in the docket number given in the October 20 proposed rule for submitting comments. The corrected docket is CMS-2026-3533. The proposed rule's comment period still closes December 15, 2026, per the Federal Register record.

Who this affects

Anyone commenting on CMS-4214-P (implementation of Consolidated Appropriations Act, 2026 sections 6219, 6220 and 6224 in 42 CFR parts 422 and 423).

Why it matters

Teams preparing comments should file to the corrected docket number.

Recommended action

  • Government Relations or Compliance: if commenting, use docket CMS-2026-3533 and file by 2026-12-15.

Scope and timing

Authority status
Proposed
Responsible owner
Compliance
Publication date
2026-11-09 (correction); proposed rule 2026-10-20
Comment deadline
2026-12-15
Other dates
Correction filed for public inspection 2026-11-06, 8:45 am

Not established

The 5 p.m. Eastern time of the deadline comes from the November 4, 2026 edition and was not re-verified in the proposed rule text.

Earlier article: November 4, 2026 edition →

Sources

Noridian JE Part B: Ask the Contractor Meeting December 9; pre-submitted questions due November 23

Lower priorityNew in this edition

What changed

Noridian posted on November 9 that the JE Part B Ask the Contractor Meeting is December 9 and that questions must be in by November 23 to be part of the pre-submitted portion. Later questions may be asked live.

Who this affects

JE Part B providers and billers.

Why it matters

Voluntary.

Recommended action

  • Professional billing: send any questions by 2026-11-23.

Scope and timing

Authority status
Announced
Responsible owner
Revenue Cycle
Publication date
2026-11-09
Other dates
Pre-submitted questions by 2026-11-23; meeting 2026-12-09

Sources

CMS announces $10 billion second-year Rural Health Transformation Program awards to all 50 states (November 9)

WatchUpdated

What changed

CMS announced on November 9, 2026 $10 billion in awards to all 50 states for the second year of the Rural Health Transformation Program (RHTP); the press release's table lists California's FY 2027 award as $231,105,823. Published after this edition's window.

Who this affects

States, including California, and rural providers.

Scope and timing

Authority status
Announced
Publication date
2026-11-09

Not established

The state award documents on medicaid.gov were not opened.

Earlier article: November 4, 2026 edition →

Sources

Earlier developments first reported here

DWC updates workers' compensation inpatient hospital fee schedule for services on or after December 1, 2026

Lower priorityNew in this edition

What changed

The Division of Workers' Compensation (DWC) of the California Department of Industrial Relations (DIR) announced on October 30, 2026 an order updating the inpatient hospital section of the Official Medical Fee Schedule to adopt fourth-quarter 2026 Medicare updates for services rendered on or after December 1, 2026, as required by Labor Code section 5307.1.

Who this affects

Hospitals billing California workers' compensation inpatient services

Why it matters

Inference: hospital revenue cycle should load the updated Official Medical Fee Schedule (OMFS) inpatient factors for workers' compensation claims with December 1 service dates.

Recommended action

  • Update workers' compensation inpatient pricing for services on or after 2026-12-01.

Scope and timing

Authority status
Final
Responsible owner
Revenue Cycle
Publication date
2026-10-30
Other dates
Effective date is for services rendered on or after 2026-12-01, as stated

Not established

The order itself on the OMFS page was not retrieved.

Sources

MLN Matters MM14653: ICD-10 and other coding revisions to NCDs, April 2027 update (CR 14653)

Lower priorityNew in this edition

What changed

The Medicare Learning Network (MLN) Matters article MM14653 describes April 2027 coding changes to six National Coverage Determinations (NCDs), including Ventricular Assist Devices, Hyperbaric Oxygen Therapy, Next Generation Sequencing and Heart Transplants, effective April 1, 2027. Earlier editions did not report it; it appeared in the November 5 MLN Connects newsletter.

Who this affects

Physicians, suppliers and other providers billing Medicare Administrative Contractors (MACs).

Why it matters

Inference: coding edits for the listed NCDs change for April 2027 dates of service.

Recommended action

  • Coding: load the April 2027 NCD code changes for the six listed NCDs.

Scope and timing

Authority status
Guidance
Responsible owner
Revenue Cycle (coding)
Publication date
2026-10-27 (MM14653 document history: initial article released; the transmittal index gives the same date)
Effective date
2027-04-01
Implementation date
2027-04-05
Other dates
CR 14653 and transmittal R14022OTN released 2026-10-23; listed in the MLN Connects newsletter of 2026-11-05

Sources

Forward horizon

0 to 30 days

31 to 60 days

61 to 90 days

91 to 180 days (payer horizon)

Beyond 180 days (long lead)

Coverage limitations

What this edition covers. Developments dated November 1 through November 7, 2026 (Pacific) in the federal and California sources this briefing follows, and items found after that week closed, which are labeled as such. A statement of fact in an entry written in full rests on a passage quoted from a retained copy of an official source. Entries say where a statement comes only from an earlier edition of this briefing.

Sources reviewed this week beyond the regular list. HHS Departmental Appeals Board and administrative law judge decision indexes (four decisions in the week; the Medicare Appeals Council index was not checked), the EEOC newsroom, ASPR emergency declarations, USCIS news, IRS news, the CMS physician self-referral page, the California Privacy Protection Agency, the Department of Insurance, the Civil Rights Department and Council, the Dental Board, the Department of Consumer Affairs, the Department of Developmental Services and the Board of Pharmacy.

Sources reviewed only in part. FDA (drug shortages and compounding actions were not established), DEA (press releases could not be retrieved), SAMHSA and 42 CFR Part 2 (the Part 2 pages were not read), CISA and HC3 (HC3 products were not read), accreditors, CDC (the health alert index could not be retrieved), the Department of Labor and OPM, court opinions (the official collection had no Second Circuit and few Ninth Circuit opinions, and unpublished decisions are not covered), and state attorneys general other than California (New York only).

Sources not reviewed. Federal OSHA, AHRQ, the Office of Refugee Resettlement, EPA news, the FCC, the NRC and the California EMS Authority. Three more could not be opened without passing an automated verification step and were left alone: the Joint Commission news pages, the Department of Toxic Substances Control newsroom, and some Justice Department listing and district release pages. No statement in this edition depends on them.

Evidence read in a browser. Some official sites refuse automated requests. For those, the page was opened in a browser and its text retained. This applies to the HHS appeals decisions, the Medi-Cal items read from the provider news site, and the searches that returned nothing for the week at the HHS Office for Civil Rights, the Department of Managed Health Care, the FTC, the federal Medicaid guidance list and the California bill search.

Carried items. An item carried from an earlier edition keeps a full entry only when it is high priority. Every other carried item is one row in a table: its name, its priority, the dates its record still shows ahead, what stands behind the row, and a link to the earlier article. A row is a pointer to the earlier article, not a fresh statement of the item's status. Where the official source could not be reached, the row says the item was not re-verified, and its dates are those the earlier article reported. Confirm against the primary source before acting on a row.

Items no longer carried. Leaving the list is an editorial step, not a finding that a matter is finished. An enforcement item leaves 30 days after its event unless a dated step is recorded ahead; other items leave when the date they carried has passed.

Source families

  • Federal Register (Reviewed): All 466 documents published 2026-11-02 to 2026-11-06 were listed through the Federal Register API and screened; 34 agency queries matched the tallies. No weekend issue.
  • HHS and OCR (Partial): HHS press room page read in a browser (five releases in the window; the only regulatory one is the physician fee schedule announcement). Not read: OCR guidance and FAQ pages, HRSA news. hhs.gov refuses direct requests.
  • HHS OIG (Reviewed): What's New list, reports by issue date, advisory opinions (latest AO 26-19, posted October 27), guidance, fraud alerts and exclusion notices checked for the window.
  • Justice Department policy (Partial): None of the 26 Main Justice releases in the window is a policy release. Not checked: the speeches listing (the endpoint returned an error), the Justice Manual and Criminal Division policy pages.
  • CMS (Partial): Federal Register and public inspection lists, and the survey and certification memo index (none in the window), were read. Not done: CMS Innovation Center announcements were not enumerated.
  • ASTP/ONC (Reviewed): News pages, the site's content API for items published or modified in the window, HTI rule pages, certification and standards pages. The certified product list was not checked.
  • FTC (Reviewed): Press release list read in a browser (the site refuses direct requests): three releases in the window, none about healthcare. Case and proceeding pages were not separately read.
  • California Legislature (Reviewed): Bill search for history actions dated 11/01/2026 to 11/07/2026 returned zero bills (browser capture, made 2026-11-09). Governor's newsroom read for the window: no healthcare bill action, order or proclamation.
  • California regulators (Partial): Read: Attorney General policy releases, CDPH All Facilities Letters and news, HCAI and OHCA, Cal/OSHA and DIR, the November 6 Notice Register, privacy, insurance, civil rights, Dental Board, Consumer Affairs, Developmental Services, Board of Pharmacy. Not established: DMHC All Plan Letters and rulemaking (site refuses direct requests; not opened in a browser), CDPH health officer orders, Medical Board, Board of Registered Nursing, Social Services, EMSA, Toxic Substances Control (human-verification check).
  • CMS newsroom (Reviewed): Dated newsroom articles listing covers the window: ten items, all retained. The newsroom search page refuses direct requests and was not needed.
  • MLN Connects (Partial): One newsletter edition in the window (November 5) and the transmittal list's provider-education columns were read. Not checked: Special Edition articles that are not tied to a change request.
  • CMS transmittals (Reviewed): Complete 2026 list read (291 rows); three transmittals issued in the window.
  • Medicare manuals and coverage (Partial): Manual changes from the three transmittals and national coverage activity were read. Not established: local coverage determinations and billing articles for the window, because the Coverage Database had not been refreshed past 2026-11-02. Not attempted: UPIC and SMRC pages. Quality Payment Program resources partly dated.
  • Medicare Advantage and D-SNP (Partial): The HPMS weekly memo archive had not posted the November 2 to 6 week when checked on 2026-11-09. Plan enforcement, compliance and D-SNP pages read (nothing in the window). CMS newsroom feed covered only from November 4.
  • Medicaid and CHIP (Partial): Federal policy guidance list read in a browser: newest document October 9, 2026, none in the window. Not read: the new-and-notable page, and California state plan amendment and waiver approvals.
  • Noridian (Medicare contractor) (Reviewed): Noridian JE Part A and Part B latest-updates lists read in full for the window. Coverage Database confirmation of local changes is not available yet (see medicare-manuals).
  • DHCS (Partial): Read in a browser: the 2026 behavioral health notice index, the managed care All Plan Letter index and the Medi-Cal provider news list for the window, and two news articles. Not read: DHCS stakeholder updates and news releases, CalAIM, provider enrollment, rate and supplemental-payment notices, state plan and waiver public notices, Medi-Cal Rx and dental notices, and the notice PDFs themselves.
  • OIG enforcement (Reviewed): Enforcement listing filtered to the window (six actions); Corporate Integrity Agreement repository checked for the window and the 90 days ending November 7.
  • Justice Department healthcare releases (Reviewed): All 417 Justice Department press releases dated in the window were retrieved through the official press release API and screened. The web listings sit behind a bot check, so the API set could not be cross-checked against them.
  • OCR enforcement (Reviewed): Resolution agreements index read in a browser: newest entry October 9, 2026, none in the window. The HHS press room shows no OCR release in the window. OCR's own newsroom page was not separately read.
  • FTC health privacy (Partial): The press release list shows no health-privacy action in the window. Not read: FTC case and proceeding pages, where an order can appear without a release.
  • California enforcement (Partial): Four of five queries established: DMHC enforcement search (zero in the window; a control search confirmed the date filter), Attorney General releases, the separate Medi-Cal fraud division search, and the CDPH enforcement export (zero records with a penalty issue date in the window; the export gives no refresh date). Not established: DHCS audit publications. The DHCS audits page has no dated list; only the suspended-provider list was read, through the state open-data copy.

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