Starting September 1, 2025, HHSC has signed off on new payment rates for personal attendant services, effective September 1, 2025. The update isn’t limited to one program; it stretches across nearly the entire system. Assisted Living Facilities (ALF) and the CLASS waiver are included, as are Community First Choice (CFC) and Day Activity and Health Services (DAHS). The Deaf-Blind with Multiple Disabilities waiver (DBMD) is part of the change as well.
They also extend to Home and Community-Based Services for Adult Mental Health (HCBS-AMH), the HCS waiver, and Intermediate Care Facilities for Individuals with Intellectual or Related Conditions (ICF/IID). In addition, Personal Care Services (PCS), Primary Home Care, Community Attendant Services, Family Care (PHC, CAS, FC), and Residential Care (RC) are covered.
The rate changes further include STAR Kids and STAR Health programs, the Medically Dependent Children’s Program (MDCP), and state plan services, along with STAR+PLUS HCBS and non-HCBS programs. The Texas Home Living waiver (TxHmL) is also part of the update.
HHSC has issued Information Letter (IL) 2025-17 detailing the approved payment rates for these services. Additional details are available on the HHSC Provider Finance Department web page.
Providers are encouraged to review the IL for complete information. For further questions, they may contact HHSC PFD, Long-term Services and Supports (LTSS), Center for Information and Training at PFD-LTSS@hhs.texas.gov or call (737) 867-7817.
The Texas Health and Human Services Commission (HHSC) has completed a review and update of several clinical prior authorization criteria guides.
Managed care organizations (MCOs) are responsible for incorporating these updates into their respective lists of clinical prior authorizations.
The Pharmacy Clinical Prior Authorization Assistance Chart provides a comparison of each MCO’s prior authorizations with those used to process fee-for-service Medicaid claims. This chart is updated on a quarterly basis.
Providers may use the MCO search tool to access links to each MCO’s list of clinical prior authorizations.
HHSC will issue notifications to pharmacies whenever updated prior authorization criteria are implemented for Medicaid fee-for-service.
Comments or questions may be directed to vdp-formulary@hhsc.state.tx.us.
Starting Dec 01, 2025, UnitedHealthcare Community Plan in North Carolina will require notification/prior authorization for the following specialty medications:
| Medication | HCPCS code(s) |
| Casgevy® (exagamglogene autotemcel) | J3392 |
| Elevidys™ (delandistrogene moxeparvovec-rokl) | J1413 |
| Hemgenix™ (etranacogene dezaparvovec-drlb) | J1411 |
| Lenmeldy™ (atidarsagene autotemcel) | J3391 |
| Luxturna® (voretigene neparvovec-rzyl) | J3398 |
| Lyfgenia™ (lovotibeglogene autotemcel) | J3394 |
| Roctavian™ (valoctogcogene roxaparvovec-rvox) | J1412 |
| Skysona® (elivaldogene autotemcel) | J3490, J3590, C9399 |
| Zolgensma® (onasemnogene abeparvovec-xioi) | J3399 |
| Zynteglo™ (betibeglogene autotemcel) | J3393 |
How to submit and manage prior authorizations
For training, providers can view the Prior Authorization and Notification interactive guide.
They must contact Optum Transplant Services (888-805-1802) to submit prior authorization requests for the following cell and gene therapies:
All prior authorization requests must be submitted before the date of service. If a request is not submitted in advance and the claim is denied, providers cannot balance bill the member.
For more information, providers can connect with UnitedHealthcare through 24/7 chat in the Provider Portal.
UnitedHealthcare Community Plan Hawaii has stayed true to its health members by establishing new standards for depression screening requirements under the Centers of Medicare and Medicaid Services (CMS) Screening for Depression and Follow-Up Plan (CDF).
Under the program, all Medicaid beneficiaries aged 12 years and above are supposed to be screened against depression whenever they visit outpatient clinics in Hawaii. Screening should be achieved with a standardized age-sensitive instrument on the appointment day or within 14 days of the appointment.
In the event that a screening result is positive, a follow-up care plan should be documented by providers the same day. This step would help provide early care and access to mental health services in line with CMS’s objective of enhancing early recognition and treatment of depression.
CMS adult technical specifications and CMS child technical specifications can be reviewed for further guidance.
Providers can access the UnitedHealthcare Provider Portal to find further guidance, resources, and support, including 24/7 chat assistance.
California now has new maternal mental health screening requirements, which it hopes will lead to better care of pregnant and postpartum patients. Under the policy, a health care professional dealing with prenatal care or after birth care is required to perform at least one mental health screening during pregnancy, a screening during the first six weeks after childbirth, and carry out further postpartum screenings in case medically required.
The rules coincide with the recommendations of the American College of Obstetricians and Gynecologists (ACOG), which recommends that obstetric health care providers, such as obstetricians, gynecologists, and others, be screened for depression and anxiety during the first prenatal appointment, during pregnancy, and during postpartum visits using validated and standardizable tools.
Maternal Mental Health Screenings
Providers can access the UnitedHealthcare Provider Portal to find further guidance, resources, and support, including 24/7 chat assistance. Maternal and mental health screening quick reference guide resources are also available.
On July 31, 2025, the Centers for Medicare and Medicaid Services (CMS) published the FY 2026 final rule of the Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS). This sweeping regulation was released as CMS-1833-F and describes the payment rate adjustments, changes to the quality reporting, and regulatory conditions of the hospitals involved in Medicare participation in inpatient and long-term care.
IPPS Rate Changes
CMS completed the adoption of a 2.6 percent increase in operating payment rates to general acute care hospitals that report quality data under the Hospital Inpatient Quality Reporting (IQR) program and report Promoting Interoperability data. This translates to 3.3 percent market basket improvement with a 0.7 percentage point compensation in productivity adjustment. The IPPS market basket was also rebased by CMS to a 2023 base year, with a new national labor-related factor of 66 percent.
The updates will raise the aggregate IPPS payment by $5.0 billion, with an increase of $2.0 billion in Medicare uncompensated care payments and $192 million in new technology add-on payments. The Congressional Budget Office estimates that, unless otherwise renewed by Congress, payments to Medicare-Dependent Hospitals and low-volume hospitals will expire on September 30, 2025, otherwise providing an addition of another $0.5 billion to FY 2026 payments.
LTCH PPS Updates
CMS is adding 2.7 percent as a bump to the LTCH standard payment rate, translating to an anticipated LTCH PPS payment increase of $72 million. The outlier threshold increase will also be undertaken to hold the statutory requirement that outlier payments reflect roughly 8 percent of total payments.
Policy Transition: Adjustment of Low-Wage Index
According to a ruling of the D.C. Circuit Court (Bridgeport Hosp. v. Becerra), CMS will no longer apply the low-wage index hospital policy beginning FY 2026. There will be a narrow transitional exception for seriously affected hospitals.
Quality Reporting and Digital Progression
CMS is furthering digital quality measurement (dQMs) using FHIR-enabled reporting and is sustaining performance-based models across both the IQR and Promoting Interoperability Programs.
ECE policy was also modified by CMS, as it doubled the timeframe of the request submission to 60 days.
Promoting Interoperability Program
Starting no later than CY 2026, CMS will need:
The program is also heading in the direction of performance-based scoring, and the Query of PDMP measure may be updated to capture additional types of drugs and metrics of reporting.
Other Program Updates
LTCH QRP Updates
Starting FY 2028, LTCHs will not have to report four patient assessment items, which pertain to SDOH. CMS also settled changes to the COVID-19 vaccination measure and revised the policy of reconsideration.
Introduction of the TEAM Model
The Transforming Episode Accountability Model (TEAM) starts on 2026 January 1. The chosen hospitals will organize care of five surgical procedures and absorb the costs during the initial 30 days after discharge. Under the model, CMS is tightening performance tracking, pricing procedures, and the process of care transitions.
Administrative Streamlining and Health IT Certification
CMS is requesting input as to how to decrease administrative burdens in accordance with Executive Order 14192 (January 2025). Also, the CMS made final rules to make improvements in e-prescribing, real-time prescription benefits, and electronic prior authorization.
Resources
Full rule text: Federal Register - CMS-1833-F
TEAM model details: CMS Innovation Center
Medicare Regulatory Relief RFI: CMS RFI Portal
The Centers for Medicare & Medicaid Services (CMS) has published its final rule for the Fiscal Year 2026 Skilled Nursing Facility Prospective Payment System (PPS), which contains modifications in the Medicare payment policies and quality programs covering skilled nursing facilities in the country. The last regulation that was issued in the Federal Register [CMS-1827-F] has considerable payment rates, value-based purchasing, and reporting changes on quality.
SNF PPS ( Payment Update )
CMS has completed a 3.2 percent adjustment in SNF PPS payment rates that would increase Medicare payments to SNFs by an estimated 1.16 billion, compared to FY 2025. This growth is based on a 3.3 percent market basket adjustment, 0.6 percent forecast error, and 0.7 percent productivity adjustment. Such numbers do not include the potential decreases in some facilities based on the SNF Value-Based Purchasing (VBP) Program that will amount to 208.36 million dollars.
ICD-10 Code mapping PDPM Revisions
In accordance with the Patient-Driven Payment Model, which was announced in FY 2020, CMS completed 34 ICD-10-CM code mapping updates. The changes are intended to improve primary diagnoses of skilled care to be more accurate and clinically appropriate, and consistent with the most recent ICD-10-CM coding recommendations.
SNF Value-Based Purchasing (VBP) Program
CMS will still retain 2% of what is paid out by SNFs on their part A Medicare dollar to finance the SNF VBP Program, and then redistribution performance will be based on 50-70 percent of what is withheld. Some of the updates are as follows:
SNF QRP (Quality Reporting Program) Changes
The SNFs that do not report under the QRP are liable to a 2 percent reduction in their Annual Payment Update. These four SDOH data elements will be deleted by CMS as part of the Minimum Data Set (MDS), beginning effective October 1, 2025, including two data elements related to food and one each related to living situation and utilities.
CMS also completed the process of revising its reconsideration policy to enable SNFs to apply extensions to reconsideration requests and expand the reasons to request reconsideration. The agency also provided an overview of the stakeholder responses to RFIs covering future quality indicators, digital reporting innovations, and interoperability enhancement.
Seek Public Input
CMS is seeking ongoing stakeholder feedback on regulatory simplification and reduction of administrative burden with a standalone Request for Information (RFI), available at CMS Regulatory Relief RFI. The comments should be submitted by September 15, 2025.
More Information
This last regulation is seen to be an onward step of CMS to increase the accuracy of payment as well as quality improvement, and a decrease of regulatory burden within the SNF industry. The updates will come into force as of October 1, 2025.
Texas Health and Human Services Commission (HHSC) has published the July 2025 National Drug Code (NDC) to Healthcare Common Procedure Coding System (HCPCS) Crosswalk. This monthly change is essential to clinician-administered drug (CAD) processing, and it helps in the submission of accurate Medicaid claims.
The crosswalk details existing NDC-Medicaid-reimbursable HCPCS code ties. It is built on quarterly updates of the Centers for Medicare & Medicaid Services (CMS) list of rebate-eligible drugs, as well as new drug additions to the First Databank pricing compendia.
In order to avoid claims denials, prescribing providers should use the crosswalk to achieve compliance. The most recent changes can be viewed with the CAD Search tool or can be downloaded directly. There are instructions on the use of the search tool also.
Providers can contact HHSC with any additional help or feedback at vdp-cad@hhsc.state.tx.us.
COLUMBUS, OH- As of June 1, 2025, UnitedHealthcare Community Plan of Ohio will deny claims to some home health services unless they use the state-mandated Electronic Visit Verification (EVV) system with Sandata. This complies with the 21st Century Cures Act and the Ohio Medicaid.
Affected services are-
To prevent denials, the providers need to enroll in Sandata and get the required training, and make accurate visits in the EVV platform.
The Ohio Department of Medicaid provides supporting resources such as webinars, fact sheets, and helpline sessions. To get help, the providers may write to ODMCustomerCareEmail@Sandata.com, dial 855-805-3505, or visit a 24/7 chat on the UnitedHealthcare Provider Portal.
To learn more, see the Sandata EVV Portal or the Ohio Medicaid EVV webpage.
One of the latest digital tools meant to simplify the process of provider enrollment introduced by the Texas Medicaid & Healthcare Partnership (TMHP) is the Provider Enrollment Assistant Tool (PEAT). The above interactive, question-based software is also found on the TMHP Provider Enrollment web page, and this software is intended to assist providers in getting quick and precise answers to their questions related to enrollment.
PEAT is an automated assistant, and a user can enter enrollment queries and be responded to with answers or direct links to the resources. The tool will simplify the complex provider enrollment activities and simply assist users through common activities, which include:
In order to access PEAT, the providers must click the Enrollment Help link in the left-hand column of the Provider Enrollment page, then click the Provider Enrollment Assistant Tool button.
Providers who want to use PEAT should have important information like their National Provider Identifier (NPI), ZIP code, taxonomy number, and contact information linked to the NPI.
Other support can be obtained via enrollment walk-through sessions with TMHP provider recruitment and retention experts. It is also possible to schedule sessions with PEAT.
More resources are available through the PEMS Instructional Website and the TMHP YouTube Channel.
You can contact TMHP Center at 800-925-9126.
