CMS has issued new guidance to help states prepare for a policy change that begins on October 01, 2026. Under this change, states will face new limits on claiming federal matching funds for Medicaid and the Children’s Health Insurance Program (CHIP) for certain noncitizens. This includes people who are not U.S. citizens or U.S. nationals, along with other groups named in federal law.
CMS said the guidance is meant to help states understand their role and apply the new rules correctly.
“The Trump administration has a public mandate, a statutory obligation, and a moral duty to safeguard our federal healthcare programs,” said CMS Administrator Dr. Mehmet Oz. “Today, we’re honoring all three by providing clear guidelines to help states follow the law and safeguard taxpayer dollars.”
The State Health Official letter explains how states should carry out Section 71109 of the Working Families Tax Cut legislation, Public Law 119-21. It gives direction on eligibility systems, applications, verification, and claims processing. CMS will also offer technical help and use its current oversight tools to support compliance and accurate federal fund claims.
Some exceptions remain under the new limits. Federal Medicaid matching funds will still be available for the treatment of emergency medical conditions. The law also does not change the option for states to cover lawfully residing children and pregnant women through Medicaid and CHIP. It also does not affect matching funds for Health Services Initiatives in CHIP.
To view the State Health Official letter, visit: https://www.medicaid.gov/federal-policy-guidance/downloads/sho26001.pdf
The CMS Innovation Center has issued a request for applications (RFA) for the Long-term Enhanced ACO Design (LEAD) model. This is a new 10-year accountable care program set to start in 2027. It updates how ACOs are benchmarked, paid, and structured and brings some features of Medicare Advantage into original Medicare. Applications are due by May 17, 2026.
For healthcare stakeholders, LEAD changes how accountable care programs may be approached. Its design around benchmarks, risk, and patient incentives can affect financial results, care delivery, and competition between ACOs and Medicare Advantage plans.
As specialty care providers prepare for changes in payment and reporting under the Centers for Medicare & Medicaid Services Ambulatory Specialty Model (ASM), healthcare lenders should also take note.
The ASM is a required, five-year payment model with two-sided risk. It starts on January 01, 2027. The model focuses on managing chronic conditions through planned care. It runs from 2027 to 2031, followed by two years for data reporting, payment review, and final adjustments, ending in 2033.
Payment changes apply two years after each performance year, using a timeline similar to the Merit-based Incentive Payment System.
Under the mandate of the Center for Medicare and Medicaid Innovation (CMMI), CMS will keep a portion of redistributed funds to ensure Medicare savings. Payments are based on performance within condition-specific groups, so clinicians are compared with peers treating the same condition.
The ASM relies on the MIPS framework. These measures are still new in practice, so the model will test them before any wider use. Expansion to other specialties may come later.
This model marks a move from voluntary programs to required, clinician-level accountability. It uses a longer time frame to support lasting change. Early participants include specialists treating heart failure and low back pain in selected areas, with the final list expected by summer 2026.
The ASM ties payments to how each clinician performs. This creates more variation in revenue. Practices with strong care processes, good EHR use, and clear coordination will handle this shift better. Others may see unstable payments as accountability moves to the clinician level.
For lenders, operations and data systems now matter more in risk review. Practices that can track episodes, manage referrals, and link pay to outcomes are more likely to keep steady cash flow.
Key points to watch:
ASM brings the required two-sided risk to specialty care. It reduces payment certainty and shifts focus to performance. Lenders need a closer look at operations, data, and clinician-level results when assessing risk.
The Texas Medicaid & Healthcare Partnership (TMHP) has released a detailed timeline for processing and paying Long-Term Care (LTC) Fee-for-Service (FFS) claims.
The timeline shows each step after a claim is submitted. It helps providers understand how claims move through the system.
Providers can access the timeline under the General Information section on the TMHP LTC Reference Material page or within the 1915(c) Waiver Programs Reference Material section.
For updates on claim and payment processing, including alerts about delays such as holidays or office closures, providers can subscribe to LTC Provider Alerts issued by the Texas Health andHuman Services Commission (HHSC).
For any questions or support, providers can contact the TMHP LTC Help Desk at 800-626-4117.
Starting July 01, 2026, OhioRISE enrollment will begin on the first day of the month a member becomes eligible.
This update comes from the Ohio Department of Medicaid under rule 5160-59-02. The change aligns enrollment with managed care timelines and reduces the need for retroactive enrollments, especially for inpatient behavioral health cases.
Providers can connect through 24/7 chat via the UnitedHealthcare Provider Portal.
Starting July 01, 2026, UnitedHealthcare will introduce prior authorization requirements for two transcatheter heart valve procedure codes under select UnitedHealthcare Community Plans:
These procedure codes were previously categorized as unproven. Following recent changes in clinical evidence, the services are now recognized as proven in specific clinical situations. Because of this update, requests for these services will now go through a medical necessity review to confirm whether coverage criteria are satisfied. More information can be found in the UnitedHealthcare Community Plan Medical Policy.
This change applies to UnitedHealthcare Community Plans in the following states:
Providers can submit and manage requests through the UnitedHealthcare Provider Portal by following these steps:
For additional help, providers can use the 24/7 chat support available through the UnitedHealthcare Provider Portal.
Effective July 01, 2026, UnitedHealthcare will update its prior authorization requirements for genetic and molecular testing to align with the latest changes issued by the American Medical Association. This update applies to select UnitedHealthcare commercial plans as well as UnitedHealthcare Individual Exchange Plans.
The revised requirements apply nationwide to the following plans:
Along with the currently included codes, the following procedure codes will now require prior authorization or advance notification:
Additional details are available in UnitedHealthcare’s genetic and molecular testing resources.
Providers can complete the process through the UnitedHealthcare Provider Portal by following these steps:
For support, providers can connect with UnitedHealthcare through the 24/7 chat feature available in the UnitedHealthcare Provider Portal.
Starting January 01, 2026, UnitedHealthcare Community Plan of New York no longer requires referrals for one follow-up visit with certain specialists when the visit takes place within 7 days of a member’s discharge from the hospital or emergency room.
This change applies to these specialist categories:
The referral waiver applies only to the first follow-up visit after discharge. If the member needs more visits after that, the specialist must get a referral from the member’s primary care provider (PCP) to continue care.
If a member is not connected with a PCP or does not know who their PCP is, UnitedHealthcare asks the member to call Member Services using the phone number listed on the back of their ID card.
Providers who need help can also use the chat feature in the UnitedHealthcare Provider Portal, which is available 24/7.
To align with American Medical Association code changes, UnitedHealthcare will update prior authorization and advance notification requirements for certain genetic and molecular procedure codes starting July 01, 2026.
Providers are asked to review the state-specific code lists to confirm which prior authorization or advance notification requirements are being added or removed.
These changes will apply to the following UnitedHealthcare Community Plans:
To submit and manage prior authorizations, providers can use the UnitedHealthcare Provider Portal with a One Healthcare ID.
The process includes:
UnitedHealthcare also directs providers to its Genetic and Molecular Testing Prior Authorization/Advance Notification Program resources for more information.
Providers who need help can use the chat feature in the UnitedHealthcare Provider Portal, which is available 24/7.
Starting January 01, 2026, the Centers for Medicare & Medicaid Services updated radiation treatment procedure codes as part of the 2026 annual HCPCS update.
As part of the annual update, CMS discontinued previously active procedure codes 77014, 77385, and 77386 and the following G codes for claims for image-guidance services in offices and clinics:
| G Codes | ||||||
| G6001 | G6002 | G6003 | G6004 | G6005 | G6006 | G6007 |
| G6008 | G6009 | G6010 | G6011 | G6012 | G6013 | G6014 |
| G6015 | G6016 | G6017 | ||||
CMS did not assign direct replacement codes for the discontinued codes.
The usual review period for payers and state Medicaid programs was shorter than normal because of the federal government shutdown. CMS could not release the annual HCPCS file on its usual schedule. Because of that delay, many programs did not have enough time to fully review the effect on claims and reimbursement before the changes started.
The Texas Health and Human Services Commission said it is aware of the problem and the effect it may have on providers and members receiving care. HHSC is working on a fix and has submitted a Medicaid State Plan Amendment to CMS. HHSC requested an effective date of January 01, 2026.
HHSC will also hold a rate hearing on April 24, 2026. The hearing will cover proposed changes meant to address the effect of the discontinued codes. Providers can find meeting notices on the Texas Health and Human Services Meetings & Events page. Rate hearing packets are also available on the Provider Finance Department page.
At this time, CMS allows reimbursement for the affected services in office and clinic settings under these procedure codes:
HHSC is asking affected providers to file claims on time using the code that best matches the service provided. For now, that means using 77402, 77407, or 77412 while system updates are still in progress.
Because the HCPCS update took effect on January 1, 2026, the first 95-day filing deadline for these claims is Monday, April 06, 2026.
Providers should still submit timely claims, but they should also know that claims may continue to be denied in some cases. This may affect billing providers that use 77402, 77406, or 77412 in office or clinic settings until CMS approvals are complete and HHSC finishes the rate hearing process.
HHSC said it will share more guidance on claims submission and any added steps that providers or MCOs may need to take.
For more information, providers can contact the Texas Medicaid & Healthcare Partnership Contact Center at 800-925-9126.
