The Centers for Medicare & Medicaid Services (CMS) has unveiled a series of proposed measures aimed at increasing transparency, strengthening oversight, and improving accountability within the Medicare hospice program. These proposals are part of the FY 2027 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Program (HQRP) requirements.
At the center of the proposal is a publicly accessible hospice scoring system designed to identify providers that may exhibit patterns of inappropriate utilization, compliance concerns, or questionable billing practices. The system introduces the Service and Spending Variation Index (SSVI), which evaluates hospices based on several key indicators, including non-hospice spending, long lengths of stay (180+ days), average care minutes per day, and patterns of live discharges.
While CMS emphasizes that a high SSVI score does not directly indicate fraud, it signals potential areas of concern that may warrant further review. Provider-level data and scores would be made available on CMS platforms, enabling greater visibility for regulators and the public.
To further empower patients and families, CMS is proposing the addition of a consumer-friendly indicator on the Medicare.gov Care Compare tool. This icon would identify hospices that fail to meet HQRP reporting requirements, alerting users when sufficient quality data is unavailable to evaluate a provider’s performance.
CMS reports that approximately 20% of hospices were non-compliant with HQRP requirements in 2025, a trend that has remained consistent in recent years. The proposed measure aims to incentivize compliance while helping beneficiaries make informed care decisions.
Another key proposal would require hospices to provide a hospice election statement addendum to all Medicare beneficiaries at the time of enrollment. Previously issued only upon request, this document outlines which services, medications, and conditions are not covered under the hospice benefit.
By making this information universally available upfront, CMS intends to reduce confusion, improve transparency, and potentially lower out-of-pocket costs for patients and their families during end-of-life care.
These proposals build on CMS’s broader program integrity initiatives, which include unannounced site visits and targeted oversight in high-risk states such as Arizona, California, Nevada, and Texas. These efforts have already led to over 200 hospice enrollment revocations due to non-compliance, with expanded oversight now extending to additional states.
CMS also outlined updates to hospice payment rates for FY 2027. The agency proposes a 2.4% increase in hospice payments, equating to an estimated $785 million rise from FY 2026. This adjustment reflects a 3.2% market basket increase offset by a 0.8 percentage point productivity adjustment.
However, hospices that fail to submit required quality data would face a financial penalty. Their payment rates would be reduced by four percentage points, resulting in a 1.6% decrease compared to the previous year.
Additionally, the proposed hospice aggregate cap for FY 2027 is set at $36,210.11, limiting the total annual payments a hospice provider may receive.
CMS officials state that these measures are intended to safeguard Medicare beneficiaries, curb misuse of funds, and support high-quality hospice providers delivering compassionate care. The proposed rule reflects a continued shift toward data-driven oversight and increased transparency across the healthcare system.
If finalized, these changes could significantly reshape how hospice providers are evaluated, monitored, and reimbursed under Medicare.
In a significant escalation of federal healthcare fraud enforcement, the Centers for Medicare & Medicaid Services (CMS) has announced a six-month nationwide enrollment moratorium on select durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers. The moratorium, effective February 27, 2026, marks the first time CMS has implemented such a restriction on a national scale.
The move aligns with a broader anti-fraud initiative under the administration of Donald Trump, following a March 16 executive order establishing the Task Force to Eliminate Fraud. The task force, chaired by JD Vance, is expected to deliver a coordinated national strategy within 90 days. CMS Administrator Mehmet Oz emphasized that the moratorium is designed to curb fraud, safeguard beneficiaries, and ensure quality care delivery.
The moratorium, currently set to run through August 27, 2026, applies to seven categories of DMEPOS suppliers classified as “medical supply companies,” including those employing orthotics, prosthetics, pedorthic personnel, pharmacists, and respiratory therapists. Initial enrollment applications submitted during this period will be denied, while those filed before the effective date remain under review.
CMS retains the authority to extend the moratorium in six-month increments under federal regulation (42 C.F.R. § 424.570), citing concerns over fraud, waste, and abuse. The agency has also warned that attempts to bypass the restrictions could result in severe penalties, including up to a 10-year re-enrollment ban and referral to oversight bodies such as the Office of Inspector General (OIG).
Adding further complexity, CMS expanded the “36-month rule” (42 C.F.R. § 424.551) to include DMEPOS suppliers effective January 1, 2026. Under this rule, a change in majority ownership (CIMO) within 36 months of enrollment triggers a requirement for re-enrollment—effectively subjecting such transactions to the moratorium.
This development has major implications for mergers and acquisitions (M&A). Asset purchases, which typically require new enrollment, are effectively blocked during the moratorium unless buyers can delay closing or operate without Medicare or Medicaid revenue. Even stock transactions may carry risks, including exposure to historical liabilities.
In a rapid response to CMS’s call for state-level action, Florida became the first state to implement a Medicaid-specific DMEPOS enrollment moratorium. Approved by CMS and announced on March 25, 2026, the state’s freeze took effect retroactively from March 20 and will remain in place through approximately September 20, 2026.
Issued by the Florida Agency for Health Care Administration (AHCA), the moratorium applies broadly to DME providers (provider type 90) across all counties. Similar to the federal rule, it excludes pharmacies, hospitals, and providers for whom DME services are not a primary function.
Applications submitted before March 20 will continue to be processed, while existing providers may maintain operations and billing. However, the delayed issuance of AHCA’s alert five days after the effective date has raised concerns that some providers may have unknowingly submitted applications during the restricted period.
The federal and Florida moratoria are not fully synchronized. While the CMS restriction ends on August 27, Florida’s extends nearly three weeks longer, potentially creating operational uncertainty for suppliers operating in both programs.
Additionally, CMS’s moratorium targets specific supplier categories, whereas Florida’s applies broadly without subcategory distinctions. This divergence may result in suppliers being restricted under one program but not the other.
The dual moratoria significantly restrict market entry in Florida, particularly affecting suppliers serving dual-eligible populations. With most Medicaid beneficiaries enrolled in managed care, the inability to onboard new suppliers could strain network adequacy and shift negotiating leverage toward existing providers.
Managed care organizations (MCOs), which require Medicaid enrollment prior to credentialing, may face challenges in maintaining sufficient provider networks during the moratorium period.
| Element | Florida Medicaid Moratorium |
| Effective Date | March 20, 2026 |
| Duration | Initial six-month period (through approximately September 20, 2026) |
| Scope | DME providers (provider type 90) in all Florida counties |
| Exclusions | Pharmacies, hospitals, or other medical providers that provide DME as a “secondary function.” |
| Pending Applications | Applications submitted on or before March 20, 2026, will continue to be processed |
| Existing Providers | May continue to deliver and bill for authorized services |
CMS has signaled intensified oversight across all program integrity areas, including enrollment verification, billing practices, site inspections, and ownership disclosures. The agency continues to exercise strict enforcement of DMEPOS supplier standards, with even minor compliance failures potentially leading to revocation and re-enrollment bars.
Suppliers are advised to maintain rigorous documentation, conduct internal audits, and prepare for heightened scrutiny. Engagement with legal counsel is recommended in the event of inquiries from CMS, the OIG, the Department of Justice, or state Medicaid Fraud Control Units.
CMS’s invitation for states to adopt similar Medicaid moratoria suggests that additional states may follow Florida’s lead. Jurisdictions with historically high levels of DME fraud—such as Texas, California, and Michigan are considered likely candidates.
As regulatory activity accelerates, DMEPOS suppliers, investors, and healthcare stakeholders must closely monitor federal and state developments and reassess compliance strategies, transaction structures, and market entry plans in a rapidly evolving enforcement environment.
In a significant move to modernize chronic care delivery, the Centers for Medicare & Medicaid Services (CMS) has announced the launch of the Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model. This new initiative is designed to expand the use of digital health technologies while shifting reimbursement toward measurable patient outcomes.
The ACCESS Model introduces Outcome-Aligned Payments (OAP), a structure in which providers receive fixed per-beneficiary payments tied directly to the achievement of defined clinical outcomes. This marks a clear transition from traditional fee-for-service models to value-based care.
The model is scheduled to run from July 5, 2026, through June 30, 2036, with applications opening in 2026 and continuing on a rolling basis through early 2033. Providers seeking to join the first cohort, beginning July 2026, were required to submit applications by April 1, 2026.
Eligible participants include Medicare Part B-enrolled providers and suppliers, excluding Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) providers and laboratories. Notably, digital health companies that are not directly enrolled may participate through partnerships with eligible providers.
The model is aimed at Original Medicare (fee-for-service) beneficiaries with qualifying chronic conditions categorized under four clinical tracks:
Participation requires the use of FDA-compliant digital health tools, including connected devices and software solutions, as well as technologies involved in the TEMPO Pilot.
Payment levels range from $90 to $420 annually per beneficiary, depending on the clinical track and other factors. Half of the payment is distributed monthly, while the remaining 50% is withheld and released at year-end based on performance. Providers can recover the full withheld amount if at least 50% of their patients meet the defined clinical outcome targets.
A key requirement of the ACCESS Model is that participating providers cannot bill Medicare Fee-for-Service (FFS) for beneficiaries during active care periods under the program. However, CMS has clarified that participants may still engage in other CMS initiatives, including upcoming models such as LEAD.
Additionally, CMS is evaluating a temporary policy to exclude ACCESS-related spending from accountable care organization (ACO) financial benchmarks during the program’s first year, with plans to incorporate these costs into broader total cost-of-care calculations in subsequent years.
The ACCESS Model represents a major step in CMS’s broader strategy to integrate digital health into routine care while aligning financial incentives with patient outcomes. By emphasizing measurable improvements in chronic disease management, the initiative is expected to accelerate innovation and improve long-term care quality for Medicare beneficiaries.
A significant reimbursement policy change has been announced affecting orthotists enrolled in the Children with Special Health Care Needs (CSHCN) Services Program. Effective April 2, 2026, procedure code L6028 will no longer be reimbursable for orthotists for dates of service on or after April 1, 2025.
However, TMHP has confirmed that reimbursement for procedure code L6028 may still be available when billed by prosthetists and durable medical equipment (DME) suppliers, provided all applicable billing guidelines and requirements are met.
For additional details or clarification, providers can contact the TMHP-CSHCN Services Program Contact Center at 800-568-2413.
Effective April 1, 2026, the Texas Medicaid & Healthcare Partnership (TMHP) will apply surgical procedure code additions, deletions, and revisions tied to the 2026 updates for the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS). These ICD-10-PCS codes are used for inpatient hospital procedures and should be submitted only on inpatient hospital claims, when applicable.
For professional services and outpatient procedures, providers should continue using the American Medical Association Current Procedural Terminology manual and the Centers for Medicare & Medicaid Services Healthcare Common Procedure Coding System manual.
When reviewing ICD-10-PCS procedure codes, providers should check the official code set from the appropriate copyright holder for full descriptions of all newly added, discontinued, and revised codes. Texas Medicaid will no longer reimburse discontinued procedure codes for dates of service on or after April 1, 2026.
These surgical procedure codes are used to support proper diagnosis-related group assignment for an inpatient hospital stay. They are processed for informational purposes only.
| New PCS Surgical Procedure Codes | |||||||||
| 02HM3JZ | 02HM3KZ | 02HM3MZ | 02HM3NZ | 02HM3YZ | 0DDU0ZZ | 0DDU4ZZ | 0DDV0ZZ | 0DDV4ZZ | 0F9480D |
| 0F9480E | 0F9580D | 0F9580E | 0F9680D | 0F9680E | 0F9780D | 0F9780E | 0F9880D | 0F9880E | 0F9980D |
| 0F9980E | 0F9C80D | 0F9C80E | 0F9D80D | 0F9D80E | 0F9F80D | 0F9F80E | 0F9G80D | 0F9G80E | 0TXB0Z6 |
| 0TXB0Z7 | 0TXB4Z6 | 0TXB4Z7 | 0VT00ZE | 0VT04ZE | 0VT07ZE | 0VT08ZE | 3E033AZ | 3E043AZ | 4A0FXEJ |
| 5A0221E | F07DYD0 | F07EYD0 | F07FYD0 | F07GYD0 | F07HYD0 | F08E5AZ | F08E5BZ | F08E5CZ | F08E5DZ |
| F08E5EZ | F08E5FZ | F08E5UZ | F08E5YZ | F08E5ZZ | F08P5AZ | F08P5BZ | F08P5CZ | F08P5DZ | F08P5EZ |
| F08P5FZ | F08P5UZ | F08P5YZ | X2723CB | X2HM3GB | X2HV3GB | X2K00FB | X2KG0FB | X9HD01B | X9HE01B |
| X9HF01B | XU7G71B | XW0330B | XW0331B | XW0430B | XW0431B | XW0534B | XW0632B | XW0E33B | |
| Discontinued PCS Surgical Procedure Codes | |||||||||
| 30233AZ | 30243AZ | ||||||||
| Revised PCS Surgical Procedure Code | |||||||||
| X2H03BB | |||||||||
Providers who need more information may contact the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.
TMHP also reminds providers that Texas Medicaid managed care organizations are responsible for covering all medically necessary Medicaid services for enrolled members. Even so, administrative requirements such as prior authorization, precertification, referrals, claims filing, and encounter data submission may differ from traditional fee-for-service Medicaid and may also vary between managed care organizations. Providers should check directly with the member’s specific MCO for plan-level requirements.
Beginning April 1, 2026, TMHP will apply the second-quarter NCCI updates to Texas Medicaid and the Children with Special Health Care Needs Services Program.
Providers can review the updated Medicaid NCCI guidance, coding edits, and procedure relationships on the CMS Medicaid NCCI webpage. Since these rules may change, it is important for providers to review the CMS page regularly for the latest information. TMHP also includes a link to that page under the Rate and Code Updates section on tmhp.com.
For support, providers may contact the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.
Note: TMHP also reminds providers that Medicaid managed care organizations in Texas must continue to provide all medically necessary covered services to enrolled members. However, the administrative side of the process may differ. Prior authorizations, referrals, precertification, and claim submission steps may vary from traditional Medicaid and may not be the same across all MCOs. Providers should confirm the exact process with the member’s health plan before proceeding.
Texas Medicaid has released an important clarification regarding reimbursement policies for procedure code L6028, impacting prosthetist and orthotist providers.
Effective March 26, 2026, procedure code L6028 has been officially recognized as a payable benefit for prosthetist providers, applicable to dates of service on or after April 1, 2025. Additionally, the code remains a payable benefit for durable medical equipment (DME) suppliers.
However, Texas Medicaid identified a processing discrepancy affecting claims submitted on or after April 1, 2026. Due to this issue, some claims may have been incorrectly reimbursed to orthotist providers while being erroneously denied for prosthetist providers. The agency has clarified that orthotist providers are not eligible for reimbursement under procedure code L6028.
To address this error, Texas Medicaid has confirmed that all affected claims will be systematically reprocessed. Any resulting recoupments or additional reimbursements will be reflected in the upcoming Remittance and Status (R&S) Reports.
Providers are advised to monitor their reports closely for adjustments related to this update. For further assistance or clarification, providers may contact the Texas Medicaid & Healthcare Partnership (TMHP) Contact Center at 800-925-9126.
This update underscores the importance of accurate provider classification in claims submission and ongoing vigilance in reviewing reimbursement reports.
Effective October 1, 2026, new prior authorization requirements will be implemented for specific oncology-related procedure and medication codes across multiple health plans. The update applies broadly to commercial, Medicare, Medicaid, and individual exchange plans, aligning with recent procedure code changes issued by the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA).
Prior authorization will now be required for the following HCPCS codes when used in outpatient settings for cancer treatment:
The updated prior authorization requirements will affect a wide range of plans under UnitedHealthcare, including:
For additional guidance or clarification, providers can:
In a major step toward modernizing health care administration, the Centers for Medicare & Medicaid Services (CMS) has finalized the Administrative Simplification; Adoption of Standards for Health Care Claims Attachments Transactions and Electronic Signatures Final Rule (CMS-0053-F).
This rule introduces, for the first time under HIPAA, standardized methods for the electronic exchange of healthcare claims attachments, significantly reducing reliance on manual processes such as faxing and mailing.
The rule creates a unified framework for securely transmitting supporting clinical documentation required for claims adjudication, including:
In addition, it mandates electronic signature standards to ensure all transactions are authenticated, secure, and compliant with federal regulations.
These standards define how attachments are requested and transmitted electronically.
These frameworks ensure consistency in how clinical documentation is structured and shared.
CMS projects that the implementation of these standards will deliver measurable improvements across the health care ecosystem:
The rule fulfills long-standing federal mandates under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which required the adoption of standardized electronic transactions for health care data exchange.
It also aligns with provisions of the Patient Protection and Affordable Care Act, which reinforced the need for standardized health claims attachment transactions.
Historically, the absence of such standards forced providers to rely on inefficient manual submission methods, contributing to delays, increased costs, and administrative complexity.
The rule has been developed in collaboration with a wide range of stakeholders, including:
Its implementation is expected to streamline workflows and improve interoperability across the health care system.
CMS is urging all stakeholders to begin preparation immediately to ensure timely compliance.
The CMS-0053-F final rule marks a pivotal advancement in health care data exchange, introducing long-awaited standardization for claims attachments. By enabling secure, electronic transmission of clinical documentation, the rule is expected to reduce administrative friction, enhance efficiency, and ultimately support better patient care outcomes across the U.S. health care system.
UnitedHealthcare has announced an expanded list of clearinghouse vendors capable of transmitting EDI 275 unsolicited claim attachments, reinforcing its push toward faster, more efficient, and fully electronic claims processing.
The update is aimed at healthcare providers seeking to streamline billing workflows and reduce administrative burdens associated with paper-based documentation.
The adoption of Electronic Data Interchange (EDI) 275 allows providers to submit supporting documentation electronically at the time of claim submission, eliminating the need for traditional mail-based processes. This transition is expected to significantly enhance claim adjudication timelines and reduce delays caused by missing or incomplete information.
According to the update, using a clearinghouse for claim transactions improves processing speed and accelerates reimbursements compared to paper claims.
UnitedHealthcare highlighted several operational and financial advantages associated with EDI 275 transactions:
UnitedHealthcare confirmed it currently accepts EDI 275 unsolicited claim attachments through the following clearinghouse vendors:
Providers are encouraged to contact their respective clearinghouse partners to enable EDI 275 transactions within their existing workflows.
For providers not yet utilizing EDI 275, UnitedHealthcare confirmed that supporting documentation, both solicited and unsolicited, can still be uploaded via the UnitedHealthcare Provider Portal. This ensures continued flexibility while organizations transition to electronic submission methods.
UnitedHealthcare advises providers to explore additional EDI transaction capabilities and code sets to understand system functionality better and optimize usage.
For assistance, providers can access 24/7 chat support through the Provider Portal or contact UnitedHealthcare EDI Support for technical guidance related to EDI 275 submissions.
