The Centers of Medicare and Medicaid Services (CMS) confirmed that all 50 states have applied for the $50 billion Rural Health Transformation Program, which is an extensive initiative established under the Working Families Tax Cuts law ( Public Law 119-21). The program will be used to restore and modernize the rural health care systems in the country.
The application period, which is open between September 15 and November 5, 2025, advises states to suggest detailed plans to increase access, improve quality, and health outcomes in rural communities. Both proposals contain plans specific to enhancing infrastructure, expediting innovation, and promoting long-term sustainability.
HHS Secretary Robert F. Kennedy, Jr. said, “When every state steps up to strengthen rural health, it shows the true character of our nation.” “Seeing all 50 states come forward to reimagine the future of rural health is an extraordinary moment,” said CMS Administrator Dr. Mehmet Oz. “
The program is based on five strategic objectives that are to:
CMS will now review all submissions for completeness and eligibility. States meeting the baseline criteria will receive 50% of the total program funds. The remaining 50% will be allocated through a merit-based review conducted by federal and non-federal experts to ensure alignment with program objectives.
Award announcements are expected by December 31, 2025. Funding will be disbursed over five years beginning in fiscal year 2026, with CMS’s Office of Rural Health Transformation providing ongoing technical assistance throughout implementation.
Additional information is available at:
https://www.cms.gov/priorities/rural-health-transformation-rht-program/rural-health-transformation-rht-program
The update specifies the conditions in CHOW scenarios, differentiating between procedures when the buyer (new owner) and the seller (Old owner) have identical National Provider Identifier (NPI) or different NPIs.
Two procedures exist for the use of different NPIs/ Atypical Provider Identifier (API) between the new and old owners:
Note: The old NPI will be disenrolled after the new enrollment is done. Others filed under the old NPI on services provided after the CHOW effective date will not be reimbursed.
When the seller and the buyer have the same NPI, the buyer lacks an active enrollment against this identifier, and the buyer is required to file a PEMS-New Enrollment application to create a new profile, indicating the new ownership. Disenrolling the former ownership profile will then be done.
| NPI/API Change? | PEMS Application Type |
| No | New Enrollment |
| Yes, and the new owner’s NPI/API is active in PEMS | Existing Enrollment |
| Yes, and the new owner’s NPI/API is not active in PEMS | New Enrollment |
The clarification emphasizes reviewing §489.18 Change of ownership or leasing: Effect on provider agreement to identify whether a transaction is a true CHOW.
A CHOW is not represented by the following:
These changes should rather be reported under PEMS-Maintenance - Ownership/Controlling Interest update.
Additional guidance is available to the providers through:
To help, the providers can refer to the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.
Texas Health and Human Services Commission has introduced a new condition on Day Activity and Health Services (DAHS) providers who want to be enrolled in Texas Medicaid. Providers are required to reveal an activities director as a part of their application in the Provider Enrollment and Management System (PEMS).
The activities director will be considered a managing employee or principal. Therefore, this person should be included in the section of the PEMS application that is called Owner/Creditors/Principals.
To avoid delays in the processing of providers, it is recommended that they carefully complete the following steps:
PEMS instructional materials would be updated in line with this new requirement. To help, the TMHP Care Help Desk can be reached at 800-626-4117 by the DAHS providers.
UnitedHealthcare has confirmed significant changes in its Individual Exchange plans in 30 states. They plan to expand services in 11 states.
Visit the UnitedHealthcare Individual Exchange plan resources for the latest information.
Sanitas Medical Group will introduce new capitated primary care plans in the San Antonio region in Texas. The Kelsey-Seybold capitated plans will still be in the Houston market. Further plan and network information can be found in the Interactive Guide or the Texas Quick Reference Guide for Exchanges
The Massachusetts (Navigate) and New York (Compass) Individual Exchange plans of the UnitedHealthcare will move to a new claims platform as of Jan. 1, 2026. This will lead to altered remittance formats, and new addresses of the appeal submission have been provided.
For Massachusetts and New York medical, OBH, dental, or vision cases, submit appeals to:
For pharmacy cases, if the appeal or non-formulary exception is before Jan. 1, 2026, and the member doesn’t have coverage after Jan. 1, 2026, submit appeals to:
For pharmacy cases, if the appeal or non-formulary exception is before Jan. 1, 2026, and the member has coverage after Jan. 1, 2026, submit appeals to:
You can go to the list of codes requiring prior authorization for more info.
UnitedHealthcare has published revised materials for providers as mentioned below:
Providers are advised to:
The providers have the option of seeking assistance via the provider advocate, the UnitedHealthcare Provider Portal, or the Individual Exchange plans resource center.
According to UnitedHealthcare Community Plan of Texas, there is an announcement of a significant change to the previous process of prior authorization of the long-term skilled nursing services in Texas Medicaid.
It is effective immediately, so the providers should no longer place prior authorization requests directly with UnitedHealthcare on procedure codes S9123 and S9124. Rather, a provider has to call a service coordinator in order to seek an assessment in case a member needs long-term skilled nursing support.
In the new process, service coordinators will complete patient assessments and provide them to Texas Health and Human Services Commission (HHSC) to be evaluated as eligible under Home and Community-Based Services (HCBS) or Long-Term Services and Supports (LTSS). HHSC shall decide on the eligibility.
The UnitedHealthcare service coordinator can be contacted by calling 800-349-0550 by the providers who require assistance in the case of STAR+PLUS members.
The STAR+PLUS Medicaid program members who are subject to HCBS waivers might be eligible to receive long-term skilled nursing services that last six months or more, under the condition of medical need.
In the case of acute skilled nursing, prior authorization is relevant to both procedure codes G0299 and G0300 regarding short-term care that is medically necessary in a home health or hospice facility by a registered or licensed practical nurse. Using One Healthcare ID, providers are able to send requests via the UnitedHealthcare Provider Portal.
If you believe our member, your patient, needs acute skilled nursing care, then:
The UnitedHealthcare Provider Portal also offers 24/7 chat support to providers.
The Texas Health and Human Services Commission (HHSC) reminds providers that any healthcare professional enrolling in Texas Medicaid must also be registered with Medicare if they serve Medicare beneficiaries. This rule applies to all new enrollments, revalidations, and updates completed through the Provider Enrollment and Management System (PEMS).
In the updated PEMS system, providers who answer “No” to the question “Are you using a Medicare certification number for this location?” will now receive an on-screen warning. The message refers to the Texas Administrative Code, Title 1, Part 15, Section 352.13, Medicare Certification or Enrollment in Medicare, where the providers are required to be enrolled or certified in Medicare before submitting their Medicaid applications.
HHSC also states that, in accordance with Section Texas Administrative Code, Title 1, Part 15, Section 371.1703(c)(4), the enrollment contract of a provider can be rejected or canceled under the condition of providing false information in the application procedure. If a provider selects no and later provides Medicare services without prior Medicare will face reprimands such as termination in Texas Medicaid as stated in 42 CFR Section 455.416(g)(1).
Providers should confirm their Medicare enrollment status before they make Medicaid enrollment applications in PEMS. The individuals who work with Medicare beneficiaries need to get a valid Medicare ID and make sure that PEMS records are updated accordingly.
To have a step-wise instruction, the providers may access the TMHP Provider Enrollment webpage or call the TMHP Contact Center, 800-925-9126.
October 16, 2025 -UnitedHealthcare has declared that it will cover Medicare Advantage (MA) members with its full telehealth benefits until 2026, regardless of Origins Medicare’s reduced temporary COVID-19 telehealth flexibilities on September 30, 2025.
This ruling means that the members of the UnitedHealthcare MA are able to receive both audio-video and audio-only telehealth visits at home as long as they are offered by an in-network physician, non-physician practitioner (NPs and physician assistants (PAs)), and mental health professional. Covered services should be added to the existing Medicare Telehealth List for the Centers for Medicare and Medicaid Services (CMS).
Coverage Details
The move follows CMS’s expiration of pandemic-era telehealth provisions for Original Medicare, which now only covers limited in-home telehealth, including mental health services (with prior in-person visits), ESRD home dialysis, and visits from qualifying rural originating sites equipped for remote care.
UnitedHealthcare’s continued coverage aims to preserve convenient, equitable access to care for Medicare Advantage members nationwide, supporting both physical and mental health needs from the comfort of home.
Providers and members seeking more information can connect with UnitedHealthcare through the 24/7 chat support available on the UnitedHealthcare Provider Portal.
Beginning January 1, 2026, the majority of members of UnitedHealthcare Medicare Advantage HMO and HMO-POS plans will need to get a referral from a primary care practitioner (PCP) before seeing some of the specialists in an outpatient, office, or home environment. With this new policy, PCPs will have to process the referral with UnitedHealthcare prior to the specialization visit.
The referral will not be necessary in the case of:
UnitedHealthcare is not to deny claims without referrals to the date of service until April 30, 2026. Nevertheless, as of May 1, 2026, claims made regarding specialist services in the absence of an approved referral will be rejected, and the rejection must be treated as provider liability-members should not be balance billed in the circumstance.
It is worth mentioning that the referrals to the 2026 plan year cannot be made prior to January 1, 2026. Besides, the claims can still be rejected in case of a referral, even when the service is not covered by the plan of a member, or when necessary prior authorization is not presented.
The changes are not applicable to members who take Institutional SNP plans, Erickson Advantage plans, or the Michigan Integrated DSNP plan (H2247-005). Delegated provider groups are also allowed to have their referral processes.
The current referral policies in California, Nevada, and Texas will remain the same, in which referrals are already obligatory to all services in 2026. The providers are advised to consult the Evidence of Coverage of the members for state-specific information and exclusions.
UnitedHealthcare has even provided a number of digital tools that providers can use to check eligibility, referrals, and referral statuses using the UnitedHealthcare Provider Portal. Additional details are available under the UnitedHealthcare Medicare Advantage Referral Guide and 2026 Medicare Advantage, CSNP & DSNP Plan Overview Course.
To get additional help, the providers can contact the representatives of UnitedHealthcare through the 24/7 chat support in the Provider Portal.
UHC announced that starting January 1, 2026, it will have new requirements for members of its Special Needs Plans (SNP) (Chronic (C-SNP), Dual-Eligible (D-SNP), and Institutional Equivalent (IE-SNP)) in accordance with new Centers for Medicare & Medicaid Services (CMS) regulations.
With this change, there are new and current SNP members who have a qualifying chronic condition documented to be able to receive Special Supplemental Benefits for the Chronically Ill (SSBCI), in which coverage of healthy food and/or utility expenditures is included. The requirement makes sure that Medicare Advantage plans verify and document the status of each eligible member on the following chronic conditions.
The list of eligible conditions may be found at CMS.gov.
Verification Process
C-SNPs and IE-SNPs: The eligibility will be established by using a chronic condition verification form in the registration of the plan and qualification to SSBCI.
D-SNP members: The confirmation will consist of a record attestation of a qualified diagnosis or attestation of the provider. UnitedHealthcare shall also call the office of a provider to verify eligibility in the event that the existence of the record does not prove the same.
The failure to do the verification within 60 days will lead to the loss of SSBCI benefits, although its members may apply to get it after the documentation.
SNPs are set to provide specific care to patients who have chronic or disabling conditions, dual eligibility, or institutional care needs.
To find help or to request additional clarification, medical professionals may contact the representatives of UnitedHealthcare 24/7 through chat on the Provider Portal.
Effective January 1, 2026, prior authorization and notification will be mandatory for outpatient chemotherapy and radiation therapy services for individuals covered under the Idaho Medicare Medicaid Coordinated Plan (MMCP). Providers should continue to submit these requests through the Optum Cancer Guidance Program (CGP), which is fully integrated with MMCP and adheres to established oncology procedures.
Radiation Therapy Services Requiring Prior Authorization
Starting January 1, 2026, some radiation therapy treatments will need prior authorization and notification before they can be provided. These include:
This update is part of the Cancer Guidance Program (CGP), designed to ensure appropriate, evidence-based management of oncology service requests.
How to Submit a Prior Authorization
Coverage and Payment Details
You can review coverage determination guidelines to understand the criteria for radiation therapy services. Please note that an approved prior authorization does not guarantee payment. All claims are subject to:
Additional Resources
For more details, live training sessions, and ongoing updates, visit the Oncology Prior Authorization and Notification resources page.
