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The Centers for Medicare & Medicaid Services’ (“CMS’s”) guidance governing Medicare Advantage marketing practices has continued to evolve over the past several years, with regulatory requirements shifting significantly across administrations. These changes reflect both the ongoing development of health care coverage models and differing policy priorities among governing parties. As a result, organizations involved in Medicare Advantage marketing have faced a regulatory landscape marked by frequent and often substantial revisions.
Background and Context
Each fall, CMS releases a proposed…
Continue Reading CMS Revises Medicare Advantage Marketing Guidance for Scope of Appointment Forms

On May 22, 2026, the Centers for Medicare & Medicaid Services (“CMS”) published a proposed rule regarding both Medicaid State directed payments (“SDPs”) and Medicaid fee-for-service reimbursement. The proposed rule is based on two distinct but reinforcing authorities: (i) section 71116 of H.R. 1 (a/k/a the “One Big Beautiful Bill Act”); and (ii) the Presidential Memorandum titled “Eliminating Waste, Fraud, and Abuse in Medicaid” (effective June 6, 2025).

The proposed rule would implement section 71116 by revising the SDP…
Continue Reading New CMS Proposed Rule Would Impose a Payment Limit on Additional State Directed Payments and Establish a Payment Limit for ‘Targeted’ Medicaid Fee-for-Service Payments

In April, the Centers for Medicare & Medicaid Services (“CMS”) released the FY 2027 Inpatient Prospective Payment System (“IPPS”) Proposed Rule (“Proposed Rule”) to update IPPS payment rates and uncompensated care payments, refine CMS’s definition of new GME residency programs, request input on new quality measures, expand the joint replacement payment model, CJR-X, on a nationwide basis and introduce quality measures into the Transforming Episode Accountability Model (“TEAM”) program.
Increase to Payment Rates Under the IPPS
Following a rebasing…
Continue Reading CMS Publishes FY 2027 IPPS Proposed Rule

If you have had a chronic condition that recently worsened, you might be wondering if your long-term disability (LTD) claim could be denied on the basis that your condition was pre-existing. Or, you might have already received a denial because the insurance company is saying your condition is pre-existing.

Many LTD policies do have pre-existing condition exclusions and they are a common reason used by insurance companies to deny claims. Being aware of these provisions can help you determine…
Continue Reading Can My Long-Term Disability Claim be Denied Because My Condition is Pre-Existing?

On April 14, 2026, the Centers for Medicare & Medicaid Services (“CMS”) published the Fiscal Year (“FY”) 2027 Inpatient Prospective Payment System (“IPPS”) Proposed Rule (the “Proposed Rule”), which can be found here. Among other things, the Proposed Rule would make updates to Graduate Medical Education (“GME”) policies for teaching hospitals under the Medicare program. These updates include (i) modifications to the criteria by which a program is deemed a “new program” for Medicare funding purposes; (ii) clarification…
Continue Reading CMS Proposes Changes to Graduate Medical Education in 2027 IPPS Proposed Rule

CMS is imposing a six-month nationwide moratorium on new Medicare enrollment for hospices and home health agencies in a sweeping effort to combat fraud.

Effective immediately, CMS will not process new Medicare enrollment applications or certain changes in majority ownership for hospices and home health agencies across the country for the next six months. This action is designed to prevent fraudulent providers from entering the Medicare program and to disrupt schemes that exploit vulnerable beneficiaries and taxpayer funds. Existing…
Continue Reading Moratorium on New Medicare Enrollment

Indiana Medicaid’s effort to rein in Applied Behavior Analysis (“ABA”) therapy costs has led to a proposed moratorium on provider enrollment. On May 7, 2026, the Indiana Health Coverage Programs (“IHCP”) announced it is seeking approval from the Centers for Medicare and Medicaid Services (“CMS”) to implement the statewide provider enrollment moratorium, beginning June 6, 2026, for both new ABA therapy group enrollments, as well as changes of ownership for existing ABA therapy agencies. If approved, the moratorium will…
Continue Reading Indiana Medicaid Seeks Moratorium for ABA Provider Enrollment

On April 14, 2026, the Centers for Medicare & Medicaid Services (“CMS”) published the fiscal year (FY) 2027 Inpatient Prospective Payment System (IPPS) proposed rule (the “Proposed Rule”) in the Federal Register, which included several proposals that would affect organ acquisition reimbursement policies for Independent Organ Procurement Organizations (“IOPOs”), as well as Organ Procurement Organizations (“OPOs”) more broadly, histocompatibility laboratories (“HCLs”) and transplant hospitals. Although CMS characterizes some of the changes as codifying longstanding policy, others substantively alter how…
Continue Reading FY 2027 IPPS Proposed Rule – Changes to Organ Acquisition and Reasonable Cost Payment Policies

Among the nearly three dozen new laws Gov. Tony Evers signed recently is one generating hope within the prison reentry community because it allows expansion of Medicaid coverage for those nearing the end of incarceration and returning home.

While the impact of the new law, Act 233, will not be felt immediately, there is nevertheless cause for excitement for those involved in reentry services.

“We don’t know how this is going to pan out,” said The Community’s Shannon

…
Continue Reading Promising New Law Allows Medicaid Expansion to Those Leaving Prison

The first nationwide test of a mandatory episode-based payment model has been unveiled. In the Fiscal Year (“FY”) 2027 Inpatient Prospective Payment System (“IPPS”) Proposed Rule, the Centers for Medicare & Medicaid Services (“CMS”) proposes resurrecting and expanding the original Comprehensive Care for Joint Replacement (“CJR”) Model to establish a mandatory, nationwide episode-based payment model for most hospitals paid under the IPPS beginning October 1, 2027.     

Under the proposed model, known as the Comprehensive Care for Joint Replacement…
Continue Reading CMS Proposes Resurrection and Nationwide Expansion of Mandatory Joint Replacement Bundled Payment Model (CJR-X) 

The FFY 2027 IPPS Proposed Rule (“Proposed Rule”) was released on April 10, 2026, and CMS published the associated tables on its Proposed Rule homepage. The Proposed Rule is expected to be published in the Federal Register on April 14.

The release of the Proposed Rule and the accompanying tables triggers the start of several deadlines for hospitals, including the unofficial start of the Medicare Geographic Classification Review Board (“MGCRB”) application process. Hospitals should conduct a preliminary review…
Continue Reading CMS Releases FFY 2027 IPPS Proposed Rule; Wage Index Deadlines

Indiana Medicaid implemented significant updates for applied behavior analysis (“ABA”) therapy—one of the most widely used interventions for children with autism spectrum disorder—effective April 1, 2026. The reforms include phased cuts to reimbursement for ABA therapy, updates to member eligibility and revisions to provider qualifications.

The Indiana Health Coverage Programs (“IHCP”) began covering ABA therapy in 2016. Indiana’s expenditures on ABA therapy skyrocketed since coverage began and culminated in increased scrutiny following a Wall Street Journal investigation. Governor Mike…
Continue Reading Indiana Medicaid’s ABA Therapy Overhaul: What Changed on April 1, 2026

Our previous article, In Defense of IGTs from Governmental Health Care Providers, noted that the Secretary of the Department of Health and Human Services (“HHS”) is required to “consult with the States” before issuing any regulations changing the treatment of intergovernmental transfers (“IGTs”). We received requests for further information about this requirement following the publication of that article, and the requirement gained additional attention following the Secretary’s February 27, 2026, request for information (“RFI”) seeking stakeholder feedback on…
Continue Reading The Secretary of HHS Must Consult with the States Before Issuing Regulations Changing the Treatment of IGTs

If you have been receiving long term disability (LTD) benefits, you have probably received a letter from your insurance company telling you to apply for Social Security Disability Insurance benefits, also known as SSDI. They may have offered to connect you with a service to help with this application.

You might be wondering why the insurer cares so much about whether you apply for SSDI. The short answer is that it usually saves the insurance company money. However, applying…
Continue Reading Why Long Term Disability Insurers Require You to Apply for SSDI (And How It Affects You)

The U.S. Department of Health & Human Services Office of Inspector General (“OIG”) has long been the north star for health care entities seeking guidance on creating and implementing an effective compliance program. As the author of the General Compliance Program Guidance (“GCPG”), OIG has used its years of investigative and oversight experience with health care entities to identify and recommend best practices for a wide range of entities in the U.S. health care industry.

To further OIG’s assistance…
Continue Reading Medicare Advantage Industry Segment-Specific Compliance Program Guidance Issued

The Centers for Medicare and Medicaid Services (“CMS“) issued a wide-ranging Request for Information (“RFI”) on February 26, which could reshape current program integrity efforts to prevent and detect fraud, waste and abuse in  government health care programs. CMS, under its new Comprehensive Regulations to Uncover Suspicious Healthcare (“CRUSH”) initiative, is seeking stakeholder input on potential regulatory and operational changes aimed at strengthening program integrity across Medicare, Medicaid, CHIP and the Health Insurance Marketplace (“Marketplace”). The RFI spans topics…
Continue Reading CMS Issues Sweeping Anti-Fraud RFI Under New CRUSH Initiative