A denial of long-term disability benefits is not necessarily the end of an ERISA claim. Instead, it usually begins one of its most important stages: the administrative appeal.
Two issues deserve immediate attention. First, there is a deadline for appealing. Second, the appeal is an opportunity to develop the evidence supporting your disability claim. Simply telling the insurer that its decision was wrong is rarely enough.
For someone who has spent years or decades in a career and
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Federal Court Upholds CMS’s OPO Performance Rule but Allows Earlier Judicial Challenges
On September 29, 2026, in LifeLink Foundation, Inc. v. Kennedy, the U.S. District Court for the Middle District of Florida (the “Court”) upheld the Centers for Medicare & Medicaid Services (“CMS”) 2020 rule governing Organ Procurement Organization (“OPO”) performance measures and tier classifications (the “Final Rule”). The decision rejects one significant legal challenge to the Final Rule and, for now, leaves the current framework in place for the 2026–2030 recertification cycle, although other lawsuits challenging the framework remain
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Skilled Nursing Update: CMS Deregulatory Effort for Skilled Nursing Facilities at OMB
The Trump administration continues to pursue regulatory reform initiatives across the health care sector. A proposed Centers for Medicare & Medicaid Services (“CMS”) rule affecting Medicare-participating providers, including skilled nursing facilities, is currently under review by the Office of Management and Budget, a key step before publication. The proposal appears consistent with prior CMS efforts to reduce administrative burden and streamline provider requirements, including the agency’s 2019 “Patients Over Paperwork” initiative.
At this stage, the details of the proposal
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DMEPOS Supplier Enrollment Opens as Medicare Moratorium Expires
On August 27, 2026, the Centers for Medicare & Medicaid Services (“CMS”) announced that the moratorium on accepting Medicare supplier enrollment applications for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (“DMEPOS”) suppliers, which went into effect on February 27, 2026, has expired.
The National Provider Enrollment Contractors are once again accepting initial enrollment applications from DMEPOS suppliers.
Practical Takeaways
- DMEPOS suppliers seeking to submit applications to CMS should submit as soon as possible before the bidding window opens for
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CMS Changes to Graduate Medical Education in 2027 IPPS Final Rule
On August 4, 2026, the Centers for Medicare & Medicaid Services (“CMS”) published the Fiscal Year (“FY”) 2027 Inpatient Prospective Payment System (“IPPS”) Final Rule (the “Final Rule”), which can be found here. The Final Rule is effective October 1, 2026, and includes several updates affecting Graduate Medical Education (“GME”) and Nursing and Allied Health (“NAH”) education programs under Medicare. These updates include: (i) modifications to the criteria for determining whether a residency program qualifies as a “new
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Compliance Program Lessons from the Complete Health Settlement
On August 4, 2026, the United States Department of Justice (“DOJ”) on behalf of the Office of Inspector General (“OIG”) of the U.S. Department of Health and Human Services announced it had entered into a $14.1M settlement with Complete Health Partners Holdings (“Complete Health”), a Florida management services organization (“MSO”), to resolve allegations that Complete Health submitted false risk adjustment scores in violation of the False Claims Act. As an MSO, Complete Health provides non-clinical administrative and operational support
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Should I Appeal my Long-Term Disability Denial on My Own or Hire a Lawyer?
Receiving a long-term disability (LTD) denial can feel overwhelming. After months of medical appointments, paperwork, and waiting for a decision, many people are left wondering what to do next and whether they should appeal on their own or hire a lawyer. The honest answer is: it depends.
Whether you should appeal on your own depends on why your claim was denied, what evidence is already in your file, and what opportunities you have to strengthen your case before your
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Skilled Nursing Facility Update: CMS Finalizes FY 2027 SNF PPS Rule: Payment Increase, QRP Reforms and Expanded MDS Reporting Requirements
On July 30, 2026, the Centers for Medicare & Medicaid Services (“CMS”) issued its final rule updating Medicare payment policies and rates for skilled nursing facilities (“SNFs”) under the Skilled Nursing Facility Prospective Payment System (“SNF PPS”) for federal fiscal year (“FY”) 2027. The final rule also includes significant revisions to the Skilled Nursing Facility Quality Reporting Program (“SNF QRP”) and the Skilled Nursing Facility Value-Based Purchasing (“SNF VBP”) Program. The rule becomes effective October 1, 2026.
HHS Begins Decertification of Network for Hope, Kentucky’s Organ Procurement Organization
On August 5, 2026, the U.S. Department of Health and Human Services (“HHS”) announced that the Centers for Medicare & Medicaid Services (“CMS”) has begun the decertification process for Network for Hope, the organ procurement organization (“OPO”) with a service area that includes Kentucky and portions of Indiana, Ohio and West Virginia. According to HHS, the action follows multiple federal reviews that identified ongoing patient safety concerns and determined that the OPO had not demonstrated sufficient improvement despite corrective
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Indiana HCBS Update: Indiana Imposes Statewide HCBS Provider Certification and Enrollment Moratorium
The Indiana Health Coverage Programs announced that it has received approval from the Centers for Medicare & Medicaid Services (“CMS”) to implement a statewide provider certification and enrollment moratorium for numerous Home- and Community-Based Services (“HCBS”) 1915(c) waiver providers. The moratorium becomes effective August 1, 2026, and initially will remain in effect for six months, although Indiana may seek six-month extensions.
Unlike many Medicaid enrollment moratoria that apply to a single provider type or geographic area, Indiana’s action applies
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Understanding the Functional Screen Test
July 23, 2026
When applying for Wisconsin Medicaid long-term care programs, financial eligibility is only part of the process. Individuals must also demonstrate that they meet the required level of care through what is known as the functional screen test.
The functional screen is a standardized assessment used in Wisconsin to determine whether an individual qualifies for Medicaid-funded long-term care services. Rather than focusing on finances, the screening evaluates a person’s ability to safely care for themselves and function
Turning TEAM Risk into Opportunity: The Case for a Value-Based Enterprise
On January 1, 2027, mandatory downside financial risk under the Centers for Medicare & Medicaid Services’ (“CMS”) Transforming Episode Accountability Model (“TEAM”) will begin for most participating hospitals. TEAM is a mandatory, episode-based alternative payment model that took effect on January 1, 2026, and will end on December 31, 2030. Most hospitals located in any of the 188 Core-Based Statistical Areas (“CBSAs”) selected by CMS were required to participate. Calendar Year 2026 is Performance Year One (“PY1”) and is
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Wisconsin’s APRN Modernization Act – New Emergency Rules Chart the Path to Independent Practice
For years, Wisconsin has been among a shrinking group of states that require advanced practice nurses to maintain a collaborative agreement with a physician or dentist in order to practice. That is about to change. On September 1, 2026, the APRN Modernization Act (Act 17) takes effect, moving Wisconsin from a system that certifies advanced practice nurse prescribers (APNPs) to one that licenses advanced practice registered nurses (APRNs) and, for qualifying nurses, permits independent practice for the first time.
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Skilled Nursing Update: CMS Implements Nationwide Risk-Based Surveys For Higher-Performing Skilled Nursing Facilities
The Centers for Medicare & Medicaid Services (“CMS”) has announced the nationwide implementation of a new Risk-Based Survey (“RBS”) process for qualifying nursing homes beginning September 8, 2026. CMS Memorandum QSO-26-14-NH explains that the RBS is intended to allow State Survey Agencies (“SAs”) to use fewer survey resources at higher-performing facilities and redirect resources toward complaint investigations and facilities where residents may face greater risk of harm.
CMS estimates that approximately 12% of nursing homes nationwide currently qualify. Qualifying
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How Much Does Long-Term Care Cost and How Do I Pay for It?
By McKenna K. Coffeen | Elder Law
July 8, 2026
One of the most common concerns families face when discussing long-term care is cost. Whether care is provided at home, in an assisted living facility, or in a nursing home, long-term care expenses can become significant very quickly.
In Wisconsin, nursing home care can cost thousands of dollars each month, and even part-time in-home assistance may create substantial financial strain over time. Because Medicare coverage for long-term care is
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DOJ’s Continued Focus on Medicare and Medicaid Fraud Produces $6.5 Billion Health Care Fraud Takedown
The results of the 2026 National Health Care Fraud Takedown (the “Takedown”) were announced on June 23, 2026; the Department of Justice (“DOJ”) charged 455 individuals in connection with alleged health care fraud schemes involving over $6.5 billion in false claims. Ninety of the charged individuals were physicians or other medical professionals.
The Takedown, dating back to 2007, is conducted annually by DOJ, the Department of Health and Human Services Office of Inspector General (“HHS-OIG”), the Federal Bureau
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