IHPP - Weekly, November 10, 2025

Summary

For the first time since the government shut down began, there is off ramp in sight to reopen the government. Over the weekend, the Senate approved a procedural vote to move forward with a continuing resolution (CR) to fund the government through January 30, 2026 coupled with a minibus for fiscal year 2026 appropriations bills for Military Construction, Veterans Affairs, and Related Agencies, the Department of Agriculture, and the Legislative Branch (legislative text). Notably, the bill will extend funding for health care programs that lapsed at the start of the shutdown, including the Medicare COVID-19 telehealth flexibilities. The package also includes language to repeal the reduction in force (RIF) instituted at the beginning of the shutdown and prevent any future RIFs through January 30^th.

The Senate will reconvene at 11 am today, but it is unclear when the chamber will ultimately pass the bill this week. If passed, pressure will then be on the House to pass the package where bipartisan cooperation has not been taking place. Speaker Johnson has indicated that the House will reconvene 36 hours after Senate passage but the current state of flights around the United States may make convening all House members difficult. Additionally, reports have indicated that Republicans they will pursue the bill under a rule, which requires a House Rules Committee meetings, rule debate, and rule vote.  Republicans can only afford to lose two votes on the bill

The Senate vote was made possible when eight Democrat Senators, Sens. Cortez Masto (D-NV), Durbin (D-IL), Fetterman (D-PA), Hassan (D-NH), Kaine (D-VA), King (I-ME), Rosen (D-NV), and Shaheen (D-NH), broke ranks with their party in hope of crafting a bipartisan health care bill. Senate Majority Leader Thune (R-SD) has already committed to holding a Senate vote on the expiring enhanced premium tax credits before the end of December. However, it is less clear where House Republican leadership stands on the tax credit issue. While a group of bipartisan House members released principles to temporarily extend the tax credits, broad Republican support is less likely.

Update on Medicare Telehealth Claims Processing

In updated guidance released Friday, the Centers for Medicare & Medicaid Services (CMS) says that it directed Medicare Administrative Contractors (MACs) to resume payment for telehealth claims dated on or after October 1, 2025, when the services clearly meet current statutory requirements. This includes behavioral and mental health services which it details in a table, or by diagnosis codes F01.A0-F99 when billed with place of service 10 (patient’s home), excluding services furnished by physical therapists, occupations therapists, speech language pathologists, or audiologists. CMS also authorized payment for a limited set of other telehealth claims that it could confirm as permissible under existing law.

However, CMS acknowledged systems limitations have prevented it from identifying all telehealth claims payable under current law, particularly some behavioral health services that lack mental health diagnosis codes and telehealth services furnished by clinicians in eligible Medicare Shared Savings Program Accountable Care Organizations (ACOs). As a result, those claims have been held since October 1, 2025.

To address this and improve cash flow, the agency said it will return all held telehealth claims submitted on or before November 10, 2025, allowing practitioners to resubmit claims that meet statutory requirements. CMS said practitioners may hold or resubmit non-payable claims depending on their preference, either waiting for potential congressional action to restore broader telehealth coverage or submitting claims with the GY modifier for formal denial, which preserves appeal rights if retroactive coverage is later enacted. The agency further clarified that clinicians in eligible ACOs, those furnishing behavioral and mental health or monthly ESRD-related assessments, and those providing other services meeting statutory requirements may bill as usual.

CMS also confirmed that the legal authority for the Acute Hospital Care at Home (AHCAH) waivers expired on September 30, 2025, requiring all participating hospitals to discharge or readmit inpatients by that date absent new congressional action. Claims for AHCAH services dated October 1, 2025, or later will be returned or denied, as these services are now no longer covered. The agency says hospitals may either hold claims in anticipation of potential legislation extending the waivers or submit them for formal denial using bill type 110 and condition code 21, which preserves appeal rights if Congress later restores payment authority.

Regulatory Update

The Office of Management and Budget (OMB) completed reviewing the following:

• Medicaid and Immigration Status. A final rule titled, “Medicaid Eligibility Changes Under the Affordable Care Act of 2010; Giving States Freedom to Use Immigration Information to Determine State Residency for Medicaid Eligibility.” The final rule is part of the Trump administration’s efforts to increase federal oversight on states using Federal Medicaid funding for the health care of undocumented immigrants.

OMB is also reviewing the following:

• Medicare:
  • CY 2027 Medicare Advantage/Part D Policy. Proposed CY 2027 policy and technical changes to Medicare Advantage, Medicare Prescription Drug Benefit, Medicare Cost Plan, and PACE
  • Medicare Payment Rules. The CY 2026 Hospital Outpatient PPS final rule, the CY 2026 ESRD final rule, and the CY 2026 Home Health PPS final rule.
  • Procurement of Domestic PPE. An advance notice of proposed rulemaking that would detail program incentives and requirements for Medicare providers and suppliers to invest and phase-in the procurement of American made personal protective equipment (PPE) and essential medicine to secure our nation’s health and safety.

• Medicaid:
  • Gender-Affirming Care.
    • A proposed rule titled, “Medicaid Program; Prohibition on Federal Medicaid Funding for Sex Trait Modification Procedures Furnished to Children and Youth.”
    • A proposed rule titled, “Medicare and Medicaid Programs; Hospital Condition of Participation: Limiting Participation Based on the Performance of Sex Trait Modification Procedures on Children.”
  • State Directed Payments. A proposed rule titled, “Medicaid Managed Care-State Directed Payments.” The proposed rule appears intended to advance a presidential memorandum released on June 6, which directs HHS to “eliminate waste, fraud, and abuse in Medicaid, including by ensuring Medicaid payments rates are not higher than Medicare, to the extent permitted by applicable law.”

• Prescription Drugs:
  • A proposed rule titled, “Improving Transparency into Pharmacy Benefit Manager Fee Disclosure” and a proposed rule addressing Transparency in Coverage requirements.
  • CMMI Drug Pricing Models. A proposed rule for a Global Benchmark for Efficient Drug Pricing (GLOBE) Model and a proposed rule for Guarding U.S. Medicare Against Rising Drug Costs (GUARD) Model

• Nutrition:
  • Head Start. A notice from the Administration for Children and Families titled, “Publish Request for Information: Nutrition Services in Head Start Programs

• Immigration:
  • Unaccompanied Children. An interim final rule titled, “Unaccompanied Children Program Foundational Rule; Update to Include Proof of Identity and Income Verification Standards.”