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Tags Posts tagged with "CMS"

CMS

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Following the creation of the Rural Health Transformation (RHT) Program under President Trump’s Working Families Tax Cut legislation, the Centers for Medicare and Medicaid Services (CMS) has announced the establishment of the Office of Rural Health Transformation (ORHT). This new office will be located within the Center for Medicaid and CHIP Services (CMCS) and will continue overseeing the RHT Program. The RHT Program is a $50 billion initiative to strengthen rural health systems and expand access to care nationwide. As noted in RCPA’s Alert from December 30, 2025, Pennsylvania will receive nearly $200 million in 2026.

ORHT, which announced approved awardees on December 29, 2025, will guide states in implementing their rural health transformation plans, provide technical assistance, coordinate federal and state partnerships, and ensure strong oversight and accountability throughout the five-year program, which will run through September 30, 2031.

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Press release from the Centers for Medicare & Medicaid Services:

The Centers for Medicare & Medicaid Services (CMS) has announced that all 50 states will receive awards under the Rural Health Transformation Program, a $50 billion initiative established under President Trump’s Working Families Tax Cuts legislation (Public Law 119-21) to strengthen and modernize health care in rural communities across the country. In 2026, states will receive first-year awards from CMS averaging $200 million, within a range of $147 million to $281 million. This unprecedented federal investment will help states expand access to care in rural communities, strengthen the rural health workforce, modernize rural facilities and technology, and support innovative models that bring high-quality, dependable care closer to home.

Awardees and Funding Amounts

The Rural Health Transformation Program’s $50 billion in funds will be allocated to approved states over five years, with $10 billion available each year from 2026 through 2030. As directed by Public Law 119-21:

  • 50% of the funding is distributed equally among all approved states. This provides states with a strong foundation to begin implementing their Rural Health Transformation Plans; and
  • 50% is allocated based on a variety of factors. As described in the Notice of Funding Opportunity, those factors include individual state metrics around rurality and a state’s rural health system, current or proposed state policy actions that enhance access and quality of care in rural communities, and application initiatives or activities that reflect the greatest potential for, and scale of, impact on the health of rural communities. All scoring factors are outlined further in the Notice of Funding Opportunity.

Read the full press release here.

Pennsylvania submitted their plan to CMS in November, and the plan is currently being evaluated. CMS made funding awards to all 50 states, with Pennsylvania receiving $193,294,054.

RCPA continues to work with the Department of Human Services (DHS) in answering questions from members as well as gaining an understanding on the implementation values for PA specific initiatives from both funding allocation pathways.

If you have any questions, please contact RCPA COO Jim Sharp.

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The Office of Developmental Programs (ODP) has shared ODPANN 25-116. The purpose of this communication is to inform providers of Adult Autism Waiver (AAW) services and Supports Coordination Organizations (SCO) of the updated provider qualification process.

The Centers for Medicare and Medicaid Services (CMS) require a statewide process to ensure providers are qualified to render services to waiver-funded individuals. The Provider Qualification Process described in the communication outlines the steps the provider must follow to meet these requirements, and the steps Supports Coordinators (SC) must take to transition individuals if needed. This communication does not describe the qualification process for AAW SCOs.

NOTE: The release of this communication obsoletes ODP Announcement 20-110 New Adult Autism Waiver (AAW) Provider Qualification Process.

Providers that are shared across Intellectual Disability/Autism (ID/A) and the AAW must complete the Provider Qualification processes with both their assigned Administrative Entity (AE) for the ID/A waivers and the Bureau of Supports for Autism and Special Populations (BSASP) for the AAW.

Please view the full announcement for complete details.

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The Centers for Medicare & Medicaid Services (CMS), in partnership with the Department of Labor and the Department of the Treasury (the Departments), included major updates to the health care price transparency rules established during President Trump’s first term in a proposed rule published in today’s Federal Register. The proposed rule is in line with Executive Order 14221, which ensures health care pricing data is not only public but impactful and actionable.

Key improvements include:

  • Requiring plans and issuers to exclude from the In-network Rate Files certain data for services providers would be unlikely to perform.
  • Reorganizing In-network Rate Files by provider network rather than by plan, cutting redundancy, and aligning with how most hospitals report data pursuant to the Hospital Price Transparency requirements.
  • Requiring Change-log and Utilization Files so users can easily identify what has changed from one In-network Rate File to the next and have clear information on which in-network providers are actively furnishing which items and services.
  • Reducing reporting cadence for In-network Rate and Allowed Amount Files from monthly to quarterly, significantly reducing burden while maintaining meaningful transparency.
  • Increasing the amount of out-of-network pricing information reported by reorganizing Allowed Amount files by health insurance market type, reducing the claims threshold to 11 or more claims, and increasing the reporting period from 90 days to 6 months and the lookback period of data from 180 days to 9 months.

The Departments are proposing these changes to open the door for more organizations, including those with fewer technical resources, to analyze pricing data, build consumer-friendly tools, and drive competition across the health care industry.

Under the proposal, group health plans and health insurance issuers would be required to provide the same detailed cost-sharing information whether viewed online, or in print or provided by telephone, upon request. This modernization would ensure that transparency is not limited by internet access or digital literacy. Further, updated disclosures will take into account new federal protections against balance billing under the No Surprises Act. These disclosures would ensure patients understand their rights and potential financial responsibilities before they seek care.

Additional information is provided on the CMS fact sheet. Feedback and comments on the proposed rule will be accepted until February 23, 2026.

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The Centers for Medicare and Medicaid Services (CMS) recently published an errata document to the inpatient rehabilitation facility patient assessment instrument (IRF-PAI) Manual, Version 4.2, related to the coding of items J1750, J1800, and J1900. This errata document was issued to update guidance related to the Falls with Major Injury (FMI) measure in the IRF Quality Reporting Program (QRP), which is effective on January 1, 2026. Specifically, the guidance related to item J1900 Number of Falls Since Admission item has revisions to the definition of Injury (except Major) and Major Injury.

CMS also released the official Technical Specification Report for the Falls with Major Injury (FMI) measure. This report incorporates feedback received during the cross-setting Technical Expert Panel (TEP) held in May 2025. The report provides an overview of the measure, a high-level summary of the key features of the re-specified measure, a description of the methodology used to construct the FMI measure, and an overview of measure testing results. Additional guidance and related updates to the IRF-PAI Manual, Quality Measure Calculations and Reporting User’s Manual, and public reporting timelines will be provided at a future date. The report is available in the Downloads section on the IRF QRP Measures Information web page.

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The Office of Developmental Programs (ODP) has shared ODPANN 25-111. This communication clarifies new qualification requirements for providers of CPS, In-Home and Community Support and/or Companion services in the Consolidated, Community Living, and P/FDS Waivers that were recently approved by the Centers for Medicare and Medicaid Services (CMS). These requirements do not apply to services rendered by Support Service Professionals through a Participant-Directed Services option.

These amendments include the following provider qualification requirements:

  • Providers newly enrolling to render Community Participation Support, In-Home and Community Support, and/or Companion must provide Office of Developmental Programs (ODP) home and community-based services to a minimum of 3 separate and distinct participants in the first fiscal year after enrollment.
  • Starting July 1, 2026, currently enrolled providers must render ODP home and community-based services to a minimum of 3 separate and distinct participants each fiscal year. ODP will use the provider’s Master Provider Index number to determine if the provider is rendering any ODP waiver services to a minimum of 3 separate and distinct participants.
  • Additionally, the provider must render ODP home and community-based services each quarter.

Please review the announcement for more details.

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The Office of Developmental Programs (ODP) has shared ODPANN 25-107. This communication is to inform all interested parties that the Centers for Medicare and Medicaid Services (CMS) approved amendments to the 1915(b)(4) Performance-Based Contracting (PBC) waiver and the Consolidated, Community Living, and P/FDS Waivers effective January 1, 2026. All waivers are available on the Department of Human Services’ (DHS) website.

ODP will be holding one webinar to provide a high-level overview of Performance-Based Contracting and additional major changes made in the approved waivers. There will be time during the session for presenters to answer questions submitted by participants during the webinar.

Consolidated, Community Living, and P/FDS Waiver Amendment Overview
December 15, 2025
11:00 am – 12:00 pm
Register Here

Please review the ODP Announcement for more details.

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The Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2026 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) final payment system rule. The final rule not only includes policies and payment rates for CY 2026 but also updates CMS’ existing Hospital Price Transparency requirements. Hospitals and ASCs that meet their quality reporting requirements will see a 2.6% increase in their OPPS rates. CMS also finalized proposals to eliminate the Inpatient Only list over a three-year period, beginning with the removal of nearly 300 musculoskeletal procedures from the list in CY 2026.

For additional information, members are encouraged to review CMS’ press release on the rule as well as the fact sheet.

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