CMS updates focus on improving patient care and streamlining processes

The latest CMS changes aim to improve patient care while simplifying administrative procedures, including a nationwide push to remove ineligible Medicaid enrollees, new requirements for dual eligible special needs plans (D-SNPs) by 2027 to integrate member IDs and health risk assessments, the finalization of a prior authorization rule to enhance health data exchange, and the extension of certain telehealth flexibilities through September 30, 2025. Additionally, CMS is working to address administrative burden through efforts like the prior authorization rule and a request for information on reducing administrative resources. 

• Medicaid Eligibility: CMS launched a nationwide initiative to remove ineligible Medicaid enrollees and uphold citizenship requirements. 
• Dual Eligible Special Needs Plans (D-SNPs): By 2027, D-SNPs must provide integrated member identification cards and conduct integrated health risk assessments to improve coordination of care. 
• Prior Authorization and Interoperability: The CMS Interoperability and Prior Authorization Final Rule, with key provisions effective in 2027, requires payers to implement application programming interfaces (APIs) to improve health information exchange and streamline prior authorization processes. 
• Telehealth Flexibilities: Various Medicare telehealth flexibilities are extended through September 30, 2025, including geographic flexibilities for non-behavioral/mental health services and the ability for FQHCs and RHCs to serve as distant site providers. 
• Marketplace Integrity and Affordability: A final rule establishes a "preponderance of the evidence" standard for terminating Marketplace Agreements with agents, brokers, and web-brokers for non-compliance, enhancing transparency and accountability. 
• Hospital Inpatient Prospective Payment System: A final rule issued on July 31, 2025, updates Medicare payment policies and rates for hospitals for FY 2026. 
• Administrative Burden Reduction: CMS released a request for information (RFI) to gather feedback on how to support goals related to reducing administrative resources and burdens on providers.