(Nov. 14, 2025) – CMS Clarifies Telehealth and Hospital-at-Home Claims Hold
As the federal government shutdown continues, the Centers for Medicare & Medicaid Services released additional information about the temporary hold on telehealth and acute hospital-care-at-home claims. For the telehealth claims currently being held and submitted on or before Nov. 10, with dates of service on or after Oct. 1, CMS will return those claims to providers. Professional claims will be returned with the following messages: CARC 16 and RARC M77. Practitioners may resubmit returned claims that meet the current statutory requirements.
CMS Announces New GENEROUS Drug Payment Model
The Centers for Medicare & Medicaid Services announced details about a new drug payment model designed to strengthen Medicaid and better serve vulnerable Americans. State Medicaid programs that opt to participate in the GENErating cost Reductions for U.S. Medicaid (GENEROUS) Model will be able to purchase drugs included in the pilot at prices aligned with those paid in select other countries. The model allows CMS to negotiate with participating manufacturers for lower prices, while states adopting the model will implement uniform, transparent coverage criteria.