September 20 - October 17, 2025

Welcome to The Partnership to Empower Physician-Led Care monthly newsletter, which includes news from our members, legislative and Administration updates, news clips, and studies about value-based care, primary care, and independent physicians. 

 Administration News  

CMS (9/23) CMS Issued Guidance Clarifying that ACA Marketplace Insurers Will Be Permitted to Adjust Their Rates Between September 30 and October 1 - CMS issued guidance clarifying that issuers must use the September 30–October 1 data change window to update QHP applications, rate filings, and form filings in compliance with a federal court order on actuarial value policy. Issuers may also revise rates to reflect expanded catastrophic coverage and other approved changes due to market uncertainty.

CMS (9/26) CMS Released Projections About 2026 Premiums, Benefits, and Access to Plan Options for MA And Medicare Part D Prescription Drug Plans - CMS announced that average premiums for Medicare Advantage and Medicare Part D plans are projected to decrease in 2026, while benefits and plan availability are expected to remain stable. The information was released ahead of the Medicare Open Enrollment period, which runs from October 15 to December 7, 2025.

CMS (10/1) CMS Recommended Practitioners to Issue Advance Beneficiary Notices (ABNs) for Services That May Not Be Covered as a Result of Expiration of Statutory Flexibilities – In the absence of Congressional action, CMS advises that practitioners may consider providing an Advance Beneficiary Notice of Noncoverage (ABN) for telehealth services not payable by Medicare on or after October 1, 2025. 

CDC (10/6) CDC Immunization Schedule Adopts Individual-Based Decision-Making for COVID-19 and Standalone Vaccination for Chickenpox in Toddlers - The Centers for Disease Control and Prevention (CDC) today updated its adult and child immunization schedules to apply individual-based decision-making to COVID-19 vaccination and recommend that toddlers receive protection from varicella (chickenpox) as a standalone immunization rather than in combination with measles, mumps, and rubella vaccination.

CMS (10/16) CMS Releases Updated Guidance on Implementing a Temporary Claims Hold During the Government Shutdown - Effective October 1, 2025, CMS instructed all Medicare Administrative Contractors (MACs) to hold claims with dates of service of October 1, 2025, and later for services impacted by the expired Medicare legislative payment provisions passed under the Full-Year Continuing Appropriations and Extensions Act, 2025. In light of the continuing government shutdown, CMS will continue to process and pay held claims in a timely manner with the exception of select claims for services impacted by the expired provisions. To date, no payments have been delayed as statute already requires all claims to be held for a minimum of fourteen days, and this recent hold is consistent with that statutory requirement. Providers may continue to submit claims accordingly.

 Legislative News  

GAO (9/22) GAO Published a Report on Health Care Consolidation - The Government Accountability Office (GAO) has released a new report examining the extent and effects of physician consolidation. The report confirms that consolidation among hospitals, insurers, and private equity firms is associated with higher costs for patients and Medicare without clear evidence of better quality, while also raising concerns about competition and access.

Senate Finance Comittee (9/22) 18 Senate Democrats Urge CMS to Reevaluate WISeR Model Implementation - A group of 18 Senate Democrats, led by Senate Finance Committee Ranking Member Wyden (D-OR), Senate Special Committee on Aging Ranking Member Gillibrand (D-NY), and Senate Permanent Subcommittee on Investigations Ranking Member Blumenthal (D-CT), urged the Trump administration to halt implementation of the WISeR model, which uses AI-driven prior authorization to determine coverage for certain services in Traditional Medicare. They expressed concern that the model could delay care, increase administrative burden, and lacks sufficient patient protections as it is set to roll out across six states.

Senate Finance Committee (10/1) Senate and House Democrats Introduce Resolution to Overturn Trump Administration Rule Increasing ACA Marketplace Costs and Barriers - Senators Wyden (D-OR), Warner (D-VA), Schumer (D-NY), Ossoff (D-GA), and 38 colleagues, along with Rep. Sykes (D-OH) in the House, introduced a Congressional Review Act resolution to repeal a June 2025 Trump administration rule affecting enrollment in Affordable Care Act (ACA) marketplaces. The rule is expected to impact premiums, covered services, administrative processes, and coverage for some enrollees.

House Energy and Commerce Committee (10/9) Ranking Members Palone and Neal Urge Administration to Allow Access to Telehealth - Energy and Commerce Committee Ranking Member Pallone (D-NJ) and Ways and Means Committee Ranking Member Neal (D-MA) sent a letter urging HHS Secretary Kennedy and CMS Administrator Oz to use existing legal authority to prevent disruptions in telehealth and hospital-at-home services for seniors amid the government shutdown.

Right to Override Act (10/9) - Senator Markey (D-MA) introduced the Right to Override Act, which would require health care facilities and plans to allow human overrides of AI-driven clinical decisions and protect health care workers who exercise their professional judgment.

Member News  

MGMA (10/2) MGMA Urges Congress to Restore Expired Healthcare Policies - MGMA sent a letter to Congress urging the restoration of two critical healthcare policies that expired on September 30, 2025. The first policy is the 1.0 Work Geographic Practice Cost Index (GPCI) floor, which ensures fair Medicare payments in areas with higher practice costs. The second is the telehealth flexibilities that expanded access to care during the COVID-19 pandemic. MGMA emphasized that the expiration of these policies could disrupt care delivery and financial stability for medical group practices.

MGMA (10/15) MGMA Supports the Medicare Advantage Prompt Pay Act – MGMA sent a letter expressing strong support for the Medicare Advantage Prompt Pay Act, a bipartisan bill introduced by Representatives Jodey Arrington and Linda T. Sánchez and Senators Marsha Blackburn and Catherine Cortez Masto. The letter emphasized that the legislation, which would require Medicare Advantage plans to promptly pay medical group practices for services, is crucial to prevent delayed reimbursements that strain practice operations and patient care. MGMA highlighted that timely payments are essential for maintaining financial stability and ensuring quality care for patients.

AAFP (10/16) 4 Takeaways from the AAFP’s Response to the 2026 MPFS Proposed Rule - AAFP highlighted four key points in its response to the 2026 Medicare Physician Fee Schedule (MPFS) proposed rule, including planned payment increases, improvements in data collection, updates to advanced primary care management coding, and the maintenance of the Quality Payment Program performance threshold. The organization also emphasized the need for permanent Medicare payment reform and adjustments to better support family physicians.

News Clips  

JHU Center for Health Systems and Policy Modeling - Johns Hopkins released Site-Neutral Payment for Ambulatory Care: A Medicare Policy Framework, outlining key considerations for implementing site-neutral payment policies. The report highlights decisions around services, settings, and payment structures, recommending a focus on low-complexity, non-emergent services often delivered in office settings. It also emphasizes the need to address implementation challenges, such as billing differences and claims system limitations, to ensure policy effectiveness.

Fierce (9/29) Jury Delivers $500M-Plus Verdict Against Universal Health Services Over Illegal Poaching - A Nevada jury found that Universal Health Services subsidiaries unlawfully solicited physicians and staff from Saint Mary’s Health Network, leading to disrupted patient care and breached contracts.

Health Affairs (10/3) Can AI Help Deliver CMS’s Value-Based Care Agenda? - CMS’s proposed 2026 rule signals a faster shift toward downside risk in value-based care, but many providers lack the readiness and tools to succeed. A more effective transition may require AI-driven support and improved digital quality measures to reduce clinician burden and close care gaps.

Healthcare Dive (10/14) Blumenthal Questions Medicare Advantage Insurers on AI Claims Denials - Sen. Blumenthal (D-CT) has sent letters to CVS Health, UnitedHealthcare, and Humana, raising concerns about their use of artificial intelligence in Medicare Advantage coverage decisions and requesting details on safeguards. The move follows ongoing scrutiny over AI-driven denials and a 2023 Senate report highlighting potential misuse of predictive technologies in post-acute care.

Medscape (10/14) Medicare Advantage Plans May Increase Preventive Care - A new study using 2018–2019 Medicare claims data found that Medicare Advantage enrollees were significantly more likely to receive an Annual Wellness Visit (AWV) than those in Traditional Medicare (TM), especially among vulnerable groups like dual eligibles, Black beneficiaries, and those with Alzheimer’s disease and related dementias (ADRD). The findings suggest MA may play a key role in expanding preventive care access and advancing health equity.

Inside Health Policy (10/16) CMS Reverses Broad Physician Claims Hold After Surprising Stakeholders with Guidance - CMS initially announced a hold on all Medicare Physician Fee Schedule claims due to the government shutdown but later clarified it will only delay claims related to expired provisions, such as telehealth and the geographic practice cost index (GPCI) floor.

Events

• October 29, 2025 - Meeting the Moment: Reforming Accountable Care to Achieve the Promise of Better Health and Health Care
• October 30-31, 2025 – MACPAC October 2025 Public Meeting*

*Dependent on government shutdown

If you would like your event to be included in the next newsletter, please email maggie@physiciansforvalue.org