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October 16, 2025 – Over the last couple of weeks, stakeholders have raised many questions about how the government shutdown will affect different healthcare initiatives and programs, and Medicare Advantage (MA) is no exception. The Centers for Medicare & Medicaid Services (CMS) has provided guidance related to Medicare claims processing, telehealth services, and other operations, but most of that has pertained to Medicare fee-for-service (traditional Medicare). MA plans have been largely responsible for figuring out how the information applies to them. About half of Medicare beneficiaries are in MA, meaning more than 35 million Medicare beneficiaries and the providers who care for them rely on MA plans to communicate how benefits and coverage have, or have not, changed. As the shutdown drags on, CMS’s work to establish future MA policies and payment rates through rulemaking and notices also could be impeded. To discuss some of the ways that the shutdown has impacted MA and may continue to do so, I’m bringing in my colleague Lynn Nonnemaker.
On October 1, 2025, CMS provided guidance about claims processing and telehealth for Medicare fee-for-service but did not state how or if that guidance applied to MA. On October 10, 2025, CMS told MA plans to “turn their attention” to this fee-for-service guidance, but did not provide additional instructions for the plans.
In the October 1 guidance, CMS instructed Medicare Administrative Contractors (MACs) to hold claims for 10 business days. CMS noted that this hold should limit payment impacts, since by law MACs have a 14-day payment floor for electronic claims. On October 15, CMS updated the guidance to state that “ 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.” However, MACs are only responsible for reimbursing Medicare fee-for-service claims. MA plans directly reimburse providers for care in accordance with contractual agreements between the plan and provider. Those contractual agreements must include a prompt pay provision; the specifics of the provision are up to the plan and provider. MA also has concrete rules for how non-contracted providers who provide care outside of the plan network are reimbursed for services, and those have not changed. Under existing regulations, MA plans have 30 days from receipt to pay 95% of “clean claims” for services furnished by non-contracted providers or submitted by, or on behalf of, an enrollee of an MA private fee-for-service plan. MA plans have 60 calendar days from the date of request to pay or deny all other claims from non-contracted providers.
In its October 1 guidance document, CMS stated that “absent Congressional action, beginning October 1, 2025, many of the statutory limitations that were in place for Medicare telehealth services prior to the COVID-19 Public Health Emergency will take effect again for services that are not behavioral and mental health services. These include prohibition of many services provided to beneficiaries in their homes and outside of rural areas and hospice recertifications that require a face-to-face encounter” (emphasis added). While CMS refers to Medicare telehealth services in this statement, the agency does not distinguish between Medicare fee-for-service and MA, leaving some ambiguity in terms of how telehealth is impacted in the MA program.
In many cases, the expired telehealth waivers only pertain to Medicare fee-for-service and have no bearing on MA plans. Section 50323 of the Bipartisan Budget Act of 2018 allows MA plans to offer additional telehealth benefits as part of Medicare-funded “basic benefits.” These flexibilities are permanent and did not expire on September 30, 2025. However, as with all things in healthcare, it’s a bit complicated and we cannot simply say that telehealth in MA remains unchanged. The true answer is: it depends. MA plans spell out their coverage designs in their annual bids to CMS, which usually include how they plan to cover telehealth services. Some MA plans could have stated that their coverage of telehealth would match the rules of Medicare fee-for-service, and since the waivers expired, those coverage requirements could now be changed. In a final rule implementing provisions of the 2018 legislation, CMS also put limitations on MA plans’ ability to offer additional telehealth benefits. Thus, coverage of telehealth services across MA plans depends on the specific terms of the telehealth coverage included in the MA plan bid.
Because there is not one simple answer to the important question of whether MA plans can continue to provide expansive telehealth coverage, there has been some confusion over this issue. On October 10, 2025, CMS issued a reminder to MA plans that they are allowed to temporarily hold telehealth claims similar to Medicare fee-for-service, as long as all prompt payment requirements are met.
During a government shutdown CMS has a limited number of staff working, and the agency says to “expect delays in rule-making and other policy development.” However, the regulatory process has not ground to a complete halt, and there has been some movement on Medicare rules that are statutorily required to be released. For example, a few of the annual Medicare fee-for-service payment rules, including the calendar year 2026 Outpatient Prospective Payment System final rule, have been sent to the Office of Management and Budget (OMB) for review during the shutdown (review by OMB is the last stage in the clearance process before a rule is issued.) The deadline for publication of the OPPS is set in statute, making it and similar rules such as the Medicare Physician Fee Schedule final rule a priority for CMS and OMB despite the shutdown. It remains to be seen whether those rules will be released on schedule 60 days prior to the start of the new calendar year, on or around November 1, 2025.
When it comes to MA, the annual advance and final rate notices are the only regulatory items with statutory deadlines. At least 60 days prior to the first Monday in April, CMS must put out an advance notice of proposed payment rates and policies that MA plans must adhere to when submitting bids for the coming year. CMS must give stakeholders at least 30 days to review and comment. By the first Monday in April each year, CMS must put out the final notice establishing these payment rates and policies. That way, MA plans have enough time to review the final rates and policies before bids are due on the first Monday in June.
For the 2027 plan year, the advance notice will likely come out in early February 2026, and the final notice will be issued on or before April 6, 2026. Those dates are still well in the future and should not be affected by the current shutdown.
Although not statutorily required, CMS typically releases a more comprehensive rule each year that makes policy and technical changes to the MA and Part D programs. Subject to a 60-day comment period, this rule is typically released before the advance notice, with the goal of a final rule being released around the same time as the final rate notice. That allows MA plans to know all the program rules that will be in place for the coming year and to incorporate in bids the expected costs of administering the program and providing benefits to their enrollees.
As expected, last month CMS sent a proposed rule for 2027 to OMB for review. Absent the shutdown, we would have expected the proposed rule to be released in November or December 2025, leaving ample time for the rule to be finalized before 2027 bids are due.
Because the proposed rule is not mandated, CMS and OMB staff may not be able to work on it during the shutdown, potentially delaying its release. CMS staff may still be able to work on the advance notice to ensure that it comes out on schedule in early 2026. Thus, while the 2027 advance notice may not be affected, it is unclear whether the 2027 MA and Part D proposed rule will be delayed.
As the shutdown continues, we are likely to see more questions about how it will affect the MA program and the millions of beneficiaries and providers it touches. While things may seem as clear as mud now, we hope that the shutdown comes to an end soon, with minimal disruption to patient care.
Until next week, this is Jeffrey (and Lynn) saying, enjoy reading regs with your eggs.
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