THIS WEEK’S DOSE
- Congressional disagreements on addressing healthcare costs continue. The looming expiration of the enhanced advanced premium tax credits (APTCs) continues to be a major topic of discussion for lawmakers, with no bipartisan agreement in sight.
- Numerous congressional hearings on healthcare. The Senate Finance Committee examined the rising cost of healthcare and the Senate Aging Committee analyzed domestic production of medicine. In the House, the Ways and Means Committee reviewed chronic disease prevention and treatment, the House Energy and Commerce Committee examined the risks associated with AI chatbots, and the Budget Committee held an oversight hearing on the Congressional Budget Office (CBO).
- Senate advances nomination for HHS inspector general. The nomination of Thomas Bell to be inspector general of the US Department of Health and Human Services (HHS) was advanced through both the Senate Committee on Homeland Security & Governmental Affairs and the Senate Finance Committee, which means it is ready for full Senate consideration.
- CMS issues guidance on Medicaid provider and MCO tax provisions of OBBBA. The Centers for Medicare & Medicaid Services (CMS) clarified two tax provisions, applicable to providers and managed care organizations (MCOs), included in the One Big Beautiful Bill Act (OBBBA).
- CMS announces 2026 premiums and deductibles for Medicare Parts A and B. In 2026, Medicare Parts A and B premiums and deductibles will increase.
- HHS advances caregiver support efforts. HHS announced new initiatives aimed at strengthening caregiver support and expanding the caregiving workforce.
- DHS releases proposed rule on public charge determinations. The Department of Homeland Security (DHS) proposed rule would revise how immigration officers assess public-charge determinations, potentially affecting enrollment in programs like Medicaid.
- CMS updates Medicare claims processing guidance. CMS’ updated guidance reflects the end of the government shutdown and the restoration of certain payment waivers and flexibilities.
- CMS releases final CY 2026 ESRD rule. The final rule updates payment rates and policies under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for calendar year (CY) 2026.
CONGRESS
Congressional disagreements on addressing healthcare costs continue. With the record-setting 43-day government shutdown in the rearview mirror, the House and Senate were back in full swing this week, and the fast-approaching expiration of the enhanced APTCs kept healthcare affordability issues front and center. While part of the deal to reopen the government included Senate Majority Leader Thune’s (R-SD) promise of a floor vote on an enhanced APTC extension bill of the Democrats’ choosing by the second week of December, a path forward has yet to be determined. While Democrats have continued to advocate for a straightforward enhanced APTC extension, many Republicans appear to be in favor of an approach that sends money directly to consumers, such as through health savings accounts (HSAs). President Trump issued a statement to this end, and Republican lawmakers are also touting this concept, though the exact language and mechanics of such a proposal has yet to be put forward. Additionally, on the topic of HSAs, the Government Accountability Office (GAO) released a report following their interviews with nine HSA providers and other stakeholders looking at features of HSAs, how they are marketed, how HSA holders use their accounts, and the characteristics of individuals who use HSAs and other tax-advantage savings accounts. The issue of HSAs and APTCs was front and center at the Senate Finance Committee’s hearing on healthcare costs (see next story) and will likely remain so into December.
Numerous congressional hearings on healthcare. With both the House and Senate in session this week for the first time since mid-September, committees on both sides of the Capitol held a number of healthcare-focused hearings.
Senate:
- Finance Committee hearing on healthcare costs. In this hearing, Republican members of the committee generally supported the concept of providing funds to individuals using HSAs instead of offering discounted coverage on the marketplace through the APTCs as a solution to rising healthcare costs. In contrast, Democratic senators, and the witnesses invited by the Democrats, argued that the extension of the enhanced APTCs is the crisis facing millions of Americans come January 1, 2026, and that needs to be the immediate focus. Democratic senators and some of the witnesses also agreed that longer-term health reforms aren’t possible before that date.
- Aging Committee hearing on restoring trust in medicines. Witnesses in the Senate Aging Committee hearing shared the regulatory and financial barriers they face as US-based drug manufacturers, and expressed concerns with the increasing dependence on foreign-made medicines leading to drug shortages and threats to national security and patient health. Senators on the committee emphasized the importance of improving quality and reliability of the nation’s medical supply and asked the witnesses to identify policy changes would most benefit them and patients. Additionally, Chair Scott (R-FL) shared plans to introduce legislation that would require country-of-origin information on drug labeling to ensure patients know where their medications are coming from.
House:
- Energy and Commerce Oversight and Investigations Subcommittee hearing on AI chatbots. During this hearing, committee members expressed concerns about the potential harmful effects AI chatbots could pose as they become increasingly popular. Their questions focused on issues related to mental health, child safety, and privacy, emphasizing the importance of mitigating the risks of misinformation and disinformation in AI chatbots. Witnesses shared insights on negative mental health outcomes from AI chatbots and emphasized that AI chatbots should not replace human relationships.
- Ways and Means Health Subcommittee hearing on care coordination. During this hearing on chronic disease prevention and treatment, Democrats on the committee expressed concerns over Americans who might lose their health insurance because of the rise in health insurance premiums. They emphasized that without extending the APTCs, many Americans would not be able to access health services. Republican members of the committee emphasized that the ACA must be replaced and noted that HSAs would be an affordable option for people to access care. Both parties emphasized that telehealth services should be expanded and highlighted the benefits rural communities experience with telehealth.
- House Budget Committee hearing with CBO director. This hearing included a focus on the recent cyberattack at CBO and calls for an independent audit, and many members focused their questions on CBO’s scoring of OBBBA’s healthcare provisions and the expiration of the enhanced APTCs. CBO Director Swagel noted that during negotiations for OBBBA, CBO had to decide between timeliness and transparency when releasing information. Now that the bill has been enacted, he affirmed CBO will release a more in-depth analysis on OBBBA in February 2026, including budget estimates. Democratic members expressed concerns about the enhanced APTCs’ expiration and asked Director Swagel about CBO’s analysis of OBBBA’s impact on the national debt and number of uninsured Americans. Chair Arrington (R-TX) indicated that the committee may hold a healthcare-related hearing in the future.
Senate advances nomination for HHS inspector general. This week the Senate Committee on Homeland Security & Governmental Affairs held a hearing to consider the nomination of Thomas Bell to be HHS inspector general. The committee then held a business meeting where they advanced his nomination by a vote of 8-7, along party lines. With the Senate Finance Committee also moving the nomination forward this week by a vote of 14-13 along party lines, it will now proceed to the Senate floor.
ADMINISTRATION
CMS issues guidance on provider and MCO tax provisions of OBBBA. In a Dear Colleague letter, the Center for Medicaid and CHIP Services (CMCS) provided guidance on implementing certain Medicaid provisions from the OBBBA.
- Providers. Section 71115 of OBBBA specifies the requirements for an expansion or non-expansion state that “has enacted a tax and imposes such tax,” referring to the healthcare-related provider taxes. CMS’ guidance clarifies the definitions of “enacted” and “imposed” under new rules in the OBBBA. The guidance outlines that non-expansion states may maintain existing “hold harmless” arrangements, while expansion states must gradually reduce their thresholds starting in fiscal year 2028. CMS is also collecting data on current tax structures to support consistent application of the new thresholds and to inform future rulemaking and state planning.
- MCOs. Section 71117 of OBBBA addresses provider tax waivers by tightening rules around the federal requirements that provider taxes be uniform and broad-based, meaning they must be applied at the same level and to all providers in the state. States have been allowed to seek CMS waivers if their tax structures were redistributive and not directly tied to Medicaid payments, but CMS grew concerned that this allowed states to tax Medicaid MCOs at higher rates than others. To close this loophole, Section 71117 empowered CMS to phase out non-compliant taxes through a transition period of up to three fiscal years. Before OBBBA was enacted, CMS had proposed a similar rule in May 2025, though it offered a more limited transition period – only for states whose waiver approvals were granted more than two years before the final rule’s effective date.
In this guidance, CMS also provides the following transition periods, which differ from the May proposed rule:
- States with MCO taxes that use this loophole and received a waiver approval before the July 4, 2025, enactment of OBBBA will have until the end of the applicable state’s fiscal year ending in calendar year 2026.
- States with all other taxes that use this loophole and received a waiver approval before the July 4, 2025, enactment of OBBBA will have until the end of the applicable state’s fiscal year ending in calendar year 2028, but no later than October 1, 2028.
While the information provided in the letter is preliminary in nature, CMS plans to release a rule with more formal guidance.
CMS announces 2026 premiums and deductibles for Medicare Parts A and B. Key changes for 2026 include:
- Part B. The Part B standard monthly premium for 2026 will be $202.90, an increase of 9.7% over the 2025 Part B standard monthly premium of $185.00. The annual Part B deductible for 2026 will be $283.00, an increase of 10.1% over the 2025 Part B deductible of $257. CMS noted that the increase in the 2026 Part B standard premium and deductible is mainly due to projected price changes and assumed utilization increases that are consistent with historical experience. Additionally, CMS reported that as a result of reductions in payment amounts for skin substitutes finalized in the recent Medicare Physician Fee Schedule final rule, the 2026 Part B premium is about $11 less than it would otherwise have been.
- Part A. The Part A monthly premium will be $565, an increase of 9.1% over the 2025 Part A monthly premium of $518. While most Part A enrollees do not pay a monthly premium for Part A coverage, certain individuals who do not qualify for premium-free coverage are eligible for coverage subject to a monthly premium and are therefore impacted by the premium increase for 2026. The Part A inpatient deductible will be $1,736, an increase of 3.6% over the 2025 deductible of $1,676. The 2026 cost sharing for inpatient stays that exceed 60 days will be $434 per day for days 61 – 90 and $868 per day for lifetime reserve days.
HHS advances caregiver-support efforts. During an event in which experts in caregiving and family caregivers discussed the financial and emotional challenges facing caregivers and their families, HHS highlighted the need to strengthen the workforce through financial support. Additionally, HHS Secretary Kennedy announced the Caregiver Artificial Intelligence Prize Competition and called upon innovators to develop AI caregiver tools that support family members, friends, and the direct-care workforce in providing safe, person-centered care at home, as well as AI caregiver workforce tools that help employers improve efficiency, scheduling, and training. The Administration for Community Living (ACL) will award innovators who can harness the power of AI to reduce the administrative burden on caregivers. The ACL will provide up to $2 million in prizes to 10 awardees over a three-year period to help scale the initiative.
DHS releases proposed rule on public-charge determinations. The proposed rule would change how immigration officers determine whether noncitizens are likely to become dependent on government assistance. Under federal immigration law, noncitizens applying for a visa, admission to the United States, or an adjustment of status to lawful permanent resident can be denied if they are deemed likely to become reliant on the government, known as being a “public charge.” The statute states that immigration officers, at a minimum, must consider an individual’s “age; health; family status; assets, resources, and financial status; and education and skills” when making a public-charge determination.
The proposed rule would rescind the 2022 final rule and give officers greater discretion to consider all statutory and case-specific factors when determining inadmissibility under the public charge standard. DHS also plans to develop new policy and interpretive tools to guide these determinations and is seeking public input on their design. DHS now estimates that the proposed rule could reduce federal and state spending on public programs by at least $8.97 billion annually, due to an expected disenrollment or forgone enrollment of about 950,000 individuals from programs such as Medicaid, the Children’s Health Insurance Program (CHIP), SNAP, Temporary Assistance for Needy Families, and Supplemental Security Income.
CMS updates Medicare claims processing guidance. CMS released updated Medicare claims processing guidance to reflect the end of the shutdown and the restoration of certain payment waivers and flexibilities, including Medicare telehealth flexibilities and the Acute Hospital Care at Home (AHCAH) waiver. In this guidance, CMS clarified that all telehealth claims are now payable if they meet applicable requirements and directed clinicians to resubmit returned or held claims. Similarly, hospitals participating in the AHCAH program may now resubmit claims for services on or after October 1, 2025. CMS also instructed the Medicare Administrative Contractors (MACs) to make adjustments to claims affected by the recent congressional action to retroactively restore lapsed programs, including low-volume hospital adjustment and the Medicare-dependent hospital program. CMS expects normal processing operations to resume shortly and advised providers to contact their MACs only if discrepancies arise.
Separately, CMS posted revised frequently asked questions (FAQs) on Medicare telehealth services. The FAQs state that the Medicare telehealth waivers and flexibilities now expire on January 30, 2026. Providers can submit Medicare telehealth claims for dates of service on or after October 1, 2025. CMS states in the FAQs that it will continue to pay telehealth claims in the “same way they had been paid before October 1, 2025. Telehealth flexibilities will apply retroactively as if there hadn’t been a temporary lapse in the application of the telehealth flexibilities through January 30, 2026.” CMS also discussed the issue of using a provider’s home address when the clinician provides telehealth services from their home, stating that “practitioners can provide telehealth services from their home and in many cases do not need to report their home address.”
CMS releases final CY 2026 ESRD rule. The rule finalizes the following:
- The final CY 2026 ESRD PPS base rate is set at $281.71, an increase from the CY 2025 ESRD PPS base rate of $273.82. The final amount reflects the application of the wage index budget neutrality adjustment factor, the budget neutrality factor for the final non-contiguous areas payment adjustment (NAPA) (0.99860), and a final ESRD Bundled market basket update of 2.1%
- CMS modifies the timeframe for Transitional Drug Add-on Payment Adjustment (TDAPA) eligibility to provide that a new renal dialysis drug or biological product must have been approved by the Food and Drug Administration within the past three years at the time of submission of the TDAPA application. This revised eligibility timeframe will apply for all new drugs and biological products for which a TDAPA application is submitted on or after January 1, 2028.
- CMS will terminate the End-Stage Renal Disease Treatment Choices Model, ending December 31, 2025.
A fact sheet from CMS can be found here.
QUICK HITS
- Republican House committee leaders release letter on Organ Procurement and Transplantation Network. Energy and Commerce Committee Chair Guthrie (R-KY) and Energy and Commerce Oversight and Investigations Subcommittee Chair Joyce (R-PA) sent a letter to CMS Administrator Oz requesting a briefing by December 1, 2025, to better understand HHS’ recent actions and ongoing work to enhance safety within the Organ Procurement and Transplantation Network.
- House and Senate release 2026 legislative calendars. The House 2026 legislative calendar and the Senate 2026 legislative calendar show the days each chamber plans to be in session in the new year. While the calendars are generally similar, there are weeks in which one chamber will be in session while the other will be in recess. Additionally, both chambers will be out of session for most of October 2026, due to the approaching midterm elections.
- HHS releases updated report on pediatric gender-affirming care. The previously published report is critical of pediatric gender-affirming care, focusing on the potential risks and long-term health impacts associated with treatments such as puberty blockers, hormones, and surgeries. This update shows that the report was peer-reviewed.
- GAO releases report on Medicaid enrollment across state lines. The GAO found that the federal government and six states overpaid MCOs in fiscal year (FY) 2023 and recommends CMS implement controls to prevent duplicate Social Security numbers on marketplace policies receiving APTC benefits and require marketplaces and Medicaid/CHIP agencies to submit enrollment data for frequent interstate matching and resolve discrepancies to verify eligibility or terminate coverage.
NEXT WEEK’S DIAGNOSIS
Congress will be in recess next week for the Thanksgiving holiday. Lawmakers are set to return the week of December 1, 2025, at which time we expect the Senate’s plans to become clearer on timing for an APTC vote, along with potential progress on the next package of the nine remaining FY 2026 appropriations bills, which must be addressed prior to the new January 30, 2026, funding deadline.
With Congress out next week, the Check-Up will return on December 5, 2025. We wish you a Happy Thanksgiving!
