Updated November 19, 2025
On November 12, Congress passed H.R.5371, Continuing Appropriations, Agriculture, Legislative Branch, Military Construction and Veterans Affairs, and Extensions Act, 2026, to reopen the federal government. The bill provided funding for government agencies and contained provisions that extend healthcare-related programs and policies.
The legislation included a provision that will prevent $536 billion in scheduled cuts to the Medicare program in the next decade. These automatic cuts are a provision of federal statute known as the Pay-As-You-Go (PAYGO) Law, which requires revenue reductions to be offset with mandatory spending cuts to the federal budget, including Medicare. Significant deficit increases enacted by the One Big Beautiful Bill Act (OBBBA) raised the PAYGO score card, setting up automatic cuts to federal programs. The reversal of automatic PAYGO-triggered reductions will prevent any payment changes that could have impacted Medicare providers and beneficiaries. While these additional Medicare PAYGO cuts were prevented by the bill, the current 2% reduction in payment (sequestration) for all Medicare fee-for-service claims is still in place.
The legislation restored COVID-era Medicare telehealth flexibilities, which will remove geographic restrictions for services and allow eligible providers to offer telehealth, among other provisions. The flexibilities were extended to January 30, 2026, where they are set to expire again if Congress does not extend them. The legislation will also pay retroactively for Medicare telehealth services furnished during the shutdown.
The funding bill also preserved the 1.0 work Geographic Practice Cost Index (GPCI) floor, which supports Medicare providers in rural or underserved areas who would receive lower payments otherwise. To account for the GPCI payment increase, processed Physician Fee Schedule claims with dates of service after October 1, 2025 may need to be reprocessed by Medicare Administrative Contractors (MACs). The floor is set to expire on January 30, 2026.
Unfortunately, Congress was unable to reach a funding consensus before the end of the federal fiscal year (September 30), and the US federal government shut down as of 12:01 a.m. on October 1. During a shutdown, non-essential federal employees are furloughed, and many government services are paused until funding is restored. The Committee for a Responsible Federal Budget has created a comprehensive FAQ for reference, but APMA has captured the main concerns below. APMA consultant Hart Health Strategies has also compiled an extensive resource document addressing the shutdown impact.
How Will the Shutdown Affect My Practice?
On October 15, 2025, CMS released a Medicare Learning Network (MLN) Connects Newsletter clarifying that Medicare Administrative Contractors (MACs) would continue to process and pay held claims in a timely manner with the exception of select claims for services impacted by the expired provisions with dates of service on or after October 1. As initially indicated, this hold "prevents the need for reprocessing large volumes of claims should Congress act after the statutory expiration date” to extend certain statutory provisions that have expired, including certain telehealth flexibilities. Providers can continue to submit claims during this hold time, but payment will not be released for very limited service types described below until the hold is lifted.
On October 21, CMS released updated guidance lifting many of the temporary claims holds. The temporary claims hold was lifted for claims paid under the Medicare Physician Fee Schedule, ground ambulance transport claims, and Federally Qualified Health Center (FQHC) claims. Claims holds on behavioral and mental health services have also been lifted.
CMS has directed all MACs to continue to temporarily hold claims for telehealth services that CMS cannot confirm are definitively for behavioral and mental health services. CMS has also directed all MACs to continue to temporarily hold Hospital Care at Home claims.
CMS will also continue to pay Medicaid reimbursement as long as funds allow without a reauthorization in appropriations. APMA will not know how long CMS Medicaid reimbursement will continue until shutdown contingency instructions are released. Additionally, providers may have delays in responses to billing questions and process enrollment applications because the employees for these functions are paid through annual appropriations and could be affected by the shutdown.
The Department of Veterans Affairs (VA) will require physicians to report to work and deliver clinical care, but there will be a delay in reimbursement and administrative functions. The VA recently released its shutdown contingency instructions.
Telehealth Extension
Medicare telehealth benefits originally established during the COVID-19 Public Health Emergency have expired. This means that absent any additional Congressional action, telehealth services are prohibited for Medicare beneficiaries who do not live in rural areas. Home-based telehealth services are no longer be reimbursed, and patients are required to travel to a medical facility to receive Medicare telehealth. The Acute Hospital Care at Home Program has also expired along with the ability to provide audio-only visits as well. CMS has advised that practitioners choosing to perform telehealth benefits on or after October 1 should consider providing beneficiaries with an Advance Beneficiary Notice of Noncoverage.
Please note, that for DME requiring a face-to-face encounter prior to dispensing, the more restrictive, reinstated telehealth restrictions will again apply:
2) Items Requiring a Face-to-Face Encounter. For PMDs and other DMEPOS items selected for inclusion on the Required Face-to-Face Encounter and Written Order Prior to Delivery List, the treating practitioner must document and communicate to the DMEPOS supplier that the treating practitioner has had a face-to-face encounter with the beneficiary within the 6 months preceding the date of the written order/prescription.
(i) The encounter must be used for the purpose of gathering subjective and objective information associated with diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered.
(ii) If it is a telehealth encounter, the requirements of §§ 410.78 and 414.65 of this chapter must be met.
410.78 includes requirements for originating site and geographic location requirements for telehealth (among other requirements). This means that any face-to-face encounter via telehealth used to support the ordering of DME will need to comply with the more restrictive reinstated telehealth restrictions. APMA recommends that providers confirm that the face-to-face visit was either in-person or conducted in accordance with the more restrictive telehealth policies that are now in place before dispensing DME after October 1, 2025.
Members can view the full list of DME items that require a face-to-face encounter here: https://www.cms.gov/files/document/required-face-face-encounter-and-written-order-prior-delivery-list.pdf.