The Centers for Medicare & Medicaid Services, also called CMS, has made several important changes that affect Medicare, Medicaid, and healthcare programs across the United States. These updates come at the same time as a federal government shutdown, which has caused concern for many patients, doctors, and states.
CMS said that Medicare Advantage plans must now share yearly reports on how they use prior authorization, denials, appeals, and overturns. This means insurance companies must tell how often they block or delay care. The new rule will help patients and doctors see more clearly how plans work. Many hospitals and advocates say this is needed because prior authorizations often slow down treatment.
CMS also gave states new guidance on emergency Medicaid funding. This helps states get federal money to cover emergency medical care, especially for noncitizens and low-income families. With more people needing emergency help, this rule will give states financial support when they need it most.
Another big change is CMS’s plan to move most Medicare and Medicaid users into accountable care programs by 2030. These programs focus on saving money and making care more efficient. But some experts warn that this could mean fewer choices for patients, more prior approvals, and smaller doctor networks. Seniors and patient groups are worried this could make it harder to get the right care on time.
Even with the government shutdown, Medicare and Medicaid payments will continue. Telehealth visits are still billable, and CHIP payments for kids will also go out. Still, CMS is working with fewer staff, so things like program updates, new waivers, and policy approvals may move slowly.
Other CMS news includes:
- A new J-Code for the drug Ryoncil, now covered by Medicare and Medicaid.
- A data privacy issue in Oregon, where Medicaid user data was shared outside.
- A study showing that many adults who may lose coverage under work rules are chronically ill.
- Oversight plans for noncitizen Medicaid enrollment and the end of COVID-era continuous eligibility waivers.
For patients, these changes mean both good and bad news:
- ✅ More transparency in Medicare Advantage decisions.
- ✅ States can get federal help for emergency care.
- ⚠️ Possible reduced freedom in choosing doctors under accountable care.
- ⚠️ Slower CMS services due to fewer workers during shutdown.
In short, CMS is reshaping how Medicare and Medicaid work in 2025, balancing cost control with patient access. Hospitals, states, and advocacy groups will be watching closely as these new rules roll out.
