CMS & CMMI Updates

Key Actions:

In the past 90 days, CMS has released several transmittals impacting various aspects of Medicare coverage and payment policies. Notable actions include:

- Transmittal R13611NCD and R13611CP were issued on January 30, 2026, with an implementation date of October 22, 2025. These relate to new National Coverage Determinations (NCD) and corresponding claims processing provisions. Details on the policy changes can be accessed through the links: R13611NCD and R13611CP.

- In addition, Transmittal R13599BP was also published on January 30, 2026, set to take effect on May 1, 2026. It pertains to new updates regarding Medicare payment regulations as identified in publication #100-02.

- Furthermore, transmittals R13612NCD and R13612CP, both issued on January 30, 2026, are set to take effect on April 6, 2026. These documents detail updated coverage and claim processing protocols related to new NCD proposals. Access these transmittals here: R13612NCD and R13612CP.

Implications for VBC Stakeholders:

The recent transmittals signify critical changes for ACOs and MA plans. Stakeholders must review how these new coverage determinations (NCDs) are integrated into current operational frameworks. Particularly for those tied to Medicare Advantage and ACO models, the payment structure and associated care delivery expectations may shift, necessitating adjustments in clinical protocols and documentation strategies.

Additionally, with claims processing protocols updated in transmittals R13599BP, ACOs and providers will need to align billing practices with the new standards to avoid denial of reimbursement. The May 1, 2026 effective date provides a timeline for necessary education and training.

Overall, health systems and physician groups must strategically plan for these changes to ensure compliance, especially as new NCDs utilize evolving evidence-based guidelines which could influence patient management and care pathways.

What to Watch:

VBC leaders should closely monitor the effective dates for the aforementioned transmittals, particularly March 2026 for updates impacting Medicare payment policies. Additionally, as the newly established Trump administration aligns strategies with CMMI, any forthcoming discussions or releases regarding innovation models warrant attention. Pay attention to any signals from the CMMI leadership, as their strategic direction may encourage shifts towards integrated care models that support value-based initiatives. This will influence upcoming cycle planning, particularly for organizations actively participating in Medicare models.