Summary of CY26 CMS Proposed Rules for RHCs
Further Modifications to Care Management Billing Opportunities and More
Sarah Hohman, Director of Government Affairs, NARHC
This summer, the Centers for Medicare and Medicaid Services (CMS) issued the CY 2026 Medicare Physician Fee Schedule (MPFS) Proposed Rule. While this year’s 1,803 page rule contains fewer Rural Health Clinic (RHC) specific policy proposals than the past few years, we encourage you to read this summary for important updates on care management billing reforms, telehealth, and more.
“CMS continues to move RHC care management billing towards a fee-for-service methodology in this year’s proposed rule,” said Nathan Baugh, Executive Director of NARHC. “Our priority throughout this ongoing transition is to press CMS and the MACs to make sure that care management billing and coding actually works as intended.”
We were hoping that CMS would use this year’s rule to fix issues with Annual Wellness Visits and the complex E/M add-on code for RHCs. Unfortunately, neither of those issues was addressed in this proposal, but NARHC will continue to meet with CMS officials to discuss how they can improve their policies.
If these regulations are finalized by CMS this November, they will go into effect January 1, 2026, unless otherwise specified.
As always, please contact Sarah Hohman, NARHC Director of Government Affairs at Sarah.Hohman@narhc.org with any questions or other feedback, or stop by one of NARHC’s upcoming Office Hours.
Medicare Care Management Reforms and New Opportunities
Care Management in RHCs Background
From 2016-2025, RHCs have been able to bill for Chronic Care Management (CCM) services through a consolidated care management code: G0511. This special payment rule pays approximately $54.67 in 2025, which is the average of the Physician Fee Schedule (PFS) rates for CCM, principal care management (PCM) services, Chronic Pain Management, General Behavioral Health Integration, as well as codes newly added in 2024: Remote Physiological Monitoring (RPM), Remote Therapeutic Monitoring (RTM), Community Health Integration (CHI), and Principal Illness Navigation (PIN) Services.
Beginning in 2024, the G0511 code was finally billable more than once per patient per month, so long as requirements are met and resource costs are not double counted, which NARHC had long advocated for. However, because the single consolidated code represented 22 care management services, this aggregation presented a myriad of billing issues and Medicare Administrative Contractor (MAC) confusion.
For several years, NARHC encouraged CMS to consider a revision to this complex bundled approach to RHC care management billing, either by allowing RHCs to bill care management services through a fee-for-service methodology or creating more G-codes for the different buckets of care management services (i.e. RPM, RTM, CCM, etc.).
Beginning on January 1, 2025 (but optional until September 30, 2025 as billing systems transition to the new policy) RHCs are now to bill traditional Medicare care management services as the individual CPT care management codes (shown here) on the UB-04. Currently, RHCs are supposed to be reimbursed at the PFS national non-facility rate for these services if they bill the underlying CPT code. The consolidated G0511 code is set to be eliminated on October 1.
While NARHC was supportive of this transition and alignment with FFS billing opportunities overall, throughout the last eight months, this policy has proven difficult for CMS and the MACs to implement. Various CMS guidance documents were delayed, and MACs across the country have operationalized this policy incorrectly and inconsistently. We have consistently elevated these issues to CMS throughout the year and the issues have broadly been resolved. However, if you continue to face any issues billing the care management CPT codes, please contact NARHC.
Advanced Primary Care Management (APCM) in RHCs Background
Separately, beginning on January 1, 2025, CMS created a new care management billing opportunity – Advanced Primary Care Management, or APCM. These three bundled G-codes were intended to bundle existing care management codes based on complexity of patient condition as per calendar month bundles. If an RHC bills for these codes, they would not be allowed to bill the fee-for-service methodology explained above for that same patient.
G0556: For beneficiaries with one or fewer chronic conditions; reimburses $15.20 per month
G0557: For beneficiaries with two or more chronic conditions; reimburses $48.84 per month
G0558: For dually eligible (Medicare and Medicaid) beneficiaries with two or more chronic conditions; reimburses $107.07 per month
Anecdotally, we have heard that some RHCs have begun billing for APCM codes. One benefit of billing for these codes, as opposed to individual care management codes (99490, 99491, etc.), is that they are not time-based, therefore you don’t need to hit a specific number of minutes of services in order to bill. The challenges with APCM however, are the more comprehensive and, potentially burdensome, requirements that exceed the requirements necessary to bill for Chronic Care Management. For example, in order to bill APCM, RHCs are required to conduct “population-level management” which requires you to “analyze patient population data to identify gaps in care” and “risk stratify the practice population.”
We encourage you to review the requirements of APCM here. Within this year’s proposed rule, CMS issued a specific Request for Information on the use of APCM. If your RHC is billing for, or attempting to bill for APCM services, please let NARHC know what is going well and what challenges you are facing so that we can communicate that to CMS.
Care Management Changes Proposed for 2026
CMS continues to prioritize care management as “one of the critical components of primary care” and makes various proposals in the 2026 rule to support this.
Unbundling of G0512 (Psychiatric Collaborative Care Model)
CMS is proposing to unbundle G0512, and permit RHCs to bill CPT codes 99492, 99493, and
99494,beginning January 1, 2026. More details on these codes can be found in Table 34 of the
proposed rule.
Adding Optional Add-On Codes for Behavioral Health Services to Advanced Primary Care Management
(APCM)
CMS currently allows RHCs to bill G0512 (above) and G0323, which is essentially behavioral health
care management services, under the direction of a clinical psychologist or clinical social worker. In this
year’s proposed rule, CMS is further emphasizing the value of integration of behavioral health and
primary care by creating optional add-on codes for complementary behavioral health integration
services provided at the same time as APCM services.
Instead of time-based tracking of these services, these codes would require the complementary
availability of certain behavioral health services and collaboration, including the development of an
individualized treatment plan, tracking patient progress, coordinating treatment, etc. while the facility is
providing APCM services.
If a facility bills for these services, they will not bill 99492, 99493, and 99484 for that patient.
Unbundling of G0071
RHCs are currently eligible to bill the consolidated G0071 code ($13.91) when the conditions for codes
G2010 (remote evaluation of video/images submitted by an established patient; interpretation and
follow-up) or G2012 (virtual check-in; 5-10 minutes) are met.
CMS is proposing to unbundle G0071, and permit RHCs to bill CPT codes G2010 and G2250 (which
has replaced G2012), beginning January 1, 2026. More details on these codes can be found in Table
35 of the proposed rule.
General Alignment of Care Management Opportunities with Fee-for-Service Practitioners
CMS acknowledges that the number of care management services has continuously increased over the
last several years, and that maintaining separate lists of care management services billable in the RHC
setting versus in fee-for-service settings is becoming more cumbersome and inefficient.
Therefore, they propose that beginning in CY2027, when care management services are proposed to
be billable under the PFS, that they are simultaneously and automatically added as care management
services eligible for separate payment, at the national non-facility rate, for RHCs as well.
We believe this is a smart approach that will grant RHCs more consistently similar opportunities as their
fee-for-service peers, however, we will emphasize to CMS that it is critical that sub-regulatory guidance
be issued annually in a timely manner. NARHC knows that many RHCs are providing care
management services without billing for them because of the constantly changing billing requirements
and delayed guidance/improper implementation from MACs.
RHC Telehealth Policy
Background
Current Medicare medical telehealth flexibilities will expire on September 30, 2025 without Congressional action. NARHC has been consistently advocating on Capitol Hill for an extension of these policies that includes a fix to reimbursement to ensure that RHCs are paid at parity for in-person and telehealth visits, like fee-for-service providers have received since 2020. To make your voices heard on this issue, please visit NARHC.org.
What CMS Proposed
CMS elected to use their authority in this year’s proposed rule to ensure that medical telehealth billing flexibilities do not lapse for RHCs in the event Congress fails to pass telehealth legislation by September 30. They are proposing to extend current telehealth policy (the G2025 methodology) through December 31, 2026, if Congress does not otherwise act. Additionally, they are proposing to waive the occasional in-person requirement currently on the books for mental health telehealth through December 31, 2026, as well.
NARHC Commentary
Given how bipartisan and popular telehealth is, it is widely expected that Congress will pass telehealth legislation before it lapses later this year. However, NARHC is appreciative of CMS using their authority to try to limit disruptions in care in the event legislation is not passed.
Instead of simply extending the current G2025 policy however, NARHC believes that CMS should instead use their authority to change the RHC medical definition of a visit to include visits done via telecommunications technology. This would result in normal RHC billing for telehealth visits that would generate an All-Inclusive Rate payment. In this year’s proposed rule, CMS acknowledges this as an alternate proposal to extending G2025 policy, and NARHC will comment strongly in this alternative direction.
Of important note: CMS is only using their authority here to extend the distant site billing flexibility for RHCs, not originating site flexibilities (i.e. where the patient is located). This policy still requires action by Congress to ensure that patients can still receive telehealth services from their homes and other locations after September 30, 2025. In other words, despite this CMS proposal, it is critically important for Congress to act before September 30th to preserve telehealth services as they exist.
Medicare Shared Savings Program (MSSP)
Over 2,000 RHCs are currently participating in the Medicare Shared Savings Program, or MSSP. CMS proposed several changes to MSSP that may be of interest to participating providers, including:
- Limiting ACOs to a single five-year period in the BASIC (one-sided risk) track before requiring them to transition to two-sided risk based on performance in their second agreement period.
- Requiring ACOs to have at least 5,000 beneficiaries in benchmark year 3, beginning January 1, 2027.
- Eliminating the health equity adjustment.
What Was NOT Proposed
While covering what is included in the proposed rules is important, we also wanted to share various policy changes that NARHC has proposed to CMS that were not addressed in this year’s rule.
NARHC again encouraged CMS to utilize this rulemaking opportunity to further expand upon preventive care eligible for adequate reimbursement in the RHC setting by amending the definition of an RHC medical visit to allow for Annual Wellness Visits (other than IPPEs) to be eligible for same day billing, as well as allowing those AWVs to be completed by RNs, as they are in non-RHC settings.
Additionally, CMS did not propose to make RHCs eligible for separate reimbursement associated with the complex E/M add-on code (G2211) or modify the group visits limitation, despite Medicare now covering providers such as Marriage and Family Therapists that frequently perform group visits.
NARHC also continues to respond to inquiries put forth by this Administration to share regulations that hinder RHC efficiency and increase administrative burden.
Finally, while NARHC is advocating for a legislative change to the arbitrary 49% threshold on the amount of behavioral health services that RHCs can provide (organizations interested in endorsing this legislation can do so here), we continue to make CMS aware of the variations in interpretation of this policy by surveyors across the country.
Final Comments
NARHC appreciates the RHC provisions included in this year’s proposed rule and we look forward to engaging with CMS to ensure that they are finalized in such ways to achieve the greatest positive impact for our safety-net providers.
The National Association of Rural Health Clinics (NARHC) will be submitting comments on all RHC-provisions, which will be reviewed by the NARHC Policy Committee, to CMS by September 12, 2025.
