Summary of CY26 CMS Final Rules for RHCs

Summary of CY26 CMS Final Rules for RHCs
Further Modifications to Care Management Billing Opportunities and More
By: Sarah Hohman, NARHC Director of Government Affairs

This fall, the Centers for Medicare and Medicaid Services (CMS) finalized the CY26 Medicare Physician Fee Schedule. 

As NARHC shared with you over the summer, prior to submitting formal comments, the rule contained various care management and telehealth proposals that will go into effect January 1, 2026. 

We are already engaging with CMS on regulatory changes the RHC community requests for CY27 rules. With any questions, please contact Sarah Hohman, NARHC Director of Government Affairs at Sarah.Hohman@narhc.org.

Medicare Care Management Reforms and New Opportunities

Care Management in RHCs Background 

From 2016-2025, RHCs were able to bill for a variety of care management services through the consolidated code G0511, which reimbursed approximately $54 per service. 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.
 
Effective October 1, 2025, G0511 is no longer payable. Instead, RHCs are to bill traditional Medicare care management services as the individual HCPCS codes shown here. 

NARHC remains supportive of this transition and alignment with fee-for-service billing opportunities, and the majority of implementation issues across MACs have been resolved. However, if your facility encounters any billing challenges with care management, please contact us so we can escalate appropriately! 

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 (2025) 
G0557: For beneficiaries with two or more chronic conditions; reimburses $48.84 per month (2025)
G0558: For dually eligible (Medicare and Medicaid) beneficiaries with two or more chronic conditions; reimburses $107.07 per month (2025)

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. 

Care Management Changes Beginning January 1, 2026 

CMS continues to prioritize care management as “one of the critical components of primary care” and finalizes various proposals to begin in 2026 to support this. 

Unbundling of G0512 (Psychiatric Collaborative Care Model) 
CMS unbundles G0512, and permits RHCs to bill CPT codes 99492, 99493, and 99494, beginning January 1, 2026. 

Adding Optional Add-On Codes for Behavioral Health Services to Advanced Primary Care Management (APCM) 
Through December 31, 2025, CMS 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. Beginning in 2026, 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 will 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 also 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. 

Beginning January 1, 2026, CMS is proposing to unbundle G0071, and permit RHCs to bill CPT codes G2010 and G2250 (which has replaced G2012).

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, beginning in CY2027, when care management services are proposed to be billable under the PFS, they will be simultaneously and automatically added as care management services eligible for separate payment, at the national non-facility rate, for RHCs as well. 

This approach that will grant RHCs more consistently similar opportunities as their fee-for-service peers, however, we will continue to urge CMS to issue sub-regulatory guidance to support these billing changes in a timelier 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. 

For more information on care management billing opportunities in 2026, please watch NARHC’s recent comprehensive webinar here. 

RHC Telehealth Policy

Background 
Per Congressional authority, Medicare medical telehealth flexibilities will expire on January 30, 2026 without another extension. 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. 

CMS Telehealth Policy 
CMS elected to use their authority to ensure that medical telehealth billing flexibilities do not lapse for RHCs in the event Congress fails to pass telehealth legislation by January 30. They extended current telehealth policy (the G2025 methodology) through December 31, 2026, if Congress does not otherwise act. 

CMS later clarified in an FAQ that “The home and any geographic location may continue to serve as a distant site and originating site for beneficiaries receiving telecommunications services furnished by RHCs and FQHCs.”

For the most up to date telehealth policy for RHCs, please visit NARHC.org.