Behavioral Health Changes Nationwide

What changed. On October 29, 2026, the U.S. District Court for the District of Massachusetts held that the definition of medical frailty in CMS's interim final rule on Medicaid community engagement requirements (CMS-2454-IFC) is contrary to law, vacated that language, issued a permanent injunction, and granted the plaintiff states a six month stay of enforcement to accommodate errors or delays during the initial roll out of the work requirements. The suit, filed in June 2026, was co-led by the Massachusetts, California and New Jersey attorneys general and joined by Arizona, Colorado, Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, the governor of Kentucky, Maine, Maryland, Michigan, Minnesota, Nevada, New Mexico, New York, North Carolina, Oregon, the governor of Pennsylvania, Rhode Island, Vermont, Virginia, Washington and Wisconsin. New York's attorney general says the ruling keeps people living with a serious mental health condition or addiction from having to prove they are sick enough to keep coverage.

What it means. If your patients are in the Medicaid expansion group, ask your state Medicaid agency how it will apply the medically frail exemption for people with substance use or mental health disorders now that the federal definition is vacated, and plan documentation support for exemption requests. Calendar a check in spring 2027, when the six month stay of enforcement in the plaintiff states runs out.

What changed. OJJDP posted the FY 2026 Mentoring for Youth Impacted by Opioids and Other Substance Use solicitation on October 9, 2026, with an estimated $16,500,000 available, awards of up to $2,000,000 each and no cost sharing. Eligible applicants are units of local government, national organizations and organizations with statewide reach that provide mentoring services to youth who are using or dependent on substances, at risk of substance use, or living with family members who use substances, through one-on-one, group, peer or hybrid mentoring. The Grants.gov deadline is November 16, 2026 at 11:59 pm Eastern and the JustGrants deadline is November 23, 2026 at 8:59 pm Eastern.

What it means. If your organization runs or partners on a statewide youth mentoring program, decide this week whether to apply, because the first step in Grants.gov closes November 16 and a missed Grants.gov submission locks you out of JustGrants. A treatment program without statewide mentoring reach can still approach a local government or statewide mentoring organization that would subcontract clinical, family or peer services under its application.

What changed. Permanent order BHS 26-2026, filed and effective November 4, 2026, amends seven rules in OAR 309-040 (adult foster homes licensed by OHA for adults with serious mental illness) to implement HB 4016 and HB 4115 and replaces the temporary rules filed under BHS 11-2026. The order adds a definition of Owner, requires a Tax Compliance Certification from the Oregon Department of Revenue for each owner with 20 percent or more ownership and for the business entity that operates the home at initial licensure and with each renewal packet, and adds an owner's violation of the tax laws in ORS 305.380 as a reason to deny, suspend, revoke or refuse a license. It also changes the required new background check from every two years to every three years and lets the Division proctor the AFH test on an online platform. OHA's rulemaking page lists no public comment received on the August 19, 2026 notice.

What it means. If you hold or are applying for an OHA mental health adult foster home license, add the Department of Revenue Tax Compliance Certification for every 20 percent owner and for the operating entity to your application and renewal packets now, since the rule is already in effect. Update your staff file tracker so background checks for providers, resident managers and substitute caregivers are rerun every three years instead of two, and keep the two year cadence until each person's next check comes due.

What changed. Premera's medical policy 2.01.526, Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders, was revised in an interim review approved October 13, 2026 and took effect November 1, 2026. The policy history says the requirement that each failed medication be individually identified with its reason for failure now sits in the medication criteria for major depressive disorder, bipolar depression and OCD; for OCD, failed trials may now be two SSRIs plus risperidone or aripiprazole as augmentation to a failed SSRI, or clomipramine and one SSRI plus that augmentation; and a repeat full intensive course of TMS may be medically necessary after a failed course when performed with a different protocol. Premera's medical policy updates page lists the same changes, along with a renumbering of Prescription Digital Therapeutics for Substance Use Disorders to 5.01.643 effective November 1.

What it means. If you provide TMS to Premera members in Washington or Alaska, update your prior authorization templates so each failed medication and its reason for failure is documented in the MDD, bipolar and OCD sections, and use the new OCD augmentation pathways where they apply. Flag repeat TMS requests after a failed course as a different protocol in the request, since that is now the stated path to medical necessity.

What changed. All Facilities Letter 26-32, dated October 30, 2026, tells acute psychiatric hospitals that CDPH is giving the five working day notice required by Government Code 11346.1(a)(2) for the readoption of emergency regulatory action DPH-19-001E, which readopts Title 22 CCR sections 71213.1 and 71215.1 to carry out the nurse to patient ratio standards for acute psychiatric hospitals under Health and Safety Code 1276.4. The notice period runs November 2 through November 6, 2026, CDPH will file the readoption with the Office of Administrative Law on November 9, 2026, OAL then allows five calendar days for comments to its reference attorney, and the regulations are to be in effect November 28, 2026.

What it means. Acute psychiatric hospitals in California should pull the emergency text and finding of emergency from CDPH's DPH-19-001E page and send any objections to CDPH by November 6 or to OAL's reference attorney during the five days after the November 9 filing. Confirm your nurse staffing plans and ratio documentation stay in line with sections 71213.1 and 71215.1 past November 28, since the readoption keeps the standards in force.

What changed. A Notice of Proposed Rulemaking published in the DC Register on October 9, 2026 (Vol. 73/41, Notice N146769) would add Section 3437 to 22-A DCMR Chapter 34 and Section 6353 to Chapter 63, listing the services DBH will pay for with local funds for Healthcare Alliance members and uninsured residents who do not qualify for Medicaid or Medicare. The MHRS list covers diagnostic assessment, medication and somatic treatment, counseling, crisis services, day services, ACT, several trauma and family therapies, care coordination, supported employment, clubhouse and stabilization services; the SUD list covers residential treatment, medically monitored inpatient withdrawal management, counseling, drug screening, medication management, medications for opioid use disorder and recovery support services only alongside residential treatment. Comments are due not later than 30 days after publication, which is November 8, 2026, to dbh.policy@dc.gov.

What it means. If you are a DBH certified MHRS or SUD provider that serves Alliance or uninsured clients, compare the proposed lists with what you bill locally today, since Community Support Services is left out of the MHRS package and recovery support services are limited to clients in residential treatment. Send comments by November 8, 2026 if a service you deliver is missing.

What changed. The October 15, 2026 Utah State Bulletin (Vol. 2026, No. 20) carries a proposed amendment to R523-7, Designated Examiner and Case Manager Certification, Filing ID 58277. The filing replaces the Office of Substance Use and Mental Health with the Division of Integrated Health as the administrative authority, clarifies the supervision required for an applicant completing an approved practicum to become a certified case manager and for certified case managers afterward, and expands the ways people who provide daily supervision to case managers can meet the requirements. Comments are accepted until November 16, 2026.

What it means. If your Utah program employs certified case managers or runs a case management practicum, compare your supervision structure with the proposed text and confirm who on your staff can serve as a daily supervisor under the expanded options. Comment by November 16, 2026 if the practicum supervision terms do not fit how you train.

What changed. DMAS opened a guidance document comment forum on a proposed revision of the Mental Health Services Manual, Appendix G (Comprehensive Crisis and Transition Services), published in the Virginia Register on October 19, 2026 (Vol. 43 Issue 5). The proposed text defines a Mobile Crisis Response Episode as all service components delivered in response to a single precipitating behavioral health crisis event, not to exceed four hours (16 units) within the 24 hours from the time of admission, with all contacts arising from the same event forming a single episode with a single registration and payment. The comment period closes at 11:59 p.m. on November 18, 2026 and the planned effective date is November 19, 2026.

What it means. If you bill Virginia Medicaid for mobile crisis response, compare your average episode length and repeat visit patterns against the four hour, 16 unit cap and the single registration rule, and model the revenue effect. Post comments on the Town Hall forum by November 18, 2026 and update your crisis documentation and billing workflow for November 19.

What changed. A fast-track action published in the October 19, 2026 Virginia Register (Vol. 43 Issue 5) amends 18VAC115-80-110 to let a qualified mental health professional-trainee whose registration expired within one year renew it by paying the late renewal fee and renewal fee, and to let a trainee whose registration has been expired for a year or more reinstate by paying the $75 reinstatement fee and submitting evidence of enrollment in or completion of a bachelor's degree program. No public hearing is scheduled, the public comment deadline is November 18, 2026 and the effective date is December 3, 2026 unless objections stop the fast-track process.

What it means. If your Virginia program employs QMHP-trainees, identify any whose registration has lapsed and plan for them to renew or reinstate after December 3, 2026 rather than start over. Comment by November 18, 2026 if the fees or the education evidence requirement raise issues for your staff.

What changed. A Notice of Intent to Adopt Rules dated September 29, 2026 proposes amending Medicaid Rules Chapter 40, Psychiatric Residential Treatment Facilities, which governs inpatient psychiatric services for people under 21 in PRTFs. The Statement of Reasons says the amendment lets the Department, as part of prior authorization or medical necessity review, allow the required pre-admission psychiatric evaluation to be conducted and signed by a qualified board certified or board eligible psychiatrist rather than only a child and adolescent psychiatrist, without changing the clinical or medical necessity standards for admission. Written comments go to denzel.clifton1@wyo.gov and the comment period ends November 17, 2026; no hearing is scheduled unless 25 people or a qualifying group request one.

What it means. If you operate or refer to a PRTF serving Wyoming Medicaid youth, review your admission packet process so a board certified or board eligible psychiatrist can complete the evaluation once the rule takes effect, and keep in mind the Department can still require a second opinion. Comment by November 17, 2026 if the change affects your intake timelines.

What changed. An October 23, 2026 DHS memorandum opens a 30 day comment period on a proposed rule implementing Act 556 of 2025, which mandated Medicaid coverage for health care services provided in mobile units. The rule adds a new Section 171.520 on mobile units to Section I of the Arkansas Medicaid Provider Manual and revises the Counseling and Crisis Services manual, among others, adding place of service code 15 (Mobile Unit) to individual, family and other behavioral health counseling codes. DHS projects an effective date of February 1, 2027 if approved and a fiscal impact of $2,858,520 in state fiscal year 2027; comments are due by November 21, 2026 to ORP@dhs.arkansas.gov.

What it means. If you run an Arkansas outpatient behavioral health or counseling program, read the revised Counseling and Crisis Services manual pages and decide whether a mobile unit tied to your enrolled practice would reach clients you cannot serve in the office. Send comments by November 21, 2026 and plan billing with place of service 15 for the February 1, 2027 start.

What changed. A Notice of General Public Interest released October 29, 2026 supplements the June 30, 2026 notice on proposed State Plan Amendment 26-0033 and Alternative Benefit Plan SPA 26-0034, which update the Medicaid State Plan and ABP provisions on Behavioral Health Treatment services to clarify policy, including utilization management controls, and support program integrity efforts aimed at reducing fraud, waste and abuse. The revised notice applies only to ABP SPA 26-0034, adds the 42 CFR 440.386 public input language for the ABP, states an effective date of July 1, 2026 for both SPAs subject to CMS approval, and says DHCS expects no added cost. Comments go to PublicInput@dhcs.ca.gov or the Benefits Division by mail, with no closing date stated.

What it means. Providers of Behavioral Health Treatment, including applied behavior analysis, for Medi-Cal members should read the revised notice and send DHCS any concerns about the utilization management controls, since the amendment is written to apply from July 1, 2026 once CMS approves it. Watch the DHCS pending SPA page for the submitted text and plan for tighter authorization and documentation review on BHT claims.

What changed. DHCS posted the Round 1 Request for Applications for the Behavioral Health Data: Consent, Access, and Real Time Exchange (BH-CARE) Grant Program on November 2 and 3, 2026. Round 1 is open to county behavioral health programs (Category 1) and data exchange intermediaries (Category 2) and pays milestone based awards for technology, workflows and consent management that advance real time behavioral health data exchange, with up to $59.9 million allocated across the program. Applications are due November 20, 2026 at 5:00 PM Pacific by email to DHCSDataSharing@dhcs.ca.gov, Round 1 awards are planned for January 2027, the grant period runs through December 31, 2028, and DHCS says a Round 2 for county-contracted providers and Continuums of Care will be announced in 2027.

What it means. Provider organizations cannot apply in Round 1, but your county behavioral health plan can, so ask it whether it is applying and how its consent management and data exchange build will reach contracted providers, including 42 CFR Part 2 records. Watch for the 2027 Round 2 that DHCS says will fund county-contracted providers directly.

What changed. A November 3, 2026 Magellan e-blast says the IBHP Provider Handbook Supplement and Appendix C (program services) have been updated effective December 2, 2026, with revision logs posted under For Providers, Provider Handbooks. The supplement log adds a pre-screening process for new providers and for existing providers adding levels of care, a new Supervisory Protocol section (supervising clinicians must hold an independent Idaho license and be credentialed with Magellan; non-independently licensed staff billing Medicaid need at least one individual supervision session a month, group supervision limited to six supervisees, and supervision records kept for audit), and credentialing and quality of care concern changes. The Appendix C log adds Assertive Community Treatment (H0040 per diem with modifier Q2, a Notice of Admission, and $0.01 encounter claims for each bundled service) and revises CDA, skills building, case management, peer support, CANS, Child and Family Team, WInS, telehealth and SUD assessment entries.

What it means. If you are in the Magellan IBHP network, read both revision logs before December 2 and update supervision policies, supervision logs, billing setup for supervised staff and ACT encounter claims to match. If you plan to add a level of care or join the network, expect Magellan's pre-screening checklist (program descriptions, supervision and 42 CFR Part 2 policies, exclusion screenings, staff rosters) before contracting moves forward.

What changed. Blue Cross of Idaho's medical policy notifications page (provider alert sent November 1, 2026) says that effective January 1, 2027 it is archiving multiple medical policies, including 3.01.506 Psychological Testing, 3.01.508 Neuropsychological Testing and 3.01.550 Repetitive Transcranial Magnetic Stimulation (rTMS) as a Treatment of Depression and Other Psychiatric/Neurologic Disorders, with medical necessity reviews continuing under the criteria in MP 9.01.501 General Coverage Guidelines. The 3.01.550 policy page states that Change Healthcare InterQual criteria will be used for medical necessity reviews effective January 1, 2027. A new policy, 3.01.510 Psychological and Neuropsychological Testing (original policy date January 2027), points to InterQual Behavioral Health Services criteria for psychological and neuropsychological testing requests and describes additional scenarios that may be considered.

What it means. If you bill Blue Cross of Idaho for TMS or psychological and neuropsychological testing, pull the InterQual Behavioral Health criteria from the provider portal and align your authorization requests and documentation to them for dates of service on or after January 1, 2027. Watch for the 3.01.510 policy text to post and remove references to the three archived policy numbers from your authorization templates.

What changed. The November 4, 2026 Idaho Administrative Bulletin (Vol. 26-11) publishes a Notice of Rulemaking, Adoption of Pending Rule, for docket 24-1501-2601, IDAPA 24.15.01, dated October 2, 2026. The Division adopted the rule as originally proposed in the August 5, 2026 bulletin (Vol. 26-8, pages 27 to 30), with no changes, no fee and no general fund fiscal impact; the earlier proposal reduced the direct supervision hours marriage and family therapists need within their postgraduate experience. The rule is now pending review by the 2027 Idaho Legislature and takes effect only if approved by concurrent resolution, on July 1 following the session unless the resolution sets another date.

What it means. Idaho programs that employ MFT candidates should keep supervision contracts at the current hour requirements until the Legislature acts in the 2027 session, then plan for the lower load from July 1, 2027 if the rule is approved. Watch the Legislature's administrative rules review pages in January for the concurrent resolution that decides it.

What changed. FSSA reissued its notice of the annual Post-Award Forum on the Healthy Indiana Plan, Substance Use Disorder and Severe Mental Illness Section 1115 demonstration waiver, posted October 21, 2026 in the Indiana Register under 42 CFR 431.420(c). FSSA presented the operational status of the waiver to the Medicaid Advisory Committee on October 27, 2026, and the public notice period runs from October 21 through November 20, 2026. Written comments go to the Office of Medicaid Policy and Planning or spacomment@fssa.in.gov, identified as COMMENT RE: HIP POST-AWARD FORUM.

What it means. If you treat Indiana Medicaid members under the SUD or SMI components of the waiver, such as residential stays in institutions for mental diseases, read the most recent annual report and send comments on access, authorization or payment problems by November 20, 2026. This is the yearly chance to put provider experience on the record with FSSA and CMS.

What changed. The October 1, 2026 Administrative Register of Kentucky (Volume 53, Number 4) carries a proposed amendment to 201 KAR 32:035, Supervision of marriage and family therapist associates. The amendment defines group supervision as three to six supervisees and individual supervision as one or two, defines raw data as video recorded sessions, live observation or co-therapy with a board approved supervisor, and rewrites the Board-Approved Supervisor requirements, including annual renewal and two continuing education hours in supervision each year for supervisors who are not AAMFT Approved Supervisors or Supervisor Candidates. A public hearing is set for November 23, 2026 at 11:00 a.m. at the Mayo-Underwood Building in Frankfort, and written comments are accepted through November 30, 2026.

What it means. If your Kentucky program employs MFT associates or board approved supervisors, compare your supervision contracts, group sizes and recording practices with the new definitions and check that each supervisor can meet the annual renewal and continuing education terms. Notify the board five workdays before November 23, 2026 to speak at the hearing, or comment in writing by November 30.

What changed. In a November 3, 2026 bulletin, the Office of MaineCare Services says that beginning December 1, 2026 members must have completed a Single Assessment within the past 12 months before it processes referrals, prior authorization requests and continued stay reviews for children's medium and high intensity services. The temporary direct to provider referral and prior authorization process reinstated in March 2026 ends November 30, 2026. The Department says assessments are now completed in an average of 7.5 business days after a request.

What it means. If you serve MaineCare children in medium or high intensity behavioral health services, confirm every active and incoming client has a Single Assessment dated within the last 12 months before December 1, 2026, and route new referrals and continued stay reviews through that process. Build the assessment request into intake so authorizations are not held up.

What changed. On October 30, 2026 the Office of MaineCare Services held its annual Expert Technical Advisory Panel consultation on the draft Calendar Year 2027 rate determination schedule and posted the recording, presented materials and proposed schedule. The draft lists work carried over from 2026, including Multi-Dimensional Family Therapy (Section 65), Private Non-Medical Institution Appendices C, D, E and F (Section 97), Psychiatric Hospitals (Section 46) and Substance Use Disorder Health Homes including Opioid Health Home Services (Section 93), and lists Private Non-Medical Institution Appendix B, Substance Use Disorder Residential Treatment Facilities (Section 97), among the rate determinations to be initiated in 2027. Written comments are accepted until 5:00 PM on November 24, 2026 at RateReform.OMS@maine.gov; the final schedule will be posted with a summary of comments.

What it means. If you bill MaineCare for PNMI residential SUD or mental health care, psychiatric hospital care, MDFT or an Opioid Health Home, read the draft schedule and comment by November 24, 2026 if your service should move up or needs a different approach. Calendar the final schedule posting on the Rate System Reform page and plan cost report readiness for any 2027 rate determination that touches you.

What changed. Bulletin MMP 26-48, issued October 30, 2026 and effective December 1, 2026, implements Section 5121 of the Consolidated Appropriations Act of 2023 for Medicaid, CHIP and Healthy Michigan Plan. It creates the REENTRY-MA benefit plan covering screening, diagnostic and targeted case management services in the 30 days before release for eligible post-adjudication individuals under 21 or former foster care individuals up to 26, and expands the TCM-INC benefit plan to cover up to one year of post-release targeted case management. CCBHCs, CMHSPs, FQHCs, RHCs, tribal health centers and other qualified providers may deliver the services; providers must enroll in CHAMPS, meet Type 1 and Type 2 requirements, obtain an NPI and complete the CAA Application and Attestation forms, and payment follows a CAA Reentry Services Fee Schedule to be posted on the MDHHS Billing and Reimbursement page.

What it means. If you are a Michigan CCBHC or CMHSP near a juvenile justice facility or county jail, read the bulletin and the CAA Operational Guide, complete the Application and Attestation forms in CHAMPS, and set up workflows to confirm a REENTRY-MA or TCM-INC benefit plan is assigned before billing. Calendar December 1, 2026 and watch for the fee schedule.

What changed. On October 30, 2026, DOJ's National Fraud Enforcement Division and the U.S. Attorney's Office for the District of Minnesota announced that since September 30 they have charged, convicted or sentenced 13 defendants in schemes with nearly $83 million in intended losses, including about $29.1 million in newly charged cases. Three new indictments and an information target the Minnesota Medicaid EIDBI autism therapy program: a Licensed Clinical Social Worker charged with serving as Qualified Supervising Professional for multiple providers without performing the duties and signing false certifications on individual treatment plans ($7.7 million); an owner charged with billing services not rendered and services by employees who were outside the United States, with almost every claim at the same amount ($8.2 million); and a provider charged with paying kickbacks to parents of Medicaid recipients for the right to bill ($19.1 million). A separate Integrated Community Supports indictment alleges fake patient notes generated with an AI tool to justify claims.

What it means. Audit the three billing patterns named here in your own program: clinical supervisors who sign treatment plan certifications they did not review, claims that do not vary with the service or hours delivered, and time records for staff who were traveling or working other jobs. Confirm no payments, gifts or housing flow to clients or families in exchange for enrollment, and log who wrote each progress note and when.

What changed. A notice of proposed rulemaking filed October 29, 2026 would amend OAR 410-125-0045 so Caring Contacts, the suicide prevention follow up that ORS 441.053 and OAR 333-520-0070 require hospitals to provide after a behavioral health crisis, is covered by Medicaid as a hospital service even when delivered outside the hospital's licensed facility, and would amend OAR 410-125-0220 to set billing rules. Under the proposed text the hospital must initiate and document outreach within 48 hours of release, the contact must be made by a behavioral health clinician, a crisis counselor under a clinician's direction, a QMHA, a trained registered nurse or a certified peer, family or youth support specialist, and the hospital may deliver it in person, by telehealth or by phone, contract with a qualified community based behavioral health provider, or use a suicide prevention hotline, billing on the 837I or UB-04. OHA says hospitals have struggled to provide the service since HB 3090 and HB 3091 (2017) because there was no reimbursement. The hearing is November 16, 2026 at 10:00 AM and comments close November 21, 2026 at 5:00 PM.

What it means. If your program provides crisis follow up or peer support for people discharged from an emergency department, this rule would let a hospital contract with you to deliver Caring Contacts and bill OHP, so start the conversation with your local hospitals now and check that your clinicians, QMHAs and peers meet the listed qualifications. Send comments to medicaid.rules@oha.oregon.gov by November 21 if the 48 hour window or the qualified provider list does not fit how your crisis team works.

What changed. A notice in the October 23, 2026 Texas Register (51 TexReg 7462) says HHSC will hold a public hearing on November 20, 2026 at 9:00 a.m., in person in Austin and online, on proposed Medicaid and non-Medicaid payment rates. The topics include a Special Review of Peer Specialist (TOS 3) rates, non-medical transportation rates for the Youth Empowerment Services (YES) and HCBS Adult Mental Health programs effective July 1, 2026, employment services rates for the YES and HCBS-AMH waivers effective January 1, 2027, and a Health and Behavior Assessment and Intervention clean-up for codes 96170 and 96171. The briefing packet will be posted at pfd.hhs.texas.gov/rate-packets on or before November 9, 2026, and written comments are accepted until 5:00 p.m. the day of the hearing at PFDAcuteCare@hhs.texas.gov.

What it means. If you bill Texas Medicaid for peer specialist services or deliver YES or HCBS-AMH waiver services, pull the rate packet after November 9, 2026 and compare the proposed peer specialist and employment services rates with your costs. Register for the November 20 hearing or send written comments by 5:00 p.m. that day.

What changed. DOH's behavioral health agency rules in progress page now reports that the survey on its chapter 246-337 WAC residential treatment facility clean up (CR-101 filed September 11, 2026) has closed, that a kickoff webinar was held October 28, 2026, and that rule making workshops will run on Tuesdays from 1 to 3 PM on November 10, 17 and 24 and December 1, 8, 15 and 22, 2026, each covering new topics from a tentative plan shared at the kickoff, with registration links on the page. The slide deck from the kickoff is available on request and updates go out through GovDelivery.

What it means. If you run or plan a licensed residential treatment facility in Washington, register for the November and December workshops so your staffing, physical plant and admission concerns are on the record before DOH drafts the CR-102. Ask DOH for the kickoff slide deck and the topic schedule so you attend the sessions that cover your service lines.

What changed. HCA's permanent rule making order CR-103P, WSR 26-22-053, adopted October 29, 2026 under the proposal filed as WSR 26-19-090, amends WAC 182-501-0160 and 182-501-0165 to comply with the CMS interoperability and prior authorization rule CMS-0057-F (42 CFR 440.230(e)(4)), with no changes from the proposed version. Effective January 1, 2027, the agency must decide a standard prior authorization request no later than seven calendar days after receiving it and an expedited request no later than 72 hours, replacing the current fifteen business day standard, and the related exception to rule and additional information windows move to seven calendar days.

What it means. If you bill Apple Health fee for service for behavioral health services that need prior authorization, calendar January 1, 2027 and expect faster decisions and shorter windows to return requested information, since the agency will deny a request when the provider does not supply additional information within seven calendar days. Update your authorization tracking so follow ups happen inside the new seven day window rather than the old fifteen business days.

What changed. Coordinated Care's October 2026 Provider News (dated October 29, 2026) says it is transitioning claims and non-claims payments from Payspan to Zelis, with Medicare, Medicaid, Behavioral Health and Ambetter programs moving in phases throughout November, December and into early 2027. Providers already enrolled with Zelis on ZAPP Edge for ACH or virtual card need no action; others are told to choose ZAPP Edge, a virtual card or the free ePayment Center EFT and ERA option, and anyone not enrolled will be paid by paper check. The same issue lists clinical policy revisions, including WA.CP.BH.528 (HRSN Intensive Behavioral Supportive Supervision, revised October 1, 2026) and CP.BH.104 Applied Behavior Analysis Therapy for Ambetter effective January 1, 2027.

What it means. If you bill Coordinated Care (Apple Health or Ambetter), confirm your Zelis enrollment now so behavioral health payments and remittances do not fall back to paper checks when your program moves, and register separately if you receive non-claims payments. Calendar the January 1, 2027 CP.BH.104 revision if you provide ABA to Ambetter members.

What changed. In WSR 26-20-042, filed September 30, 2026 and published in Washington State Register issue 26-20, L&I states that under RCW 49.46.020 it has calculated the 2027 state minimum wage at $17.73 per hour, effective January 1, 2027, a $0.60 per hour increase from 2026, based on the consumer price index for urban wage earners and clerical workers.

What it means. Washington behavioral health employers should reset pay for any peer, residential, housekeeping or front desk roles paid at or near minimum wage before the first January 2027 payroll, and check local minimum wages that run higher than the state rate. Rebuild 2027 staffing budgets with the new floor, since it also drives the overtime exemption thresholds L&I set in a companion notice.

What changed. In WSR 26-20-043, filed September 30, 2026, L&I publishes the 2027 salary thresholds for the executive, administrative and professional overtime exemption under WAC 296-128-545, which are multiples of the $17.73 minimum wage. For employers with 50 or fewer employees the 2027 threshold is $1,595.70 per week ($82,976.40 a year, 2.25 times minimum wage); for employers with 51 or more employees it is $1,773.00 per week ($92,196.00 a year, 2.5 times minimum wage); exempt computer professionals must earn $62.06 per hour. L&I notes the multiplier reaches 2.5 times minimum wage for all employers in 2028.

What it means. Review every salaried clinical supervisor, program manager and clinician classified as exempt in Washington and confirm their 2027 salary meets the threshold for your employer size, or reclassify them as overtime eligible and start tracking hours. Programs with 51 or more employees should budget for the $92,196 floor, and smaller programs should plan for the jump to 2.5 times minimum wage in 2028.

What changed. In WSR 26-20-044, filed September 30, 2026, L&I publishes the inflation adjusted 2027 earnings thresholds below which a noncompetition agreement is unenforceable under RCW 49.62: $131,326.59 for employees (RCW 49.62.020) and $328,316.49 for independent contractors (RCW 49.62.030), up from $126,858.83 and $317,147.09 in 2026. The notice also states that noncompete agreements are void and unenforceable after June 30, 2027 because of amendments passed in the 2026 legislative session.

What it means. If your Washington employment or contractor agreements for clinicians, prescribers or executives include a noncompete, check each person's 2027 earnings against the new thresholds and plan to retire the clauses by June 30, 2027. Shift retention efforts to nonsolicitation terms, confidentiality agreements and compensation rather than noncompetes, and have counsel review templates before the 2027 hiring cycle.

What changed. A November 1, 2026 UnitedHealthcare Network News article says that beginning December 1, 2026 it will remove nearly two thirds of prior authorization requirements for select services provided to patients under age 18 in UnitedHealthcare commercial, Individual Exchange and Community Plans, with code removals varying by state and plan. The commercial code list includes adaptive behavior codes 0362T, 0373T and 97151 through 97158; the Individual Exchange list includes psychological testing codes 96130, 96131 and 96136 through 96139; the Community Plan list includes TMS codes 90867 and 90868 and testing codes 96121, 96130 through 96133, 96136 through 96139 and 96146. UMR plans not following the UMR prior authorization list, Health Plan of Nevada Medicaid, Dual Eligible Special Needs Plans and Medicare Advantage plans are excluded.

What it means. If you serve UnitedHealthcare members under 18, check each code list for your plan type and state and, from December 1, confirm in the Prior Authorization and Notification tool before you skip an authorization, since the removals vary by state and plan. UnitedHealthcare still encourages advance notification for some codes so members can be connected to care management.

What changed. A final rule published in the Federal Register on November 3, 2026 revises 45 CFR 84.4(g), the Section 504 regulation for recipients of HHS funding, to state that the statutory exclusion for gender identity disorders not resulting from physical impairments includes gender dysphoria not resulting from a physical impairment. HHS says the change resolves ambiguity in the preamble to its May 9, 2024 Section 504 final rule, which had said gender dysphoria does not fall within the statutory exclusions, and the text is unchanged from the proposed rule. The rule is effective January 4, 2027.

What it means. If your program takes Medicaid, Medicare or federal grant money, review your disability nondiscrimination policy, grievance procedure and reasonable modification practice with counsel before January 4, 2027, since gender dysphoria alone will no longer be treated as a Section 504 disability under the HHS regulation. Check your state nondiscrimination law and any other federal obligations separately, because this rule changes only the HHS Section 504 regulation.

What changed. CMS issued the CY 2027 Physician Fee Schedule final rule (CMS-1848-F) on November 4, 2026, effective for services on or after January 1, 2027: the non-qualifying APM conversion factor falls to $32.63, a 2.31% decrease from $33.40, and the qualifying APM factor to $32.95. Smoking and tobacco cessation and SBIRT services join the final year of the transition for timed behavioral health codes, CoCM work RVUs rise and the Behavioral Health Care Manager clinical labor rates are updated, and the G2211 visit complexity add-on becomes modifier B1, adding 16% to the associated E/M code. For RHCs and FQHCs, CMS finalized conforming changes so in-person visit requirements do not apply to mental health visits furnished through December 31, 2027.

What it means. Load the new conversion factors, the B1 modifier in place of G2211 and the revalued CoCM codes into your Medicare charge master and claim edits before January 1, 2027. If you bill tele-mental health from an RHC or FQHC, keep running those visits without an in-person requirement through December 31, 2027.

What changed. The CY 2027 OPPS and ASC final rule with comment period (CMS-1850-FC), on public inspection November 4, 2026 for Federal Register publication November 6, keeps two IOP APCs and two PHP APCs for each provider type and keeps CMHC rates at 40 percent of hospital-based costs. Table 78 lists the final CY 2027 geometric mean per diem costs that the rates are built on: $309.85 for hospital-based IOP or PHP days with three services and $507.39 for four or more services, and $123.94 and $202.96 for the same days at Community Mental Health Centers. The provisions take effect January 1, 2027, and comments on the items CMS left open are due January 4, 2027.

What it means. If you bill Medicare for IOP or PHP days, rebuild your 2027 per diem expectations from these figures and confirm each day carries at least three billable services, since a four-service day pays about 64 percent more than a three-service day in both settings. Check the published Addendum A rates when the rule prints on November 6 before you update contracts or budgets.

What changed. On October 22, 2026, the Justice Department's Civil Division and HHS launched the Healthcare False Claims Act Self-Disclosure Pilot Program (FCA SDPP), a six month program that accepts electronic submissions to FCA-SDPP@usdoj.gov through April 22, 2027. A disclosing company must describe the conduct and remedial actions, produce documents, and repay the government with a 1.25 to 1.6 multiplier set by timeliness, duration and scope, senior leadership involvement, financial benefit and successor liability; in return it receives a coordinated civil release under the FCA and certain HHS administrative authorities. Potential criminal conduct still goes to DOJ's National Fraud Enforcement Division under the self-disclosure policy announced October 15.

What it means. If an internal audit has turned up overpayments you have not yet refunded, have counsel weigh this pilot against the 60 day overpayment rule and the HHS-OIG self-disclosure protocol before April 22, 2027, since late or incomplete submissions will not be reviewed. Document the remediation steps now, because the multiplier rewards fast, complete disclosures.