Government Shutdown Updates | | |
A federal government shutdown took effect on October 1, 2025, after the Senate failed to advance a continuing resolution previously passed by the House to fund operations through November 21. While roughly half of the Centers for Medicare and Medicaid Services (CMS) workforce was initially furloughed, staff were recalled effective October 27. Many employees are expected to resume their regular duties; however, certain functions may remain paused until full operations are restored. With staff returning, the release of the calendar year (CY) 2026 Medicare Physician Fee Schedule (PFS) final rule is anticipated imminently.
Throughout the shutdown, essential Medicare program operations have continued. CMS recently instructed its Medicare Administrative Contractors (MACs) to resume normal processing for most claims, including those paid under the Medicare Physician Fee Schedule, ground ambulance transports, and Federally Qualified Health Center (FQHC) services. This includes claims affected by the expired 1.0 work Geographic Practice Cost Index (GPCI) floor, which would be paid at the lower, non-floor rate. If Congress later extends the GPCI floor retroactively, those claims may be reprocessed to reflect the higher payment amount. CMS also directed MACs to continue holding telehealth claims that cannot be verified as behavioral or mental health services, as statutory Medicare telehealth flexibilities expired on September 30, 2025. Rheumatology practices furnishing non-covered telehealth services should consider using an Advance Beneficiary Notice of Noncoverage (ABN) to inform beneficiaries that they may be responsible for payment if Congress does not reinstate the COVID-era telehealth flexibilities.
CSRO will continue to monitor developments related to Medicare operations and provide updates as additional information becomes available.
| HRSA Launches 340B Rebate Model Pilot Program for Select Manufacturers | The Health Resources and Services Administration (HRSA) Office of Pharmacy Affairs (OPA) announced the approval of eight manufacturer plans under the new 340B Rebate Model Pilot Program, set to begin January 1, 2026. As discussed in the application notice, the pilot is designed to methodically evaluate the 340B rebate model’s fairness, transparency, and operational feasibility, gathering stakeholder feedback to inform potential future models consistent with the 340B statute and the Administration’s goals. Participating manufacturers, including Bristol Myers Squibb, Immunex (Amgen), AstraZeneca, Pharmacyclics (AbbVie), Merck, Boehringer Ingelheim, Novo Nordisk, and Janssen, will issue unit-level rebates for selected drugs, including Eliquis, Enbrel, Farxiga, Imbruvica, Januvia, Jardiance, NovoLog, Fiasp, Stelara, and Xarelto. As explained on HRSA’s website, “…covered entities must continue to make purchases through their 340B wholesaler account and must ensure they are only requesting rebates on the above drugs dispensed to 340B eligible patients after a purchase is made,” and would submit specific pharmacy/medical claims data to validate rebate eligibility. | | Legislation Around the Country | LA: CSRO Calls on PBM Advisory Council to Advance Delinking Policy | | |
Joseph Nesheiwat, MD, past President of the Rheumatology Alliance of Louisiana (RAL), testified on behalf of CSRO during Monday’s Pharmacy Benefit Manager (PBM) Monitoring Advisory Council meeting, held as part of Louisiana’s special legislative session. Dr. Nesheiwat provided a physician’s perspective as the Council examined the influence of drug manufacturers, PBMs, and health plans on drug pricing. He focused his remarks on the growing threat that PBMs pose to patients’ access to life-saving prescriptions and shared CSRO’s support for delinking PBM compensation from drug prices and increasing transparency requirements.
Dr. Nesheiwat’s testimony was well received by Council members, who expressed disappointment that representatives from the state’s three largest PBMs declined to participate in the meeting. While the Council Chair, Senator Bass, did not specify when the next session would occur, members appeared eager to continue discussions on advancing meaningful PBM reforms.
| OH: CSRO Submits Written Testimony in Support of Copay Accumulator Adjustment Program Ban | |
Last week, CSRO joined a broad coalition of patient advocacy and provider organizations in submitting written testimony in support of Senate Bill 207, legislation that would prohibit copay accumulator adjustment programs. Over the past two weeks, the Ohio Senate’s Financial Institutions, Insurance, and Technology Committee has held hearings on the measure, inviting input from all stakeholders in Ohio.
CSRO emphasized in its written testimony that the bill puts patients first by preventing health plans and PBMs from using tactics that undermine patient assistance programs—including Alternative Funding Programs (AFPs) and maximizer programs. The Ohio coalition has also launched a comprehensive educational campaign for lawmakers and the public to counter misleading claims from health plans and PBMs suggesting the bill would increase premiums in the state.
| |
Want to learn more about the legislation introduced in your state? Visit CSRO’s Map Tool to find all of the new and enacted bills within CSRO’s policy priorities.
| |
| | |
What's Happening in the States
CSRO tracks legislative activity relevant to the rheumatology community and their patients. Check out the list below to see the status of CSRO priority bills from the past two weeks, and click here to view a full status report of CSRO priority bills.
| Interested in learning more about CSRO’s engagement in the states? Visit our State Legislation Correspondence page to review the letters submitted to state legislatures on CSRO’s priority issues. | | |
MA
- Prior Authorization (HB1136): Accompanied a new draft, see H4616
- Prior Authorization (HB4616): Reported favorably by committee and referred to the committee on Health Care Financing
NH
- White Bagging (SB256): Committee Report: Ought to Pass with Amendment # 2025-3029s, 10/22/2025; Vote 5-0; CC;
NY
- PBM Reform (A9184): REFERRED TO INSURANCE
OH
- Non-Medical Switching (SB160): Senate Financial Institutions, Insurance and Technology: 3rd Hearing
- Prior Authorization (HB220): House Insurance: 3rd Hearing
WI
- Prior Authorization (AB432): Representative Palmeri added as a coauthor
| | Mark Your Calendar: Upcoming Events
| | |
CSRO Advocacy Town Hall: November 19, 2025
Join CSRO leadership for a virtual Town Hall to discuss recent actions by the Trump Administration and Congress. Hear how CSRO is leading advocacy efforts nationwide to protect rheumatology practices, improve patient access, and reform PBM and utilization management policies. Register here!
| |
Join CSRO for the next Business of Rheumatology seminar supporting practices in strengthening their operations. This session will cover the new cap, its impact on patient access and affordability, and strategies to navigate the changing payment landscape. Register here! Special thanks to Johnson & Johnson for sponsoring this series.
| |
CSRO State Legislative Forecast: February 11, 2026
Kick off the year with CSRO’s virtual State Policy Update, highlighting key priorities and trends for the 2026 legislative session. Hear from our government affairs team about upcoming policies affecting private practice, reimbursement, and patient access—and how you can advocate effectively. Register here!
| | |
Action Center
Use CSRO's convenient online platform to easily find out who your elected officials are and engage with them directly.
Career Center
Locate the perfect fit whether you're looking for new career opportunities or trying to find the right candidate.
Explanatory Statement: “Underwater” Biosimilars
To aid in addressing the issue of "underwater" biosimilars with payers, CSRO has created a document to illustrate the extent of the problem.
Legislative Map Tool
Find your state on our interactive map tool to learn about current or proposed policy and ways you can take action to make an impact.
Payer Issues Reporting Form
Request assistance with any payer relation issues that may be impacting your patients or office.
Policy Correspondence
Easily access all of CSRO’s policy letters submitted to payers, state, and federal governments as an informational resource.
Rheum for Action
Learn about the latest advocacy issues in CSRO's advocacy column authored by Dr. Madelaine Feldman and produced in partnership with Medscape.
Step Therapy Cover Sheets
Review CSRO's state-specific step therapy materials that help guide practices in gaining an exemption from step therapy protocols.
| | |
Questions?
Please visit the CSRO website for other news and updates, and do not hesitate to contact us with any questions at info@csro.info.
| | | | |
