On October 15, 2025, the Centers for Medicare and Medicaid Services (CMS) issued a statement on the continued hold of all fee schedule claims. You may have heard that CMS decided to pause reimbursement for all Medicare claims until after the shutdown, but this decision was quickly reversed after much pushback. In this blog, we discuss the latest update and what it means for you.
Certain Medicare Claims Will Remain on Hold
While CMS initially instructed Medicare Administrative Contractors (MACs) to continue to hold all Medicare claims until further notice, this decision was quickly reversed after significant pushback.
Now, only Medicare claims impacted by expired provisions will remain on hold. While this is good news for claims outside of these provisions, there are still many types of claims that remain affected, including claims for telehealth other than behavioral and mental health services and claims for care delivered in low-cost geographic areas. In some cases, Medicare claims reimbursements across entire states are affected, as we discuss in the next section of this blog.
Note that the claims hold does not apply to Medicare Advantage or to Medicaid.
For more information on the types of claims affected by expired provisions and additional details on the shutdown, refer to our previous blog: What You Need to Know about the Government Shutdown.
You can also click on the dropdown below for a reminder on the telehealth flexibilities that expired on September 30, 2025. Claims for these services will not be reimbursed unless Congress acts to renew these flexibilities.
The Medicare fee-for-service telehealth flexibilities that were established during the COVID-19 Public Health Emergency (PHE) expired on September 30, 2025. This means that as of October 1, 2025, in order to be reimbursable, telehealth visits must meet the pre-COVID-19 PHE requirements, including the following:
- Geographic and Originating Site Requirement: As of October 1, 2025, the patient’s home is no longer considered an “originating site.” For non-behavioral or mental health services, patients can only receive care from specific sites, such as a provider’s office or hospital.
- No More Audio-Only Telehealth: Audio-only telehealth visits are no longer reimbursable unless they are for behavioral or mental health.
- In-Person Visit Requirement: Patients receiving behavioral health telehealth services must first have an in-person visit and continue to have an in-person visit at least once every 12 months.
For telehealth services that do not meet the criteria to be covered, CMS recommends that providers consider using an Advance Beneficiary Notice of Noncoverage (ABN) before delivering the service to inform patients that Medicare is unlikely to provide coverage.
Medicare Shared Savings Program Accountable Care Organizations (ACOs) will continue to be reimbursed for covered telehealth services.
For Medicare Advantage, many plans, such as Aetna and United Healthcare, are continuing to offer payment for expanded telehealth services.
Medicaid plans may also continue to offer expanded telehealth services.
For both Medicaid and Medicare Advantage, we recommend checking with specific plans to see if they are continuing coverage.
Impact on Medicare Reimbursement in Low-Cost Geographic Areas
On September 30, 2025, the 1.0 floor on the geographic practice cost index (GPCI) adjustment to the physician work component of Medicare reimbursements expired. As it is uncertain whether the floor will be reinstated by Congress when they pass the budget, CMS is holding all claims impacted by the expiration of the 1.0 work GPCI floor. This impacts 51 of the 109 Medicare localities, 30 of which encompass entire states and/or US territories.
GPCIs are geographic adjustment factors that Medicare uses to modify physician fee schedule payments based on geographic variations in the cost of providing care. Think of GPCIs as CMS’ way of acknowledging that practicing medicine in Manhattan costs significantly more than practicing in Wisconsin.
There are different GPCIs for different Medicare cost components; the one impacted by this expired policy is the work GPCI (physician labor costs). In areas with a lower cost-of-living than the national average, the work GPCI is less than 1.0, meaning that the reimbursed amounts for the physician work component would be less than the fee schedule amount.
Congress previously passed a temporary policy, followed by numerous subsequent extensions, to create a 1.0 floor for the work GPCI. This floor meant that the reimbursement for physician labor costs could not have a downward geographic adjustment. This floor expired on September 30, 2025.
Click on the dropdown below to see the 51 localities impacted by the expiration of the GPCI work floor. For these localities, payments will be held until the shutdown ends or until further CMS action.
Localities that encompass entire states or US territories are in bold.
To see the localities that were not impacted by the expiration of the GPCI work floor, click on the dropdown below. For these localities, payments will be processed normally.
Localities that encompass entire states or districts (i.e., Washington, DC), are in bold.
Next Steps
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Written By: Jessica Peterson, MD, MPH & Sarrah Hakim, MHSA
About the Authors:
Jessica Peterson, MD, MPH is the Senior Director of Value-Based Care Policy at Anatomy IT.
Sarrah Hakim, MHSA is a Manager of Health Policy at Anatomy IT.