Effective for dates of service on or after July 01, 2026, omidubicel-onlv (Omisirge) is now a covered benefit under Texas Medicaid when billed using procedure code J3590. Prior authorization will be required starting September 01, 2026.
Omidubicel-onlv (Omisirge) is a nicotinamide modified allogeneic hematopoietic progenitor cell therapy derived from cord blood. It is indicated for two patient populations. The first is clients who are 12 years of age or older with hematologic malignancies who are scheduled for umbilical cord blood transplantation (UCBT) following myeloablative conditioning, to help reduce the time to neutrophil recovery and lower the risk of infection. The second is clients who are six years of age or older with severe aplastic anemia (SAA), following reduced intensity conditioning. This treatment is administered once per lifetime.
Providers must submit prior authorization requests using the Special Medical Prior Authorization (SMPA) Request Form. Prior authorization may be approved for 12 months for clients who meet the criteria for one of the following diagnoses.
For hematologic malignancies, all of the following must be met: the client is 12 years of age or older, has a confirmed diagnosis of a high-risk hematologic malignancy and is scheduled for UCBT after a myeloablative conditioning regimen such as radiation and chemotherapy under diagnosis code D701, D708, D709, or Z9481, is receiving therapy to reduce the time to neutrophil recovery and the risk of infection, does not have a matched related or unrelated donor for allogeneic hematopoietic stem cell transplantation (HSCT), and has no history of prior allogeneic HSCT.
For SAA, all of the following must be met: the client is six years of age or older, has a confirmed SAA diagnosis following a reduced intensity conditioning regimen under diagnosis code D611, D612, D6189, or D619, has a history of intolerance or failure to respond to immunosuppressive therapy, and does not have a matched related or unrelated donor.
Regardless of diagnosis, the client must not have a known sensitivity to dimethyl sulfoxide, Dextran 40, gentamicin, human serum albumin, or bovine material.
After the infusion, providers must monitor the client for allergic reactions particularly in those with a history of antibiotic allergies, graft failure, graft-versus-host disease, engraftment syndrome, infections, secondary malignancies, and other post-transplant complications.
For more information, call the TMHP Contact Center at 800-925-9126.
Note: Texas Medicaid MCOs must provide all medically necessary Medicaid-covered services to enrolled members. Administrative procedures may differ from traditional Medicaid fee-for-service and from one MCO to another. Providers should contact the member's specific MCO for details.
Starting September 01, 2026, prior authorization will be required for onasemnogene abeparvovec-brve (Itvisma), billed under procedure code J3405, for Texas Medicaid clients.
Onasemnogene abeparvovec-brve (Itvisma) is an adeno-associated virus (AAV) vector-based gene therapy used to treat spinal muscular atrophy (SMA) in adult and pediatric clients who are two years of age or older and have a confirmed mutation in the survivor motor neuron 1 (SMN1) gene. This treatment is limited to one administration per lifetime. It is not a covered benefit for clients who have a tracheostomy or use invasive ventilator support.
Providers must submit prior authorization requests using the Special Medical Prior Authorization (SMPA) Request Form. The request must include documentation confirming all of the following:
The client is two years of age or older. The client has a confirmed SMA diagnosis under diagnosis code G120, G121, G1225, G128, or G129. An SMA diagnostic test has confirmed SMN1 deletion, or prior documentation of a confirmed SMN1 deletion exists. The client's medical record supports one of the following: homozygous gene deletion of the SMN1 gene, homozygous mutation of the SMN1 gene such as biallelic mutation of exon 7, or compound heterozygous mutation in the SMN1 gene such as deletion of SMN1 exon 7 on one allele and a mutation on the other.
The client must have a baseline AAV serotype 9 (AAV9) antibody titer of 1:50 or lower as confirmed by enzyme-linked immunosorbent assay (ELISA) binding immunoassay. The client's overall health must be stable, meaning complete blood count, liver function, and creatinine are within normal limits, and the client shows no signs or symptoms of active infection.
Female clients of childbearing age must have been counseled about using effective contraception during treatment and to avoid egg donation for up to six months after receiving the therapy. Male clients should avoid fathering a child or donating sperm for three months following therapy.
The client must not have previously received onasemnogene abeparvovec-brve (Itvisma), onasemnogene abeparvovec-xioi (Zolgensma), or any other gene therapy for SMA. If nusinersen (Spinraza) or risdiplam (Evrysdi) was previously prescribed, the provider must document either clinical deterioration while on that therapy or that the therapy was discontinued before switching to Itvisma.
Because this therapy can cause acute serious liver injury or failure, providers must check liver function through clinical examination and laboratory testing including aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin, and prothrombin time before the infusion. A systemic corticosteroid must be administered before and after the infusion, and liver function must continue to be monitored for at least three months following treatment.
After administering the intrathecal injection, providers must monitor the client for signs of hepatotoxicity, thrombocytopenia, peripheral sensory neuropathy, thrombotic microangiopathy, and elevated cardiac troponin I levels.
For more information, call the TMHP Contact Center at 800-925-9126.
Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary Medicaid-covered services to enrolled members. Administrative procedures including prior authorization, precertification, referrals, and claims filing may differ from traditional Medicaid fee-for-service and from one MCO to another. Providers should contact the member's specific MCO for details.
On July 23, 2026, CMS proposed a rule that would significantly restrict how states use provider taxes to fund their Medicaid programs. For Medicaid expansion states, the rule would cut the allowable tax threshold from 6% down to 3.5% of net patient revenue over several years.
Non-expansion states would be frozen at whatever rates they had in place as of July 04, 2025, and no state would be allowed to create new provider taxes going forward. The rule puts into effect the requirements of the One Big Beautiful Bill Act, formally known as the Working Families Tax Cut (WFTC) legislation, and could force states to either cut Medicaid payments to providers or find other sources of revenue to make up the difference.
Provider taxes are fees that states charge hospitals, nursing facilities, and other healthcare providers. They have long served as a financing tool that helps states generate the non-federal share of Medicaid funding needed to draw down federal matching dollars and sustain provider payments. Under current rules, these taxes are allowed as long as they are broad-based, uniformly applied, and stay below the 6% of net patient revenue safe harbor threshold. Section 71115 of the WFTC directed CMS to significantly scale back this financing mechanism.
Under the proposed rule, the existing uniform 6% safe harbor would be replaced by a state-specific threshold tied to each state's actual tax rate as of July 04, 2025, the date the One Big Beautiful Bill was signed into law. For each permissible class of providers, such as hospitals or nursing facilities, a state's baseline threshold would be set at whatever rate it had enacted and imposed on that date. If a state had no tax in place for a particular provider class by July 04, 2025, the threshold for that class would be set at zero. Any tax increases made after July 04, 2025 would not count toward the baseline.
A tax would be considered "enacted" if the state completed the legislative process to authorize it by July 04, 2025, and "imposed" if taxpayers were under a legally enforceable obligation to pay it as of that date. For expansion states, starting in federal fiscal year (FFY) 2028, the threshold would phase down beginning at 5.5% and dropping by 0.5 percentage points each year until it reaches 3.5% in FFY 2032. The applicable threshold for each provider class in an expansion state would be whichever is lower: the July 04, 2025 calculated threshold or the phased-down percentage for that fiscal year.
The proposed rule would also add a new category of taxable entities. CMS is proposing to create a new permissible class for services of health insurers, separate from the existing class for managed care organizations (MCOs). This new class could include group and individual market health insurance, short-term limited-duration insurance, excepted benefits, certain Medicare-related premium revenue, and section 1115 premium assistance arrangements. Health insurer taxes enacted and imposed by July 04, 2025 would receive a calculated threshold under the new framework. Those not in place by that date would have a zero percent threshold. Expansion state phase-down rules would also apply to this new class.
The proposed rule would also eliminate the secondary prong of the existing indirect hold harmless test, commonly known as the 75/75 test. Under the current framework, this test checks whether 75% or more of taxpayers receive back 75% or more of their tax costs through Medicaid payments or benefits. CMS is proposing to sunset this test so that the thresholds calculated as of July 04, 2025 serve as the maximum permissible level.
New reporting requirements would also be introduced, including a one-time interim report due by December 31, 2026, a final threshold report due by June 30, 2028, and quarterly enhanced reporting beginning with FFY 2027. States that fail to meet reporting requirements could face reduced grant awards, deferrals, disallowances, or withheld approval of payment proposals.
Comments on the proposed rule are due by September 21, 2026. Given the significant implications for hospital and provider reimbursement, particularly in expansion states where provider taxes support supplemental payment programs and expansion population coverage, stakeholders are strongly encouraged to submit comments. The proposed rule can be found on the Federal Register website.
The Centers for Medicare & Medicaid Services (CMS) has released the State Medicaid and Children's Health Insurance Program (CHIP) Applied Behavior Analysis (ABA) Toolkit, a comprehensive resource to help state Medicaid and CHIP agencies better oversee autism services, address rising costs, and crack down on fraud targeting children with autism spectrum disorder (ASD).
HHS Secretary Robert F. Kennedy, Jr. said the toolkit gives states practical tools to identify bad actors, protect families, and hold providers accountable, calling the protection of vulnerable children and taxpayer dollars a top priority for the Trump Administration. CMS Administrator Dr. Mehmet Oz added that every dollar lost to fraud is a dollar that cannot reach a child who genuinely needs it, and that families deserve confidence that ABA services are clinically appropriate and delivered by qualified providers.
CMS data shows that between 2021 and 2025, ABA spending in Medicaid and CHIP jumped 421%, while the number of children with an ASD diagnosis receiving services grew by only 67%. That gap raises serious questions about whether spending is consistently tied to medical need, and a troubling number of fraud investigations, prosecutions, and convictions related to kickbacks and harm to children have added urgency to the issue.
It is important to note what this toolkit is not. It does not create new federal requirements, reduce Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) obligations, endorse any single ABA treatment approach, or direct states to cut access to medically necessary care. It is a practical guide to help states ensure children get individualized, evidence-based care that is free from fraud and delivered by qualified providers.
The toolkit covers a wide range of areas including clinical standards, Medicaid benefit design, payment methodologies, provider enrollment and credentialing, utilization management, and program integrity strategies. A checklist is also included to help states assess whether their ABA policies support strong oversight and responsible use of Medicaid funds.
The toolkit was developed using Medicaid data, peer-reviewed research, and input from a broad group of stakeholders. It draws on a review of more than 40 literature sources, an assessment of more than 240 publicly available state-level Medicaid coverage and policy references, and qualitative input from state agencies, providers, advocates, and others.
The ABA toolkit is available at https://www.medicaid.gov/medicaid/downloads/autism-services-aba-toolkit.pdf
The Centers for Medicare & Medicaid Services (CMS) has published a Proposed Rule to implement Section 71115 of H.R. 1, which CMS refers to as the Working Families Tax Cut (WFTC). The rule revises the regulatory framework around provider taxes and the indirect hold harmless safe harbor, which governs how states use healthcare-related taxes to fund their share of Medicaid spending. CMS actuaries estimate the proposal would reduce federal Medicaid spending by roughly $246 billion over 10 years. Comments are due by September 21, 2026.
Background
Provider taxes have long been a key tool states use to fund the non-federal share of Medicaid costs. Under existing rules, these taxes are allowed as long as they are broad-based, applied uniformly, and do not include a hold harmless arrangement that effectively refunds providers for what they paid. Historically, a provider tax was considered compliant if it stayed below 6 percent of providers' net patient revenues.
The WFTC changes this framework significantly. Instead of one uniform 6 percent threshold that applies to everyone, Section 71115 replaces it with class-specific limits based on provider taxes that were both enacted and imposed as of July 04, 2025. These new thresholds take effect for fiscal years beginning on or after October 01, 2026. States that did not have a provider tax in place for a particular provider class as of July 04, 2025 will generally not be allowed to create a new one, since their applicable percentage would be zero.
Medicaid expansion states face an additional layer of restrictions. Starting in federal fiscal year (FFY) 2028, those states must comply with whichever is lower: the new class-specific threshold or a rate that phases down by 0.5 percentage points each year until it reaches 3.5 percent in FFY 2032.
Key Highlights of the Proposed Rule
For FFY 2027, CMS proposes replacing the current two-step evaluation method with a single "applicable percent" standard calculated on a statewide basis for each provider tax class, based on taxes that were both enacted and imposed as of July 04, 2025.
One of the most notable shifts from CMS's November 2025 guidance involves how the terms "enacted" and "imposed" are interpreted. Under the Proposed Rule, CMS is taking a more flexible approach. A tax would be considered "enacted" if the state completed the legislative process to authorize the tax structure that was in place on July 04, 2025. It would be considered "imposed" if the tax was in effect on that date and any required waiver has been approved with a retroactive effective date of July 04, 2025 or earlier. Importantly, the earlier requirement that states be actively collecting the tax as of July 04, 2025 has been dropped.
CMS is also proposing to eliminate the 75/75 alternative compliance test starting October 01, 2026. Under the old system, states could use this test to qualify provider taxes that exceeded the 6 percent threshold. CMS says keeping it would undermine the new class-specific thresholds Congress established. States that already had a CMS-approved rate above 6 percent under the 75/75 test as of July 04, 2025 can keep that rate, though Medicaid expansion states will still be subject to the phasedown.
In addition, CMS is proposing a brand new permissible provider tax class for services of health insurers, separate from the existing class for managed care organization services. This new class would follow the same threshold and phasedown rules, with a zero percent applicable threshold for any taxes not enacted and imposed by July 04, 2025.
Finally, the Proposed Rule significantly expands reporting requirements. States would need to submit one-time interim reports on provider tax and net patient revenue data for the state fiscal year containing July 04, 2025 by December 31, 2026, using best available or estimated data. Final reports using actual data would be due by June 30, 2028. Starting October 01, 2026, states would also need to file quarterly reports on provider tax collections, how those revenues are being used, and whether public providers are exempt.
This is one of three major rules implementing the Medicaid financing provisions in the reconciliation law. CMS previously released a Proposed Rule on State Directed Payments in May 2026, and a third rule titled "Strengthening the Integrity of Medicaid and CHIP (Children's Health Insurance Program)" is still under review by the Office of Management and Budget (OMB).
On July 16, 2026, the Centers for Medicare & Medicaid Services (CMS) published the 2027 Physician Fee Schedule (PFS) proposed rule. One of the most significant changes in the rule is a proposal to make 340B claims data reporting mandatory, converting what was previously a voluntary process into a required one for all 340B Covered Entities starting in 2027.
Background
Sections 11101 and 11102 of the Inflation Reduction Act of 2022 (IRA) established inflation rebates on Medicare Part B and Part D drug utilization. For Part D specifically, the law requires CMS to exclude from inflation rebate calculations any drug units for which a manufacturer already provided a discount through the 340B Drug Pricing Program. In other words, CMS cannot collect an inflation rebate on a drug that was purchased at the discounted 340B price.
To identify which claims qualify for this exclusion, CMS finalized a Prescriber-Pharmacy Methodology in the 2026 PFS final rule. Under this approach, CMS flags potentially 340B-eligible claims by checking whether the prescriber is affiliated with a registered 340B covered entity and whether the dispensing pharmacy is a contract pharmacy tied to that entity. Claims identified this way are excluded from Part D inflation rebate calculations for dates of service on or after January 01, 2026.
CMS also established a voluntary 340B Repository in the 2026 PFS final rule to collect data from covered entities, with a launch planned for fall 2026 for testing. CMS was clear at the time that data submitted to the voluntary repository would not be used in rebate calculations unless a separate rulemaking process was completed first.
The Key Change: Mandatory Reporting Starting 2027
Under the 2027 proposed rule, CMS is now proposing to make participation in the 340B Repository mandatory. Providers and suppliers that qualify as covered entities under 42 C.F.R. § 10.3 would be required to submit Part D 340B claims data to the repository on a quarterly basis, starting in 2027 for claims with dates of service on or after January 01, 2027.
The data must cover each claim for units of a covered Part D drug billed to Medicare by the covered entity or its contractors, including contract pharmacies, where a manufacturer provided a 340B discount. This includes claims from contract pharmacies identified as 340B-eligible and claims dispensed through the covered entity's own in-house pharmacy.
CMS says making this mandatory will produce more complete and reliable data, which will help the agency determine whether the repository data can eventually be used to more accurately exclude 340B units from Part D inflation rebate calculations. Even so, CMS confirms that the repository data will not be used for rebate calculations at this time. The Prescriber-Pharmacy Methodology will remain in place, and any future decision to use repository data for rebate calculations would require a separate notice-and-comment rulemaking process.
CMS also notes that fulfilling this new reporting requirement will count toward a 340B provider's obligation to provide access to documentation related to covered Part D drugs in order to maintain Medicare enrollment.
What 340B Covered Entities Should Do Now
Covered entities, including hospitals, federally qualified health centers (FQHCs), other safety-net providers, and their contract pharmacy partners, should start assessing their readiness to comply. Key steps include making sure internal systems can accurately identify 340B-eligible Part D claims, including those processed through contract pharmacies and retrospective replenishment models, setting up processes for quarterly data submissions with proper validation, monitoring updates on the repository's operational launch this fall, and submitting comments to CMS about any operational concerns before the comment deadline of September 14, 2026.
The Texas Medicaid & Healthcare Partnership (TMHP) is rolling out upgrades to the Provider Enrollment and Management System (PEMS) starting July 31, 2026. The updates include two new features, SmartTips and WalkMe walkthroughs, designed to make the enrollment process easier and faster for providers by reducing application processing times.
The rollout will happen in phases, starting with applications where providers need to address deficiencies. Full implementation is expected to be completed by the end of 2026.
SmartTips
SmartTips are short, helpful pop-ups that give providers additional information or definitions about specific fields and buttons within PEMS. They appear as question mark icons inside a blue circle, and the information shows up when a user hovers over the icon.
WalkMe Walkthroughs
WalkMe walkthroughs become available after an application has been submitted and deficiencies have been identified. Providers can activate the walkthrough by clicking the Deficiencies Help button located at the top right of the window. The walkthrough then displays step-by-step instructions for correcting each deficiency.
Providers should remember that after fixing all identified deficiencies, they must go to the Agreements page in PEMS to officially submit their updated application.
For more information, providers can call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN (Children with Special Health Care Needs) Services Program Contact Center at 800-568-2413.
Texas providers participating in the Children with Special Health Care Needs (CSHCN) Services Program should take note of an upcoming update to the program's provider manual.
On October 15, 2026, the Texas Medicaid & Healthcare Partnership (TMHP) will update Chapter 14, "Dental," of the CSHCN Services Program Provider Manual. The update will clarify that providers are required to submit the ET modifier along with claims for procedure code D9110 to indicate that the service was provided on an emergency basis.
For questions, providers can call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.
D-SNP alignment can affect patient retention, network participation, and day-to-day administrative workflows. Getting ahead of it can help your practice manage upcoming transitions while keeping care coordinated for your patients.
When Medicare and Medicaid coverage are aligned under one health plan, there are real benefits for both members and providers. For providers, this can mean simpler billing and claims management since you will be working with just one health plan for both benefit types. It can also mean a more efficient prior authorization process, fewer eligibility and coordination-of-benefits issues, better overall care coordination, and fewer delays in patients getting the services they need.
To minimize disruptions, providers should take the following steps now. Start by identifying which of your patients are D-SNP members. Confirm that you participate in both the Medicare and Medicaid plans for those members. Re-check eligibility ahead of upcoming visits and make sure your front-office staff are prepared to answer member questions about coverage changes.
Before alignment requirements take effect, also review your participation status using My Practice Profile in the UnitedHealthcare Provider Portal.
For questions, connect through chat 24/7 in the UnitedHealthcare Provider Portal.
California-based providers should be aware that between August and December 2026, some may be selected to take part in the Provider Appointment Availability Survey (PAAS). This is an annual survey required by the California Department of Managed Health Care (DMHC), and if you are selected, participation is not optional.
The survey is administered by Sutherland Healthcare Solutions (Sutherland) on behalf of participating health plans, including UnitedHealthcare.
If selected, Sutherland will reach out by email, fax, or phone to provide your assigned survey window and instructions. The survey itself takes less than 10 minutes to complete and asks for the next available appointment date and time for urgent, non-urgent, and follow-up care. Providers must complete the survey during their assigned window.
To avoid any delays, office staff who handle scheduling and appointment availability should be made aware of this survey ahead of time so they are ready to respond if contacted. Also worth noting: if you are contacted by more than one health plan, you are required to complete a separate survey for each request.
Failing to respond may negatively affect your compliance with both state requirements and your UnitedHealthcare contractual obligations.
For questions, connect through chat 24/7 in the UnitedHealthcare Provider Portal.
