IHA Daily Briefing: November 10

UPDATE: Medicare Telehealth Under the Government Shutdown
As the federal government shutdown continues, IHA has updated our fact sheet on telehealth coverage changes to reflect new guidance from the Centers for Medicare & Medicaid Services (CMS) released on Friday, Nov. 7. CMS has identified telehealth claims that may have been incorrectly denied over the last month. The agency is encouraging clinicians to resubmit claims that should be permissible to pay under current law, submitted between Oct. 1 and Nov. 10, 2025 and returned with the messages "CARC 16" and "RARC M77", specifically from:

• Applicable Medicare Shared Savings Program Accountable Care Organizations, which may receive payment for covered telehealth services to certain Medicare beneficiaries without geographic restrictions, including in the beneficiary's home; and/or,
• Behavioral and mental health services, which may not include a diagnosis code in the range previously identified by CMS as covered during the shutdown.

Staff contact: Lia Daniels

CMS Launches New Drug Payment Model for State Medicaid Programs
The Centers for Medicare & Medicaid Services (CMS) has announced the GENErating cost Reductions fOr U.S. (GENEROUS) Medicaid Model, a new initiative for state Medicaid programs to purchase prescription drugs at prices aligned with those paid in other countries, known as most-favored-nation (MFN) pricing.

According to a news release, CMS is releasing a Request for Applications for drug manufacturers interested in participating in the GENEROUS Model. The agency will also seek letters of intent from state Medicaid agencies interested in participating. States that express interest can formally apply and potentially opt into the terms and prices CMS negotiates with participating drug manufacturers whose applications are accepted.

Also on Nov. 6, the White House announced agreements with Eli Lilly and Novo Nordisk to offer MFN prices for their drugs.

REGISTER: ISHRM Webinar on HIPAA Modifications, ICE Presence Nov. 13
Legal experts from HeplerBroom LLC will lead a webinar this Thursday on recent modifications to HIPAA. From noon-1 p.m. CT, the Nov. 13 session, "Beyond the Basics: Application of HIPAA to Oddly Common Situations in the Healthcare Setting," will cover how HIPAA applies when law enforcement arrive during an investigation, the presence of ICE activity, fractured family situations, subpoenas, including grand jury subpoenas, and more.

LaDonna Boeckman, a partner at HeplerBroom, which has offices across Illinois, will present the webinar with Chelsea Caldwell, an associate attorney. The webinar is offered through the Illinois Society of Healthcare Risk Management (ISHRM) and sponsored by IHA. The program is designed for healthcare providers, nurses, risk managers and attorneys. Registration is free for ISHRM members and $25 for non-members. Register today.

Staff contact: Teresa Baumgartner

IDPH Issues Reminder About Potential Hazards of Consuming Raw Milk
The Illinois Dept. of Public Health (IDPH) has issued a general reminder to the public about the potential dangers of consuming raw milk after at least 11 people were recently sickened by such products. While most milk products sold in the state are pasteurized, meaning they have been treated with heat to kill viruses, germs, and other substances that can cause illness, raw milk has not been pasteurized, making it more likely to be a source of foodborne illness.

IDPH has so far identified an outbreak of 11 cases of Campylobacter infection that appear to be linked to consumption of raw milk from a common source. According to IDPH, the producer is taking steps to notify customers and is cooperating with the investigation. Campylobacter is a bacteria that can cause diarrhea (which can be bloody), fever and stomach cramps. In more severe cases, the infection can lead to irritable bowel syndrome, arthritis and Guillain-Barré syndrome. IDPH recommends that anyone who has consumed raw milk and begins to exhibit those symptoms to contact their medical provider.

Illinois raw milk rules require testing for temperature, antibiotics and certain signs that could indicate infection within the product. However, specific pathogen testing for germs like Campylobacter or other disease-causing agents like E. coli or Salmonella is not required. For more information on raw milk and its potential hazards, click here.