Congress did not pass legislation before a Jan. 30 deadline that would have funded most of the government, extend expiring Medicare coverage policies, and make sweeping reforms to pharmacy benefit managers (PBMs).
Allergists should therefore continue preparing for possible Medicare claim payment disruptions for the same coverage policies impacted during the October – November government shutdown. These include, but are not limited to, the 1.0 work GPCI floor and the COVID-era telehealth coverage flexibilities.
Congress was supposed to pass an extension of these coverage policies as part of an appropriations “minibus” bill of the final six annual appropriations bills that fund the federal government through the rest of the fiscal year (Sept. 30). This includes the bill that funds the HHS and its subagencies such as CMS. It also included a large package of health care policies unrelated to federal appropriations. This package featured a major Pharmacy Benefit Manager (PBM) reform package, and an extension of the Medicare “extenders” through 2026 and the telehealth flexibilities through 2027.
The House passed this bill and the Senate was expected to pass it before the deadline. However, Senate Democrats withheld their support for the minibus in response to federal immigration enforcement policies.
The Department of Homeland Security (DHS) appropriations bill that funds the Border Patrol and Immigrations and Customs Enforcement (ICE) is also part of the minibus package. Senate Democrats refused to vote for the package unless the DHS bill is either removed or amended to include major reforms to ICE and related agencies.
Subsequently, the White House and the Senate agreed in principle to “carve out” the DHS bill by only extending its funding for two weeks to allow more time for negotiations on reforms. The rest of the minibus – including the PBM reforms and “extenders” policies – would not be changed. The Senate passed this bill on Friday night.
The House must reconsider the bill with the Senate’s changes. As this process could not be completed before the Jan. 30 deadline, funding for these agencies lapsed and the Medicare extenders and telehealth flexibilities expired.
The House is not guaranteed to vote on the bill today. As of Sunday evening, a vote has not been scheduled in the House, though that could change. It is not clear if the House will be able to pass the bill, as a significant number of Members from both parties have reservations about the Senate version.
If the situation remains unresolved into the week, we expect CMS to handle the situation the same as it did during October and November of 2025, the last government shutdown. CMS could decide to temporarily hold impacted claims for up to 14 days, in hopes that Congress can extend these policies within that time frame. After 14 days, CMS will make a decision about how it will treat impacted claims. Look for official announcements from CMS and Medicare Administrative Contractors (MACs) for more information about how this situation will impact Medicare claims.
A brief lapse in funding is unlikely to trigger a full government shutdown of the agencies funded by the minibus if there is optimism that Congress can quickly pass funding legislation. If this process drags out through the week, we could see the government initiate a shutdown for impacted agencies.
The Advocacy Council will keep members informed as this situation develops.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
