October is when payers show their hand for the coming year. This month we have three sets of changes that will land on independent practices in different ways: one that was supposed to start reducing payments on October 1 and was paused at the last minute, one that is supposed to make prior authorization easier from January 1, 2026, and one that will move a lot of Medicare patients between plans during the annual enrollment period, which opened October 15 and runs through December 7.
None of these is a surprise to anyone who reads payer bulletins. All of them are surprises to the front desk and the billing team if nobody translates them into workflow. That is what this article tries to do.
Key takeaways
- Cigna paused its E/M Coding Accuracy policy (R49) days before its October 1 start date after pressure from medical societies and a California regulator. It has not withdrawn it. Use the pause to audit your level 4 and 5 visits before it returns.
- The voluntary prior authorization commitments insurers announced in June 2025 come due January 1, 2026, and so do the binding decision deadlines in the CMS interoperability and prior authorization rule for Medicare Advantage, Medicaid managed care and marketplace plans.
- UnitedHealthcare, Humana and Aetna cut counties and plans for 2026, and CMS projects Medicare Advantage enrollment to fall for the first time. Expect patients to change plans, networks and authorization rules in January.
- The workflow response to all three is the same: check remittances line by line, keep authorization details in the chart, and re-verify eligibility for every Medicare patient in January.
1. Cigna's E/M downcoding policy, paused but not withdrawn
Cigna's reimbursement policy R49, titled Evaluation and Management Coding Accuracy, was scheduled to take effect on October 1, 2025. Under it, Cigna would automatically reduce a level 4 or level 5 office or consultation visit by one level when its claim-based review concluded the reported level was not supported. The codes in scope were 99204 and 99205, 99214 and 99215, and 99244 and 99245. A 99215 would become a 99214; a 99214 would become a 99213. The reduction would show on the remittance with Cigna's code C150, indicating a higher-level E/M visit was downcoded, and Cigna said it would restore the original level if the practice sent records showing the medical decision making or time.
Physician organizations including the AMA, the AAFP, the ASGE and several state medical associations objected through September, arguing that a claim form cannot show the complexity documented in the note, and the California Department of Managed Health Care opened a review. In the last days of September Cigna announced a temporary pause. As of this writing the policy has no new effective date, and Cigna has not said it is abandoning the approach.
We think the pause is an opportunity, not a reprieve. The policy targets a specific pattern: a level 4 or 5 visit whose diagnosis codes, in Cigna's view, do not indicate that level of medical decision making. A level 4 visit with a single primary diagnosis of a minor acute problem, and nothing else on the claim, is exactly what the algorithm is built to catch. The fix is to report every condition addressed at the visit, which is what the E/M guidelines already require, and to make sure the note supports the level. Audit twenty Cigna level 4 and 5 visits now. If the documentation supports the level, you are ready to appeal routinely when the policy returns. If it does not, that is a provider education problem, and Cigna is not the only payer that will notice.
The money at stake is real. On a 99214 reduced to 99213 the difference is often $35 to $45 per visit at commercial rates; on a 99215 reduced to 99214 it is more. A practice sending Cigna 300 level 4 and 5 claims a month and losing one level on a fifth of them would give up roughly $2,500 a month without a single denial appearing in the denial report, because a downcoded line pays, just less.
2. The prior authorization commitments due January 1, 2026
On June 23, 2025, at an event with the HHS Secretary and the CMS Administrator, a group of major insurers including Aetna, Cigna, Elevance Health, Humana, UnitedHealthcare and Blue Cross Blue Shield plans, with AHIP and the Blue Cross Blue Shield Association, announced a set of voluntary prior authorization commitments covering commercial, Medicare Advantage and Medicaid managed care members. Several of them come due on January 1, 2026:
- Reduce the number of services that require prior authorization, with specific reductions announced by each plan for its own markets.
- When a patient changes plans mid-treatment, honor an existing prior authorization from the prior plan for benefit-equivalent in-network services during a 90-day transition period.
- Provide clear, personalized explanations of denials, including what was reviewed, next steps and how to appeal.
Further commitments, including a standardized FHIR-based electronic prior authorization framework and real-time responses for most electronic requests with complete documentation, are targeted for 2027.
Separately, and this is binding rather than voluntary, the CMS Interoperability and Prior Authorization final rule published in January 2024 requires Medicare Advantage plans, Medicaid and CHIP fee-for-service and managed care plans, and marketplace plans on the federal exchange to decide expedited prior authorization requests within 72 hours and standard requests within seven calendar days starting January 1, 2026, to give a specific reason for denials, and to publicly report prior authorization metrics starting in 2026. Commercial employer plans are not covered by that rule.
| Requirement | Source | Plans covered | Effective |
|---|---|---|---|
| Standard decision in 7 calendar days, expedited in 72 hours | CMS final rule, January 2024 | MA, Medicaid and CHIP, federal marketplace plans | January 1, 2026 |
| Specific denial reason on every prior authorization denial | CMS final rule | Same | January 1, 2026 |
| Public reporting of approval, denial and turnaround metrics | CMS final rule | Same | Annual, starting 2026 |
| Honor prior plan's authorization for 90 days after a plan change | Voluntary industry commitment, June 2025 | Signatory plans, commercial and MA | January 1, 2026 |
| Fewer services subject to prior authorization | Voluntary industry commitment | Signatory plans | Demonstrated by January 1, 2026 |
| Electronic prior authorization on a common standard | Voluntary commitment and CMS API requirement | Signatory plans; CMS-regulated plans | January 1, 2027 |
What this means for the practice: the 90-day continuity commitment is the one to build a workflow around, because the enrollment period will move patients between plans in January. Keep the authorization number, dates, approved units and the plan name from the old plan in the chart, and reference them when the new plan asks. If a plan denies a January service that was authorized by the patient's prior plan in December, cite the commitment in the appeal. The decision deadlines give your authorization team a firm date to escalate: a standard MA request with no answer after seven days is out of compliance, and the plan should be told so, with the date the request was submitted.
3. Medicare Advantage exits and benefit cuts for 2026
The 2026 plan filings show the largest carriers pulling back. According to reporting on the filings in early October, UnitedHealthcare reduced its footprint by one state and 109 counties, Humana by three states and 194 counties, and Aetna by one state and 100 counties. UnitedHealthcare has said its PPO exits affect about 600,000 members. Smaller regional plans exited entirely in some markets. Analysts estimated that hundreds of thousands of MA members, possibly more than a million, will need to choose a new plan this fall. CMS itself, in its September 26 announcement of 2026 premiums, projected MA enrollment of about 34 million in 2026 against 34.9 million in 2025, the first projected decline in the program's modern history, while saying it expected actual enrollment to hold up better than the plans' own projections.
Benefits are thinner too. Aetna, Elevance and UnitedHealthcare cut over-the-counter allowances for non-special-needs plans, and deductibles and out-of-pocket maximums rose on many plans, with a shift toward HMO designs that restrict networks. CMS projected that the average MA premium would fall to about $14.00 a month from $16.40, which sounds like good news until you notice it is partly because plans trimmed benefits to get there.
What the MA changes mean at the front desk
Every one of these plan decisions becomes an eligibility problem in January. A patient whose plan terminated and who did nothing is in Original Medicare on January 1 without a Part D plan. A patient who moved from a PPO to an HMO now needs referrals. A patient who moved to a carrier you do not contract with is out of network and probably does not know it. The practice finds out at the first January visit, or worse, at the first February denial. The table is the workflow we recommend.
| Change | Effect on the practice | Workflow response |
|---|---|---|
| Patient's plan terminated for 2026 | Patient reverts to Original Medicare if they do nothing, or picks a new MA plan | Re-verify eligibility for every Medicare patient in the first two weeks of January |
| New plan or new HMO product in the market | Practice may not be in network, or may need referrals it did not need before | Check contracts and credentialing for every new product now, not in January |
| Higher deductibles and MOOP | More patient responsibility on early-year visits | Estimate and collect at the visit; update the financial policy script |
| Prior plan authorizations | Ongoing treatments may need re-authorization or a continuity request | List active authorizations by patient and plan in December |
Questions we hear
Cigna paused R49. Can we ignore it?
No. A pause with no end date is a delay, and the underlying tool, claim-based review of E/M levels against diagnoses, is one other payers already use in audits. Do the twenty-chart review now while nothing is at stake. If Cigna restarts the policy, you will know your exposure and your appeal rate before the first C150 appears.
Are the June prior authorization commitments enforceable?
Not in the way a regulation is. They are public promises by named plans, and the useful part is that you can quote them. A denial letter that ignores a documented prior authorization from the patient's previous plan, inside 90 days, should be appealed with the commitment cited by name and date. The CMS rule deadlines, by contrast, are enforceable for the plans it covers, and a pattern of late decisions can be reported to the plan's CMS account manager or the state Medicaid agency.
How do we find out which MA plans are leaving our counties?
Ask the plans directly through provider relations, and check the plan-level data files CMS released with the enrollment period. Your own eligibility responses in December are the best source for where patients actually moved, because the 271 response usually carries the new plan name and product type.
What to do this month
- Audit twenty Cigna level 4 and 5 visits against the note and the diagnosis codes on the claim. Fix documentation and diagnosis capture where they fall short.
- Add a C150 filter to your Cigna remittance review now, so it is already running if the policy restarts.
- Build the January authorization list: every patient with an active authorization for a recurring service, the plan, the number, the units and the end date.
- Ask your top MA plans which of their products are terminating in your counties and which new products are launching. Confirm your participation status in writing.
- Set the escalation rule for authorization staff: standard MA requests with no decision after seven calendar days get a call and a documented complaint from January 1.
- Refresh the front desk estimate script for 2026 deductibles and the Part B deductible when CMS announces it.
Practices on our denial management service will see downcoded lines categorized separately from denials, and our credentialing team is checking network status against the 2026 MA filings for the practices we support.
