CPT 98960 is referenced in 18 tracked payer policy changes from Anthem BCBS, L.A. Care Health Plan, and 11 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 98960 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Effective January 1, 2027, HealthKeepers, Inc. (Anthem HealthKeepers Plus Medicaid in Virginia) will discontinue reimbursement for 44 specific procedure codes to align with the Virginia Department of Medical Assistance Services (DMAS) fee schedule. The practice must stop billing these codes for dates of service on or after that date, as claims for discontinued codes will be denied or subject to adjustment and recovery.
Effective January 1, 2027, L.A. Care Health Plan members with Unsatisfactory Immigration Status (UIS) will transition from Medi-Cal managed care to Medi-Cal Fee-for-Service (FFS). Providers must be enrolled in Medi-Cal FFS through PAVE by January 1, 2027 to continue serving these patients and receive reimbursement. Billing workflows must shift from managed care to FFS processes, and providers should familiarize themselves with FFS billing requirements, rates, and newly available care management billing codes.
Effective January 1, 2027, Anthem Medi-Cal Managed Care members with unsatisfactory immigration status (UIS) will transition to Medi-Cal fee-for-service (FFS) delivery. Providers must be enrolled in Medi-Cal FFS through PAVE by January 1, 2027, to continue serving these members and receive reimbursement. Billing workflows must shift from managed care to FFS processes, including Treatment Authorization Requests (TARs) and FFS-specific billing codes.
Effective January 1, 2027, Medi-Cal members with unsatisfactory immigration status (UIS) will transition from managed care plans to Medi-Cal Fee-for-Service (FFS). Providers must enroll in Medi-Cal FFS through DHCS to continue serving these patients and receive reimbursement. Billing workflows, care coordination processes, and prior authorization procedures will shift from managed care to FFS requirements.
Nevada Medicaid updated shadow billing codes for Federally Qualified Health Centers (FQHCs) effective January 1, 2026. Key changes include: CPT codes 99205, 99242-99245, and H0049 now billable with both medical and behavioral health encounters; CPT 99401 with Modifier FP added with a 2-unit annual limit; and six codes (59514, 59612, 59620, 59812, 99401 with Modifier CR, G2214) are end-dated and no longer billable. Additionally, CPT codes 98960, 98961, and 98962 are restricted to medical encounters only.
BCBSRI has implemented multiple policy changes affecting preventive services, coding, and reimbursement across various specialties. Key changes include new breast cancer screening coverage requirements, updated STI testing billing procedures, hearing aid coverage increases, and several new CPT/HCPCS codes for various services.
Point32Health will continue telehealth coverage for Medicare Advantage members as supplemental benefits effective October 1, 2025, regardless of CMS decisions. Specific codes across multiple specialties including cardiac rehab, mental health, physical therapy, and pulmonary rehab will remain eligible for telehealth reimbursement.
Professional claims (CMS 1500) are reduced by the 1.6% increase previously applied to fee-for-service rates for dates of service on or after October 1, 2025, with targeted rate reductions for dental codes and Pediatric Behavioral Therapy codes effective October 1, 2025. Manually priced DMEPOS and prosthetics claims that follow the MSRP less or invoice acquisition plus methods are reduced to MSRP less 13.78% or invoice acquisition cost plus 24.06%, effective October 1, 2025. Continuous glucose monitor products and supplies must carry the NDC, the HCPCS code and the modifier combination on claims beginning November 1, 2025, and CGMs for members enrolled in physical health managed care plans must be billed as fee-for-service claims.
Multiple policy updates affecting various services including COVID-19 treatments, bundled services, preventive care, and Medicare Advantage acupuncture coverage. Key changes include CPT code corrections for monoclonal antibodies, new bundling restrictions effective October 2025, and elimination of most acupuncture coverage for Medicare Advantage in 2026.
DHCS has published clarifications on Medi-Cal coverage for Community Health Worker (CHW) services, specifically addressing billing requirements for individual services (CPT 98960, HCPCS G0019/G0022) and group services (CPT 98961/98962), telehealth modality use, and health navigation services. The policy emphasizes that CHWs may now assist members with maintaining Medi-Cal enrollment and enrollment in related assistance programs (CalWORKs, CalFRESH) as part of covered health navigation services.
Already effective July 1, 2026 for New York State Medicaid fee-for-service, and effective November 1, 2026 for Medicaid managed care plans, enhanced reimbursement applies to certain physical health services in OASAS, OMH and OPWDD certified outpatient clinics. Rates increase 20 percent for listed services in OASAS clinics, Article 31 MHOTRS clinics and Article 16 OPWDD clinics, and 20 percent for all services in Article 31 clinics for individuals eligible for the OPWDD waiver or enrolled in the TBI waiver. Services in OASAS Article 32 clinics for those individuals increase 50 percent.
Pennsylvania Medicaid now covers Community Health Worker (CHW) services as a preventive benefit effective January 1, 2026. Billing teams must implement new procedure code 98960–U2 (or T1015 for certain clinic settings), limited to 3 units per member per year at $25 per unit, with specific documentation and referral requirements.
BCBSRI now requires lactation consultation services to be billed with the mother as the patient, not the infant. Claims submitted under infants (ages 0-12 months) will be denied, and only one unit of CPT 98960 per date of service will be reimbursed.
Starting August 25, 2025, New Mexico Medicaid reimburses Community Health Worker and Community Health Representative (CHW/CHR) services in an outpatient setting, covering system navigation, health promotion and health coaching, and clinical support when the services are medically necessary and ordered by a physician or ordering licensed practitioner. Claims go on the CMS-1500 or electronic equivalent with CPT 98960, 98961 or 98962, and must include a Z diagnosis code from Appendix A as a primary or secondary diagnosis. CHW/Rs are limited to 10 units or 5 hours per day of member-facing time, and services above 16 units or 8 hours per 30-day period require prior authorization.
EmblemHealth will begin covering the Chronic Disease Self-Management Program (CDSMP) for Medicaid and HARP members age 18+ with arthritis diagnoses starting June 1, 2025, using CPT code 98960. This is a new covered benefit for evidence-based group and individual chronic disease management services.
Nevada Medicaid now allows Public Health Clinics (Provider Type 17, Specialty 174) to submit claims for patient education and training codes 98960-98962 without automatic suspension, effective May 19, 2025. Previously suspended claims dating back to June 2022 have been released for reprocessing.
Aetna considers the treatments listed in this bulletin experimental, investigational or unproven for Alzheimer's disease because their effectiveness for that indication has not been established. The list includes acupuncture, applied behavior analysis, deep brain stimulation, gene therapy, intravenous immunoglobulins, lithium, music therapy, statins, stem cell therapy, transcranial magnetic and direct current stimulation, vagus nerve stimulation, and monoclonal antibodies such as solanezumab, bapineuzumab, crenezumab and semorinemab. The CPT, HCPCS and ICD-10 codes named in the bulletin are not covered for the indications the bulletin lists, including Alzheimer's disease (ICD-10 G30.0 through G30.9).
California DHCS is updating the Medi-Cal Provider Manual to clarify billing requirements for Community Health Worker (CHW) preventive services, including individual and group billing procedures using specific CPT and HCPCS codes, and telehealth usage guidelines.
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