Valued Client , your January 2026 edition of RKL's Medical Billing Update is here!

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2026 Medicare Deductibles, Coinsurance and KX Modifier Thresholds

Effective January 1, 2026, the Medicare Part A co-insurance increased to $217/day for Skilled Nursing days 21-100, the Medicare Part B deductible increased to $283 and the KX modifier threshold increased to $2,480 for OT and $2,480 for PT/SLP combined. Medicare is continuing with the Medical Review threshold for therapy provided over the KX modifier threshold. The Medical Review threshold amount is $3,000 for OT and $3,000 for PT/SLP combined and will continue until calendar year 2028. Learn more about the new 2026 deductibles and coinsurance rates. Read more about the threshold amounts.

Skilled Nursing Facility Update: January 1 Revalidation Deadline Indefinitely Suspended for CMS-855A

CMS had previously provided Skilled Nursing Facilities (SNFs) with a deadline of January 1, 2026, to submit a CMS-855A Revalidation, however CMS has now announced they are indefinitely suspending the deadline. SNFs are also encouraged to continue collecting data on ownership, managerial and related party information and to submit their revalidation. Any SNFs who have already filed their CMS-855A revalidations will notice they are in Pending status on PECOS. Please continue to monitor your Medicare Administrative Contractor’s website for additional information. For assistance or questions, please contact Stephanie Kessler.

Veterans Administration Updates Contracts to Begin Using Patient Driven Payment Model (PDPM) for Reimbursement

The Veterans Administration (VA) historically had followed Medicare and reimbursed providers for providing care to Veterans at levels associated with Resource Utilization Groups (RUGS). However, to keep the VA more in line with Medicare and their reimbursement method, Patient Driven Payment Model (PDPM), the VA is moving to the same payment methodology. A phase-in approach for existing contracted SNFs with the VA will begin as Contract Nursing Home (CNH) contracts are coming up for renewal. The new contracts are identified as Veteran Care Agreements (VCAs) and will have an effective term of 3 years, down from the CNH term of 5 years.

The new payment model offers two levels of reimbursement and is based on days of care in an SNF. Days 1-100 will be reimbursed at 93% of the PDPM HIPPS calculation and does include all ancillary charges incurred during this time frame. If the veteran remains in the SNF, beginning on day 101, the SNF is reimbursed at 125% of the PDPM HIPPS calculation, minus the therapy components, and therapy is billed on a separate claim. Therapy services are limited to specific Healthcare Common Procedure Coding System (HCPCS).

Claims under the CNH Contracts were and will continue to be submitted to your local VA Office. However, claims under the new VCA contracts are submitted electronically to Payer ID 12115.

Find more information about these changes and the 2026 fee schedules at va.gov. If you are a provider who has already been updated to the new reimbursement model and need assistance with setting up your Electronic Health Record, please contact Lacy Albright to connect you with one of our specialists.

Pennsylvania Amerihealth Community HealthChoices and Keystone First Community HealthChoices Announce Change in Type of Bill for SNFs, Effective February 1, 2026

Amerihealth Caritas PA, and Keystone First have announced through provider notifications that they will begin to require type of bill (TOB) 021X, instead of accepting TOB 026X, because the Centers for Medicare and Medicaid Services (CMS) and the National Standards Group have determined the use of TOB 026X to be non-compliant with HIPAA Administrative Simplification provisions. To align their practices, effective February 1, 2026, Amerihealth Caritas PA, Amerihealth Caritas PA Community HealthChoices, Keystone First and Keystone First Community Healthchoices will no longer accept claims billed with TOB 026X and will apply this standard to all claims regardless of the date of service.

Corrected claims submitted after February 1, 2026, will require a TOB 217, regardless of the date of service.

PA Health & Wellness, UPMC and Medicaid Fee-For-Service have not released the same changes as of the date of this publication. For more information, please contact Lindsay Esterline.

Pennsylvania Employees Benefit Trust Fund Announces Change in Plan Administration, Effective January 1, 2026

Pennsylvania Employees Benefit Trust Fund (PEBTF) will no longer offer plans through Geisinger Health Plan. Instead, Beginning January 1, 2026, PEBTF will offer a statewide custom HMO plan through Aetna. Learn more.

CareFirst Provides Update Medicare Advantage Fax Line, Effective January 1, 2026

Beginning February 1, 2026, all Medicare Advantage faxes should be sent to their new dedicated fax line: 443-753-2346. All previous fax numbers will be decomissioned and will no longer be available for use. CareFirst is also issuing new insurance cards to many of their members, so remember to ask for residents' newest version of their ID cards.

Sentara Health Plans Announce Changes for Virginia and North Carolina Members in 2026

Sentara Health Plans is eliminating some Medicare Advantage plans for 2026 in Virginia and North Carolina. Dual eligible members who have the Non-Dual Medicare Advantage, Medicare Advantage Prescription Drug HMO, or Chronic Condition Special Needs plans will have to enroll in a new plan for 2026.

PCC Corner

Point Click Care (PCC) provides tracking for Medicaid renewal dates within the User Defined Fields under the Resident Profile. To set this up and begin using this feature, follow the steps below.

In PCC, search the resident under the Admissions tab.
Go to the Resident Profile tab.
Go to the section labeled User Defined Fields.
Click New.
In Field Type enter Medicaid Recertification Date.
In Item Description enter the renewal date.

If you currently do not have this field setup as an option in PCC, follow these steps to enable the feature:

Admin → Setup → User Defined Fields → New

Note: The order will vary based on how many options your facility already has.

Click Save

To run the report from PCC to identify the renewal dates of all residents, follow the steps below.

Go to the Reports Tab.
Search for the Resident List Report *New* under the ALL tab if this is your first time running this report.

Under the Report Options section, make sure that the following fields are properly checked:

Unit: All
Floor: All
Check the Status box and select “Current” from the dropdown box.
Uncheck “Include Outpatients”.
Sort By Resident Name.

In the Fields to Display section, you can customize the report to the information you would like to view within the report.

Select the format you wish to have your report displayed in, either PDF or Excel*.

* It’s recommended in the Report Outcome Format to use Excel so you can filter the report to just those residents with Medicaid Recertifications.

For assistance or questions, please contact Paula Hynum.

MatrixCare Matters

If your organization is considering the implementation of MatrixCare 360 and would like expert guidance on the integration process, RKL’s experienced team can support you every step of the way. Our professionals are well-versed in navigating system transitions and can provide tailored advice to ensure seamless integration, minimize disruptions and optimize your operational workflow. To learn more about how RKL can assist with your MatrixCare 360 implementation, please contact Dawn Leis or Lacy Albright for a consultation.

In addition, MatrixCare recently announced a change beginning in 2026. RISE will become Resmed Connect and their annual user conference will be November 10-12, 2026. As users, you are encouraged to attend the conference to see what is new, what enhancements are coming and to network with your peers.