2026 Regulatory Roundup: Mid-Year Health Plan Compliance Developments
Regulatory change in healthcare rarely arrives all at once—but now, several major policy shifts are coming into effect on January 1, 2027. Health plans that start planning for these changes now will be better positioned to avoid disruption. Payers that choose to wait risk facing compliance gaps, operational friction, and negative member impact.
During the August meeting of the HealthEdge® Regulatory Compliance User Group, our experts discussed the adjustments to interoperability, obstetric coding, Medicaid work requirements, and the No Surprises Act—some are finalized, some are still proposed, and all of them deserve your attention.
Key Takeaways
- Interoperability requirements under CMS-0057-F are driving significant platform development across the industry.Obstetric CPT coding is being restructured by the American Medical Association (AMA), effective January 1, 2027—this change is finalized. A proposed CMS rule could create a dual-track billing system, but it's not yet final.
- Federal Medicaid work requirements take effect January 1, 2027, with Nebraska already dis-enrolling members and more states entering enforcement phases.
- No Surprises Act qualified payment amount (QPA) calculation rules are being revised following recent court decisions, and a proposed rule on Advanced Explanation of Benefits (AEOB) may arrive as early as September 2026.
- Health plans should monitor multiple regulatory tracks simultaneously, as finalization timelines differ and some states are moving independently of federal outcomes.
Interoperability: Where Do Health Plans Stand on CMS-0057-F?
The Centers for Medicare and Medicaid Services (CMS) interoperability final rule—known as CMS-0057-F—requires health plans to build out a set of application programming interfaces (APIs) covering provider directory access, patient access, provider access, and payer-to-payer data sharing. These aren't new requirements, but the compliance deadlines are real and approaching.
HealthEdge is actively working to support HealthRules® Payer customers in meeting these requirements. Progress is underway across the required API capabilities, with work continuing toward full compliance. Health plans should be reviewing their own readiness now—not just vendor readiness, but internal data governance, provider outreach, and testing timelines.
The broader industry implication here is significant. Interoperability isn't just a compliance checkbox. Done well, it improves care coordination, reduces administrative burden on providers, and gives members better access to their own health information.
Obstetric Coding Changes: What’s Finalized and What’s Still Proposed?
The AMA’s Decision Is Final
Starting January 1, 2027, the American Medical Association (AMA) will eliminate global maternity CPT codes—the longstanding billing model that bundled antepartum care, delivery, and postpartum care into a single code. In their place, the AMA has introduced phase-based billing codes that separately capture each stage of obstetric care: antepartum, labor and delivery, and postpartum.
This change is finalized. It will happen regardless of what CMS does or doesn't do at the federal level.
What CMS Is Still Deciding
CMS's proposed 2027 Physician Fee Schedule introduces 15 new G codes (a specialized set of HCPCS Level II billing codes) designed to let health plans continue using a global billing model as an alternative to the new phase-based approach. If finalized, this would create a dual-track system—one using the AMA's new codes, one using the CMS G codes—that could introduce significant complexity for health plans, providers, and billing departments alike.
The comment period on this proposed rule closes September 14, 2026, with a final rule expected in early November 2026.
Adding another layer of complexity: some states aren't waiting for the federal outcome. New York, for example, is moving forward with adopting the new AMA obstetric codes on its own timeline. Health plans operating in multiple states should prepare for a fragmented implementation landscape, at least in the near term.
Medicaid Work Requirements: What’s Live, and What’s Coming?
Federal Requirements Take Effect January 1, 2027
Federal Medicaid work requirements—formally called "community engagement requirements"—are set to take effect nationally on January 1, 2027. These rules require certain Medicaid beneficiaries to meet minimum work, volunteering, or educational activity thresholds to maintain eligibility.
Some states are getting ahead of this deadline with their own guidelines.
Where States Stand Right Now
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Nebraska is the first state to enforce work requirements and currently the only state actively dis-enrolling members. Approximately 200 members were dis-enrolled in the first enforcement round, with that number expected to grow as more members reach renewal periods.
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Montana and Arkansas are live with their programs but remain in soft-launch, notice-only phases—no dis-enrollments have occurred yet.
The Medical Frailty Exemption Dispute
CMS narrowed the medical frailty exemption to a stricter, case-by-case standard, limiting the number of beneficiaries who qualify for an automatic carve-out from work requirements. Several states filed legal challenges seeking to pause enforcement. An emergency injunction request was denied in July 2026, though the underlying legal case remains open. Health plans operating in affected states should continue monitoring litigation developments closely, as a court ruling could alter exemption criteria with limited notice.
No Surprises Act: Court Decisions and What Comes Next
QPA Rules Are Shifting
The No Surprises Act established a process for determining the qualified payment amount (QPA)—the benchmark used to calculate out-of-network payments. Several rules governing QPA calculations have been struck down by the courts in recent months, including:
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A prohibition on using so-called "ghost rates"—low-volume or atypical rates—in median in-network rate calculations
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A requirement to incorporate bonus and incentive payments into QPA calculations
These court decisions create immediate operational questions for health plans managing out-of-network payment disputes. The Departments of Health and Human Services (HHS) issued a statement confirming that they are coordinating with other authoritative agencies on guidance in response to the August 2026 Texas Medical Association decision.
AEOB Rule on the Horizon
A proposed rule addressing Advanced Explanation of Benefits (AEOB)—a long-pending piece of the No Surprises Act—may be released as early as September 2026. AEOB requirements would obligate health plans to provide members with cost estimates before they receive certain services. This has significant implications for plan systems, provider data infrastructure, and member communications workflows.
Stay Ahead of What’s Coming
The regulatory calendar heading into 2027 is one of the most complex in recent memory. Health plans are managing finalized changes, proposed rules still in comment or forthcoming, active litigation, and court decisions that will likely result in revised calculations.
The plans that navigate this successfully will be the ones that invest in monitoring, preparation, and flexible operational infrastructure now.
For continued updates as these rules finalize and take effect, explore HealthEdge's regulatory compliance resources—including webinars, blog
