The Government Shutdown: What Providers Need to Know (Medicare, MA, VA, and ERISA)

Published on October 8, 2025 in MEMBER ADVISORIES

I. Reduced CMS Guidance & Oversight for Medicare & Medicare Advantage Organizations (MAOs)

CMS won’t be issuing many clarifications or fielding most provider questions regarding policy.

“Outreach and education activities, including handling provider questions and issuing clarifications, will cease or be significantly reduced.” (CMS FY 2026 Contingency Plan, HHS.gov)
- Providers can’t rely on CMS for billing or compliance answers. The ability to handle billing and compliance questions, and issue clarifying guidance for providers will be significantly hampered. This means health care providers will have limited access to federal support for policy-related issues.

Impact: Higher risk of denials or disputes because CMS isn’t correcting misinterpretation

Oversight of major contractors will be limited.

“CMS would be largely unable to provide oversight to many of its major contractors, including MACs, call centers, and IT vendors.” (HHS.gov)
- - Contractors (MACs, call centers, IT vendors) still operate, but with less supervision.

Impact: Payors and contractors may “interpret” the rules their own way which may result in longer delays, more errors, and fewer escalation options when issues arise.

Non-urgent facility surveys will be delayed.

“Survey and certification functions would be limited to complaint investigations alleging the most serious harm (immediate jeopardy). Initial, recertification, and other complaint surveys would be suspended.” (HHS.gov)
- - Routine inspections pause.

Impact: Backlogged surveys later = compliance pressure surge post-shutdown.

Key Takeaway: With CMS scaling back guidance and oversight, payors and contractors may push their own interpretations of policy. Providers must rely on a strong understanding of administrative law and regulations to protect revenue, stem payor misconduct, and stay compliant until CMS oversight

Appeals are still legally required.

42 CFR Part 405 Subpart I – Providers must submit redeterminations within 120 days from the initial claim determination. MACs must complete redeterminations in 60 days.
42 CFR Part 422 Subpart M/Part C&D Appeals Guidance – Providers must submit reconsiderations within 65 calendar days of the denial and MAOs must process and effectuate reconsidered decisions within 60 calendar days.

Impact: Providers retain full appeal rights, and MACs and MAOs retain full responsibility to process them — no tolling of deadlines.

Responses may be delayed.

“Delays in administrative functions may occur, but essential beneficiary and provider services continue.” (CMS FY 2026 Contingency Plan)

Impact: Slower turnaround, potential cash flow strain, but appeals remain valid.

Payments continue.

“Medicare claims processing, payments to Medicare Advantage and Part D plans, and provider payments will continue.” (HHS.gov)

Impact: Delays possible, but denials based solely on shutdown are invalid.

Key Takeaway: The risk is delay and slower responses in non-essential areas, not loss of rights or payment. Providers who anchor their appeals and compliance work in laws and regulations can push back against payors attempting to withhold revenue, even when responses are delayed.

II. VA Guidance and Oversight

97% of VA employees remain working.

- VA benefits will continue to be processed and delivered. (VA.gov)
- The Board of Veterans’ Appeals will continue to render decisions, conduct hearings, and remand cases as required. (VA Human Capital Contingency Plan – (VA.gov)
- VA confirms compensation, pensions, education benefits, and provider payments will not stop. (VA.gov)

Impact: Core VA operations continue despite shutdown.

Advance appropriations protect VA healthcare.

38 U.S.C. §117 ensures medical care accounts are funded a year in advance.

Impact: Payments to providers and veteran care continue without disruption.

Key Takeaway: Nearly all VA staff and funding for medical care are protected, meaning core operations and payments continue without disruption. Providers should demand consistency in payment and care delivery even during the shutdown.

III. ERISA Guidance and Oversight

75% of the Employee Benefits Security Administration (EBSA) staff will be furloughed.

According to the DOL, during a shutdown, “compliance assistance, regulatory, policy, research, advisories, responding to inquiries, most oversight, hearing preparation and cooperative activities will cease.”
- - Despite this, critical requirements like Form 5500 filings are remaining in effect with unchanged deadlines, but the department’s staffing constraints will delay processing times.
  - While most activities, such as audits and investigations, will be paused, essential guidance subject to statutory deadlines normally could continue. This is particularly true for appointed employees, such as the new head of EBSA, Daniel Aronowitz, who would remain on duty during a shutdown. (https://www.dol.gov/sites/dolgov/files/general/plans/dol-contingency-plan.pdf)

Impact: EBSA Complaint review will be significantly hampered and backlogged during and post-shutdown.

Key Takeaway: The risk are self-funded employers and TPAs engaging in mismanagement of the trust and ERISA violations without oversight. Providers must secure authorized representative forms by the patient, when needed, and rely on a strong understanding of administrative law and regulations to protect revenue, stem payor misconduct, and stay compliant until EBSA oversight resumes.

ERN Government Shutdown Playbook for Providers

If a plan/MAC cites “shutdown” to delay/deny payment:

“Our claim and appeal deadlines, along with your payment obligations, continue during a lapse in appropriations. Under existing federal law, payments to Medicare Advantage Plans continue as mandated by 42 U.S.C. 1395w–23] (a), and MAOs must comply with 42 CFR Part 422 to process claims and appeals timely. Please release the federal funds intended for the beneficiary under the standard regulatory timeframes.”

If an MA plan delays reconsideration:

Cite 42 CFR 422.504(a) (MAOs must comply with all requirements of subpart M governing coverage determinations, grievances, and appeals “at all times”) and Subpart M adjudication clocks.

If a MAC slows a redetermination:

Remind them Level-1 redeterminations have statutory deadlines in 42 CFR Part 405 Subpart I.

If VA payment delays arise:

Cite 38 U.S.C. §117 (advance appropriations) and the VA contingency plan (97% of staff retained). Push back on “shutdown” as a basis for non-payment.

Key Takeaway: Shutdowns do not suspend payment or appeal obligations. By citing the governing statutes and regulations providers can push back when payors or contractors attempt to use the shutdown as a reason to delay or deny revenue.

When to expect the government to resume?

Government shutdowns have typically been short, with the pay of military service members often seen as a deadline for restoring funding. The next military pay date at risk is October 15.

House lawmakers aren’t expected to return to Washington, D.C., until next week (WSJ, Oct. 1). Any funding proposal would need their approval.

Unlike the 2019 shutdown (34 days), Congress has not passed any appropriations bills this cycle, so no agencies are funded.

Since 1977, the federal government has shut down 21 times, averaging 8 days in length.

The longest shutdown in the past 50 years was under the Trump administration, Dec 2018 – Jan 2019 (35 days).

Final Takeaway: Government shutdowns may reduce oversight and slow responses, but they do not remove statutory obligations for payment or appeals. Providers who understand and apply the governing laws and regulations can maintain compliance, protect revenue, and preserve patient access to care, even when federal agencies are limited.

If you have questions or need clarification, contact ERN at info@ernenterprises.org

DISCLAIMER: This office advocates for medically appropriate healthcare pursuant to Wickline vs. State. The intent of our advocacy, training, consulting, and representation is to present accurate and authoritative information to the subject matter covered. It is presented with the understanding that ERN is not engaged in the rendition of legal advice. If legal advice is required, you should seek the counsel of an attorney with the expertise in the area of inquiry.