Sellers Dorsey outlines approaches for state Medicaid programs to balance community integration commitments with fiscal pressures in home and community-based services. The piece addresses operational challenges including 607,000 people on HCBS waiting lists, workforce shortages, and cost growth outpacing enrollment, while noting evolving federal expectations for transparency and program integrity. The analysis is framed around maintaining ADA compliance while managing waiver capacity constraints and rising per-member costs.

The SUSTAIN 340B legislation codifies point-of-sale discounts for covered entities including Medicaid safety-net providers, requires manufacturers to honor 340B pricing regardless of contract pharmacy arrangements, and introduces new program integrity standards including clearinghouse oversight for duplicate discount prevention. For Medicaid MCOs and state agencies, the bill would formalize contract pharmacy protections while adding transparency requirements that could affect claims processing, pharmacy network management, and coordination between 340B discounts and Medicaid rebates. The proposal would also sunset CMS's planned rebate model pilot within a year of enactment.

Sellers Dorsey explores how schools can function as coordination hubs connecting Medicaid-funded behavioral health services with child welfare agencies and community providers. The brief addresses fragmentation across systems serving children and proposes schools as an access point for integrating care delivery. This model has direct implications for MCO network adequacy, care coordination strategies, and how managed care plans structure pediatric behavioral health benefits and community partnerships.

CMS has proposed replacing the current 6% indirect hold harmless threshold for health care-related taxes with state-specific thresholds, implementing provisions from federal budget reconciliation legislation. The rule would phase down thresholds for expansion states starting in 2028, add health insurers as a new permissible tax class, eliminate the 75/75 test, and create new reporting requirements. With an estimated $246 billion reduction in federal Medicaid spending over ten years, this proposal has significant implications for how states finance their Medicaid programs and could affect MCO premium rates and overall program funding.

This piece examines seven operational challenges facing Medicaid MCOs—including frequent eligibility redeterminations, care continuity during coverage gaps, network adequacy pressures, and evolving state quality expectations—and outlines how technology platforms can help address them. The analysis focuses on practical tech-enabled solutions like real-time eligibility tracking, care coordination tools that preserve member history across enrollment gaps, and interoperability platforms that unify clinical and claims data. It's directly relevant to MCO compliance teams and executives managing operational strategy in a high-churn, high-accountability environment.

CMS's proposed rule would significantly restrict state directed payments in Medicaid managed care by imposing Medicare-based payment caps not only on the four service categories specified by Congress (inpatient, outpatient, nursing facility, and academic physician services) but also on other non-grandfathered SDPs beyond the statutory text. The rule threatens a critical Medicaid financing mechanism states use to ensure provider access and system stability, with stakeholders arguing CMS has overreached its authority. Despite broad potential impact across states and provider types, public comment volume has been unexpectedly low compared to other recent Medicaid rulemakings, creating advocacy opportunities for MCOs and affected stakeholders.

A new whitepaper examines strategies for rural hospitals, FQHCs, and community health organizations to leverage operational data for better workflow efficiency and patient outcomes. The analysis focuses on how safety-net providers—which serve large Medicaid populations and often contract with MCOs—can close gaps in their use of performance intelligence. While not exclusively focused on Medicaid managed care, the operational improvements discussed directly affect how these providers participate in value-based arrangements and meet MCO quality standards.

Sellers Dorsey breaks down a new CMS State Medicaid Director Letter that implements statutory budget neutrality requirements for Section 1115 demonstrations approved after January 2027, stemming from federal legislation. The guidance previews forthcoming rulemaking and provides states with early direction on compliance with these new fiscal guardrails. This matters for MCOs because 1115 waivers often define managed care program structure, covered populations, and available funding—and tighter budget neutrality requirements may constrain demonstration scope and financing approaches.

CMS has published an interim final rule implementing federally mandated Medicaid community engagement (work) requirements, establishing narrow definitions for exemptions like medical frailty and family caregiving while limiting state flexibility to define these terms independently. The rule places specific constraints on what managed care plans can do regarding these requirements and projects that 15 percent of affected enrollees will lose coverage due to noncompliance or procedural issues. For MCO compliance teams and state Medicaid officials, this creates immediate operational challenges around member identification, verification processes, and disenrollment protocols effective July 31, 2026.

Sellers Dorsey experts discuss how CMS and state pressure for Medicare-Medicaid integration is forcing health plans to fundamentally restructure operations beyond basic D-SNP compliance toward fully integrated dual-eligible models. The conversation covers critical pain points including care coordination architecture, provider incentive misalignment, and the operational differences between traditional D-SNPs and FIDE SNPs. The firm emphasizes that successful integration requires comprehensive organizational change affecting data systems, member experience design, and value-based contracting strategy across both programs.

CMS has released a proposed rule that would formalize state directed payment limits under recent federal legislation and introduce new restrictions on targeted fee-for-service provider payments in Medicaid. The rule clarifies existing SDP payment limits, grandfathering provisions, and phase-down requirements that will directly affect how states structure supplemental payments through managed care arrangements. Sellers Dorsey provides a detailed breakdown of the key provisions during the 60-day comment period.

Rural providers now have basic data infrastructure but lack the ability to translate information into actionable clinical and operational decisions, creating ongoing challenges in value-based care participation and care coordination. State programs like the Rural Health Transformation Program are shifting investment toward analytics integration and workflow tools rather than just connectivity. For Medicaid MCOs operating in rural markets, this highlights the gap between data exchange requirements and providers' actual capacity to use shared information effectively in care management.

Sellers Dorsey analyzes nearly 200 stakeholder comments submitted to CMS regarding the CRUSH Request for Information, which proposes sweeping changes to Medicaid program integrity oversight including restrictions on intergovernmental transfers, supplemental payments, state-directed payments, provider enrollment screening, and eligibility verification. The firm's summary provides Medicaid officials and MCO compliance teams insight into how various stakeholders are responding to proposed federal oversight expansions that could fundamentally reshape Medicaid financing mechanisms and regulatory requirements for states and health plans.

Sellers Dorsey has released a practical guide addressing why most Dual Eligible Special Needs Plans still struggle to achieve full coordination between Medicare and Medicaid benefits, despite that being their core design intent. The playbook identifies specific operational barriers health plans face and provides concrete implementation strategies to overcome coordination gaps, directly relevant to MCOs managing dual-eligible populations and state Medicaid agencies overseeing D-SNP contracts.

Sellers Dorsey's analysis of 40 governors' proposed FY2027 budgets reveals emerging themes that will shape Medicaid managed care operations, including budget pressures driving spending cuts, workforce pay adjustments, and targeted investments in behavioral health and children's services. The review provides MCO executives and state Medicaid directors an early look at policy priorities before legislatures finalize budgets this summer, helping plans anticipate rate pressures, program changes, and investment opportunities across states.

Sellers Dorsey experts argue that Medicaid can serve as a primary prevention tool against child abuse and neglect by funding upstream interventions including behavioral health treatment, home visiting programs, and postpartum depression screening for at-risk parents. The discussion frames child maltreatment prevention as a multi-sector healthcare challenge rather than solely a child welfare issue, emphasizing how managed care organizations and state Medicaid programs can support families experiencing substance use disorders, mental health conditions, and other stressors that compromise parenting capacity before crises escalate.

Dual Eligible Special Needs Plans were designed to seamlessly coordinate Medicare and Medicaid for beneficiaries, but most health plans remain far from achieving this operationally. Medicaid-dominant plans bring strong LTSS and community relationships but lack Medicare Star rating and risk adjustment expertise, while Medicare-focused plans excel at utilization management but struggle with state oversight and community-based service coordination. The article argues this structural mismatch between organizational capabilities and D-SNP requirements remains the defining operational challenge for plans serving dually eligible populations.

The piece argues that Medicaid-financed healthcare encounters—from pregnancy through early childhood—represent underutilized prevention opportunities to identify family risk factors and connect vulnerable families to services before child maltreatment occurs. It highlights specific Medicaid payment strategies (value-based care, bundled maternity payments) and care delivery models that support early identification of maternal behavioral health needs, housing instability, and other social determinants that can lead to neglect or abuse. The analysis is directly relevant to MCO care management strategies, provider network design, and how states structure maternity and pediatric benefit packages to achieve cross-system outcomes.

The piece examines how Medicaid 1115 waivers evolved over the past decade from narrow pilots to comprehensive program frameworks encompassing managed care, behavioral health integration, and LTSS redesign. It reviews what worked—particularly improved access to SUD treatment and mental health services—while noting the administrative complexity, budget neutrality pressures, and increased federal scrutiny states now face. The analysis is directly relevant to MCO executives and state Medicaid officials navigating waiver renewals, expansions, and changing federal policy.

Since 2014 regulatory changes removed IEP/IFSP documentation requirements, 25 states now allow Medicaid reimbursement for school-based mental health services provided to any enrolled student with medical necessity. With nearly 20% of students using school-based mental health services and youth suicide rates climbing, this represents a significant care delivery and financing opportunity for Medicaid managed care plans to improve behavioral health access while helping schools leverage federal matching funds. The piece frames school settings as prevention-focused venues that reduce access barriers for families and address rising adolescent mental health needs.