This analysis examines how H.R. 1's Medicaid work requirements, shortened retroactive coverage, new cost-sharing rules, and the end of enhanced ACA premium subsidies will drive an estimated 14 million people to lose coverage by 2028, with approximately 6 million losing Medicaid alone. The piece argues that Medicaid MCOs and dual-market plans must prepare for significant membership attrition, adverse risk selection as healthier members disenroll, and increased administrative complexity from new verification and redetermination processes. Provider-sponsored plans and those heavily reliant on Medicaid expansion populations face particularly acute financial and operational risk requiring data-driven retention strategies and product realignment.

The piece argues that health system CFOs need to evolve from viewing managed care as a transactional contracting function to treating it as a strategic enterprise lever that shapes broader organizational direction. It illustrates how strategic CFOs consider systemwide portfolio implications—like ambulatory strategy and site decisions—when negotiating payer contracts, rather than evaluating terms in isolation. The shift matters for Medicaid MCO professionals because it signals how provider partners are rethinking their approach to payer relationships and contract structures.

Manatt's 50-state survey finds that despite COVID-era expansions, state pharmacy laws still impose inconsistent restrictions on adult vaccine administration—including narrow vaccine lists, prescription requirements, and limits on technician authority. These variations can delay access when FDA approves new vaccines or CDC updates recommendations. The analysis recommends three policy reforms: broad vaccine authorization tied to FDA/CDC approval, eliminating prescription requirements for pharmacists, and extending administration authority to trained pharmacy technicians.

This white paper argues that state child welfare agencies should strategically realign funding by expanding Medicaid coverage for behavioral health and clinical services while reserving Title IV-E federal funds for safety and permanency supports that Medicaid cannot cover. The authors contend that better coordination between Medicaid and child welfare financing can reduce fragmentation, decrease reliance on congregate care settings, and stabilize state budgets as federal Title IV-E reimbursement declines. For Medicaid managed care leaders, this presents both an opportunity and a challenge: MCOs may see expanded behavioral health service obligations for foster and at-risk children while state agencies seek stronger cross-system data sharing and care coordination.

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.

Guidehouse argues that pharmaceutical key account management remains fundamentally a rebranded sales function rather than a true value-based engagement model, even as the customer base has shifted toward payers, government programs, and integrated delivery systems. The piece describes how pharma companies continue measuring account managers on traditional sales metrics while healthcare purchasers—including Medicaid programs and managed care organizations—now make formulary and utilization decisions based on population health value rather than individual prescriber relationships. For Medicaid MCOs, this signals ongoing misalignment between pharmaceutical commercial strategies and the outcomes-focused contracting models that managed care plans actually need.

New ONC data shows that while 68% of substance use and mental health treatment facilities have adopted electronic health records, only 20% participate in health information exchanges—a gap that directly affects Medicaid MCOs' ability to coordinate care for members with behavioral health needs. The exclusion of behavioral health providers from HITECH Act incentives continues to create care coordination challenges, particularly for complex Medicaid populations requiring integration across physical and behavioral health settings. State-operated facilities lag significantly behind federally-operated ones in EHR adoption, presenting varied challenges depending on a state's Medicaid delivery system structure.

Manatt Health outlines strategic approaches for states to deploy Rural Health Transformation Program funding—a five-year, $50 billion federal investment distributing roughly $1 billion per state—with emphasis on creating infrastructure that outlasts the program itself. The piece advocates for hub-and-spoke telehealth networks, workforce pipeline investments, and value-based payment models as mechanisms to address rural access gaps while generating sustainable Medicaid reimbursement. For Medicaid MCOs and state directors, this represents both a capital infusion into struggling rural networks and an opportunity to restructure how Medicaid beneficiaries access specialty and hospital care in underserved areas.

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.

A Manatt-supported health technology convening found that while AI reduces individual health plan costs for prior authorization and medical coding, it increases transaction volume system-wide and may drive up overall spending. Provider AI tools are inflating billing intensity, prompting plans to respond with blanket downcoding and reimbursement cuts, though their effectiveness remains unclear. The analysis suggests reimbursement policy changes offer stronger levers for administrative efficiency than technology alone.

Health care investors are showing renewed interest in home- and community-based services as a strategy to reduce costs for high-complexity Medicaid populations, particularly those requiring long-term services and supports. The investor focus reflects both emerging regulatory clarity and a shift toward care models that can demonstrate near-term return on investment rather than long-horizon value-based arrangements. While the piece addresses broader health care investment trends, it identifies Medicaid LTSS as a specific area where institutional capital sees opportunity to bend the cost curve.

Milliman's analysis of 2026 Medicare Advantage data reveals that D-SNP enrollment growth remains minimal outside of states transitioning Medicare-Medicaid Plans, while plans increasingly use C-SNPs to enroll dual eligibles and sidestep state Medicaid agency contracting requirements. The trend reflects MAO responses to tightening CMS integration requirements and state policies limiting D-SNP availability, with implications for how dual eligibles access coordinated Medicare-Medicaid benefits. The shift raises questions for state Medicaid agencies about care coordination oversight and whether dual eligibles in C-SNPs receive comparable integration as those in contracted D-SNPs.

The $50 billion Rural Health Transformation Program is moving from federal framework to state-level implementation, with significant state flexibility in designing models across five strategic areas including workforce, access, and digital capabilities. While the program targets rural providers broadly, states' implementation choices will affect Medicaid managed care operations in rural markets, particularly around network adequacy, alternative payment models, and care delivery innovation. Providers are advised to align early with state priorities and begin operational planning as program details crystallize.

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.

Milliman examines how state Medicaid agencies and managed care plans can leverage HHS's newly released open-source dataset of provider-level Medicaid spending from 2018-2024, which includes service-level payments across both fee-for-service and managed care. The analysis identifies four strategic applications including contract negotiation support, fraud detection, network adequacy planning, and benchmarking—while noting data limitations and interpretation challenges MCOs should consider when using national aggregated claims data for operational decisions.

A new California Health Care Foundation report co-authored by Manatt reveals that approximately half of county behavioral health, public health, and social services agencies have minimal or no electronic data exchange with healthcare partners, with 71% of behavioral health agencies unable to receive hospital alerts for mental health emergencies. The research identifies four priority areas—technology standards, workforce, financing, and policy guidance—to address fragmentation that particularly affects Medicaid enrollees with complex needs. These findings are directly relevant to California Medicaid managed care plans that contract with counties for behavioral health services and must coordinate care across siloed systems.