CMS is overhauling kidney care through transplant system modernization, new organ procurement standards, and the mandatory IOTA Model launched in mid-2025, while simultaneously sunsetting underperforming value-based care models like ESRD Treatment Choices. The piece examines how federal payment reforms, emerging xenotransplant technology, and refined Kidney Care Choices models are reshaping the dialysis and transplant ecosystem. While primarily Medicare-focused, these structural changes affect Medicaid managed care plans covering dual-eligible populations and states with integrated care models for members with end-stage renal disease.

Manatt Health and two Telehealth Centers of Excellence examine how artificial intelligence can streamline provider-to-provider electronic consultations in Medicaid and CHIP, which became reimbursable in 2023 but face adoption barriers from workflow burden and billing constraints. The analysis argues AI integration could reduce administrative friction, expand specialty access in underserved areas, and help Medicaid managed care organizations scale asynchronous specialty consultation programs more effectively. This is part of a four-brief series exploring AI applications across telehealth use cases relevant to payer and provider strategy.

This piece outlines six implementation requirements for hospitals entering global budget arrangements, which shift traditional insurance risk from health plans to provider systems. While focused primarily on Medicare models like CMS's AHEAD program and state all-payer demonstrations, the shift affects how Medicaid managed care organizations structure provider contracts and share risk. MCO compliance and finance teams should understand these models as they increasingly appear in Medicaid alongside Medicare and commercial payers.

Manatt outlines operational and compliance considerations for state Medicaid agencies as they design consumer notices for new federal work reporting requirements under H.R. 1. The piece emphasizes that poorly designed notices have historically contributed to inappropriate coverage loss and increased administrative burden, and urges states to invest in plain-language, user-tested communications before rolling out new outreach and non-compliance notices. For MCOs partnering with states on eligibility operations or member communications, this guidance offers practical design principles to support continuity of coverage.

The 2026 CMS Quality Conference outlined major policy directions affecting both Medicare and Medicaid managed care, emphasizing prevention-focused models, technology-enabled whole-person care, real-time quality measurement, and AI integration. CMS leadership signaled that quality strategies will increasingly prioritize upstream preventive interventions and align payment incentives with clinical outcomes, requiring health plans to demonstrate how their programs contribute to prevention and reduce downstream utilization. These emerging federal priorities will shape how Medicaid MCOs structure their quality improvement programs, demonstrate value, and respond to evolving state contract requirements.

Milliman explains why state savings from Medicaid enrollment reductions are often overstated in managed care environments. When lower-cost members disenroll—such as through work requirements—average capitation rates rise because the remaining enrolled population becomes sicker and more expensive, meaning states don't save the full per-member capitation amount. The firm provides an interactive modeling tool to help states understand the complex fiscal dynamics of eligibility changes, including federal match implications, MCO tax structures, and administrative costs.

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.

CMS released detailed guidance outlining over 20 strategies for state Medicaid and CHIP agencies to strengthen child and youth behavioral health systems under EPSDT requirements, which mandate all medically necessary services for children under 21. The toolkit covers delivery system development, provider network adequacy, care coordination, and equity improvements, with concrete state examples of implementing services like coordinated specialty care and wraparound programs. For MCOs, this signals heightened federal expectations around pediatric behavioral health coverage, network capacity, and utilization management practices that comply with EPSDT's broad entitlement standards.

CMS's 10-year ACO LEAD demonstration will test Medicare-Medicaid integration in two states—one using managed care, one fee-for-service—with enhanced payment models designed to support complex, high-need dual-eligible populations. Milliman's analysis outlines participation scenarios and strategic considerations for state Medicaid agencies, managed care plans, ACOs, and providers as they evaluate partnership opportunities under the new model. The piece examines how different stakeholder approaches could shape member outcomes, financial performance, and care coordination for dually eligible beneficiaries.

Federal oversight of state Medicaid program integrity is intensifying, with CMS now investigating New York's claiming patterns and spending levels following similar inquiries in Minnesota, California, and Maine. Minnesota has filed suit challenging CMS's decision to defer $260 million in federal payments for already-reimbursed services, marking the first legal challenge to the agency's expanded enforcement efforts. The piece outlines CMS's two enforcement mechanisms—payment deferrals without prior hearings and prospective withholding requiring hearings—giving MCOs and state officials insight into how federal program integrity actions may affect cash flow and compliance expectations.

Medicaid programs are increasingly moving away from bundled payment methodologies for cell and gene therapies in order to separately identify these drugs and collect manufacturer rebates under the Medicaid Drug Rebate Program. This shift provides more predictable reimbursement for providers but increases rebate exposure for manufacturers. The piece also explores the expansion of CAR-T administration into community outpatient settings and implications for access and reimbursement across payer types.

This white paper examines how state Medicaid agencies can strengthen their oversight of MCOs through improved performance management systems, particularly in light of the 2024 CMS final rule requiring quality rating systems by 2028. The analysis outlines common challenges states face in monitoring managed care programs and proposes strategies for using data and performance measures more effectively to drive improvements in access, quality, and equity. The piece is directly aimed at helping state Medicaid directors and MCO oversight teams adapt to heightened federal accountability requirements while building stronger partnerships with health plans.

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.

Avalere examines how state Medicaid programs are responding to budget pressure from the One Big Beautiful Bill Act, new provider tax restrictions, and rising utilization. States are adjusting managed care rates, benefits packages, and procurement timelines to navigate tighter fiscal conditions while managing administrative constraints. The analysis outlines decision-making factors that will shape state actions affecting MCO contracts and payment structures in the current budget cycle.

The new Rural Health Transformation Program is distributing $50 billion to states over five years to strengthen rural healthcare through cooperative agreements. States are now transitioning from planning to implementation, with CMS finalizing agreements and establishing spending timelines that require budget period funds to be used within roughly 18 months. While the program addresses broad rural health priorities including technology, behavioral health, and value-based care, its structure and state-level implementation may intersect with Medicaid managed care operations in rural markets.

States implementing new Medicaid work requirements must identify medically frail enrollees exempt from these rules, but traditional claims data in MMIS systems lag behind real-time clinical information—creating coverage continuity risks. This analysis explores how health information exchanges can supplement state data systems with more current diagnostic and utilization information to support timely ex parte exemption determinations. The approach is particularly critical for managed care plans where encounter data reporting delays compound identification challenges.

The federal Rural Health Transformation Program allocates $50 billion over five years through state cooperative agreements to strengthen rural healthcare delivery, with significant implications for how FQHCs serve Medicaid beneficiaries in underserved areas. While funding flows through states rather than directly to providers, the program's focus on access expansion, workforce retention, and care model innovation could reshape FQHC participation in Medicaid managed care networks and delivery system reform. States are designing tailored rural health transformation plans that will determine how safety-net providers integrate behavioral health, dental, and other services for Medicaid populations.

Gene therapies for rare diseases create structural tension between one-time treatments with multi-decade outcomes and payer systems built on annual budgets and short-term evidence cycles. With 26 FDA-approved gene therapies now in use and more coming, the piece argues healthcare delivery infrastructure and financing models—not just clinical science—will determine patient access and long-term sustainability. For Medicaid MCOs, this raises questions about payment structures, coverage decisions, and evidence generation obligations for high-cost, one-time interventions.

A federal court approved a class action settlement requiring New York to overhaul how it delivers intensive home- and community-based mental health services to Medicaid-enrolled children and youth, joining at least ten other states subject to similar consent decrees since the 2006 Rosie D. case. The settlement stems from allegations that New York failed to meet its EPSDT obligations, ADA requirements, and Section 504 compliance, resulting in unnecessary institutionalization of youth with behavioral health needs. For Medicaid managed care plans, this settlement will likely require significant operational changes to expand intensive home- and community-based service capacity, strengthen care coordination for high-need youth, and ensure compliance with EPSDT's broader amelioration standard compared to commercial coverage.

Life sciences companies seeking to understand Medicaid managed care purchasing behavior need to grasp how risk adjustment models translate member acuity into plan payments and profitability. The piece explains that Medicaid capitation rates are risk-adjusted based on enrollee health conditions and demographics, directly affecting plan revenue and financial performance. Because risk scores influence plan margins, they also shape formulary design and coverage decisions—meaning pharmaceutical manufacturers must account for how their products affect plan risk profiles and reimbursement.