SAMHSA's designation of January as National SUD Treatment Month underscores ongoing challenges in substance use disorder treatment access and quality that directly affect Medicaid managed care plans. Despite evidence-based treatment guidelines and locator tools, significant treatment gaps persist, particularly for medication-assisted treatment for opioid and alcohol use disorders—conditions disproportionately affecting Medicaid populations. The commentary frames systemic barriers including inadequate provider networks and treatment system features that MCO compliance teams and behavioral health directors must address to improve recovery outcomes.

CMS Innovation Center has launched seven new alternative payment models focused primarily on Medicare beneficiaries, with three chronic care management models (ACCESS, MAHA-ELEVATE, and LEAD) explicitly offering opportunities for multi-payer integration including Medicaid. Four additional models target drug pricing with one (GENEROUS) specifically aimed at Medicaid, while the existing Integrated Behavioral Health model may expand to additional states. The models align with the administration's prevention-focused MAHA agenda but lack critical implementation details including payment structures.

This discussion examines how Medicaid managed care organizations can better coordinate with child welfare, behavioral health, and other family-serving systems to improve outcomes for children and families—Medicaid's largest user population. The conversation addresses common barriers like agency silos, policy volatility, and capacity constraints that prevent effective cross-system collaboration. For MCO compliance teams and state Medicaid directors, this speaks to growing expectations around care coordination and whole-family approaches in managed care contracting and operations.

Sellers Dorsey provides a state-by-state breakdown of how the new $50 billion Rural Health Transformation Program allocated first-year funding to stabilize rural health systems and expand care access. While the program addresses rural provider infrastructure broadly, it has implications for Medicaid managed care networks that depend on rural providers for network adequacy and member access. The analysis offers state-specific details relevant to MCOs operating in rural service areas or managing provider relationships in underserved regions.

The reconstituted Advisory Committee on Immunization Practices made changes to pediatric immunization schedules in December 2025 and signaled potential 2026 policy shifts affecting vaccines for HPV, RSV, influenza, and pregnancy-related immunizations. Because ACIP recommendations trigger mandatory Medicaid coverage without cost-sharing when published in official immunization schedules, these deliberations—and the committee's altered composition and process—carry direct implications for MCO benefit design, preventive care obligations, and pediatric and maternal health programs. The exclusion of traditional medical society liaisons from work groups may affect the clinical grounding of future recommendations that Medicaid plans must operationalize.

The 340B drug discount program reached $81.4 billion in 2024, with disproportionate share hospitals accounting for 78% of purchases. Many DSH hospitals also participate in Medicaid managed care, and pending federal reforms—including the 340B Rebate Model pilot and congressional bills—could reshape how these entities finance care for Medicaid beneficiaries. The program now exceeds Medicaid drug spending, making potential policy changes significant for state programs and MCOs contracting with 340B-eligible providers.

Major changes to the Advisory Committee on Immunization Practices—including replacement of all members and elimination of expert working groups—may affect Medicaid coverage requirements, since ACIP recommendations trigger mandatory coverage under federal law and determine which vaccines qualify for the Vaccines for Children program. The white paper examines how these structural changes could disrupt the evidence-based processes that underpin Medicaid immunization benefits and patient access protections.

Ten states have implemented and sixteen are considering the Family CNA model, which trains and reimburses family members to provide home care for medically complex children that would otherwise require RN, LPN, or non-family CNA services. Most states implement through mandatory home health or optional private duty nursing state plan benefits, though some use 1915(c) waivers or could use 1115 demonstrations. Oklahoma estimates the model could generate significant annual cost savings while expanding access to care for children with medical complexity.

Sellers Dorsey's CEO argues that recent federal policy changes, including H.R.1, are forcing Medicaid programs to move away from one-size-fits-all models toward community-tailored strategies backed by stronger data analytics and accountability measures. The commentary positions 2025 as an inflection point requiring states and MCOs to demonstrate measurable value, modernize operations, and use technology to target interventions more precisely across diverse populations and geographies.

Manatt Health analyzes the new GENEROUS Model announced by CMS, comparing its pricing metrics to previously used most-favored-nation (MFN) approaches and outlining key design elements and timeline. The piece examines participation opportunities and risks for both pharmaceutical manufacturers and state Medicaid programs, addressing outstanding design questions that affect drug pricing and reimbursement in Medicaid managed care.

CMS achieved an average 62% discount off list prices for 15 drugs in the second cohort of Medicare drug price negotiations, representing a 28% reduction below statutory ceiling prices—nearly double the discount margin achieved in year one. While the negotiation program is Medicare-focused, the outcomes have implications for Medicaid managed care organizations through potential manufacturer price adjustments, best price calculations, and rebate dynamics that could affect MCO pharmacy budgets and formulary strategies. The deeper discounts may also influence cross-program pricing pressure and state supplemental rebate negotiations.

Eight states have established Prescription Drug Affordability Review Boards (PDABs) to control drug costs, with four states (CO, MD, MN, WA) authorized to set Upper Price Limits that typically apply to both Medicaid and state-regulated commercial plans. Colorado became the first state to implement a UPL in October 2025, setting a $600 per-unit cap on Enbrel aligned with federal negotiated pricing. For Medicaid managed care plans operating in these states, PDABs represent a new layer of price regulation affecting pharmacy benefits and potentially reimbursement structures for approximately 7.8 million covered lives.

CMS's Rural Health Transformation (RHT) Program is directing significant federal funding to states to improve rural healthcare infrastructure, workforce, and services, with Medicaid agencies expected to play a coordinating role. States must design comprehensive rural health initiatives with clear accountability measures, as demonstrated by New Mexico's $1 billion application and Tennessee's $197 million in awarded funding. While the program extends beyond Medicaid to include broader rural health system support, state Medicaid directors will likely be involved in planning and implementation given their role in rural coverage and provider networks.

Sellers Dorsey experts discuss how states are leveraging Medicaid waivers to customize programs and test innovative approaches for child and family well-being, including mobile crisis response, school-based behavioral health services, and home-based family support. The conversation focuses on waiver design and implementation as tools for states to secure federal funding for services that address gaps in traditional Medicaid coverage. This is directly relevant for MCO compliance teams and state Medicaid officials navigating waiver strategies and service expansion requirements.

Milliman's second installment in a risk adjustment series argues that effective risk adjustment depends on coordinated organizational infrastructure—not just coding accuracy—spanning governance, staffing, provider engagement, data systems, and compliance functions. The paper provides operational benchmarks and leading practices applicable across Medicare Advantage, Medicaid, and ACA plans, with direct implications for how Medicaid managed care organizations structure teams, oversee vendors, and integrate risk adjustment into care management and revenue integrity workflows.

Nineteen states have received federal approval to implement Medicaid reentry demonstrations that provide pre-release services and care coordination for incarcerated individuals transitioning back to communities. States are building new eligibility workflows, clinical service delivery systems, and data-sharing protocols across diverse correctional facilities, with early implementers like California, Montana, and Washington already serving populations. Despite fiscal pressures and new federal requirements under H.R. 1, states continue prioritizing these initiatives as critical to health outcomes for justice-involved populations.

CMS has introduced the ACCESS Model, a voluntary ten-year demonstration for Medicare Part B providers to receive outcome-based payments for technology-supported chronic condition management starting July 2026. While the model is Medicare-focused, it establishes payment and care delivery precedents that could influence how Medicaid managed care organizations approach chronic care management, value-based arrangements, and technology integration. Health tech companies will need to partner with enrolled Medicare providers or enroll directly to participate in the payment model.

Sellers Dorsey reviews state applications to the newly established Rural Health Transformation Program, a $50 billion federal initiative to modernize rural healthcare delivery under H.R.1. While not Medicaid-specific, the program has clear implications for Medicaid managed care organizations operating in rural areas, as many beneficiaries in these regions rely on Medicaid coverage and states may coordinate RHTP funds with Medicaid delivery system investments.

Milliman's white paper provides guidance on optimizing risk adjustment operations across public programs including Medicaid managed care, focusing on how accurate documentation and coding ensure plans receive appropriate capitated payments that reflect member health status. The piece addresses how health plans can align risk adjustment processes with financial performance, emphasizing that risk scores directly influence revenue in capitated payment models. While it covers multiple programs, the operational and financial implications are directly relevant to Medicaid MCO compliance and finance teams managing risk-based payments.

Sellers Dorsey's issue brief examines how Medicaid has developed from its inception through major policy milestones including HCBS waivers, the Olmstead decision, and managed LTSS models to become the primary coverage source for 35% of Americans with disabilities. The analysis covers both historical innovations in person-centered care and self-direction as well as ongoing operational challenges like workforce shortages that affect service delivery. For MCO executives and state Medicaid leaders, the piece provides context on how disability policy and LTSS have become central to managed care obligations and program design.