Sellers Dorsey outlines a multi-step assessment process to determine whether hospitals are organizationally and financially prepared to enter risk-based arrangements with payers, including Medicaid managed care organizations. The framework begins with evaluating existing managed care contracts and operational structures to optimize hospital sustainability while maintaining care quality. While the piece addresses both Medicare and Medicaid populations, its focus on payer contracting and managed care operations has direct application for hospitals negotiating with Medicaid MCOs.

Children adopted from foster care face significantly elevated rates of chronic physical conditions and mental health challenges, with up to 80% experiencing significant behavioral health issues compared to 18-22% of the general population. The piece emphasizes that these children maintain Medicaid eligibility post-adoption and rely on comprehensive, trauma-informed Medicaid services to address complex medical and behavioral health needs. While focused on adoption awareness, it underscores the critical role of Medicaid managed care in serving this high-acuity pediatric population.

The Trump administration is encouraging manufacturers to launch direct-to-consumer drug purchasing platforms that bypass traditional pharmacy benefit structures, with 10 manufacturers now offering such programs. While these cash-pay and potentially insurance-integrated platforms promise price transparency and patient choice, they create uncertainty for Medicaid MCOs around claims tracking, formulary management, adherence monitoring, and Stars performance measurement. The piece explores manufacturer design considerations but does not substantively address Medicaid-specific implications.

This white paper examines how state Medicaid agencies can strengthen enforcement of mental health parity requirements for managed care entities, even as federal priorities shift following the 2025 suspension of certain commercial market rules. The analysis walks through the three types of treatment limitations under MHPAEA—financial requirements, quantitative limits, and nonquantitative treatment limitations—and emphasizes that existing Medicaid parity obligations remain in effect regardless of federal enforcement changes. For MCO compliance teams and state Medicaid directors, this offers a roadmap for improving oversight of behavioral health access in managed care programs, which collectively represent the largest payer for mental health and substance use disorder services.

HRSA is launching a pilot program in January 2026 that fundamentally changes how the 340B drug pricing program works—moving from upfront discounts to a rebate model for 10 high-cost drugs subject to Medicare price negotiation. This shift has direct implications for state Medicaid programs and their managed care plans, particularly around duplicate discount prevention, claims processing, pharmacy reimbursement, and financial reconciliation processes that have been built around the traditional 340B discount structure for over 30 years. States need to assess operational readiness now to handle the accounting and reporting changes this model introduces.

A 50-state review finds persistent disparities in how Medicaid reimburses physician offices, pharmacies, and FQHCs for adult vaccines, with physician offices typically paid less than Medicare rates and pharmacies receiving low administration fees. While some states have modestly increased non-COVID vaccine administration rates and expanded pharmacy billing permissions, new federal fiscal constraints and potential ACIP recommendation changes may further pressure state vaccine access policies. These reimbursement structures directly affect managed care contracting strategies and network adequacy for preventive services.

This analysis examines the evolution of care delivery for dual-eligible beneficiaries who require coordination between Medicare and Medicaid, particularly for long-term services and supports that Medicare excludes. The piece traces how integrated care models including D-SNPs and PACE programs have emerged as essential tools for managing this complex, high-need population. For Medicaid MCOs and state directors, understanding dual-eligible integration is critical given these beneficiaries' disproportionate cost and care coordination challenges.

The obesity treatment landscape is rapidly expanding beyond GLP-1s with next-generation combination therapies and new label indications extending into cardiovascular disease, sleep apnea, and potentially inflammatory conditions. This evolution—driven by cultural destigmatization, FDA approvals positioning obesity drugs as disease-modifying therapies, and a pipeline projected to reach $95 billion by 2030—will intensify utilization management and formulary challenges for Medicaid managed care plans. While the piece focuses broadly on market dynamics rather than Medicaid policy specifically, the coverage and access implications for state programs and MCOs are substantial given current variability in state Medicaid obesity drug coverage and budget pressures.

Sellers Dorsey released a comprehensive guide examining how states can better leverage and coordinate federal funding sources—including Medicaid—to support child welfare and family well-being programs. The playbook addresses challenges in blending multiple funding streams and identifies opportunities for enhanced coordination. This is relevant to Medicaid MCOs increasingly serving foster care populations and managing behavioral health services for children involved in welfare systems.

CMS has reversed its longstanding interpretation of how Medicaid managed care organizations should handle payments for emergency services provided to undocumented immigrants, issuing new guidance that affects MCO capitation arrangements and emergency service reimbursement protocols. The policy shift carries significant operational and financial implications for how states structure their managed care contracts and how MCOs process and pay claims for this population. Sellers Dorsey's analysis examines CMS's legal reasoning for the change and outlines the compliance options available to state Medicaid agencies and their contracted health plans.

Manatt Health uses National Recovery Month as a framework to outline evidence-based recovery principles that should guide Medicaid policies addressing substance use disorders and mental illness. The piece emphasizes SAMHSA's four recovery dimensions—health, home, purpose, and community—and presents recovery data showing that over 74% of adults who perceived alcohol or drug problems consider themselves in recovery or recovered. The analysis offers a public health roadmap relevant to Medicaid MCOs designing behavioral health benefits and state agencies setting policy standards for recovery-oriented care.

Avalere outlines major federal health policy developments expected through the end of 2025, including Medicare Part D formulary changes, drug pricing negotiations, and ongoing PBM scrutiny under the Trump administration. While focused primarily on Medicare, the piece touches on broader regulatory trends around drug pricing and benefit management that affect Medicaid managed care operations and state policy planning. The analysis provides context for understanding how federal pharmaceutical policy changes may influence Medicaid managed care contracting and formulary strategies.

Sellers Dorsey leaders discuss the role of care coordinators in helping children and families with child welfare involvement navigate complex healthcare systems. The conversation focuses on care coordination as a critical function for serving vulnerable pediatric populations with complex needs, a growing priority area for Medicaid MCOs serving children and families. This addresses operational and clinical coordination challenges relevant to plans managing maternal and child health populations under Medicaid.

Federal legislation enacted in July 2025 introduces mandatory work requirements, accelerated eligibility redeterminations, and immigration status restrictions expected to affect 7.8 million Medicaid enrollees by 2034. The law also restricts states' use of provider taxes to finance their Medicaid programs, forcing significant changes to state funding strategies and managed care operations. MCOs will face new compliance obligations around work requirement verification, more frequent eligibility reviews, and dual market impacts as disenrolled members shift to exchange coverage.

Avalere examines how federal policy changes—including OBBBA Medicaid cuts, Medicare Part D redesign, and MFN pricing—are forcing pharmaceutical manufacturers to recalibrate market access strategies based on shifting payer mix across therapeutic areas. The analysis suggests Medicaid enrollment declines could push patients into commercial or uninsured coverage, affecting manufacturer uptake dynamics and requiring MCOs and state Medicaid programs to actively engage manufacturers to maintain therapeutic area prioritization. Manufacturers may need to redesign patient support programs and channel strategies as Medicaid's share of coverage for certain drugs contracts.

Avalere analyzes emerging state and federal legislation that would restrict or ban PBM ownership of pharmacies, following Arkansas's pioneering but contested prohibition. For Medicaid MCOs—which contract with PBMs for pharmacy benefits and must ensure adequate network access—these reforms could force restructuring of pharmacy relationships, potentially affecting network adequacy, pharmacy reimbursement models, and the vertical integration strategies that many health plans have pursued to control pharmacy costs.

CMS has released the application notice for its Rural Health Transformation Program, a $50 billion initiative designed to help state governments improve healthcare access and outcomes in rural communities. While the program is state-administered and addresses healthcare infrastructure broadly, Medicaid managed care organizations with rural service areas may find relevant opportunities given states' typical reliance on Medicaid financing for rural safety net providers and potential integration with managed care delivery systems.

This analysis examines Medicaid's coverage of foster care youth—reaching 99% of this population—and identifies system fragmentation as a barrier to effective care delivery. The piece outlines federal policy frameworks connecting Medicaid to child welfare and highlights state opportunities to improve coordination between health plans and child welfare agencies. For MCO compliance teams and state directors, it offers a policy roadmap for addressing a high-needs population with complex behavioral health and care transition requirements.

Analysis of 2018-2022 Medicare Part D claims reveals growing pharmacy spending for beneficiaries in home and community-based settings, while nursing facility spending declined. This trend mirrors the broader shift in long-term services and supports delivery that Medicaid managed care organizations are navigating, particularly as states expand HCBS waivers and MCOs increasingly coordinate pharmacy benefits for dually eligible members receiving LTSS in non-institutional settings.

Kinship care—placement of children with relatives—affects nearly 1 in 11 children and offers better placement stability and behavioral health outcomes than other arrangements. Medicaid MCOs have an opportunity to support these caregivers, who face financial constraints and system navigation challenges, through tools like TCARE that identify caregiver needs and connect them to services. The discussion explores practical ways health plans can fill critical support gaps for kinship families.