CMS announced heightened financial scrutiny of state Medicaid programs' emergency coverage for undocumented immigrants and other noncitizens, citing concerns that some states have exceeded permissible services under the emergency benefit exception. The agency plans focused expenditure reviews and financial management audits, while urging states to audit their policies, cost allocation plans, and IT systems to ensure compliance with immigration-based eligibility restrictions. This shift creates new compliance and financial risk for MCOs serving this population and may trigger changes in covered services and payment models.

The House-passed reconciliation bill includes sweeping Medicaid changes that would cut funding for ACA expansion populations, restrict state financing mechanisms, impose new administrative requirements on states and beneficiaries, and add coverage prohibitions for certain providers and populations. CBO estimates at least 8.6 million people would lose coverage by 2034 from Medicaid provisions alone, with additional losses expected from Marketplace changes. The legislation now moves to the Senate, where modifications are expected before a targeted July 4 vote.

The FDA has announced a new approval framework restricting routine COVID-19 booster recommendations to adults over 65 and individuals with risk factors, while requiring large clinical trials for approval in healthy populations. HHS Secretary Kennedy subsequently announced CDC will no longer recommend COVID vaccines for healthy children and pregnant women, though CDC's formal guidance allows vaccines for healthy children through shared decision-making and does not explicitly exclude pregnant women. These policy shifts create uncertainty for Medicaid managed care organizations around coverage obligations, particularly for CHIP enrollees and pregnant beneficiaries who represent mandatory coverage populations under federal Medicaid law.

Manatt Health's state-by-state modeling of the House Budget Bill estimates that provisions including work requirements for expansion adults, more frequent renewals, repeal of streamlined enrollment rules, and limits on state directed payments would reduce Medicaid enrollment by 8.7 million people annually and cut total program expenditures by at least $1.3 trillion over ten years. The analysis shows coverage losses would extend beyond expansion populations to seniors, people with disabilities, and children, with combined federal and state funding reductions significantly exceeding CBO's federal-only estimates—critical intelligence for MCO executives planning network adequacy and state Medicaid directors projecting budget impacts.

Sellers Dorsey has released a comprehensive playbook guiding states, managed care organizations, and vendors through the design and implementation of Medicaid work and community engagement requirements. Drawing on insights from former state Medicaid directors, the framework addresses operational considerations, compliance strategies, and lessons from previous work requirement initiatives. This resource is directly relevant to MCO compliance teams and state officials preparing for potential federal policy shifts around beneficiary eligibility conditions.

Sellers Dorsey has released an interactive map providing child welfare agency leadership contacts, program structures, and resources across all states to help managed care organizations and providers identify partnership opportunities. The tool is designed to streamline business development and collaboration efforts for MCOs seeking to work with child welfare systems, including potential pilot programs and subcontracting arrangements. This resource addresses a common challenge for Medicaid MCOs navigating the complex landscape of state child welfare agencies, particularly as more states integrate health and welfare services.

This report compiles governor-proposed budgets for fiscal year 2026 with focused attention on Medicaid spending plans across states. The compilation provides state-by-state intelligence on how Medicaid programs are being funded and prioritized in the upcoming budget cycle, along with related spending on social determinants like housing and workforce development. For MCO executives and state Medicaid directors, this offers strategic insight into upcoming rate-setting cycles, program expansions or contractions, and budget pressures that will shape contract negotiations and program design.

Avalere's national and state-level modeling quantifies the economic burden of opioid use disorder at nearly $1 trillion annually, with state and local government costs ranging from $137 to $524 per capita depending on geography. The analysis demonstrates that medication-assisted treatments—including methadone, buprenorphine formulations, and behavioral therapy—generate significant per-case cost savings, a finding directly relevant to Medicaid MCO benefit design, utilization management policies, and state pharmacy carve-in/carve-out decisions. With Medicaid covering a disproportionate share of individuals with substance use disorders, these cost-offset calculations inform managed care contracting, quality incentives, and state budget planning.

CMS has issued a proposed rule that would prohibit states from imposing higher provider tax rates on Medicaid managed care services compared to commercial services, addressing concerns that current tax structures undermine redistributive goals. The rule would require states seeking waivers from broad-based or uniform tax requirements to meet both existing statistical tests and new redistributive standards that prevent targeting Medicaid revenue. This proposal directly impacts state Medicaid financing strategies and MCO tax obligations, with transition periods for existing waiver arrangements.

Avalere analyzed pharmacy claims across payer types including Managed Medicaid to assess on-label and off-label use of GLP-1 and GIP/GLP-1 receptor agonists for diabetes and weight management. The piece examines product differentiation strategies for manufacturers and notes that USP Drug Classification limitations affect coverage decisions in non-Part D plans. While focused primarily on manufacturer strategy and market dynamics, the analysis incorporates Medicaid managed care data and touches on formulary implications relevant to MCO pharmacy benefit management.

Sellers Dorsey compiles state-specific impact analyses from nine states examining how potential federal Medicaid funding cuts could affect healthcare systems, coverage, and state economies. The resource aggregates recent state reports and links to supplementary analysis from KFF on enrollment and Commonwealth Fund on related SNAP funding impacts. This compilation serves as a centralized reference for managed care organizations and state officials navigating potential federal policy changes and their fiscal consequences.

This policy tracker monitors five significant federal Medicaid reform proposals currently under consideration: limitations on provider taxes, restrictions on state-directed payments, per capita cap proposals, FMAP reductions, and work requirement expansions. Each represents a potential structural change to Medicaid financing or coverage that would directly affect how states fund programs and how MCOs operate, with implications for rate-setting, provider networks, enrollment, and revenue streams.

This piece outlines practical strategies for aligning Medicaid managed care operations with state child welfare systems to serve foster children more effectively. It advocates for integrated care models using Section 1115 waivers, specialized care coordination roles, cross-agency data sharing agreements, and MCO contracting requirements that address the unique needs of children in foster care. The recommendations are directly actionable for state Medicaid directors and MCO executives managing populations with complex behavioral health and coordination needs.

Manatt Health released detailed national and state-level estimates showing how Congressional reconciliation proposals targeting at least $880 billion in federal Medicaid savings would affect children's coverage, access to care, and state budgets. The analysis emphasizes that while not explicitly targeting children, the scale of proposed cuts makes it impossible for states to shield pediatric populations—including the two in five children nationwide who rely on Medicaid—from coverage losses and service reductions. The modeling provides MCOs and state Medicaid directors with quantitative projections to assess potential enrollment changes and program restructuring needs under different federal funding scenarios.

Manatt Health and MUSC outline how telehealth modalities like virtual nursing and eConsults, combined with AI-enabled automation, could extend workforce capacity amid severe provider shortages projected to worsen through 2037. The analysis identifies barriers to telehealth scale including limited reimbursement and insufficient evidence, challenges directly relevant to MCO network adequacy and access strategies. While not Medicaid-specific, the workforce crisis disproportionately affects Medicaid populations and the solutions discussed have clear implications for managed care operations and state policy decisions around telehealth coverage.

Milliman analyzed non-emergency medical transportation programs across seven state Medicaid clients, comparing delivery models and per-member-per-month costs as the NEMT market grows toward a projected $15.58 billion by 2028. The analysis examines how states exercise discretion in administering this federally required benefit, which serves 4-5% of Medicaid enrollees annually, and develops hypotheses for improving oversight and cost management. The findings are directly relevant to MCO finance teams and state Medicaid directors responsible for NEMT benefit design and vendor management.

Manatt Health presents a methodology for calculating the total value employed primary care practices generate for health systems through downstream revenue, reduced network leakage, quality bonuses, and acute care cost avoidance—even when practices show operating losses of $249,000 per physician. The analysis includes an illustrative case study of a 40-physician practice with 100,000 paneled lives including 15,000 Medicare Advantage members, demonstrating how primary care investment supports value-based care models. While the framework touches Medicaid managed care indirectly through its focus on Medicare Advantage and general managed care principles, the piece does not substantively address Medicaid-specific policy, MCO operations, or state program considerations.

Avalere modeling of three Congressional funding reform scenarios—per capita caps, expansion FMAP reductions, and removal of the 50% FMAP floor—projects total federal Medicaid cuts of $436-779 billion over ten years, with children's services losing between $57-114 billion. The analysis breaks down state-by-state impacts across different reform approaches, showing per capita caps would affect all states uniformly while FMAP changes would create highly variable impacts depending on expansion status. These projections provide MCOs and state Medicaid directors critical baseline data for understanding how federal funding restructuring could affect managed care capitation rates and children's service adequacy.

With Congress seeking Medicaid savings through budget reconciliation, mandatory work requirements across states are gaining momentum as a cost-cutting measure. The analysis reviews how past state implementations in Arkansas and Georgia led to coverage loss and administrative complexity, with key design variables including which populations face requirements, exemption processes, and reporting burdens. For MCOs, renewed work requirements would require significant changes to eligibility verification systems, member outreach, and retention strategies while potentially shrinking enrollment.

This panel discussion examines the role managed care organizations can play in improving outcomes for children involved in the child welfare system, a population predominantly covered by Medicaid. The webinar explores strategies for MCOs to better coordinate care and address the complex health needs of this vulnerable population. Given the high Medicaid enrollment among foster children and families involved with child welfare services, this content directly addresses managed care plans' responsibilities for a key member population.