HHS announced that 10 states—Alaska, Colorado, Hawaii, Louisiana, Maryland, Mississippi, Montana, North Dakota, Washington, and West Virginia—will join the Certified Community Behavioral Health Clinic (CCBHC) Medicaid Demonstration Program. The demonstration, operated jointly by CMS and SAMHSA, tests an alternative payment model for comprehensive community behavioral health services. CCBHCs provide a defined scope of crisis, mental health, and substance use disorder services under a prospective payment system. For participating states, managed care organizations will need to contract with CCBHCs and adjust payment methodologies to comply with the demonstration's requirements.
Why it matters for managed care
MCOs in these 10 states must prepare to integrate CCBHCs into their networks and implement prospective payment methodologies that differ from standard fee-for-service or capitated behavioral health reimbursement.
HHS announced that 10 states—Alaska, Colorado, Hawaii, Louisiana, Maryland, Mississippi, Montana, North Dakota, Washington, and West Virginia—will join the Certified Community Behavioral Health Clinic (CCBHC) Medicaid Demonstration Program. The demonstration program, jointly administered by CMS and SAMHSA, tests an alternative payment model for community-based behavioral health services. CCBHCs provide comprehensive mental health and substance use disorder services under enhanced Medicaid payment arrangements. This expansion increases access to integrated behavioral health care in participating states and affects how Medicaid managed care organizations contract for and reimburse behavioral health services in their networks.
Why it matters for managed care
Medicaid MCOs in these 10 states will need to adapt their behavioral health networks, contracting models, and payment arrangements to accommodate CCBHC providers operating under demonstration-specific reimbursement methodologies.
The number of uninsured children under age 6 increased 23% between 2022 and 2024, reaching the highest level in nearly a decade, compared to a 17% increase for school-aged children. The sharper rise among younger children coincides with Medicaid redeterminations that began after the end of the continuous enrollment provision in spring 2023. Young children face higher procedural disenrollment risk due to more frequent address changes and verification requirements. The data suggests gaps in ex parte renewal processes and family communication strategies that disproportionately affect families with infants, toddlers, and preschoolers.
Why it matters for managed care
MCOs must strengthen outreach and renewal assistance for members with young children, who face elevated procedural disenrollment risk and represent a population segment with high preventive care needs and quality measure stakes.
The number of uninsured children under age 6 increased 23% between 2022 and 2024, reaching the highest level in nearly a decade, compared to a 17% increase for school-aged children. The disproportionate rise among infants, toddlers, and preschoolers coincides with the end of Medicaid continuous enrollment protections that expired in spring 2023. Young children are particularly vulnerable to coverage gaps during redeterminations because families with infants and toddlers move more frequently and face higher procedural disenrollment rates. The trend reflects ongoing challenges in states' unwinding processes and parent awareness of eligibility rules for young children.
Why it matters for managed care
MCOs face enrollment volatility and higher costs when young children churn between coverage and emergency department use, and states may implement targeted redetermination processes or presumptive eligibility expansions that affect plan operations.
The Department of Health and Human Services announced an action plan targeting psychiatric overprescribing and promoting deprescribing when clinically appropriate. HHS Secretary Robert F. Kennedy, Jr. outlined the initiative at a mental health summit focused on overmedicalization. The announcement did not specify implementation timelines, enforcement mechanisms, or how the plan would apply to Medicaid managed care organizations. HHS has not released detailed guidance on prescribing standards, prior authorization changes, or utilization management requirements that would affect MCO behavioral health benefit administration.
Why it matters for managed care
Any federal directive to reduce psychiatric prescribing could require MCOs to revise utilization management protocols, prior authorization criteria, and pharmacy benefit designs for behavioral health drugs, though operational details remain unclear.
samhsa.gov →Behavioral Health · Pharmacy · Managed Care
A group of Democratic senators released a policy framework Wednesday to create a new Medicare home care benefit and expand Medicaid home- and community-based services. The proposal represents a significant shift in federal long-term care policy, potentially affecting how both Medicare and Medicaid fund home-based care. Details on implementation timelines, eligibility criteria, and financing mechanisms have not yet been specified. If enacted, the framework could reshape payment structures and access requirements for home health and HCBS providers serving dual-eligible and Medicaid-only populations.
Why it matters for managed care
Medicaid managed care organizations would need to prepare for expanded HCBS obligations, potential new dual-eligible coordination requirements, and shifts in state-federal financing if the proposal advances to legislation.
A group of Democratic senators released a policy framework Wednesday to create a new Medicare home care benefit and expand Medicaid home- and community-based services. The proposal represents a significant shift in federal long-term care policy. The framework aims to improve access to home-based care and stabilize payment structures for providers. Timing for legislative action remains unclear, but the proposal signals renewed congressional interest in expanding home care coverage under both Medicare and Medicaid.
Why it matters for managed care
Medicaid managed care organizations with LTSS responsibilities would see expanded HCBS obligations, potentially affecting network adequacy requirements, capitation rates, and care coordination models if the framework advances legislatively.
HHS Secretary Robert F. Kennedy, Jr. announced a new action plan aimed at curbing psychiatric overprescribing and promoting deprescribing when clinically appropriate. The announcement was made at a MAHA Institute summit focused on mental health and overmedicalization. The plan seeks to ensure psychiatric medications are prescribed appropriately across health care settings. Specific implementation timelines, enforcement mechanisms, and clinical guidelines have not yet been detailed.
Why it matters for managed care
Medicaid managed care organizations with behavioral health carve-ins or delegated pharmacy management will need to monitor for federal guidance on prescribing standards, utilization management criteria, and potential prior authorization or deprescribing protocols that could affect pharmacy costs and clinical workflows.
samhsa.gov →Behavioral Health · Pharmacy · Managed Care
The Centers for Disease Control and Prevention reported that the U.S. uninsurance rate remained stable in 2024 compared to the prior year. The data provides a baseline before anticipated coverage losses from federal healthcare spending cuts included in recent budget legislation. Medicaid managed care organizations may see enrollment declines if federal funding reductions lead to eligibility restrictions or benefit changes. The timing of any coverage losses will depend on how states implement budget cuts and whether Medicaid programs face disproportionate reductions.
Why it matters for managed care
Stable enrollment provides a pre-policy baseline for MCOs to measure potential membership and revenue impacts from federal spending cuts that may trigger state Medicaid program reductions.
The CDC reports the U.S. uninsurance rate remained flat in 2025 compared to 2024. However, coverage losses are projected to increase in coming years due to federal healthcare spending cuts included in the "Big Beautiful Bill." The legislation is expected to reduce Medicaid enrollment, which will affect managed care organizations' membership and revenue. Timing of coverage reductions depends on final bill provisions and state implementation.
Why it matters for managed care
Expected Medicaid spending cuts will reduce MCO enrollment and capitation revenue, requiring plans to adjust member acquisition strategies, network capacity, and financial forecasts.
Rep. Beth Van Duyne (R-Texas) introduced the Protecting Seniors and Stopping Fraudsters Act on Wednesday to increase Medicare oversight of home health and hospice services. The bill aims to crack down on fraudulent providers and enhance beneficiary protections in these sectors. The National Alliance for Care at Home has expressed support for the legislation. While the bill targets Medicare, Medicaid managed care organizations that contract with home health and hospice providers should monitor this legislation, as federal fraud enforcement standards often inform state oversight approaches and MCO network adequacy requirements.
Why it matters for managed care
Medicaid MCOs with home health or hospice networks may face heightened scrutiny if Medicare fraud enforcement standards are later applied to Medicaid programs or if states adopt similar provider vetting requirements.
Rep. Beth Van Duyne (R-Texas) introduced the Protecting Seniors and Stopping Fraudsters Act on Wednesday to increase Medicare oversight of home health and hospice services. The bill aims to crack down on fraudulent providers and enhance protections for seniors receiving home-based care. The National Alliance for Care at Home publicly supports the legislation. While focused on Medicare, the bill's fraud prevention framework could influence Medicaid managed care organizations that contract with home health and hospice providers for dual-eligible members and long-term services and supports.
Why it matters for managed care
Enhanced federal fraud controls for home health and hospice providers may lead to tighter credentialing standards and monitoring requirements that Medicaid MCOs will need to apply when contracting with these providers for LTSS and dual-eligible populations.
Federal regulators released a final rule Thursday governing how health plans and providers resolve payment disputes over out-of-network emergency and certain non-emergency services under the No Surprises Act. The rule refines the independent dispute resolution process that applies when plans and providers cannot agree on payment rates for surprise bills. Health plans criticized the rule for not doing enough to prevent providers from exploiting the arbitration system, while the rule's proponents say it balances provider and plan interests. The changes take effect upon publication in the Federal Register.
Why it matters for managed care
Medicaid managed care organizations contracting with commercial providers or operating dual-eligible plans need to understand how federal surprise billing arbitration rules affect their network adequacy strategies, rate negotiations, and member cost-sharing obligations when out-of-network care occurs.
The Substance Abuse and Mental Health Services Administration awarded $255 million to Vibrant Emotional Health to continue administering the 988 Suicide & Crisis Lifeline. The contract supports a national network of over 200 local crisis contact centers that have handled more than 25 million contacts since the lifeline's launch. The funding sustains federal infrastructure for crisis response services that increasingly intersect with Medicaid-funded behavioral health benefits. Medicaid managed care organizations often coordinate with 988 for crisis intervention and may face network adequacy requirements tied to crisis services availability.
Why it matters for managed care
Medicaid MCOs increasingly coordinate behavioral health benefits with 988 crisis services and may need to demonstrate crisis network adequacy as states expand crisis system infrastructure under federal behavioral health parity and access requirements.
The U.S. Department of Labor formally rescinded the 2024 overtime rule and returned to the 2019 salary threshold framework. The 2024 rule would have expanded overtime eligibility for home care workers, but courts vacated it after the first threshold increase took effect. The rescission provides immediate relief to home health and home care providers who faced increased labor costs under the 2024 standards. Providers operating under Medicaid managed care contracts can now plan staffing and budgets using the lower 2019 thresholds.
Why it matters for managed care
Medicaid managed care organizations with home and community-based services contracts face lower labor cost pressures and greater staffing flexibility under the 2019 overtime thresholds, affecting capitation rate adequacy and LTSS network stability.
The U.S. Department of Labor formally rescinded its 2024 overtime rule and returned to the 2019 salary threshold framework for overtime eligibility. The 2024 rule had partially taken effect before courts vacated it following the first salary threshold increase. The rescission provides immediate relief to home health and personal care providers who faced significant compliance and cost pressures under the expanded overtime requirements. The reversion to 2019 thresholds stabilizes wage and hour obligations for home care agencies, many of which serve Medicaid beneficiaries.
Why it matters for managed care
Medicaid managed care organizations with home and community-based services contracts will see reduced labor cost pressure from network providers, improving workforce stability and potentially easing rate adequacy concerns in LTSS programs.
The Substance Abuse and Mental Health Services Administration awarded a $255 million contract to Vibrant Emotional Health to continue administering the 988 Suicide & Crisis Lifeline. The lifeline operates as a national network of more than 200 local crisis contact centers and has handled over 25 million contacts since launch through multiple channels including phone, text, chat, and ASL videophone. The contract ensures continued federal support for crisis intervention infrastructure that states and Medicaid managed care organizations increasingly integrate into behavioral health delivery systems.
Why it matters for managed care
Medicaid MCOs with behavioral health responsibilities must coordinate with 988 infrastructure for crisis response, and federal investment in the lifeline affects state expectations for managed care crisis service integration and reporting.
The Department of Health and Human Services finalized a rule Thursday updating the independent dispute resolution process for out-of-network billing disputes under the No Surprises Act. The rule revises how arbiters weigh the qualifying payment amount and other factors when resolving payment disputes between health plans and providers. Health plans criticized the final rule, arguing it does not adequately address provider overuse of arbitration or curb what they characterize as excessive out-of-network charges. The rule takes effect 60 days after publication in the Federal Register.
Why it matters for managed care
Medicaid managed care organizations with affiliated commercial lines or dual-eligible populations may face increased arbitration costs and administrative burden if providers escalate disputes over emergency and out-of-network claims.
The Trump administration's $50 billion rural health initiative will not fund hospital reopenings, despite Republican campaign messaging around rural healthcare access. The fund's structure focuses on operational support for existing facilities rather than capital investment to restore shuttered hospitals. Rural hospital closures disproportionately affect Medicaid beneficiaries, who comprise a significant share of patient populations in these areas. The policy gap means communities that have already lost hospital access will not see facility restoration through this federal initiative.
Why it matters for managed care
Medicaid managed care organizations operating in rural areas must plan network adequacy strategies without expectation of federal support for reopening closed hospitals, requiring alternative solutions for beneficiary access to inpatient and emergency services.
A GAO report found that HUD lacks uniform data entry procedures for service coordinators in multifamily housing and cannot determine how many properties employ them or whether properties comply with program requirements. HUD also does not routinely analyze performance reports from service coordinators. Stakeholders reported service coordinators help residents avoid eviction and apply for Medicaid, but five studies showed mixed results on health, financial, and housing outcomes. Rural challenges include managing multiple funding sources, limited service providers, and long distances to services.
Why it matters for managed care
Medicaid managed care organizations partner with housing providers to address social determinants of health, and weak HUD oversight of service coordinators limits visibility into whether housing-based care coordination effectively connects members to Medicaid services and reduces avoidable utilization.
A Government Accountability Office report identified significant data quality problems in HUD's multifamily housing service coordinator program, which funds staff who connect affordable housing residents to health care, meals, transportation, and other supportive services. HUD lacks uniform data entry procedures and cannot accurately determine how many properties employ service coordinators or verify compliance with program requirements. The agency also does not routinely analyze required performance reports. GAO found some evidence that service coordinators help residents access Medicaid and avoid eviction, though studies show mixed effects on health and housing outcomes. Rural challenges include limited provider networks and long distances between properties and services.
Why it matters for managed care
Medicaid managed care organizations serving rural areas often rely on service coordinators to connect dual-eligible and high-need members to housing stability and health services, making HUD's inability to track program effectiveness a blind spot for care coordination partnerships.
Home-based care providers are responding to cumulative reimbursement cuts by diversifying payer portfolios and building local partnerships to maintain financial viability. Industry leaders report that incremental payment reductions and policy shifts across government and commercial payers are forcing strategic changes in contracting approaches. Providers are actively expanding relationships beyond traditional Medicare fee-for-service to include managed care contracts and alternative payment arrangements. The shift reflects growing pressure on home health economics that directly affects network adequacy and access for Medicaid managed care enrollees.
Why it matters for managed care
Deteriorating home health margins may compromise network adequacy for Medicaid MCOs serving populations with long-term services and supports needs, particularly as providers prioritize higher-paying commercial and Medicare Advantage contracts over Medicaid managed care.
Pregnant women with gum disease are three to four times more likely to develop pre-eclampsia, an emergency condition that poses serious maternal and fetal health risks. The finding underscores the clinical importance of integrating oral health into prenatal care delivery models. Growing evidence linking dental health to maternal outcomes is prompting ob-gyns, state Medicaid programs, and health plans to reconsider care coordination and benefit design. No specific policy action or timeline is described.
Why it matters for managed care
Managed care organizations covering pregnant Medicaid beneficiaries may face higher medical costs and quality measure penalties if they fail to coordinate dental and prenatal care, particularly given the elevated pre-eclampsia risk among members with untreated periodontal disease.
Pregnant women with gum disease are three to four times more likely to develop pre-eclampsia, an emergency condition, according to recent findings highlighting the link between oral health and maternal outcomes. The data underscores the clinical need for integrated dental and prenatal care coordination. Health plans covering maternity benefits and states administering Medicaid pregnancy coverage should consider how dental network access and care management protocols address periodontal screening and treatment for pregnant enrollees. The article emphasizes the importance of ob-gyns, state Medicaid programs, and health plans prioritizing oral health interventions during pregnancy.
Why it matters for managed care
Medicaid managed care organizations cover a majority of births nationally and may face increased maternal health costs and quality measure penalties if prenatal dental care gaps contribute to preventable pre-eclampsia cases and adverse outcomes.
A new report shows uninsurance among children birth through age 5 has reached its highest level in nearly a decade, with more than 220,000 young children losing coverage between 2022 and 2024. The increase follows the end of Medicaid continuous enrollment protections and state redetermination processes. The trend represents a reversal of coverage gains achieved during the public health emergency. Young children are predominantly enrolled in Medicaid and CHIP, making these coverage losses directly relevant to state program performance and managed care plan enrollment.
Why it matters for managed care
Rising uninsurance among young children signals potential enrollment and retention challenges for Medicaid MCOs as states complete redeterminations and families navigate renewed eligibility processes, affecting plan membership and risk adjustment.
A new report shows that over 220,000 additional children under age 6 became uninsured between 2022 and 2024, pushing the uninsurance rate for this age group to its highest level in nearly a decade. The increase follows the end of Medicaid continuous coverage requirements that were in place during the COVID-19 public health emergency. Young children are particularly vulnerable to coverage gaps because they rely heavily on Medicaid and CHIP for health insurance. The trend signals growing challenges for states and managed care plans in maintaining enrollment and preventing coverage loss during renewal periods.
Why it matters for managed care
Rising pediatric uninsurance rates indicate potential problems with state renewal processes, auto-enrollment systems, and MCO outreach that directly affect plan membership, HEDIS measures, and performance-based payments tied to enrollment retention.
Physicians may lose the ability to mail mifepristone starting Monday due to ongoing legal challenges, though abortion advocates indicate alternative distribution channels will remain available. The restriction would affect direct-to-patient telemedicine abortion services that expanded during the pandemic. The timing suggests a court-imposed deadline or regulatory change taking effect. While this primarily affects private abortion providers and retail pharmacy channels, Medicaid managed care organizations covering abortion services in states where it remains legal may see members redirected to in-person dispensing or alternative medication abortion protocols.
Why it matters for managed care
MCOs in states covering abortion services must prepare for potential disruptions to telemedicine abortion pathways and may see increased utilization of in-person family planning services or alternative abortion methods if mifepristone mailing access changes.
A court order potentially effective Monday may prohibit doctors from mailing mifepristone, one of two drugs used in medication abortion. The restriction would increase barriers to access but abortion advocates indicate alternative pathways for mail-order abortion pills would remain available. The timing and full scope of enforcement remain unclear. For Medicaid managed care organizations, the development affects network provider compliance obligations and member access to covered reproductive health services where abortion is a covered benefit.
Why it matters for managed care
MCOs with abortion coverage must monitor provider compliance with evolving legal restrictions on medication abortion distribution methods and may need to revise utilization management protocols and member communications.
Home-based care providers are restructuring their business models in response to sustained reimbursement cuts and policy changes across payers. Providers report cumulative financial strain from incremental rate reductions and inconsistent payment structures. In response, agencies are diversifying their payer portfolios and forming local partnerships to maintain financial viability. These strategic shifts are occurring now as providers adapt to what industry leaders describe as accumulating incremental cuts rather than single policy changes.
Why it matters for managed care
Medicaid managed care organizations contracting with home health agencies may face network adequacy challenges and service disruptions as providers restructure their operations or limit Medicaid participation due to reimbursement pressures.
Metabolic gene therapies are creating new financial pressures for health plans and benefits managers. These treatments offer clinical benefits for patients with serious conditions but carry high costs that require specialized coverage and payment strategies. The article discusses how plans must prepare benefits structures to manage these emerging high-cost therapies. No specific implementation timeline or regulatory action is described.
Why it matters for managed care
Medicaid MCOs will need to develop utilization management protocols, negotiate manufacturer arrangements, and potentially restructure capitation agreements to account for gene therapy costs that can exceed $1 million per patient.
Health plans are preparing for the commercial availability of metabolic gene therapies, which offer potential cures for serious genetic conditions but carry costs that can exceed $1 million per treatment. Payers must develop new benefits management strategies including prior authorization frameworks, payment models, and utilization controls to balance patient access with financial sustainability. These treatments differ from traditional pharmaceuticals in their one-time administration and long-term outcomes, requiring innovative coverage approaches. The shift affects how plans structure pharmacy benefits, negotiate with manufacturers, and manage specialty drug spending.
Why it matters for managed care
Medicaid managed care organizations will need to adapt pharmacy benefit designs, rate negotiations with states, and utilization management protocols to accommodate ultra-high-cost gene therapies while maintaining actuarial soundness.
President Trump's $50 billion rural healthcare fund, announced during midterm campaigns, will not include provisions to reopen shuttered rural hospitals. The fund focuses on telehealth expansion and workforce recruitment but does not address hospital closures that have left rural communities without emergency and inpatient services. Rural hospital closures disproportionately affect Medicaid populations who rely on local facilities for emergency care, obstetric services, and behavioral health treatment. The funding structure prioritizes existing facilities rather than infrastructure restoration.
Why it matters for managed care
Rural hospital closures directly impact Medicaid managed care network adequacy requirements and beneficiary access to emergency services, particularly in states with significant rural populations and capitated Medicaid programs.
npr.org →Managed Care · Maternal · Behavioral Health
Telehealth platforms have rapidly scaled access to GLP-1 weight loss medications in response to surging patient demand. Researchers and physicians have raised concerns that some online providers may not adequately screen patients for contraindications or provide appropriate clinical monitoring during treatment. The safety questions emerge as telehealth prescribing of these high-cost medications expands outside traditional clinical settings. The controversy affects how managed care organizations evaluate telehealth vendor networks and pharmacy benefit management for GLP-1 drugs.
Why it matters for managed care
Managed care organizations must evaluate telehealth vendor credentialing standards and clinical protocols for high-cost GLP-1 prescribing, as inadequate screening could drive adverse events, prior authorization disputes, and pharmacy cost increases.
An investigation of Minnesota hospital data reveals most facilities provide minimal financial assistance to uninsured patients and create barriers to accessing charity care programs. The analysis examined hospital charity care spending and program accessibility as the state's uninsured population grows. The findings highlight systemic gaps in the healthcare safety net that affect uninsured individuals who may be eligible for Medicaid but face enrollment barriers or fall into coverage gaps. These charity care shortfalls increase the likelihood that uninsured patients delay care or accumulate medical debt, potentially affecting downstream Medicaid enrollment and emergency department utilization patterns.
Why it matters for managed care
Limited hospital charity care increases uninsured patients' likelihood of delaying treatment until conditions worsen, driving higher-acuity Medicaid enrollment and emergency department costs that MCOs ultimately bear through risk adjustment and supplemental payments.
An investigation into Minnesota hospital financial assistance programs reveals that most hospitals provide minimal charity care and create barriers to accessing aid, even as the state's uninsured population grows. The analysis examined hospital data and charity care policies across Minnesota facilities. The findings highlight gaps in safety net coverage that affect uninsured and underinsured patients who may otherwise qualify for Medicaid but face enrollment barriers or coverage gaps. The investigation raises questions about hospital community benefit obligations and the adequacy of financial assistance policies for low-income patients.
Why it matters for managed care
Inadequate hospital charity care programs increase the likelihood that uninsured patients will delay care or face collections, potentially driving Medicaid enrollment as hospitals refer patients to coverage options or as financial distress triggers eligibility.
Telehealth companies are rapidly expanding access to GLP-1 weight loss medications in response to surging demand. Researchers and physicians report concerns that some online providers lack adequate patient screening and monitoring protocols for these medications. The criticism comes as telehealth prescribing of GLP-1s becomes a significant business model for digital health companies. The safety and oversight questions could prompt regulatory scrutiny of telehealth prescribing practices.
Why it matters for managed care
Medicaid managed care organizations covering GLP-1s through telehealth arrangements face potential utilization management, quality oversight, and pharmacy cost implications if screening and monitoring standards are inconsistent across providers.