Federal Policy
6Federal Policy·7:30 AM MT
CMS released updated guidance on the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit in 2024, marking the first comprehensive policy update in approximately ten years. The guidance, issued through a state health official letter, provides states with revised operational and coverage requirements for Medicaid's mandatory pediatric benefit. This updated playbook affects how states structure EPSDT services, including screening schedules, diagnostic services, and treatment coverage for Medicaid-enrolled children. The guidance clarifies federal expectations for state compliance and likely impacts how managed care organizations implement and document EPSDT services in their contracts.
Why it matters for managed careManaged care organizations must review their EPSDT policies, provider contracts, and utilization management processes to ensure compliance with the updated federal standards, as state contracts will likely incorporate these revised requirements.
Federal Policy·1:31 PM MT
The Government Accountability Office has identified 38 priority recommendations for the Department of Health and Human Services as of May 2026, with seven new recommendations added in the past year. HHS has implemented four recommendations since May 2025. GAO is prioritizing two areas: strengthening Medicare and Medicaid program integrity and oversight, and improving public health program oversight and coordination. The recommendations aim to increase efficiency, reduce fraud and waste, and improve federal health care program operations. GAO sends these priority letters to agencies whose implementation could save significant federal funds or address high-risk issues.
Why it matters for managed careGAO's focus on Medicaid program integrity signals continued federal scrutiny of managed care oversight, fraud prevention, and administrative efficiency—areas where MCOs face heightened compliance expectations and potential enforcement risk.
Federal Policy·7:30 AM MT
Recent federal actions and proposals have sparked renewed debate over the use of methadone and buprenorphine for opioid use disorder treatment. Addiction medicine experts and patient advocacy organizations have expressed concern about potential restrictions on medication-assisted treatment (MAT). The developments come as Medicaid managed care organizations cover the majority of MAT services nationally, with medication costs and behavioral health integration representing significant budget and network adequacy considerations. Any federal policy changes affecting MAT access would directly impact MCO formularies, prior authorization protocols, and substance use disorder program design.
Why it matters for managed careMedicaid MCOs are the primary payer for medication-assisted treatment nationally, and federal policy shifts on methadone and buprenorphine access would require immediate changes to formulary management, care coordination models, and substance use disorder networks.
Federal Policy·7:30 AM MT
CMS Administrator Dr. Mehmet Oz presented the agency's affordability strategy at the Healthcare Financial Management Association Annual Conference on Tuesday, addressing Medicare fraud, drug pricing, and nutrition initiatives. The presentation outlined CMS's policy priorities across multiple program areas. While the speech focused primarily on Medicare, any policy shifts at CMS have potential spillover effects on Medicaid managed care operations, particularly in areas like fraud prevention, pharmaceutical pricing strategies, and preventive health initiatives that may be adopted across programs.
Why it matters for managed careCMS policy direction under new leadership signals potential shifts in federal oversight priorities, fraud prevention approaches, and pharmaceutical pricing strategies that could extend to Medicaid managed care programs.
Federal Policy·1:31 PM MT
The American College of Obstetricians and Gynecologists has published its own recommended vaccine schedule for pregnant patients, creating guidance that differs from Centers for Disease Control and Prevention recommendations. The departure represents an unusual break from standard public health practice, where professional medical societies typically align with CDC vaccine guidance. The development affects how maternity care providers counsel pregnant Medicaid beneficiaries on immunizations and may create confusion about which protocols Medicaid managed care plans should follow for quality measures and prenatal care standards.
Why it matters for managed careConflicting vaccine guidance between ACOG and CDC creates compliance uncertainty for Medicaid MCOs that use prenatal vaccination rates in quality metrics, value-based purchasing arrangements, and HEDIS measures for maternal care.
Federal Policy·1:30 PM MT
The American College of Obstetricians & Gynecologists released a recommended maternal vaccine schedule that differs from CDC guidance for the first time. ACOG recommends four vaccines during pregnancy: influenza, COVID-19, Tdap, and RSV. The new schedule affects prenatal care protocols and provider counseling for pregnant Medicaid beneficiaries. This divergence creates potential confusion for managed care organizations that must decide whether to align coverage policies and quality metrics with CDC or ACOG recommendations for their maternal health programs.
Why it matters for managed careMedicaid MCOs must determine whether to update maternal health quality measures, provider protocols, and HEDIS vaccine metrics to align with ACOG guidance that now differs from CDC recommendations affecting approximately 40% of U.e. births covered by Medicaid.
State Policy
5State Policy·OH·1:30 PM MT
Ohio lawmakers removed language from House Bill 795 that would have prohibited family members living with Medicaid recipients from serving as certified caregivers. The provision was withdrawn Monday following significant public opposition. The proposal targeted Ohio's Medicaid home healthcare program, which allows beneficiaries to hire family members as paid caregivers. The reversal preserves existing caregiver arrangements for Medicaid managed care plans operating in Ohio's home and community-based services programs.
Why it matters for managed careMCOs administering Ohio Medicaid LTSS would have faced provider network disruption and member appeals if the family caregiver ban had advanced, potentially affecting thousands of existing care arrangements.
State Policy·MO·1:30 PM MT
Missouri terminated Medicaid coverage for 333,265 beneficiaries between January 2025 and February 2026, with 91.9% disenrolled for procedural reasons rather than ineligibility determinations, according to CMS data. The state's high procedural termination rate indicates systemic renewal and redetermination processing problems. This disenrollment pattern affects managed care organizations through membership loss, revenue reduction, and potential contractual quality metric penalties tied to continuity of coverage. MCOs operating in Missouri face continued enrollment volatility as the state processes redeterminations.
Why it matters for managed careHigh procedural disenrollment rates in Missouri signal sustained membership churn that directly impacts MCO revenue, care continuity metrics, and administrative costs associated with re-enrollment and outreach.
State Policy·MN·1:30 PM MT
Minnesota's Department of Human Services received provisional license applications from 433 of 481 autism service provider sites under a new state law requiring licensure for Medicaid-funded autism services. The licensing requirement was enacted to increase oversight following explosive program growth and fraud allegations in recent years. The high application rate suggests most providers are seeking to remain in the Medicaid program under the new regulatory framework. This represents a significant expansion of state oversight over previously less-regulated autism service delivery.
Why it matters for managed careManaged care organizations contracting with autism service providers in Minnesota will need to verify provisional licensure status and prepare for potential network disruptions if non-compliant providers exit the program.
State Policy·1:30 PM MT
Nearly 60 Planned Parenthood clinics have closed or consolidated since last year due to state-level funding restrictions, according to a KFF report. The closures affect access to family planning, STI testing, and preventive care services in affected communities. The timing and specific states are not detailed in the brief article, but the trend reflects ongoing state policy actions targeting reproductive health funding. For Medicaid managed care organizations, these closures may disrupt member access to covered family planning services and require network adequacy adjustments in affected service areas.
Why it matters for managed careMCOs must ensure continued access to family planning and preventive services when network providers close, particularly in states with mandatory family planning coverage under Medicaid managed care contracts.
State Policy·CA·7:30 AM MT
A major California healthcare union has introduced two ballot initiatives targeting community clinics and capping executive and managerial compensation at hospitals and physician groups. The measures have triggered widespread opposition from healthcare industry stakeholders. The initiatives emerge amid anticipated Medicaid budget reductions in California, intensifying long-standing labor-industry tensions. If approved by voters, the measures would impose operational and financial restrictions on healthcare entities that contract with Medicaid managed care organizations.
Why it matters for managed careCompensation caps and new clinic regulations would affect MCO provider networks, potentially limiting access to safety-net providers and changing contract negotiations with hospital systems and medical groups that serve Medi-Cal enrollees.
Industry
3Industry·7:30 AM MT
Prescription drug shortages in the United States decreased by 23% in 2024 according to a new analysis, but systemic supply chain problems persist. The analysis identified ongoing structural vulnerabilities in pharmaceutical manufacturing and distribution that continue to affect medication availability. While the overall number of shortages declined, the duration and severity of certain shortages worsened. For Medicaid managed care organizations, drug shortages create formulary management challenges, increase member access barriers, and complicate pharmacy benefit administration when preferred products become unavailable.
Why it matters for managed careDrug shortages force MCOs to manage formulary disruptions, implement therapeutic substitutions, and address member access complaints while maintaining quality metrics and contract compliance.
Industry·1:31 PM MT
A new analysis shows the average drug shortage in 2025 has lasted 5.3 years, up from 4.3 years in 2024. The extended duration reflects chronic supply chain instability affecting generic medications, many of which are used extensively in Medicaid populations. The analysis highlights growing challenges in maintaining formulary stability and managing therapeutic alternatives. For Medicaid managed care plans, prolonged shortages complicate prior authorization processes, increase member access issues, and drive utilization of more expensive therapeutic substitutes.
Why it matters for managed careLonger drug shortages force Medicaid MCOs to manage more frequent formulary disruptions, therapeutic substitutions, and member grievances while absorbing cost increases from alternative medications under fixed capitation rates.
Industry·1:30 PM MT
Health systems are increasingly establishing their own specialty pharmacy operations in response to tightening reimbursement and manufacturer restrictions on 340B contract pharmacy arrangements. Hospitals and health systems now represent the fastest-growing segment of direct participants in the specialty pharmacy market. The shift is driven by both revenue generation goals and manufacturers' evolving 340B policies that limit contract pharmacy access. This infrastructure buildout allows health systems to capture specialty drug dispensing margins and maintain access to 340B savings despite manufacturer restrictions.
Why it matters for managed careHealth system-owned specialty pharmacies may compete with MCO pharmacy benefit management strategies and alter specialty drug distribution channels that affect network adequacy, utilization management, and total cost of care arrangements.