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 mattersManaged 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.
Managed Care · CHIP
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 mattersGAO'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.
Managed Care · Finance
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 mattersMedicaid 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.
Behavioral Health · Managed Care
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 mattersCMS 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.
Managed Care · Pharmacy
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 mattersMedicaid 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.
Maternal · Managed Care