Federal Policy
5Federal Policy·1:31 PM MT
The Kaiser Family Foundation maintains an ongoing tracker of federal Medicaid program integrity developments and their state-specific implications. The resource documents CMS enforcement actions, audit findings, and compliance initiatives as they emerge across different states. The tracker serves as a reference for monitoring federal oversight activity affecting state Medicaid programs. It compiles information on federal actions rather than reporting a single policy change or rulemaking.
Why it matters for managed careManaged care organizations need to monitor federal program integrity trends to anticipate heightened scrutiny, audit focus areas, and potential state-level compliance requirements that could affect MCO operations and reporting obligations.
Federal Policy·7:31 AM MT
A bipartisan bill in Congress would end the requirement that methadone for opioid use disorder be dispensed only through specialty opioid treatment programs, allowing qualified practitioners to prescribe it directly like buprenorphine. The legislation would enable office-based prescribing and pharmacy dispensing of methadone, dramatically expanding access beyond the current clinic-only model. If enacted, the change would remove a longstanding barrier to medication-assisted treatment that has limited access particularly in rural and underserved areas. The timing and specific requirements for prescriber qualifications remain unclear pending legislative details.
Why it matters for managed careMedicaid managed care organizations would need to credential new methadone prescribers, establish pharmacy networks capable of dispensing methadone, update prior authorization protocols, and potentially renegotiate rates as treatment shifts from specialized clinics to office-based settings.
Federal Policy·7:30 AM MT
CMS projects national home health care spending will grow 7.9% in 2026, down from 10.3% in 2025, according to a Health Affairs report on national health expenditure projections. The deceleration reflects moderating post-pandemic utilization trends while still indicating strong growth in the home health sector. The projections cover total national home health spending across all payers, including Medicare, Medicaid, and commercial insurance. For Medicaid managed care organizations with home health benefit responsibility or LTSS carve-ins, the projections signal continued upward pressure on capitated rates and medical expense ratios in the home health category.
Why it matters for managed careSustained high home health spending growth will drive capitation rate negotiations and medical loss ratio management for MCOs covering home health benefits or LTSS services delivered in home settings.
Federal Policy·7:31 AM MT
CMS actuaries project total U.S. health spending will reach $5.7 trillion in 2025, with growth primarily driven by increased utilization rather than unit cost increases. Prescription drug spending is accelerating sharply, particularly for GLP-1 medications used for diabetes and weight management. The utilization trend affects all payers including Medicaid managed care plans, which face rising pharmacy costs and member demand for high-cost specialty drugs. CMS expects spending growth to moderate in subsequent years as utilization patterns stabilize.
Why it matters for managed careRising utilization of high-cost drugs like GLP-1s will pressure MCO pharmacy budgets and may trigger mid-year capitation rate adjustments if state actuaries did not adequately account for this trend in rate development.
Federal Policy·1:30 PM MT
Senator Bill Cassidy has introduced legislation to restrict eligibility for the 340B drug discount program, which allows certain hospitals and health centers to purchase outpatient drugs at steep discounts. The proposal comes as hospitals face broader federal funding pressures. While specific provisions are not detailed in the brief article, any 340B restrictions typically target hospital eligibility criteria, contract pharmacy arrangements, or program oversight. The timing is significant as hospitals already navigate budget constraints and prior 340B enforcement actions.
Why it matters for managed careMedicaid MCOs reimburse 340B-eligible hospitals at higher rates for drugs purchased at discount, creating budget pressures and rate-setting complexities if eligibility rules change.
State Policy
5State Policy·CA·1:30 PM MT
California has replaced the Mental Health Services Act (MHSA) with the Behavioral Health Services Act (BHSA), changing how counties allocate mental health funding. The BHSA modifies funding allocation requirements and county spending priorities for mental health and substance use disorder services. The change affects how counties structure behavioral health programs and redirect existing MHSA revenues. California Health Care Foundation has published resources detailing the differences between the two funding frameworks.
Why it matters for managed careMedicaid managed care plans in California must understand new county behavioral health funding flows and program structures as the BHSA reshapes the delivery system for specialty mental health and substance use disorder services covered under Medi-Cal managed care carve-outs.
State Policy·NM·7:30 AM MT
New Mexico is experiencing confusion and conflicts as it implements a new regional structure to rebuild its behavioral health infrastructure. State officials are working to repair the system, but the restructuring has created challenges at the community level. The article does not specify implementation timelines or affected populations. This matters for Medicaid managed care organizations because behavioral health network adequacy and provider coordination are core contractual requirements, and state infrastructure changes can disrupt existing MCO networks and referral pathways.
Why it matters for managed careState behavioral health restructuring can require MCOs to reconfigure provider networks, update care coordination protocols, and modify member access workflows to align with new regional frameworks.
State Policy·IL·1:30 PM MT
Illinois Governor J.B. Pritzker signed the Reproductive Health Records Privacy Act on June 24, 2025, requiring abortion services and gender dysphoria diagnoses to be separated from patients' electronic medical records and limiting disclosure to out-of-state entities. The law takes effect July 1, 2027. Healthcare providers, including Medicaid managed care organizations, must implement new record-keeping protocols to segregate these specific health information categories and establish controls preventing out-of-state disclosure.
Why it matters for managed careIllinois Medicaid MCOs must develop new health information management systems to segregate reproductive health records and implement compliance protocols for multi-state coordination requests, affecting care coordination, third-party liability processes, and data sharing agreements.
State Policy·KY·7:32 AM MT
Eastern Kentucky is using opioid settlement funding to support programs addressing substance use disorders, housing instability, and food insecurity in rural communities. The initiative targets regions heavily affected by the opioid crisis with integrated support services. No specific implementation timeline or funding amount is provided in the reporting. This represents Kentucky's approach to deploying settlement resources for behavioral health infrastructure in underserved areas.
Why it matters for managed careKentucky Medicaid MCOs operating in rural regions may see increased utilization of substance use disorder treatment services as settlement-funded programs expand access and connect members to care networks.
State Policy·FL·7:30 AM MT
Florida Attorney General Ashley Moody has launched an investigation into CVS Health for alleged anticompetitive pharmacy practices. The probe examines whether CVS is using its integrated pharmacy benefit manager and retail pharmacy operations to disadvantage competitors and increase drug costs. This investigation follows similar state-level actions targeting PBM practices and comes amid broader scrutiny of vertical integration in the pharmacy supply chain. The inquiry could result in enforcement actions, consent agreements, or legislation affecting how PBMs operate in Florida's commercial and Medicaid markets.
Why it matters for managed careFlorida Medicaid managed care organizations contract with PBMs including CVS Caremark, and any enforcement action or resulting policy changes could affect pharmacy network arrangements, reimbursement structures, and prescription drug spending in Medicaid managed care contracts.