Federal Policy
5Federal Policy·7:13 AM MT
A new poll finds that most Americans do not believe Medicaid beneficiaries are the primary source of program fraud, contradicting recent allegations from some Republican leaders. Respondents view current fraud enforcement rhetoric as politically motivated rather than substantive. The poll results come amid ongoing congressional and administrative debates over program integrity measures, oversight authority, and enforcement resource allocation. Public perception could influence state Medicaid agency priorities and federal oversight emphasis as policymakers weigh beneficiary-focused versus provider-focused fraud detection strategies.
Why it mattersPublic opinion data may shape state agency enforcement priorities and federal policy decisions around where to direct program integrity resources — beneficiary eligibility verification versus provider billing audits — affecting compliance costs and audit focus for managed care plans.
Federal Policy·1:00 PM MT
Federal regulations require state Medicaid agencies to notify enrollees affected by new work requirements, and most states are planning additional outreach including phone calls, public advertising, and social media. States face operational challenges meeting tight implementation timelines while complying with federal notice requirements. The brief examines state compliance strategies and the administrative burden of implementing work requirement communications across diverse enrollee populations.
Why it mattersState Medicaid agencies must rapidly build outreach infrastructure to comply with federal notice mandates while managed care plans may need to coordinate member communications and track compliance for affected enrollees.
Federal Policy·7:14 AM MT
CMS issued implementation guidance July 22 following a federal district court injunction that blocked eight provisions of its 2027 notice of benefit and payment parameters final rule. The injunction, issued July 16, prevents enforcement of provisions set to take effect July 20. CMS directed exchanges to immediately stop removing or denying advance premium tax credits for applicants who failed to file and reconcile prior years' credits, effective for plan years 2026 and 2027. The agency also reinstated the automatic 60-day extension for resolving household income data inconsistencies.
Why it mattersThe injunction and revised implementation timeline affect marketplace operations and eligibility determinations for plan years 2026-2027, requiring immediate system changes by state and federal exchanges.
Federal Policy·7:10 AM MT
The Connecting Health and Records Technology for Seniors (CHARTS) Act has been introduced in the U.S. House of Representatives to provide up to $500,000 grants for home health, long-term care, and post-acute care providers to implement electronic health records and improve health information sharing. The legislation aims to reduce implementation costs and administrative burden for providers serving Medicare and Medicaid beneficiaries. If passed, the grants would support interoperability efforts critical to care coordination for dual-eligible and Medicaid long-term services and supports populations. The bill is in the early legislative stage with no timeline for passage.
Why it mattersThe bill addresses a longstanding barrier to care coordination for Medicaid LTSS populations by funding EHR adoption in home- and community-based settings where electronic records lag behind institutional providers.
Federal Policy·6:33 AM MT
The Department of Health and Human Services filed an appeal to reinstate portions of a 2025 Affordable Care Act rule that a federal judge invalidated in June 2026. The invalidated provisions include shortened enrollment periods and stricter eligibility verification requirements for marketplace coverage. The appeal seeks to restore these requirements, which originally applied to ACA marketplace plans beginning with the 2026 plan year. The outcome affects marketplace operations and enrollment procedures, with potential implications for Medicaid-marketplace coordination on eligibility determinations and transitions between coverage types.
Why it mattersThe appeal affects how state Medicaid agencies coordinate eligibility determinations with marketplace exchanges, particularly for individuals transitioning between Medicaid and subsidized marketplace coverage during modified enrollment windows.
State Policy
4State Policy·CA·1:02 PM MT
California's Medi-Cal program lost 730,000 enrollees—a 5% decline—between June 2025 and March 2026, according to California Health Care Foundation data analysis. Undocumented children and young adults experienced disproportionate coverage losses during this period. The enrollment decline follows the end of Medicaid continuous coverage requirements that had kept enrollment elevated during the public health emergency. State agencies and managed care plans should anticipate continued membership volatility and assess impacts on network capacity, risk adjustment, and community-based provider networks serving populations with higher disenrollment rates.
Why it mattersA 730,000-member drop in California, the nation's largest Medicaid program, signals significant managed care plan revenue loss, potential network adequacy shifts, and administrative strain from processing eligibility changes at scale.
State Policy·1:00 PM MT
This interactive resource tracks state-level abortion coverage policies across Medicaid, private insurance, and ACA exchange plans as of 2025. The tracker shows the number of states with laws restricting abortion coverage in Medicaid and private insurance has increased since 2010. It provides a state-by-state breakdown of coverage restrictions, exceptions for life endangerment or other circumstances, and differences between Medicaid fee-for-service and managed care plan coverage. The tool allows Medicaid agencies, health plans, and advocates to compare abortion coverage rules across states and insurance types.
Why it mattersState Medicaid agencies and MCOs must ensure their coverage policies, member communications, and provider networks comply with state-specific abortion coverage requirements, which vary significantly and affect care coordination, benefits administration, and regulatory compliance.
State Policy·7:10 AM MT
Political tensions are escalating around states' use of Medicaid payment deferrals, with home care providers caught in the crossfire. The dispute centers on whether states can delay payments to manage budget cycles, a practice that disproportionately affects home- and community-based services providers operating on thin margins. Home care advocates warn that payment timing conflicts threaten provider solvency and beneficiary access to HCBS. The controversy reflects broader partisan divisions over Medicaid financing and state flexibility in program administration.
Why it mattersPayment deferral disputes directly affect HCBS provider cash flow and network stability, with implications for states' ability to maintain home care access and comply with federal maintenance-of-effort requirements.
State Policy·WI·1:01 PM MT
Wisconsin Medicaid requires applicants for long-term care programs to pass a functional screen test in addition to meeting financial eligibility criteria. The functional screen assessment evaluates an individual's ability to perform activities of daily living and need for assistance to determine whether they meet the level of care required for program enrollment. The screen applies to programs including Family Care, IRIS, and institutional care. For applicants and providers, understanding functional screening requirements is critical to navigating Wisconsin's long-term care access and ensuring appropriate program placement.
Why it mattersThe functional screen acts as a gatekeeper to Wisconsin's Medicaid long-term care programs, directly affecting which beneficiaries can access managed long-term care services and institutional placements.
Legal
4Legal·1:01 PM MT
On July 21, 2026, HHS Secretary Kennedy announced that CMS now has direct exclusion authority, previously held only by the HHS Office of Inspector General. CMS revoked 1,413 Medicare and Medicaid providers and suppliers in Q1 2026, a 40% increase over prior years and the largest quarterly surge on record. The delegation gives CMS "force multiplier" capacity to exclude providers from federal health programs based on fraud, abuse, or program integrity concerns. Medicaid managed care organizations must screen networks for excluded providers and may face increased mid-year terminations and provider adequacy challenges as revocation volumes accelerate.
Why it mattersMedicaid MCOs must immediately verify provider eligibility against expanded exclusion lists and prepare for network disruption as CMS ramps up enforcement using new delegated authority.
Legal·12:28 PM MT
HHS and CMS filed an appeal in July 2026 challenging a Maryland federal district court's June 2026 decision that vacated portions of CMS's 2025 Marketplace Integrity and Affordability Rule. The underlying case was brought by the city governments of Columbus, Baltimore, and Chicago, along with other plaintiffs. The district court ruled on summary judgment to strike down specific provisions of the rule. The appeal will determine whether those provisions remain enforceable or are permanently set aside.
Why it mattersThe appeal could restore marketplace rule provisions that may affect Medicaid-eligible populations at the ACA marketplace interface, particularly for states with Bridge programs or enrollment pathways between exchange and Medicaid coverage.
Legal·7:13 AM MT
CMS released the calendar year 2027 Home Health Prospective Payment System proposed rule, combining payment updates with expanded program integrity enforcement authority. The rule introduces new enrollment enforcement mechanisms targeting home health agencies participating in Medicare. While the rule focuses on Medicare home health, the enforcement framework may signal CMS's broader compliance and enrollment oversight direction. Comments on the proposed rule are due 60 days after Federal Register publication.
Why it mattersCMS enforcement frameworks introduced in Medicare often migrate to Medicaid managed care network adequacy and provider enrollment oversight, particularly for home health services covered under LTSS and managed care contracts.
Legal·WA·7:08 AM MT
A lawsuit filed July 21, 2026 in U.S. District Court for the Western District of Washington alleges Swedish Medical Center and the United Network for Organ Sharing used a race-based kidney function formula that delayed the plaintiff's transplant waitlist eligibility by six years. The complaint challenges the use of race-adjusted eGFR calculations in determining transplant eligibility. The case follows broader clinical and policy shifts away from race-based algorithms in kidney function assessment. The outcome could affect transplant referral protocols and eligibility determinations for Medicaid beneficiaries with end-stage renal disease.
Why it mattersMedicaid covers a substantial share of dialysis and transplant patients, and state agencies and managed care plans that delegate or oversee transplant referrals may face compliance or liability exposure if race-based clinical algorithms are found unlawful or discriminatory in organ allocation.
Industry
5Industry·1:00 PM MT
Community Health Systems reported second-quarter financial results reflecting higher-than-expected uninsured patient volumes, primarily attributed to patients dropping Affordable Care Act coverage. The for-profit hospital operator indicated these uninsured volumes are affecting revenue and margins more significantly than projected. The trend reflects broader ACA enrollment shifts impacting hospital payer mix. CHS joins other hospital systems reporting increased uncompensated care costs as commercial and subsidized coverage levels fluctuate.
Why it mattersRising uninsured volumes signal potential upstream pressure on Medicaid enrollment and state uncompensated care pools as patients lose commercial coverage, affecting hospital finances and state Medicaid budget planning.
Industry·1:00 PM MT
Independent rural hospitals in Minnesota, North Dakota, and Ohio are forming regional networks to gain scale and compete with consolidating health systems and payers, according to a Commonwealth Fund report published July 22, 2026. North Dakota's Rough Rider High-Value Network includes 23 critical access hospitals and launched with $3.5 million in funding. These networks aim to preserve local control while building collective bargaining power with payers and operational efficiencies. The consolidation trend affects Medicaid managed care plans contracting with rural providers and state agencies monitoring network adequacy in rural areas.
Why it mattersRural hospital consolidation into regional networks may affect Medicaid managed care network adequacy requirements and reimbursement negotiations in states with significant rural populations.
Industry·1:00 PM MT
Major for-profit hospital operators including HCA Healthcare, Community Health Systems, and Tenet Healthcare reported in second-quarter 2026 earnings calls that ACA premium tax credit expiration produced larger-than-anticipated increases in uninsured patient volume. Patients who lost subsidized marketplace coverage are not transitioning to other insurance but instead remaining uninsured and continuing to seek care. The development affects hospital bad debt and charity care volumes effective second quarter 2026. This matters because increased uninsured volume at major hospital chains signals broader coverage losses that affect Medicaid-eligible populations through coverage transitions and emergency department utilization patterns.
Why it mattersRising uninsured volumes at major hospital systems indicate coverage disruptions that likely include patients churning between Medicaid and uninsured status, affecting state program enrollment and managed care plan membership stability.
Industry·1:00 PM MT
A study using Danish data found that patients taking GLP-1 medications had 17 percent fewer long-term sick leave absences compared to those not on the drugs. The research suggests potential workforce participation and productivity benefits beyond clinical outcomes for obesity and diabetes treatment. The findings may inform Medicaid coverage decisions and utilization management policies for GLP-1s, which have been subject to state budget scrutiny due to high costs. The study did not specify implementation timelines but reflects ongoing evaluation of these drugs' broader economic impacts.
Why it mattersThis evidence of reduced absenteeism may influence state Medicaid agencies' cost-benefit analyses for GLP-1 coverage, particularly as states weigh budget impact against potential downstream savings from improved workforce participation among beneficiaries.
Industry·7:08 AM MT
UnitedHealth Group and Elevance Health reported second-quarter 2026 earnings showing increased reliance on their services divisions rather than traditional insurance operations. The companies continue to invest heavily in these non-insurance business units, accelerating a long-term diversification trend. This shift affects how major payers — many of which operate Medicaid managed care plans — allocate capital and structure their operations. The earnings reports reflect a broader industry pivot away from pure risk-bearing insurance models toward integrated care delivery and services.
Why it mattersMedicaid health plans operated by these large insurers may see strategic resource shifts as parent companies prioritize higher-margin services businesses over traditional managed care operations.