Federal Policy
6Federal Policy·7:00 AM MT
KFF released a policy analysis examining how Medicaid work requirements could affect Supplementary Security Income (SSI) applicants. The analysis finds that SSI applicants are at heightened risk of losing Medicaid coverage due to challenges navigating the medical frailty exclusion verification process under work requirement policies. While individuals with disabilities are typically exempt from work requirements through medical frailty provisions, SSI applicants — who are in the process of establishing disability status — may struggle to document their conditions quickly enough to maintain continuous coverage. The analysis highlights operational barriers that could lead to coverage gaps for this vulnerable population.
Why it mattersState Medicaid agencies implementing work requirements must design medical frailty screening processes that accommodate SSI applicants in disability determination, or risk inappropriate coverage terminations for individuals who should qualify for exemptions.
Federal Policy·7:00 AM MT
Sen. Andy Kim (D-NJ) introduced S. 5037, the MediKids Act, to establish guaranteed healthcare coverage for all children in America. The bill was cosponsored by four Democratic senators and referred to the Senate Finance Committee. No timeline for committee consideration has been announced. If enacted, the legislation would significantly expand federal health coverage for children beyond current Medicaid and CHIP eligibility thresholds, affecting state program design and federal-state financing arrangements.
Why it mattersThis legislation could fundamentally reshape pediatric coverage policy by establishing universal federal eligibility standards that would override state Medicaid and CHIP income limits and enrollment procedures.
Federal Policy·1:00 PM MT
HHS Secretary Robert F. Kennedy, Jr. held a roundtable with healthcare leaders, insurers, medical societies, and behavioral health providers who pledged to advance best practices for mental health and addiction treatment. The meeting occurred on July 29, 2026, at HHS headquarters in Washington. The voluntary commitments focus on improving care quality and patient outcomes across the behavioral health system. The initiative signals federal priority attention to behavioral health standards but lacks binding requirements or timelines for implementation.
Why it mattersThis federal convening indicates potential future HHS guidance or regulatory action on behavioral health quality standards that could affect Medicaid managed care network adequacy, value-based payment arrangements, and behavioral health integration requirements.
Federal Policy·7:00 AM MT
The Association for Community Affiliated Plans and the Center for Health Care Strategies announced a learning and action series to help safety net health plans implement newly established Medicaid work requirements. The initiative will provide technical assistance to plans as they develop operational processes for verifying beneficiary compliance, managing exemptions, and coordinating with state agencies. The timing suggests recent federal policy changes have authorized or expanded work requirement programs in multiple states. Safety net plans serving Medicaid populations will need new systems for tracking work activities, processing beneficiary documentation, and managing potential coverage terminations for noncompliance.
Why it mattersSafety net health plans must rapidly build administrative infrastructure to comply with work requirement verification and reporting obligations while minimizing inappropriate coverage loss for eligible members.
Federal Policy·7:00 AM MT
CMS has re-established a Privacy Act matching program with the Office of Personnel Management to verify minimum essential coverage through OPM health benefit plans. The data match enables CMS and State Administering Entities to determine eligibility for qualified health plans through exchanges and insurance affordability programs, including Medicaid and CHIP. The match supports initial eligibility determinations, renewals, redeterminations, and appeals. Effective July 29, 2026, this routine data exchange ensures states can verify coverage status when individuals apply for Medicaid or marketplace subsidies.
Why it mattersState Medicaid agencies rely on this OPM data match to accurately verify applicants' existing coverage and prevent inappropriate enrollment or subsidy payments, making it a core operational tool for eligibility systems.
Federal Policy·7:00 AM MT
The Agency for Healthcare Research and Quality has spent less than $15 million of its $345 million fiscal year 2026 appropriation on grants and has not issued new grants in over a year. The agency typically funds health services research including quality measurement, patient safety, and care delivery studies that inform Medicaid program design and quality initiatives. The spending freeze affects research that state Medicaid agencies and managed care plans rely on for evidence-based policy development, quality improvement, and payment reform.
Why it mattersState Medicaid agencies and MCOs depend on AHRQ-funded research for quality measures, clinical guidelines, and evidence supporting value-based payment models and care delivery reforms.
State Policy
5State Policy·OR·7:00 AM MT
Oregon Health Plan enrollees will be subject to new eligibility requirements beginning January 2027 under the One Big Beautiful Bill Act (HR1). The federal legislation mandates a slate of new requirements for Medicaid beneficiaries that Oregon must implement. The changes take effect in approximately six months. Oregon Medicaid agencies and managed care plans will need to modify systems, processes, and beneficiary communications to comply with the federal mandate.
Why it mattersOregon's Medicaid agency and contracted health plans must prepare operational changes to enrollment, eligibility verification, and member outreach within six months to meet federal compliance deadlines.
State Policy·LA·1:00 PM MT
Louisiana enacted Act 913 on June 12, establishing a commercial market reimbursement floor for pharmacy benefit managers that requires use of National Average Drug Acquisition Cost (NADAC) as the reimbursement benchmark. The law applies to commercial PBM arrangements and includes provisions intended to prevent cost-shifting to patients. The legislation took effect upon signing and affects how PBMs reimburse pharmacies in commercial insurance markets in Louisiana.
Why it mattersLouisiana's commercial PBM reform establishes precedent that may influence future Medicaid managed care pharmacy reimbursement policy in the state, as NADAC is already the federal benchmark for Medicaid fee-for-service pharmacy reimbursement.
State Policy·CA·7:00 AM MT
A California business association leader is opposing a November 2026 ballot measure that would impose a tax on billionaires to address Medi-Cal funding shortfalls and rising living costs. The op-ed argues the measure would harm long-term economic growth despite potential short-term revenue gains. The ballot measure has not yet been voted on. This matters for California Medi-Cal stakeholders because the measure, if passed, could alter the state's Medicaid funding landscape and sustainability.
Why it mattersThe ballot measure could significantly change California's Medi-Cal revenue structure and program sustainability if approved by voters in November 2026.
State Policy·6:58 AM MT
Three state Medicaid directors describe operational approaches for gathering and acting on member feedback, including advisory councils, community listening sessions, and embedding member voices in agency decision-making. The leaders discuss how they structure engagement to reach diverse populations, particularly members with complex needs, and translate input into policy and operational changes. These practices aim to improve program responsiveness and member experience across eligibility, benefits, and service delivery.
Why it mattersState Medicaid agencies seeking to strengthen member engagement can apply these tested structures for advisory councils, community outreach, and feedback loops to improve program design and member satisfaction.
State Policy·NM·7:00 AM MT
The University of New Mexico Health Sciences Center launched Vive Bien/Live Well, a healthy aging program designed to help older adults maintain health, independence, and quality of life. The program is funded by the New Mexico Health Care Authority and aligns with the World Health Organization's Integrated Care for Older People framework. The initiative targets the state's aging population with tools to support independent living and reduce care needs.
Why it mattersState-funded aging programs can reduce institutional long-term care utilization and shift costs toward home- and community-based services, potentially affecting LTSS budget planning and managed care contract specifications.
Industry
6Industry·8:40 AM MT
Universal Health Services reported increased uninsured patient volumes in the second quarter of 2026, with executives attributing the trend to individuals losing Affordable Care Act marketplace coverage. The hospital operator now projects an additional $10 million loss for the year beyond initial expectations due to the coverage losses. The trend affects UHS's hospital operations as patients transition from insured to uninsured status, impacting revenue cycle performance and bad debt provisions.
Why it mattersRising uninsured volumes signal broader marketplace instability that could affect Medicaid managed care plans through increased emergency Medicaid applications and churn between coverage types.
Industry·7:00 AM MT
Rural hospitals accounted for all net hospital losses in the United States between 2001 and 2023, closing at more than three times the rate they opened, according to Yale University's Health Care Affordability Lab data. The data tracks both openings and closures during this 22-year period. Rural hospital closures disproportionately affect Medicaid beneficiaries who rely on these facilities for emergency care, obstetric services, and behavioral health treatment, often with limited alternative access points.
Why it mattersRural hospital closures reduce Medicaid beneficiaries' access to emergency services, inpatient care, and specialty services, forcing managed care plans to expand networks across wider geographic areas and potentially increasing transportation costs for members.
Industry·7:00 AM MT
HHS is introducing a behavioral health pledge on July 29, 2026, to advance mental health and addiction care nationwide, bringing together payers and medical associations in Washington, D.C. Optum will be the first private-sector company to sign the pledge, according to CEO Patrick Conway, and is simultaneously rolling out new behavioral health products. The pledge aims to expand access to mental health and substance use disorder services across the healthcare system. This represents a coordinated public-private effort to address behavioral health access gaps that affect Medicaid programs, which cover a disproportionate share of Americans with serious mental illness and substance use disorders.
Why it mattersOptum's participation and new service rollout signals major managed care organization movement on behavioral health infrastructure that will directly affect Medicaid beneficiary access, particularly given Optum's extensive Medicaid managed care footprint across multiple states.
Industry·7:00 AM MT
A study published in JAMA Network Open found that heart failure patients receiving advanced medical care at home had comparable post-discharge outcomes to those treated in traditional hospital settings, with no significant differences in readmission rates. The research supports hospital-at-home as a viable alternative care delivery model for heart failure management. The findings may inform future Medicaid coverage policies and managed care contracting decisions around alternative site-of-service arrangements. The study provides evidence on quality and safety parity between home-based and facility-based acute care for this high-cost, high-utilization condition.
Why it mattersMedicaid managed care plans covering dual-eligible and aged/disabled populations may use this evidence to expand hospital-at-home benefits, potentially reducing facility costs while maintaining quality for beneficiaries with heart failure, a leading driver of hospitalizations and readmissions in Medicaid.
Industry·7:00 AM MT
Higher borrowing costs have slowed merger and acquisition activity in the home-based care sector, but investors willing to enter the market now may benefit from more favorable deal terms. The slower dealmaking environment has made compliance screening a more important factor in transactions. Buyers able to absorb higher interest rates are finding opportunities as sellers face pressure to consolidate. The shift affects Medicaid managed care organizations and state agencies contracting with home health and home- and community-based services providers.
Why it mattersM&A consolidation in home-based care affects LTSS network stability, provider availability, and compliance oversight for state Medicaid agencies and health plans managing HCBS benefits.
Industry·7:00 AM MT
The expiration of enhanced ACA premium tax credits is improving profit margins for several health insurers while increasing uninsured volume at major hospital systems. The enhanced credits, which reduced exchange premiums for millions of enrollees, lapsed and are no longer available. Insurers are seeing improved margins as healthier enrollees drop coverage while sicker members remain, and as medical loss ratios decline. Hospitals report increased uninsured and self-pay volumes as former exchange enrollees seek care without coverage.
Why it mattersMedicaid redeterminations and ACA coverage shifts can drive enrollment growth in Medicaid managed care plans and affect risk pool composition for dual-eligible products.