Jefferson Health and Horizon Blue Cross Blue Shield have reached a contract impasse that could remove three South Jersey hospitals, in Cherry Hill, Stratford and Washington Township, from Horizon's network starting March 1, 2027. Jefferson says Horizon abruptly ended negotiations, while Horizon says Jefferson is demanding $185 million more over three years and canceled an already-reached agreement covering members who rely on Medicaid for coverage. Horizon characterizes Jefferson's move as using Medicaid enrollees as leverage in the broader rate dispute. Patients can still receive in-network care at the three hospitals through February 28, 2027, while the two sides continue negotiating.
Why it mattersMedicaid managed care enrollees in South Jersey could lose in-network access to three Jefferson hospitals if the rate dispute is not resolved before March 2027.
Managed Care
At a FUTURE conference panel in August, home-based care industry leaders described how providers are responding to intensified fraud enforcement by strengthening documentation, audit readiness, enrollment accuracy and policy reviews. Executives from the National Alliance for Care at Home, Home Care Delivered and Freedom Senior Services said CMS is increasingly taking enforcement action, including suspensions and revocations, without a prior fraud finding, making it harder to distinguish compliant operators who make occasional errors from intentional bad actors. Panelists argued compliant providers can use the scrutiny to differentiate themselves by demonstrating clean track records and proactive compliance practices, including unannounced internal audits and claims scrubbing. The discussion covers home health, hospice and Medicaid home- and community-based care providers who serve this population.
Why it mattersMedicaid HCBS and home health providers face mounting risk of enrollment restrictions, suspensions, or revocations even absent a fraud finding, making robust compliance infrastructure a near-term operational necessity rather than optional best practice.
LTSS
Skilled Nursing News reports GLP-1 medications are increasingly common among nursing home admissions, with Venza Care seeing 30-40% of new residents arriving on these drugs for diabetes, weight loss, cardiovascular and metabolic conditions. Facilities face added clinical burdens including staff education, frailty monitoring, and dietitian oversight, alongside complex payment questions. CMS's bridge program covers certain GLP-1s under Medicare Part D for weight loss with a $50 monthly fee, but dual-eligible residents may lack funds to cover it, and the more permanent BALANCE program has been delayed indefinitely while the bridge program was extended through 2027. Residents on Medicare Part A with existing GLP-1 prescriptions shift the medication cost burden onto the nursing facility itself.
Why it mattersSkilled nursing operators face rising, unbudgeted pharmacy costs and clinical oversight burdens from GLP-1 use, while dual-eligible residents risk coverage gaps as CMS delays a permanent reimbursement solution.
LTSS · Pharmacy · Finance
Aetna Better Health of Oklahoma has named Traylor Rains as its new CEO, where he will oversee Medicaid strategy and operations for enrollees in the state's SoonerSelect managed care program. Rains previously served as Oklahoma's Medicaid director and held senior leadership roles at the state's Department of Mental Health and Substance Abuse Services and Department of Human Services. His move from state regulator to health plan executive brings direct knowledge of Oklahoma's Medicaid managed care rollout to the insurer's leadership.
Why it mattersThe appointment gives Aetna's Oklahoma Medicaid plan a leader with insider knowledge of the state agency overseeing SoonerSelect, potentially shaping how the plan navigates contract compliance and state relations.
Managed Care
After third-quarter earnings, the four largest for-profit hospital operators diverged on 2026 expectations. HCA kept its guidance range but now expects to land in the upper half, while Tenet raised its EBITDA and free cash flow outlook for the second straight quarter on strong same-store revenue growth. Community Health Systems cut guidance again, citing weaker payer mix and acuity amid a challenging macro environment, and Universal Health Services reiterated its range but now expects results toward the lower end due to slower de novo hospital ramp-up. Several operators, including HCA and Tenet, cited an unfavorable payer mix tied to patients losing exchange coverage and rising uninsured volume, while HCA also noted a modest increase in net benefit from Medicaid supplemental payment programs.
Why it mattersHospital operators' diverging outlooks signal how exchange coverage losses, uninsured volume growth, and Medicaid supplemental payment trends are reshaping payer mix and margins across the largest Medicaid-serving systems.
Finance · Managed Care
In a Becker's Hospital Review roundup, ten hospital and health system CEOs describe how they are communicating with employees as Medicaid cuts, 340B changes and site-neutral payment proposals squeeze hospital budgets heading into 2027. CEOs from organizations including River Valley Health, Daviess Community Hospital, Sinai Chicago, Bluestem Health, Seneca Healthcare District and University of Rochester Medicine describe tactics such as monthly all-staff financial reviews, department-level budget transparency, advance notice to affected staff before organization-wide announcements, and enlisting frontline employees to identify cost-saving opportunities. Several CEOs, including Sinai Chicago's Ngozi Ezike, specifically cite Medicaid reimbursement pressure tied to federal legislation as a driver of the financial strain. The piece frames transparency and staff participation as strategies for sustaining trust through layoffs, service changes and restructuring.
Why it mattersSafety-net and rural hospitals absorbing Medicaid reimbursement cuts face workforce retention risk alongside financial strain, making CEO communication strategy a direct operational concern for Medicaid-dependent providers.
Finance
A Health Affairs study published in November 2026 found Medicare Advantage enrollees were less likely than traditional Medicare beneficiaries to receive post-hospital care at top-rated skilled nursing facilities or at facilities near their homes. Researchers examined more than 1.45 million Medicare beneficiaries discharged to skilled nursing facilities in 2022, finding MA enrollees in narrow-network plans were 22% less likely to enter a five-star facility, and those in broader networks were still 13% less likely. Higher-quality facilities with stronger nurse staffing were more often excluded from MA networks, and Black, Hispanic, and Asian beneficiaries, along with people dually eligible for Medicare and Medicaid, were more likely to be enrolled in plans with narrower networks. Researchers say current federal network adequacy standards are weak and recommend stronger requirements to ensure access to high-quality facilities.
Why it mattersDual-eligible beneficiaries and Medicaid-serving plans face compounding access barriers when Medicare Advantage network designs systematically exclude higher-quality nursing facilities.
LTSS · Managed Care
A study published Nov. 2 in Health Affairs, by researchers from Tulane and Northeastern universities, finds that nonprofit hospitals in high-need communities set income eligibility thresholds for free and discounted care that are similar to those set by hospitals in lower-need areas. Drawing on IRS data from 1,624 nonprofit hospitals between 2013 and 2022, the researchers found that expanding free care eligibility by 100 percentage points of the federal poverty level was associated with roughly $184,600 more in charity care and $539,600 less in bad debt for a hospital with median operating expenses. That association was stronger in high-need counties, where the same expansion correlated with about $383,400 more in charity care and $1.68 million less in bad debt. The authors conclude that eligibility thresholds may signal charitable intent, but actual charity care delivered is driven largely by local community demand.
Why it mattersHospital financial assistance policies directly affect uninsured and underinsured patients' out-of-pocket exposure and influence uncompensated care costs that states and Medicaid stakeholders track in assessing community need.
Finance
Novant Health has completed its acquisition of Northern Regional Hospital, a 133-bed facility in Mount Airy, North Carolina, now renamed Novant Health Northern Regional Medical Center. The Surry County Board of Commissioners approved the deal in June, and the hospital's roughly 1,000 employees officially joined Novant on November 2. This is Novant's second rural hospital acquisition in northwest North Carolina in five months, following its acquisition of Community Hospital of Stokes in Danbury. Novant now operates 23 hospitals and more than 900 locations across North Carolina and South Carolina, and plans to expand services at the newly acquired facility.
Why it mattersConsolidation of rural hospitals into larger systems can affect Medicaid beneficiaries' access to local services, provider network composition, and state oversight of rural safety-net facilities.
At Becker's CEO + CFO Roundtable in Chicago on November 2, four rural hospital and health system CEOs discussed strategies for sustaining access amid workforce shortages, thin margins and limited capital. Leaders from Hospital Sisses Health System, Edgerton Hospital, Avera Sacred Heart and Troy Regional Medical Center highlighted tactics including swing-bed programs for longer-term rehab, community-based clinics in unconventional locations like a public library, stable local emergency physician staffing, and specialized service lines such as geropsych and addiction medicine units. The common theme across responses was prioritizing patient access and community presence over short-term margin optimization.
Why it mattersRural hospitals that serve high shares of Medicaid patients are testing service-line and staffing models that could shape how Medicaid managed care plans structure rural network adequacy and reimbursement arrangements.
LTSS · Behavioral Health
Becker's Hospital Review reports five hospital acquisitions completed in the first two days of November. Novant Health acquired Northern Regional Hospital in Mount Airy, N.C., its second rural North Carolina hospital in five months. Bon Secours Mercy Health acquired Fauquier Health in Warrenton, Va. from Lifepoint Health, entering Northern Virginia and reaching 48 hospitals system-wide. Other deals include MultiCare Health System's affiliation with Samaritan Health Services, UW Health's acquisition of a Marshfield, Wis. campus from Sanford Health, and Baystate Health's takeover of Mercy Medical Center in Springfield, Mass. from Trinity Health of New England.
Why it mattersHospital consolidation reshapes Medicaid managed care network adequacy, contracting leverage, and rate negotiations across the affected states as acquiring systems absorb facilities, staff, and payer contracts.
Managed Care
In a Becker's Hospital Review interview, Stephanie Everett, administrator and CEO of Mountrail County Health Center in Stanley, N.D., describes her facility's four-year, $53 million expansion that includes a new nursing home with more assisted living units, expected to be completed in early 2028. Everett argues that nursing homes remain essential as rural areas face nursing shortages, workforce gaps, and weather-related barriers that make home-based care and AI tools impractical substitutes for in-person care. She contrasts this with industry trends of hospital-at-home expansion alongside reported closures and reductions in home health, hospice, and hospital-at-home programs elsewhere. Everett also emphasizes building workplace cultures that empower staff judgment and trust as key to sustaining nursing home operations long-term.
Why it mattersLong-term care providers and state Medicaid LTSS programs face mounting workforce and capacity pressures that shape nursing facility bed availability and access for Medicaid-dependent nursing home residents.
LTSS
Kansas City-based Children's Mercy, a nonprofit pediatric hospital system, announced Nov. 2 it will eliminate 115 positions, about 1.2% of its nearly 9,000-person workforce, largely in nonclinical administrative, leadership and support roles. Separately, the system is outsourcing 473 revenue cycle and scheduling employees to Ensemble, a revenue cycle management vendor, who will continue supporting hospital operations under the new arrangement. The hospital cited rising costs and reimbursement that has not kept pace as drivers of the restructuring, and said the changes are meant to preserve its status as one of 28 independent freestanding children's hospitals nationally.
Why it mattersPediatric hospitals reliant heavily on Medicaid reimbursement are restructuring operations as cost growth outpaces payment rates, a financial pressure point relevant to state agencies and plans negotiating rates with children's hospitals.
Finance
University Hospitals, a Cleveland-based health system, still has no estimated timeline for restoring IT systems nearly two weeks after detecting unusual server activity on Oct. 22. A Nov. 2 update said facilities, emergency departments and physician offices remain open with most appointments proceeding as scheduled, but the MyChart patient portal is offline and the system cannot process payments at time of service since it operates cashless. Providers are using phone, Zoom or in-person visits in place of video calls, and printing, faxing or calling in prescriptions when e-prescribing is unavailable. UH has not disclosed the cause of the incident or whether patient data was compromised.
Why it mattersProviders and patients relying on University Hospitals face prolonged disruptions to billing, prescribing and records access, and any confirmed data compromise could trigger breach notification and compliance obligations affecting Medicaid-enrolled patients served by the system.
MultiCare Health System and Samaritan Health Services officially completed their merger on Sunday after receiving approval from state regulators. Tacoma, Washington-based MultiCare has committed to investing $700 million over the next decade into Samaritan's facilities and technology. The merger combines two nonprofit health systems, consolidating their operations and resources under MultiCare.
Why it mattersHospital system consolidation of this scale can reshape local provider networks and negotiating leverage that Medicaid managed care plans rely on for network adequacy and contracting.
Managed Care
At Becker's CEO + CFO Roundtable on Nov. 2, WVU Medicine CEO Albert Wright Jr. described how the West Virginia system grew from five hospitals in 2014 to 31 across four states, most recently acquiring Greensburg, Pa.-based Independence Health System. Wright said the expansion into Pennsylvania's Pittsburgh suburbs adds roughly 750,000 people to the system's referral base, supporting low-volume, high-complexity programs at its Morgantown academic medical center and adding scale for its group purchasing organization and its provider-sponsored plan, Peak Health, which will launch Medicare Advantage plans in Pennsylvania. Wright emphasized the system's model of local hospital boards, capped corporate overhead, and reinvesting profits in local communities, contrasting it with the corporate structure Independence brought that WVU Medicine is now dismantling. He said the strategy reflects the system's founding mission to keep West Virginia hospitals under in-state control rather than out-of-state operators.
Why it mattersHealth systems and plans tracking multistate consolidation should note WVU Medicine's acquisition pattern and its provider-sponsored plan's entry into Pennsylvania's Medicare Advantage market as a sign of expanding payer competition in the region.
Sutter Health's board has approved $189 million for the first phase of an expansion at Memorial Medical Center in Modesto, California, according to a Nov. 2 news release. Construction is expected to begin in spring 2028 and will activate two shelled floors, adding 56 medical and telemetry beds, a 20-bed NICU, and 36 postpartum maternity beds. The project builds on the system's nearby Advanced Cancer Center and Care Complex, a 165,000-square-foot facility slated to open in 2029. The expansion aims to boost inpatient capacity as demand for hospital services grows in the region.
Why it mattersAdded NICU and postpartum capacity at a major regional hospital expands access to maternal and newborn care that Medicaid-covered births and infants in the Central Valley rely on.
Maternal
In a Becker's Hospital Review series, hospital and health system revenue cycle executives describe how payer behavior has shifted over the past year and how their teams responded. Executives from Access Medical Clinic, Thorek Memorial Hospital and UC Davis Health cite increased prepayment medical record reviews, outsourced utilization review vendors with shifting authorization criteria, and more aggressive medical necessity challenges even after prior authorization was secured. Responses included negotiating directly with payers using sample documentation to remove blanket claim edits, building CPT-code-specific authorization tracking work queues, and integrating utilization management and clinical teams to strengthen documentation before claims submission. The piece is a recurring Q&A series soliciting further reader responses on payer-related operational challenges.
Why it mattersHospital finance leaders face rising administrative burden and cash-flow delays from automated payer review tactics, requiring new documentation and payer-negotiation strategies to protect reimbursement.
Finance
Bon Secours Mercy Health closed two Virginia transactions on Nov. 1: acquiring Fauquier Health, a 97-bed acute care hospital in Warrenton, from Lifepoint Health, and acquiring Hampton Roads-based Sports Medicine & Orthopaedic Center. Fauquier Health marks Bon Secours' first hospital presence in Northern Virginia, bringing its statewide hospital count to 12 and its system-wide total to 48 hospitals. The hospital will operate as a network partner, retaining its current president, services and staff without interruption to patient care. The orthopedic practice's three locations will be rebranded as Bon Secours Orthopedics, with its providers offered positions within the system; financial terms of both deals were not disclosed.
Why it mattersThe consolidation expands a major health system's regional market presence and provider network, which can affect Medicaid managed care plans' contracting leverage and network adequacy calculations in Northern Virginia.
Managed Care
BrightSpring Health Services reported Q3 2026 home healthcare revenue of $288 million, up 50% year-over-year, driven largely by its 2025 acquisitions of Amedisys and LHC Group assets. Total company revenue reached $4.21 billion, up 24.6%, with pharmacy solutions contributing the majority. CEO Jon Rousseau outlined plans to expand virtual primary care as a "linchpin" for integrated care, aiming to deepen relationships with Medicare Advantage plans, hospitals and ACOs. The company also announced it was selected for a new Medicare ACO model, LEAD, beginning January 2027, with expected financial impact by 2028.
Why it mattersHealth plans and ACOs partnering with BrightSpring on Medicare Advantage and value-based arrangements should watch how its primary care and ACO expansion reshapes referral patterns and care coordination for dually eligible and high-risk populations.
LTSS
MultiCare Health System completed its affiliation with Samaritan Health Services on November 1, finalizing a deal first announced in 2025. MultiCare committed $700 million over 10 years to expand access, recruit and retain clinicians, support workforce development, and upgrade facilities and technology across Samaritan's Oregon service area. Samaritan retains its name, local leadership, and community-based governance, while its CEO also becomes a senior vice president at MultiCare. The affiliation grows MultiCare into an 18-hospital system spanning Washington, Oregon, and Idaho, with Samaritan's five hospitals serving over 280,000 residents in Oregon's mid-Willamette Valley and central coast.
Why it mattersMedicaid managed care plans and providers in Oregon's mid-Willamette Valley and central coast will deal with a larger, differently governed health system that could reshape provider network contracts and Medicaid-serving capacity in the region.
Managed Care
Tulsa-based Hillcrest HealthCare System went out of network with Aetna on Nov. 1 after the two sides failed to reach a new contract, affecting roughly 15,000 people with Aetna employer-sponsored commercial or Medicare Advantage coverage. Hillcrest says Aetna's below-market rates and payment practices drove the split, while Aetna says Hillcrest sought price increases that would raise costs for members and plan sponsors. Medicaid members enrolled in Aetna Better Health are not affected, and emergency care remains covered; some patients may qualify for continuity-of-care protections. Both parties say they remain open to further negotiation.
Why it mattersThe dispute underscores how payer-provider rate fights can disrupt commercial and Medicare Advantage access even when a plan's Medicaid managed care line is explicitly carved out and protected.
Managed Care
Remote Area Medical, a Tennessee-based nonprofit, ran a free pop-up clinic at a high school in Takoma Park, Maryland, on October 17, where dozens of people slept overnight in cars to secure spots for medical, dental, and vision care. The clinic served 467 patients, most of them uninsured, though about one in four had coverage through Medicare or an employer but still could not afford out-of-pocket costs like routine dental care. More than 300 volunteer clinicians, plus U.S. Public Health Service staff, treated patients, many for high blood pressure, diabetes, and tooth extractions, and referred them to community health centers for ongoing care. The event, in an area with a median household income over $108,000 and 94% insurance coverage, illustrates persistent gaps in affordability and coverage even in wealthier suburban areas.
Why it mattersThe clinic highlights coverage and affordability gaps, including dental benefit exclusions in Medicare and underinsurance, that drive uninsured and underinsured patients toward emergency and charity care rather than stable primary care access.
Dental
SEIU Local 73, representing about 200 advanced practice providers at Chicago's UI Health, filed a 10-day notice of intent to strike, with a potential walkout starting on or after Nov. 11. Members authorized a strike in October after seeking a 2% wage increase already given to other campus workers, plus changes to pay transparency, staffing, meal breaks and sick time. UI Health says an Illinois Appellate Court order has temporarily paused collective bargaining obligations and considers a strike unlawful while that order stands, though it has contingency plans to maintain hospital operations. The union says it remains open to mediation rather than a picket line.
Why it mattersA strike at UI Health, a major safety-net academic medical center, could disrupt care access and staffing for Medicaid patients served by the University of Illinois Hospital & Clinics.
Macleods Pharma USA has voluntarily recalled 3,744 bottles of a three-drug blood pressure medication combining olmesartan medoxomil, amlodipine and hydrochlorothiazide after the tablets failed dissolution testing. The recall covers two lots of 40mg/10mg/12.5mg tablets, both expiring May 31, 2027, and affects pharmacies and patients nationwide who received the product. The company notified consignees by letter and began the recall October 7; the FDA classified it Class II on October 26, meaning exposure could cause temporary or reversible health effects. The recall is ongoing and follows a similar September recall of chlorthalidone tablets by Inventia Healthcare for the same dissolution failure.
Why it mattersPharmacies and providers dispensing these lots must identify and remove affected bottles from inventory to avoid dispensing medication with unreliable drug release and effectiveness.
Pharmacy
