Medicaid Monitor
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Becker's Hospital Review

234 stories

Industry·1d ago

Hospital Revenue Cycle Leaders Flag 10 AI-Driven Payer Risks

In a Becker's Hospital Review roundup, revenue cycle executives from health systems including UC Davis Health, Harvard Medical Faculty Physicians, Rush University Medical Center, Carle Health, Lurie Children's Hospital, and Centerstone identify 10 top threats facing hospital billing operations. Leading concerns include payers using AI to review and deny claims faster than providers can respond, automation scaling existing workflow errors, governance gaps in AI-assisted coding creating compliance liability, silent "downcoding" that erodes revenue without appearing in denial reports, expanding prior authorization burdens, and organizational fragmentation that leaves no one accountable for end-to-end financial impact. The piece also highlights unmeasured "care abandonment" by patients unable to navigate administrative hurdles. No new regulation or enforcement action is reported; this is an industry survey of operational risks.

Industry·1d ago

AARP Foundation: Senior Poverty Rate Climbs for Fifth Year

An AARP Foundation analysis of 2025 Census Bureau data found poverty among adults 65 and older has risen for five consecutive years, reaching 15.4% in 2025, up from 9.4% in 2020. The analysis uses the Supplemental Poverty Measure, which factors in government benefits, taxes, and cost of living. Among adults 50 and older, 17.2 million lived in poverty in 2025; those 50-64 had the lowest rate at 12.1%, while women over 65 faced higher poverty (16.8%) than men (13.7%). The report highlights a broader trend of rising poverty across age groups since a 2020 low point.

Federal Policy·1d ago

CDC Proposal Would Cut Disability Questions From Health Survey

CDC has proposed a major redesign of its National Health Interview Survey, set to take effect in 2028, shifting from in-person interviews to a "sequential mixed-mode" approach with shorter, simplified questionnaires. Many detailed topics fielded annually would be dropped, including a question asking whether a physician diagnosed the respondent with an intellectual or developmental disability or autism; only "foundational measures" based on the Washington Group Short Set on functional status would remain. Disability advocates, including The Arc's CEO Katy Neas, warn the change could worsen undercounting of people with disabilities and disrupt longitudinal tracking of disability prevalence, health outcomes, and funding decisions. The proposal, dated Aug. 20, is open for public comment until Oct. 19.

Industry·1d ago

Insurers Trim 2027 Medicare Advantage Plans, Shift Toward Special Needs Plans

Becker's Hospital Review reports that Medicare Advantage insurers are cutting plan offerings in 28 states for 2027, with total plan counts dipping from 5,553 to about 5,532, even as national enrollment projections hold roughly flat at 34 million. Twelve insurers that sold MA plans in 2026, including several health system-owned plans and some Blue Cross Blue Shield affiliates, will exit the market entirely, while large national carriers like Centene, UnitedHealthcare, and Aetna are each leaving over 100 counties. Growth is concentrated in special needs plans, which will grow 9.4%, with some insurers limiting new dual-eligible enrollment to members already in the insurer's affiliated Medicaid plan. CMS raised 2027 MA payments by 2.48% (4.98% counting risk score trends), which insurers say is insufficient to offset rising medical costs, setting up a second consecutive year of enrollment upheaval ahead of the Oct. 15–Dec. 7 annual enrollment period.

Industry·1d ago

Rural Surgeon Shortages Drive Worse Patient Outcomes, Data Show

Becker's Hospital Review compiles data showing rural surgical workforce shortages are worsening patient outcomes. Nationally there are 59.2 surgeons per 100,000 people, with a projected shortage of nearly 28,000 surgeons by 2038, and 30% of counties have no identified surgeon. Rural Medicare beneficiaries face higher 30-day mortality, complications and readmissions after common surgeries, and death rates from emergency conditions like appendicitis and hernias are now 86% higher in rural areas than urban ones. Responses include federal rural health transformation funding, state-funded workforce grants such as UNC System's rural surgery partnership, and new accreditation pathways from the American College of Surgeons for rural cancer programs.

Legal·AZ·1d ago

Arizona AG Sues Express Scripts, Optum Over Opioid Role

Arizona Attorney General Kris Mayes filed a consumer fraud lawsuit Oct. 1 against pharmacy benefit managers Express Scripts and Optum, alleging their formulary and rebate practices fueled the state's opioid epidemic over more than two decades. The complaint alleges the PBMs gave OxyContin unrestricted preferred formulary status in exchange for confidential payments from Purdue Pharma, avoided prior authorization and step-therapy controls, distributed misleading materials downplaying addiction risk, and sold prescriber data for targeted opioid marketing. Filed under the Arizona Consumer Fraud Act, the suit seeks restitution, civil penalties, injunctive relief, disgorgement and corrective programs. It closely mirrors a similar Arkansas lawsuit filed against the same two PBMs in June 2024, part of a broader wave of state litigation scrutinizing PBM business practices.

Industry·AZ·1d ago

Aetna to Acquire Mercy Care Stakes From Ascension, CommonSpirit

CommonSpirit's Dignity Health and Ascension have each agreed to transfer their combined ownership stakes in Arizona's Mercy Care health plan to CVS Health subsidiary Aetna. CommonSpirit held a 49.75% stake in the plan as of mid-2026, and Ascension co-owns the remainder with Dignity Health. Aetna has run Mercy Care's daily operations and administrative services for more than 20 years, and the companies describe the ownership transfer as a natural evolution of that existing partnership. Mercy Care serves Medicaid and dual-eligible members through Arizona's Medicaid program and Medicare Special Needs Plans; the deal is expected to close in fiscal year 2027 pending regulatory review.

Legal·2d ago

Oracle Health Breach Now Affects 29 Hospital Systems

Becker's Hospital Review reports that 29 hospitals and health systems have confirmed patient data was compromised in a 2025 breach of Oracle Health's legacy Cerner systems, with the intrusion dating back to at least Jan. 22, 2025. Affected organizations include Atrium Health, AdventHealth, Christus Health, Baptist Health South Florida, and LifeBridge Health, among others. Oracle Health reportedly asked healthcare organizations to delay patient notification while the investigation continued, and the vendor now faces legal action over the incident. Health systems are continuing to notify patients as the full scope of affected entities becomes clearer.

Industry·WA·2d ago

MultiCare Health System Launches New Medicare Advantage Plan

MultiCare Health System, a 13-hospital nonprofit system based in Tacoma, Wash., announced on Oct. 1 the launch of MultiCare Health Plan, a wholly owned subsidiary. Its first product will be a Medicare Advantage HMO with drug benefits, available for the 2027 plan year in three Washington counties, supported by independent physician association Physicians of Southwest Washington. Karen Decaran-Voigt, a longtime payer and provider executive with prior roles at Molina, UnitedHealth, CommonSpirit and Elevance, will lead the new plan. The move comes as MultiCare pursues an affiliation with Samaritan Health Services, whose own health plan continues to offer Medicaid and D-SNP products, and runs counter to a broader trend of health systems shutting down their own insurance plans amid rising costs.

Industry·OK·2d ago

Oklahoma Critical Access Hospital Plans Staffing, Contract Cuts for 2027

In a Becker's Hospital Review report, Arbuckle Memorial Hospital CFO Denise Welch describes how the Sulphur, Oklahoma critical access hospital is preparing its 2027 budget amid financial pressure. The hospital plans to cut staffing redundancies and hold outside contract spending flat rather than reduce wages, which Welch says would hurt amid competitive labor markets. Welch said the hospital will continue investing in technology and informatics infrastructure to avoid care delays and reduce outside exposure, while updating fully depreciated building infrastructure to maintain its current reimbursement status. The comments illustrate budget tradeoffs facing small rural hospitals heading into 2027.

Industry·TN·2d ago

Vanderbilt Health's FY2026 Margin Jumps on TennCare Payments, Acquisition

Vanderbilt Health reported fiscal 2026 operating income of $452 million (4.7% margin), up from $255 million (3.0% margin) in fiscal 2025, per its Sept. 30 financial report. Operating revenue rose 12% to $9.5 billion, driven by higher surgical, procedural, ambulatory and pharmacy volumes, while expenses grew 9.9% on staffing and drug cost increases. The system recognized $230 million in fiscal 2026 from TennCare's Hospital Investment Program, a supplemental Medicaid payment program using an average commercial rate approach, up from $179 million the year prior. Vanderbilt also completed full acquisition of Tennova Healthcare-Clarksville in February, and net income rose to $775 million from $424 million.

Industry·2d ago

BRG Study Finds 340B Drug Margin Hit $142 Billion in 2025

In its "6 study notes" roundup, Becker's Hospital Review reports on an October Berkeley Research Group study estimating patients and payers spent $244.3 billion on 340B drugs in 2025, more than double 2021's $108.4 billion. BRG calculates a "340B drug margin", the gap between covered entities' discounted acquisition cost and what patients and payers are later charged, at $142.2 billion in 2025, over double the 2021 figure. Commercial insurers bore 63% of that margin, Medicare 25%, and Medicaid managed care 7%, while Medicaid fee-for-service generates no margin since it reimburses at acquisition cost. BRG attributes growth to hospital acquisition of off-site clinics, expanded hospital participation, and a surge in contract pharmacies from roughly 1,300 in 2010 to about 35,000 today.

Legal·2d ago

DOJ Memo Prioritizes Healthcare Fraud in Corporate Investigations

An Oct. 1 memo from Assistant Attorney General Colin McDonald directs the Justice Department's National Fraud Enforcement Division to prioritize healthcare fraud, including controlled substance distribution and FDCA violations, as one of four focus areas for corporate investigations. Prosecutors must weigh 10 factors when deciding on charges or plea agreements, including corporate management's knowledge of schemes, efforts to conceal fraud from government auditors, and conduct causing substantial harm to taxpayer-funded programs. The division, formed in April from the former Criminal Division Health Care Fraud Unit, is using data analytics to accelerate new investigations and will develop whistleblower incentive programs, including for participants in misconduct. The policy also directs prosecutors to follow existing self-disclosure and cooperation credit guidance while avoiding overly broad enforcement.

Industry·2d ago

Aledade Promotes ACO Model to Boost Primary Care Coordination

In a sponsored Becker's Hospital Review piece, Aledade argues that strengthening primary care as a health system's coordinating hub improves outcomes and financial sustainability. The piece cites research showing Medicare patients with limited primary care access face higher rates of emergency surgery, postoperative complications, and 30-day readmissions. It contends health systems often struggle with fragmented EHRs and delayed claims data that undermine timely care coordination, and promotes Aledade's accountable care organization model as a way to give clinicians operational support without replacing existing infrastructure. The piece is industry marketing content rather than a report of new policy or regulatory action.

Industry·2d ago

Health Systems Build Digital-First Primary Care Teams Alongside Clinics

Becker's Hospital Review reports that Cleveland Clinic, Inova Health System and MCR Health are redesigning primary care delivery to treat digital engagement as a parallel "second clinic" alongside traditional in-person visits. Cleveland Clinic Florida is building dedicated teams of medical assistants, nurses, pharmacists and advanced practice providers to manage a 153% surge in patient portal messaging since 2020, separate from scheduled office visits. Inova is restructuring scheduling and access pathways around patient convenience rather than traditional clinic hours, while MCR Health, a federally qualified health center, is emphasizing mobile services, community partnerships and outreach to overcome transportation and trust barriers. The shift reflects a broader industry move toward team-based, longitudinal care that is not tied to a single clinician, location or visit type.

Industry·2d ago

Hospital Leaders Detail Tactics to Cut Observation-Status Denials

In a Becker's Healthcare webinar sponsored by CorroHealth, five hospital and health system leaders discussed strategies for reducing revenue loss tied to observation-versus-inpatient status decisions. Panelists from Bozeman Health, Premier Health, Jackson Memorial Hospital, Children's Hospital of Philadelphia, and CorroHealth described rising payer denial rates, some markets now exceeding 30%, up from under 17% in 2020, often tracing back to the initial status call at admission. Tactics discussed include embedding observation liaisons in emergency departments, daily case rounds within 24 hours of admission, cross-functional teams spanning the revenue cycle, and change management to drive clinician buy-in. The panel emphasized that technology alone cannot fix denial trends without organizational alignment and provider-driven, regulation-consistent status strategies.

Industry·2d ago

Aspirion Pitches AI Tool to Find Patterns Behind Clinical Denials

In a Becker's Hospital Review piece, Aspirion executives argue that hospitals focused only on overturning individual clinical denials miss the recurring patterns driving them, and promote the company's AI-enabled "ClinIQ" platform as a solution. The piece cites Kodiak Solutions data showing revenue leakage across more than 2,300 hospitals rose about 25% in 2025 to $48.4 billion, driven partly by clinical denials tied to medical necessity, and a survey finding 76% of revenue cycle leaders expect denial rates to keep rising. Aspirion frames denials as falling into two categories, payer behavior versus provider documentation gaps, and says its tool helps health systems distinguish the two at scale and route insights to CDI, utilization management, and managed care teams. Aspirion reports its clients see appeals filed 2.2 times faster and a 64% resolution rate using this approach.

Industry·2d ago

State Officials Press for Scrutiny of Hospital Megamergers

Minnesota Attorney General Keith Ellison is reviewing HealthPartners' proposed acquisition of Essentia Health, a deal that would create a 22-hospital nonprofit system with roughly 45,000 employees, and is seeking public input under state healthcare, charities and antitrust laws. In North Carolina, State Treasurer Brad Briner has called on the state attorney general and federal regulators to scrutinize Atrium Health's proposed combination with WakeMed Health & Hospitals, citing concerns about prices, competition and access. Both deals exemplify a broader wave of cross-market "megamergers" as systems seek scale, diversified risk and stronger payer leverage instead of same-market deals that draw heavier antitrust review. Kaufman Hall data shows two-thirds of Q2 hospital transactions involved independent systems seeking partners from positions of strength rather than financial distress, signaling consolidation is accelerating even among stable organizations.

State Policy·CA·2d ago

California Enacts AI Clinical Judgment and Bias Safeguards for Healthcare

Gov. Gavin Newsom signed AB 1979 and SB 503 on Sept. 30, establishing new safeguards that protect physicians' and licensed providers' professional judgment when AI or clinical decision tools are used in patient care, and requiring AI developers to take reasonable steps to reduce known or predictable bias in those tools. The laws are part of a broader package addressing AI's role in workplaces and consumer protection. Newsom vetoed a related bill, AB 2575, which would have barred retaliation against healthcare workers who override unsafe AI recommendations; the California Nurses Association criticized the veto. The California Hospital Association said it no longer opposes AB 1979.

Industry·CA·2d ago

CommonSpirit Narrows Operating Loss, Books $2.3B Conifer Exit Charge

CommonSpirit's fiscal 2026 financial report shows an operating loss of $430 million (-1.0% margin) excluding special charges, improved from a $687 million loss the prior year. Including $2.8 billion in special charges, largely a $2.3 billion hit tied to exiting its Conifer Health Solutions revenue cycle venture, plus a tradename impairment and restructuring costs, the system's total operating loss was $3.2 billion. Revenue grew 8.5% to $42.4 billion, helped by $991 million in California Provider Fee Program net income, up sharply from $305 million the year before. The 136-hospital system posted a net loss of $662 million for the year, compared to $1.1 billion in net income in fiscal 2025.

Federal Policy·3d ago

CMS Finalizes International Reference Pricing Model for Part B Drugs

CMS finalized the GLOBE Model, a mandatory payment model tying Medicare Part B drug inflation rebates to prices paid in 19 reference countries, per a Sept. 30 CMS news release. The regulation takes effect Nov. 30, with voluntary manufacturer data submission beginning Jan. 1, 2027, a five-year performance period from April 2027 through March 2032, and a seven-year payment period running through March 2034. The final model is narrower than proposed, excluding orphan-only drugs, biosimilars, plasma-derived products and certain cell and gene therapies, cutting projected Medicare Part B savings from $8.4 billion to $440 million over the payment period. GLOBE applies to a random sample of ZIP code areas covering about 25% of Original Medicare Part B beneficiaries and follows the Medicaid-focused GENEROUS model, under which 40 states and Puerto Rico have already agreed to similar international benchmarking for Medicaid drug pricing.

Industry·TX·3d ago

Baylor Scott & White's Health Plan Exits Medicaid, Individual Markets

Baylor Scott & White Health reported operating income of $1.5 billion, an 8.3% margin, for the fiscal year ending June 30, 2026, down from $1.7 billion (10% margin) the prior year, despite a 6.6% rise in operating revenue. The Dallas-based system's health plan arm exited the Medicaid and individual insurance markets during the period, according to financial statements published Sept. 30. The system did not detail the exact states or enrollment affected in the summary provided. The move reflects broader insurer pullback from Medicaid managed care amid redetermination-driven enrollment losses and tightening margins.

Federal Policy·3d ago

Seven Healthcare Laws, Including Medicaid Eligibility Limits, Start Oct. 1

Becker's Hospital Review rounds up seven federal and state healthcare laws taking effect October 1, including a federal provision narrowing Medicaid eligibility for many lawfully present noncitizens under Section 71109 of HR 1, which limits federal eligibility for certain immigrant groups. The roundup also covers Connecticut's certificate-of-need overhaul and Maryland's new hospital staffing framework among other state-specific changes. These laws affect state Medicaid agencies administering eligibility determinations, health plans serving affected populations, and hospitals in Connecticut and Maryland. The changes take effect October 1, 2026.

Industry·OH·3d ago

UPMC Completes Acquisition of Trinity Health System From CommonSpirit

UPMC has completed its acquisition of Steubenville, Ohio-based Trinity Health System from CommonSpirit Health, with ownership transferring October 1. The deal gives Pittsburgh-based UPMC its first hospital footprint in Ohio, adding four facilities: Trinity West and Trinity East in Steubenville, Trinity Twin City Medical Center in Dennison, and Trinity St. Clairsville Neighborhood Hospital. The acquisition expands UPMC's regional health system presence across the Pennsylvania-Ohio border into a new state market.

Federal Policy·3d ago

Commerce Defines Exemptions to New 100% Pharma Import Tariff

The 100% Section 232 tariff on patented pharmaceuticals and related pharmaceutical ingredients took full effect September 29 for companies not covered under the earlier July 31 implementation date. The Commerce Department's Bureau of Industry and Security has specified which specialty pharmaceutical products qualify for a 0% tariff rate and which countries are eligible for exemptions. Drug manufacturers, importers, and distributors must now determine whether their products fall under the exempt categories or face the full tariff. The distinction affects sourcing and pricing decisions across the pharmaceutical supply chain.

Industry·MN·4d ago

HealthPartners, Essentia Health Plan Merger Into 22-Hospital System

HealthPartners of Bloomington and Essentia Health of Duluth announced plans on Sept. 29 to merge into a combined 22-hospital health system, marking the third major deal involving a Minnesota-based system in 2026. The consolidation underscores accelerating hospital and health system M&A activity concentrated in Minnesota this year. Terms and a target closing date were not detailed in the announcement. HealthPartners also operates a Medicaid managed care plan, so the combined entity's scale could affect provider networks and negotiating leverage in the state.

Industry·4d ago

Survey: ACA Subsidy Expiration Slowing Hospital Procedure Volumes

Becker's Hospital Review reports on a Sept. 23 Evercore ISI survey finding that nearly one in four hospital executives say the expiration of enhanced ACA premium subsidies has already begun slowing procedure volumes at their facilities. Evercore ISI, the equity research arm of investment bank Evercore, surveyed hospital executives to gauge early operational effects of the subsidy lapse. The findings suggest patients losing or facing higher-cost ACA marketplace coverage may be delaying or forgoing elective and other procedures. The survey signals early volume and revenue pressure for hospitals as coverage losses tied to the subsidy expiration ripple through the health system.

State Policy·4d ago

Four States, Indiana Health System Erase $1.1B Medical Debt

Four states and an Indiana health system partnered with the nonprofit Undue Medical Debt in 2026 to erase more than $1.1 billion in residents' medical debt. The organization works by purchasing bundled medical debt at reduced rates and canceling it for qualifying individuals. Undue Medical Debt states it has eliminated more than $40 billion in medical debt nationwide since it was founded in 2014. The initiative affects residents carrying unpaid medical bills, many of whom may also be Medicaid-eligible or uninsured populations facing collections and credit impacts.

Industry·4d ago

AMA Report: Top Four PBMs Now Control 75% of Market

The American Medical Association's September 2026 Policy Research Perspective, drawing on Decision Resources Group data from 2022 to 2024, found the four largest pharmacy benefit managers now control 75% of the national market, up from 70% in 2022. The report documents continued consolidation among PBMs and insurers tracked over the study period. Becker's Hospital Review summarizes six key findings from the analysis. The data underscores ongoing concentration trends affecting drug pricing and negotiation leverage across the pharmaceutical supply chain.

Industry·4d ago

Becker's: 2027 Drug Pricing Changes Pose Cash Flow, Not Margin, Risk

In a Becker's Hospital Review commentary, the author argues that three federal drug pricing changes taking effect Jan. 1, 2027 should be understood primarily as a cash flow timing problem rather than a permanent margin loss for providers and pharmacies. The piece pushes back on recent coverage characterizing the changes as catastrophic, arguing the actual financial mechanics are more nuanced. The commentary frames the issue around how multiple federal changes converging on the same prescription create timing mismatches in reimbursement rather than structural profitability declines. The author's argument centers on encouraging providers and pharmacy stakeholders to reassess their operational and financial planning assumptions ahead of the effective date.

Industry·4d ago

McKinsey: AI Could Handle Up to 22% of Outpatient Care

A McKinsey & Co. analysis published Sept. 28 estimates AI could perform the clinical work behind 16% to 22% of U.S. outpatient claims, representing roughly 2 billion to 3 billion claims and 13% to 19% of outpatient spending. The analysis draws on 2024 commercial, Medicare and Medicaid claims data. It suggests a substantial share of outpatient services across payer types, including Medicaid, involve tasks that current AI capabilities could technically automate. The report does not specify implementation timelines or payer-specific adoption plans.

Legal·MD·5d ago

UMMS Settles With Maryland AG Over Facility Fee Billing

University of Maryland Medical System agreed to pay more than $2.25 million in restitution to patients to resolve a dispute with the Maryland attorney general's office over outpatient facility fees. The settlement covers facility fees charged between January 1, 2017 and June 30, 2021, and was signed in September. Affected patients who were billed these fees during the covered period will receive refunds under the agreement. The case highlights continued regulatory scrutiny of hospital facility fee billing practices that affect commercially insured and government payer patients alike.

Legal·5d ago

UnitedHealthcare, TeamHealth Settle $100M Upcoding Lawsuit

UnitedHealthcare and TeamHealth voluntarily dismissed with prejudice a lawsuit in which the insurer had accused the physician staffing company of upcoding emergency department claims. The dismissal, filed September 24 in Tennessee federal court, followed the parties notifying the court on August 11 that they had reached a settlement. Terms of the settlement were not disclosed in available court records. While the case involved commercial claims rather than Medicaid specifically, the underlying upcoding allegations against a major ED staffing firm are relevant to program integrity efforts across payers, including Medicaid managed care plans that contract with or reimburse similar staffing arrangements.

Managed Care·5d ago

Yale Researchers Propose 10 Policies to Cut Healthcare Spending

Yale University researchers published 10 policy proposals aimed at reducing U.S. healthcare spending, touching Medicare Advantage payment methodology, site-neutral payment policy, drug pricing, and nursing home care. Nine of the proposals come with combined annual savings estimates ranging from roughly $70 billion to $84 billion; the tenth is not quantified in the same way. The proposals target federal payers and providers broadly rather than Medicaid specifically, though several areas, drug costs and nursing home/LTSS spending, overlap with state Medicaid programs. No implementation timeline or legislative vehicle is specified; these are research recommendations, not enacted policy.

Industry·5d ago

Hospital CEOs Warn 340B Rebate Pilot Could Strain Cash Flow

Becker's Hospital Review reports that hospital CEOs are closely watching a limited federal rebate pilot set to begin January 1, 2027, that would change how some 340B drug discounts are delivered. Currently, eligible hospitals receive 340B discounts upfront at the point of purchase; the pilot would instead require hospitals to pay full price and later receive a rebate, delaying access to discount funds. CEOs interviewed say this shift could affect hospital cash flow and staffing decisions, particularly for safety-net and disproportionate-share hospitals that rely on 340B savings to fund operations. The change comes amid ongoing legal challenges to the 340B program's administration.

Industry·AL·5d ago

DCH Health System to End Fayette Medical Center Lease Early

DCH Health System and the Fayette County Hospital Board announced they will not continue their lease agreement for Fayette Medical Center, ending it ahead of its scheduled September 30, 2027 expiration. The arrangement began in October 2007 and covered 20 years of hospital operations in Fayette County, Alabama. The release cites financial factors as the reason for winding down the lease, though the exact termination date and transition plan were not detailed in the announcement. The change affects hospital governance and operations in the county, with implications for Medicaid beneficiaries who rely on the facility for care.

Industry·5d ago

Fair Health Reports Rising Commercial Delivery Costs Nationwide

Fair Health's Cost of Giving Birth tracker finds the median in-network cost of a vaginal delivery reached $15,728 nationally, up 3.6% year-over-year, while cesarean section costs rose 3.2% to $19,911. The analysis draws on commercial claims data and breaks out costs by state. The report does not address Medicaid-specific reimbursement rates or state Medicaid delivery costs, which are typically set separately through state fee schedules or managed care contracts. It matters for benchmarking maternity cost trends even though the underlying data reflects commercial, not Medicaid, payment levels.

Federal Policy·5d ago

Trump Administration Plans to Reshore Production of 86 Key Drugs

According to a Sept. 25 Bloomberg report cited by Becker's Hospital Review, the Trump administration is developing an initiative to move manufacturing of 86 essential medicines to the U.S. within 18 months. Under the plan, the Office of Management and Budget would solicit proposals from healthcare industry stakeholders on how to reshore production of drugs on the list. The report does not specify an effective date or regulatory vehicle for the initiative. Because many of the listed medicines are generics commonly used in Medicaid populations, supply chain shifts could affect drug availability and pricing that state Medicaid pharmacy programs and MCOs manage.

Industry·5d ago

R1 Completes Acquisition of Prior Authorization AI Firm Humata Health

R1 has closed its acquisition of Humata Health, an AI-powered touchless prior authorization company, following an August announcement of the deal. The acquisition supports R1's stated strategy to automate revenue cycle operations through its Phare Operating platform. Health systems and providers using R1's revenue cycle services may see prior authorization workflows increasingly automated as the technology is integrated. The deal reflects broader industry investment in AI tools to speed up prior authorization, a process that affects Medicaid MCO utilization management and provider administrative burden.

Federal Policy·5d ago

Study Finds Sudden Infant Death Widening Black-White Mortality Gap

A study published Sept. 22 in JAMA Network Open found that the gap in infant mortality rates between Black and white babies widened between 2020 and 2024, with sudden unexpected infant death identified as the largest single driver of the disparity. Researchers analyzed federal birth and infant death records covering nearly 58 million live births to reach these findings. The study does not describe a specific policy action or regulatory change tied to the findings. For Medicaid programs, which finance a large share of births and infant care, the research underscores persistent racial disparities in birth outcomes relevant to maternal and infant health initiatives.

Industry·6d ago

Centene Reports Multiple Executive Departures Following $6.7 Billion Loss

Centene has experienced widespread leadership turnover in 2026, spanning state health plan executives to C-suite roles, following a $6.7 billion loss in 2025. The loss was primarily driven by a non-cash goodwill impairment related to HR 1 and the company's declining market value, alongside a 91.9% medical loss ratio. The departures signal organizational instability at one of the nation's largest Medicaid managed care organizations. Centene serves Medicaid beneficiaries across more than 30 states, making leadership continuity significant for state agency oversight and member care continuity.

Legal·8d ago

Labcorp Settles Multistate Data Breach Investigation for $2.28 Million

Labcorp agreed to pay $2.28 million to 44 state attorneys general to resolve an investigation into a 2019 data breach at its former debt-collection vendor, American Medical Collection Agency (AMCA). The breach at AMCA's parent company, Retrieval-Masters Creditors Bureau, exposed personal information of more than 27.5 million people nationwide. The settlement resolves state enforcement actions stemming from the vendor's inadequate data security practices. For Medicaid managed care organizations and providers using third-party vendors for billing and collections, this enforcement action underscores state regulators' willingness to hold covered entities accountable for vendor data security failures affecting patient information, including Medicaid beneficiaries.

Federal Policy·8d ago

New Customs Requirements Set to Disrupt Canadian Prescription Imports October 22

The Wall Street Journal reports that new customs requirements taking effect October 22, 2026, could disrupt access to prescription drugs for millions of Americans who purchase medications from Canadian and other foreign mail-order pharmacies. The change affects individuals who rely on imported pharmaceuticals for cost savings. The timing and scope of enforcement will determine how many consumers and which medication categories face immediate supply interruptions. For Medicaid programs, this could increase formulary pressure if beneficiaries who previously self-paid for imported drugs now seek coverage through state plans, and may affect dual-eligible populations managing Medicare Part D coverage gaps.

Federal Policy·8d ago

AHA Urges Permanent Ban on 340B Rebate Models in SECURE 340B Act Comments

The American Hospital Association submitted comments on September 23 supporting the bipartisan SECURE 340B Act introduced in July, urging Congress to permanently prohibit rebate models in the 340B drug pricing program. The legislation combines hospital-sought protections with new program requirements. AHA stated it shares the bill's goals while seeking the rebate ban provision. This affects how safety-net hospitals and Medicaid providers access discounted pharmaceuticals under 340B, with potential implications for pharmacy carve-outs and drug purchasing arrangements in Medicaid managed care.

State Policy·CA·9d ago

Watsonville Community Hospital Reports $10M Loss in Six Months, Considers Service Cuts

Watsonville Community Hospital in California lost $10 million in the last six months and $22.4 million in 2025, according to a hospital spokesperson. The hospital's board reviewed potential operational changes at a September 22 retreat, including growth opportunities and possible service closures, amid an $85,000 daily cash shortfall. The hospital's financial distress may affect access to care for Medicaid beneficiaries in the Watsonville area, particularly if services are reduced or eliminated.

Industry·9d ago

BCBS Study Finds Hospital AI Billing Tools Added $942M in Excess Costs

The Blue Cross Blue Shield Association released a second study estimating that hospitals' use of AI-assisted billing tools generated approximately $942 million in excess costs to BCBS plans over two years. The findings contribute to an ongoing dispute between hospitals and payers over AI-driven billing and claims practices. The study did not specify a timeframe for the two-year period or detail methodology. For Medicaid managed care organizations contracting with hospitals that deploy AI billing software, the findings suggest potential cost pressures similar to those documented in commercial insurance, though no Medicaid-specific impact data was provided.

Industry·9d ago

John Oliver Episode Spotlights UnitedHealth Vertical Integration Amid Cyberattack and Earnings Decline

In a September 20 episode, late-night host John Oliver questioned UnitedHealth Group's current structure amid heightened scrutiny of its vertical integration. The segment follows a period marked by a major cyberattack, declining earnings, and broader regulatory and public attention to the company's combined insurance and provider operations. No specific policy action or enforcement is reported. The episode reflects growing public and political discourse around health care consolidation, particularly involving firms that operate both health plans and clinical services.

Industry·9d ago

LHC Group Reports Patient Data Breach After Employee Phishing Attack

LHC Group, a home health and hospice provider owned by UnitedHealth Group's Optum, disclosed a data breach stemming from a voice phishing (vishing) attack on an employee. The company became aware of the incident on April 7, 2026, and issued a public notice in September 2026. Patient information was exposed in the breach. The notice does not specify the number of affected individuals or what types of patient data were compromised.

Industry·9d ago

Hospital CEOs Prioritize Budget Increases for 2027 Amid Medicaid Cuts

Hospital and health system CEOs are finalizing 2027 budget priorities as the industry faces deepened Medicaid cuts and revised 340B rebate policies from the Health Resources and Services Administration. The article identifies which budget lines executives are increasing and decreasing in response to these pressures. For Medicaid-dependent providers, these strategic budget shifts signal how hospitals are absorbing state and federal reimbursement reductions and addressing operational sustainability under constrained Medicaid revenue.

Industry·10d ago

Health System CEOs Cite Medicaid Funding Cuts as Top 2027 Priority

Health system CEOs report Medicaid funding reductions as a leading concern heading into 2027, alongside affordability pressures, workforce shortages, and care delivery transformation. The executives describe balancing operational fundamentals with strategic innovation as they plan for multiple simultaneous challenges. The article does not specify which states are implementing cuts, when reductions take effect, or the scale of anticipated funding impacts. For health systems with significant Medicaid patient volume, funding uncertainty affects budget planning, service line decisions, and payer contracting strategies.

Industry·NC·10d ago

North Carolina Treasurer Calls for Scrutiny of Atrium-WakeMed Combination

North Carolina Treasurer Brad Briner is urging state and federal regulators to scrutinize the proposed combination of WakeMed Health & Hospitals and Atrium Health, arguing the deal could reduce competition and raise healthcare costs. The Wake County Board of Commissioners voted 5-2 on September 21, 2026, to approve the proposed combination. The merger would unite two major North Carolina health systems operating in separate geographic markets. For Medicaid managed care organizations, hospital system consolidation can affect network adequacy, contract negotiations, and provider rate leverage in counties where state Medicaid contracts require adequate provider networks.

Legal·10d ago

DOJ Revises False Claims Act Manual to Clarify Enforcement Standards

The Department of Justice updated its False Claims Act manual on September 18, 2026, reinstating and expanding a 2017 policy that subregulatory guidance cannot impose legal obligations beyond those established by statute or regulation. The revision aims to promote fairness and effective enforcement in fraud cases. The change affects how DOJ evaluates and pursues False Claims Act cases, including those involving Medicaid providers and health plans. The updated standards took effect immediately upon publication.

Federal Policy·10d ago

CMS Administrator Oz Announces AI Fraud Detection Priority at Oracle Summit

CMS Administrator Mehmet Oz, speaking at the Oracle Health and Life Sciences Summit, identified AI-driven fraud detection as a top agency priority, drawing parallels to banking sector tools that pushed fraudulent activity into healthcare. The announcement signals CMS intent to deploy advanced detection technology across its programs. Timing for implementation was not specified. For Medicaid state agencies and managed care plans, this represents a coming shift in program integrity oversight and potential new reporting or compliance requirements once CMS operationalizes the approach.

Industry·10d ago

Off-Label GLP-1 Prescribing Rose 15-Fold From 2021 to 2025, Study Finds

A study published in Obesity analyzed medical records from over 92 million U.S. adults and found that off-label use of GLP-1 medications — prescribing to patients without documented obesity or diabetes — increased 15-fold between 2021 and 2025. The research documents a surge in prescribing outside FDA-approved indications during a period of intense commercial and clinical interest in GLP-1s for weight management. For Medicaid programs, rising off-label use raises questions about pharmacy benefit management, prior authorization protocols, and whether state fee-for-service or managed care plans are covering GLP-1s for conditions not meeting medical necessity criteria tied to approved diagnoses.

Industry·10d ago

Becker's Analysis Examines Health System Preparedness for Cell and Gene Therapy Scale-Up

In a commentary piece, Becker's Hospital Review examines operational challenges health systems face as the cell and gene therapy pipeline expands beyond rare disease applications into broader patient populations. With more than 35 FDA-approved cell and gene therapies now on the market and additional approvals expected, the article explores infrastructure, workflow, and care delivery model changes required to administer these treatments at scale. The piece is oriented toward hospital systems and does not address Medicaid-specific coverage, reimbursement, or managed care contract implications for these therapies. While Medicaid programs and managed care organizations will eventually confront CGT coverage and payment policy questions as utilization grows, this particular analysis focuses on provider delivery system readiness without Medicaid program context.

State Policy·TN·10d ago

Tennessee Hospital to Resume Labor and Delivery Services in Spring 2027

Henry County Hospital in Paris, Tennessee will restore maternity services beginning spring 2027, according to a September 22 announcement from West Tennessee Healthcare. The hospital has recruited an additional physician to its women's health team to support the resumption of deliveries. The restoration addresses a gap in local access to obstetric care in the region. For Medicaid agencies and managed care plans serving pregnant beneficiaries in rural Tennessee, this represents restoration of a delivery site that affects network adequacy and access to maternity benefits in Henry County.

Legal·FL·10d ago

Florida Sues Insulin Manufacturers and PBMs Over Alleged Price Inflation Scheme

Florida Attorney General James Uthmeier filed suit in Miami-Dade County Circuit Court against Eli Lilly, Novo Nordisk, Sanofi, and three pharmacy benefit managers, alleging they inflated insulin list prices and paid rebates that increased costs for consumers. The lawsuit accuses the companies of a coordinated pricing scheme involving diabetes medications. The action reflects growing state enforcement efforts targeting pharmaceutical pricing practices that affect state Medicaid pharmacy expenditures and beneficiary access to essential medications. The complaint follows similar insulin pricing litigation in other states.

Federal Policy·10d ago

Becker's Compiles 20 CMS Policy Actions Under Trump Administration in 2026

In its compilation titled 'CMS under Trump: 20 key actions,' Becker's Hospital Review reports CMS has advanced coverage, payment, and program integrity changes throughout 2026. The actions span Medicare and Medicaid payment reforms, ACA marketplace oversight, prior authorization requirements, fraud enforcement, and new value-based care models. The compilation provides an overview of major federal healthcare policy developments across both Medicare and Medicaid programs during the current administration. For Medicaid stakeholders, the relevant subset of these 20 actions may include Medicaid-specific payment policy changes, program integrity enforcement affecting Medicaid managed care, and ACA marketplace changes affecting dual-eligible populations.

Industry·11d ago

Becker's Tracks 14 Healthcare Bankruptcies in 2026 to Date

Becker's Hospital Review is tracking healthcare organization bankruptcies in 2026, reporting 14 filings year-to-date. The publication notes an upward trend from 15 bankruptcies in 2024 to 20 in 2025, attributing financial pressures to workforce shortages, rising operational costs, and declining reimbursement rates. The article appears to be an ongoing tracker compiling bankruptcy filings as they occur rather than reporting a specific bankruptcy event.

Federal Policy·11d ago

CDC Reports Suicide Becomes 10th Leading Cause of Death in 2024

The CDC's National Center for Health Statistics reported on September 22, 2026, that suicide rose to the 10th leading cause of death in the United States in 2024, despite a decline in the absolute number of suicide deaths from the prior year. The final mortality data comes from the CDC's annual leading causes of death report. The shift in ranking reflects changes in other causes of death rather than an increase in suicide mortality. For Medicaid managed care organizations and state agencies, suicide mortality trends directly affect behavioral health network adequacy requirements, crisis intervention program design, and performance measure benchmarks tied to behavioral health access and outcomes.

Industry·MO·11d ago

Missouri Hospital Ends Labor and Delivery Services After Acquisition Citing Financial Losses

Fitzgibbon Hospital in Marshall, Missouri will end labor and delivery services on September 30, 2026, following its acquisition earlier this month by American Medical Administrators. The closure follows a review of hospital operations and financial sustainability, with the inpatient labor and delivery unit operating at a loss. This affects access to maternity services in a rural Missouri community. The decision reflects broader pressures on rural hospitals to maintain obstetric services amid declining volumes and reimbursement challenges.

Industry·11d ago

CommonSpirit Revenue Cycle Leader Outlines AI Guardrails for Denials Management

CommonSpirit Health's system lead for denials management, Deborah Greer, MD, discussed how the health system is implementing artificial intelligence in denials and appeals processes while maintaining physician oversight. Greer emphasized that physician decision-making authority must remain central even as AI tools are deployed by both hospitals and health plans to speed review and denial processes. The article addresses how major health systems are navigating the operational and clinical implications of AI-driven prior authorization and denials management. No specific policy changes or effective dates are identified.

Federal Policy·12d ago

Out-of-Network Emergency Spending Declined After No Surprises Act Implementation

Analysis finds out-of-network emergency care spending has fallen since the No Surprises Act took effect in 2022, contrary to debate focused on arbitration costs. The law protects patients from surprise billing for emergency services they cannot choose. For Medicaid managed care plans with emergency coverage obligations, this federal benchmark on balance billing and dispute resolution may inform state approaches to network adequacy and emergency access requirements, particularly where Medicaid enrollees receive emergency care at out-of-network facilities.

Industry·12d ago

34 Academic Health Systems Acquire Community Hospitals Amid Financial Pressure

Academic health systems are acquiring distressed community hospitals at an accelerated pace driven by financial strain. Staffing shortages, aging infrastructure, heavy reliance on Medicaid and Medicare reimbursement, and rising payer denials are forcing community hospitals to seek partnerships or face closure. Large nonprofit and regional systems are absorbing these facilities as consolidation intensifies across the healthcare sector. The trend reflects broader market pressures affecting safety-net providers serving high Medicaid populations.

Industry·NC·12d ago

Wake County Approves WakeMed-Atrium Health Merger, Sends Deal to State Review

The Wake County Board of Commissioners voted 5-2 on September 21, 2026 to approve the proposed merger between WakeMed Health & Hospitals and Atrium Health. The transaction now proceeds to North Carolina state regulatory review. The merger would combine Raleigh-based WakeMed with Charlotte-based Atrium Health, creating a larger health system footprint across the state. The deal has drawn scrutiny from local stakeholders during the county approval process.

Federal Policy·12d ago

Senators Reintroduce Bill Setting Federal Cybersecurity Standards for Hospitals

Sens. Mark Warner (D-Va.) and Ron Wyden (D-Ore.) reintroduced the Health Infrastructure Security and Accountability Act on September 17, 2026. The legislation would establish minimum federal cybersecurity standards for healthcare organizations and allocate $1.3 billion to help hospitals strengthen their defenses. The bill sets mandatory cybersecurity requirements for healthcare providers, addressing vulnerabilities exposed by recent ransomware attacks on hospital systems. If enacted, it would affect all hospitals and potentially apply to Medicaid providers serving beneficiaries through fee-for-service or managed care arrangements.

Industry·12d ago

Epic AI Tool Rollout Overwhelms Health Systems With Implementation Decisions

Epic Systems is releasing hundreds of AI tools simultaneously, forcing health systems to develop their own prioritization frameworks without clear vendor guidance. Seattle Children's CMIO reports that Epic is deploying 100-300 AI applications at once, leaving providers to independently assess clinical value, workflow integration, and implementation sequencing. Health systems must now triage which AI tools warrant investment and staff training resources. This reflects a broader industry challenge as EHR vendors accelerate AI deployment faster than healthcare organizations can evaluate and integrate new technologies.

Legal·12d ago

NYU Langone, UPMC Settle DOJ Gender-Affirming Care Cases for $9.45M

NYU Langone Health and University of Pittsburgh Medical Center reached settlements with the U.S. Department of Justice totaling $9.45 million ($8.5 million and $950,000 respectively) and agreed to discontinue pediatric gender-affirming care services. The settlements were announced September 18, 2026. The agreements affect pediatric behavioral health and specialty care delivery at two major academic medical centers, both of which likely serve Medicaid-enrolled children. The DOJ enforcement action signals heightened federal scrutiny of gender-affirming care practices for minors, with direct implications for health systems, managed care plans covering these services, and state Medicaid agencies determining covered benefits.

Industry·13d ago

Commercial Payers Deploy AI for Claims Review Faster Than Hospital Revenue Cycle Teams

Commercial health plans are implementing artificial intelligence to automate claims review, pattern recognition, and payment decisions at scale, outpacing hospital revenue cycle automation efforts. The article examines how payer-side AI adoption affects provider revenue cycle strategy and operational planning. This development is relevant to Medicaid managed care organizations that process claims using similar technology platforms and face the same automation economics as commercial plans. The timing and scope of payer AI deployment remain unspecified in the source material.

Federal Policy·13d ago

FDA Approves First Gene Therapy for Sanfilippo Syndrome Type A

The FDA approved Fayuvi (rebisufligene etisparvovec-hopf) on September 17, 2026, as the first treatment for mucopolysaccharidosis type IIIA (Sanfilippo syndrome type A) in pediatric patients. Fayuvi is a one-time intravenous gene therapy using adeno-associated virus serotype 9 to deliver a functional SGSH gene. The approval provides a treatment option for a rare pediatric genetic disease previously without FDA-approved therapies. State Medicaid programs and managed care plans will need to determine coverage and reimbursement policies for this specialty gene therapy.

Industry·13d ago

New Federal Student Loan Limits May Restrict Medical School Access

New federal limits on student borrowing are taking effect that may restrict access to medical school at a time when physician shortages are resulting in patients waiting weeks or months for appointments. The policy affects medical school affordability for prospective students. The exact timing of implementation and specific borrowing caps are not detailed in the available excerpt. The change could compound existing physician workforce shortages affecting healthcare access nationwide.

Industry·15d ago

60 Hospitals Close Departments or End Services Citing Financial Pressures, Staffing Shortages

Becker's Hospital Review compiled 60 hospital department closures and service discontinuations reported since January 1, 2026. Healthcare organizations cite financial challenges, efforts to focus on higher-demand services, and staffing shortages as primary drivers. The closures affect various service lines across facilities nationwide. The trend reflects ongoing operational pressures facing hospitals that may affect Medicaid beneficiaries' access to care depending on the services eliminated and markets affected.

Managed Care·15d ago

Health Systems Report Claims Automation Gap with Payers Creating Revenue Cycle Pressure

Revenue cycle executives at 17 health systems report that payers are now reviewing and denying claims at volumes and speeds that providers cannot match, creating what they describe as an unsustainable financial asymmetry. The automation gap affects providers' ability to respond to denials and prior authorization requests in real time. The imbalance is intensifying as payers deploy AI and automation tools faster than health systems can adopt corresponding technology. For Medicaid managed care organizations and their provider networks, this dynamic accelerates existing tensions over claims processing, prior authorization burden, and network adequacy tied to provider financial stability.

Industry·15d ago

Rural Hospitals Deploy Seven Workforce Strategies to Address Provider Shortages

Forty-three million Americans live in rural areas facing primary care shortages, and workforce instability ranks among the top strategic challenges for rural hospitals and health systems. Physician and clinician shortfalls, burnout, and thin talent pipelines limit access and strain already-lean operations, particularly in markets affected by closures and consolidations. The article outlines seven workforce transformation strategies rural providers are using to address these pressures. For Medicaid stakeholders, rural workforce challenges directly affect network adequacy, access to care for beneficiaries, and health plan compliance in rural service areas.

Industry·NY·16d ago

NYC Health + Hospitals-Maimonides Merger Clears State Public Health Council

New York's Public Health and Health Planning Council unanimously approved NYC Health + Hospitals' proposed acquisition of Maimonides Health on September 17, 2026. The transaction still requires additional state regulatory approvals before closing. NYC Health + Hospitals is the nation's largest public health system and a major Medicaid provider in New York City. The merger would consolidate provider capacity in Brooklyn, where both systems operate and serve substantial Medicaid and uninsured populations.

Industry·16d ago

HCA Reports Elective Surgery Volume Decline Tied to Exchange Coverage Loss

HCA Healthcare reported softer elective surgery volumes linked to patients losing health insurance exchange coverage, CFO Mike Marks told investors September 15. The 189-hospital for-profit system cited broader affordability pressures as a potential contributing factor to the slowdown. HCA continues to see strong overall demand for healthcare services despite the elective procedure decline. The trend signals potential financial pressure on hospital systems as coverage instability affects commercially insured patient volumes.

Managed Care·16d ago

ECRI Finds 73% of Medication Reconciliation Errors Occur During Care Transitions

ECRI reported September 16 that 73% of medication reconciliation errors occur when patients move between care settings, based on analysis of 10,000 safety events. The findings highlight care transitions as a high-risk period for medication safety failures. The report emphasizes the need for improved handoff protocols and communication systems between settings. For Medicaid managed care plans, this underscores operational risk in care coordination programs, particularly for high-utilizing populations moving between hospital, SNF, home health, and outpatient settings.

Industry·16d ago

HCA CFO Says Hospitals Lag Payers on AI-Driven Claims Processing

HCA Healthcare CFO Mike Marks stated September 15 that health insurers have outpaced hospitals in deploying artificial intelligence for claims processing, exacerbating existing friction over denials, underpayments, and prior authorization. Marks' comments highlight a technology gap that puts hospitals at a disadvantage in revenue cycle management as payers increasingly automate claims review and adjudication. The remarks suggest growing competitive pressure on hospital systems to accelerate AI adoption to match payer capabilities in claims operations.

Industry·AZ·16d ago

Ascension Transfers Mercy Care Ownership Stake to Aetna

Ascension has agreed to transfer its ownership stake in Mercy Care, an Arizona managed care health plan, to Aetna (CVS Health). Ascension co-owns the plan with CommonSpirit's Dignity Health. The transaction is subject to regulatory approval. The deal represents consolidation in the Arizona managed care market, with a national commercial insurer acquiring equity from health system owners.

Industry·16d ago

Health Systems Lease SNF Beds to Address Patient Boarding and Discharge Delays

Hospitals are leasing skilled nursing facility beds to reduce emergency department boarding and expedite patient discharges as SNF capacity tightens. Four health systems report success using bed leasing arrangements that include value alignment with SNF partners, transparent patient selection criteria, and regular operational check-ins. The approach addresses growing pressure from an aging population and declining overall SNF bed supply. Systems largely exited the SNF business years ago but are now contracting for guaranteed bed access.

Federal Policy·16d ago

HHS Secretary Kennedy Appoints Eight Members to U.S. Preventive Services Task Force

HHS Secretary Robert F. Kennedy Jr. appointed eight new members to the U.S. Preventive Services Task Force on September 17, 2026, through the Agency for Healthcare Research and Quality, bringing the panel to 16 total members. The task force issues evidence-based recommendations on clinical preventive services including screenings, counseling, and preventive medications. These recommendations directly affect Medicaid coverage requirements under the Affordable Care Act, which mandates coverage of USPSTF Grade A and B services without cost-sharing for certain populations.

Industry·17d ago

ASHP Advocates for Medicare Pharmacist Coverage, 340B Protections in Congressional Meetings

The American Society of Health-System Pharmacists (ASHP) is conducting Capitol Hill meetings on September 16 to advocate for three pharmacy priorities: expanded Medicare coverage of pharmacist-provided care, protections for the 340B Drug Pricing Program, and pharmacy residency training support. The advocacy day reflects organized pharmacy's push for provider status recognition and safeguarding discount drug programs. ASHP announced the legislative agenda in a September 15 news release ahead of member meetings with congressional offices.

Managed Care·18d ago

Network Health Launches Epic Prior Authorization API Ahead of 2027 CMS Deadline

Network Health has implemented Epic's prior authorization application programming interface (API) in advance of CMS's January 1, 2027 interoperability rule deadline. The rule requires insurers to deploy APIs for patient access, provider access, provider directory, payer-to-payer data exchange, and prior authorization. Network Health is among the early adopters working with Epic to meet these requirements before the mandate takes effect. The implementation aims to streamline prior authorization processes between the health plan and providers using Epic's electronic health record system.

Federal Policy·18d ago

CMS Adds Four Condition Tracks to ACCESS Model in Spring 2027

CMS announced September 15 that it will expand the Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) model to include four new condition tracks: heart failure, chronic obstructive pulmonary disease, substance use disorders, and tobacco cessation. The expansion takes effect in spring 2027. The addition broadens the model's scope beyond its current conditions, creating new opportunities for providers to participate in value-based care arrangements for these chronic conditions under Medicaid and Medicare.

Industry·18d ago

Hospital Margins Fall to 1.4% in July Amid Rising Bad Debt and Charity Care

Hospital operating margins declined to 1.4% in July 2026, with bad debt and charity care rising significantly, according to Kaufman Hall's National Hospital Flash Report analyzing data from over 1,300 hospitals. The increases in uncompensated care suggest deteriorating payer mix, meaning fewer patients with commercial insurance and more with Medicaid or no coverage. The trend pressures hospital financial sustainability and may affect provider participation in Medicaid managed care networks as hospitals reassess contracting strategies. Kaufman Hall warns hospitals may need to redesign financial and operational strategies to remain viable.

Industry·18d ago

Hospital Physician Advisor Overturns 78% of Payer Denials Across 11-Hospital System

Dr. Maliha Iqbal, physician advisor at Beacon Health System, completed 5,118 utilization reviews in 2025 as the sole physician advisor across 11 hospitals, overturning 78% of peer-to-peer denials. The workload doubled following a health system merger. The article profiles operational practices for managing high-volume utilization review and payer denial appeals at scale. This reflects ongoing provider strategies to combat managed care prior authorization and medical necessity denials.

Industry·18d ago

Hospitals Lease SNF Beds to Reduce ED Boarding Amid Post-Acute Capacity Crunch

Hospital systems are leasing skilled nursing facility beds to address emergency department boarding driven by post-acute discharge bottlenecks. The strategy responds to reduced overall SNF capacity, an aging population, and persistent throughput challenges despite testing other post-acute alternatives. Systems previously exited the SNF business but are now returning to secure discharge capacity. Implementation timelines and specific health system participation were not detailed in the available excerpt.

Industry·19d ago

Latent Adds Seven Health Systems for AI-Driven Specialty Pharmacy Platform

Latent, an enterprise pharmacy intelligence platform, announced partnerships with seven health systems including Cleveland Clinic and AdventHealth, bringing its total partner count to 60. The company is deploying autonomous AI agents designed to address specialty drug access bottlenecks by automating pharmacy operations rather than simply flagging issues for human review. The expansion reflects growing health system interest in automation tools to manage complex specialty pharmacy workflows as the specialty drug pipeline continues to expand faster than traditional operational infrastructure can support.

State Policy·CA·19d ago

California Adopts 3.5% Hospital Spending Growth Cap Through 2029

California's Office of Health Care Affordability has adopted a 3.5% annual spending growth cap for hospitals, physician groups, and insurers, effective through 2029. Entities exceeding the cap will face penalties. The framework applies to all payers, including Medicaid managed care organizations contracting with hospitals and physician groups in California. This marks California's first enforceable cost growth benchmark, directly affecting Medi-Cal managed care contract negotiations and capitation rate development.

Industry·20d ago

CMS Health Technology Ecosystem Falls Short on Interoperability Promise

President Trump's 2025 pledge to eliminate redundant patient paperwork through CMS's Health Technology Ecosystem has not been fully realized. Healthcare providers still face significant barriers to seamless record exchange across appointments and care settings. The initiative aimed to reduce administrative burden through improved data interoperability, but implementation challenges persist. For Medicaid managed care organizations and providers, gaps in health information exchange continue to drive care coordination inefficiencies and administrative costs.

Industry·20d ago

Rural Hospitals Form Clinically Integrated Networks Across Eight States

Over 150 independent rural hospitals across eight states have formed clinically integrated networks in the past three years to maintain independence and negotiate with payers. The most recent is Missouri's Show-Me High Value Network, comprising 23 hospitals. These networks aim to achieve scale, share data, and strengthen contract negotiations while avoiding acquisition by larger health systems or managed care organizations. The trend reflects rural providers' strategy to remain viable amid industry consolidation.

Industry·22d ago

UnitedHealth Group Drops Prior Authorization for 1,700 Services, Faces Maryland Lawsuit

UnitedHealth Group has announced plans to eliminate prior authorization requirements for 1,700 services, a significant operational change affecting providers and patients. The company also faces a lawsuit from Maryland's attorney general, though specific allegations were not detailed in the brief. Additional updates include the appointment of Ujjwal Ratan as chief AI officer at Optum Insight. These developments span regulatory compliance, clinical operations, and corporate leadership at the nation's largest health insurer.

Industry·23d ago

Hospitals and Health Systems Cut Jobs Amid Financial Strain in 2026

Multiple hospitals and health systems are reducing workforces in 2026, citing lower reimbursement rates, rising labor and supply costs, and operational realignment needs. The layoffs are part of broader financial stabilization efforts as organizations respond to ongoing margin pressures. Timing and scale of specific reductions vary by organization. These workforce reductions reflect persistent financial challenges across the hospital sector that affect provider capacity and network stability.

Federal Policy·24d ago

CMS Announces 16 State Rural Health Transformation Program Distributions

CMS has announced 16 state-level allocations from the Rural Health Transformation Program over the past month, directing funding toward technology upgrades, service expansions, and workforce development. These distributions follow CMS's December 2025 approval of $50 billion in total Rural Health Transformation Program funding for fiscal year 2026. States are now earmarking specific portions of their allocations for targeted rural health initiatives. The distributions affect Medicaid-participating rural providers and community health systems receiving transformation funding.

Federal Policy·24d ago

Study Finds State-Directed Payment Caps Could Cut Medicaid Spending 10-25% in 17 States

A Health Affairs study published September 9 projects that 17 states could see Medicaid spending reductions of 10% to 25% under new federal limits on state-directed payments introduced in HR 1. The analysis by health policy analyst Debra Lipson examined state-directed payment applications approved by CMS through May 31 for rating periods beginning in 2024. The findings suggest significant fiscal impact on state Medicaid programs and provider payments as federal restrictions on state-directed payment arrangements take effect.

Federal Policy·25d ago

CMS EMTALA Citations Reach Highest Level in Over a Decade

Hospitals are receiving Emergency Medical Treatment and Labor Act (EMTALA) violation citations at record levels, according to CMS inspection data analyzed by Becker's Hospital Review. EMTALA requires hospitals to screen and stabilize anyone arriving at the emergency department regardless of ability to pay. The increased enforcement reflects heightened CMS scrutiny of emergency department compliance. This trend affects Medicaid-participating hospitals, which face potential termination from the program for serious or repeated EMTALA violations.

Industry·27d ago

Rural Hospital Leader Argues Home-Based Care Reduces System Costs

A rural health care executive argues that providing care locally in rural communities generates system savings compared to patient transfers, but rate-setting bodies do not adequately account for these cost benefits. The author contends that policymakers making rural health care decisions need to hear directly from practitioners who deliver local care. The commentary emphasizes that rural care delivery models keeping patients near home are cost-effective but undervalued in current payment structures. No specific policy change or data is presented.

Industry·29d ago

WVU Medicine Launches Provider-Sponsored Health Plan as Joint Venture with Marshall Health and Valley Health

WVU Medicine has created Peak Health, a provider-sponsored health plan structured as a joint venture with Marshall Health Network and Valley Health. Unlike typical health system insurance arms designed to capture margin, Peak Health is built to redirect savings back to participating providers. The plan represents a provider-led approach to health insurance in West Virginia and Virginia markets. This matters for Medicaid stakeholders because provider-sponsored plans increasingly compete for Medicaid managed care contracts and can reshape network dynamics and provider reimbursement models in their markets.

Industry·30d ago

59 Hospitals Close Departments or End Services Since January

Becker's Hospital Review reports that 59 healthcare organizations have closed medical departments or ended services at facilities since January 1. The closures are attributed to financial pressures, shifts toward higher-demand services, and staffing shortages. The report includes Catholic Health facilities in Buffalo, N.Y., among the affected organizations. The specific departments closed and effective dates vary by facility.

State Policy·31d ago

Self-Pay Hospital Visits Rise Following Medicaid Disenrollment, Epic Research Finds

Self-pay hospital visits are increasing as Medicaid enrollment declines following the end of pandemic-era continuous enrollment protections, according to an Epic Research study published August 31, 2026. The research documents rising uncompensated care across hospital settings linked to coverage losses in both Medicaid and ACA markets. The trend reflects ongoing fallout from Medicaid redeterminations that began in spring 2023, with states continuing to process eligibility reviews and disenroll individuals who no longer qualify or fail to complete renewal paperwork. State Medicaid agencies and safety-net hospitals face mounting financial pressure as former enrollees present for care without coverage.

Federal Policy·31d ago

Congress Blocks OMB Grant Rule Through Dec. 11, Averting Federal Shutdown

Congress passed a continuing resolution Sept. 1 funding the government through Dec. 11 and temporarily blocking an OMB proposal to revise federal grant regulations. The proposal would give agencies broader authority to modify, suspend, or terminate grant awards based on evolving priorities, raising concerns from the American Hospital Association about funding predictability for multiyear investments in workforce, research, and infrastructure. The AHA has sought clarity on whether the rule would affect Medicare rural programs, CMMI arrangements, supplemental Medicaid payments, and Medicaid managed care capitation. The temporary block expires Dec. 11, leaving hospitals facing renewed uncertainty unless OMB withdraws or revises the proposal.

Managed Care·31d ago

UnitedHealthcare, Aetna, BCBS Plans Implement Lab Testing and Provider Reimbursement Policy Changes

Six major health insurers implemented reimbursement policy changes effective September 1, 2026. UnitedHealthcare is tightening lab testing reimbursement across commercial, Medicare Advantage, and Medicaid plans, with Medicaid rollouts staggered by state from August through December. Changes include caps on allergen testing (20 allergens per year for patients 20+), limits on hepatic fibrosis testing to once every six months, and vitamin B12 testing restrictions to once every three months. BCBS Michigan is phasing out incident-to billing starting September 1, requiring enrollment-eligible clinicians to add modifier SA; by March 2027, clinicians with their own NPI must bill directly or face 80% fee schedule reimbursement. Molina Healthcare of Ohio is implementing new specialty medication administration site-of-care policies and revised buy-and-bill pharmacy policies for several drugs.

State Policy·HI·32d ago

Hawaii Receives $58M Federal Grant for EMS Infrastructure and Health Workforce

Hawaii has been awarded $58 million through the federal Rural Health Transformation Program to expand emergency medical services and healthcare workforce capacity. The University of Hawaii John A. Burns School of Medicine will receive $45 million for workforce development programs, while the Hawaii Department of Health will use the remaining $13 million to purchase ambulances and upgrade emergency communications systems. The funding addresses rural healthcare infrastructure gaps and provider shortages affecting access to care statewide.

State Policy·33d ago

Five States Face Medicaid Ballot Measures in November Midterm Elections

Multiple state ballot measures in the upcoming November midterm elections will determine Medicaid program direction, including potential coverage expansions, funding restrictions, or administrative changes. Specific proposals vary by state but could affect eligibility rules, state budget allocations for Medicaid, or program structure. Voters will decide these measures on Election Day, with implementation timelines depending on state law. The outcomes will directly shape Medicaid program scope and financing in affected states.

Industry·33d ago

FDA Expands Mounjaro Approval to Reduce Cardiovascular Risk in Type 2 Diabetes

The FDA approved Mounjaro (tirzepatide) to reduce major adverse cardiovascular events — cardiovascular death, nonfatal heart attack, and nonfatal stroke — in adults with type 2 diabetes at high cardiovascular risk. The approval follows the Surpass-CVOT trial involving over 13,000 participants across 30 countries. The expanded indication is effective immediately. This matters for Medicaid managed care organizations because cardiovascular disease is a leading driver of costs in diabetic populations, and the new indication may affect prior authorization policies, formulary placement, and utilization management for tirzepatide in high-risk beneficiaries.

Industry·36d ago

Hospital CEOs Navigate Site-Neutral Payment Pressures Amid Medicaid Changes

Health system CEOs are confronting multiple financial pressures, including Medicaid coverage and reimbursement changes under HR 1, ongoing 340B drug discount program policy challenges, and site-neutral payment considerations. These policy shifts are influencing where health systems invest and deliver care. The article features perspectives from executives at Valley Health and other systems on how they are adapting their care delivery and investment strategies in response to these combined pressures.

Federal Policy·GA·37d ago

CMS Awards Georgia $93.3M for Rural Telehealth and AHEAD Model Readiness

CMS announced $93.3 million in federal Rural Health Transformation Program funding to Georgia on August 27, 2026, supporting 87 rural hospitals in expanding telehealth services, surgical robotics, and modernizing healthcare access. The funding is designed to help these hospitals prepare for CMS' AHEAD Model, a value-based care initiative. The investment targets rural healthcare infrastructure improvements with a focus on technology adoption and alternative payment model readiness. Medicaid managed care plans operating in Georgia's rural markets may see network capacity changes as hospitals enhance capabilities and potentially shift toward value-based arrangements.

Legal·FL·37d ago

Florida Grand Jury Finds $10M from Centene Medicaid Settlement Misappropriated

A Florida state grand jury determined that $10 million from a Centene Medicaid settlement was misappropriated under the DeSantis administration, according to a sealed January 28 document obtained by CBS News Miami. The grand jury found insufficient evidence to bring criminal charges. The settlement originated from claims against Centene related to its Florida Medicaid managed care operations. The finding raises questions about state oversight of Medicaid settlement funds and their designated use.

Industry·38d ago

Becker's Compiles Trump Administration Health Technology Policy Actions

Becker's Hospital Review has compiled a tracker of recent Trump administration actions affecting health technology policy, including moves related to AI adoption, digital infrastructure, data sharing rules, cybersecurity requirements, and federal oversight mechanisms. The compilation covers regulatory changes and policy shifts reported by Becker's across multiple areas of healthcare technology. The tracker appears to be an ongoing compilation rather than reporting a single discrete policy event, aggregating developments that may affect hospitals, health systems, and other healthcare entities operating digital health programs.

Legal·39d ago

129 Groups Urge OIG to Create Anti-Kickback Safe Harbor for Clinical Trial Participant Expenses

The American Cancer Society Cancer Action Network and 128 other advocacy and professional groups submitted a comment letter to HHS OIG on August 24, 2026, requesting a new safe harbor under the federal anti-kickback statute. The proposed safe harbor would allow clinical trial sponsors to cover participants' travel, lodging, and other expenses without exposure to fraud and abuse liability. The comment period timing suggests OIG is considering rulemaking on this issue. For Medicaid providers participating in clinical trials, this matters because current anti-kickback constraints limit their ability to cover beneficiary costs, potentially reducing trial participation among Medicaid populations who face the greatest financial barriers to access.

Industry·39d ago

Pediatric Drugs Lead FDA Active Shortage List with 18 Products

Pediatric medications account for more active FDA-listed drug shortages than any other therapeutic category as of August 25, 2026, with 18 products in shortage. Anesthesia and cardiovascular drugs are tied for second with 10 active shortages each, followed by analgesia and addiction treatment medications with 9 shortages. The data comes from the FDA's drug shortage database tracking current supply disruptions across therapeutic categories.

State Policy·CT·40d ago

Connecticut Children's Psychiatric Hospital Reports 21% of Staff Out on Workers' Compensation

About 21% of staff at Solnit South, Connecticut's state-operated children's psychiatric hospital in Middletown, are currently out on workers' compensation for on-the-job injuries, according to the Hartford Courant. State lawmakers have characterized the situation as a "safety crisis," with employees citing chronic understaffing, workplace injuries, and deteriorating facility conditions. The hospital is operated by UConn Health. The high injury rate raises immediate questions about provider network adequacy and continuity of behavioral health services for Connecticut Medicaid beneficiaries served at the facility.

State Policy·AL·40d ago

Alabama Awards $144M in Rural Health Grants from CMS Transformation Program

Alabama Governor Kay Ivey announced 138 grants totaling over $144 million to healthcare providers and institutions across all 67 Alabama counties on August 24, 2026. The grants are the first disbursement under the Alabama Rural Health Transformation Program, funded by a $203.4 million CMS award. The program addresses rural healthcare access and infrastructure challenges across the state. Additional grant rounds are expected as the state distributes the remaining federal funds.

Federal Policy·41d ago

Senate Confirms Mark Cruz as Indian Health Service Director

The Senate confirmed Mark Cruz, a citizen of the Klamath Tribes and former HHS adviser, as director of the Indian Health Service on August 7, 2026, following President Trump's June 1 nomination. President Trump signed the commission on August 21. The IHS director oversees federal health services for approximately 2.8 million American Indians and Alaska Natives through direct care facilities, tribal health programs, and urban Indian health centers. Cruz's appointment comes as IHS facilities face ongoing staffing shortages and underfunding challenges that affect care delivery.

Managed Care·NY·44d ago

EmblemHealth Issues Cease-and-Desist to Mount Sinai Over Government Plan Patient Access

EmblemHealth sent a cease-and-desist letter to Mount Sinai Health System's independent practice association on August 19, 2026, after the provider stopped accepting new patients from some of the insurer's government-backed plans. The action targets Mount Sinai's restriction on new patient intake, which appears to affect publicly-funded health plan enrollees. The cease-and-desist letter suggests the insurer views the access limitation as a potential contract violation. This development highlights ongoing network adequacy and access tensions between major health systems and Medicaid and Medicare Advantage plans in New York's competitive managed care market.

State Policy·MN·44d ago

Minnesota Hospital Settles AG Claim Over Uninsured Patient Discount Calculations

Stevens Community Medical Center agreed to provide up to $1.4 million in refunds or debt reductions to resolve allegations by the Minnesota Attorney General that it improperly calculated discounts for uninsured patients. The settlement covers 3,478 patients who received services between April 1, 2020, and December 31, 2025. The case involves state enforcement of patient billing practices and charity care requirements, which can overlap with Medicaid program eligibility and hospital compliance with state Medicaid rules on presumptive eligibility and uncompensated care policies.

Legal·44d ago

Federal Court Decertifies 11 Clinics from 340B Program in Drugmaker Lawsuit

A federal district court in Washington, D.C. granted partial summary judgment to drugmakers including Amgen and Genentech on August 14, 2026, ordering 11 clinics' 340B certifications set aside for failing to meet statutory participation requirements. The ruling addresses longstanding disputes between drugmakers and covered entities over 340B program eligibility. The decision affects clinic access to discounted drugs under the 340B program and may signal stricter judicial scrutiny of covered entity qualifications.

State Policy·IL·45d ago

Cook County Illinois Medical Debt Relief Program Erases Over $1 Billion

Cook County, Illinois has erased more than $1 billion in medical debt through its relief initiative launched in 2022, the largest amount eliminated by any U.S. county. The program operates through a partnership with nonprofit Undue Medical Debt, which purchases and forgives medical debt at significantly reduced rates. The initiative affects residents of Cook County, which includes Chicago, who held qualifying medical debt. This approach represents a county-level intervention to address healthcare affordability challenges that can affect Medicaid eligibility and enrollment patterns.

Managed Care·NY·45d ago

Mount Sinai Stops Accepting New Patients with Centene Medicaid and Medicare Plans

Mount Sinai Health System in New York City has stopped accepting new patients enrolled in Centene's Fidelis Care Medicaid, exchange, and Medicare Advantage plans, as well as Wellcare Medicare Advantage plans. The health system removed public notices about the change from its website after initially posting them. The effective date and whether existing patients are affected remain unclear from available information. The move raises questions about network adequacy and access for Medicaid and Medicare Advantage enrollees in New York City, particularly those covered by Centene products.

Industry·45d ago

CareCloud Reports Data Breach Affecting 3.8 Million Patients

Health IT vendor CareCloud disclosed a data breach impacting 3,756,469 individuals following a March 16, 2026 network disruption in its CareCloud Health division. The incident temporarily disrupted access to one of six electronic health record environments for approximately eight hours. A subsequent forensic investigation confirmed unauthorized access occurred. The breach affects patients whose data was stored in CareCloud's EHR system, which serves healthcare providers including those participating in Medicaid programs.

Federal Policy·45d ago

Rural Hospital CEO Defends $50B Federal Transformation Program Amid Implementation Concerns

A rural hospital CEO is defending the $50 billion Rural Health Transformation Program included in HR-1 against skepticism from other rural leaders. Critics have questioned whether the federal funding will reach intended provider recipients and raised concerns about potential state-level redirection of funds before they reach hospitals. The debate reflects ongoing uncertainty about the program's design and implementation mechanisms, though specific details about fund distribution timelines, eligibility criteria, or Medicaid program integration are not provided in the available content.

Industry·45d ago

PBMs Agree to Display TrumpRx Cash Prices in Real-Time Benefit Tools

The Pharmaceutical Care Management Association announced that its members will share TrumpRx's cash drug prices through real-time benefit tools and cost transparency platforms. The commitment follows coordination with the Trump administration and CMS Administrator Mehmet Oz. PCMA members include CarelonRx, CVS Health, and Cigna. The announcement was made in an August 13 news release.

Industry·46d ago

CommonSpirit Sets Five Benchmarks for Payer Prior Authorization Reform Progress

CommonSpirit Health has established five targets to evaluate health plan progress on prior authorization reform following 2024 federal interoperability and prior authorization rules. The health system announced it has reached a milestone with Humana on these metrics. The 2024 regulation required insurers to begin reporting prior authorization data, but CommonSpirit argues the aggregated data lacks operational context for providers. The benchmarks aim to measure meaningful improvement in prior authorization processes beyond raw data reporting.

Industry·47d ago

HHS Analysis Finds Rural Hospitals Face Anesthesia Access Challenges

A recent HHS analysis examined anesthesia access and outcomes in rural hospitals amid ongoing closures and service reductions. Rural hospitals are experiencing difficulties maintaining anesthesia services as facilities close and specialty care becomes less available locally. The analysis comes as patients in rural communities travel increasingly longer distances for surgical procedures. The findings matter for Medicaid programs because rural beneficiaries rely heavily on local hospitals for surgical access, and anesthesia service availability directly affects whether facilities can maintain surgical capabilities.

Federal Policy·47d ago

CDC Reports Kindergarten MMR Coverage Falls Below Herd Immunity Threshold at 92.4%

CDC data for the 2025-26 school year shows kindergarten vaccination coverage for measles, mumps, and rubella (MMR) dropped to 92.4%, down from 92.5% the prior year and below the 95% herd immunity threshold recommended by public health officials. Exemption rates reached a record 4.2%. The decline in vaccination rates raises public health concerns about potential disease outbreaks and may affect Medicaid EPSDT compliance, as childhood immunizations are a required preventive service under Early and Periodic Screening, Diagnostic and Treatment benefits for children enrolled in Medicaid and CHIP.

Federal Policy·47d ago

ONC Seeks Comment on TEFCA Performance Monitoring Data Collection

The Office of the National Coordinator for Health Information Technology (ONC) published a notice on August 17, 2026, requesting public comment on a three-year data collection initiative for the Trusted Exchange Framework and Common Agreement (TEFCA). The proposed collection would gather routine feedback on service delivery and program performance from Qualified Health Information Networks (QHINs). Comments are due under standard federal notice procedures. For Medicaid programs increasingly reliant on interoperability for care coordination, managed care reporting, and health information exchange, this reflects ONC's evolving oversight approach for the national framework governing health data exchange among QHINs.

Industry·50d ago

57 Hospitals Close Departments or End Services Amid Financial, Staffing Pressures

Becker's Hospital Review reports that 57 hospitals have closed medical departments or ended services since January 1, 2026, citing financial pressures, shifts toward more in-demand services, and staffing shortages. The closures span multiple facilities nationwide, including Henderson Hospital in Nevada. The scope and timing of these operational changes reflect broader challenges in hospital sustainability and service line management across the healthcare industry.

Industry·51d ago

Providence Reports 0.8% Q2 Operating Margin as Health Plan Wind-Down Continues

Providence reported a $64 million operating income (0.8% margin) for the quarter ended June 30, 2026, compared to $24 million (0.3%) in the prior-year period. The year-over-year results reflect discontinued-operations accounting related to the health system's planned sale, transition, or wind-down of its health plan operations. The financial report was released August 13, 2026. The margin improvement comes as the organization restructures its insurance operations.

Legal·51d ago

Federal Government Refers Hospitals, PBMs to DOJ Over Gender-Affirming Care Billing

The Vice President and HHS Secretary have referred dozens of hospitals, pharmacy benefit managers, and pharmacies to the Department of Justice and HHS Office of Inspector General for investigation of potentially fraudulent billing related to pediatric gender-affirming care. The referrals follow a new HHS report identifying organizations for scrutiny. The investigations will focus on billing practices for these services. This represents a significant enforcement action affecting hospitals and pharmacies providing or processing claims for pediatric gender-affirming treatment.

Industry·51d ago

Bipartisan Senate Pressure on Insurers Intensifies Ahead of 2027

Senators Elizabeth Warren (D-Mass.) and Josh Hawley (R-Mo.) have introduced legislation targeting health insurers amid mounting bipartisan criticism over contracting practices, vertical integration, and prior authorization policies. The legislative effort reflects escalating tensions between insurers, lawmakers, employers, and patients heading into 2027. While the article does not specify effective dates or comment periods, it signals a legislative environment increasingly hostile to insurer business practices across both commercial and government-sponsored programs.

Industry·52d ago

St. Luke's and UnitedHealthcare Automate 88% of Claim Status Updates via Epic

St. Luke's University Health Network and UnitedHealthcare have automated claim status updates for 88% of claims exchanged between them using Epic's Payer Platform. The automation gives St. Luke's staff real-time visibility into claim processing status. Epic reported this implementation in its 2026-2027 Almanac as an example of administrative efficiency gains through electronic data exchange between providers and payers.

Industry·52d ago

Hospital M&A Activity Surges in Early 2026 After Multiyear Slowdown

Hospital and health system merger and acquisition activity reached its highest level since early 2020, with 22 transactions announced in Q1 2026 and 18 more in Q2, following a multiyear slowdown that hit a decade-low in 2025. The rebound follows a period when hospital boards delayed deals amid federal policy uncertainty. Industry observers characterize the current wave as proactive strategic positioning rather than distress-driven consolidation, suggesting financially stronger systems are pursuing market expansion and service line integration opportunities.

Industry·52d ago

Medicare Value-Based Payment Programs Raise Hospital Administrative Costs, Study Finds

A study published August 7 in JAMA Health Forum found that participation in mandatory CMS value-based payment programs is associated with significantly higher annual administrative costs for hospitals. Researchers at Brown University School of Public Health analyzed Medicare cost report data from 2006 to 2020 covering 4,332 hospitals, including 2,820 participating in value-based arrangements. The findings suggest that administrative burden from quality reporting, performance tracking, and program compliance may offset financial benefits hospitals seek from value-based contracting.

Federal Policy·52d ago

HRSA Launches Framework to Modernize National Newborn Screening Panel Review Process

The Health Resources and Services Administration announced a new framework on August 11, 2026, to streamline how conditions are evaluated for addition to the national newborn screening panel. The initiative aims to update a review process that officials say has not kept pace with advances in genetic medicine. The framework establishes a standardized pathway for assessing which screenable conditions should be recommended for inclusion. This affects state Medicaid programs and CHIP, which finance newborn screening for the majority of U.S. births and must determine coverage for newly recommended tests.

Federal Policy·53d ago

CMS Final Rule Bars Federal Medicaid, CHIP Funds for Pediatric Gender-Affirming Care

CMS issued a final rule prohibiting federal Medicaid and CHIP matching funds for gender-affirming care for minors, including puberty blockers, hormone therapy, and related surgeries such as mastectomies. The rule takes effect October 13, 2026. States will no longer receive federal financial participation for these services furnished to children enrolled in Medicaid or CHIP. The policy represents a federal prohibition on a category of care previously covered under state Medicaid programs' Early and Periodic Screening, Diagnostic and Treatment benefit and other authorities.

Legal·53d ago

Drug Manufacturers Challenge State 340B Contract Pharmacy Laws in Illinois, South Dakota

AbbVie and Novartis filed suit against Illinois on August 7, 2026, seeking to block the state's new 340B contract pharmacy law. Three days later, a federal judge in South Dakota dismissed three separate lawsuits from AbbVie, AstraZeneca, and PhRMA challenging South Dakota's similar law. The legal battles center on state efforts to require drug manufacturers to honor 340B pricing at contract pharmacies. The outcome will determine whether states can enforce 340B contract pharmacy requirements against manufacturer restrictions.

Federal Policy·53d ago

Sequoia Project Names 19 Members to TEFCA Governing Council

The Sequoia Project updated its TEFCA Governing Council roster on August 10, 2026, naming 19 representatives from health systems, health information networks, technology vendors, and federal agencies. TEFCA is the ONC-overseen national framework for exchanging health data across qualified health information networks. The Governing Council advises on implementation and policy for the framework. The update reflects ongoing governance structure for the national interoperability initiative.

State Policy·MD·54d ago

Maryland Awards $80M to Expand Rural Primary Care, Behavioral Health, Dental Access

Maryland's Department of Health awarded $80 million to 41 grantees under the first round of the Rural Health Transformation Program on August 10, 2026. The funds will expand primary care, behavioral health, and dental services across Maryland's 18 designated rural areas. The program addresses workforce shortages and access gaps in underserved regions. For Maryland Medicaid managed care plans and providers, this represents new capacity and potential network expansion opportunities in rural markets where provider networks are historically thin.

Federal Policy·54d ago

Trump Executive Order Revises Federal Childhood Vaccine Schedule, Separates MMR

President Trump signed an executive order on August 10, 2026, revising federal childhood vaccine schedules by requiring separate measles, mumps, and rubella shots instead of the combined MMR vaccine and narrowing the list of immunizations recommended for all children. The order, titled Gold Standard Childhood Vaccine Recommendations, affects the federally recommended schedule that state Medicaid programs and health plans use for EPSDT coverage determinations. The changes take effect immediately for federal guidance, though state Medicaid agencies will need to determine whether and how quickly to align coverage policies with the revised schedule. This matters for state agencies and health plans because EPSDT requires coverage of ACIP-recommended vaccines, and any federal schedule changes trigger operational questions about coverage mandates, provider network readiness, and member communication.

Industry·54d ago

Four States Report No Rural Hospitals at Closure Risk

A July 2026 Center for Healthcare Quality and Payment Reform analysis identified 700 rural hospitals at risk of closing nationwide, but found zero at-risk facilities in Delaware, Maryland, and two other states. The report examined financial vulnerability indicators across rural hospitals. While rural hospital closures can affect Medicaid beneficiaries' access to care, particularly in states with large rural Medicaid populations, this analysis focuses on overall hospital financial stability rather than Medicaid-specific policy or payment changes.

State Policy·WI·54d ago

Wisconsin Expands Family Care Managed LTSS to 9,000 Members in 2027

Wisconsin's Department of Health Services will expand managed long-term care options to over 9,000 Medicaid members in southeastern Wisconsin starting in 2027. The expansion affects enrollees in Family Care and Family Care Partnership, the state's managed LTSS programs for older adults and people with disabilities. Implementation begins in 2027, though specific effective dates were not provided in the July 2026 announcement. The expansion increases managed care penetration in Wisconsin's LTSS delivery system and may trigger network adequacy requirements and contract amendments for participating MCOs.

Legal·55d ago

Senate HELP Committee Presses DOJ on Steward CEO Contempt Referral

The Senate HELP Committee sent a letter August 6, 2026, to Acting Attorney General Todd Blanche requesting an update on the criminal contempt referral against former Steward Health Care CEO Ralph de la Torre. The committee, led by Chairman Sen. Bill Cassidy (R-La.), seeks information on DOJ action following Dr. de la Torre's failure to comply with congressional testimony requirements. The referral stems from ongoing congressional oversight of Steward's bankruptcy and operations. This follows the committee's investigation into Steward's financial practices and facility closures affecting patient access.

State Policy·58d ago

Six States Face Medicaid Compliance Challenges Following HR 1 Work Requirements

More than a year after HR 1 passage, six states are grappling with implementation of more frequent eligibility checks and work requirements for Medicaid enrollees. The states face ongoing uncertainty around policy shifts, fraud concerns, and insurer strategies as they prepare for 2027 program changes. The article highlights states experiencing particular difficulty adapting to the new federal requirements. Affected states must navigate operational changes to eligibility systems, beneficiary engagement, and managed care plan coordination.

State Policy·AZ·58d ago

Arizona Erases $1 Billion in Medical Debt for 670,000 Residents

Arizona has eliminated over $1 billion in medical debt for 670,963 residents through a partnership with Undue Medical Debt, with more than 200,000 relief letters sent this week. The initiative provides debt relief to qualifying Arizonans. Governor Katie Hobbs' office announced the milestone on August 5, 2026. The program addresses medical debt burdens that disproportionately affect Medicaid-eligible and low-income populations who cycle between coverage and uninsured status.

Federal Policy·58d ago

Senate Democrats Urge CMS to Withdraw Medicaid Work Requirements Rule

All 47 Senate Democrats and independents sent a letter to CMS Administrator Mehmet Oz on August 4, 2026, calling for withdrawal of the June 2026 interim final rule on Medicaid work requirements. The rule establishes community engagement requirements for the Medicaid expansion population beginning in 2027. The letter represents unified Democratic opposition to the policy ahead of its planned implementation. State Medicaid agencies and managed care organizations face operational and compliance implications if the rule proceeds or is rescinded.

Federal Policy·59d ago

Expert Panel Issues Guidelines on GLP-1 Use in Pregnancy

An international expert panel published systematic review and consensus guidelines on incretin-based medications (GLP-1s including semaglutide, liraglutide, dulaglutide, exenatide) in women's reproductive health, covering use before, during, and after pregnancy. The guidance, published in Obesity Reviews and based on 34 studies, provides counseling recommendations for clinicians treating patients on these medications. The guidelines address an emerging clinical question as GLP-1 use expands among women of reproductive age, including Medicaid beneficiaries with obesity and diabetes.

Federal Policy·59d ago

CMS Proposes 340B Cuts, Site-Neutral Payment Changes for 2027 Outpatient Rule

CMS released a proposed 2027 outpatient payment rule on July 2, 2026, that would cut billions from 340B drug payments and expand site-neutral payment policies affecting hospital reimbursement. The rule compounds financial pressure on hospitals already facing margin challenges, combining payment reductions that hospital finance leaders have previously fought separately. Comments on the proposed rule are due under the standard federal rulemaking timeline, typically 60 days from publication. The combined effect threatens Medicaid DSH hospitals and safety-net providers that rely heavily on 340B revenue and outpatient volume.

Industry·CA·60d ago

UC Davis Launches Telenephrology Program for Rural Mendocino County

UC Davis Health is partnering with Adventist Health Ukiah Valley to provide remote nephrology services to patients in rural Mendocino County, California, a region that previously lacked local kidney specialty care. The telenephrology program connects UC Davis nephrologists in Sacramento with patients and clinicians at the 50-bed rural hospital. The partnership aims to expand access to specialty care in an underserved area through telehealth infrastructure. No timeline or operational details were provided in the brief announcement.

Managed Care·60d ago

UnitedHealthcare Limits Lab Test Reimbursement Across Medicaid and Other Lines

UnitedHealthcare will implement new reimbursement limits on five categories of lab tests — allergen testing, liver fibrosis testing, in vitro chemotherapy sensitivity assays, testosterone blood tests, and vitamin B12 testing — effective September 1, 2026. The policies apply across the company's commercial, ACA exchange, Medicare Advantage, and Medicaid product lines. UnitedHealthcare Medicaid plans will be affected by the same utilization management criteria being applied to other lines of business. The changes will affect laboratory providers billing UnitedHealthcare Medicaid plans and could impact member access to certain diagnostic tests.

Industry·61d ago

Rural Health Systems Prioritize Strategic Tech Investment Over Volume Spending

Rural healthcare leaders are focusing on targeted technology investments rather than high-volume spending as they receive federal funding from the $50 billion Rural Health Transformation Program. The article examines how resource constraints are driving more intentional technology adoption decisions in rural health systems. Organizations achieving the strongest results are evaluating innovation based on practical impact rather than novelty. The piece outlines seven operational approaches rural providers are using to maximize technology investment returns.

State Policy·CA·61d ago

California Cuts Medi-Cal Asset Limits 84% Effective July 2027

California will reduce Medi-Cal asset limits by 84% starting July 1, 2027. Current limits of $130,000 for an individual (plus $65,000 per additional household member, up to 10 people) will drop to $21,000 for one person. The change affects eligibility determination for Medi-Cal applicants and enrollees subject to asset tests. This represents a significant tightening of financial eligibility criteria that will reduce the asset threshold available to certain Medi-Cal populations.

Federal Policy·62d ago

CMS Finalizes 2.3% IPPS Rate Increase, Mandatory Joint Replacement Bundled Payment Model for FY 2027

CMS finalized its fiscal year 2027 Inpatient Prospective Payment System (IPPS) rule on July 31, establishing a 2.3% payment rate increase for acute care and long-term care hospitals. The rule introduces the first mandatory, nationwide episode-based payment model for joint replacement procedures covering knee, hip, and ankle replacements. The rule takes effect October 1, 2026 (FY 2027 start). This matters for Medicaid because many state programs base their hospital payment rates on Medicare methodologies, and the bundled payment model could influence state approaches to managing orthopedic services under managed care and fee-for-service arrangements.

Industry·64d ago

438 Urban Hospitals Closed Since 2000, Yale Data Shows

Between 2000 and June 2026, 438 urban hospitals closed across the United States, according to Yale University's Health Care Affordability Lab data. For the 2001-2023 period when both openings and closures are tracked, urban hospitals showed a net gain of only 11 facilities nationally. The data provides state-by-state breakdowns of hospital closures and net changes in urban markets.

Industry·64d ago

Health Plans Deploy AI to Assist Customer Service Representatives During Member Calls

Health insurers, including UnitedHealth Group, are using AI tools to support customer service representatives in real time during member calls. UnitedHealth reports deploying AI in over 1,000 use cases, including chatbots that initially handle customer inquiries and AI assistants that provide guidance to representatives as they speak with members. The technology is operational now. This matters for Medicaid managed care organizations considering similar tools to reduce call handling time, improve response accuracy, and manage administrative costs in member services operations.

State Policy·NE·64d ago

Nebraska Launches Dashboard Tracking Rural Health Transformation Program Funding

Nebraska's Department of Health and Human Services launched a public dashboard on July 30, 2026, to track the distribution of Rural Health Transformation Program funds across the state. The tool provides transparency on how transformation program dollars are allocated to rural providers and communities. The dashboard is live and accessible to stakeholders and the public. This matters for Nebraska Medicaid providers and state agencies because it increases visibility into state-administered funding flows that may support rural provider participation in Medicaid programs and value-based care initiatives.

Industry·64d ago

Centene Projects $315M-$365M in Severance Costs from Voluntary Buyouts

Centene announced projected severance costs of $315 million to $365 million for the second half of 2026, primarily from voluntary employee buyouts offered in June. The company already incurred $61 million in related expenses during the second quarter. The buyouts were extended to most employees across the organization. These workforce reduction costs will affect Centene's financial performance through year-end 2026.

Industry·65d ago

UnitedHealth Group Ranks Fourth Largest Company Globally by Revenue

UnitedHealth Group climbed to the fourth-largest company worldwide by revenue in the 2026 Fortune Global 500, posting $447 billion in revenue for fiscal year 2025, an 11.8% year-over-year increase. The ranking reflects UnitedHealth's continued growth across its health insurance and Optum health services divisions. This milestone occurred in 2026 based on 2025 financial results. The scale positions UnitedHealth as a dominant force in health care markets, including Medicaid managed care, where its subsidiary plans serve millions of beneficiaries across dozens of states.

State Policy·IL·65d ago

Illinois Medicaid Disenrollment Drives Hospital Revenue Loss Ahead of Federal Work Requirements

Hospitals in Illinois are reporting financial losses as Medicaid enrollment declines in advance of federal work requirements scheduled to take effect in early 2027 under HR-1. William Davis, president of Deaconess Health System's Illinois region, is tracking enrollment drops among patients who previously had Medicaid coverage. The disenrollment is occurring before the federal mandate becomes operational, suggesting state-level eligibility changes or procedural terminations are already under way. The trend indicates that providers in states preparing for work requirement implementation may face immediate revenue pressure from coverage losses.

Industry·65d ago

Seven Health Systems Deploy ED Diversion Strategies for Behavioral Health Patients

Seven health systems are implementing programs to reduce emergency department boarding times and redirect behavioral health patients to more appropriate care settings. The initiatives aim to address prolonged ED wait times for psychiatric patients and reduce reliance on costly emergency care for conditions that could be managed in alternative settings. Approaches vary by system but focus on routing patients away from the ED when clinically appropriate. The efforts reflect broader industry attempts to manage behavioral health utilization and costs while improving patient experience in acute care settings.

Industry·66d ago

Provider-Sponsored Health Plans Face Closures as Providence Exits Insurance Business

Providence Health Plan, owned by Renton, Wash.-based Providence health system, will close most of its insurance operations starting in 2027. Similar closures have occurred at provider-sponsored plans operated by Carle Health in Illinois and Michigan Medicine. These closures reflect ongoing financial and operational challenges for health system-owned insurance companies. The trend affects provider-sponsored plans that serve Medicaid managed care markets alongside commercial lines of business.

Industry·66d ago

Five Health Systems Announce Major Layoffs in 2026

Multiple health systems have announced significant workforce reductions in 2026, driven by diverse operational pressures. A Texas psychiatric hospital eliminated 648 positions following CMS certification loss. Baylor Scott & White Health Plan also conducted layoffs amid broader industry trends including regulatory penalties, exits from unprofitable insurance markets, and outsourcing arrangements. The reductions reflect ongoing financial and operational challenges facing health systems and their affiliated health plans. Specific effective dates and total numbers across all five systems were not detailed in the summary.

Industry·VT·66d ago

UVM Health Cuts Costs After Vermont Policy Reduces Revenue by $220M

UVM Health is reducing expenses, restructuring leadership, and cutting positions after Vermont state policy changes reduced annual revenue at its flagship academic medical center by approximately $220 million starting January 1, 2026. The system is implementing affordability-focused operational changes under new leadership. These actions reflect broader financial pressures facing health systems, with implications for provider networks and service capacity in Vermont's Medicaid program.

State Policy·LA·66d ago

Louisiana Enacts Commercial PBM Reimbursement Floor Using NADAC

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.

State Policy·NM·67d ago

New Mexico Launches Healthy Aging App for Older Adults via UNM Health Sciences

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.

Industry·67d ago

ACA Subsidy Expiration Boosts Payer Margins, Shifts Hospital Payer Mix

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.

Industry·67d ago

Rural Hospitals Closed at Triple the Opening Rate Since 2001, Yale Data Shows

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.

Industry·67d ago

HHS Launches Behavioral Health Pledge as Optum Signs On First

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.

Industry·67d ago

UHS Says Talkspace Acquisition Will Expand Outpatient Behavioral Health Capacity

Universal Health Services executives stated the pending Talkspace acquisition will address two key obstacles to outpatient behavioral health growth: access to virtual care and therapist capacity for post-discharge patients. UHS CFO Steve Filton described Talkspace as providing both a virtual delivery platform and a larger therapist network to serve patients transitioning from inpatient settings. The acquisition, announced earlier in 2026, is positioned as an accelerant for UHS's outpatient behavioral health expansion strategy. This reflects ongoing consolidation in behavioral health delivery and growing emphasis on virtual care integration.

Federal Policy·67d ago

HHS OIG Audits Department AI Governance Framework for Federal Compliance

The HHS Office of Inspector General has initiated an audit examining whether the Department of Health and Human Services has established adequate governance for developing and deploying artificial intelligence tools across its operations. The audit will assess compliance with federal requirements, including National Institute of Standards and Technology AI risk management standards and departmental policies. The review covers AI governance structures affecting HHS agencies including CMS. The audit's scope and timeline for completion have not been publicly specified.

Industry·68d ago

Rural Hospitals Face New IT Compliance Pressures from HIPAA Security Rule Updates

Federal policymakers are increasing cybersecurity and AI requirements for healthcare providers, with proposed updates to the HIPAA Security Rule that would significantly expand compliance obligations. Rural hospitals face particular challenges implementing these requirements given constrained IT budgets and workforce capacity. The changes affect operational technology infrastructure, data security practices, and regulatory compliance frameworks. This matters for rural providers and safety-net systems already operating on thin margins, where IT investments compete with clinical priorities and workforce recruitment.

Legal·68d ago

CVS Moves to Dismiss Hospital Lawsuits Over 340B Savings Diversion

CVS Health filed motions to dismiss lawsuits brought by hospital systems in New York and Michigan alleging the company diverted 340B Drug Pricing Program savings. In a July 22 filing in the Eastern District of Michigan, CVS argued that University of Michigan Hospitals and Health Centers' lawsuit is a contract dispute rather than a 340B policy matter. The lawsuits center on allegations that CVS improperly retained savings intended for 340B-covered entities. The outcome could affect how pharmacy benefit managers handle 340B claims and reimbursements for safety-net providers, including Medicaid Disproportionate Share Hospitals.

Industry·68d ago

Healthcare Spending Projected to Accelerate Amid Rising Utilization and Policy Changes

Healthcare spending is projected to increase sharply in coming years driven by higher medical utilization, according to multiple data sources. Contributing factors include H.R. 1 legislation that is restructuring Medicaid programs and the expiration of enhanced ACA subsidies, which may increase uninsured rates. The convergence of rising utilization and major policy shifts affecting coverage is expected to pressure healthcare costs across payers and providers. Medicaid program changes under H.R. 1 will directly affect state agencies, managed care organizations, and provider reimbursement structures.

Federal Policy·68d ago

HRSA Rural Maternal Health Program Reaches 8,600 Women Across Three States

The Health Resources and Services Administration's Rural Maternity and Obstetrics Management Strategies Program (RMOMS) improved prenatal and postpartum care access for more than 8,600 women through networks in Minnesota, Missouri, and West Virginia, according to a 2026 program report covering the second cohort. The program addresses maternal care gaps in rural areas where provider shortages and hospital closures limit access to obstetric services. RMOMS networks coordinate care across providers, implement telehealth, and expand midwifery services to maintain maternal health infrastructure in underserved communities. For Medicaid agencies and managed care organizations covering rural populations, the program demonstrates models for sustaining maternal care capacity where traditional hospital-based delivery is no longer viable.

Legal·69d ago

HHS Appeals Ruling Vacating Portions of 2025 Marketplace Integrity Rule

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.

Industry·71d ago

For-Profit Hospital Systems Report Higher-Than-Expected Uninsured Volume After ACA Subsidy Expiration

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.

Industry·71d ago

Rural Hospitals in Three States Form Regional Networks to Compete with Larger Systems

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.

Industry·72d ago

Major Health Insurers Shift Focus to Services Units in Q2 Earnings

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.

Legal·WA·72d ago

Seattle Hospital, UNOS Sued Over Race-Adjusted Kidney Function Formula Delaying Transplant Eligibility

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.

State Policy·72d ago

Rhode Island and Hawaii Enact Healthcare AI Laws; Arizona Governor Vetoes Chatbot Bill

Rhode Island and Hawaii enacted healthcare AI legislation in June and July 2026, while Arizona's governor vetoed a similar chatbot disclosure bill. Rhode Island Governor Dan McKee signed two AI-related healthcare bills into law. The measures reflect divergent state approaches to regulating artificial intelligence in healthcare settings. These laws may affect how Medicaid managed care organizations deploy AI tools for utilization management, care coordination, or member services in these states.

Legal·74d ago

D.C. Circuit Rules Drugmakers Need HHS Approval for 340B Rebate Models

The U.S. Court of Appeals for the D.C. Circuit ruled July 21, 2026, that pharmaceutical manufacturers cannot implement 340B rebate models without prior approval from the HHS secretary. The decision upheld lower court rulings against Novartis, Johnson & Johnson Health Care Systems, Bristol Myers Squibb, and Eli Lilly. The ruling reinforces federal authority over 340B program administration and blocks manufacturer attempts to unilaterally restructure drug discount delivery mechanisms. For Medicaid managed care organizations with provider networks that include 340B-eligible entities, the decision preserves existing 340B purchasing pathways and prevents disruption to contract pharmacy arrangements that affect covered entity participation and pharmacy network stability.

Federal Policy·74d ago

CMS Proposes Ban on Medicare Payment for Third-Party Remote Patient Monitoring

CMS has issued a proposed rule that would prohibit Medicare payment for remote patient monitoring services delivered by third-party vendors. Health systems, physician groups, and telehealth trade associations are opposing the proposal, citing concerns about disrupted RPM programs and unclear reimbursement alternatives. The proposal has prompted some organizations to pause RPM expansion plans and appears to conflict with congressional support for broader telehealth access. If finalized, the policy would require Medicare providers to deliver RPM services directly rather than through vendor arrangements.

Federal Policy·74d ago

Rural Hospital CEO Criticizes $50B Federal Rural Health Transformation Program Structure

A rural hospital CEO has publicly criticized the $50 billion Rural Health Transformation Program, which launched last year following Medicaid cuts under HR-1. Rural health executives are questioning the program's design, citing concerns that states control funding distribution, eligible uses are narrowly defined, and the structure may not adequately address care access challenges in communities affected by Medicaid reductions. The criticism reflects broader implementation concerns among rural providers about whether federal support will effectively reach facilities serving Medicaid populations.

State Policy·DE·75d ago

Delaware Enacts Hospital Price Caps, Charity Care Expansion, PE Acquisition Moratorium

Delaware Governor Matt Meyer signed three healthcare bills on July 20, 2026, that will phase in hospital price caps, expand charity care eligibility, and temporarily block private equity acquisitions of nonprofit hospitals. The legislation aims to improve healthcare affordability and access in Delaware. The price cap implementation will be delayed to allow a phased approach. These changes affect hospital reimbursement structures and access requirements that impact Medicaid managed care organizations contracting with Delaware hospitals.

Managed Care·75d ago

Health Insurers Report Progress on Prior Authorization Simplification One Year After Voluntary Pledge

In June 2025, major health insurers committed to simplifying and reducing prior authorization requirements for plans covering 257 million Americans. One year later, payers report progress on their voluntary commitments, though implementation remains incomplete. The initiative affects commercial, Medicare Advantage, and potentially Medicaid managed care plans. For Medicaid MCOs, this signals industry-wide movement toward streamlined utilization management practices that may inform state contract requirements and CMS managed care rules.

Federal Policy·75d ago

Compounding Pharmacies Modify GLP-1 Formulations to Circumvent FDA Compounding Restrictions

A JAMA Health Forum study published July 17, 2026 finds that some compounding pharmacies are making minor compositional changes to semaglutide and tirzepatide products to evade FDA restrictions on compounding copies of approved drugs. The FDA previously added these GLP-1 medications to its drug shortage list due to surging demand, which legally permitted compounding. As shortages resolve and FDA moves to restrict compounding of these products, some pharmacies are altering formulations to maintain legal compounding status. This affects Medicaid managed care organizations that cover GLP-1s for diabetes and obesity, as it creates uncertainty around formulary management, prior authorization protocols, and pharmacy network oversight.

Federal Policy·79d ago

Pharmacy Groups Warn Revised ACIP Charter Could Delay Vaccine Recommendations

Nine pharmacy organizations wrote to HHS Secretary Robert F. Kennedy Jr. on July 9, 2026, warning that CDC's revised charter for the Advisory Committee on Immunization Practices (ACIP), issued June 25, could undermine the evidence-based framework for U.S. immunization policy. The letter follows a year of ACIP restructuring. The groups expressed concern that changes to ACIP's charter and processes could delay vaccine access and recommendations. For Medicaid managed care organizations, ACIP recommendations determine vaccine coverage requirements under EPSDT and adult preventive services, making any disruption to the committee's timeline or evidentiary standards operationally significant.

Managed Care·79d ago

Total GLP-1 Payments Rose Sharply Through 2022 Despite Lower Patient Cost-Sharing

A Northwestern University study published July 16 in the Journal of the American Heart Association found that average total payments for GLP-1 users without diabetes increased significantly between 2017 and 2022, even as patient out-of-pocket costs declined. The study documents the growing financial burden on payers during the period when GLP-1 utilization expanded beyond diabetes treatment. The findings reflect cost trends during a period that predates recent Medicare coverage expansion and current utilization management strategies. The research provides baseline data as Medicaid managed care organizations continue to face pressure to cover GLP-1s for weight loss and cardiovascular indications.

Industry·79d ago

Rural Hospitals Face Unique Payer Contracting Pressures from Geography and Payer Mix

Rural hospitals are confronting distinct challenges in managed care contracting driven by limited scale, geographic isolation, and constrained payer mix. These providers must navigate tighter margins than their urban counterparts while negotiating contracts that often fail to account for rural delivery realities. The article examines how rural facilities can strengthen their negotiating position despite structural disadvantages. These dynamics affect Medicaid managed care organizations with rural network obligations and rural health plan adequacy requirements.

State Policy·CA·80d ago

California Psychiatric Hospital Staffing Mandate Shows Early Implementation Challenges

California's nurse-to-patient staffing ratios for acute psychiatric hospitals took effect June 1, 2026, establishing mandated minimums for freestanding psychiatric facilities for the first time in over 20 years. Hospital leaders report concerns about workforce turnover and potential impacts on behavioral health access six weeks into implementation. The mandate applies to acute psychiatric hospitals previously exempt from state staffing ratio requirements. The early implementation period reveals operational challenges as facilities adjust to the new requirements.

Industry·80d ago

Children's Hospitals Face 16 Active Pediatric Drug Shortages Including Six IV Products

Pediatric drugs represent the therapeutic category most affected by active drug shortages, with 16 ongoing shortages including six involving IV fluids and additives. Children's hospitals face unique challenges managing these shortages compared to adult health systems due to weight-based dosing, limited alternative formulations, and smaller patient volumes that reduce purchasing leverage. The article examines operational strategies pediatric hospitals use to manage supply disruptions, though specific policy interventions or effective dates are not detailed.

Industry·80d ago

720 Rural Hospitals at Risk of Closure as Surgical Access Gaps Widen

A Center for Healthcare Quality and Payment Reform report finds that roughly one-third of rural hospitals — 720 facilities — face closure risk, raising questions about surgical access in underserved areas. As rural hospitals retreat from operating room services, the analysis highlights growing surgical care deserts. The report does not specify a timeline for closures but underscores ongoing financial instability in rural provider markets. For Medicaid managed care organizations with rural network obligations, this trend signals potential network adequacy challenges and increased need for alternative surgical access strategies.

Industry·81d ago

Providers Report Rising Denial Rates Despite Revenue Cycle Automation Gains

Health systems have invested heavily in revenue cycle automation over two decades, with the 2025 CAQH Index estimating $258 billion in avoided administrative costs in 2024. Despite these efficiency gains, denial rates continue to climb, with 41 percent of providers now reporting at least one in ten claims denied—a figure that has increased annually. The trend suggests automation alone has not resolved underlying issues driving claim denials, including prior authorization requirements, documentation standards, and payer policies.

Industry·85d ago

Sturgis Hospital Closes After 101 Years as 720 U.S. Hospitals Face Closure Risk

Sturgis Hospital in Michigan closed June 19, 2026, after 101 years of operation, following a 13% volume decrease over two years. An estimated 720 hospitals nationwide are at risk of closure. The closures disproportionately affect rural facilities facing declining patient volumes and financial pressures. For Medicaid managed care organizations, rural hospital closures threaten network adequacy, emergency access, and continuity of care for beneficiaries in underserved areas.

Industry·IA·85d ago

CommonSpirit Closes Labor and Delivery Services at Iowa Hospital

CHI Health Mercy Council Bluffs will end labor and delivery and Level 2 NICU services on August 31, 2026. CommonSpirit Health will consolidate these services at its Omaha birth centers, located approximately 15 minutes away, which currently deliver over 4,460 babies annually. Patients will transition to the Omaha facilities for obstetric care.

Industry·87d ago

Safety Net CIOs Tighten IT Spending Amid Medicaid Budget Reductions

Public safety net systems like Valleywise Health in Maricopa County are applying stricter financial scrutiny to technology investments as Medicaid funding reductions take effect. Chief information officers are requiring business cases for every technology decision, intensifying pre-existing budget discipline. The approach reflects broader operational adjustments underway at safety net providers preparing for sustained Medicaid cuts. The article does not specify timing of cuts or which technology investments are being deferred or prioritized.

Legal·87d ago

Four Major Pharmacy Litigation Tracks Progress: PBM Ownership, 340B, Antitrust, Fraud

Pharmacy litigation is proceeding on four major fronts. State laws banning PBM ownership of pharmacies face constitutional challenges. Drugmakers are challenging state 340B protections in multiple jurisdictions. PBMs face antitrust claims over reimbursement practices. Federal fraud enforcement actions target rebate and claims manipulation by PBMs. These cases are ongoing with varying timelines across federal and state courts.

Industry·88d ago

Four Health Plans Expand Specialty Pharmacy Strategies to Address Drug Cost Growth

Four health insurers are implementing new specialty pharmacy approaches in 2026 to address rising prescription drug costs, a major driver of overall cost growth. Strategies include expanding service offerings, entering healthcare delivery, and pursuing partnerships to increase cost discipline. The initiatives reflect broader industry efforts to manage high-cost specialty medications through vertical integration and improved utilization management. Specific plan names and implementation details were not provided in the source material.

Legal·88d ago

5,000 Independent Pharmacies Sue Prime Therapeutics for Alleged Antitrust Violations

Nearly 5,000 independent pharmacies filed a federal antitrust lawsuit on July 2, 2026, in the U.S. District Court for the Western District of Washington against Prime Therapeutics, alleging the PBM conspired with Express Scripts to suppress pharmacy reimbursement rates and increase fees. The complaint claims violations of federal antitrust law through coordinated pricing practices. The lawsuit targets PBM reimbursement methodologies that affect pharmacy network economics. This litigation follows broader scrutiny of PBM pricing practices and their impact on pharmacy access.

Federal Policy·88d ago

CMS Launches Medicare GLP-1 Bridge Program with Fixed-Cost Access

The Centers for Medicare & Medicaid Services launched its Medicare GLP-1 Bridge program on July 1, 2026, offering select beneficiaries fixed-cost access to GLP-1 medications including Foundayo and Wegovy. The program arrives as GLP-1 use among US adults reached 11% in 2026, up from 3% in 2024, according to a July 7 Gallup poll. The new Medicare benefit structure establishes precedent for coverage of anti-obesity medications that could influence Medicaid managed care pharmacy benefits and prior authorization protocols. Medicaid MCOs should monitor whether states adopt similar fixed-cost or expanded coverage models for their programs.

Industry·88d ago

Yale Study Finds Most Telehealth GLP-1 Vendors Skip Live Clinician Visits

A secret shopper study published July 6 in JAMA found that most telehealth platforms prescribing GLP-1 medications do not require real-time clinician interaction with patients before prescribing. Yale researchers documented prescribing practices across online vendors selling these weight-loss and diabetes medications. The study raises questions about appropriateness of care, patient safety, and adherence to clinical practice standards in the rapidly growing direct-to-consumer telehealth market for high-cost specialty drugs. Implications for Medicaid managed care organizations include potential utilization management concerns and pharmacy benefit oversight challenges.

Federal Policy·89d ago

602 Hospitals Face 50-75% Wider Deficits Under Federal Cuts, NNU Projects

National Nurses United released a report July 6 projecting that 602 financially vulnerable hospitals could see their combined deficit grow by 50% to 75% under the combined impact of Medicare sequestration, Medicaid cuts tied to HR 1, and the expiration of enhanced ACA marketplace subsidies. The report identifies these hospitals as particularly at risk from the confluence of federal payment reductions. The analysis warns of a preventable financial crisis affecting provider networks that serve Medicaid populations.

Industry·89d ago

15 Hospitals Close Maternity Units in First Half of 2026

Fifteen hospitals closed labor and delivery services in the first half of 2026, continuing a trend that saw 29 closures in the prior year. The closures are driven by financial pressures, staffing shortages, and declining birth rates. The pattern reflects ongoing consolidation in maternity care delivery that affects network adequacy and access to prenatal and delivery services. These closures require Medicaid managed care plans to assess network gaps and ensure adequate coverage for pregnant members.

Legal·NY·94d ago

HHS OIG Suspends Federal Funding to New York Medicaid Fraud Unit

The HHS Office of Inspector General notified New York on June 30 that federal grant funds to the state's Medicaid fraud control unit are suspended effective July 1, 2026. The unit receives approximately $60 million annually in federal funding. The suspension affects the state's capacity to investigate and prosecute Medicaid fraud, including cases involving managed care organizations. No end date for the suspension was specified in the OIG letter.

Industry·94d ago

Four Chemotherapy Drugs Remain in Shortage Until October

Cisplatin, carboplatin, oxaliplatin, and ifosfamide remain in active shortage, with full resupply of some formulations not expected until October 2026, according to the American Society of Health-System Pharmacists. These chemotherapy drugs are essential for treating breast, lung, ovarian, testicular, bladder, and head and neck cancers. Manufacturers have provided updated timelines for when supply will normalize. The shortages affect hospitals and health systems managing cancer treatment protocols.

Managed Care·IL·96d ago

Chicago Safety-Net Hospital Faces Closure Over Medicaid MCO Payment Delays

Roseland Community Hospital on Chicago's South Side is struggling to make payroll due to delayed payments from CountyCare, Cook County's largest Medicaid managed care organization. The facility barely met its June 30 payroll and CEO Tim Egan described the financial situation as critical. The hospital serves a predominantly Medicaid population in an underserved area. Payment delays from Medicaid MCOs threaten the facility's ability to remain operational.

State Policy·CA·96d ago

California Grants Staffing Waivers to 23 Psychiatric Hospitals After New Nurse Ratio Rules

California's Department of Public Health approved temporary waivers for 23 of 35 psychiatric hospitals required to comply with new nurse-to-patient ratios that took effect June 1, 2026. The regulations mandate one nurse per six adult patients and one nurse per five youth patients in psychiatric units. The waivers allow non-compliant facilities to continue operating while they work toward meeting staffing requirements. This affects Medicaid managed care organizations with behavioral health carve-ins or delegated inpatient psychiatric contracts, as network adequacy and access standards depend on participating hospitals maintaining operational capacity.

State Policy·IL·100d ago

Illinois Law Restricts Out-of-State Access to Abortion, Gender Dysphoria Records

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.

Industry·AR·101d ago

Arkansas nonprofit launches GME center to expand physician training in rural areas

Heartland Whole Health Institute, a nonprofit founded by Alice Walton, has launched a statewide Graduate Medical Education Technical Assistance Center in Arkansas focused on expanding physician residency training in rural and underserved communities. The institute released a report outlining strategies to grow the physician pipeline through GME program development. The center aims to address provider shortages that affect care access in areas where Medicaid managed care organizations operate networks.

Industry·OK·101d ago

Ascension St. John Nowata Seeks Conversion to Rural Emergency Hospital

Ascension St. John Nowata in Oklahoma has applied to the state health department to convert from a critical access hospital to a rural emergency hospital designation. The facility would maintain 24/7 emergency services and outpatient care under the REH model. The conversion reflects a broader trend of rural hospitals adopting the REH designation created under the Consolidated Appropriations Act of 2021, which allows hospitals to eliminate inpatient beds while maintaining emergency and outpatient services with enhanced Medicare reimbursement.

State Policy·MI·101d ago

Michigan Erases $74M in Medical Debt Through Nonprofit Partnership

Michigan has eliminated over $74 million in medical debt for 71,871 residents through a partnership with nonprofit Undue Medical Debt, bringing the state's total debt relief to more than $200 million. Governor Gretchen Whitmer's office announced the initiative on June 22. The program targets qualifying residents with medical debt, though specific eligibility criteria and coverage periods were not detailed in the announcement. This marks Michigan's continued expansion of its medical debt relief efforts using state budget allocations to purchase and forgive outstanding hospital and provider balances.

Industry·102d ago

NCI Cancer Center Distribution Misaligned with U.S. Cancer Burden Geography

National Cancer Institute-designated cancer centers, the most research-intensive cancer facilities in the U.S., are not geographically distributed to match where cancer burden is highest, according to leaders at Becker's Oncology Executive Summit in April. This mismatch creates access challenges for patients in high-burden areas who cannot reach NCI centers. The speakers characterized this as oncology's "last-mile problem" in care delivery.

Industry·102d ago

Health Plan M&A Shifts to Targeted Acquisitions Over Large-Scale Consolidation

Health plan mergers and acquisitions are moving away from sweeping consolidations toward more disciplined, targeted transactions, according to EY-Parthenon principal Deblina Ghosh. The current M&A environment emphasizes precision and strategic fit, particularly in the nonprofit sector where partner alignment is critical. This shift reflects broader market conditions favoring selective portfolio adjustments over transformative mega-mergers. The trend affects how Medicaid managed care organizations evaluate growth opportunities and competitive positioning.

Industry·102d ago

Nursing home staffing reaches 3.49 million workers, up from pandemic low

Nursing home and residential care facility employment has climbed to approximately 3.49 million workers as of May, according to Bureau of Labor Statistics data, recovering from a pandemic low of 2.96 million. The industry has added more than 500,000 workers since its lowest staffing point during the COVID-19 pandemic. This represents a steady upward trend in nursing facility workforce levels, though the article does not specify whether current staffing meets pre-pandemic benchmarks or regulatory adequacy standards.

Industry·102d ago

One-Third of Rural Hospitals at Financial Risk, Analysis Finds

A Center for Healthcare Quality and Payment Reform analysis found 720 rural hospitals—roughly one-third of all rural facilities nationwide—are at risk of closure due to financial instability. Healthcare leaders are advocating for increased collaboration among rural providers rather than competition to strengthen outcomes and ensure long-term sustainability. The analysis highlights ongoing financial pressures threatening rural access to care. No specific implementation timeline or policy action is indicated.

Industry·102d ago

Inventia Healthcare recalls 11,460 bottles of chlorthalidone tablets after dissolution failure

Inventia Healthcare Limited is recalling 11,460 bottles of Chlorthalidone Tablets USP, 25 mg, distributed nationwide after the product failed dissolution specifications. The FDA classified the recall as Class II on June 22, following the manufacturer's June 5 recall initiation. Chlorthalidone is a diuretic used to treat hypertension. Class II recalls indicate the product may cause temporary or medically reversible adverse health consequences, with a remote probability of serious harm.

State Policy·MI·103d ago

Michigan House Speaker Proposes Hospital Cost Review Board, 10% Price Caps

Michigan House Speaker Matt Hall introduced legislation establishing a state hospital cost review board with authority to cap healthcare prices and restrict hospital consolidation. The bill would impose a 10% reduction on certain hospital prices and create new regulatory oversight of hospital costs. The Michigan Health & Hospital Association opposes the measure, arguing it would worsen affordability challenges. If enacted, the law would apply to all hospitals operating in Michigan, including those contracting with Medicaid managed care organizations.

Industry·103d ago

FDA Panel Recommends Moderna mRNA Flu Vaccine for Adults 50 and Older

An FDA advisory panel recommended approval of Moderna's mFlusiva, the first mRNA-based influenza vaccine, for adults ages 50-64 and those 65 and older under specific conditions. In late-stage trials, the vaccine demonstrated 27% greater effectiveness compared to standard flu shots. The panel's recommendation followed a June 18 meeting where FDA officials reviewed the clinical data. Final FDA approval would mark the first mRNA flu vaccine on the market, potentially expanding vaccine options for Medicaid managed care plans covering adult populations.

Industry·107d ago

Eli Lilly Denies 340B Discounts to Hospitals Without Claims Data

Eli Lilly has begun denying 340B drug discounts to hospitals that have not submitted claims-level data under its reporting requirements, according to the American Hospital Association. The AHA confirmed the action in a June 18 statement, calling it "extraordinary." The move affects hospitals participating in the 340B Drug Pricing Program, which provides discounted outpatient drugs to eligible safety-net providers. This follows ongoing disputes between drug manufacturers and covered entities over data-sharing requirements that manufacturers have imposed despite regulatory uncertainty.

Managed Care·107d ago

California, New York, Ohio Account for 26% of National Medicaid Drug Spend in FY 2024

California, New York, and Ohio led all states in gross Medicaid prescription drug spending in fiscal year 2024, representing more than a quarter of national expenditures, according to a KFF analysis of federal data. The figures reflect gross spending before manufacturer rebates on covered outpatient drugs under the Medicaid Drug Rebate Program. The data provides a state-by-state breakdown of prescription drug costs, highlighting geographic variation in Medicaid pharmacy spending patterns. This information is relevant for managed care organizations operating in multiple states to benchmark their pharmacy spending and assess market-specific cost drivers.

Industry·KS·108d ago

Seven Rural Kansas Hospitals Form Clinically Integrated Network

Seven independent rural hospitals in Kansas have formed the Kansas High Value Network, a clinically integrated network serving approximately 190,000 patients. The founding member hospitals represent a combined net revenue of $545 million. The network aims to support value-based care delivery and reduce purchasing costs through collective contracting and operational coordination. The formation reflects broader consolidation trends among rural providers seeking scale to participate in value-based payment arrangements.

Managed Care·108d ago

CDC Reports Infant Mortality Rate Falls to Record Low in 2025

The CDC's National Vital Statistics System reported that infant mortality rates in the United States reached an all-time low in 2025, based on provisional death and birth data. The infant mortality rate measures deaths under age one per 1,000 live births. Final figures will be released later this year. The decline continues a multiyear trend in improved birth outcomes, though racial and geographic disparities persist.

Managed Care·109d ago

Medicaid MCOs Prepare for 2027 Community Engagement Requirements Under HR 1

The Reconciliation Act (HR 1) established community engagement requirements for non-elderly, nonpregnant Medicaid adults effective 2027. CMS has released an implementation framework detailing how states must operationalize work requirements for beneficiaries aged 19-64. Health plans cannot contract directly with states to administer these requirements, but managed care organizations are developing member engagement and support strategies to maintain enrollment and help beneficiaries comply. The requirements will affect eligibility determination, member outreach, and care coordination workflows across Medicaid MCOs.

Industry·110d ago

Centene Announces Voluntary Separation Program for Most Employees

Centene Corporation confirmed it is offering a voluntary separation program to most employees as part of a broader repositioning effort. The managed care giant stated the program aims to deliver a simpler experience for members and partners while adapting to current healthcare market conditions. The announcement affects Centene's workforce across its health plan operations, though specific numbers of affected employees and program details were not disclosed. The timing follows industrywide pressure on managed care margins and administrative cost reduction initiatives.

Industry·111d ago

Bipartisan Policy Center Finds Health AI Tools Largely Unregulated

A Bipartisan Policy Center report finds that most health AI tools currently deployed in healthcare settings operate outside existing regulatory frameworks. The report maps oversight gaps across federal agencies and identifies clinical AI scribes and prior authorization tools as examples of widely used applications with unclear regulatory authority. The analysis highlights inconsistencies in how different types of AI tools are classified and overseen by FDA, ONC, OCR, and other agencies. For Medicaid managed care organizations, the findings underscore the need for internal governance frameworks for AI utilization review, clinical documentation, and administrative automation tools until federal oversight clarifies.

Managed Care·CA·115d ago

CalOptima Health Allocates $430M for Hospital and Specialist Rate Increases Through 2027

CalOptima Health's board approved $429.6 million from reserves to increase hospital and specialist rates over the next 30 months, bringing total provider rate increases to nearly $1 billion since 2024. The Orange County Medi-Cal plan is using reserve funds to address provider payment adequacy. The rate increases will be implemented through 2027. This reflects ongoing pressure on Medicaid managed care organizations to maintain network adequacy and provider participation amid rising costs.

Industry·115d ago

Health Systems Expand In-House Specialty Pharmacy Operations Amid 340B Restrictions

Health systems are increasingly establishing their own specialty pharmacy operations in response to tightening reimbursement and manufacturer restrictions on 340B contract pharmacy arrangements. Hospitals and health systems now represent the fastest-growing segment of direct participants in the specialty pharmacy market. The shift is driven by both revenue generation goals and manufacturers' evolving 340B policies that limit contract pharmacy access. This infrastructure buildout allows health systems to capture specialty drug dispensing margins and maintain access to 340B savings despite manufacturer restrictions.

Industry·117d ago

Eli Lilly 340B Deadline Passes, Noncompliant Hospitals Lose Discounts

Eli Lilly's June 1 deadline for hospitals to submit claims data to maintain 340B drug discounts has passed without HRSA intervention. Hospitals that failed to comply with Lilly's data submission requirements will lose access to discounted pricing on covered drugs. HRSA has not responded to requests from hospital and pharmacy groups to intervene in the dispute. The action affects hospitals participating in the 340B program that purchase Lilly medications.

Industry·117d ago

Three Hospital Closures Reported in Early 2026, Down from 13 Year Prior

Three U.S. hospitals and emergency departments closed in early 2026, compared to 13 at the same point in 2025. Total closures in 2025 reached 23, nearly matching the 25 reported in 2024. The article suggests the early 2026 slowdown may not indicate structural improvement in hospital financial stability. The trend continues a multi-year pattern of hospital closures driven by financial pressures.

Industry·NC·121d ago

Novant Health Reports 1,595 Bed Days Saved Through Hospital-at-Home Program

Novant Health's 19-hospital system launched a hospital-at-home program at Hanover Regional Medical Center in Wilmington, North Carolina, saving 1,595 inpatient bed days. The health system is advocating for expanded private payer coverage of the care model and seeking federal legislation to make hospital-at-home a permanent option beyond current emergency waivers. The program allows acute-care patients to receive hospital-level services in their homes, reducing facility capacity strain while maintaining care quality.

Legal·121d ago

Federal Trial Links Fake Nursing Diploma Mill to Patient Death in Florida Fraud Case

Federal prosecutors opened trial in Fort Lauderdale on June 1 for the final contested case from Operation Nightingale, a fraud scheme that sold approximately 15,000 fake nursing credentials over three years. For the first time, prosecutors are connecting the diploma mill scheme to a patient death. The trial represents the conclusion of a federal enforcement action that exposed thousands of individuals with fraudulent nursing degrees working in healthcare facilities nationwide.

Industry·NY·122d ago

Westchester Medical Center Partners with MVP Health Care on Care Coordination

Westchester Medical Center Health Network in New York has launched a partnership with MVP Health Care to improve care coordination for hospitalized patients and during discharge transitions. MVP clinical care managers will be embedded in hospital care teams and will continue supporting members after they return home. The partnership aims to reduce readmissions and improve care continuity. The arrangement reflects growing collaboration between health systems and payers on care transition programs.

State Policy·HI·123d ago

Hawaii Launches $28M Rural Health Workforce Program With Service Commitments

Hawaii is launching a $28 million full-tuition program for healthcare students who commit to practicing in rural communities. The Hawai'i Outreach for Medical Education in Rural Under-resourced Neighborhoods program will cover tuition and fees for students pursuing healthcare and Health IT training beginning in September. In exchange, participants must work in designated rural areas after graduation. The program aims to address persistent provider shortages in Hawaii's underserved communities.

State Policy·NJ·123d ago

New Jersey Hospital System Mobilizes to Retain 500,000 Medicaid Patients Facing Disenrollment

Hackensack Meridian Health is launching an outreach campaign to educate approximately 500,000 New Jersey Medicaid beneficiaries at risk of losing coverage, with $3.5 billion in reimbursement at stake for the 18-hospital system. The health system president cited concerns about increased emergency department utilization if patients lose coverage and delay care. The disenrollment threat appears connected to federal legislation referenced as the One Big Beautiful Bill Act. Hackensack Meridian is working to help eligible patients maintain enrollment through education and assistance with renewal processes.

State Policy·CA·123d ago

California Implements Emergency Psychiatric Hospital Staffing Ratios With Financial Penalties

California's Department of Public Health implemented emergency regulations on June 1, 2025, establishing minimum nurse-to-patient ratios for psychiatric hospitals and imposing financial penalties for noncompliance. The regulations were developed in response to a February 2025 San Francisco Chronicle investigation documenting dysfunction, abuse, and understaffing at California behavioral health facilities. The emergency rules apply to all psychiatric hospitals operating in California. Facilities must meet the new staffing standards immediately or face state-imposed penalties.

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