Medicaid Monitor
Policy Intelligence
Medicaid Monitor
Policy Intelligence
Updated Fri 12:06 PM MT
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Federal Policy·1d ago

CMS Finalizes Major Updates to Medicare TAVR Coverage Rules

CMS issued a Decision Memorandum on September 10, 2026, finalizing a reconsideration of the National Coverage Determination for Transcatheter Aortic Valve Replacement, prompted by a request from device manufacturer Edwards Lifesciences. The updated NCD relaxes the 2019 rules by allowing asynchronous heart-team patient evaluations, eliminating the requirement for two operators from different specialties, replacing hospital-level volume requirements with operator-level thresholds (20 valve procedures annually, 15 of which must be TAVR), and ending coverage-with-evidence-development requirements for symptomatic severe aortic stenosis. CMS also created a new coverage pathway for asymptomatic severe aortic stenosis, limited to CMS-approved studies. Hospitals and physicians performing TAVR must comply with the revised conditions of Medicare payment, as noncompliance can trigger False Claims Act exposure.

State Policy·IN·3d ago

Indiana Law Shifts Long-Stay Nursing Home Residents to Fee-for-Service

Indiana enacted House Enrolled Act 1277, a Medicaid reform law altering the state's PathWays for Aging managed care program and other long-term services and supports. Most provisions took effect July 1, 2026, but the law also directs a transition of certain long-stay nursing facility residents out of managed care and into fee-for-service Medicaid, with that transition beginning on a later timeline described in the update. Long-term care and HCBS providers, along with PathWays managed care plans, must adjust billing, care coordination, and enrollment processes to align with the new structure. The change affects how nursing facilities and HCBS providers interact with payers for affected residents going forward.

Federal Policy·11d ago

CMS Proposed Rule on SNF Deregulation Under OMB Review

A proposed CMS rule affecting Medicare-participating skilled nursing facilities is under review by the Office of Management and Budget. The proposal appears aligned with prior CMS deregulatory efforts under the Trump administration. OMB review is the final step before a proposed rule is published in the Federal Register, after which a public comment period typically follows. The timing and scope of the proposal remain uncertain pending OMB clearance.

State Policy·WI·15d ago

Wisconsin Extends Civil Rights Compliance Period for Medicaid Providers Through 2028

The Wisconsin Department of Health Services extended the civil rights compliance period for recipients of federal financial assistance through December 31, 2028. The compliance period, which began January 1, 2022, was originally set to expire on December 31, 2026. This extension affects Medicaid providers and health plans that receive federal financial assistance through DHS and must maintain compliance with civil rights requirements. The extension provides an additional two years under the current compliance framework before any potential updates to civil rights compliance requirements take effect.

State Policy·IN·16d ago

Indiana Proposes Expanded Resident Rights and HCBS Standards for Residential Care Facilities

The Indiana Department of Health has issued a second public comment notice on proposed amendments to Residential Care Facility regulations. The rulemaking would expand resident rights protections, incorporate federal Home and Community-Based Services setting requirements into state assisted living regulations, and create new eviction procedures for facilities. The proposal affects residential care facilities serving Medicaid HCBS waiver beneficiaries in Indiana. Public comment is now open on the revised proposal, which builds on an earlier version published this year.

Federal Policy·22d ago

CMS Proposes Expanded Site-Neutral Payment and 340B Changes for Hospitals

CMS has proposed expanding site-neutral reimbursement policies and modifying the 340B drug pricing program, affecting hospital payment rates. The American Hospital Association and other provider groups oppose the proposals, arguing they fail to account for Medicare patient volume, care complexity, and regulatory requirements hospitals face. The timing and effective date of the proposals are not specified in this summary. The changes would affect hospital finances and facility investment, with potential downstream impacts on Medicaid-participating safety-net hospitals that rely on 340B savings and serve dual-eligible beneficiaries.

Legal·22d ago

Second Circuit Eases Pleading Standards for Reverse False Claims Act Cases

The U.S. Court of Appeals for the Second Circuit ruled that False Claims Act relators can satisfy Federal Rule of Civil Procedure 9(b) pleading requirements without identifying every false claim in an alleged fraudulent scheme. The decision in United States ex rel. Gallian v. AmerisourceBergen also left unresolved whether Rule 9(b)'s heightened pleading standards apply at all to reverse False Claims Act claims, which involve defendants who improperly retain government overpayments rather than submitting false claims for payment. The ruling applies to cases filed in the Second Circuit (Connecticut, New York, Vermont) and may influence how FCA cases proceed in other jurisdictions.

Legal·27d ago

HRSA Issues FQHC Scope of Project Manual Governing Provider Arrangements and 340B Operations

On August 11, 2026, HRSA released its Health Center Program Scope of Project Policy Manual, providing comprehensive guidance on what constitutes an FQHC's approved scope of project under Section 330 of the Public Health Service Act. The manual took effect immediately upon release. It addresses provider-patient relationships, arrangements with other providers, and 340B drug pricing program operations for federally qualified health centers. The guidance affects how FQHCs structure their service delivery, contractual relationships, and participation in federal programs, with implications for Medicaid managed care plans contracting with FQHCs and state agencies overseeing network adequacy.

Legal·FL·39d ago

DOJ Settles with Complete Health MSO for $14.1M Over Compliance Allegations

The Department of Justice announced a $14.1 million settlement with Complete Health Partners Holdings, a Florida management services organization, to resolve allegations under the False Claims Act. The settlement, finalized August 4, 2026, addresses compliance failures at the MSO level that likely involve arrangements affecting federal health programs. The case highlights enforcement risks for management services organizations operating in or adjacent to Medicaid managed care markets. Specific compliance program deficiencies leading to the settlement offer instructive lessons for MSOs, Medicaid health plans, and affiliated provider organizations subject to federal fraud and abuse laws.

Legal·47d ago

OIG Approves FQHC Produce Benefits for Patients with Chronic Conditions

The HHS Office of Inspector General issued Advisory Opinion 26-16 approving a federally qualified health center's program to provide produce boxes and vouchers to patients with certain chronic health conditions. The arrangement would typically constitute prohibited remuneration under the Beneficiary Inducements Civil Monetary Penalty statute, but OIG determined it qualifies for protection. The opinion provides compliance guidance for FQHCs and other Medicaid providers seeking to implement food-as-medicine interventions without triggering anti-kickback or beneficiary inducement penalties.

Industry·57d ago

Rural Hospitals Form Regional Networks to Maintain Independence Amid Consolidation

Independent rural hospitals are forming regional networks to gain negotiating power, reduce costs, and participate in value-based care while avoiding acquisition by larger health systems. North Dakota's 23-hospital Rough Rider High-Value Network exemplifies this trend, launched with state support to serve a significant portion of the state's Medicaid and Medicare population. These networks allow small hospitals to achieve economies of scale in contracting and care delivery without surrendering operational control. The trend reflects rural providers' efforts to remain viable as standalone entities while meeting evolving payment and quality requirements.

Federal Policy·57d ago

CMS Finalizes FY 2027 SNF PPS Rule With Payment Updates and MDS Reporting Changes

CMS published its final rule updating Medicare payment rates and policies for skilled nursing facilities under the SNF PPS for federal fiscal year 2027, effective October 1, 2026. The rule includes a payment rate increase, revisions to the Skilled Nursing Facility Quality Reporting Program (QRP), and expanded Minimum Data Set (MDS) reporting requirements. The changes affect SNF reimbursement levels, quality reporting obligations, and administrative requirements for facilities participating in Medicare. For Medicaid programs, these changes may influence state rate-setting for dual-eligible beneficiaries and facility operations where Medicare and Medicaid patients receive services in the same settings.

Legal·66d ago

Texas District Court Vacates CMS Rule Excluding 1115 Waiver Days from DSH Calculations

On July 27, 2026, the U.S. District Court for the Northern District of Texas vacated a 2023 CMS regulation that excluded inpatient days covered by Section 1115 waiver uncompensated care funding pools from Medicaid disproportionate share hospital (DSH) day counts. This is the second time the court has struck down this rule in Covenant Medical Center v. Kennedy. The ruling affects how hospitals calculate their Medicaid patient volume for DSH payment eligibility. The decision takes effect immediately, allowing hospitals to include these waiver days in their DSH calculations until CMS takes further action.

State Policy·IN·67d ago

Indiana Imposes Six-Month Enrollment Moratorium on HCBS Waiver Providers Effective August 1

Indiana received CMS approval to implement a statewide provider certification and enrollment moratorium for multiple Home- and Community-Based Services (HCBS) 1915(c) waiver provider types. The moratorium takes effect August 1, 2026, and will initially remain in place for six months. The action halts new HCBS provider certifications and enrollments across Indiana's waiver programs during this period. Indiana Medicaid managed care organizations will be unable to contract with new HCBS providers in the affected categories while the moratorium is in effect, potentially limiting network expansion and member access to services.

Legal·72d ago

OIG Advisory Opinion Finds Hospital Discharge Referral Software Creates Anti-Kickback Risk

The HHS Office of Inspector General issued Advisory Opinion 26-15 concluding that a subscription-based referral management software platform used in hospital discharge planning could generate prohibited remuneration under the Federal Anti-Kickback Statute. OIG determined that providers paying subscription fees to use the platform may receive improper referrals in exchange for those payments. The opinion affects hospitals, post-acute care providers, and technology vendors involved in discharge planning and care coordination arrangements. The advisory opinion provides immediate compliance guidance for similar arrangements nationwide.

Federal Policy·76d ago

CMS Launches Risk-Based Survey Process for Higher-Performing Nursing Homes September 8

CMS announced nationwide implementation of a Risk-Based Survey process for qualifying nursing homes starting September 8, 2026, per QSO-26-14-NH. The RBS allows State Survey Agencies to use fewer resources surveying higher-performing facilities and redirect them toward lower-performing providers. Qualifying facilities must meet specific performance thresholds to be eligible for the streamlined survey approach. This changes how survey resources are allocated across skilled nursing facilities participating in Medicare and Medicaid.

State Policy·WI·79d ago

Wisconsin APRN Modernization Act Removes Physician Collaboration Requirement September 1

Wisconsin's APRN Modernization Act takes effect September 1, 2026, eliminating the requirement that advanced practice registered nurses maintain collaborative arrangements with physicians or dentists to practice. The law modifies state licensure requirements for qualified APRNs. This change affects network adequacy and provider access strategies for Medicaid managed care organizations operating in Wisconsin, as APRNs gain independent practice authority. MCOs may need to update credentialing policies, provider contracts, and network composition to reflect the expanded scope of practice.

Legal·80d ago

OIG Releases Updated Corporate Integrity Agreement Template with Enhanced Compliance Requirements

On April 30, 2026, the HHS Office of Inspector General unveiled a revised Corporate Integrity Agreement template at the Health Care Compliance Association's annual conference, using the Kinex Medical Company CIA as the model. The updated template retains core compliance program elements while introducing enhanced compliance obligations for health care organizations entering into settlement agreements with OIG. CIAs are typically imposed on providers and health plans that resolve fraud and abuse allegations, requiring heightened compliance measures for three to five years. The new template will apply to future CIA settlements and affects any Medicaid managed care organization facing potential OIG enforcement actions.

State Policy·NY·89d ago

New York Medical Aid in Dying Act Takes Effect August 5, 2026

New York's Medical Aid in Dying Act becomes effective August 5, 2026, establishing a legal framework for terminally ill adults to request and self-administer life-ending medication. The law, introduced in January 2025 and amended in February 2026, affects health plans, providers, and facilities operating in New York's Medicaid program. Managed care organizations must prepare compliance protocols, update provider contracts, and clarify coverage policies before the effective date. The law represents the latest state-level expansion of medical aid in dying, joining ten other states with similar statutes.

Federal Policy·90d ago

CMS Proposes Provider Enrollment and Billing Privilege Changes in Home Health Rule

CMS included proposed changes to Medicare provider enrollment regulations (42 CFR Part 424, Subpart P) in its July 1, 2026 Home Health Prospective Payment System proposed rule. The changes would affect requirements for providers and suppliers to obtain and maintain Medicare billing privileges. The proposed modifications are embedded in the home health payment rule rather than issued as standalone enrollment guidance. Comment periods and effective dates follow standard rulemaking timelines for proposed rules.

Legal·96d ago

DOJ Antitrust Settlements Target Hospital Steering Restrictions in Commercial Payer Contracts

The U.S. Department of Justice Antitrust Division filed civil complaints against hospital systems for using contract provisions that require health insurers to include them in nearly all commercial networks at preferred benefit tiers. These steering restrictions limit insurers' ability to design narrow network products. The OhioHealth settlement reflects DOJ's increased enforcement focus on payer contracting practices that constrain network design flexibility. While the cases involve commercial insurance, the enforcement trend signals heightened scrutiny of similar anti-steering and anti-tiering provisions that may appear in Medicaid managed care contracts.

Legal·100d ago

Federal Court Orders Unsealing of Decade-Old False Claims Act Filings in HCR ManorCare Case

A federal court in Pennsylvania ordered the unsealing of nearly ten years of False Claims Act filings in U.S. ex rel. Compton v. HCR ManorCare, Inc., ruling that the government failed to justify continued sealing under the strong presumption of public access to judicial records. The decision, issued April 17, 2026, requires disclosure of qui tam complaint materials that have been under seal since 2016. The ruling reflects growing judicial scrutiny of extended seal periods in FCA cases, which typically remain sealed while the government investigates allegations of fraud against federal health programs including Medicaid.

State Policy·IN·107d ago

Indiana Proposes Major Revisions to Residential Care Facility Rights and Eviction Rules

The Indiana Department of Health published proposed amendments to regulations governing residential care facilities, addressing resident rights, residency agreements, and involuntary evictions under 410 IAC 16.2-5. The proposal represents one of the most significant updates to Indiana's assisted living regulatory framework in recent years. The changes are intended to align Indiana's rules with current standards, though the effective date and comment period are not specified in the available excerpt. The revisions will affect assisted living providers and may impact Medicaid managed care organizations that contract with residential care facilities for long-term services and supports.

Legal·107d ago

California Court Issues Evidentiary Ruling in EKRA Criminal Prosecution

A federal district court in California ruled on evidentiary and testimonial issues in United States v. Simons, a criminal prosecution under the Eliminating Kickbacks in Recovery Act (EKRA). The May 1, 2026 decision provides early judicial guidance on how courts will handle evidence in EKRA cases as enforcement expands beyond substance use disorder treatment facilities. EKRA prohibits kickbacks for patient referrals to recovery homes and clinical treatment facilities. The ruling affects Medicaid managed care organizations that contract with behavioral health providers, substance use disorder treatment networks, and recovery services, as EKRA enforcement increasingly targets referral arrangements in these settings.

State Policy·IN·111d ago

Indiana Expands Civil Commitment Standard, Links Homelessness Law to Emergency Detention

Indiana Senate Enrolled Act 285 broadens the state's definition of "gravely disabled" for involuntary civil commitment purposes and establishes a new framework requiring law enforcement to assess the need for emergency detention before enforcing criminal penalties for unauthorized camping or sleeping on public property. The misdemeanor street-camping provisions take effect July 1, 2026. The law creates a mandatory assessment pathway that directs individuals experiencing psychiatric crises toward treatment rather than immediate criminal sanctions. For Medicaid managed care organizations operating in Indiana, this changes the front-end pipeline for behavioral health emergency services and may affect contractual obligations around crisis response and emergency detention coordination.

Industry·113d ago

AMA Issues Policy Urging Exemptions in Upcoming Medicaid Work Requirements

The American Medical Association has issued policy guidance calling for exemptions in Medicaid work requirements expected to be implemented in multiple states. The AMA's position addresses work requirement policies that states may pursue following federal regulatory changes. The timing aligns with several states preparing to implement or expand work requirement programs. This matters for Medicaid managed care organizations because MCOs are typically responsible for verifying member compliance with work requirements and managing eligibility transitions, which adds administrative burden and affects member retention.

Legal·115d ago

USCIS Restricts Green Card Adjustments to Extraordinary Relief Cases

On May 21, 2026, USCIS issued a policy memo limiting green card issuance through adjustment of status to applicants demonstrating extraordinary circumstances. The memo recharacterizes adjustment of status as a discretionary measure rather than an expected benefit. This policy change affects the immigration pathways available to foreign-born healthcare workers, including those employed by Medicaid managed care organizations and provider networks. The restriction takes effect immediately and may impact MCO workforce planning and recruitment strategies for clinical and administrative staff.

State Policy·WI·122d ago

Wisconsin APRN Modernization Act Grants Full Practice Authority Effective September 1, 2026

Wisconsin's APRN Modernization Act, passed in August 2025, takes effect September 1, 2026, granting Advanced Practice Registered Nurses full practice authority without requiring collaborative arrangements with physicians. Wisconsin becomes one of approximately two dozen states with full practice authority for APRNs. The change affects how Medicaid managed care organizations credential, contract with, and reimburse APRNs as independent practitioners. MCOs must update provider networks, credentialing policies, and reimbursement methodologies to reflect APRNs' expanded scope of practice.

Legal·TX·122d ago

Texas Appeals Court Denies Novartis Petition to Halt Medicaid Fraud Qui Tam Case

The Fifteenth Court of Appeals in Texas denied Novartis Pharmaceuticals' request for mandamus relief to halt a Medicaid qui tam action brought under the Texas Medicaid Fraud Prevention Act (TMFPA). While the court acknowledged "weighty" constitutional questions raised by Novartis regarding the TMFPA's qui tam provisions, it ruled that these challenges must be addressed through ordinary appellate review rather than through extraordinary mandamus relief. The decision allows the underlying fraud case to proceed. The ruling affirms that constitutional challenges to state Medicaid fraud statutes, even when substantial, do not automatically warrant immediate appellate intervention before trial court resolution.

Legal·123d ago

DOJ Announces Faster False Claims Act Reviews and Expanded Federal Program Fraud Enforcement

The Department of Justice issued a May 27 memorandum accelerating False Claims Act enforcement timelines and expanding focus on federal benefits programs. The new policy directs faster qui tam case reviews, earlier enforcement decisions, and more aggressive fraud identification in federal health programs including Medicaid. The changes take effect immediately and apply to all pending and future FCA matters. This shift means managed care organizations should expect shorter review periods before DOJ intervenes or declines qui tam cases, with heightened scrutiny of billing practices and program integrity across all federal healthcare programs.

Legal·123d ago

DOJ Launches West Coast Strike Force Targeting Health Care Fraud in Three Districts

The Department of Justice announced the creation of the West Coast Health Care Fraud Strike Force on April 30, 2026, combining fraud enforcement operations across the District of Arizona, District of Nevada, and Northern District of California with a focus on Silicon Valley. The strike force will coordinate investigations and prosecutions across these three federal districts. This expanded enforcement capacity increases audit and investigation risk for Medicaid managed care organizations operating in the western states, particularly those with behavioral health, telehealth, or technology-enabled care delivery models that have drawn recent DOJ scrutiny.

Federal Policy·128d ago

USCIS Tightens Adjustment of Status Rules for Green Card Applicants

On May 21, 2026, USCIS issued a policy memo restricting adjustment of status applications, requiring applicants to demonstrate extraordinary circumstances to obtain lawful permanent residence without consular processing. The memo recharacterizes adjustment of status as discretionary relief rather than a routine pathway. This change affects healthcare organizations that sponsor foreign-born clinical staff and may complicate workforce planning for Medicaid managed care plans that rely on immigrant physicians, nurses, and behavioral health providers in shortage areas. Plans should review existing sponsorship pipelines and anticipate longer credentialing timelines.

Federal Policy·128d ago

CMS Proposes Payment Limits on State Directed Payments and Targeted Fee-for-Service Rates

CMS published a proposed rule on May 22, 2026, that would impose payment limits on additional state directed payments in Medicaid managed care and establish new limits for targeted fee-for-service payments. The rule draws authority from section 71116 of H.R. 1 (the "One Big Beautiful Bill Act") and presidential directives. State directed payments allow states to require managed care organizations to adopt specific provider payment arrangements, and new limits could constrain state flexibility in setting enhanced reimbursement rates for hospitals, nursing facilities, and other providers. The proposal would affect how states design rate strategies and could require MCOs to renegotiate provider contracts if existing SDP arrangements exceed new federal limits.

Federal Policy·129d ago

CMS Proposes FY 2027 IPPS Payment Updates, Quality Measures, Joint Replacement Model Expansion

CMS released the FY 2027 Inpatient Prospective Payment System proposed rule updating Medicare hospital payment rates, uncompensated care payments, and graduate medical education residency program definitions. The rule expands the CJR-X joint replacement payment model and solicits comment on new quality measures. While IPPS primarily governs Medicare fee-for-service hospital payments, changes to quality measures and payment methodologies often influence Medicaid managed care quality programs and hospital contract negotiations. The comment period timeline was not specified in the excerpt.

Industry·129d ago

Health Care REITs Shift Investment Focus from Nursing Homes to Senior Housing Communities

Health care real estate investment trusts are increasingly pivoting away from nursing home investments toward senior housing communities offering independent living options. The shift reflects broader real estate market trends over the past two years, with potential implications for hospital system partnerships in the senior housing sector. The article outlines strategic considerations for hospital systems exploring senior housing collaborations. This trend may affect Medicaid managed care organizations with long-term services and supports responsibilities, particularly those managing dual-eligible populations transitioning between care settings.

Legal·129d ago

DOJ Launches AI-Driven False Claims Act Enforcement Initiative Targeting Health Care Fraud

The Department of Justice launched the Fraud Oversight through Careful Use of Statistics (FOCUS) initiative on April 7, 2026, deploying artificial intelligence and large-scale data analytics to identify and pursue False Claims Act violations in health care. The initiative marks a fundamental shift in federal enforcement methodology, using statistical modeling to flag potential fraud patterns across provider billing data. Medicaid managed care organizations should anticipate increased scrutiny of claims patterns, particularly in high-risk service categories, and may face FCA exposure for delegated utilization management and provider oversight functions. MCOs should review fraud detection protocols and ensure compliance with federal program integrity requirements.

Industry·129d ago

CMS Pauses Hospice, Home Health Medicare Enrollments in Fraud Crackdown

CMS has paused new Medicare enrollments for hospice and home health agencies as part of a fraud prevention initiative. The enrollment moratorium affects providers seeking to enter Medicare in these categories while CMS implements enhanced screening measures. The action reflects heightened federal scrutiny of post-acute care billing practices. Medicaid managed care plans with Medicare-Medicaid dual eligible members or LTSS carved-in arrangements may see network disruptions if moratorium extends or existing providers face termination.

Federal Policy·129d ago

OIG Clears Limited Free Orthodontic Services in Advisory Opinion 26-09

On May 1, 2026, OIG issued Advisory Opinion 26-09 addressing a pediatric dental and orthodontic provider's proposal to offer free orthodontic treatment to one patient annually at each of its three practice locations. The opinion provides guidance on how such charitable arrangements may comply with federal anti-kickback statute and beneficiary inducement provisions. For Medicaid managed care dental plans and MCOs with dental benefits, this opinion clarifies acceptable parameters for provider charitable care arrangements that could affect network adequacy and access strategies, particularly for orthodontic services where cost barriers are common.

Industry·129d ago

OIG Advisory Opinion Addresses Hospital Lease Arrangements; Construction Costs Stabilize

The HHS Office of Inspector General has issued a new advisory opinion on hospital lease arrangements, providing compliance guidance for healthcare real estate transactions. Separately, healthcare construction costs have leveled out after years of increases, potentially affecting facility expansion plans. These developments come as regional healthcare real estate markets show divergent growth patterns, with the Southeast and West Coast outperforming the Midwest and Northeast. For Medicaid managed care organizations with capital investments or provider network expansion plans, the OIG guidance clarifies Anti-Kickback Statute considerations in lease negotiations, while stabilizing construction costs may create opportunities for facility development.

Federal Policy·129d ago

CMS pauses Medicare enrollment for home health and hospice providers

CMS has temporarily halted new provider enrollment for home health and hospice services in Medicare, though specific details on duration and scope are not provided in the brief announcement. The enrollment pause likely reflects heightened scrutiny of fraud vulnerabilities in these sectors, which have been subjects of recent OIG investigations. Medicaid managed care organizations with delegated or integrated home health and hospice networks should monitor whether similar restrictions emerge in their contracts or state programs, particularly for dual-eligible populations where Medicare enrollment status affects network adequacy.

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