Medicaid Monitor
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Medicaid Monitor
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Healthcare Dive

116 stories

Legal·1d ago

Independence Blue Cross Pays $22.5M to Settle MA Fraud Claims

Independence Blue Cross agreed to pay $22.5 million to resolve allegations that it inflated diagnosis codes for Medicare Advantage beneficiaries to boost risk-adjustment payments. The insurer described the settlement, along with similar resolutions by other payers, as reflecting "industry-wide challenges" in applying Medicare Advantage risk adjustment standards. The matter concerns Medicare Advantage rather than Medicaid managed care directly, though risk adjustment practices and enforcement scrutiny often extend across both program types for payers operating in both markets.

Federal Policy·2d ago

HRSA Names Manufacturers Approved for Expanded 340B Rebate Pilot

HRSA has disclosed which drug manufacturers are approved to participate in a revised 340B rebate pilot, under which ten drugmakers will shift 21 drugs from upfront discounts to after-the-fact rebate payments starting next year. The change expands on the administration's earlier rebate pilot attempt. Covered entities purchasing these drugs through 340B will need to pay full price at the point of sale and later seek rebates, rather than receiving discounts immediately. The shift takes effect at the start of next year.

Industry·3d ago

Elevance Moves to Curb Hospital Billing for Off-Campus Care

Elevance Health is implementing a policy to restrict hospitals from charging facility fees or higher reimbursement rates for services delivered at off-campus outpatient departments, aiming to align payment with site-neutral principles. Hospital groups oppose the move, arguing the reimbursement reductions could jeopardize patient access to care, particularly in markets where hospital-owned outpatient clinics are prevalent. The policy affects hospitals and health systems contracted with Elevance across its commercial and potentially Medicaid managed care lines. Details on effective dates and scope across Elevance's state Medicaid contracts were not specified.

Industry·4d ago

Covista Report Warns Clinician Shortage Will Double by 2040

A new report from healthcare education company Covista projects that the U.S. clinician shortage will double by 2040, warning of a looming workforce crisis across the health care system. The report highlights growing gaps in physicians, nurses, and other clinical staff that could strain care delivery nationwide. Covista argues the trend is not yet irreversible and points to workforce education and training strategies as potential mitigation steps. The report does not detail a specific timeline for policy action but frames the issue as an urgent, worsening trend.

Industry·4d ago

UnitedHealthcare Names Robert Hunter as New President

UnitedHealthcare has appointed Robert Hunter as president, tasking him with leading the company's "modernization agenda." The move is the latest in a series of leadership changes at parent company UnitedHealth Group as it seeks to rebuild its public image. No specific start date or further details on Hunter's mandate were provided beyond the modernization focus.

Industry·5d ago

Study Finds Long COVID Persists Among Healthcare Workers

A new study finds that healthcare workers continue to experience persistent long COVID symptoms, compounding existing workforce burnout and staffing shortages. The findings affect hospitals, nursing facilities, and other providers that serve Medicaid patients and already face labor supply constraints. No specific policy action or effective date is described in this report. The study's findings matter for Medicaid stakeholders because provider workforce shortages directly affect beneficiary access to care, particularly in long-term care and safety-net settings that rely heavily on Medicaid reimbursement.

Industry·5d ago

Insurers, Billing Vendors Clash Over AI's Impact on Health Costs

An insurance industry report claims that AI-powered billing tools used by providers could add billions of dollars in extra health spending. Billing technology companies dispute that framing, arguing the underlying problem is the complexity of the healthcare billing system itself rather than AI tools. Providers, payers, and billing vendors are affected as this dispute shapes how AI-driven coding and claims practices get scrutinized going forward. No specific effective date or regulatory action is described in the report.

Managed Care·6d ago

Utilization Management Emerges as Key Challenge for Healthcare AI Adoption

Healthcare AI developers face significant technical and operational barriers in applying artificial intelligence to utilization management and prior authorization processes. The challenge lies in predicting reimbursement outcomes before denials occur, requiring AI systems to navigate complex medical necessity criteria, payer-specific coverage policies, and claims adjudication logic that varies across health plans and service categories. For Medicaid managed care organizations, this affects the feasibility of AI-driven automation in authorization workflows, claims processing, and appeals management. The difficulty stems from the need to replicate payer decision-making logic across thousands of procedure-diagnosis combinations and benefit design variations.

Industry·8d ago

Report Finds 340B Hospitals Spend Less on Charity Care Than Non-340B Peers

A new report finds hospitals participating in the 340B drug pricing program spend less on charity care than non-participating hospitals, contrary to the program's intent to support safety-net care. The findings intensify ongoing debate over 340B program integrity and whether participating hospitals deliver commensurate community benefits. Critics argue the program has expanded without corresponding patient benefits, while hospital groups dispute the methodology of such studies. The report has no immediate regulatory implications but may inform future congressional or CMS oversight of 340B hospital eligibility and accountability measures.

Industry·9d ago

Healthcare Executives Prioritize Revenue Cycle and Utilization Management Technology Investments

A new survey finds healthcare providers are directing IT investment toward revenue cycle management tools, while payers focus technology spending on utilization management solutions. The findings reflect strategic priorities tied to financial performance and care management efficiency. The survey did not specify implementation timelines or investment amounts. This trend matters for Medicaid managed care organizations balancing administrative cost ratios with effective care management and accurate claims processing.

Federal Policy·9d ago

CMS Halts ACA Broker Registrations for 2027, Terminates 760,000 Enrollments

CMS announced Tuesday it is freezing new broker registrations for the 2027 marketplace open enrollment period and terminating coverage for more than 760,000 individuals the agency has identified as unauthorized enrollees. The broker registration pause aims to reduce fraud in the exchanges; the agency did not specify which populations or enrollment circumstances triggered the coverage terminations. The registration freeze affects brokers seeking new marketplace access for plan year 2027. The actions reflect heightened federal scrutiny of marketplace enrollment integrity following reports of unauthorized sign-ups and agent misconduct in certain states.

Federal Policy·9d ago

CMS Administrator Oz Predicts AI Will Drive Up Healthcare Costs Before Reducing Them

CMS Administrator Dr. Mehmet Oz stated Wednesday that artificial intelligence will initially increase healthcare costs by accelerating medical billing before delivering long-term savings. He described AI as likely to "turbocharge" billing processes in the near term. The comments suggest CMS anticipates cost pressure from AI adoption across the healthcare sector, including Medicaid programs and managed care plans investing in AI-driven administrative tools. No timeline or policy response was specified.

Legal·TX·11d ago

Texas Hospitals Sue Independence Blue Cross Over Denied Claims Under BlueCard Program

Five HCA-affiliated hospitals in Texas have filed suit against Independence Blue Cross alleging the insurer continues to improperly deny claims through the BlueCard program despite a previous $2.8 billion settlement over BlueCard disputes. The hospitals claim the program subjects them to excessive administrative burdens and claim denials. The litigation follows broader industry concerns about cross-state claims processing under the BlueCard reciprocal network. This matters for Medicaid managed care plans operating Blue Cross Blue Shield-branded products, as BlueCard network arrangements and claims adjudication practices affect provider participation and reimbursement across state lines.

Federal Policy·11d ago

Federal Drug Pricing Agreements with 26 Manufacturers May Limit Future Cost Controls

The federal government has announced pricing agreements with 26 pharmaceutical manufacturers. These agreements could constrain future policy options to reduce drug spending across federal programs. The specific terms, enforcement mechanisms, and timeline for these agreements have not been publicly disclosed. The agreements may affect Medicaid programs' ability to pursue independent drug cost containment strategies, particularly for states that rely on federal negotiations or supplemental rebate programs tied to federal pricing benchmarks.

Industry·12d ago

Judge Approves CVS Unit Omnicare Bankruptcy Plan

A federal bankruptcy judge approved the restructuring plan for Omnicare, a long-term care pharmacy subsidiary of CVS Health. The plan is designed to fully repay all creditors, including the Department of Justice, which held claims against the company. The approval allows Omnicare to emerge from bankruptcy proceedings and continue operations serving nursing homes and other institutional settings. The resolution affects Medicaid programs indirectly, as Omnicare serves facilities where many residents rely on Medicaid coverage for pharmacy services.

Industry·AZ·13d ago

Ascension Sells Arizona Medicaid Plan Stake to Aetna

Ascension has sold its ownership interest in an Arizona Medicaid managed care plan to Aetna. The transaction allows Ascension to exit insurance risk while Aetna acquires a stake in a plan with a profitable dual-eligible member base. The deal reflects ongoing consolidation in Medicaid managed care, with payers seeking scale in high-acuity populations. Financial terms and the effective date of the transaction were not disclosed.

Industry·15d ago

12 Million Americans Lack Broadband Access for Telehealth, Study Finds

New research indicates approximately 12 million Americans cannot access telehealth services due to unavailable or inadequate broadband infrastructure, with the majority residing in rural areas. The study highlights ongoing digital divide challenges that limit virtual care delivery in communities that could benefit most from remote access to healthcare providers. While telehealth utilization has grown across Medicaid programs since the pandemic, this infrastructure gap affects beneficiaries' ability to access covered services in underserved areas. The findings underscore persistent barriers to care delivery models that states and managed care plans have increasingly incorporated into benefit design.

Industry·15d ago

One-Third of Privately Insured Adults Carry Medical Debt, Commonwealth Fund Reports

A Commonwealth Fund study found that one-third of privately insured adults have unpaid medical debt to healthcare providers, demonstrating that medical debt affects insured populations beyond emergency care scenarios. The findings highlight ongoing affordability challenges even among those with commercial coverage. The research underscores systemic issues with cost-sharing structures and provider billing practices affecting access to care. For Medicaid managed care organizations, the data provides context for understanding financial barriers facing dual-eligible populations and individuals cycling between coverage types.

Industry·15d ago

CVS Aetna Bundles Cancer Prior Authorizations Into Single Upfront Request

CVS Aetna announced it will consolidate prior authorization requirements for cancer care into one upfront approval covering all treatment types, replacing the current piecemeal approach that requires separate authorizations for different services. The change aims to reduce administrative burden on oncology providers who currently submit multiple prior authorization requests throughout a patient's cancer treatment episode. The new bundled authorization process will apply across CVS Aetna's commercial and Medicare Advantage plans. This affects how oncologists interact with CVS Aetna's utilization management systems and may influence treatment access and care coordination for cancer patients.

Industry·16d ago

Agentic AI Deployment in Healthcare Outpacing Governance Frameworks, Imprivata Warns

Healthcare organizations are deploying agentic AI tools faster than governance frameworks are being established, according to Imprivata's chief medical and growth officer. The report warns that patient safety risks could emerge if these autonomous AI systems are implemented without adequate guardrails and oversight mechanisms. The concern centers on AI tools that can take actions independently rather than simply providing recommendations. For Medicaid stakeholders, this raises questions about managed care organizations' use of AI in utilization management, care coordination, and clinical decision support without clear regulatory standards.

Legal·16d ago

OIG Finds Humana and UnitedHealth MA Plans Generated $180M in Upcoding Overpayments

HHS OIG audits released September 17, 2026 found that HumanaChoice and UnitedHealthcare of Wisconsin overstated member health conditions in Medicare Advantage risk adjustment submissions, resulting in nearly $180 million in overpayments over a two-year period. The audits concluded both plans frequently exaggerated health needs to inflate capitation payments. OIG has referred the findings to CMS for recovery action. While these audits focus on Medicare Advantage, they signal heightened federal scrutiny of risk adjustment practices that could extend to Medicaid managed care plans using similar diagnosis-driven payment models.

Managed Care·16d ago

Eighteen Health Plans Score 5 Stars in NCQA 2026 Ratings, No For-Profits Included

Eighteen health plans achieved perfect 5-star ratings in NCQA's 2026 standards ratings, up from 11 in the previous cycle. None of the top-scoring plans are for-profit entities. The ratings measure plan performance across quality, access, and member experience metrics. The results highlight a continuing performance gap between nonprofit and for-profit health plans on nationally standardized quality measures.

Legal·AR·17d ago

Arkansas Pharmacies File First Lawsuit Against Express Scripts Under State PBM Payment Law

Twelve independent Arkansas pharmacies filed suit against Express Scripts, marking the first use of a 2025 state law authorizing pharmacies to sue pharmacy benefit managers for underpayments. The lawsuit tests new enforcement authority granted to pharmacies under Arkansas legislation targeting PBM reimbursement practices. The case could establish precedent for pharmacy challenges to PBM payment methodology in Arkansas and influence similar legislative efforts in other states. The outcome affects Medicaid managed care plans that contract with Express Scripts for pharmacy services and may impact PBM reimbursement practices across state Medicaid programs.

Federal Policy·17d ago

2.3 Million Young Adults Could Lose Medicaid Under Big Beautiful Bill

The Urban Institute estimates 2.3 million young adults could lose Medicaid coverage under the Big Beautiful Bill, a federal legislative proposal. Actual disenrollment numbers will depend on state implementation choices, particularly how states design income verification and renewal processes. Young adults face higher disenrollment risk due to frequent address changes and participation in gig economy work that complicates income documentation. The findings highlight operational challenges states and managed care plans will face in maintaining continuity of coverage for this population.

Federal Policy·18d ago

HHS Certifies 17th IDR Entity as No Surprises Act Disputes Increase

HHS has certified Physio Solutions (doing business as medlitix) as the 17th independent dispute resolution entity authorized to settle out-of-network payment disputes under the No Surprises Act. The certification comes amid growing volume of surprise billing arbitration cases and increased scrutiny of IDR entities by researchers and lawmakers. The No Surprises Act requires federal certification of dispute resolution entities to adjudicate payment disputes between providers and health plans when patients receive out-of-network emergency or certain facility-based care. The expansion of certified IDR entities affects Medicaid managed care plans that contract with out-of-network providers and face similar surprise billing scenarios under state law or federal Medicaid managed care regulations.

Industry·19d ago

Johnson & Johnson Requires Claims Data Sharing for 340B Discounts

Johnson & Johnson is requiring 340B-covered entities to share claims data as a condition of receiving 340B drug discounts. The company joins other pharmaceutical manufacturers implementing reporting requirements, citing concerns about duplicate discounts. The policy affects safety-net providers that rely on 340B pricing, including federally qualified health centers and disproportionate share hospitals that serve Medicaid populations. The requirement takes effect immediately for providers seeking to maintain access to J&J's discounted pricing under the 340B program.

Federal Policy·22d ago

Half of U.S. Hospitals Still Not Compliant with CMS Price Transparency Rules

More than half of U.S. hospitals remain noncompliant with CMS price transparency requirements despite increased federal enforcement, according to a September 2026 report from PatientRightsAdvocate.org. The rules, which took effect in January 2021, require hospitals to publicly post standard charges for services. CMS has escalated enforcement through monetary penalties for noncompliant hospitals. For Medicaid managed care plans, ongoing hospital noncompliance complicates rate negotiations, network adequacy assessments, and member cost-sharing transparency — particularly for dually eligible beneficiaries and children with complex medical needs who rely on hospital-based care.

State Policy·23d ago

Half of U.S. Hospitals Now Lack Obstetric Services Amid Medicaid Funding Pressures

Nearly half of U.S. hospitals currently operate without obstetric services, according to a new report, with closures potentially accelerating as Medicaid funding cuts threaten hospital financial stability. The loss of maternity wards disproportionately affects rural and low-income communities where Medicaid covers approximately 42% of births nationally. Hospitals cite declining Medicaid reimbursement rates and low delivery volumes as primary factors in closure decisions. The trend has significant implications for maternal health access and outcomes, particularly for Medicaid enrollees who face increased travel distances for delivery and prenatal care.

Industry·AR·24d ago

Cambia to Assume Operational Control of Arkansas Blue Cross in October

Cambia Health Solutions is moving forward with an affiliation agreement to assume operational control of Arkansas Blue Cross and Blue Shield, with the transaction expected to close in October 2026. No assets are changing hands in the deal. The affiliation will place Arkansas Blue Cross's operations, which include the state's Medicaid managed care business, under Cambia's operational control. The transaction represents a consolidation in the Blue Cross Blue Shield system affecting one of Arkansas's major Medicaid health plans.

Industry·MA·25d ago

Mass General Brigham Plan Drops Medicare Advantage Coverage for Dana-Farber Cancer Patients

Mass General Brigham's health plan has discontinued Medicare Advantage coverage for Dana-Farber Cancer Institute patients, coinciding with the organizations ending their long-standing partnership. The contract lapse affects Medicare Advantage enrollees who previously had in-network access to Dana-Farber oncology services through MGB's health plan. The change is effective as the two organizations wind down decades of clinical collaboration. This development impacts network adequacy and patient access for Medicare Advantage beneficiaries in the Boston market.

Industry·30d ago

McKesson Confirms Data Breach Affecting Oncology and Medical-Surgical Customers

McKesson disclosed a cyberattack involving third-party applications that resulted in data theft affecting a subset of customers in its oncology and medical-surgical distribution businesses. The company confirmed unauthorized access occurred but has not yet specified the types of data compromised or the number of affected customers. The incident affects healthcare providers that rely on McKesson's pharmaceutical distribution and specialty pharmacy services. Medicaid health plans and state agencies contracting with affected providers may face downstream notification requirements depending on whether protected health information or Medicaid beneficiary data was accessed.

Industry·30d ago

HaloMD Claims No Surprises Act Saved $1 Billion on Emergency Spending

HaloMD, a medical billing firm, released a study claiming the No Surprises Act has reduced out-of-network emergency medical spending by at least $1 billion. Independent researchers questioned the firm's methodology. The No Surprises Act, which took effect in 2022, prohibits surprise billing for emergency services and certain out-of-network care in commercial insurance and self-funded plans. The law does not apply to Medicaid managed care, where state laws and contract provisions govern out-of-network emergency billing and member cost-sharing protections.

Industry·MN·32d ago

Sanford Health Completes North Memorial Acquisition After Agreeing to State Oversight

Sanford Health has completed its acquisition of North Memorial Health, finalizing the deal after agreeing to 10 years of state oversight and committing $600 million in investments. The agreement allows South Dakota-based Sanford to expand into the Twin Cities market. The oversight agreement addresses state concerns about the consolidation's impact on healthcare access and costs. The deal represents significant market consolidation in Minnesota's Twin Cities region.

State Policy·32d ago

Epic Data Shows Medicaid Coverage Restrictions Shift Costs to Cash-Paying Patients

An Epic research analysis of over 550 million healthcare encounters found that restricting Medicaid coverage drives low-income patients to pay out-of-pocket for medical care. The study quantifies how Medicaid eligibility changes affect patient payment patterns and access to care. The findings are relevant to state policymakers considering Medicaid coverage restrictions and to providers managing increased bad debt and charity care. The research provides evidence of downstream financial impacts when states tighten Medicaid eligibility or benefits.

Industry·33d ago

Centene Names Bradley Bolivar Chief Information Officer

Centene Corporation has appointed Bradley Bolivar as Chief Information Officer. Bolivar joins from Fannie Mae and will lead the company's information technology strategy. The appointment comes as insurers, including Medicaid managed care organizations, increasingly integrate artificial intelligence into operations. No effective date was specified in the announcement.

Legal·FL·33d ago

Florida AG Sues Express Scripts and Prime Therapeutics for Alleged Price Fixing

Florida's attorney general filed a lawsuit against pharmacy benefit managers Express Scripts and Prime Therapeutics alleging their partnership agreement artificially depressed pharmacy reimbursement rates through price fixing. The complaint represents the latest legal challenge to the Express Scripts-Prime arrangement. The lawsuit alleges anticompetitive conduct that affects how pharmacies are paid under prescription drug benefit arrangements. This matters for Medicaid managed care organizations that contract with these PBMs or their affiliates for pharmacy services, as the allegations relate to fundamental pricing mechanisms that affect both network pharmacy relationships and overall drug cost structures.

Legal·34d ago

Specialty Providers Challenge Georgetown Study on No Surprises Act IDR Costs

Specialty physician associations representing anesthesiologists, radiologists, and emergency physicians are disputing a Georgetown University study that estimates independent dispute resolution under the No Surprises Act has generated $22 billion in unnecessary healthcare spending. The associations argue the study's methodology is flawed. The No Surprises Act, which took effect in January 2022, established an IDR process for resolving payment disputes between out-of-network providers and insurers. While the law primarily affects commercial insurance, the dispute highlights ongoing tensions over payment methodologies that could inform Medicaid managed care network adequacy and payment dispute resolution policies.

Legal·37d ago

Humana-Owned Villages Health Settles Medicare Advantage Upcoding Case for $542M

The Villages Health, acquired by Humana in 2025, agreed to pay $542 million to settle allegations it submitted fabricated diagnosis codes to inflate Medicare Advantage risk-adjusted payments from 2020 to 2024. The Department of Justice alleged the Central Florida provider systematically manufactured diagnoses to increase capitation rates. The settlement represents one of the largest Medicare Advantage fraud recoveries to date and follows heightened federal scrutiny of MA risk adjustment practices.

Industry·38d ago

No Surprises Act Dispute Resolution Costs Reach $22B, Georgetown Finds

New Georgetown University research found that independent dispute resolution under the No Surprises Act has generated $22 billion in additional healthcare costs, driven by accelerating dispute volumes and high arbitration award amounts. The researchers warn that these costs could translate into higher health insurance premiums for consumers. The No Surprises Act, which took effect in 2022, established a federal arbitration process for out-of-network billing disputes but does not apply to Medicaid managed care plans, which operate under different surprise billing protections.

Industry·38d ago

Sword Health Acquires Headspace in All-Cash Deal Expected to Close Next Month

Sword Health is acquiring Headspace in an all-cash transaction expected to close in September 2026, according to a filing with Massachusetts regulators. The deal will combine Headspace's wellness services with Sword's virtual care platform under one entity. The acquisition represents consolidation in the digital health space, bringing together musculoskeletal care and mental health/wellness capabilities. Financial terms were not disclosed in the regulatory filing.

Legal·38d ago

Monogram Health Settles Medicare Advantage Upcoding Claims for $2.4 Million

Monogram Health, a home health company, will pay $2.4 million to settle Justice Department allegations that it overcharged Medicare Advantage plans through inflated diagnostic codes in contracts with Cigna and Humana. The settlement resolves claims that Monogram systematically upcoded patient diagnoses to increase risk-adjusted payments to MA plans. The enforcement action reflects continued federal scrutiny of diagnosis coding practices in Medicare Advantage, particularly involving delegated provider arrangements that impact plan payments.

Industry·39d ago

Elevance Names Patrick Fox President of Carelon Behavioral Services

Elevance Health appointed Dr. Patrick Fox as president of Carelon Behavioral Services, effective immediately. Fox, a forensic psychiatrist with health plan leadership experience, will oversee the behavioral health division serving Elevance's Medicaid, Medicare, and commercial lines of business. The appointment reflects Elevance's continued investment in behavioral health capabilities amid growing Medicaid managed care focus on mental health and substance use disorder services. Fox replaces the previous leadership at one of the nation's largest behavioral health benefit managers serving Medicaid populations.

Industry·40d ago

Health Systems Alert Patients to MyChart Phishing Scam Impersonating Epic Portal

Health systems are warning patients about phishing attempts impersonating Epic's MyChart patient portal to steal personal information. Epic states the scam represents brand exploitation by cybercriminals rather than a security breach of its systems. The phishing attempts target patients using fake MyChart communications. This activity affects Medicaid managed care organizations and providers using Epic's widely-deployed patient portal system, potentially compromising protected health information and member data security.

Industry·43d ago

Trump Nominates Overton to Lead FDA

President Trump has nominated Heidi Overton, MD, currently deputy director of the White House Domestic Policy Council and a veteran of the America First think tank, to serve as FDA Commissioner. The nomination requires Senate confirmation. If confirmed, Overton would oversee the agency responsible for drug approvals, safety monitoring, and regulatory oversight affecting Medicaid pharmacy benefits, including biosimilar approvals and drug supply chain policies. The nomination comes as states and managed care plans manage rising prescription drug costs.

Industry·44d ago

Humana Names Shantanu Nundy Chief Medical Officer

Humana has appointed Dr. Shantanu Nundy as its new chief medical officer. Nundy joins from Accolade, a health navigation company, and brings experience advising the FDA on artificial intelligence, academic medicine, international health work with the World Bank, and clinical practice. The appointment reflects Humana's leadership priorities as a major Medicaid and Medicare managed care organization. No effective date was specified in the announcement.

Industry·44d ago

Epic Launches AI Outpatient Visit Tool with Ochsner as First User

Epic Systems has released a new artificial intelligence tool designed to enhance outpatient office visits by extracting insights from patient records. Ochsner Health in Louisiana became the first health system to implement the tool. The technology aims to streamline clinical workflows by leveraging AI to analyze patient data during outpatient encounters. The development reflects Epic's broader strategy to integrate AI capabilities into its electronic health record platform.

Industry·44d ago

R1 RCM Acquires Humata to Automate Prior Authorization Processing

R1 RCM acquired Humata, an AI-powered prior authorization platform, to automate claims processing and medical preapprovals. The acquisition aims to streamline revenue cycle operations by reducing administrative burden in the prior authorization process. The deal closed in August 2026, with integration timelines not yet disclosed. For Medicaid managed care plans and providers, this signals continued consolidation in the revenue cycle management sector and potential shifts in how AI tools are deployed for authorization workflows.

Industry·45d ago

UHS Closes $835 Million Talkspace Acquisition for Virtual Therapy

Universal Health Services completed its $835 million acquisition of Talkspace, a virtual therapy provider, on Monday. UHS CEO Marc Miller described the deal as a strategic bet on virtual behavioral health delivery. The acquisition closed in August 2026 and positions UHS to expand its behavioral health capabilities through digital channels. The deal matters for Medicaid stakeholders because many states now cover telehealth behavioral health services through managed care contracts, and UHS operates facilities serving significant Medicaid populations.

Industry·45d ago

Providence Health Plan to Exit All Lines of Business After Medicare Advantage Sale Collapses

Providence Health Plan will shut down operations entirely after a proposed sale of its Medicare Advantage business to an unnamed national insurer fell through. The regional health plan had been pursuing the transaction to sustain its MA lines, but the deal collapsed "despite significant effort on all sides," according to a Providence spokesperson. The closure will affect all plan lines, not just Medicare Advantage. The timeline for wind-down and member transitions was not disclosed in available reporting.

Legal·45d ago

Federal Judge Vacates Trump Administration Restrictions on ACA Gender-Affirming Care

A federal judge has struck down Trump administration restrictions on gender-affirming care under the Affordable Care Act while upholding other ACA policy changes. The ruling restores certain protections for gender-affirming care that had been rolled back by the administration. The decision affects coverage requirements for Medicaid managed care organizations and state agencies operating under ACA-aligned nondiscrimination standards. The ruling takes effect immediately, though appeals are likely.

Industry·46d ago

Epic Launches Real-Time Prior Authorization API at Four Health Systems

Epic Systems has launched an instant prior authorization application programming interface at Ochsner Health, Froedtert ThedaCare Health, Denver Health, and Summit Health. The API enables real-time preapproval decisions for medical items and services at the point of care. Epic states the technology should reduce prior authorization processing time by eliminating manual submission and review delays. The deployment affects workflow for providers treating Medicaid managed care enrollees at these four systems, though the article does not specify which payers are participating in the integration.

Federal Policy·46d ago

Former CMS Administrator Calls for Healthcare Data Interoperability After Kill the Clipboard Anniversary

Former CMS Administrator Seema Verma published commentary calling for improved healthcare data connectivity, marking one year since CMS launched its "Kill the Clipboard" initiative. The initiative aims to reduce administrative burden by enabling electronic data exchange across healthcare systems. Verma argues that while healthcare has been digitized, meaningful interoperability remains incomplete. For Medicaid programs, improved data exchange could streamline eligibility verification, care coordination across MCOs and providers, and integration of clinical and administrative data systems.

Industry·47d ago

Centene CFO Drew Asher to Retire, Succeeded by Lincoln Financial's Chris Neczypor

Centene Corporation announced that Chief Financial Officer Drew Asher will step down from his role effective January 1, 2027, with plans to retire at the end of 2027. Chris Neczypor, currently CFO at Lincoln Financial, will assume the CFO position on January 1. The leadership transition comes as Centene continues to operate one of the nation's largest Medicaid managed care portfolios. The timing allows for an orderly transition during a period when many state Medicaid agencies are finalizing 2027 contract terms and rate setting.

Legal·47d ago

Shareholders Sue UnitedHealth Over Change Healthcare Cyberattack and Medicare Audit Failures

Two shareholder groups filed suit alleging UnitedHealth misled investors and ignored cybersecurity vulnerabilities that enabled the Change Healthcare cyberattack, and separately shuttered an internal Medicare billing audit. The complaint claims UnitedHealth failed to address known governance and security gaps. The lawsuit seeks damages for investor losses tied to these alleged failures. The case adds legal pressure on UnitedHealth following the massive cyberattack that disrupted claims processing across the healthcare system.

Industry·47d ago

UHS Closes $835 Million Talkspace Acquisition to Expand Behavioral Health Access

Universal Health Services has completed its $835 million acquisition of Talkspace, a digital behavioral health platform. The deal aims to expand behavioral health services for UHS' existing patient population while increasing patient volume through Talkspace's consumer base. UHS CEO Marc Miller described the acquisition as a game changer for the health system's behavioral health capabilities. The integration creates opportunities for cross-referrals between virtual and facility-based care across UHS' network of behavioral health facilities.

Managed Care·48d ago

Prior Authorization Denial Rates Range from 2% to 25% Across Health Plans

Prior authorization denial rates varied from 2% to 25% among health insurers in 2025, according to a KFF analysis of newly released data mandated by CMS. The analysis reveals significant variation in how plans approve or deny coverage requests for medical services and drugs. This represents the first time CMS has required health insurers to publicly disclose prior authorization denial data, providing unprecedented transparency into plan-level utilization management practices. The data allows Medicaid managed care plans, state agencies, and regulators to benchmark denial patterns and assess whether authorization practices align with medical necessity standards and contract requirements.

Legal·50d ago

Patient Advocacy Group Sues AMA Over CPT Code Copyright

PatientRightsAdvocate.org has filed a lawsuit challenging the American Medical Association's copyright of Current Procedural Terminology (CPT) codes. The suit argues that because federal law requires use of CPT codes for billing Medicare and Medicaid, the codes should be publicly available rather than copyrighted. The lawsuit does not specify when it was filed or what relief is sought. The outcome could affect provider billing practices and access to coding information across Medicare and Medicaid programs.

Legal·50d ago

Fifth Circuit Invalidates No Surprises Act Benchmark Calculation Methods

The Fifth Circuit Court of Appeals ruled Tuesday that insurers cannot include ghost rates or exclude bonus payments when calculating the qualifying payment amount (QPA) under the No Surprises Act. The QPA serves as the default benchmark in independent dispute resolution for out-of-network emergency and air ambulance claims. The decision takes effect immediately and will increase reimbursement amounts paid to out-of-network providers. For Medicaid managed care plans that also operate commercial business, this ruling affects how their commercial lines calculate out-of-network payments, though the No Surprises Act does not apply directly to Medicaid.

Federal Policy·51d ago

Physician Advocates for Site-Neutral Payment Reform in Medicare

A physician is arguing that Congress should enact site-neutral payment reforms in Medicare to reduce healthcare spending driven by hospital consolidation. Site-neutral payments would eliminate higher Medicare reimbursement rates for services provided in hospital outpatient departments compared to physician offices. The physician contends this reform would lower costs without compromising patient care quality. While the article focuses on Medicare policy, site-neutral payment discussions often influence Medicaid policy development, particularly as states manage their own fee schedules and provider networks.

Industry·51d ago

Physician Shortage Projected to Reach 86,000 by 2036, Rural Areas Most Affected

A new AMN Healthcare report projects a U.S. physician shortage of 86,000 by 2036, with rural communities experiencing the most severe workforce gaps. The report warns that healthcare spending cuts could accelerate rural hospital closures in areas already struggling with provider access. The shortage affects all specialties but is most acute in primary care and behavioral health, sectors critical to Medicaid beneficiaries who disproportionately rely on rural safety-net providers.

Industry·51d ago

Nonprofit Hospital Operating Margins Improved in 2025 but Face Federal Funding Cuts

Nonprofit hospitals saw overall operating margin improvement in 2025, but some providers experienced declining performance, according to Fitch Ratings. The sector faces looming major federal funding cuts that threaten recent gains. The analysis indicates the recovery trajectory may have reached its peak, with financial pressures mounting for certain hospital systems. This development matters for Medicaid managed care networks as hospital financial instability can affect network adequacy, contract negotiations, and care delivery capacity for Medicaid enrollees.

State Policy·52d ago

Cato Institute Report Finds Certificate of Need Laws Restrict Healthcare Access

The Cato Institute released a report analyzing nearly 130 studies on certificate of need (CON) laws, which require healthcare providers to obtain state approval before constructing new facilities or adding services. The report concludes that CON laws restrict healthcare access and competition. CON laws remain in effect in approximately 35 states and directly affect Medicaid beneficiaries' access to nursing homes, dialysis centers, home health agencies, and other services that require state approval before expansion. The analysis adds to ongoing state-level debates over repealing or reforming CON requirements.

Federal Policy·52d ago

Brookings Researchers Challenge CMS Data Underlying Medicaid Work Requirements Rule

Brookings Institution researchers have publicly criticized the data and assumptions CMS used to support its Medicaid work requirements rule, which imposed stricter documentation standards for enrollees claiming medical exemptions from work mandates. The rule, already facing litigation, required beneficiaries to provide more extensive proof of illness or disability to qualify for exemptions than stakeholders anticipated. The Brookings critique alleges CMS misrepresented or manipulated data to justify the policy. This matters because if the agency's analytical foundation is undermined, courts may be more likely to vacate the rule, and CMS may face pressure to withdraw or revise the policy.

Industry·53d ago

DentaQuest Data Breach Affects 15 Million Individuals

DentaQuest, a dental and vision benefits administrator serving Medicaid managed care plans, reported a data breach affecting 15 million individuals — the largest breach reported this year. The company has notified affected individuals and implemented additional security controls following the incident. The breach affects Medicaid enrollees whose dental benefits are administered through DentaQuest's platform across multiple states.

Industry·53d ago

Humana Names J.P. Holland to Lead Medicaid Business

Humana appointed James "J.P." Holland as head of its Medicaid division, effective August 18, 2026. Holland previously served as an executive at Johns Hopkins. The move is part of a broader leadership restructuring announced by Humana in late 2025. The appointment comes as Humana continues to position Medicaid as a growth segment within its business portfolio.

Industry·54d ago

Healthcare Cybersecurity Risks Escalate Amid Regulatory Gaps and Consolidation

Healthcare industry experts warn that regulatory failures, inadequate funding, and consolidation are creating significant cybersecurity vulnerabilities that threaten patient safety. The vulnerabilities affect healthcare providers and payers, including Medicaid managed care organizations that hold sensitive beneficiary data and operate critical care delivery infrastructure. Security gaps expose health plans and providers to data breaches, ransomware attacks, and operational disruptions that can interrupt care access and compromise protected health information. Industry stakeholders characterize these cybersecurity weaknesses as patient safety issues requiring urgent attention.

Industry·54d ago

Unionized CVS Pharmacists Authorize Strike Over Staffing and Working Conditions

Unionized CVS pharmacists in three states authorized a strike last week, citing inadequate staffing levels and demanding input into pharmacy operational decisions. The strike authorization does not guarantee a walkout will occur but signals escalating labor tensions at one of the nation's largest retail pharmacy chains. If pharmacists do strike, Medicaid beneficiaries relying on CVS pharmacies for prescriptions could face disruptions in medication access. The action reflects broader workforce challenges in retail pharmacy that affect Medicaid providers and managed care plans dependent on stable pharmacy networks.

Industry·59d ago

CVS Health Triples Net Income on Strong Health Plan Performance

CVS Health reported significantly increased net income in its second quarter 2026 earnings, driven primarily by strong profitability in its health plan business, which includes Aetna's Medicaid and Medicare Advantage lines. The company also announced a new GLP-1 medication agreement with Eli Lilly during the earnings call. The earnings report reflects improved performance across CVS's health insurance operations. Analysts characterized the results as exceptionally strong.

Industry·60d ago

Hackensack Meridian Health Earns First Joint Commission AI Certification

Hackensack Meridian Health became the first health system to receive the Joint Commission's responsible health AI certification. The certification recognizes the system's AI governance structure, which it has been developing for several years. The Joint Commission and other private consortiums are establishing AI guardrails as federal regulations remain pending. This development reflects the healthcare industry's move toward voluntary AI standards in the absence of comprehensive federal regulatory frameworks.

Industry·60d ago

Hospitals Report Rising Uninsured Rates Six Months After ACA Exchange Cuts

For-profit hospitals report financial strain from increased uninsured patients following cuts to Affordable Care Act exchanges that took effect six months ago. Hospital executives cite declining insurance coverage among patients as a drag on revenues. The trend reflects broader coverage losses stemming from federal policy changes to ACA subsidies and eligibility. While the article focuses on ACA exchange changes rather than Medicaid-specific policy, Medicaid programs may see increased enrollment pressure as individuals lose marketplace coverage.

Federal Policy·62d ago

HRSA Proposes Second Attempt at 340B Rebate Model After Initial Failure

The Health Resources and Services Administration announced a new proposal to allow rebate models in the 340B drug pricing program, marking its second attempt in 2026 after an earlier effort failed. The proposal would change how covered entities receive 340B discounts, moving from upfront discounts to post-purchase rebates. Hospital associations immediately opposed the plan, arguing it would create cash flow problems and administrative burdens for safety-net providers. If finalized, the rebate model could affect how Medicaid providers, particularly disproportionate share hospitals and federally qualified health centers, manage pharmaceutical costs.

Industry·64d ago

Teladoc Lowers Revenue Outlook as BetterHelp Insurance Growth Outpaces Cash Pay

Teladoc Health revised its revenue outlook downward due to demand shifts at BetterHelp, its mental health subsidiary. The company reported that BetterHelp's insurance-based offerings grew faster than anticipated, reducing its higher-margin cash pay business. The shift occurred in Q2 2026 and affects Teladoc's overall financial projections for the year. For Medicaid managed care organizations contracting with Teladoc or similar telehealth vendors for behavioral health services, this signals potential pricing pressure as commercial telehealth providers compete more aggressively for insured members, including Medicaid populations.

Industry·65d ago

FTC Sues Hims & Hers for Privacy Violations and Deceptive Billing

The Federal Trade Commission filed suit against telehealth company Hims & Hers, alleging illegal sharing of patient health data with advertisers and deceptive billing practices. The company denies the allegations, calling them baseless. The lawsuit raises compliance questions for telehealth providers operating in Medicaid managed care networks, particularly around HIPAA and consumer protection standards. No immediate enforcement action or settlement terms have been announced.

Industry·66d ago

UHS Reports Rising Uninsured Volumes, Projects $10M Loss From ACA Coverage Churn

Universal Health Services reported increased uninsured patient volumes in the second quarter of 2026, with executives attributing the trend to individuals losing Affordable Care Act marketplace coverage. The hospital operator now projects an additional $10 million loss for the year beyond initial expectations due to the coverage losses. The trend affects UHS's hospital operations as patients transition from insured to uninsured status, impacting revenue cycle performance and bad debt provisions.

Industry·67d ago

Centene Reports $1B Profit in Q2, Raises 2026 Earnings Outlook

Centene swung to more than $1 billion in profit in the second quarter of 2026, marking a significant turnaround for the managed care giant. The company raised its full-year 2026 earnings outlook for the second time this year following what its CFO described as "fantastic" results. The strong performance comes after previous quarters of financial challenges and represents improved operational execution across Centene's health plan portfolio, which includes substantial Medicaid managed care operations in multiple states.

Industry·68d ago

Tenet Raises 2026 Outlook Despite $65M ACA Exchange Loss in Q2

Tenet Healthcare raised its full-year 2026 financial outlook after absorbing a $65 million loss from instability in ACA marketplace enrollment during the second quarter. The hospital operator reported less severe impacts than some competing health systems facing similar exchange headwinds. The revised guidance suggests Tenet expects to offset ACA-related losses through other revenue streams for the remainder of the fiscal year. While ACA exchange disruption affects hospital uncompensated care and payer mix, the story centers on investor-oriented financial performance rather than direct Medicaid program operations.

Industry·68d ago

HCA Reports ACA Exchange Patients Dropping Coverage at Near One-to-One Rate in Q2

HCA Healthcare reported in its second quarter earnings that patients who previously had coverage through Affordable Care Act exchanges are going uninsured at nearly a one-to-one rate. CEO Sam Hazen acknowledged the trend is negatively impacting the company's financials. The shift increases uncompensated care costs for the nation's largest hospital operator. While the article focuses on commercial exchange coverage loss, the trend signals broader coverage instability that could increase Medicaid eligibility and enrollment as patients lose marketplace plans.

Federal Policy·69d ago

HHS Appeals Court Ruling Invalidating 2025 ACA Marketplace Rule Provisions

The Department of Health and Human Services filed an appeal to reinstate portions of a 2025 Affordable Care Act rule that a federal judge invalidated in June 2026. The invalidated provisions include shortened enrollment periods and stricter eligibility verification requirements for marketplace coverage. The appeal seeks to restore these requirements, which originally applied to ACA marketplace plans beginning with the 2026 plan year. The outcome affects marketplace operations and enrollment procedures, with potential implications for Medicaid-marketplace coordination on eligibility determinations and transitions between coverage types.

Federal Policy·71d ago

No Surprises Act Disputes Rose 16% in Second Half of 2025

Providers and payers initiated 16% more disputes under the No Surprises Act in the second half of 2025 compared to the first half, according to new CMS data released July 23, 2026. Arbiters are closing cases more quickly and working through the backlog of disputes. The No Surprises Act primarily governs commercial insurance out-of-network billing disputes and does not apply to Medicaid managed care or fee-for-service.

Industry·71d ago

Community Health Systems Reports Higher Uninsured Volume Pressures Q2 Financials

Community Health Systems reported second-quarter financial results reflecting higher-than-expected uninsured patient volumes, primarily attributed to patients dropping Affordable Care Act coverage. The for-profit hospital operator indicated these uninsured volumes are affecting revenue and margins more significantly than projected. The trend reflects broader ACA enrollment shifts impacting hospital payer mix. CHS joins other hospital systems reporting increased uncompensated care costs as commercial and subsidized coverage levels fluctuate.

Industry·72d ago

Molina Healthcare Plans Additional ACA Exchange Cuts in 2027

Molina Healthcare announced plans to further reduce its participation in ACA marketplace exchanges in 2027 following second-quarter financial challenges in that segment. While the company reported stable Medicaid performance and stronger-than-expected Medicare Advantage results, ACA exchange operations underperformed expectations. CEO leadership characterized the ACA exchange trend as "unfortunate." The insurer did not specify which states or exchanges would face reductions. Molina's Medicaid operations, which represent a significant portion of its business, showed stability during the quarter.

Industry·74d ago

Novo Nordisk Sues Eli Lilly Over Obesity Drug Advertising Claims

Novo Nordisk has filed a lawsuit against Eli Lilly alleging misleading advertising of Lilly's GLP-1 obesity medications. The suit, which follows a cease-and-desist demand, claims Lilly is using deceptive advertisements to portray its products as broadly superior to Novo's competing medicines. Lilly has responded that its marketing campaign is truthful. The legal action comes as both manufacturers compete intensively in the rapidly growing obesity treatment market.

Industry·75d ago

Clinic and Physician Practice Bankruptcies Spike in 2026

Healthcare provider bankruptcies have increased sharply in 2026, driven in part by Medicaid payment cuts, according to a Gibbins Advisors report. The trend affects clinics and physician practices across the sector. The financial pressures are ongoing, with no specific effective date noted. For Medicaid managed care organizations, provider network stability is at risk as financial strain forces practice closures, potentially creating access gaps and requiring network adequacy monitoring.

Industry·75d ago

Clover Health Discloses Data Breach in Securities Filing

Clover Health reported a data breach in a securities filing last week. The Medicare Advantage insurer has not yet determined what type of data was exposed or how many individuals were affected. The company is investigating the incident and has not provided a timeline for breach notification or remediation. Clover operates Medicare Advantage plans in multiple states and serves tens of thousands of enrollees.

Managed Care·76d ago

Specialty Pharmacy Economics Require Comprehensive Cost Management Beyond Drug Trend

Specialty drug costs continue rising, but traditional specialty drug trend metrics fail to capture the full economic picture for payers. A comprehensive view of specialty pharmacy economics includes rebates, dispensing fees, patient assistance programs, and site-of-care differentials that significantly affect net costs. Managed care organizations that analyze total cost of care rather than gross trend alone can identify opportunities to steer utilization to lower-cost sites and negotiate more favorable arrangements with specialty pharmacies and manufacturers. The analysis suggests payers should evaluate specialty pharmacy performance using net cost metrics that account for all payment flows, not just claims data.

Legal·76d ago

Federal Judge Blocks CMS Rule Expanding Catastrophic ACA Plans

A federal judge issued a stay Thursday halting implementation of a CMS final rule that would have expanded access to catastrophic health plans in the ACA marketplace. The court found the policies were likely to increase costs and reduce access to comprehensive coverage. The ruling blocks the administration's changes pending further litigation. While the decision directly affects the ACA individual market, Medicaid managed care organizations operating in dual or integrated programs may see indirect effects on coverage transitions and risk pool composition.

Industry·78d ago

UnitedHealth Raises 2026 Guidance on Q2 Profit Growth

UnitedHealth reported $5.5 billion in profit for Q2 2026, driven by earnings recovery in its insurance and value-based care delivery operations. The company raised its full-year 2026 financial guidance based on improved cost controls across its business segments. UnitedHealth's insurance arm, which includes Medicaid managed care operations, showed stronger performance alongside growth in its Optum value-based care division. The earnings beat reflects operational improvements following cost control measures implemented across the enterprise.

Federal Policy·78d ago

340B Program Spending Reached $100 Billion in 2025, Federal Data Shows

Federal data shows 340B drug discount program spending reached $100 billion in 2025, marking continued growth despite regulatory efforts to limit program expansion. The spending increase reflects rising program enrollment and pharmaceutical costs. The growth trajectory affects Medicaid managed care organizations through potential impacts on pharmacy reimbursement rates, contract pharmacy relationships, and state efforts to recoup 340B savings through supplemental rebate programs. Regulators continue efforts to address program growth concerns.

Industry·79d ago

HCA Cuts 2026 Earnings Forecast After $400M Loss on ACA Coverage Drops

HCA Healthcare reduced its 2026 earnings forecast after losing $400 million in the second quarter due to payer mix changes, primarily from patients dropping Affordable Care Act marketplace coverage. The coverage losses exceeded both company and investor expectations. The development affects the second quarter of 2026, with the company announcing revised earnings guidance in July 2026. For Medicaid managed care organizations, this signals potential market instability and coverage churn that could affect member attribution, provider network partnerships, and redetermination processes if consumers losing marketplace coverage seek Medicaid eligibility.

Industry·81d ago

CVS Caremark Settles FTC Insulin Suit, Must End Rebate-Driven Formulary Preferences

CVS Caremark reached a settlement with the Federal Trade Commission over insulin pricing practices. The terms mirror the FTC's earlier settlement with Express Scripts and prohibit the pharmacy benefit manager from favoring higher-cost drug versions on standard formularies based on rebate arrangements. The settlement takes effect immediately upon court approval. For Medicaid managed care plans that contract with CVS Caremark or operate integrated PBM arrangements, this settlement signals continued federal scrutiny of rebate-driven formulary design and may preview future enforcement against similar practices affecting Medicaid populations.

Legal·82d ago

HHS OIG Excludes Over 1,200 People and Entities from Federal Programs in Six Months

The HHS Office of Inspector General excluded more than 1,200 individuals and entities from participating in federal healthcare programs between October 2025 and March 2026. The exclusions are part of increased enforcement activity under the Trump administration targeting fraud in Medicaid and Medicare Advantage. Excluded providers and entities cannot receive payment from federal programs, and managed care organizations are prohibited from contracting with or employing excluded individuals. MCOs must screen their networks against the OIG exclusion list monthly to maintain compliance and avoid penalties.

Legal·83d ago

Bankrupt Omnicare Settles DOJ Fraud Case for $440 Million

Omnicare has reached a $440 million settlement with the Department of Justice to resolve fraud charges related to improper billing of government health programs. The settlement follows Omnicare's bankruptcy filing last year after a court ordered the company to pay nearly $950 million for fraudulent billing practices. The reduced settlement amount reflects negotiations during the bankruptcy process. The case represents one of the largest False Claims Act settlements in the pharmacy services sector and concludes years of litigation over alleged improper billing to Medicaid and Medicare.

Industry·87d ago

External Audit Finds 97% of UnitedHealth HouseCalls Diagnoses Supported by Medical Records

An external audit of UnitedHealth's HouseCalls program found that nearly 97% of diagnoses identified during senior home visits were supported by patients' medical records. The audit was conducted amid scrutiny of home visit programs used to identify conditions for Medicare Advantage risk adjustment. UnitedHealth released the findings to validate the program's integrity following questions about diagnosis coding practices in home-based assessments. The results address ongoing concerns from regulators and policymakers about the accuracy of diagnosis reporting in value-based care arrangements.

Managed Care·90d ago

KLAS Spotlight Profiles RAAPID's AI-Driven Risk Adjustment Coding Platform

KLAS Research published an Emerging Company Spotlight on RAAPID, a vendor offering neuro-symbolic AI solutions designed to improve risk adjustment coding defensibility for health plans. The report includes customer satisfaction ratings and performance assessments from RAAPID clients in 2026. Risk adjustment coding accuracy directly affects capitation payments and audit exposure for Medicaid managed care organizations, particularly as CMS and state agencies intensify oversight of diagnosis reporting and hierarchical condition categories. The spotlight provides comparative data for MCOs evaluating technology vendors to support compliant coding practices.

Legal·93d ago

Federal Court Dismisses PBM Lawsuit Against FTC After Insulin Price Settlements

A federal court has dismissed a lawsuit filed by Express Scripts, CVS Caremark, and Optum Rx against the Federal Trade Commission. The three pharmacy benefit managers had sued the FTC after the agency accused them of inflating insulin costs, but the case is now closed following settlements between the PBMs and regulators. The settlements resolve the FTC's allegations regarding the PBMs' role in insulin pricing practices. The dismissal comes after the parties reached resolution on the underlying insulin pricing dispute.

Federal Policy·96d ago

ONC Awards New Contract to Oversee TEFCA Data Exchange Framework

The Office of the National Coordinator for Health Information Technology (ONC) has awarded a new contract to oversee the Trusted Exchange Framework and Common Agreement (TEFCA), the federal framework governing nationwide health information exchange. The move comes as the volume of health records exchanged through TEFCA increases significantly. The new oversight contractor will monitor compliance with TEFCA's technical and legal requirements for data sharing among qualified health information networks. This expansion of oversight signals federal emphasis on ensuring secure, standardized data exchange as TEFCA adoption accelerates.

Federal Policy·99d ago

House Hearing Surfaces Partisan Split on CMS Medicaid Funding Deferrals

A House subcommittee hearing Thursday revealed sharp partisan divides over recent CMS actions deferring or threatening Medicaid funding in multiple states. State Medicaid directors defended program integrity efforts while Democratic members questioned why only Democratic-led states have faced funding actions despite administration claims the crackdown applies nationwide. The hearing focused on CMS's authority to withhold federal matching funds and the criteria used to identify states for enhanced scrutiny. The dispute centers on whether recent enforcement actions reflect objective program integrity standards or politically motivated targeting.

Federal Policy·101d ago

CMS Projects U.S. Health Spending to Reach $5.7T in 2025, Driven by Utilization Growth

CMS actuaries project total U.S. health spending will reach $5.7 trillion in 2025, with growth primarily driven by increased utilization rather than unit cost increases. Prescription drug spending is accelerating sharply, particularly for GLP-1 medications used for diabetes and weight management. The utilization trend affects all payers including Medicaid managed care plans, which face rising pharmacy costs and member demand for high-cost specialty drugs. CMS expects spending growth to moderate in subsequent years as utilization patterns stabilize.

Industry·101d ago

Centene Appoints JPMorgan Veteran Lauren Tyler to Board

Centene Corporation has added Lauren Tyler, a finance executive with over 30 years of experience at JPMorgan, to its board of directors. Tyler brings extensive financial services leadership experience to the health plan. The appointment comes as Centene and other major insurers face operational pressures including margin compression, utilization management scrutiny, and regulatory compliance demands. The timing suggests Centene is strengthening financial oversight and strategic guidance at the board level.

State Policy·FL·101d ago

Florida AG Opens Antitrust Investigation Into CVS Pharmacy Practices

Florida Attorney General Ashley Moody has launched an investigation into CVS Health for alleged anticompetitive pharmacy practices. The probe examines whether CVS is using its integrated pharmacy benefit manager and retail pharmacy operations to disadvantage competitors and increase drug costs. This investigation follows similar state-level actions targeting PBM practices and comes amid broader scrutiny of vertical integration in the pharmacy supply chain. The inquiry could result in enforcement actions, consent agreements, or legislation affecting how PBMs operate in Florida's commercial and Medicaid markets.

Federal Policy·101d ago

Rural Hospitals Downsize Inpatient Care Under $50B Federal Transformation Fund

A $50 billion federal rural health transformation fund is driving hospitals to reduce inpatient capacity as states prioritize proven cost-saving models to qualify for funding. States are avoiding experimental approaches in favor of demonstrated strategies like downsizing acute care beds. The fund's structure incentivizes immediate cost reduction over innovation, according to health policy experts. Rural hospital consolidation and service line reductions may accelerate as a result.

Managed Care·104d ago

Health Plans Urged to Maintain Integrated Pharmacy Benefits Over Disaggregation Models

Industry commentary argues that health plans should retain integrated pharmacy benefit management rather than disaggregate services to separate PBMs or carve-out arrangements. The piece contends integrated models provide better coordination between medical and pharmacy benefits, improved utilization management, and stronger cost control compared to disaggregated approaches. No specific policy change or implementation timeline is involved; this represents strategic guidance for plan decision-making. For Medicaid MCOs facing increasing pharmacy costs and state pressure on benefit design, the integration versus disaggregation question affects contract performance, quality metrics, and administrative complexity.

Legal·IL·107d ago

PCMA Files Lawsuit Challenging Illinois PBM Reform Law

The Pharmaceutical Care Management Association (PCMA) has filed a lawsuit seeking to exempt pharmacy benefit managers from an Illinois law reforming the PBM industry. This marks the second major legal challenge PCMA has launched against state PBM reform legislation since Monday. The lawsuit targets Illinois's attempt to regulate PBM practices, though specific provisions challenged are not detailed in the article. The legal action follows a pattern of PBM industry opposition to state-level regulatory efforts through preemption and other legal arguments.

Legal·TN·109d ago

Express Scripts, PCMA Sue Tennessee Over Law Requiring PBM-Pharmacy Separation

Express Scripts and the Pharmaceutical Care Management Association filed lawsuits challenging Tennessee's FAIR Rx Act, which mandates the separation of pharmacy benefit managers from retail pharmacies. The law, passed earlier this year over strong PBM industry opposition, aims to prevent vertical integration practices that critics argue drive up drug costs and limit pharmacy access. The litigation follows similar legal action by CVS Caremark. The outcome will affect how Medicaid managed care plans structure pharmacy benefits and contract with PBMs in Tennessee and potentially influence similar legislative efforts in other states.

Legal·110d ago

Federal Judge Vacates Most of 2025 ACA Enrollment and Eligibility Rule

A federal judge on Friday vacated the majority of CMS's 2025 ACA enrollment and eligibility rule, delivering a win for insurance advocates who challenged the regulation. The vacated provisions included controversial changes to enrollment processes and eligibility verification requirements. However, many of the rule's provisions have been incorporated into the GOP's reconciliation bill currently moving through Congress, limiting the practical impact of the court decision. The ruling does not affect state-based marketplaces or Medicaid operations directly.

Managed Care·111d ago

Health Plans Deploy Analytics to Cut Maternal Care Costs and Improve Outcomes

Health plans are using predictive analytics and risk stratification to identify high-risk pregnancies earlier and reduce avoidable emergency department visits and NICU admissions. Analytics platforms enable plans to stratify members by social determinants of health, clinical complexity, and prior utilization patterns to target care management resources. Plans report reduced preterm births, lower cesarean section rates, and decreased total cost of care when analytics guide prenatal care coordination and postpartum follow-up. The approach addresses maternal health quality measures increasingly tied to MCO star ratings and value-based payment arrangements.

Industry·111d ago

UnitedHealth Reaches Proposed Settlement with FTC Over Insulin Pricing Allegations

UnitedHealth has reached a tentative settlement with the Federal Trade Commission in a lawsuit alleging the company's pharmacy benefit manager inflated insulin costs. The proposed deal follows a similar settlement CVS Health reached with the FTC several months earlier in the same case. The FTC's lawsuit targeted major PBMs for practices allegedly driving up patient costs for insulin products. Specific terms of the UnitedHealth settlement have not been disclosed and remain subject to approval.

Industry·114d ago

Health Plans Report AI Documentation Tools Driving Commercial Cost Increases

Nearly 70% of health plans surveyed by PwC identified providers' use of AI documentation and coding tools as a top three trend inflating commercial healthcare costs in the coming year. The report highlights concerns that AI-enabled coding may generate more comprehensive documentation and higher-acuity billing, potentially increasing claim volumes and costs. The findings reflect commercial market trends, as these AI tools are increasingly adopted across healthcare settings. Health plans are responding by evaluating claims review processes and utilization management protocols.

State Policy·115d ago

Planned Parenthood Closes 60 Clinics Amid State Funding Restrictions

Nearly 60 Planned Parenthood clinics have closed or consolidated since last year due to state-level funding restrictions, according to a KFF report. The closures affect access to family planning, STI testing, and preventive care services in affected communities. The timing and specific states are not detailed in the brief article, but the trend reflects ongoing state policy actions targeting reproductive health funding. For Medicaid managed care organizations, these closures may disrupt member access to covered family planning services and require network adequacy adjustments in affected service areas.

State Policy·IL·116d ago

Illinois Awards Medicaid Managed Care Contracts to Six Insurers Including Humana

Illinois announced its intent to award new Medicaid managed care contracts to six health insurers: five incumbents and new entrant Humana. The contracts, each representing tens of billions of dollars in revenue over the contract period, will cover the state's Medicaid managed care program. The awards follow a procurement process and are subject to standard protest periods before final execution. This represents a significant market entry for Humana in Illinois Medicaid and continuation for existing plans in one of the nation's largest state programs.

State Policy·117d ago

Survey: Most Medicaid Enrollees Unaware of Impending Work Requirements

A Health Management Academy survey found that over half of Medicaid enrollees are unaware of work requirements set to take effect in less than six months. Enrollees will be required to report work, education, or volunteer hours to maintain coverage. The findings suggest significant risk of coverage loss due to administrative non-compliance rather than actual ineligibility. States and managed care plans will need to intensify member outreach and education efforts to prevent disenrollment of otherwise eligible members.

Managed Care·118d ago

Health Plans Miss Surgical Cost Savings by Focusing Only on Avoidance

Health plans are neglecting significant cost savings opportunities in surgical care by focusing primarily on avoidance rather than optimizing outcomes for necessary procedures. Plans that concentrate solely on reducing surgical volume miss larger savings from complications, readmissions, and poor outcomes when surgery does occur. The shift to value-based care and risk-based contracts makes surgical outcomes optimization financially critical for managed care organizations. Strategies include directing members to high-performing surgeons, implementing episode-based payments, and using decision support tools to ensure appropriate care pathways.

Industry·118d ago

20% of U.S. Adults Report Denial of Doctor-Recommended Care

A new Commonwealth Fund study found that one in five U.S. adults were denied doctor-recommended care, leading to deteriorating health outcomes and financial strain. The research highlights increasing patient frustration with claims review processes and prior authorization barriers. Insurers maintain their utilization management protocols are medically appropriate. The findings come as regulatory scrutiny of managed care denial practices intensifies at both federal and state levels.

Industry·123d ago

Eli Lilly Threatens to Cut 340B Discounts for Hospitals Refusing Data Sharing

Eli Lilly has issued an ultimatum to certain 340B hospitals requiring them to share data proving they are not duplicating drug discounts by Monday or face loss of 340B pricing. The pharmaceutical company claims some hospitals refuse to provide documentation showing compliance with program requirements prohibiting duplicate Medicaid and 340B discounts on the same claim. Hospitals are pushing back and requesting federal government intervention. The dispute centers on manufacturer attempts to limit 340B discounts amid concerns about program integrity and duplicate discounting.

Federal Policy·125d ago

Federal Arbiters Finalize Dispute Resolution Rule for Surprise Medical Bills

Federal regulators released a final rule Thursday governing how health plans and providers resolve payment disputes over out-of-network emergency and certain non-emergency services under the No Surprises Act. The rule refines the independent dispute resolution process that applies when plans and providers cannot agree on payment rates for surprise bills. Health plans criticized the rule for not doing enough to prevent providers from exploiting the arbitration system, while the rule's proponents say it balances provider and plan interests. The changes take effect upon publication in the Federal Register.

Federal Policy·125d ago

CDC Reports 8% Uninsured Rate, 800,000 More Uninsured in 2025

The Centers for Disease Control and Prevention reported that the U.S. uninsurance rate remained stable in 2024 compared to the prior year. The data provides a baseline before anticipated coverage losses from federal healthcare spending cuts included in recent budget legislation. Medicaid managed care organizations may see enrollment declines if federal funding reductions lead to eligibility restrictions or benefit changes. The timing of any coverage losses will depend on how states implement budget cuts and whether Medicaid programs face disproportionate reductions.

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