Medicaid Monitor
Policy Intelligence
Medicaid Monitor
Policy Intelligence
Updated Fri 12:06 PM MT
© 2026 Lanphier Ventures, LLC
Informational use only. Not legal or compliance advice.
Source
← All Sources

JD Supra (Medicaid)

104 stories

Industry·1d ago

Mintz Quarterly Update Surveys PBM Policy Developments Through June 2026

In its Fall 2026 PBM Policy and Legislative Update, Mintz's Managed Care, PBMs & Pharmacies practice compiles federal and state developments affecting pharmacy benefit managers and the drug supply chain from mid-February through June 2026. The quarterly digest covers legislative and regulatory activity relevant to PBMs, health plans, and pharmacies operating across commercial and government-sponsored programs, including Medicaid. It serves as a reference roundup rather than a report on a single event, consolidating multiple developments tracked over the period. No specific effective dates apply since the piece is a periodic summary rather than a new rule or action.

Legal·3d ago

Law Firm Assesses Six Months of CMS Home Health Enrollment Moratorium

In a client alert, Arnall Golden Gregory LLP reviews the first six months of CMS's enrollment moratorium on home health and hospice agencies, imposed in May 2026 under the agency's CRUSH anti-fraud initiative. The firm examines how the moratorium has affected provider enrollment, M&A transactions, and agency growth in the sector, addressing industry concerns raised when the policy was first announced. The analysis covers practical impacts on providers and investors navigating the enrollment freeze. No new CMS action is reported; the piece is a retrospective legal analysis of an existing policy.

Federal Policy·3d ago

CMS Weighs Ending Weekly COVID Data Reporting for LTC Facilities

In a client alert, Bond Schoeneck & King reports that CMS is reportedly considering sunsetting pandemic-era requirements that long-term care facilities report COVID-19 and other respiratory illness data weekly to the CDC's National Healthcare Safety Network. The requirement currently applies to nursing homes and other CMS-regulated long-term care providers. No formal rule or timeline has yet been issued, and the firm characterizes the change as reported rather than confirmed. Nursing facilities have tracked and submitted this surveillance data throughout the pandemic as a condition of participation compliance matter.

Legal·NY·3d ago

HHS-OIG Denies Recertification of New York's Medicaid Fraud Unit

In a client alert, Harris Beach Murtha reports that HHS-OIG has denied recertification of New York's Medicaid Fraud Control Unit and suspended a substantial share of its federal grant funding, with a corrective action deadline of September 30, 2026. The firm notes this coincides with increased use of AI-driven claims analytics to flag potential fraud, creating heightened enforcement risk for New York Medicaid providers. The alert advises providers to review billing practices and compliance programs in light of both developments. No specific new enforcement action against individual providers is described beyond the MFCU funding suspension itself.

Legal·5d ago

Baker Donelson Flags 2026 Medicare Fraud Enforcement Surge for Providers

In a client alert, Baker Donelson reports that CMS has imposed three nationwide Medicare enrollment moratoria in 2026 freezing new enrollment for home health agencies, hospices, and certain durable medical equipment suppliers. The firm notes these moratoria are running alongside a multiagency fraud task force, congressional investigations, and state oversight inquiries, with an August 2026 OIG white paper on durable medical equipment fraud signaling likely future enforcement tools. Providers and suppliers in these sectors, including those with dual Medicare-Medicaid enrollment, face heightened scrutiny now. The alert advises affected entities to prepare for expanded compliance reviews and potential parallel state Medicaid enforcement actions.

Federal Policy·5d ago

CMS Cancels 760,000 ACA Enrollments, Halts New Broker Sign-Ups

CMS cancelled roughly 760,000 individual Affordable Care Act Marketplace enrollments and imposed a temporary moratorium on registering new agents and brokers for plan year 2027, effective September 22, 2026. The action accompanies enhanced verification requirements aimed at curbing improper or unauthorized enrollments in ACA plans. Agents, brokers, health plans, and affected consumers must adjust to stricter oversight and potential enrollment disruptions during the moratorium period. Morgan Lewis reports the moves signal a broader shift toward more aggressive CMS scrutiny of Marketplace enrollment integrity.

Legal·5d ago

DOJ Revises Justice Manual on FCA Guidance Use, Qui Tam Dismissals

In a client alert, Bass, Berry & Sims reports that the Department of Justice has revised its Justice Manual to limit reliance on sub-regulatory guidance to establish legal duties in False Claims Act cases and to expand DOJ's use of dismissal authority over qui tam suits. The firm notes that guidance documents such as CMS manuals and Local Coverage Determinations remain usable as evidence of scienter, notice, industry standards, and medical necessity, even though they cannot themselves create the underlying legal obligation. Healthcare providers and Medicaid managed care organizations facing FCA exposure are most affected, since many billing and coverage disputes turn on sub-regulatory guidance. The firm does not specify an effective date for the revisions in the excerpt provided.

State Policy·OH·5d ago

Ohio Medicaid Proposes Overhaul of Behavioral Health Coverage Rules

The Ohio Department of Medicaid has circulated proposed rulemaking covering 11 rules, six to be amended and five rescinded and replaced, that would significantly restructure Medicaid-covered behavioral health services statewide. The changes would affect nearly every community behavioral health provider in Ohio, altering coverage requirements and service standards. The client alert from Shumaker, Loop & Kendrick outlines the scope of the proposal but does not specify a comment deadline or effective date. Providers should review the proposed rules closely given the breadth of the restructuring and its potential impact on billing, documentation, and service delivery.

Federal Policy·6d ago

CMS Strengthens Federal ACA Marketplace Anti-Fraud Efforts

In its Health Care Week in Review, Alston & Bird reports that CMS has strengthened anti-fraud efforts for the federal ACA marketplace. The changes affect health plans participating in the federal exchange and brokers or agents facilitating enrollment. The timing and specific measures were not detailed in the available summary. The action reflects CMS's continued focus on program integrity in marketplace operations, with potential compliance implications for participating insurers and enrollment entities.

Legal·8d ago

DOJ and State MFCU Enforcement Rises in Applied Behavior Analysis Billing

Epstein Becker & Green reports that Department of Justice and state Medicaid Fraud Control Unit enforcement activity targeting applied behavior analysis (ABA) providers has increased. The firm advises ABA providers to strengthen compliance programs by monitoring state Medicaid billing rules, scope-of-practice requirements, CMS guidance, and recent OIG audit findings. No specific enforcement actions or effective dates are identified. The guidance addresses compliance risk management for ABA providers billing Medicaid, particularly for behavioral health services.

State Policy·NC·10d ago

North Carolina Medicaid Launches Expedited Reverification for High-Risk Providers

North Carolina Medicaid has initiated an expedited, off-cycle reverification process targeting certain high-risk providers. Affected providers must complete the reverification process to maintain enrollment status, with failure potentially resulting in disenrollment from the state's Medicaid program. The initiative creates immediate due diligence considerations for providers undergoing transactions, as enrollment status could be subject to accelerated review outside the standard cycle. This action follows federal program integrity requirements that permit states to conduct targeted reverifications of providers posing elevated financial or compliance risk.

Industry·11d ago

McDermott Outlines Physician Alignment Strategies Amid Payment Pressures

McDermott Will & Emery published guidance for hospitals and health systems on physician alignment models under current financial constraints, including Medicaid funding reductions, 340B uncertainty, and site-neutral payment expansion. The analysis covers alternative structures to traditional employment models that may preserve margin while maintaining physician relationships. The guidance is aimed at hospital CFOs and strategic planning teams navigating payment model transitions.

Federal Policy·12d ago

CMS Proposes RAPID Pathway to Accelerate Medicare Coverage for FDA-Approved Devices

CMS proposed the Regulatory Alignment for Predictable and Immediate Device (RAPID) pathway to coordinate FDA device approval with Medicare coverage decisions, compressing a typical five-year lag to 60-90 days. The pathway synchronizes regulatory approval and coverage determination processes from the outset. Manufacturers of breakthrough devices would participate in joint FDA-CMS reviews. This matters for Medicaid managed care organizations and state agencies because accelerated Medicare coverage pathways often influence state Medicaid coverage decisions and MCO formulary policies for medical devices and durable medical equipment.

Legal·12d ago

FinCEN Flags $17.5B in Suspected Health Care Fraud Across Medicare and Medicaid

On September 9, 2026, the Financial Crimes Enforcement Network (FinCEN) issued a Financial Trend Analysis identifying approximately $17.5 billion in suspicious activity potentially linked to health care fraud. The analysis is based on more than 5,700 Bank Secrecy Act reports filed between March 2025 and February 2026, with roughly 89 percent originating from depository institutions. The suspected fraud schemes targeted Medicare, Medicaid, and private insurance programs. This alert signals heightened financial institution monitoring of health care transactions and potential increased enforcement scrutiny across all payers, including Medicaid.

State Policy·CA·13d ago

California Requires Health Plans to Connect Callers to Live Agent Within 15 Minutes

California enacted legislation requiring large health care entities, including health plans, managed care organizations, PBMs, and pharmacies, to transfer callers from AI chatbots to human customer service representatives within 15 minutes upon request. The requirement applies to inquiries about medication refills, transfers, denied claims, prior authorizations, and specialist referrals. Hospitals obtained a broad exemption from the mandate. The law takes effect on a date not specified in this summary, and applies to large health care entities operating in California.

Federal Policy·15d ago

Law Firm Comments on CMS Proposed Rule for Remote Monitoring Payment Under 2027 Physician Fee Schedule

Epstein Becker Green submitted comments to CMS on September 14, 2026, regarding the 2027 Physician Fee Schedule Proposed Rule, focusing on payment and coverage policies for device-enabled remote monitoring services furnished to Medicare beneficiaries. The comments were submitted on behalf of health care practices providing these services. The Proposed Rule affects Medicare Part B payment rates and policies that will take effect in calendar year 2027, with the comment period having closed in mid-September 2026.

Industry·16d ago

FTC Tightens Failing Firm Defense Standards for Hospital Acquisitions

The Federal Trade Commission is applying stricter standards to the failing firm defense in hospital merger reviews, even as rural and critical access hospitals face documented financial pressures from low reimbursements, high Medicaid and Medicare volumes, uninsured patient populations, and expired pandemic relief funding. Hospitals seeking acquisition approval must now meet heightened thresholds to demonstrate they cannot remain independent or find alternative purchasers. The guidance affects health systems pursuing distressed hospital acquisitions, including those serving significant Medicaid populations.

Legal·16d ago

CMS Affiliation Rule Enables 10-Year Medicare Enrollment Bars for Physicians Without Direct Violations

Under current Medicare enrollment regulations, physicians can face up to 10-year exclusions from treating Medicare patients based solely on affiliation with another provider or supplier that has compliance issues, even when the physician has no personal history of fraud, improper billing, or disciplinary actions. The affiliation rule allows CMS to deny or revoke enrollment based on an individual's relationship with an entity that has been sanctioned or excluded. This administrative action does not require proof that the physician submitted improper claims or engaged in wrongdoing. The rule particularly affects hospice medical directors and other physicians in administrative or leadership roles where formal affiliations are documented.

Federal Policy·17d ago

CMS Expands ACCESS Model for Chronic Care Management

CMS announced an expansion of the Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model, which affects physician groups managing chronic conditions. The model offers alternative payment arrangements for chronic care coordination. The expansion creates new participation opportunities for physician practices, though specific effective dates and eligibility criteria were not detailed in the announcement. Physician groups managing Medicaid beneficiaries with chronic conditions should evaluate whether participation aligns with their care delivery infrastructure and payment model strategy.

Legal·18d ago

CMS Defers $1 Billion in Medicaid Payments and Expands Provider Exclusion Authority

CMS has deferred $1 billion in Medicaid payments as part of a federal crackdown on fraud, waste, and abuse in healthcare. The agency has also gained new authority to exclude providers from Medicaid participation. These actions represent a significant expansion of CMS enforcement powers affecting both providers and state Medicaid programs. The changes follow earlier federal commitments to intensify program integrity efforts across healthcare programs.

Legal·MD·19d ago

Maryland Sues Optum for $126 Million Over Allegedly Defective Medicaid Behavioral Health Claims System

Maryland filed suit against Optum and UnitedHealth Group alleging Optum collected over $126 million while operating a behavioral health Medicaid claims system the state contends was never fully functional during the five-year contract period. The lawsuit asserts fraud and breach of contract related to the system's performance failures. The timing of the suit is current as of September 2026, though the underlying contract issues span multiple years. This represents significant state-level enforcement against a major managed care and technology vendor, potentially signaling increased scrutiny of Medicaid administrative service contracts and vendor performance accountability.

State Policy·NY·22d ago

New York DOH Rescinds Guidance That Would Have Ended Nursing Home Medicaid for Undocumented Seniors

On September 3, 2026, the New York State Department of Health rescinded guidance issued two weeks earlier that would have terminated Medicaid coverage for many undocumented individuals aged 65 and older in nursing homes. The original directive, issued in mid-August 2026, would have effectively ended long-term care coverage for this population. The rescission restores the prior coverage policy for undocumented seniors in nursing facilities. The rapid reversal suggests significant pushback from providers, advocates, or legal concerns about the original guidance's implementation.

Federal Policy·23d ago

Latham & Watkins September 2026 Drug Pricing Digest Compiles Recent Policy Developments

Latham & Watkins published its September 2026 Drug Pricing Digest, tracking recent developments in the Medicaid Drug Rebate Program, 340B Program, Medicare, and state drug pricing laws. The digest compiles regulatory updates, guidance, and legal developments affecting pharmaceutical manufacturers and payers. This monthly reference document provides a consolidated view of drug pricing policy changes across federal and state programs. Medicaid agencies and managed care plans use these updates to track rebate program changes, 340B compliance requirements, and state legislative activity affecting drug costs.

Legal·23d ago

CMS Releases Guidance on ABA Therapy Compliance Amid Rising Fraud Concerns

CMS has issued new guidance addressing compliance and payment-integrity risks in applied behavior analysis (ABA) therapy for autism, one of Medicaid's fastest-growing service categories. The guidance responds to increasing expenditures, varying clinical practices, and reported fraud schemes in ABA services. Rapid program growth, extensive use of paraprofessional staff, and complex documentation and supervision requirements have created heightened compliance risks. The guidance affects state Medicaid agencies overseeing ABA programs, managed care organizations with behavioral health responsibilities, and ABA providers navigating fraud and abuse prevention requirements.

Legal·27d ago

CMS Blocks $1.6 Billion in Lab Payments Using AI-Powered Fraud Detection

On August 28, 2026, CMS announced it has blocked over $1.6 billion in potentially improper Medicare payments to diagnostic laboratories since the start of the current administration, using expanded AI-powered enforcement tools for payment suspensions and revocations. The enforcement actions target laboratories billing Medicare and represent a significant escalation in CMS program integrity efforts using predictive analytics. While these actions focus on Medicare fee-for-service, the AI-powered detection methods and aggressive enforcement posture signal heightened scrutiny that will likely extend to Medicaid managed care laboratory networks and state Medicaid program integrity operations.

Federal Policy·30d ago

CMS and CDC Issue RFI on Potential CLIA Regulation Updates

On July 16, 2026, CMS and CDC published a Request for Information (CMS-3485-NC) seeking input on potential updates to the Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations. The agencies are assessing whether the CLIA framework should be modernized to reflect changes in laboratory technology, operations, and risk management since the regulations were established. The RFI invites stakeholder feedback on the existing regulatory structure and potential areas for reform. Comments are due 60 days from publication in the Federal Register.

Legal·30d ago

CMS Orders Corrective Action Plan from Medicare Contractor Over AI Review Delays

CMS required Virtix Health, the contractor operating the WISeR Model in Washington, to submit a corrective action plan after failing to meet 72-hour turnaround requirements for prior authorization and prepayment determinations. The enforcement action follows findings that the company's AI-assisted review processes did not comply with statutory timeframes. While the WISeR Model applies to Medicare fee-for-service, the action signals CMS's expanding scrutiny of automated utilization management tools and could inform future oversight of similar technologies in managed care programs.

Federal Policy·31d ago

CMS Permanently Waives Home Address Reporting for Telehealth Providers with Group Practice Enrollment

CMS has made permanent an enrollment flexibility allowing providers who furnish telehealth services from home to avoid reporting home addresses on Medicare enrollment applications, provided they maintain a separate physical practice location associated with a Medicare Part B-enrolled group practice. Affected providers can enroll and bill from their physical practice location as if services were furnished in person. The policy takes effect immediately and applies to both new enrollments and existing providers. The change reduces administrative burden and privacy concerns for clinicians providing telehealth from home while maintaining program integrity through group practice oversight.

Federal Policy·31d ago

CMS Durable Medical Equipment Enrollment Moratorium Expires

CMS's moratorium on new durable medical equipment supplier enrollment has expired. The moratorium had temporarily halted new DME supplier applications in certain geographic areas as a program integrity measure. With the expiration, CMS will resume processing new DME supplier enrollment applications. The change affects Medicaid programs in states where DME suppliers seek to enroll and bill Medicaid for equipment and supplies, potentially expanding the DME provider network.

State Policy·VA·32d ago

Virginia Governor Issues Executive Order Responding to Federal Medicaid Cuts

On August 25, 2025, Virginia Governor Abigail Spanberger signed Executive Order 20 establishing the "Keep Virginia Covered" policy to address federal Medicaid and SNAP reductions enacted through H.R.1. The federal legislation cuts approximately $1 trillion from Medicaid nationwide over 10 years, with Virginia projected to lose $1.8 to $2.6 billion annually in federal funding beginning in 2028. An estimated 300,000 Virginians are at risk of losing Medicaid coverage as a result. The executive order directs state agencies to develop strategies to mitigate coverage losses and maintain program access in the face of reduced federal support.

State Policy·32d ago

Life Insurance Cash Value Remains Countable Asset Under State Medicaid Eligibility Rules

Life insurance policies with cash surrender value count as resources under Medicaid eligibility determinations in most states, potentially disqualifying applicants whose other assets fall below resource limits. State Medicaid agencies must assess policy values during initial eligibility screening and ongoing estate recovery processes. The treatment varies by state policy, with some states exempting term policies or policies below certain face value thresholds. This affects long-term care applicants and beneficiaries subject to estate recovery, requiring careful asset verification by eligibility workers and estate recovery contractors.

Legal·OH·36d ago

OhioHealth Settles DOJ Antitrust Case Over Managed Care Contracting Practices

OhioHealth entered a consent judgment with the U.S. Department of Justice and Ohio Attorney General resolving allegations that its managed care contracting practices violated federal and state antitrust laws. The settlement follows a DOJ complaint filed in February 2026 accusing OhioHealth of anticompetitive conduct in its health plan contracting. OhioHealth filed a motion to dismiss rather than answer the complaint but reached a consent judgment instead. The settlement takes effect immediately upon court approval. This matters for health systems and managed care plans negotiating provider contracts, as it signals DOJ enforcement priorities on contracting practices that may suppress competition or inflate reimbursement rates.

Federal Policy·36d ago

CMS Launches ACCESS Accountable Care Innovation Model for Providers

The Centers for Medicare and Medicaid Services has developed ACCESS, a new accountable care model for healthcare providers and organizations. The model represents CMS's latest approach to value-based care arrangements, offering an alternative framework for providers considering accountable care participation. Healthcare organizations are evaluating whether the model aligns with their operational capabilities and patient populations. The model follows CMS's broader strategy of expanding alternative payment models beyond traditional fee-for-service arrangements.

Legal·37d ago

McDermott Compliance Clinic Examines Chronic Care Management Billing Risks

McDermott Will & Emery published a compliance analysis examining chronic care management (CCM) services billing, coding, audit exposure, and enforcement risk across Medicare and Medicaid programs. The analysis addresses how providers can structure CCM programs to minimize compliance risk during government audits and investigations. It covers documentation requirements, time-tracking protocols, and common billing errors that trigger OIG scrutiny. The guidance is relevant for Medicaid managed care plans and providers offering CCM services under capitated or fee-for-service arrangements.

Legal·37d ago

CMS and OIG Prioritize Wound Care Fraud Enforcement in 2026

The Centers for Medicare and Medicaid Services and the HHS Office of Inspector General have made wound care fraud enforcement a priority in 2026. Healthcare providers offering wound care services face increased audit and investigation risk. Non-compliance can result in substantial penalties, including potential Medicare or Medicaid exclusion. Providers should review their wound care billing practices, documentation standards, and compliance programs to mitigate enforcement exposure.

Legal·37d ago

ABA Therapy Faces Growing Federal and State Fraud Enforcement Scrutiny

Applied behavior analysis therapy for autism has become a major Medicaid enforcement target as the service category expands rapidly. Federal and state regulators are increasing scrutiny of ABA providers for potential fraud, waste, and abuse violations. ABA providers face heightened compliance risk due to the service's growth trajectory, billing complexity, and evolving coverage policies. The enforcement environment creates significant operational and legal exposure for providers, managed care organizations overseeing ABA networks, and state Medicaid agencies administering these benefits.

State Policy·IN·38d ago

Indiana Submits HIP 3.0 Section 1115 Waiver Application for Public Comment

On August 5, 2026, the Indiana Family and Social Services Administration published a draft Section 1115 waiver application for the Healthy Indiana Plan 3.0, seeking to implement policies from Indiana Senate Enrolled Acts 2 (2025) and 1 (2026) and the federal Working Families Tax Cuts Act. The draft is open for public comment before submission to CMS for federal approval. The waiver application reflects state legislative directives requiring operational changes to Indiana's Medicaid program. The timeline for CMS review and approval following the comment period will determine when these policies take effect for Indiana Medicaid beneficiaries, health plans, and providers.

State Policy·OH·38d ago

Ohio Senate Bill 315 Expands Medicaid Program Integrity Oversight Effective October 6

Ohio Senate Bill 315 takes effect October 6, 2026, bringing significant expansions to program integrity requirements, enforcement authority, and oversight mechanisms across Ohio's Medicaid program. The legislation affects providers, managed care organizations, and the state Medicaid agency with new compliance obligations and enforcement tools. The law represents a substantial shift in Ohio's approach to fraud prevention and program integrity enforcement. Medicaid stakeholders operating in Ohio face new compliance requirements and heightened scrutiny under the expanded authority.

Federal Policy·39d ago

CMS Proposes Palliative Care Coverage Under Medicare Home Health Benefit in CY2027 Rule

CMS's proposed CY 2027 Home Health Prospective Payment System rule confirms that community-based palliative care may be covered under the existing Medicare home health benefit. The proposal affects home health agencies, hospices, and other providers serving frail and declining populations. The rule creates operational questions for providers in the near term and strategic opportunities for service delivery models going forward. Comment periods and effective dates follow standard Medicare rulemaking timelines for calendar year 2027.

Legal·39d ago

OIG Eliminates Prior Approval Requirement for State Medicaid Fraud Unit Data Mining

On August 13, 2026, HHS OIG issued State Fraud Policy Transmittal No. 2026-1 eliminating the federal approval requirement that previously required Medicaid Fraud Control Units to obtain OIG permission before conducting federally funded data mining on Medicaid claims. MFCUs also no longer need to renew approvals every three years. The change took effect immediately upon issuance. The policy shift gives state fraud units greater operational flexibility to deploy analytics tools against potentially fraudulent Medicaid billing without navigating a federal checkpoint, potentially accelerating fraud detection and investigation timelines.

Federal Policy·40d ago

Latham & Watkins Drug Pricing Digest Compiles August 2026 Regulatory Updates

Latham & Watkins published its Drug Pricing Digest for August 2026, tracking recent developments across the Medicaid Drug Rebate Program, 340B Program, Medicare, and state law. The digest compiles regulatory updates, guidance, and legal developments affecting pharmaceutical pricing and market access across federal and state programs. This ongoing tracker serves as a reference for manufacturers, health plans, and providers navigating drug pricing compliance and reimbursement. The publication does not report a single new regulatory action but consolidates recent activity in pharmaceutical policy.

Legal·NY·45d ago

New York Strengthens Medicaid Anti-Fraud Controls Under Federal Scrutiny

New York's Department of Health has adopted new program administrative measures to address federal concerns about oversight and compliance integrity in its Medicaid program, particularly for personal care and home health providers. The measures come as HHS scrutinizes the state for perceived gaps in program integrity controls. The changes appear designed to strengthen provider oversight and fraud prevention mechanisms in response to federal pressure. This development signals heightened compliance expectations for providers in these sectors and potential model requirements other states may face.

Federal Policy·45d ago

CMS Proposes Electronic Prior Authorization Incentives in Medicare Fee Schedule

CMS released a proposed rule on July 14, 2026, to incentivize electronic prior authorization through the Medicare Physician Fee Schedule for CY 2027. The proposal targets Medicare Ambulatory Specialty Models and the Merit-based Incentive Payment System, building on existing prior authorization requirements for health plans. The rule focuses on provider-side incentives rather than plan mandates. Comment periods and effective dates were not specified in the excerpt.

Industry·45d ago

Bankruptcy Attorney Discusses Medicaid Cuts and Hospital Closures on Restructuring Podcast

A Sheppard Mullin podcast episode features Dentons partner Samuel Maizel discussing healthcare bankruptcies, including Medicare and Medicaid provider agreement disputes and hospital and skilled nursing facility closures. The discussion covers how healthcare Chapter 11 cases differ from other bankruptcies due to provider agreements and regulatory constraints. The episode addresses financial pressures including Medicaid cuts and private equity involvement in distressed healthcare assets. No specific policy changes or case details are provided.

Federal Policy·47d ago

CMS Seeks Comment on AI in Medicine Through Physician Fee Schedule RFI

CMS has included questions about artificial intelligence in healthcare delivery within its Calendar Year 2027 Physician Fee Schedule proposed rule Request for Information. Comments are due in less than 30 days from the article date (mid-September 2026). The RFI solicits stakeholder input from physicians, health systems, and technology companies on how AI should be addressed in Medicare payment policy. This matters for Medicaid stakeholders because federal AI policy framework developed for Medicare typically influences subsequent Medicaid guidance on emerging technologies, particularly in managed care quality measurement and provider reimbursement.

Federal Policy·51d ago

CMS and CDC Launch CLIA Modernization Review for Clinical Laboratory Standards

The Centers for Medicare & Medicaid Services and Centers for Disease Control and Prevention have initiated a review to modernize the Clinical Laboratory Improvement Amendments of 1988 (CLIA), the federal regulatory framework governing clinical laboratory testing standards. The review will examine updates to quality standards, personnel qualifications, proficiency testing, and enforcement mechanisms that apply to all clinical laboratories performing testing on human specimens, including those serving Medicaid beneficiaries. Timing for proposed regulatory changes has not been announced. For Medicaid programs, CLIA compliance is a condition of participation for laboratory services reimbursement, and any regulatory changes will directly affect state agency oversight responsibilities, managed care quality assurance requirements, and laboratory provider compliance obligations.

Legal·51d ago

DOJ’s 2026 Health Care Fraud Takedown Signals Medicaid Enforcement Priorities

The Department of Justice announced its annual Health Care Fraud Takedown on June 23, 2026, with Medicaid and state health care programs representing a central enforcement focus. The takedown reflects DOJ's heightened scrutiny of fraud and abuse affecting state programs, not just Medicare. Medicaid providers, managed care organizations, and state agencies face increased risk of federal enforcement action. This enforcement prioritization signals that DOJ views Medicaid fraud as a critical target area requiring robust compliance programs and internal controls.

Federal Policy·51d ago

CMS Proposes RAPID Pathway for Breakthrough Device Coverage Under Medicare

On August 7, 2024, CMS issued a notice with comment period proposing the Regulatory Alignment for Predictable and Immediate Device (RAPID) Coverage Pathway. The pathway would accelerate Medicare coverage for medical devices receiving FDA breakthrough designation by aligning CMS coverage review with FDA premarket review before market authorization. The proposal aims to reduce the gap between FDA approval and Medicare coverage determinations for qualifying devices. Comments are due following standard notice procedures.

Federal Policy·52d ago

CMS Opens Comment Period for RAPID Device Coverage Pathway, Due October 10

CMS released a notice with comment period on August 7, 2026, establishing the framework for the Regulatory Alignment for Predictable and Immediate Device (RAPID) Coverage Pathway. The pathway aims to accelerate Medicare coverage for innovative medical devices following FDA market authorization. Comments are due October 10, 2026. The pathway creates a streamlined process that shortens the gap between FDA approval and national Medicare coverage for qualifying devices.

State Policy·NY·53d ago

New York Gets CMS Approval to Overhaul Medicaid Provider Enrollment and Revalidation

New York's Department of Health received CMS approval to implement a plan revamping the state's Medicaid provider enrollment and revalidation processes. The changes aim to improve oversight of New York's Medicaid program. The announcement follows a McDermott Will & Emery client alert from August 4, 2026, addressing Medicaid moratorium and ownership change issues in the state. The timing and scope of implementation will affect providers seeking enrollment or ownership changes in New York's Medicaid program.

Legal·54d ago

CMS Releases ABA Toolkit as Federal Enforcement Targets Autism Therapy Providers

CMS has released a new Applied Behavior Analysis toolkit amid increasing federal enforcement scrutiny of autism therapy providers. The development coincides with congressional investigations into the ABA therapy industry. The toolkit and enforcement actions reflect heightened government attention to billing practices, medical necessity determinations, and compliance issues in the autism therapy sector. State Medicaid agencies, managed care organizations, and ABA providers face increased program integrity oversight as federal authorities target potential fraud and abuse in this growing service area.

Federal Policy·54d ago

Congressional Republicans Question State Use of Enhanced Federal Medicaid Matching Funds

Congressional Republicans have raised concerns about states leveraging increased federal matching dollars from Medicaid expansion, provider taxes, and state directed payments to grow their Medicaid budgets. The lawmakers argue that states are not adequately considering the fiscal impact on the federal government when utilizing these funding mechanisms. This scrutiny comes as Congress examines Medicaid financing structures and potential reforms to federal matching formulas. The development signals potential legislative or oversight activity that could affect state Medicaid financing strategies and the availability of enhanced federal matching rates.

Federal Policy·57d ago

CMS Releases FY 2027 IPPS Final Rule

On July 31, 2026, CMS issued the FY 2027 Inpatient Prospective Payment System (IPPS) final rule. The rule sets Medicare payment rates and policies for inpatient hospital services for the fiscal year beginning October 1, 2026. While the IPPS primarily governs Medicare payments, the rule's rate methodologies and quality measures often influence Medicaid supplemental payment programs, state upper payment limit calculations, and hospital financial stability that affects Medicaid providers. The rule takes effect October 1, 2026.

Federal Policy·57d ago

CMS Releases FFY 2027 IPPS and LTCH Final Rule

On August 4, 2026, CMS published its final rule updating payment rates and policies for the inpatient prospective payment system (IPPS) and long-term care hospital prospective payment system (LTCH PPS) for federal fiscal year 2027. The rule takes effect October 1, 2026, the start of FFY 2027. While the rule primarily governs Medicare hospital payments, it may affect Medicaid programs that use Medicare rates as a baseline for supplemental payments, upper payment limit calculations, or rate-setting for Medicaid managed care hospital contracts.

Federal Policy·58d ago

McDermott Hosts Webinar on 340B Provisions in CY 2027 OPPS Proposed Rule

McDermott Will & Emery is hosting a webinar on August 11, 2026 at 12:00 pm ET to discuss 340B program changes proposed in CMS's CY 2027 Outpatient Prospective Payment System (OPPS) proposed rule. The webinar will cover key provisions affecting 340B hospitals and non-340B hospitals, potential implications, and considerations for stakeholders preparing comments before the CMS deadline. The session is designed to help organizations understand the proposed changes and formulate effective comments during the rulemaking period.

Federal Policy·58d ago

CMS Withholds $1 Billion in Medicaid Payments to California and Minnesota Pending Documentation

On July 21, 2026, CMS and HHS announced they are withholding over $1 billion in federal Medicaid payments to California ($867 million) and Minnesota ($199 million) pending submission of additional documentation showing certain claims meet federal billing requirements. The payment deferrals follow financial audits that identified compliance concerns. The states must provide supplemental documentation before CMS will release the withheld funds. This action represents a significant federal enforcement step affecting two major state Medicaid programs and their cash flow for services already delivered.

Federal Policy·59d ago

CMS Proposes Home Health Payment Changes for Palliative Care and Home Infusion

CMS released its CY 2027 Home Health Prospective Payment System proposed rule, introducing payment changes for palliative care services, home infusion therapy, and durable medical equipment in the home health setting. The proposed rule affects Medicare home health agencies and their payment structures beginning January 1, 2027. The changes reflect CMS's broader strategy to expand access to home-based care alternatives and shift care delivery from institutional to home settings. Comments on the proposed rule are typically due 60 days after publication in the Federal Register.

Legal·59d ago

Federal Courts Rule Hospices Deserve Deference on Six-Month Life Expectancy Determinations

Federal courts have issued several rulings favoring hospices in administrative appeals, particularly recognizing that hospices should receive deference when determining six-month life expectancy for patient eligibility. These rulings counter administrative law judge decisions that had reversed hospice eligibility determinations. The court decisions affect how hospices defend Medicare and Medicaid eligibility claims during audits and appeals. This development matters for hospices serving dual-eligible beneficiaries and state Medicaid programs that follow Medicare hospice coverage rules.

Legal·59d ago

District Court Requests Feasibility Briefing After Columbus II Oral Argument on 2027 NBPP Rule

Following July 8 oral argument in City of Columbus v. Kennedy, challenging CMS's 2027 Notice of Benefit and Payment Parameters Final Rule, the U.S. District Court for the District of Maryland ordered supplemental briefs on implementation feasibility. The Court asked parties to address whether relief could be granted without disrupting the 2027 Marketplace plan year and whether staying catastrophic-plan guidance would affect enrollees. The case involves provisions of the NBPP final rule affecting Exchange operations. Supplemental briefing timing will determine how quickly the Court rules and whether any injunction could affect 2027 plan year implementation.

Legal·PA·59d ago

DOJ Launches Philadelphia Medicaid Fraud Strike Force

The Department of Justice announced on August 4, 2026, the creation of a dedicated Medicaid fraud strike force in Philadelphia, expanding its Northeast Health Care Fraud Strike Force operations. The new unit will focus on investigating and prosecuting Medicaid fraud cases in the Philadelphia region. The announcement coincides with a parallel expansion of DOJ's West Coast Strike Force, signaling intensified federal enforcement activity targeting Medicaid program integrity. The move indicates heightened scrutiny of Medicaid providers, plans, and related entities operating in these regions.

Federal Policy·60d ago

CMS Proposes Restrictions on Remote Patient Monitoring in 2027 Fee Schedule

CMS issued the CY 2027 Physician Fee Schedule Proposed Rule limiting remote patient monitoring and remote therapeutic monitoring services. The proposal restricts outsourced clinical staffing, imposes new billing requirements, and reduces reimbursement for certain services. Changes would take effect January 1, 2027. The restrictions reverse CMS's 2025 expansion of RPM/RTM access and could significantly affect Medicaid managed care organizations and providers using remote monitoring for chronic condition management, particularly for dialysis and other high-cost populations.

Federal Policy·60d ago

CMS Seeks Public Comment on Potential CPT Coding System Reforms in 2027 Fee Schedule Rule

CMS published a Request for Information on July 16, 2026, soliciting stakeholder feedback on potential reforms to the American Medical Association's Current Procedural Terminology (CPT) coding system. The RFI appears in the Calendar Year 2027 Physician Fee Schedule Proposed Rule (CMS-1848-P). Comments are due 60 days after Federal Register publication, typically in mid-September 2026. The inquiry signals CMS consideration of structural changes to how physician and outpatient services are coded and reimbursed across Medicare and Medicaid programs.

Federal Policy·62d ago

CMS Proposes Ban on Outsourced Remote Patient Monitoring for Medicare

CMS released the CY 2027 Physician Fee Schedule proposed rule restricting remote patient monitoring (RPM) and remote therapeutic monitoring (RTM) under Medicare. The proposal would prohibit outsourcing of RPM/RTM services and revise reimbursement methodology, reversing 2026 expansions that lowered data-transmission thresholds and added new billing codes. The proposed changes would take effect January 1, 2027 if finalized. State Medicaid agencies that follow Medicare payment policies or allow RPM under managed care contracts may face operational and reimbursement changes if states align telehealth coverage with Medicare rules.

State Policy·NY·62d ago

New York Imposes Six-Month Moratorium on Medicaid Provider Enrollment for Certain Categories

New York's Medicaid Director announced an immediate six-month moratorium on new provider enrollments and change of ownership applications for certain provider categories, effective July 30, 2026. The moratorium affects specific provider types yet to be fully detailed but includes enrollment and ownership transfer processing freezes. The policy takes effect immediately and runs through January 2027. This represents a significant network access and administrative barrier for health plans managing provider networks, providers seeking Medicaid participation or ownership changes, and state agencies coordinating with managed care organizations on network adequacy requirements during the moratorium period.

Federal Policy·65d ago

CMS Issues Final Rule on Medicaid Provider Tax Requirements

The Centers for Medicare & Medicaid Services has released a final rule addressing Medicaid provider tax requirements. The rule follows closely after the agency's Medicaid work requirement interim final rule, which has a comment deadline of July 31, 2026. The provider tax rule affects how states can structure health care-related taxes to help finance their Medicaid programs. This action impacts state Medicaid agencies' financing strategies and their ability to leverage provider taxes for federal matching funds.

Federal Policy·65d ago

CMS Seeks Input on Potential Overhaul of CPT Coding System

On July 14, CMS published a Request for Information in the CY 2027 Physician Fee Schedule Proposed Rule seeking feedback on potential reforms to the AMA's Current Procedural Terminology (CPT) coding system. The RFI explores sweeping changes to how medical procedures and services are coded and billed across Medicare and Medicaid. CMS has not specified an effective date; this is an information-gathering exercise ahead of potential future rulemaking. The inquiry could affect how Medicaid fee-for-service and managed care organizations code, reimburse, and track healthcare services, with implications for payment accuracy, prior authorization processes, and claims administration.

State Policy·CO·66d ago

Colorado Enacts ABA Provider Licensure Law With Medicaid Implications

Colorado Governor signed HB 26-1425 on June 2, 2026, establishing the Applied Behavior Analysis Practice Act. The law creates comprehensive licensing requirements for ABA practitioners and provider entities operating in Colorado, including facility licensing, professional liability insurance mandates, and provisions affecting Medicaid reimbursement. The legislation includes phased implementation timelines. ABA providers serving Colorado Medicaid beneficiaries must prepare for new credentialing, facility standards, and compliance requirements that will affect network participation and claims processing.

Industry·66d ago

Law Firm Publishes Explainer on Special Needs Trusts and Medicaid Eligibility

Lippes Mathias LLP published an educational article explaining how special needs trusts can preserve Medicaid and SSI eligibility for individuals with disabilities who receive inheritances, gifts, or legal settlements. The piece outlines how direct financial transfers can disqualify beneficiaries from needs-based programs, and describes trust structures designed to maintain eligibility while providing supplemental support. The article is a general educational resource for families and estate planners, not a policy development or regulatory action. It does not announce new guidance, legal precedent, or program changes affecting Medicaid administration.

Legal·67d ago

D.C. Circuit Upholds CMS Authority to Retain MA Survey Data in Star Ratings

On July 14, 2026, the D.C. Circuit Court of Appeals affirmed a district court ruling that upheld CMS's decision to retain survey data used in Medicare Advantage star ratings, rejecting Alignment Healthcare's challenge that the agency acted arbitrarily by refusing to discard the data. The decision reinforces CMS's discretion in administering the star ratings methodology and handling plan-specific data challenges. While this case involves Medicare Advantage rather than Medicaid managed care, it establishes precedent for CMS's authority over survey-based quality measurement systems that parallel those used in Medicaid managed care quality rating systems in multiple states.

Federal Policy·67d ago

CMS Proposes Removing 638 Additional Procedures from Medicare Inpatient-Only List for 2027

CMS proposed removing 638 procedures from the Medicare Inpatient Only List in the CY 2027 OPPS/ASC Proposed Rule, effective January 1, 2027. This follows removal of 285 procedures in CY 2026. The broader scope includes surgical services beyond the 2026 focus on musculoskeletal procedures. The removals affect whether procedures must be performed in inpatient settings or can shift to outpatient settings under Medicare payment rules.

Federal Policy·67d ago

CMS Proposes Mandatory 340B Claims Data Reporting for Medicare Part D

CMS published the 2027 Physician Fee Schedule proposed rule on July 16, proposing to make 340B claims data reporting mandatory for covered entities participating in Medicare Part D, converting what was previously a voluntary submission. The proposal would require 340B covered entities to submit Part D claims data to the Medicare Part D Claims Data 340B Repository starting in 2027. This change affects hospitals, federally qualified health centers, and other 340B covered entities that dispense drugs under Medicare Part D, requiring new compliance infrastructure and potentially increasing administrative burden for entities that have not voluntarily reported to date.

Federal Policy·68d ago

CMS Proposes Home Health Enrollment Changes to Reduce Fraud and Improper Payments

On July 1, 2026, CMS proposed enrollment-related policy changes under the Home Health Prospective Payment System aimed at reducing improper Medicare payments and protecting beneficiaries. The proposed rule introduces new enrollment requirements and fraud deterrence measures for home health providers. While the rule targets Medicare home health providers, states with Medicaid home health programs or 1915(c) waiver programs providing home and community-based services may see similar enrollment standards adopted or referenced in future Medicaid guidance. CMS has not specified a comment deadline or effective date in the summary provided.

Legal·68d ago

HHS-OIG Spring 2026 Report Details Oversight of $2.4 Trillion in Federal Health Spending

The HHS Office of Inspector General published its Semiannual Report to Congress covering October 1, 2025, through March 31, 2026. The report documents OIG's oversight activities across Medicare, Medicaid, and related public health programs, representing more than $2.4 trillion in annual federal health care spending. The report details enforcement actions, audit findings, and program integrity recommendations relevant to Medicaid programs and managed care plans. State Medicaid agencies and health plans should review the report for emerging enforcement priorities and compliance risks.

Federal Policy·69d ago

CMS Proposes Mandatory Attestation Process for Off-Campus Hospital Outpatient Departments

The Centers for Medicare & Medicaid Services has proposed a new process requiring hospitals to submit provider-based attestations for off-campus hospital outpatient departments, converting what was previously a voluntary submission into a mandatory requirement. The proposed rule establishes a compliance framework for hospitals operating off-campus HOPDs under provider-based status. CMS has not specified an effective date or comment deadline in the available information. This change affects hospitals billing Medicare and Medicaid for services delivered at off-campus locations under provider-based arrangements, requiring new administrative processes to maintain compliance and avoid potential payment denials.

State Policy·WI·71d ago

Wisconsin Medicaid Functional Screen Determines Long-Term Care Program Eligibility

Wisconsin Medicaid requires applicants for long-term care programs to pass a functional screen test in addition to meeting financial eligibility criteria. The functional screen assessment evaluates an individual's ability to perform activities of daily living and need for assistance to determine whether they meet the level of care required for program enrollment. The screen applies to programs including Family Care, IRIS, and institutional care. For applicants and providers, understanding functional screening requirements is critical to navigating Wisconsin's long-term care access and ensuring appropriate program placement.

Legal·71d ago

HHS Delegates Exclusion Authority to CMS as Q1 2026 Revocations Surge 40%

On July 21, 2026, HHS Secretary Kennedy announced that CMS now has direct exclusion authority, previously held only by the HHS Office of Inspector General. CMS revoked 1,413 Medicare and Medicaid providers and suppliers in Q1 2026, a 40% increase over prior years and the largest quarterly surge on record. The delegation gives CMS "force multiplier" capacity to exclude providers from federal health programs based on fraud, abuse, or program integrity concerns. Medicaid managed care organizations must screen networks for excluded providers and may face increased mid-year terminations and provider adequacy challenges as revocation volumes accelerate.

Federal Policy·72d ago

CMS Proposes Medicare Payment Category for Clinical Decision Support Software

CMS released proposed rules on July 2 and July 14, 2026 establishing a new Medicare payment category called Software as a Medical Service (SaMS) for software that supports clinical decision-making through algorithmic analysis. The proposals appear in the CY 2027 Hospital Outpatient Prospective Payment System and Physician Fee Schedule proposed rules. This represents CMS's first structured approach to paying separately for clinical decision support software under Medicare. Comments on the proposed rules are typically due 60 days after publication in the Federal Register.

Legal·72d ago

CMS Proposes Sweeping Medicare Home Health Enrollment Enforcement Tools in 2027 Rule

CMS released the calendar year 2027 Home Health Prospective Payment System proposed rule, combining payment updates with expanded program integrity enforcement authority. The rule introduces new enrollment enforcement mechanisms targeting home health agencies participating in Medicare. While the rule focuses on Medicare home health, the enforcement framework may signal CMS's broader compliance and enrollment oversight direction. Comments on the proposed rule are due 60 days after Federal Register publication.

Industry·72d ago

Elder Law Firm Highlights Long-Term Care Cost Burden on Middle-Class Families

A law firm analysis describes how long-term care expenses deplete family savings, noting Medicare's limited coverage and Medicaid's spend-down requirements. The piece emphasizes that middle-class households face significant financial exposure before qualifying for Medicaid long-term services and supports. No new policy change is reported. The content reflects ongoing challenges in the LTSS financing landscape that affect Medicaid eligibility and enrollment dynamics.

Legal·72d ago

DOJ Secures Six Healthcare Fraud Convictions in Three Weeks, $1.1B in Alleged Losses

The Department of Justice's National Fraud Enforcement Division obtained six jury trial convictions between May 13 and June 1, 2026, across five federal districts. The defendants include a software platform executive and a rural nurse practitioner, among others spanning multiple healthcare settings. Total alleged losses exceed $1.1 billion to Medicare, Medicaid, and other health benefit programs. The convictions demonstrate DOJ's sustained enforcement activity across the healthcare sector, with direct implications for Medicaid managed care organizations' fraud, waste, and abuse compliance programs.

Federal Policy·72d ago

CMS Proposes Provider Enrollment Changes Across All Provider Types in 2027 Home Health Rule

CMS published a proposed rule on July 6, 2026, that includes provider enrollment changes applicable to all provider and supplier types, not just home health agencies. The changes are designed to strengthen program integrity across Medicare and Medicaid. The rule appears in the Calendar Year 2027 Home Health Prospective Payment System Proposed Rule. Comments are due 60 days after publication in the Federal Register.

Federal Policy·73d ago

CMS Proposes CY 2027 Hospital Outpatient Payment and ASC Policy Changes

CMS issued the Calendar Year 2027 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center proposed rule affecting hospitals participating in Medicare. The proposed rule includes significant payment and policy changes for hospital outpatient services and ASCs. The rule establishes payment rates and updates operational policies for calendar year 2027. While focused on Medicare payment systems, managed care organizations contracting with hospitals for Medicaid services should monitor for potential cost-shifting effects and policy precedents that states may adopt.

Legal·TX·73d ago

AstraZeneca Pays Texas $34M to Settle Medicaid Kickback Claims

AstraZeneca Pharmaceuticals LP agreed to pay $33,998,000 to Texas to resolve allegations that it provided illegal remuneration to healthcare providers in connection with prescriptions for drugs covered by the state's Medicaid program. The settlement addresses potential violations of anti-kickback statutes related to inducements tied to Medicaid prescribing. Texas Medicaid managed care organizations that reimbursed claims for the implicated drugs during the alleged period may have paid inflated costs tied to these arrangements. The settlement follows state enforcement action under Texas Medicaid fraud statutes.

Federal Policy·74d ago

CMS Proposes Tighter Remote Patient Monitoring Requirements in 2027 Physician Fee Schedule

CMS published a proposed rule on July 16, 2026, that would tighten requirements for remote patient monitoring (RPM) services in the Calendar Year 2027 Medicare Physician Fee Schedule. The changes respond to Office of Inspector General reports flagging program integrity concerns about RPM billing. The proposed rule affects how providers document and bill for remote monitoring services under Medicare. Comments on the proposed rule are typically due 60 days after publication in the Federal Register.

Legal·74d ago

23 States Sue CMS Over Medicaid Work Requirements Rule Exemptions

On June 29, 2026, twenty-three states, two governors, and the District of Columbia filed suit in U.S. District Court for Massachusetts challenging CMS implementation of Medicaid work requirements under the One Big Beautiful Bill Act. Plaintiffs allege CMS unlawfully narrowed exemptions for medically frail beneficiaries. The litigation seeks to block enforcement of the work requirements rule pending judicial review. This lawsuit directly affects managed care organizations responsible for identifying medically frail populations, verifying exemptions, and ensuring compliance with work requirement reporting.

Federal Policy·76d ago

CMS Proposes Major Changes to Remote Monitoring Payment in 2027 Fee Schedule

CMS released the calendar year 2027 Medicare Physician Fee Schedule proposed rule on July 14, 2026, proposing significant changes to payment and coverage requirements for remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) services. The changes respond to Office of Inspector General scrutiny of these services. The proposed rule affects how Medicare pays for remote monitoring services used in chronic disease management and post-discharge care. Comments on the proposed rule are typically due 60 days after publication in the Federal Register.

Federal Policy·78d ago

CMS Seeks Public Comment on Clinical Laboratory Improvement Amendments Regulations

On July 16, 2026, CMS and CDC announced they are seeking public input on regulations implementing the Clinical Laboratory Improvement Amendments of 1988 (CLIA), which have been in effect since 1992. The agencies are soliciting stakeholder feedback on various issues related to the current laboratory regulatory framework. The request for information signals potential modernization of CLIA regulations that govern clinical laboratory testing and quality standards. Public comments will inform whether CMS pursues regulatory changes to laboratory certification, personnel standards, quality control, or proficiency testing requirements.

Federal Policy·78d ago

CMS Proposes CY 2027 Physician Fee Schedule with QPP Updates

On July 14, 2026, CMS released the proposed rule for the calendar year 2027 Medicare Physician Fee Schedule, covering physician payment rates and Quality Payment Program policies. The proposed rule affects Medicare Part B physician reimbursement and MIPS/APM requirements. Comments are typically due 60 days after Federal Register publication. While the PFS primarily governs Medicare fee-for-service payments, changes to payment methodologies and quality measures often influence Medicaid managed care rate-setting, value-based purchasing arrangements, and provider network strategies.

Legal·NY·78d ago

New York Ambulette Owners Indicted for Medicaid Transportation Fraud and Kickbacks

Two New York residents face federal charges in the Eastern District of New York for conspiracy to commit healthcare fraud related to Medicaid transportation services. The defendants allegedly paid kickbacks and submitted fraudulent claims to Medicaid and other government payors for ambulette services that were either not provided or included inflated mileage. The indictment was filed in federal court in Central Islip. The case demonstrates ongoing federal enforcement activity targeting non-emergency medical transportation fraud schemes.

Legal·80d ago

CMS and OIG Increase Payment Suspensions Against Home Health Agencies

The Centers for Medicare & Medicaid Services and HHS Office of Inspector General are escalating enforcement actions against home healthcare providers suspected of fraud, including payment suspensions, recoupments, and criminal prosecution. Both Medicare and Medicaid suspensions are being deployed more frequently against home health agencies. The article outlines procedural steps for providers facing suspension. This enforcement trend affects Medicaid managed care organizations that contract with home health agencies and rely on them for post-acute and long-term services and supports delivery.

Federal Policy·81d ago

Latham & Watkins Publishes July 2026 Drug Pricing Digest

Latham & Watkins LLP released its July 2026 Drug Pricing Digest, a recurring compilation tracking developments in the Medicaid Drug Rebate Program, 340B Program, Medicare drug pricing policy, and state pharmaceutical law. The digest appears to be a monthly or periodic roundup of regulatory and legislative activity affecting prescription drug pricing and market access. No specific policy changes or rulemakings are described in the brief excerpt provided. The digest serves as a reference tool for stakeholders monitoring evolving drug pricing regulations across federal programs including Medicaid.

Federal Policy·81d ago

CMS Requests Technical Input on PBM Compensation and Affiliate Practices

On June 18, 2026, CMS published a Request for Information seeking stakeholder input on pharmacy benefit manager services, compensation structures, affiliate relationships, and data collection practices. The RFI aims to gather technical details that will inform future rulemaking on PBM operations under Medicare Part D. Comments are due approximately 60 days from publication in the Federal Register. While focused on Part D, PBM transparency requirements and data standards developed through this process could eventually extend to Medicaid managed care pharmacy operations.

Legal·81d ago

HHS Section 504 Rule Mandates Accessible Medical Diagnostic Equipment for Medicaid-Funded Providers

The U.S. Department of Health and Human Services published a final rule in May 2024 revising Section 504 of the Rehabilitation Act of 1973, which is now in effect. The rule requires healthcare systems receiving federal financial assistance, including Medicaid funding, to ensure medical diagnostic equipment is accessible to patients with disabilities. All entities that accept Medicaid payments are subject to these nondiscrimination requirements. The regulation imposes new compliance obligations on providers and health systems that contract with Medicaid managed care organizations.

Legal·82d ago

CMS Revises Medicare Overpayment Rule on Identification Timeline and Investigation Requirements

CMS has revised regulations governing Medicare and Medicaid overpayments, modifying the definition of when an overpayment is considered "identified" and updating requirements for investigating related overpayments. The revisions affect how providers determine the 60-day deadline to report and return overpayments under the Affordable Care Act. While the changes offer some additional flexibility in compliance timelines, they reinforce the need for robust internal auditing and monitoring systems. Failure to comply with revised timelines and investigation standards may result in False Claims Act liability and other enforcement actions.

Federal Policy·85d ago

CMS Issues Claims Attachment Rule Establishing HIPAA Standards for Electronic Documentation

CMS finalized a claims attachment rule establishing HIPAA standards for electronic submission of supporting documentation with health care claims. The rule requires standardized submission using the Health Level 7 (HL7) framework and covers digital signature requirements. This applies to all entities submitting electronic claims under HIPAA transaction standards, including Medicaid managed care organizations. Implementation timelines and compliance deadlines are set by CMS for covered entities to transition to the standardized format.

Federal Policy·87d ago

CMS Proposes Rule Codifying Medicare Drug Price Negotiation Program

On June 16, 2026, CMS published a proposed rule to codify the Medicare Drug Price Negotiation Program established by the Inflation Reduction Act of 2022. The rule would formalize existing program guidance, introduce new policy proposals, and establish the regulatory framework for drug selection, negotiation, re-negotiation, compliance monitoring, and civil monetary penalties. The proposed rule affects Medicare Part D plans and manufacturers. Public comments on the proposed rule are due approximately 60 days after publication in the Federal Register.

Legal·NY·88d ago

HHS-OIG Denies Recertification for New York Medicaid Fraud Control Unit, Freezes $60 Million

The HHS Office of Inspector General denied recertification for New York's Medicaid Fraud Control Unit and froze $60 million in annual federal funds effective July 1, 2026. This action came one week after DOJ's National Health Care Fraud Takedown announced partnerships with all 50 state MFCUs. The denial represents an unprecedented enforcement step against a state fraud control unit that typically partners with federal authorities on Medicaid provider fraud investigations. For Medicaid managed care organizations in New York, this creates uncertainty around ongoing fraud investigations, referral processes, and coordination with state enforcement authorities on provider integrity matters.

Legal·90d ago

CMS Payment Suspensions for Fraud or Overpayment Trigger Compliance Requirements

CMS can temporarily suspend Medicare and Medicaid payments to providers when evidence of overpayment or suspected fraud exists. While suspensions are temporary, they create immediate financial pressure and can lead to exclusion if providers fail to achieve compliance. The suspension authority applies to both fee-for-service and managed care contexts when credible allegations of fraud arise. Providers facing suspension must respond quickly to CMS documentation requests and implement corrective action plans to avoid permanent exclusion from federal healthcare programs.

Legal·93d ago

DOJ, CMS, OIG Detail Heightened Health Care Fraud Enforcement at AHLA Annual Meeting

Federal enforcement officials from the Department of Justice, Centers for Medicare & Medicaid Services, and the HHS Office of Inspector General outlined intensified fraud and abuse enforcement initiatives at the American Health Law Association's Annual Meeting in New York on July 3, 2026. The agencies described their coordinated approach to health care fraud investigations and prosecutions affecting providers and health plans. The remarks signal continued aggressive enforcement activity through 2026 and beyond. Medicaid managed care organizations should expect heightened scrutiny of billing practices, network arrangements, and compliance programs as federal agencies expand investigative resources and coordination.

Legal·93d ago

DOJ Charges 455 Defendants in 2026 Health Care Fraud Takedown Targeting Medicaid

On June 23, 2026, the Department of Justice announced criminal charges against 455 defendants, including approximately 90 licensed medical professionals, connected to more than $6.5 billion in alleged false claims. DOJ characterized this as the largest coordinated health care fraud enforcement action in its history and emphasized a renewed focus on Medicaid fraud cases. The takedown included enforcement actions in Virginia and multiple other states. Charges took effect immediately upon announcement, with defendants facing federal prosecution.

Federal Policy·WA·95d ago

CMS Launches WISeR Gold Card Exemption Program July 6 in Washington State

CMS will launch the WISeR (Worthy of Individual Systematic Exemption and Review) gold-carding exemption program on July 6, 2026, in Washington state, with quarterly rollouts planned for five additional states. The program exempts certain high-performing providers from prior authorization requirements based on performance metrics. Medicaid managed care organizations operating in Washington and the subsequent rollout states will need to implement gold card criteria and modify prior authorization workflows. The initiative aims to reduce administrative burden for providers with strong approval track records while maintaining utilization management oversight for other providers.

Federal Policy·96d ago

Latham & Watkins Digest Tracks June 2026 Drug Pricing and Rebate Developments

Latham & Watkins LLP published its third June 2026 digest tracking developments in drug pricing policy, including the Medicaid Drug Rebate Program, 340B Program, Medicare reforms, and state-level legislative activity. The digest compiles recent regulatory actions, guidance, and policy changes affecting pharmaceutical pricing and market access. The publication serves as an ongoing reference for tracking federal and state drug pricing policy developments. This tracker does not report a single new event but aggregates multiple developments from the period.

Legal·100d ago

UPIC Audits Target Medicare and Medicaid Provider Billing Compliance

Unified Program Integrity Contractors (UPICs) are CMS-hired auditors that review healthcare provider medical and billing records to identify improper payments and pursue recoupments in Medicare and Medicaid programs. UPICs operate as part of CMS's broader program integrity enforcement infrastructure. The article provides a procedural overview for providers facing UPIC audits, covering response strategies and compliance steps. This guidance is relevant for any Medicaid managed care organization or provider subject to program integrity review.

Federal Policy·100d ago

CMS Prioritizes IRA Implementation and PBM Reform in Drug Pricing Agenda

The Trump administration has placed drug pricing at the top of its health policy agenda, with CMS focusing on implementing Inflation Reduction Act provisions and pursuing pharmacy benefit manager reforms. The agency is working on Medicare price negotiation, inflation rebates, and Part D redesign while exploring PBM transparency and reform measures. These initiatives affect how Medicaid managed care organizations negotiate drug prices, manage pharmacy benefits, and coordinate with Medicare for dual-eligible beneficiaries. The timeline for specific regulatory actions remains under development.

Get the daily briefing.