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Friday, October 2 · 48 stories
- Federal Policy
CMS Finalizes Major Updates to Medicare TAVR Coverage Rules
CMS issued a Decision Memorandum on September 10, 2026, finalizing a reconsideration of the National Coverage Determination for Transcatheter Aortic Valve Replacement, prompted by a request from device manufacturer Edwards Lifesciences. The updated NCD relaxes the 2019 rules by allowing asynchronous heart-team patient evaluations, eliminating the requirement for two operators from different specialties, replacing hospital-level volume requirements with operator-level thresholds (20 valve procedures annually, 15 of which must be TAVR), and ending coverage-with-evidence-development requirements for symptomatic severe aortic stenosis. CMS also created a new coverage pathway for asymptomatic severe aortic stenosis, limited to CMS-approved studies. Hospitals and physicians performing TAVR must comply with the revised conditions of Medicare payment, as noncompliance can trigger False Claims Act exposure.
- Industry
Hospital Revenue Cycle Leaders Flag 10 AI-Driven Payer Risks
In a Becker's Hospital Review roundup, revenue cycle executives from health systems including UC Davis Health, Harvard Medical Faculty Physicians, Rush University Medical Center, Carle Health, Lurie Children's Hospital, and Centerstone identify 10 top threats facing hospital billing operations. Leading concerns include payers using AI to review and deny claims faster than providers can respond, automation scaling existing workflow errors, governance gaps in AI-assisted coding creating compliance liability, silent "downcoding" that erodes revenue without appearing in denial reports, expanding prior authorization burdens, and organizational fragmentation that leaves no one accountable for end-to-end financial impact. The piece also highlights unmeasured "care abandonment" by patients unable to navigate administrative hurdles. No new regulation or enforcement action is reported; this is an industry survey of operational risks.
- Federal Policy
Analysis: Medicare Part D Plan Premiums Vary Widely for 2027
A new analysis of the 2027 Medicare Part D stand-alone prescription drug plan (PDP) market finds a modest reduction in the number of available plans alongside uneven premium changes. Many enrollees will see monthly premium increases of less than $10, but others face increases of $50 or more if they remain in their current plan rather than switching during open enrollment. The brief highlights that passive enrollees, those who don't actively shop plans each year, are most at risk of steep cost increases. This affects the millions of Medicare beneficiaries who rely on stand-alone PDPs for drug coverage, distinct from Medicare Advantage drug plans.
- Legal
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.
- Industry
AARP Foundation: Senior Poverty Rate Climbs for Fifth Year
An AARP Foundation analysis of 2025 Census Bureau data found poverty among adults 65 and older has risen for five consecutive years, reaching 15.4% in 2025, up from 9.4% in 2020. The analysis uses the Supplemental Poverty Measure, which factors in government benefits, taxes, and cost of living. Among adults 50 and older, 17.2 million lived in poverty in 2025; those 50-64 had the lowest rate at 12.1%, while women over 65 faced higher poverty (16.8%) than men (13.7%). The report highlights a broader trend of rising poverty across age groups since a 2020 low point.
- Federal Policy
CDC Proposal Would Cut Disability Questions From Health Survey
CDC has proposed a major redesign of its National Health Interview Survey, set to take effect in 2028, shifting from in-person interviews to a "sequential mixed-mode" approach with shorter, simplified questionnaires. Many detailed topics fielded annually would be dropped, including a question asking whether a physician diagnosed the respondent with an intellectual or developmental disability or autism; only "foundational measures" based on the Washington Group Short Set on functional status would remain. Disability advocates, including The Arc's CEO Katy Neas, warn the change could worsen undercounting of people with disabilities and disrupt longitudinal tracking of disability prevalence, health outcomes, and funding decisions. The proposal, dated Aug. 20, is open for public comment until Oct. 19.
- Industry
Insurers Trim 2027 Medicare Advantage Plans, Shift Toward Special Needs Plans
Becker's Hospital Review reports that Medicare Advantage insurers are cutting plan offerings in 28 states for 2027, with total plan counts dipping from 5,553 to about 5,532, even as national enrollment projections hold roughly flat at 34 million. Twelve insurers that sold MA plans in 2026, including several health system-owned plans and some Blue Cross Blue Shield affiliates, will exit the market entirely, while large national carriers like Centene, UnitedHealthcare, and Aetna are each leaving over 100 counties. Growth is concentrated in special needs plans, which will grow 9.4%, with some insurers limiting new dual-eligible enrollment to members already in the insurer's affiliated Medicaid plan. CMS raised 2027 MA payments by 2.48% (4.98% counting risk score trends), which insurers say is insufficient to offset rising medical costs, setting up a second consecutive year of enrollment upheaval ahead of the Oct. 15–Dec. 7 annual enrollment period.
- Industry
Rural Surgeon Shortages Drive Worse Patient Outcomes, Data Show
Becker's Hospital Review compiles data showing rural surgical workforce shortages are worsening patient outcomes. Nationally there are 59.2 surgeons per 100,000 people, with a projected shortage of nearly 28,000 surgeons by 2038, and 30% of counties have no identified surgeon. Rural Medicare beneficiaries face higher 30-day mortality, complications and readmissions after common surgeries, and death rates from emergency conditions like appendicitis and hernias are now 86% higher in rural areas than urban ones. Responses include federal rural health transformation funding, state-funded workforce grants such as UNC System's rural surgery partnership, and new accreditation pathways from the American College of Surgeons for rural cancer programs.
- Legal · AZ
Arizona AG Sues Express Scripts, Optum Over Opioid Role
Arizona Attorney General Kris Mayes filed a consumer fraud lawsuit Oct. 1 against pharmacy benefit managers Express Scripts and Optum, alleging their formulary and rebate practices fueled the state's opioid epidemic over more than two decades. The complaint alleges the PBMs gave OxyContin unrestricted preferred formulary status in exchange for confidential payments from Purdue Pharma, avoided prior authorization and step-therapy controls, distributed misleading materials downplaying addiction risk, and sold prescriber data for targeted opioid marketing. Filed under the Arizona Consumer Fraud Act, the suit seeks restitution, civil penalties, injunctive relief, disgorgement and corrective programs. It closely mirrors a similar Arkansas lawsuit filed against the same two PBMs in June 2024, part of a broader wave of state litigation scrutinizing PBM business practices.
- Federal Policy · SD
CMS Awards $7.2 Million for South Dakota Ambulance Telemedicine
CMS announced $7.2 million in federal funding to expand ambulance-based telemedicine and upgrade emergency communications infrastructure across South Dakota. The funding will support rural emergency medical services, including equipment for real-time video consultation between ambulance crews and physicians during transport. South Dakota officials and providers will implement the upgrades, which aim to improve emergency care access in rural and underserved areas of the state. The announcement did not specify an implementation timeline or the funding mechanism involved.
- Federal Policy
HHS Picks 8 Communities for $96M Homelessness, Addiction Program
HHS Secretary Robert F. Kennedy Jr. announced in Houston that eight communities have been selected to receive funding through the new STREETS program, administered by SAMHSA. The program will distribute $96 million over four years to help selected communities build coordinated systems of care for people experiencing homelessness who have serious mental illness, substance use disorders, or co-occurring disorders. The announcement names the funding recipients but does not detail specific program start dates or application requirements for future rounds.
- Industry · RI
Brown University Health Cuts Jobs Citing Medicaid-Driven Cost Pressures
Brown University Health, Rhode Island's largest hospital system, announced buyouts for up to 200 non-clinical supervisors and layoffs of an unspecified number of executives, effective the start of its new fiscal year. CEO John Fernandez cited rising pharmaceutical, labor and supply costs alongside growing uncompensated care, insurer denials and bad debt. The system attributes much of the pressure to federal policy changes restricting Medicaid eligibility and ending exchange subsidies, projecting $346 million in charity care, denials and debt costs for fiscal 2027, $71 million more than the prior year, and a $64 million deficit. Despite the cuts, the system plans $210 million in capital facility upgrades and a January merit increase, and will end employee health plan coverage of GLP-1 drugs for weight loss starting Jan. 1.
- Industry
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 · SC
OIG Finds SC Underreported $108.6M in Medicaid COVID FMAP Collections
HHS OIG found that South Carolina failed to report approximately $108.6 million of the federal share of Medicaid and CHIP collections subject to the temporary increased FMAP authorized during the COVID-19 public health emergency. The finding stems from an audit examining whether the state properly identified and returned collections tied to the enhanced federal match rate. The report affects South Carolina's Medicaid agency, which will likely need to refund the unreported federal share to CMS and correct its reporting processes. The audit underscores broader compliance risk for states that received the temporary FMAP bump and must accurately reconcile collections against the higher match rate.
- Industry · AZ
Aetna to Acquire Mercy Care Stakes From Ascension, CommonSpirit
CommonSpirit's Dignity Health and Ascension have each agreed to transfer their combined ownership stakes in Arizona's Mercy Care health plan to CVS Health subsidiary Aetna. CommonSpirit held a 49.75% stake in the plan as of mid-2026, and Ascension co-owns the remainder with Dignity Health. Aetna has run Mercy Care's daily operations and administrative services for more than 20 years, and the companies describe the ownership transfer as a natural evolution of that existing partnership. Mercy Care serves Medicaid and dual-eligible members through Arizona's Medicaid program and Medicare Special Needs Plans; the deal is expected to close in fiscal year 2027 pending regulatory review.
- Legal · WI
OIG Finds Wisconsin May Have Misclaimed $455M in School Medicaid Funds
The HHS Office of Inspector General reports that Wisconsin may have improperly claimed $455 million in federal Medicaid reimbursement for its school-based services program. The finding affects the state Medicaid agency and school districts that bill Medicaid for services delivered to eligible students, as OIG's audit identifies claims that did not meet federal reimbursement requirements. The report does not specify a comment deadline but signals likely recoupment action and corrective-action requirements from CMS. The audit underscores recurring compliance risk in state school-based Medicaid billing programs nationally.
- Legal
Oracle Health Breach Now Affects 29 Hospital Systems
Becker's Hospital Review reports that 29 hospitals and health systems have confirmed patient data was compromised in a 2025 breach of Oracle Health's legacy Cerner systems, with the intrusion dating back to at least Jan. 22, 2025. Affected organizations include Atrium Health, AdventHealth, Christus Health, Baptist Health South Florida, and LifeBridge Health, among others. Oracle Health reportedly asked healthcare organizations to delay patient notification while the investigation continued, and the vendor now faces legal action over the incident. Health systems are continuing to notify patients as the full scope of affected entities becomes clearer.
- Federal Policy
Explainer Chapter Covers Medicare Eligibility, Coverage, and Financing
A Health Policy 101 educational chapter provides a primer on Medicare, the federal health insurance program covering more than 68 million people age 65 and older or with long-term disabilities. It walks through eligibility rules, covered benefits, and program spending, and reviews the growing role of private Medicare Advantage plans in delivering benefits. The chapter also discusses financing challenges driven by rising health care costs and an aging population. No new policy action or data release is reported; this is background reference material rather than a report on a specific event.
- Industry · VT
Brattleboro Memorial Hospital Names Interim CEO Amid Budget Crisis
Brattleboro Memorial Hospital's board named David Sanville, a healthcare finance consultant and former Mt. Ascutney Hospital CFO, as interim CEO effective at the start of fiscal year 2027. He replaces co-CEOs Tony Blofson and Elizabeth McLarney, who led the hospital for a year following the unexplained departures of the prior president and CFO in late 2025. The hospital faces a forecast $7.1 million deficit for fiscal 2027, following an estimated $9.5 million shortfall in fiscal 2026, and Vermont's Green Mountain Care Board recently level-funded the facility's budget pending clarification of inconsistencies in its proposal. The hospital does not expect to break even until fiscal 2028 at the earliest.
- State Policy · TN
Tennessee Faces $220M SNAP Cost Shift Under Federal Law
New federal cost-sharing rules under the One Big Beautiful Bill Act could force Tennessee to cover an estimated $220 million in additional SNAP costs next year, according to state budget data and the Sycamore Institute. The law raises states' share of SNAP administrative costs from 50% to 75%, adding $58 million to Tennessee's Department of Human Services budget in fiscal year 2026, and requires states with payment error rates above 6% to begin covering a share of SNAP benefit costs starting October 2027. Tennessee's 2025 error rate was 9.44%, which would trigger a 10% benefit cost share worth an estimated $162-171 million if it doesn't improve. States can choose 2025 or 2026 error-rate data to calculate contributions, but 2026 figures won't be released until June 2027, leaving Tennessee's exact liability uncertain. The changes took effect Thursday and arrive alongside tightened SNAP work requirements that have already removed over 100,000 Tennesseans from the program.
