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Friday, October 2 · 48 stories
- Federal Policy
Georgetown CCF Submits Comments on Senate Finance RFI on Health Coverage
Georgetown University's Center for Children and Families (CCF) submitted comments responding to a Request for Information from Senate Finance Committee Ranking Member Ron Wyden on policy proposals to improve access, quality, and affordability of health coverage nationally. The RFI sought stakeholder input on a broad range of proposals affecting health coverage, including Medicaid and CHIP. CCF's submission reflects the organization's positions on how these proposals would affect children's and families' coverage. The specific policy recommendations and their implications for state Medicaid programs are detailed in CCF's full submission.
- Industry
BRG Study Finds 340B Drug Margin Hit $142 Billion in 2025
In its "6 study notes" roundup, Becker's Hospital Review reports on an October Berkeley Research Group study estimating patients and payers spent $244.3 billion on 340B drugs in 2025, more than double 2021's $108.4 billion. BRG calculates a "340B drug margin", the gap between covered entities' discounted acquisition cost and what patients and payers are later charged, at $142.2 billion in 2025, over double the 2021 figure. Commercial insurers bore 63% of that margin, Medicare 25%, and Medicaid managed care 7%, while Medicaid fee-for-service generates no margin since it reimburses at acquisition cost. BRG attributes growth to hospital acquisition of off-site clinics, expanded hospital participation, and a surge in contract pharmacies from roughly 1,300 in 2010 to about 35,000 today.
- State Policy · OR
Oregon Panel to Send Lawmakers Universal Health Plan by Dec. 1
A nine-member Universal Health Plan Governance Board, created by the Oregon legislature in 2023, will deliver a proposal to lawmakers by December 1 for a single-payer system covering medical, vision, dental, and mental health benefits for all residents starting in 2032, with no premiums, deductibles, or copayments. Lawmakers could vote on the plan in the 2027 session or send it to voters as a 2028 ballot measure. The plan would replace insurance premiums and out-of-pocket costs with new corporate and personal taxes funding a single payment pool for all providers, and would make Oregon the first state with single-payer coverage if adopted. Similar ambitions exist in California, New York, and Washington, but prior single-payer efforts in Vermont and ballot measures in Colorado, Oregon, and California have all failed amid industry opposition.
- State Policy · VA
Federal Funding Cuts End Virginia Medicaid Coverage for Legal Immigrants
In its morning headlines roundup, Virginia Mercury highlights a VPM report that federal funding cuts have ended Medicaid eligibility for thousands of legal immigrants in Virginia. The coverage losses stem from changes in federal funding tied to the Trump administration's policy actions, affecting legal immigrants who previously qualified for the program. The roundup also includes unrelated Virginia election and news items. No specific effective date or population count is detailed in the source material beyond the general claim of thousands losing access.
- Federal Policy · OH
Census Bureau Delays Poverty Data Amid Medicaid, SNAP Cuts
The Census Bureau has indefinitely delayed its American Community Survey, a key dataset tracking state and local poverty, income, insurance and housing trends, just as deep federal safety-net cuts take hold. The bureau attributes the delay to a new Commerce Department order banning "noise infusion," a privacy-protection technique, though some scientists quoted in Science magazine suspect political motives. Researchers say the gap leaves them unable to measure the state-level impact of the One Big Beautiful Bill Act's roughly $1 trillion in Medicaid cuts and $187 billion in SNAP cuts, plus the expiration of ACA subsidies that caused Ohio's Medicaid-adjacent marketplace enrollment to drop 32.4%, the largest decline of any state. No new release date has been set.
- Legal
DOJ Memo Prioritizes Healthcare Fraud in Corporate Investigations
An Oct. 1 memo from Assistant Attorney General Colin McDonald directs the Justice Department's National Fraud Enforcement Division to prioritize healthcare fraud, including controlled substance distribution and FDCA violations, as one of four focus areas for corporate investigations. Prosecutors must weigh 10 factors when deciding on charges or plea agreements, including corporate management's knowledge of schemes, efforts to conceal fraud from government auditors, and conduct causing substantial harm to taxpayer-funded programs. The division, formed in April from the former Criminal Division Health Care Fraud Unit, is using data analytics to accelerate new investigations and will develop whistleblower incentive programs, including for participants in misconduct. The policy also directs prosecutors to follow existing self-disclosure and cooperation credit guidance while avoiding overly broad enforcement.
- Legal · IA
Iowa Attorney Sentenced for Rolls Royce Medicaid Eligibility Fraud Scheme
A federal judge sentenced Iowa attorney Timothy Anderson to six months in prison, a $25,000 fine, and $184,274 in restitution to Iowa Medicaid after he pleaded guilty to making false statements in a healthcare matter. Anderson had helped an elderly couple try to shelter over $400,000 in assets to qualify for Medicaid-funded nursing home care by submitting a falsified vehicle valuation involving his inoperable 1961 Rolls Royce Phantom V. Iowa Medicaid rejected the application, triggering an FBI investigation that led to the criminal charge. The Iowa Supreme Court has also temporarily suspended Anderson's law license following his guilty plea.
- Managed Care · NC
NC's Four Medicaid MCOs Launch Joint Fraud Task Force
North Carolina's four Medicaid managed care organizations, AmeriHealth Caritas, Healthy Blue, UnitedHealthcare and Carolina Complete Health, formed a joint task force in August through the North Carolina Association of Health Plans to combat fraud, waste and abuse. The task force unites each plan's special investigative units and government relations staff so investigators can share billing data and coordinate on providers that contract across multiple MCOs. The effort emerged from a meeting with State Auditor Dave Boliek amid heightened federal and state scrutiny of Medicaid spending, including recent fraud cases involving a substance abuse treatment center and a nursing home. Organizers say applied behavioral analysis therapy billing is a top area of concern given rapidly rising spending.
- State Policy · MA
Commentary: MassHealth GLP-1 Coverage Cuts Shift Costs, Not Savings
In a commentary piece, a CPA and nurse argues that Massachusetts insurers' decisions to end GLP-1 coverage for obesity, including MassHealth's move affecting about 22,000 members and the Group Insurance Commission's similar cut for public employees, produce illusory savings. The author cites trial data showing patients regain weight and cardiometabolic gains reverse within a year of stopping treatment, and notes insurers like Point32Health project over $100 million in savings even as premiums rise 10.4 percent for 2027. The piece argues this amounts to cost-shifting onto future payers and patients rather than genuine cost reduction, disproportionately harming lower-income residents. The author calls for Massachusetts to negotiate drug prices, adopt evidence-based eligibility criteria, and require insurers to publicly report health and cost outcomes from coverage restrictions.
- State Policy · CO
Colorado Cuts Medicaid for 5,900 Legal Immigrants Under HR1
As of October 1, Colorado's Health First Colorado program terminated Medicaid eligibility for roughly 5,900 legal immigrants, including refugees, asylees, trafficking and domestic violence survivors, and people granted humanitarian parole or withholding of removal. The eligibility changes stem from the One Big Beautiful Bill Act (HR1), which restricted federal Medicaid eligibility for certain immigrant categories. The state's Department of Health Care Policy and Financing says it notified affected members via text and email starting in May and June, though advocacy groups like COLOR report confusion and inadequate communication to impacted communities. Exemptions remain for U.S. citizens, lawful permanent residents meeting requirements, certain Cuban/Haitian entrants, children under 19, and pregnant individuals. State officials anticipate increased uncompensated care costs for hospitals and clinics as affected individuals forgo care or pay out of pocket.
- Federal Policy
Refugees, Asylum Seekers Lose Medicaid Eligibility Under H.R. 1
Starting October 1, refugees and asylum seekers nationwide are losing access to Medicaid due to eligibility restrictions enacted in H.R. 1, the Trump administration's budget law passed by congressional Republicans in summer 2025. The change removes a previously available coverage pathway for these immigrant populations, affecting their ability to access health services through Medicaid. States and Medicaid managed care plans must now determine how to handle enrollees who lose eligibility under the new rules. The cutoff is effective immediately as of October 1, 2026.
- State Policy · NH
New Hampshire Delays Medicaid Premiums Pending Federal Approval
New Hampshire has not implemented its new Medicaid premium system, which was due to start July 1, because it still lacks required federal approval, according to a Department of Health and Human Services spokesperson. State officials have flagged since January that the premium structure may conflict with the federal cost-sharing program created by the One Big Beautiful Bill Act (H.R. 1), which caps enrollee charges at $35 per service and takes effect in October 2028. Under the state plan, premiums would range from $60 to $270 monthly based on household size and income, up to 255% of the federal poverty level. Democratic lawmakers are citing the unresolved federal conflict to push for scrapping the premium system entirely, while Gov. Kelly Ayotte's administration has defended it as necessary to sustain generous eligibility limits.
- Federal Policy · OR
Five Governors Press HHS to Delay Jan. 1 Medicaid Work Rules
Oregon Gov. Tina Kotek led governors from California, Maine, New York and Virginia in a letter urging HHS Secretary Robert F. Kennedy Jr. to delay the Jan. 1 effective date for new Medicaid work-requirement and eligibility rules stemming from the 2025 federal tax and spending law. The governors say final federal rules, issued six months after initial January guidance, contradicted that earlier guidance and changed the medical frailty definition, forcing states to rebuild eligibility systems, forms and verification processes with less than 100 days to spare. This is their second such request after a May 29 letter went unanswered by HHS. The governors cite CBO estimates that the new work-reporting requirements could leave 5 million people uninsured by 2034, with roughly half of coverage losses driven by paperwork and reporting errors rather than ineligibility.
- Legal · WA
Judge Lets Some Immigrants Keep Washington Medicaid Coverage
A federal provision in the 2025 tax and spending law stripped Medicaid eligibility for refugees, asylees, trafficking survivors, and other lawfully present immigrants nationwide, cutting roughly 10,000 people in Washington from coverage as of Thursday. A U.S. District Court judge in Seattle issued a preliminary ruling preserving coverage for an estimated 800 of those immigrants who receive Supplemental Security Income, finding federal officials improperly tried to override existing eligibility rules; the government may appeal. State officials separately updated immigration records to save coverage for about 3,000 more people, reducing original loss projections from 14,000. Washington's governor has issued an executive order to track coverage losses and explore state funding options, while advocates push for state dollars to cover the gap.
Thursday, October 1 · 46 stories
- Industry
Aledade Promotes ACO Model to Boost Primary Care Coordination
In a sponsored Becker's Hospital Review piece, Aledade argues that strengthening primary care as a health system's coordinating hub improves outcomes and financial sustainability. The piece cites research showing Medicare patients with limited primary care access face higher rates of emergency surgery, postoperative complications, and 30-day readmissions. It contends health systems often struggle with fragmented EHRs and delayed claims data that undermine timely care coordination, and promotes Aledade's accountable care organization model as a way to give clinicians operational support without replacing existing infrastructure. The piece is industry marketing content rather than a report of new policy or regulatory action.
- Industry
Health Systems Build Digital-First Primary Care Teams Alongside Clinics
Becker's Hospital Review reports that Cleveland Clinic, Inova Health System and MCR Health are redesigning primary care delivery to treat digital engagement as a parallel "second clinic" alongside traditional in-person visits. Cleveland Clinic Florida is building dedicated teams of medical assistants, nurses, pharmacists and advanced practice providers to manage a 153% surge in patient portal messaging since 2020, separate from scheduled office visits. Inova is restructuring scheduling and access pathways around patient convenience rather than traditional clinic hours, while MCR Health, a federally qualified health center, is emphasizing mobile services, community partnerships and outreach to overcome transportation and trust barriers. The shift reflects a broader industry move toward team-based, longitudinal care that is not tied to a single clinician, location or visit type.
- Industry
Hospital Leaders Detail Tactics to Cut Observation-Status Denials
In a Becker's Healthcare webinar sponsored by CorroHealth, five hospital and health system leaders discussed strategies for reducing revenue loss tied to observation-versus-inpatient status decisions. Panelists from Bozeman Health, Premier Health, Jackson Memorial Hospital, Children's Hospital of Philadelphia, and CorroHealth described rising payer denial rates, some markets now exceeding 30%, up from under 17% in 2020, often tracing back to the initial status call at admission. Tactics discussed include embedding observation liaisons in emergency departments, daily case rounds within 24 hours of admission, cross-functional teams spanning the revenue cycle, and change management to drive clinician buy-in. The panel emphasized that technology alone cannot fix denial trends without organizational alignment and provider-driven, regulation-consistent status strategies.
- Federal Policy
CMS Offers Hospices Three-Month Grace Period on Addendum Rule
Hospices are now required to give every patient an addendum to the election statement explaining what is and isn't covered under the Medicare Hospice Benefit, a requirement that took effect October 1, 2026 under the FY2027 hospice payment rule. Previously, hospices only had to provide the addendum upon request. CMS announced it will exercise enforcement discretion through December 31, 2026, during which Medicare Administrative Contractors will not deny claims solely for a missing or incomplete addendum, instead focusing on provider education. After that date, hospices that fail to comply face claim denials and increased regulatory scrutiny. Advocacy group NPHI has raised concerns that the mandate creates undue administrative burden with limited patient benefit.
- Industry
Analysis Shows MA Insurers Cutting Benefits Despite 2027 PR Claims
Major Medicare Advantage insurers issued press releases Thursday touting their 2027 plans as preserving core benefits, but a Leerink Partners analysis of CMS Medicare Plan Finder data found widespread cuts to dental allowances and Part B premium givebacks. UnitedHealthcare saw dental cuts affecting nearly 70% of members and increased cost-sharing; Humana cut Part B givebacks for 62% of members while modestly raising dental allowances; Centene, CVS/Aetna, Elevance and Clover Health also reduced benefits, with Clover's cuts described as the most pervasive, including a $1,144 increase to its maximum out-of-pocket limit. The cuts come amid a broader industry pullback driven by elevated senior care costs and insurer complaints about reimbursement, with insurers projecting MA enrollment will fall 6% to 34 million in 2027, a projection CMS disputes. Medicare open enrollment runs Oct. 15 to Dec. 7.
- Federal Policy
States Face Higher SNAP Costs as New Cost-Share Rule Starts
Beginning Thursday, states must cover 75% of SNAP administrative costs, up from the historical 50-50 federal-state split, as federal funding for those operational costs is cut in half. The change stems from the One Big Beautiful Bill Act, enacted in July 2025, and is projected to reduce federal SNAP spending by $16.9 billion over five years. Advocacy groups estimate individual states could need $3 million to $670 million to fully offset the loss, with California, New York, Pennsylvania, Texas and Michigan hit hardest. A second change looms in October 2027, when states with SNAP payment error rates at or above 6% may have to start paying a share of food benefit costs themselves, a shift analysts warn could push some states toward program cuts or withdrawal.
