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Thursday, October 1 · 46 stories
- Legal · IA
Former Public Defender Sentenced for Medicaid Fraud Scheme
A former public defender and Iowa-licensed attorney, Cassi Wigington, has been sentenced to five months in prison for healthcare fraud. A federal grand jury in Nebraska charged her in June after prosecutors alleged that, beginning in 2012, she fraudulently sold medical equipment including custom-made breast prosthetic devices to cancer patients and billed Medicaid for the scheme. The case was prosecuted in federal court, and the sentencing closes out the criminal proceedings against her.
- State Policy · ND
North Dakota Shifts Rural Health Grant Management to Anchor Partners
North Dakota's Health and Human Services Department is shifting from directly managing all 500-700 grants under its Rural Health Transformation Program funding to using outside "anchor partners," in-state organizations that will handle grant applications and individual grant management while HHS oversees at a higher level. North Dakota had been the only state managing every grant itself; three anchor partners are being used, including the University of North Dakota Center for Rural Health, with two more still to be finalized. The change comes as more than $161 million of the state's $199 million award remains unawarded ahead of an October 30 deadline, prompting lawmaker concerns about transparency, selection criteria, and further delays. CMS is expected to announce North Dakota's second-year funding amount, estimated near $200 million, in October.
- Industry · MA
Out-of-State Chains' Nursing Home Buyouts Tied to Quality Declines in Mass.
Citing a Boston Globe Spotlight investigation, Skilled Nursing News reports that out-of-state chains have rapidly acquired Massachusetts nursing homes since 2020, with nine New York and New Jersey-based chains growing their holdings from 12 facilities in 2019 to 61 by 2025, about one-fifth of the state's nursing homes. Eight of the nine chains saw average federal star ratings decline after acquisition, driven by cost-cutting that slashed nursing hours while shifting payments to owner-affiliated companies. RegalCare, led by CEO Eli Mirlis, is highlighted as a case study: facilities fell from 5-star to 1-star ratings within three years as rent and related-party payments rose even as nursing spending fell. The Globe found Massachusetts regulators have not denied an acquisition application or revoked a license in seven years, though a recent law now lets them weigh an operator's out-of-state record.
- Industry · NJ
NJ Behavioral Health Nonprofit CBH Care Files Chapter 11 Bankruptcy
Hackensack, New Jersey-based Comprehensive Behavioral Health Care Inc. (CBH Care) has filed for Chapter 11 bankruptcy protection, citing a prolonged landlord dispute over its main facility that began with HVAC failures in 2018 and escalated to an eviction motion in June 2026. The nonprofit, which derives about 45% of revenue from government grants and a substantial portion of the remainder from Medicaid reimbursements, says litigation costs and building habitability problems strained its already thin margins. CBH Care operates 20 locations across Northern New Jersey offering outpatient mental health, crisis care, residential and supported living programs, employing roughly 350 staff. Its five-week cash budget shows about $2.7 million in revenue and disbursements during the bankruptcy process.
- State Policy · WV
West Virginia Awards $8 Million in Rural Health Transformation Grants
Gov. Patrick Morrisey announced more than $8 million in awards from West Virginia's federal Rural Health Transformation Program funds. Community Care of West Virginia, a federally qualified health center, will receive $1.1 million for telehealth upgrades, a mobile healthcare unit, workforce training, and an apprenticeship program. The Minnie Hamilton Health Center will get $4 million for a mobile healthcare unit, drone supply delivery, and AI-supported clinical documentation, while $3.2 million will fund AI ambient listening technology at five hospitals, a telehealth hub for rural skilled nursing residents, and staffing support through Vandalia Health. West Virginia received $199 million total under the program, created by the One Big Beautiful Bill Act, for 2026.
- Industry · TX
Baylor Scott & White's Health Plan Exits Medicaid, Individual Markets
Baylor Scott & White Health reported operating income of $1.5 billion, an 8.3% margin, for the fiscal year ending June 30, 2026, down from $1.7 billion (10% margin) the prior year, despite a 6.6% rise in operating revenue. The Dallas-based system's health plan arm exited the Medicaid and individual insurance markets during the period, according to financial statements published Sept. 30. The system did not detail the exact states or enrollment affected in the summary provided. The move reflects broader insurer pullback from Medicaid managed care amid redetermination-driven enrollment losses and tightening margins.
- State Policy · IN
Indiana Provider Warns Proposed ABA Limits Threaten Autism Care
In an Indiana Capital Chronicle commentary, an autism care provider argues that Indiana FSSA's proposed Medicaid policy changes to applied behavior analysis (ABA) therapy would harm children with autism. The author says FSSA proposed a lifetime cap on comprehensive ABA treatment hours and new supervision requirements last spring, following a 2024 federal review that flagged alleged improper payments to Indiana autism therapy providers. The author contends rising Medicaid spending reflects increased, earlier diagnoses rather than fraud, and warns the changes could cut off medically necessary care for roughly 40,000 Hoosier children on Medicaid who rely on ABA. The piece urges policymakers to pursue genuine fraud enforcement without restricting access to individualized, evidence-based treatment.
- Federal Policy
Trump Public Charge Rule Revival Sparks Multistate Lawsuit
The Trump administration revived a first-term policy letting immigration agents deny green cards or visas to applicants whose families use public benefits, effective September 18. The rule broadens eligibility factors beyond the Clinton-era standard and could count benefits used by family members, including children's Medicaid and SNAP enrollment, against immigrant applicants. Twenty-one Democratic-led states, D.C., and several major cities have sued, citing the administration's own estimates of "catastrophic" impacts on immigrant families. Advocates expect a chilling effect causing eligible U.S.-citizen children in immigrant households to be disenrolled from Medicaid and SNAP out of fear, even though most legal immigrants already don't qualify for these programs.
- Legal · FL
Florida House Democrats Ask IRS to Probe Hope Florida Funds
Florida House Democratic Leader Fentrice Driskell and Rep. Kelly Skidmore sent a letter asking the IRS to investigate whether the Hope Florida Foundation and two affiliated nonprofits properly reported, and owe taxes on, $10 million that originated from a Medicaid managed care overbilling settlement. A Leon County grand jury found the funds were misappropriated and routed through two 501(c)(4) organizations to a political committee and ultimately the Republican Party of Florida to oppose a 2024 marijuana legalization ballot measure, though it found insufficient evidence to bring criminal charges. Democrats argue the transfers violated nonprofit political-activity restrictions and are asking the IRS to assess back taxes and penalties. The request follows the August leak of the grand jury's 19-page report and seeks federal accountability after state prosecutors declined to pursue charges.
- Legal · MA
RegalCare Nursing Home Execs Pay $1M Over Billing Claims
Massachusetts nursing home operator RegalCare Management Group, along with owner Eliyahu Mirlis and executive Hector Caraballo, agreed to pay $1 million to resolve allegations that they submitted false claims to Medicare and Medicaid for medically unnecessary rehabilitation therapy. Federal prosecutors said the conduct occurred between 2018 and 2023. The settlement resolves the billing allegations against the company and the two named executives.
- State Policy · WA
14,000 Washington Immigrants Lose Medicaid Eligibility Oct. 1
Roughly 14,000 Washington state residents, refugees, humanitarian asylees, trafficking survivors, and other lawfully present immigrants without green cards, lose Apple Health (Medicaid) eligibility starting Oct. 1, under the federal law known as HR1. Washington State Health Care Authority Director Ryan Moran warns the change will strain hospitals as affected individuals lose coverage and increasingly rely on emergency departments for care. The same law also bars these immigrants from buying subsidized marketplace plans in 2027, and unsubsidized plans are expected to be unaffordable, meaning most will likely become uninsured. KUOW/Northwest News Network reports the state expects broader downstream effects on the health care system beyond the individuals directly losing coverage.
- State Policy · NC
North Carolina to Cut Full Medicaid Coverage for Thousands Oct. 1
New federal rules take effect Oct. 1 that end full Medicaid coverage for thousands of North Carolina beneficiaries, shifting many to more limited coverage instead of comprehensive benefits. Affected enrollees include certain populations whose eligibility category or verification status no longer qualifies them for full-scope coverage under the new requirements. Those impacted may still receive some services but will lose comprehensive coverage unless they take specific action after receiving a notice from the state. North Carolina Medicaid is directing beneficiaries to respond promptly to any notices to avoid gaps or reductions in coverage.
- Legal · MA
Autism Provider Sues Massachusetts to Block MassHealth Recoupment
An autism therapy provider affiliated with LEARN Behavioral has filed suit against 10 Massachusetts public officials and entities to stop MassHealth's effort to recoup millions of dollars from autism therapy providers for services delivered in 2024. Providers have publicly criticized the recoupment effort as flawed since the spring, and the lawsuit seeks to halt the clawback before it proceeds further. The case centers on disputes over billing or payment methodology used to calculate the recoupment amounts. The outcome could affect how MassHealth and other state Medicaid programs pursue retrospective recoupments against behavioral health providers.
- Federal Policy
HHS Clarifies Use of SUD Records for Medicaid Work Exemptions
The HHS Office for Civil Rights issued guidance clarifying how 42 CFR Part 2 confidentiality rules for substance use disorder patient records interact with Medicaid community engagement requirements. The notice explains when state Medicaid agencies may use Part 2 records to verify whether an applicant or beneficiary qualifies as a "specified excluded individual" exempt from the work requirements established by the July 2025 reconciliation law. It includes examples illustrating permitted circumstances for this verification use. The guidance helps states implement exemption determinations without running afoul of federal SUD confidentiality protections.
- Federal Policy
Seven Healthcare Laws, Including Medicaid Eligibility Limits, Start Oct. 1
Becker's Hospital Review rounds up seven federal and state healthcare laws taking effect October 1, including a federal provision narrowing Medicaid eligibility for many lawfully present noncitizens under Section 71109 of HR 1, which limits federal eligibility for certain immigrant groups. The roundup also covers Connecticut's certificate-of-need overhaul and Maryland's new hospital staffing framework among other state-specific changes. These laws affect state Medicaid agencies administering eligibility determinations, health plans serving affected populations, and hospitals in Connecticut and Maryland. The changes take effect October 1, 2026.
- State Policy · VT
Vermont Begins Phasing In Medicaid Eligibility Changes for 50,000
Vermont's Department of Vermont Health Access starts implementing federal Medicaid changes on Oct. 1, with a second phase beginning January 2027, stemming from the federal budget bill passed in July 2025. The first phase restricts eligibility for certain immigrants, cutting off most adult refugees and asylum seekers (an estimated 235 people), while exempting lawful permanent residents, pregnant people, and those under 21. The January phase will require roughly 49,000 Vermonters ages 19-64 to prove monthly earnings of at least $580 or document 80 hours per month of work, education, or community service, and will shorten eligibility renewal from annual to every six months, with broad exemptions for pregnant people, Indigenous people, medically frail individuals, disabled veterans, caregivers, and others. State officials say the goal is to maximize coverage retention amid heavy new paperwork burdens, and the state has added 12 staff and is pulling existing wage and benefits data to reduce self-reporting needs.
- State Policy · NE
Nebraska's First Work Requirement Data Show Coverage Losses
Nebraska, the first state to implement a Medicaid work reporting requirement, presented initial implementation data at a recent Medicaid Advisory Committee meeting. The data cover the first few months after the state began applying new work-reporting rules to new applicants, and show coverage losses attributed to administrative red tape rather than ineligibility. Beneficiaries affected include new Medicaid applicants subject to the reporting rules. The findings arrive as the work reporting requirement is set to become mandatory nationally, making Nebraska an early test case for how implementation affects enrollment.
- State Policy · MD
Maryland to Drop 4,500 Immigrants From Medicaid Under H.R. 1
New federal immigration-status restrictions under the One Big Beautiful Bill Act take effect Thursday, disqualifying an estimated 4,500 Maryland Medicaid enrollees, including refugees, asylum seekers, humanitarian parolees and trafficking victims. Green-card holders, Cuban and Haitian immigrants, and Compact of Free Association migrants remain eligible, but other noncitizens lose coverage immediately, threatening continuity of care for conditions like cancer and diabetes. Advocacy group We Are CASA warns affected residents have few alternatives, since community clinics offer limited sliding-scale services and marketplace subsidies for these populations will also end in January 2027. The same effective date triggers a shift in SNAP administrative cost-sharing that could cost Maryland up to $57 million, compounding fiscal pressure on state safety-net programs.
- State Policy · RI
Rhode Island Ends Medicaid GLP-1 Weight-Loss Coverage, Cuts Noncitizen Eligibility
Rhode Island Medicaid implemented five changes effective Oct. 1, the start of the federal fiscal year. Under the federal H.R. 1 law, asylees, refugees, parolees, and trafficking victims lose Medicaid eligibility unless they qualify through another status; the state estimates fewer than 3,500 noncitizens will be affected, though green card holders, Compact of Free Association migrants, and lawfully residing children and pregnant/postpartum women retain coverage. Separately, driven by the state budget rather than federal law, Rhode Island Medicaid will stop covering GLP-1 drugs like Wegovy and Zepbound when prescribed for weight loss, while continuing coverage for diabetes indications. The state projects the GLP-1 cut will save $6.3 million in general revenue and $20.3 million in combined state-federal funding; managed care plans were directed to review affected patients' treatment plans before the cutoff. Rhode Island is at least the seventh state in 2026 to drop GLP-1 obesity coverage.
- State Policy · ME
Maine Cuts Medicaid Coverage for Over 1,000 Immigrants Oct. 1
More than 1,000 immigrants in Maine lost MaineCare coverage starting October 1 under eligibility changes from the 2025 federal budget law (H.R. 1), which excludes refugees, asylum seekers, trafficking and abuse victims, and noncitizen veterans from Medicaid. Children under 21, pregnant people, and green card holders are unaffected. Maine DHHS has notified affected households since June, and state officials say many losing coverage are high-needs individuals with disproportionate use of home and community-based services and high rates of serious mental illness. Unlike California, New York, and Pennsylvania, Maine has no state-funded backstop program to cover the gap, though a $250 million legislative proposal to offset federal cuts failed to pass last session.
