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Thursday, September 24 · 28 stories
- State Policy · SD
CMS Awards South Dakota $13 Million for Mobile Crisis Response and Behavioral Health Expansion
CMS awarded South Dakota $13 million to expand behavioral health services and establish a statewide 24/7 mobile crisis response service. The funding will support crisis intervention teams, workforce development, and infrastructure to improve access to behavioral health care across the state. Implementation timing was not specified in the announcement. The investment addresses South Dakota's behavioral health access gaps and aligns with federal priorities to expand crisis services as alternatives to emergency department utilization.
- Legal · MO
Missouri Medicaid Enrollee Sues Over Trump Administration Work Requirement Exemption Rule
A Missouri Medicaid enrollee has filed a lawsuit challenging a Trump administration rule governing work requirement exemptions, alleging procedural failures resulted in coverage loss. The enrollee, Emily Byrd of Kansas City, lost Medicaid coverage twice due to what the complaint describes as duplicate letters, late notices, and inconsistent information from the Missouri Department of Social Services despite submitting requested documentation. The lawsuit targets federal rules on exemption processes tied to Medicaid work requirements. The case adds to ongoing litigation over state work requirement programs and their administrative burden on beneficiaries.
- Federal Policy
OIG Finds CMS Medical Loss Ratio Data Validation Process for Medicaid MCOs Has Gaps
The HHS Office of Inspector General found that CMS's process for verifying the accuracy of medical loss ratio data submitted by states for Medicaid managed care organizations has limitations that may affect oversight. The report identifies weaknesses in how CMS validates state-reported MLR data used to determine whether MCOs meet federal standards requiring at least 85% of capitation payments go toward medical care and quality improvement. OIG's findings affect CMS's ability to ensure compliance with MLR requirements and identify MCOs that may owe remittances to states. The report matters for state Medicaid agencies responsible for collecting and reporting MLR data and for managed care plans subject to MLR requirements and potential remittance obligations.
- Federal Policy
Federal Rules Expected to Cut Medicaid Provider Payments by $50 Billion Across 36 States
A peer-reviewed Health Affairs analysis estimates that new federal rules will force 36 states to reduce annual Medicaid payments to doctors and hospitals by more than $50 billion in total. The payment cuts could reduce the number of providers willing to participate in Medicaid. The analysis warns of significant implications for provider network adequacy and beneficiary access to care across affected states.
- Industry
Health System CEOs Cite Medicaid Funding Cuts as Top 2027 Priority
Health system CEOs report Medicaid funding reductions as a leading concern heading into 2027, alongside affordability pressures, workforce shortages, and care delivery transformation. The executives describe balancing operational fundamentals with strategic innovation as they plan for multiple simultaneous challenges. The article does not specify which states are implementing cuts, when reductions take effect, or the scale of anticipated funding impacts. For health systems with significant Medicaid patient volume, funding uncertainty affects budget planning, service line decisions, and payer contracting strategies.
- State Policy · NC
UNC Health Pardee Opens Adolescent Behavioral Health Inpatient Unit in Hendersonville
UNC Health Pardee has opened an inpatient adolescent behavioral health center in Hendersonville, North Carolina, serving teens in Henderson and surrounding counties experiencing mental health crises. The new facility addresses a regional gap in youth psychiatric services. The opening is relevant to North Carolina Medicaid given that Medicaid covers approximately half of all children in the state and is a major payer for behavioral health services, including inpatient psychiatric care for eligible adolescents.
- Industry · NC
North Carolina Treasurer Calls for Scrutiny of Atrium-WakeMed Combination
North Carolina Treasurer Brad Briner is urging state and federal regulators to scrutinize the proposed combination of WakeMed Health & Hospitals and Atrium Health, arguing the deal could reduce competition and raise healthcare costs. The Wake County Board of Commissioners voted 5-2 on September 21, 2026, to approve the proposed combination. The merger would unite two major North Carolina health systems operating in separate geographic markets. For Medicaid managed care organizations, hospital system consolidation can affect network adequacy, contract negotiations, and provider rate leverage in counties where state Medicaid contracts require adequate provider networks.
- State Policy · RI
Rhode Island Outlines Rural Health Projects Under $156M Federal Award
Rhode Island is developing plans for its $156.17 million allocation from a nationwide rural healthcare funding program enacted in July 2026. The state is working to finalize project details ahead of an October federal deadline. The funding is part of a $50 billion national initiative targeting rural health infrastructure and services. Rhode Island Medicaid agencies and providers serving rural populations should monitor how these dollars will be deployed and whether Medicaid-funded services or facilities are included in the state's implementation plan.
- State Policy · VT
Vermont FQHC Opens Three 340B Pharmacies Amid Statewide Closures
North Star Health, a Federally Qualified Health Center, opened pharmacies in Springfield and Londonderry, Vermont, and Charlestown, New Hampshire, in September 2026, leveraging 340B drug pricing to charge patients less than commercial pharmacies. Vermont lost 28 pharmacies between 2019 and 2024, leaving pharmacy deserts in Windsor and Rutland counties where North Star operates. The Springfield pharmacy began operations in November 2025 for out-of-pocket and commercial patients and now contracts with Medicare and Medicaid. The 340B discount allows North Star to offset losses from low primary care and behavioral health reimbursement, according to CEO Josh Dufresne.
- Federal Policy · ID
Idaho Task Force Convenes to Oversee $186 Million Rural Health Transformation Grant Distribution
Idaho's Rural Health Transformation Program Implementation Task Force held its first meeting September 23, 2026, to oversee distribution of $186 million in federal rural health grants awarded under the nationwide $50 billion Rural Health Transformation Program enacted through the One Big Beautiful Bill Act. The state received over 250 applications totaling more than $300 million for a $97 million provider infrastructure opportunity and faces an October 30 deadline to award all first-year funding. Idaho received less than the anticipated $200 million due to scoring criteria that disadvantaged states with low rural population density and low provider density, though the state scored highly on alignment with administration priorities including school fitness programs and SNAP restrictions.
- Legal
DOJ Revises False Claims Act Manual to Clarify Enforcement Standards
The Department of Justice updated its False Claims Act manual on September 18, 2026, reinstating and expanding a 2017 policy that subregulatory guidance cannot impose legal obligations beyond those established by statute or regulation. The revision aims to promote fairness and effective enforcement in fraud cases. The change affects how DOJ evaluates and pursues False Claims Act cases, including those involving Medicaid providers and health plans. The updated standards took effect immediately upon publication.
- State Policy · IN
Indiana FSSA Issues RFP for Second Short-Term Residential Facility for Disabled Adults
The Indiana Family and Social Services Administration issued a request for proposals for a provider to operate a 10-20 bed short-term residential facility for intellectually disabled adults with severe behavioral, psychiatric, or medical needs. The facility would replace a co-ed facility that closed in 2024 and address a service gap, particularly for women, as Indiana's only existing comprehensive rehabilitative management needs facility serves men only. The current per diem rate for such facilities is $703. Disability advocates have raised concerns that the new facility, combined with recent changes to Medicaid waiver assessments that have resulted in higher denial rates, could signal a shift toward institutionalization rather than community-based care.
- Federal Policy
CMS Administrator Oz Announces AI Fraud Detection Priority at Oracle Summit
CMS Administrator Mehmet Oz, speaking at the Oracle Health and Life Sciences Summit, identified AI-driven fraud detection as a top agency priority, drawing parallels to banking sector tools that pushed fraudulent activity into healthcare. The announcement signals CMS intent to deploy advanced detection technology across its programs. Timing for implementation was not specified. For Medicaid state agencies and managed care plans, this represents a coming shift in program integrity oversight and potential new reporting or compliance requirements once CMS operationalizes the approach.
- State Policy · NC
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.
- State Policy · KY
Kentucky Planned Parenthood Vows to Continue Operations After Medicaid Termination
Planned Parenthood announced it will maintain operations in Kentucky following termination from the state's Medicaid program. The organization stated it remains committed to serving patients in Kentucky despite the ban. The termination affects Medicaid beneficiaries' ability to receive reimbursed services at Planned Parenthood locations. This development follows broader state efforts to exclude certain family planning providers from Medicaid networks, requiring affected beneficiaries to seek covered services from alternative Medicaid-enrolled providers.
Wednesday, September 23 · 26 stories
- Industry
Off-Label GLP-1 Prescribing Rose 15-Fold From 2021 to 2025, Study Finds
A study published in Obesity analyzed medical records from over 92 million U.S. adults and found that off-label use of GLP-1 medications — prescribing to patients without documented obesity or diabetes — increased 15-fold between 2021 and 2025. The research documents a surge in prescribing outside FDA-approved indications during a period of intense commercial and clinical interest in GLP-1s for weight management. For Medicaid programs, rising off-label use raises questions about pharmacy benefit management, prior authorization protocols, and whether state fee-for-service or managed care plans are covering GLP-1s for conditions not meeting medical necessity criteria tied to approved diagnoses.
- Industry
Becker's Analysis Examines Health System Preparedness for Cell and Gene Therapy Scale-Up
In a commentary piece, Becker's Hospital Review examines operational challenges health systems face as the cell and gene therapy pipeline expands beyond rare disease applications into broader patient populations. With more than 35 FDA-approved cell and gene therapies now on the market and additional approvals expected, the article explores infrastructure, workflow, and care delivery model changes required to administer these treatments at scale. The piece is oriented toward hospital systems and does not address Medicaid-specific coverage, reimbursement, or managed care contract implications for these therapies. While Medicaid programs and managed care organizations will eventually confront CGT coverage and payment policy questions as utilization grows, this particular analysis focuses on provider delivery system readiness without Medicaid program context.
- State Policy · TN
Tennessee Hospital to Resume Labor and Delivery Services in Spring 2027
Henry County Hospital in Paris, Tennessee will restore maternity services beginning spring 2027, according to a September 22 announcement from West Tennessee Healthcare. The hospital has recruited an additional physician to its women's health team to support the resumption of deliveries. The restoration addresses a gap in local access to obstetric care in the region. For Medicaid agencies and managed care plans serving pregnant beneficiaries in rural Tennessee, this represents restoration of a delivery site that affects network adequacy and access to maternity benefits in Henry County.
- Federal Policy
GAO Finds State Coordination Gaps in VR and Medicaid HCBS Employment Services
In a September 2026 report, GAO examined how vocational rehabilitation (VR) and Medicaid home- and community-based services (HCBS) programs fund employment services for individuals with intellectual or developmental disabilities in Georgia, Pennsylvania, and Washington. Employment service providers reported administrative burden and service gaps when navigating two separate state agencies, including confusion over when VR closures must occur before Medicaid HCBS employment services can begin. States typically fund services sequentially — VR first, then Medicaid HCBS — rather than braiding multiple funding streams simultaneously. Federal agencies issued joint guidance in 2022 encouraging coordination strategies, but provider-reported challenges persist.
- Industry
KFF Survey Finds Health Care Costs Drive Care Delays and Medication Rationing Among Women
KFF's 2026 Women's Health Survey found that health care costs remain a major barrier for women ages 18–64, resulting in delayed care, medication rationing, and reductions in spending on basic necessities. The nationally representative survey, which included both women and men, documented the financial burden health care expenses place on women specifically. While the survey findings address broader health system affordability challenges, Medicaid managed care organizations may see implications for their predominantly female enrollee populations, particularly regarding access barriers and cost-related care avoidance patterns.