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Friday, September 11 · 19 stories
- Industry
NASHP Releases Hospital Cost Tool to Calculate Commercial Payment Breakeven Rates
The National Academy for State Health Policy (NASHP) has released a hospital cost tool that allows state payers to calculate commercial payment breakeven rates. The tool helps states and other payers analyze hospital pricing by determining the minimum commercial rates needed to cover costs when considering Medicare and Medicaid payments. This analysis is relevant for states evaluating hospital payment adequacy and negotiating commercial rates, which indirectly affects Medicaid programs through cross-subsidization dynamics and hospital financial viability. The tool is available now for state use.
- State Policy
States Begin Outreach to Medicaid Enrollees on Work Reporting Requirements
States are sending initial notices to Medicaid expansion adults about work reporting requirements scheduled to take effect in the coming months. The outreach includes targeted communications to current enrollees and new applicants explaining compliance obligations. States are simultaneously updating eligibility systems and building websites to support implementation. This represents the operational rollout phase following federal approval of work requirement waivers.
- Legal
Second Circuit Eases Pleading Standards for Reverse False Claims Act Cases
The U.S. Court of Appeals for the Second Circuit ruled that False Claims Act relators can satisfy Federal Rule of Civil Procedure 9(b) pleading requirements without identifying every false claim in an alleged fraudulent scheme. The decision in United States ex rel. Gallian v. AmerisourceBergen also left unresolved whether Rule 9(b)'s heightened pleading standards apply at all to reverse False Claims Act claims, which involve defendants who improperly retain government overpayments rather than submitting false claims for payment. The ruling applies to cases filed in the Second Circuit (Connecticut, New York, Vermont) and may influence how FCA cases proceed in other jurisdictions.
- Federal Policy
Georgetown CCF Comments on CMS Proposed Provider Tax Hold Harmless Rule
The Georgetown University Center for Children and Families submitted comments to CMS on a proposed rule that would amend the indirect hold harmless threshold for health care-related taxes. Provider taxes are a major financing mechanism states use to draw down federal Medicaid matching funds, and changes to hold harmless provisions affect how states structure these tax arrangements. The proposed rule impacts state Medicaid financing strategy and federal matching fund availability. Comments are due as part of the federal rulemaking process.
- Federal Policy
CMS Allows Tiered Medical Frailty Determinations for Medicaid Work Requirement Exemptions
CMS has issued new rules permitting states to use tiered systems when determining medical frailty exemptions from Medicaid work requirements. The guidance affects states with approved work requirement waivers and changes how beneficiaries qualify for exemptions based on health status. The rules take effect immediately for states implementing or operating work programs. Patient advocates warn the tiered approach could create administrative barriers that result in coverage loss for medically complex beneficiaries who struggle to navigate multi-level documentation requirements.
- State Policy · NY
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.
- Industry
Foley Partner to Speak on Medicare and Medicaid Administrative Enforcement Trends
Foley & Lardner partner Judy Waltz will present on Medicare and Medicaid administrative enforcement trends at the California Society for Healthcare Attorneys Fall Seminar. The session will address emerging enforcement patterns affecting healthcare providers and plans. No specific date or enforcement details are provided in the announcement.
- Industry · FL
Florida ACA Insurers Propose Premium Increases Up to 39% for 2027
Twelve insurers participating in Florida's ACA marketplace have filed proposed premium increases for 2027, ranging from 3.87% to 39.14%, with AmeriHealth Caritas Florida requesting the highest increase. The Florida Office of Insurance Regulation will review and approve final rates before open enrollment begins November 1, 2026. Florida leads the nation in marketplace enrollment but saw 442,785 residents lose coverage in 2026 after enhanced premium tax credits expired.
- State Policy · VA
Virginia Replaces SNAP EBT Cards with Chip Technology to Prevent Benefit Theft
Virginia has begun distributing chip-enabled EBT cards to approximately 749,000 SNAP recipients to reduce benefit theft. Governor Abigail Spanberger announced the rollout Thursday, with new cards featuring chip-and-tap technology replacing traditional magnetic stripe cards. The enhanced security measure addresses growing concerns about skimming and fraud that drain food assistance benefits before families can use them. While SNAP is distinct from Medicaid, states often manage both programs through integrated eligibility systems and coordinated benefit delivery infrastructure.
- State Policy · WA
Washington Approves 22% ACA Exchange Rate Increase for 2027
Washington's Insurance Commissioner approved a 22.2% average rate increase for health plans sold through the state's ACA exchange, effective January 1, 2027, affecting approximately 250,000 enrollees. The increase follows a 21% hike in 2026 and stems from rising healthcare costs, increased service utilization, and adverse selection after federal tax credits expired, causing healthier enrollees to drop coverage. Open enrollment begins November 1, 2026. The rate changes primarily affect individuals purchasing coverage outside employer-sponsored insurance and Medicaid, including self-employed individuals, early retirees, and small businesses under 50 employees.
- Federal Policy
GOP Convention Highlights Tax Law Cutting Medicaid, Safety Net Programs
Republican Congressional candidates at the 2026 GOP midterm convention promoted the One Big Beautiful Bill Act, a tax cut and spending package that included deep cuts to Medicaid and food assistance programs. The law, passed by Congress last year with all Democrats voting against it, provided tax deductions on tips and overtime while cutting safety net programs. North Carolina Republican candidate Laurie Buckhout and other GOP candidates used the convention to defend the law's tax cuts for corporations and wealthy individuals against Democratic criticism of its Medicaid reductions.
- Federal Policy · WI
Trump Administration Proposes Redirecting Federal Childcare Subsidies to Stay-at-Home Parents
The Trump administration is proposing to redirect federal childcare subsidies currently supporting working parents to subsidize stay-at-home parents instead. The policy would affect families in Wisconsin and other states where one in four childcare providers already report likely closure following the expiration of pandemic-era stabilization funding. The proposal comes amid broader Trump administration cuts to food assistance, Medicaid, and Head Start, as well as loosened federal safety standards and increased staff ratios for childcare centers. The shift would reduce available childcare subsidies for working parents at a time when 68% of mothers with children under 6 are employed and states like Wisconsin provide minimal state funding beyond federal match requirements.
- State Policy · ME
Maine DHHS Holds Hearing on Stricter Medicaid Provider Oversight Amid Privacy Concerns
Maine's Department of Health and Human Services held a public hearing on September 10, 2026, to discuss proposed stricter oversight of MaineCare (Medicaid) providers. More than a dozen legislators and members of the public testified in support of enhanced oversight. Providers and advocates acknowledged the need to address intentional wrongdoing but raised concerns about patient privacy implications under the proposed measures. The hearing reflects ongoing debate about balancing program integrity with privacy protections in Maine's Medicaid program.
- Legal · NY
Brooklyn Home Health Owner Sentenced to 76 Months for $64M Medicaid Fraud Scheme
A Brooklyn federal court sentenced Zakia Khan, owner of adult day and home health companies, to 76 months in prison for orchestrating a multiyear Medicaid fraud and illegal kickback scheme. Khan pleaded guilty in 2025 to conspiring to defraud Medicaid and pay healthcare kickbacks, fraudulently billing the program approximately $64 million. The sentence was handed down Wednesday, September 9, 2026. This case underscores heightened federal enforcement against Medicaid fraud in home health and adult day services, particularly schemes involving fiscal intermediaries and kickback arrangements.
- State Policy · TX
Texas HHSC Requests Funding to Retain 600 Eligibility Workers Amid Application Backlog
Texas Health and Human Services has asked the state Legislature for funding to convert over 600 temporary eligibility worker positions to permanent roles as backlogs in Medicaid and SNAP applications continue to grow. The request addresses operational capacity constraints affecting timely eligibility determinations for both programs. If approved, the funding would stabilize the state's eligibility workforce to process pending applications. The timing and outcome of the legislative appropriation request will directly affect Texas' ability to meet federal timeliness requirements for Medicaid enrollment.
Thursday, September 10 · 23 stories
- Industry
Novartis Investor Calls for Board Shake-Up After Trial Failures Tank Shares
Artisan Partners, a major Novartis shareholder, is demanding board changes and improved acquisition oversight after the drugmaker's shares fell to record lows following two late-stage trial failures. The setbacks include a failed muscle-wasting disorder drug from Novartis's $12 billion Avidity acquisition and disappointing heart drug pelacarsen results. The investor criticized successive chairmen for poor deal oversight. Separately, CMS Administrator Mehmet Oz says the Trump administration is pursuing additional voluntary drug pricing deals with pharmaceutical companies beyond the two dozen agreements already announced.
- Industry
Half of Hospitals Comply with Federal Price Transparency Rules, Report Finds
Patient Rights Advocate reported that 49.4% of U.S. hospitals are in full compliance with federal price transparency requirements as of September 2026, representing the highest compliance rate since the rule took effect. The report marks the eighth assessment by the nonprofit monitoring hospital adherence to CMS price disclosure requirements. While compliance has improved incrementally, over half of hospitals remain noncompliant with federal mandates to publish machine-readable files of negotiated rates with commercial payers and cash prices.
- Industry
Hospitals and Health Systems Cut Jobs Amid Financial Strain in 2026
Multiple hospitals and health systems are reducing workforces in 2026, citing lower reimbursement rates, rising labor and supply costs, and operational realignment needs. The layoffs are part of broader financial stabilization efforts as organizations respond to ongoing margin pressures. Timing and scale of specific reductions vary by organization. These workforce reductions reflect persistent financial challenges across the hospital sector that affect provider capacity and network stability.
- Industry
Commentary Proposes Applying Pharmaceutical Sales Tactics to Medicaid Work Requirements and Enrollment
An opinion piece in MedCity News suggests that health equity advocates adopt pharmaceutical sales strategies to help Medicaid beneficiaries navigate work requirements, access exemptions, and enroll in health programs. The article argues these tactics could increase referrals to evidence-based interventions and improve enrollment in programs designed to reduce health disparities. No specific policy change or implementation timeline is described. The piece appears to be commentary on operational approaches rather than a report of concrete program or policy developments.
- Federal Policy · VT
CMS Awards $11.7 Million to Expand Rural Vermont Nursing Home Access and Workforce
CMS announced $11.7 million in federal funding to expand access, improve facilities, and strengthen workforce capacity in nursing homes and long-term care facilities across rural Vermont. The funding targets facility infrastructure improvements, workforce recruitment and retention, and expanded service capacity in underserved rural areas. The initiative is effective immediately as part of broader CMS efforts to address rural long-term care access gaps. This matters for Vermont Medicaid agencies and LTSS providers because it represents direct federal investment in nursing home infrastructure and staffing in a state where Medicaid finances the majority of nursing home care.