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Friday, September 4 · 30 stories
- Federal Policy
Medicare Pilot Expands GLP-1 Coverage for Weight Loss Through 2027
A new Medicare pilot program launched July 1, 2026, allows beneficiaries with Part D coverage to access GLP-1 weight loss drugs for $50 per month through December 2027. Eligibility includes patients with BMI 35 or above, or lower BMIs with heart failure, uncontrolled hypertension, chronic kidney disease, prediabetes, or cardiovascular disease. Previously, Medicare covered GLP-1s only for diabetes management, forcing patients to wait until conditions worsened to qualify. The pilot aims to test whether expanded access reduces hospitalizations and overall healthcare costs.
- State Policy · NC
North Carolina Budget Adds $160M for Childcare Subsidies, Pilots Family Childcare Home Supports
North Carolina's new state budget includes approximately $160 million in additional childcare subsidy funding, bringing annual subsidy spending above $650 million and establishing the state's first reimbursement floor tied to 2023 market rates. The budget also funds rural home-based childcare pilots, workforce academies, and a liability insurance study, as the state grapples with a dramatic decline in licensed family childcare homes — from 4,500 in 2005 to just over 1,000 today. Ninety-six percent of providers will see subsidy reimbursement increases. The North Carolina Task Force on Child Care and Early Education, which met on August 31, emphasized that family childcare homes provide essential capacity for infants, toddlers, nontraditional work schedules, and rural communities, but providers face financial barriers including health insurance costs, administrative burdens, and lack of retirement benefits that undermine program sustainability.
- Legal · ND
OIG Inspection Finds North Dakota Medicaid Fraud Control Unit in Compliance
The HHS Office of Inspector General completed its periodic inspection of the North Dakota Medicaid Fraud Control Unit in 2025, examining the unit's compliance with federal certification standards for investigating and prosecuting Medicaid provider fraud and patient abuse cases. The inspection covered staffing, case management, prosecution coordination, and reporting requirements. North Dakota's unit was found to meet federal requirements for continued federal financial participation at the 75 percent match rate. OIG conducts these inspections every three years for all state fraud control units as required by federal law.
- State Policy · AR
CMS Approves $149M Arkansas Medicaid Waiver for Rural Telehealth and Preventive Care
CMS approved a $149.3 million Arkansas Medicaid demonstration waiver to expand telehealth services and improve access to specialty care and preventive screenings in rural areas. The waiver allows Arkansas to use federal matching funds to support telehealth infrastructure, provider networks, and care coordination for Medicaid beneficiaries in underserved rural communities. The demonstration period begins immediately and runs through a specified end date. This matters for Arkansas Medicaid managed care plans and rural providers who will need to integrate new telehealth capabilities and expand specialty care networks under the waiver terms.
- State Policy · IN
CMS Approves $120 Million Indiana Medicaid Waiver for Maternal Health and Workforce Expansion
CMS approved Indiana's 1115 waiver amendment providing $120 million in federal funding to expand maternal and infant health services, increase primary care access, and grow the healthcare workforce. The waiver includes targeted services for pregnant individuals and infants, workforce recruitment and retention programs, and enhanced care coordination. Effective immediately, the waiver runs through the current demonstration period. This approval reflects CMS's continued support for state flexibility in addressing maternal health outcomes and provider shortages through Medicaid demonstration authority.
- Federal Policy · NY
CMS Awards New York $76 Million for Regional Health IT Modernization
CMS announced $76 million in federal funding to New York to strengthen regional healthcare coordination and modernize health information technology infrastructure. The funding supports interoperability improvements and care coordination initiatives across the state's Medicaid program. Implementation timelines and specific technology priorities were not detailed in the announcement. The investment targets infrastructure that underpins Medicaid managed care network integration and data exchange capabilities.
- Legal · OR
OIG Finds Health Share of Oregon Failed Federal Requirements in Prior Authorization Denials
The HHS Office of Inspector General found that Health Share of Oregon, a Medicaid coordinated care organization, did not always comply with federal and state requirements when denying prior authorization requests. The audit identified deficiencies in the CCO's denial processes, including inadequate documentation and failure to meet regulatory standards for timely and appropriate prior authorization determinations. Health Share of Oregon serves Medicaid beneficiaries in the Portland metro area under Oregon's 1115 waiver. The findings carry implications for federal compliance oversight of Medicaid managed care organizations' utilization management practices.
- Legal · KS
OIG Finds Kansas Failed to Enforce Mental Health Parity Rules for MCO Prior Authorization
The HHS Office of Inspector General determined that Kansas did not ensure its Medicaid managed care organizations complied with federal mental health and substance use disorder parity requirements related to prior authorization. The audit found Kansas MCOs applied more restrictive prior authorization requirements for behavioral health services than for medical/surgical services, violating parity rules. OIG recommended Kansas implement oversight mechanisms to ensure MCO compliance with parity requirements and recover inappropriate payments if applicable. This represents federal enforcement action against a state's failure to monitor MCO compliance with long-standing but frequently unenforced parity rules.
- Legal · NY
OIG Finds New York Failed to Enforce Mental Health Parity in Medicaid MCO Prior Authorization
The HHS Office of Inspector General determined that New York did not ensure selected Medicaid managed care organizations complied with mental health and substance use disorder parity requirements for prior authorization processes. The findings indicate state oversight gaps in enforcing the Mental Health Parity and Addiction Equity Act (MHPAEA) as it applies to Medicaid managed care. OIG identified instances where MCOs imposed more restrictive prior authorization requirements on behavioral health services compared to medical/surgical benefits. The report will likely prompt corrective action plans from New York and increased scrutiny of parity compliance in other states' Medicaid managed care programs.
- Legal · AZ
OIG Finds Arizona Failed to Monitor MCO Mental Health Parity Compliance on Prior Authorization
The HHS Office of Inspector General found that Arizona did not ensure its selected Medicaid managed care organizations complied with federal mental health and substance use disorder parity requirements related to prior authorization processes. The review identified gaps in state oversight of whether MCOs applied comparable authorization standards for behavioral health and medical/surgical benefits, as required under the Mental Health Parity and Addiction Equity Act. The report recommends Arizona strengthen monitoring and enforcement mechanisms to verify MCO compliance with parity requirements. This review follows increased federal scrutiny of parity compliance across states and managed care plans.
- Legal · CO
Colorado Sues Trump Administration Over Medicaid Gender-Affirming Care Funding Ban
Colorado Attorney General Phil Weiser filed a lawsuit Wednesday in U.S. District Court in Massachusetts challenging a Trump administration rule that prohibits states from using federal Medicaid funds for gender-affirming healthcare. The lawsuit, joined by other Democratic-led states, argues HHS lacks authority to categorically ban state coverage of this medical care. The challenge affects state Medicaid programs that currently cover gender-affirming services and could determine whether states retain flexibility to define medically necessary services under their state plans.
Thursday, September 3 · 11 stories
- Legal
CMS Orders Corrective Action Plan from Medicare Contractor Over AI Review Delays
CMS required Virtix Health, the contractor operating the WISeR Model in Washington, to submit a corrective action plan after failing to meet 72-hour turnaround requirements for prior authorization and prepayment determinations. The enforcement action follows findings that the company's AI-assisted review processes did not comply with statutory timeframes. While the WISeR Model applies to Medicare fee-for-service, the action signals CMS's expanding scrutiny of automated utilization management tools and could inform future oversight of similar technologies in managed care programs.
- Managed Care · FL
Florida Health Plan Highlights Operational Requirements for Self-Directed Care Programs
Independent Living Systems, a Florida-based health plan serving Medicaid long-term care enrollees, discussed the operational complexities of administering self-directed care when it transitioned to plan status in 2018. The plan required specialized administrative partnerships to support participant-directed services within Florida's Medicaid LTSS program. Self-directed care allows enrollees to manage their own services and supports, but requires health plans to build infrastructure for enrollment, budgeting, and compliance. The article addresses common misconceptions and operational realities for plans administering these programs.
- State Policy · KS
Kansas Advocacy Report Calls for Medicaid Rate Increase, Maternal Health Reforms
The United Methodist Health Ministry Fund released a report urging Kansas to raise Medicaid obstetric reimbursement rates for the first time in over 30 years and expand maternity care access in underserved areas. The report recommends increasing insurance coverage, expanding telehealth, creating regional care partnerships, and coordinating community-based providers to address workforce shortages and maternal mortality — which has doubled in 20 years and is 75% higher for Black women than white women. The assessment targets geographic and racial inequities affecting Medicaid beneficiaries and low-income mothers, who face higher mortality risk. Implementation would require state budget action and policy changes to sustain obstetric services in rural hospitals, many of which have closed maternity units in the past decade.
- State Policy · OK
Oklahoma Warns 250,000 Medicaid Enrollees of New Federal Work Requirements
The Oklahoma Health Care Authority has notified over 250,000 SoonerCare enrollees that new federal work requirements may affect their Medicaid eligibility. Yellow letters were mailed last week instructing recipients how to maintain coverage. The state agency is implementing the federal mandate, which would require certain adult Medicaid beneficiaries to meet work, training, or community engagement activities to remain eligible. Implementation timing and specific exemption categories were not detailed in the announcement.
- State Policy · IL
Illinois Hospitals Face Billions in Losses Under Federal Medicaid Financing Changes
A new study finds that Illinois hospitals stand to lose billions of dollars due to federal changes in Medicaid financing policy. The analysis projects significant financial strain on hospital systems statewide as reimbursement structures shift. The changes will particularly affect hospitals that rely heavily on Medicaid revenue, potentially threatening access to care in vulnerable communities. Hospital associations are evaluating options to offset the anticipated revenue losses through state policy adjustments or supplemental payment programs.
- Federal Policy
CMS Permanently Waives Home Address Reporting for Telehealth Providers with Group Practice Enrollment
CMS has made permanent an enrollment flexibility allowing providers who furnish telehealth services from home to avoid reporting home addresses on Medicare enrollment applications, provided they maintain a separate physical practice location associated with a Medicare Part B-enrolled group practice. Affected providers can enroll and bill from their physical practice location as if services were furnished in person. The policy takes effect immediately and applies to both new enrollments and existing providers. The change reduces administrative burden and privacy concerns for clinicians providing telehealth from home while maintaining program integrity through group practice oversight.
- State Policy · CT
Connecticut Lawmakers Threaten Subpoena Over Hospital's Gender Care Agreement with DOJ
Connecticut House Human Services Committee co-chairs Matt Lesser and Jillian Gilchrest are threatening to subpoena Connecticut Children's Medical Center to obtain details of the hospital's settlement with the U.S. Department of Justice regarding gender-affirming care for minors. The DOJ announced in August 2026 that Connecticut Children's agreed to stop providing gender-affirming care to minors, including hormones and puberty blockers, and pay a monetary penalty plus $500,000 in additional medical care. The lawmakers sent a letter requesting copies of the agreement and all correspondence between the hospital and DOJ, citing state law granting committee chairs subpoena power. Connecticut Children's agreed to meet with lawmakers next week and stated it did not turn over patient health information during the investigation or settlement process.
- State Policy · RI
Rhode Island Governor Pledges $16M Medicaid Primary Care Rate Increase in 2027 Budget
Rhode Island Governor Dan McKee announced plans to include $16 million in his next budget to increase Medicaid reimbursement rates for primary care providers. The commitment follows a yearlong review by the state's Office of the Health Insurance Commissioner examining primary care payment rates. The proposal would take effect with the fiscal year 2027 state budget if McKee is reelected. The rate increase responds to chronic concerns about Medicaid primary care access and provider participation driven by below-market fee schedules.
- State Policy · PA
Pennsylvania Labor Agency Launches Proactive Wage Compliance Reviews of Home Care Providers
Pennsylvania's Department of Labor and Industry announced September 2, 2026, that it will proactively investigate Minimum Wage Act violations across home care agencies statewide, rather than waiting for worker complaints. The initiative targets an industry where nearly 40% of the state's wage complaints originate, affecting an estimated 100,000 home care workers. Agencies received legal demands for wage and hour records starting Wednesday. The state will focus on unpaid overtime, travel time between clients, and improper sleep-time deductions — common violations in a sector heavily reliant on Medicaid reimbursement for personal care services.
