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Wednesday, August 19 · 20 stories
- Federal Policy
CMS Proposes Electronic Prior Authorization Incentives in Medicare Fee Schedule
CMS released a proposed rule on July 14, 2026, to incentivize electronic prior authorization through the Medicare Physician Fee Schedule for CY 2027. The proposal targets Medicare Ambulatory Specialty Models and the Merit-based Incentive Payment System, building on existing prior authorization requirements for health plans. The rule focuses on provider-side incentives rather than plan mandates. Comment periods and effective dates were not specified in the excerpt.
- Federal Policy
Rural Hospital CEO Defends $50B Federal Transformation Program Amid Implementation Concerns
A rural hospital CEO is defending the $50 billion Rural Health Transformation Program included in HR-1 against skepticism from other rural leaders. Critics have questioned whether the federal funding will reach intended provider recipients and raised concerns about potential state-level redirection of funds before they reach hospitals. The debate reflects ongoing uncertainty about the program's design and implementation mechanisms, though specific details about fund distribution timelines, eligibility criteria, or Medicaid program integration are not provided in the available content.
- Industry
PBMs Agree to Display TrumpRx Cash Prices in Real-Time Benefit Tools
The Pharmaceutical Care Management Association announced that its members will share TrumpRx's cash drug prices through real-time benefit tools and cost transparency platforms. The commitment follows coordination with the Trump administration and CMS Administrator Mehmet Oz. PCMA members include CarelonRx, CVS Health, and Cigna. The announcement was made in an August 13 news release.
- Industry
Bankruptcy Attorney Discusses Medicaid Cuts and Hospital Closures on Restructuring Podcast
A Sheppard Mullin podcast episode features Dentons partner Samuel Maizel discussing healthcare bankruptcies, including Medicare and Medicaid provider agreement disputes and hospital and skilled nursing facility closures. The discussion covers how healthcare Chapter 11 cases differ from other bankruptcies due to provider agreements and regulatory constraints. The episode addresses financial pressures including Medicaid cuts and private equity involvement in distressed healthcare assets. No specific policy changes or case details are provided.
- Industry
Providence Health Plan to Exit All Lines of Business After Medicare Advantage Sale Collapses
Providence Health Plan will shut down operations entirely after a proposed sale of its Medicare Advantage business to an unnamed national insurer fell through. The regional health plan had been pursuing the transaction to sustain its MA lines, but the deal collapsed "despite significant effort on all sides," according to a Providence spokesperson. The closure will affect all plan lines, not just Medicare Advantage. The timeline for wind-down and member transitions was not disclosed in available reporting.
- Legal
Federal Judge Vacates Trump Administration Restrictions on ACA Gender-Affirming Care
A federal judge has struck down Trump administration restrictions on gender-affirming care under the Affordable Care Act while upholding other ACA policy changes. The ruling restores certain protections for gender-affirming care that had been rolled back by the administration. The decision affects coverage requirements for Medicaid managed care organizations and state agencies operating under ACA-aligned nondiscrimination standards. The ruling takes effect immediately, though appeals are likely.
- Federal Policy · CT
Connecticut Providers Prepare for 110K HUSKY Disenrollments Under Federal Eligibility Changes
Federal Medicaid eligibility changes take effect in January 2027 and could result in approximately 110,000 Connecticut residents losing HUSKY coverage. Connecticut health care providers, including hospitals and clinics, are actively preparing for the expected enrollment losses. The changes stem from federal legislation that modifies Medicaid eligibility criteria. Providers are most concerned about continuity of care disruptions and potential increases in uncompensated care as beneficiaries lose coverage.
- Legal · MA
Massachusetts Medicaid Transportation Vendor Contests Fraud Charges, Cites Broker Recordkeeping Failures
A defendant charged with defrauding MassHealth's non-emergency medical transportation (NEMT) program is contesting the allegations, attributing billing discrepancies to inadequate recordkeeping by brokers and vendors managing scheduling, patient records, and billing for Medicaid-covered rides. The case highlights operational weaknesses in the NEMT broker infrastructure that supports ride services for MassHealth members. The defense strategy suggests systemic documentation problems may complicate fraud prosecution and raise questions about broker oversight and accountability in Massachusetts' NEMT program.
- Industry
VNS Health Virtual Caregiver Coaching Program Cuts Hospitalizations for Heart Failure Patients
VNS Health's Center for Home Care Policy & Research reports that its virtual caregiver coaching program for informal caregivers of heart failure patients reduced hospitalizations and improved quality of life. The program helps caregivers manage stress and improve self-care for the patients they support. The initiative demonstrates potential cost savings through reduced acute care utilization. The finding is relevant for Medicaid programs that cover substantial home and community-based services and long-term care populations where caregiver support affects institutional utilization.
- Federal Policy
CMS Launches QualTech Event to Identify AI and Digital Quality Technology Solutions
CMS announced QualTech, a new event seeking technology proposals from U.S.-based teams, academic institutions, nonprofits, private companies, and industry associations. Proposals must address one of four priority areas: AI to protect patients and strengthen quality, AI to increase Medicare annual wellness visits, next-generation digital quality measure calculators, or a national quality hospital dashboard. Applications are due September 4, 2026, with finalists presenting at CMS headquarters to agency leadership. CMS may pursue continued engagement with selected organizations, including potential pilots, demonstrations, or roles in the 2027 CMS Quality Conference.
- Federal Policy · WI
Wisconsin Governor Candidate Criticized Over 2025 Medicaid Cut Vote
Healthcare advocates are targeting Wisconsin gubernatorial candidate Tom Tiffany over his June 2025 vote for HR 1, federal legislation that included Medicaid cuts. Tiffany, a Republican U.S. Representative, was among all House Republicans who supported the bill, which passed with no Democratic votes. The vote has become a focal point in criticism from healthcare advocates as Tiffany campaigns for governor. The article does not specify what Medicaid cuts were included in HR 1 or their implementation timeline.
- Federal Policy
Georgetown Analysis Shows Medicaid Covers 43% of Children Under Age 3
Georgetown University's Center for Children and Families analyzed 2015-2024 Census data on health coverage for infants and toddlers under age 3. The analysis uses American Community Survey data to track coverage trends for this population, which has historically high Medicaid enrollment rates. The brief provides state-level and national estimates of coverage patterns over the decade. The findings offer a baseline for assessing coverage changes as states continue to complete Medicaid redeterminations following the end of continuous enrollment.
- Industry
CommonSpirit Sets Five Benchmarks for Payer Prior Authorization Reform Progress
CommonSpirit Health has established five targets to evaluate health plan progress on prior authorization reform following 2024 federal interoperability and prior authorization rules. The health system announced it has reached a milestone with Humana on these metrics. The 2024 regulation required insurers to begin reporting prior authorization data, but CommonSpirit argues the aggregated data lacks operational context for providers. The benchmarks aim to measure meaningful improvement in prior authorization processes beyond raw data reporting.
- Industry
Home Care Providers Adapt Operations for Higher-Acuity Post-Acute Discharges
Home care providers are receiving more referrals of clients with higher acuity needs following shorter rehabilitation stays. Growth-focused companies are responding by ensuring adequate caregiver capacity, developing systems to match clients with available payer sources, and building data-driven relationships with referral partners. The shift reflects broader post-acute care trends affecting discharge planning and community-based service capacity. Providers must adjust staffing models and payer mix strategies to serve this population sustainably.
- Industry · VT
Vermont Approves Modest Premium Increases for 2027 Marketplace Plans
The Green Mountain Care Board approved modest rate increases for Vermont's 2027 health insurance marketplace plans. The approved rates aim to balance keeping premiums affordable for consumers while ensuring insurers can cover healthcare costs in Vermont. The increases will take effect for the 2027 plan year. The rate decisions affect individual and small group marketplace plans sold through Vermont Health Connect, impacting consumers purchasing coverage and insurers operating in the state's exchange market.
- Federal Policy
HHS Awards $96.7 Million in SAMHSA Behavioral Health Grants
The Department of Health and Human Services announced $96.7 million in grants through the Substance Abuse and Mental Health Services Administration for behavioral health services. The grants fund programs for individuals with serious mental illness experiencing homelessness, suicide prevention and early intervention, substance use disorder treatment, training and technical assistance, peer support, and disaster-related emotional support. The funding supports service delivery infrastructure that Medicaid managed care organizations and behavioral health providers rely on to serve beneficiaries with complex needs.
Tuesday, August 18 · 13 stories
- Industry
Municipalities Cut Public Employee Health Benefits Amid Rising Insurance Costs
Municipalities across the United States are reducing health insurance benefits for government workers as costs continue to rise, according to a STAT report. Local governments are implementing higher deductibles, increased premium contributions, and narrower provider networks to manage budget pressures. The changes affect millions of public sector employees including teachers, police officers, and municipal staff. These benefit reductions reflect broader healthcare cost inflation impacting public sector budgets, though the specific impact on Medicaid programs or managed care operations is not detailed in the coverage.
- Industry
Epic Launches Real-Time Prior Authorization API at Four Health Systems
Epic Systems has launched an instant prior authorization application programming interface at Ochsner Health, Froedtert ThedaCare Health, Denver Health, and Summit Health. The API enables real-time preapproval decisions for medical items and services at the point of care. Epic states the technology should reduce prior authorization processing time by eliminating manual submission and review delays. The deployment affects workflow for providers treating Medicaid managed care enrollees at these four systems, though the article does not specify which payers are participating in the integration.
- Federal Policy
Former CMS Administrator Calls for Healthcare Data Interoperability After Kill the Clipboard Anniversary
Former CMS Administrator Seema Verma published commentary calling for improved healthcare data connectivity, marking one year since CMS launched its "Kill the Clipboard" initiative. The initiative aims to reduce administrative burden by enabling electronic data exchange across healthcare systems. Verma argues that while healthcare has been digitized, meaningful interoperability remains incomplete. For Medicaid programs, improved data exchange could streamline eligibility verification, care coordination across MCOs and providers, and integration of clinical and administrative data systems.
- State Policy · MO
Missouri Behavioral Health Healthcare Homes Address Serious Mental Illness Through Integrated Care Model
Missouri has implemented Behavioral Health Healthcare Homes to integrate physical and behavioral health services for Medicaid enrollees with serious mental illness. The program aims to reduce the lifespan gap—people with serious mental illness die on average 15-20 years earlier than the general population—by coordinating care and managing chronic conditions. The model targets improved health outcomes while controlling costs through enhanced care coordination and provider partnerships. Missouri's approach offers a replicable framework for other states addressing behavioral health integration under Medicaid.
