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Saturday, August 15 · 6 stories
- Managed Care
Utah Mindfulness Therapy for Opioid Misuse Shows Cost Savings in Economic Analysis
A new economic analysis of a University of Utah mindfulness-based treatment for opioid misuse found potential savings of hundreds of thousands of dollars per patient when accounting for healthcare, criminal justice, and lost productivity costs. The study builds on earlier research demonstrating the therapy's clinical effectiveness in reducing opioid misuse. The analysis did not specify implementation timelines or whether the intervention is currently covered by Medicaid in any state.
- Industry
Dartmouth Publishes First Clinical Trial Results for Mental Health AI Chatbot
Dartmouth's Center for Technology and Behavioral Health published the first peer-reviewed clinical trial demonstrating effectiveness of Therabot, a generative AI mental health chatbot. The trial showed measurable clinical outcomes for users receiving AI-delivered mental health interventions. The research marks a significant development in digital behavioral health tools that could eventually serve Medicaid populations, though no Medicaid deployment or coverage decisions are reported. Results published in August 2026.
- State Policy · VT
Vermont Regulators Question Brattleboro Memorial Hospital Financial Turnaround Plan
Vermont's Green Mountain Care Board on Friday expressed concerns about financial mismanagement at Brattleboro Memorial Hospital while evaluating the facility's financial recovery strategy. Board members cited evidence of operational and fiscal problems at the community hospital. The session comes as the hospital works to stabilize its finances amid regulatory scrutiny. The outcome affects network adequacy and access to care for Medicaid managed care enrollees in southeastern Vermont, where Brattleboro Memorial serves as a key safety-net provider.
- Legal
DOJ Fraud Division Targets Home Health and Hospice with Data-Driven Enforcement
The Department of Justice Fraud Division identified home health and hospice as top enforcement priorities in a Thursday memorandum, signaling intensified scrutiny of these sectors. The agency plans to deploy advanced data analysis techniques to detect fraud schemes and increase staffing for healthcare fraud investigations. The directive takes effect immediately as DOJ resource allocation shifts toward these provider types. This matters for Medicaid managed care plans and state agencies because home- and community-based services, including home health and hospice, represent significant portions of LTSS spending, and heightened federal fraud enforcement will likely require enhanced provider credentialing, claims auditing, and program integrity protocols.
- State Policy · NM
New Mexico Approves $40M for Rural Behavioral Health Services Restoration
A New Mexico state committee approved over $40 million in funding plans to restore behavioral health services in rural areas on Friday, August 14, 2026. The funds target rebuilding behavioral health infrastructure across multiple rural regions of the state. The approval comes as part of broader state efforts to restore the behavioral health delivery system. The decision directly affects Medicaid beneficiaries in rural New Mexico who rely on state-funded behavioral health services, as well as providers and managed care plans serving those populations.
- State Policy · GA
Georgia Seeks Federal Funding as Rule Changes Expected to Boost Partial Expansion Enrollment
Georgia's Board of Community Health announced Thursday that new federal Medicaid rules are projected to increase enrollment in the state's partial expansion program by approximately 100,000 people, prompting state officials to request additional federal funding from the Trump administration. The enrollment growth stems from federal regulatory changes whose specific provisions were not detailed in the announcement. Georgia operates a partial Medicaid expansion with work requirements and limited income eligibility, making it uniquely vulnerable to federal rule modifications that could expand the eligible population beyond what the state initially budgeted for.
Friday, August 14 · 14 stories
- Legal
Patient Advocacy Group Sues AMA Over CPT Code Copyright
PatientRightsAdvocate.org has filed a lawsuit challenging the American Medical Association's copyright of Current Procedural Terminology (CPT) codes. The suit argues that because federal law requires use of CPT codes for billing Medicare and Medicaid, the codes should be publicly available rather than copyrighted. The lawsuit does not specify when it was filed or what relief is sought. The outcome could affect provider billing practices and access to coding information across Medicare and Medicaid programs.
- Industry
57 Hospitals Close Departments or End Services Amid Financial, Staffing Pressures
Becker's Hospital Review reports that 57 hospitals have closed medical departments or ended services since January 1, 2026, citing financial pressures, shifts toward more in-demand services, and staffing shortages. The closures span multiple facilities nationwide, including Henderson Hospital in Nevada. The scope and timing of these operational changes reflect broader challenges in hospital sustainability and service line management across the healthcare industry.
- Legal
Fifth Circuit Invalidates No Surprises Act Benchmark Calculation Methods
The Fifth Circuit Court of Appeals ruled Tuesday that insurers cannot include ghost rates or exclude bonus payments when calculating the qualifying payment amount (QPA) under the No Surprises Act. The QPA serves as the default benchmark in independent dispute resolution for out-of-network emergency and air ambulance claims. The decision takes effect immediately and will increase reimbursement amounts paid to out-of-network providers. For Medicaid managed care plans that also operate commercial business, this ruling affects how their commercial lines calculate out-of-network payments, though the No Surprises Act does not apply directly to Medicaid.
- Federal Policy
37 States Face Cuts to Hospital State Directed Payments Under 2025 Reconciliation Law
At least 37 states operate Medicaid state directed payment (SDP) arrangements for hospital services that exceed new federal limits established by the 2025 reconciliation law. These limits, when fully implemented, will require states to reduce federal spending on hospital SDPs that currently surpass statutory caps. The analysis estimates the scope of current federal spending that will be affected as states come into compliance with the new restrictions. Hospital SDPs, which allow states to direct managed care plans to make supplemental payments to hospitals, have grown significantly in recent years and represent a major revenue source for safety-net hospitals.
- Legal
Hospice Disenrollment Affects 1 in 16 Patients Who Improve
Approximately 6% of hospice patients are discharged from hospice care when their condition improves or stabilizes, losing eligibility under Medicare's requirement that patients have a life expectancy of six months or less. These disenrollments affect patients and families who must navigate care transitions after receiving terminal diagnoses. The practice reflects Medicare hospice benefit certification requirements that physicians must recertify terminal prognosis at specific intervals. This matters for Medicaid beneficiaries eligible for hospice through their state programs, as Medicaid hospice benefits typically mirror Medicare eligibility standards, and disenrollment can disrupt continuity of care for dually eligible individuals.
- Industry
Aveanna Plans Home Health and Hospice M&A After Hitting Payer Strategy Goals
Aveanna Healthcare reported achieving its preferred payer strategy goals ahead of schedule and announced plans to pursue additional acquisitions in home health and hospice, its fastest-growing segment. The company cited improved federal government affairs and payer contracting results as key drivers for expanding in this service line. Aveanna updated its home health and hospice organic growth projections from 5-7% based on these developments. The company's focus on preferred payer arrangements and acquisition activity reflects broader industry consolidation in post-acute care.
- Industry
Providence Reports 0.8% Q2 Operating Margin as Health Plan Wind-Down Continues
Providence reported a $64 million operating income (0.8% margin) for the quarter ended June 30, 2026, compared to $24 million (0.3%) in the prior-year period. The year-over-year results reflect discontinued-operations accounting related to the health system's planned sale, transition, or wind-down of its health plan operations. The financial report was released August 13, 2026. The margin improvement comes as the organization restructures its insurance operations.
- Federal Policy
CMS and CDC Launch CLIA Modernization Review for Clinical Laboratory Standards
The Centers for Medicare & Medicaid Services and Centers for Disease Control and Prevention have initiated a review to modernize the Clinical Laboratory Improvement Amendments of 1988 (CLIA), the federal regulatory framework governing clinical laboratory testing standards. The review will examine updates to quality standards, personnel qualifications, proficiency testing, and enforcement mechanisms that apply to all clinical laboratories performing testing on human specimens, including those serving Medicaid beneficiaries. Timing for proposed regulatory changes has not been announced. For Medicaid programs, CLIA compliance is a condition of participation for laboratory services reimbursement, and any regulatory changes will directly affect state agency oversight responsibilities, managed care quality assurance requirements, and laboratory provider compliance obligations.
- Federal Policy
Analysis Examines ICHIA Coverage Option as Mitigation for 2025 Reconciliation Coverage Losses
A policy brief analyzes how state use of the Immigrant Children's Health Improvement Act (ICHIA) option could offset coverage losses among lawfully present immigrant children resulting from the 2025 reconciliation law. The analysis examines current enrollment patterns and coverage rates for noncitizen children to assess ICHIA's potential role. The brief provides states with data on how expanded ICHIA adoption could preserve Medicaid and CHIP coverage for eligible immigrant children affected by reconciliation-related restrictions. This matters for state Medicaid agencies evaluating coverage preservation strategies and assessing budget implications of expanded ICHIA elections.
- State Policy · GA
Georgia Adds HIV Diagnoses to Medicaid Work Requirement Exemptions
Georgia health officials amended the state's medically frail criteria to include certain HIV diagnoses, exempting these enrollees from work requirements to maintain Medicaid eligibility. The change reverses an earlier decision that excluded HIV from the exemption list, which had drawn concern from advocates. The revision affects low-income Medicaid enrollees living with qualifying HIV diagnoses in Georgia's program. This reflects state discretion in defining medical frailty under work requirement policies.
- State Policy · AZ
Arizona Audit Finds AHCCCS Failed to Implement Parent Caregiver Payment Limits
A state audit found that Arizona's Medicaid agency (AHCCCS) has not implemented legally required payment limits for parents who serve as paid caregivers for their developmentally disabled children, more than a year after the regulations became law. Auditors estimate the delay has cost the state hundreds of millions of dollars as program costs continue to escalate. The audit flags ongoing failure to enforce standardized payment guardrails designed to control expenditures in the state's long-term services and supports program for individuals with developmental disabilities.
- Legal
DOJ’s 2026 Health Care Fraud Takedown Signals Medicaid Enforcement Priorities
The Department of Justice announced its annual Health Care Fraud Takedown on June 23, 2026, with Medicaid and state health care programs representing a central enforcement focus. The takedown reflects DOJ's heightened scrutiny of fraud and abuse affecting state programs, not just Medicare. Medicaid providers, managed care organizations, and state agencies face increased risk of federal enforcement action. This enforcement prioritization signals that DOJ views Medicaid fraud as a critical target area requiring robust compliance programs and internal controls.
- State Policy · NE
Nebraska Medicaid Director Resigns Amid Work Requirement Implementation
Drew Gonshorowski has resigned as director of Nebraska's Division of Medicaid and Long-Term Care after less than two years, as the state became the first to implement more aggressive Medicaid work requirements. The leadership change comes at a critical juncture for Nebraska's program. The timing and circumstances of the resignation were not detailed in available reporting. A new director will need to oversee ongoing implementation of the work requirement policy and address any operational challenges in the state's Medicaid program.
- Legal
Federal Government Refers Hospitals, PBMs to DOJ Over Gender-Affirming Care Billing
The Vice President and HHS Secretary have referred dozens of hospitals, pharmacy benefit managers, and pharmacies to the Department of Justice and HHS Office of Inspector General for investigation of potentially fraudulent billing related to pediatric gender-affirming care. The referrals follow a new HHS report identifying organizations for scrutiny. The investigations will focus on billing practices for these services. This represents a significant enforcement action affecting hospitals and pharmacies providing or processing claims for pediatric gender-affirming treatment.