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Wednesday, August 5 · 20 stories
- Legal
Federal Courts Rule Hospices Deserve Deference on Six-Month Life Expectancy Determinations
Federal courts have issued several rulings favoring hospices in administrative appeals, particularly recognizing that hospices should receive deference when determining six-month life expectancy for patient eligibility. These rulings counter administrative law judge decisions that had reversed hospice eligibility determinations. The court decisions affect how hospices defend Medicare and Medicaid eligibility claims during audits and appeals. This development matters for hospices serving dual-eligible beneficiaries and state Medicaid programs that follow Medicare hospice coverage rules.
- Federal Policy
CMS Proposes 340B Cuts, Site-Neutral Payment Changes for 2027 Outpatient Rule
CMS released a proposed 2027 outpatient payment rule on July 2, 2026, that would cut billions from 340B drug payments and expand site-neutral payment policies affecting hospital reimbursement. The rule compounds financial pressure on hospitals already facing margin challenges, combining payment reductions that hospital finance leaders have previously fought separately. Comments on the proposed rule are due under the standard federal rulemaking timeline, typically 60 days from publication. The combined effect threatens Medicaid DSH hospitals and safety-net providers that rely heavily on 340B revenue and outpatient volume.
- State Policy
Seven States Improve Medicaid Access to Continuous Glucose Monitors Beyond Coverage Mandates
Seven states implemented strategies to strengthen access to continuous glucose monitors (CGMs) for Medicaid enrollees with diabetes, going beyond coverage policies to address utilization barriers. The Center for Health Care Strategies report examines how these states improved actual device uptake and diabetes care outcomes. The findings highlight operational approaches to bridge the gap between coverage on paper and real-world access. This matters for state Medicaid agencies and managed care plans working to translate diabetes technology coverage into measurable improvements in member health outcomes.
- Legal
District Court Requests Feasibility Briefing After Columbus II Oral Argument on 2027 NBPP Rule
Following July 8 oral argument in City of Columbus v. Kennedy, challenging CMS's 2027 Notice of Benefit and Payment Parameters Final Rule, the U.S. District Court for the District of Maryland ordered supplemental briefs on implementation feasibility. The Court asked parties to address whether relief could be granted without disrupting the 2027 Marketplace plan year and whether staying catastrophic-plan guidance would affect enrollees. The case involves provisions of the NBPP final rule affecting Exchange operations. Supplemental briefing timing will determine how quickly the Court rules and whether any injunction could affect 2027 plan year implementation.
- Legal · PA
DOJ Launches Philadelphia Medicaid Fraud Strike Force
The Department of Justice announced on August 4, 2026, the creation of a dedicated Medicaid fraud strike force in Philadelphia, expanding its Northeast Health Care Fraud Strike Force operations. The new unit will focus on investigating and prosecuting Medicaid fraud cases in the Philadelphia region. The announcement coincides with a parallel expansion of DOJ's West Coast Strike Force, signaling intensified federal enforcement activity targeting Medicaid program integrity. The move indicates heightened scrutiny of Medicaid providers, plans, and related entities operating in these regions.
- Industry
Hackensack Meridian Health Earns First Joint Commission AI Certification
Hackensack Meridian Health became the first health system to receive the Joint Commission's responsible health AI certification. The certification recognizes the system's AI governance structure, which it has been developing for several years. The Joint Commission and other private consortiums are establishing AI guardrails as federal regulations remain pending. This development reflects the healthcare industry's move toward voluntary AI standards in the absence of comprehensive federal regulatory frameworks.
- Managed Care · MD
Baltimore Launches Alternative 911 Response for Health Crises
Baltimore is creating a new 911 response service designed to address health crises before they escalate. The city will deploy alternative responders when people call 911 for certain health-related emergencies. The initiative aims to connect individuals to appropriate health services rather than traditional emergency response. For Medicaid managed care organizations and behavioral health providers, this represents a shift in crisis intervention that may affect emergency department utilization, care coordination requirements, and community-based crisis response networks.
- Federal Policy
CMS Re-Establishes Data Matching Program With Department of War for ACA Coverage Verification
CMS is re-establishing a Privacy Act matching program with the Department of War to verify minimum essential coverage under the Affordable Care Act through War Department health benefit plans. The matching program allows CMS to cross-reference enrollment data to confirm ACA coverage requirements are met. The notice was published August 5, 2026, under Privacy Act requirements. This routine administrative action maintains existing data-sharing arrangements between federal agencies for coverage verification purposes.
- State Policy
States Move to Restrict Medicaid Coverage of ABA Therapy for Autism
Multiple states are implementing new restrictions on Applied Behavior Analysis (ABA) therapy coverage for children with autism under Medicaid. The changes include stricter prior authorization requirements, reduced therapy hour caps, and new medical necessity criteria. State Medicaid agencies cite rising program costs and utilization management concerns as drivers for the policy shifts. The restrictions affect access to the primary evidence-based treatment for autism covered by Medicaid, which serves as the largest payer of autism services nationally.
- Federal Policy
Pediatricians Develop Independent Vaccine Guidance After CDC Policy Changes
Following changes to federal vaccine recommendations under the Trump administration, pediatricians and state health departments report they can no longer rely on CDC guidance as a trusted resource for families. Some providers are developing their own vaccine schedules and educational materials. The shift affects Medicaid-enrolled children, who comprise approximately 40% of the pediatric population and depend on EPSDT-mandated preventive services including immunizations. State Medicaid agencies may face inconsistent vaccine coverage determinations if provider guidance diverges from federal standards.
- Industry · CA
UC Davis Launches Telenephrology Program for Rural Mendocino County
UC Davis Health is partnering with Adventist Health Ukiah Valley to provide remote nephrology services to patients in rural Mendocino County, California, a region that previously lacked local kidney specialty care. The telenephrology program connects UC Davis nephrologists in Sacramento with patients and clinicians at the 50-bed rural hospital. The partnership aims to expand access to specialty care in an underserved area through telehealth infrastructure. No timeline or operational details were provided in the brief announcement.
- State Policy · IN
Indiana to Implement Medicaid Work Requirements and New Eligibility Rules Over Next 18 Months
Indiana will implement new Medicaid work requirements and eligibility rules over the next 18 months, following a redetermination period that already removed hundreds of thousands of beneficiaries from coverage. The changes represent a second phase of enrollment restrictions after the unwinding of pandemic-era continuous coverage protections. The new requirements will determine whether additional beneficiaries lose Medicaid coverage. State agencies and managed care plans operating in Indiana will need to adjust operations to support compliance tracking and member communications around the work requirement policy.
- State Policy · CT
Connecticut Medicaid Considers Restricting HIV Medication Treatment Options
Connecticut's Medicaid program is considering implementing restrictions on HIV medication access that would limit available treatment options for beneficiaries. The proposed limitations would affect patients currently receiving or seeking HIV treatment through the state's Medicaid program. The timing and specific scope of the restrictions under consideration have not been publicly detailed. This development raises concerns about medication continuity and treatment adherence for Connecticut Medicaid beneficiaries living with HIV, particularly given clinical evidence supporting treatment choice in managing the condition.
- State Policy · NC
Study Finds Medicaid Expansion Did Not Reduce Firearm Suicides Among Most Men
A new study found that Medicaid expansion has not reduced firearm suicide rates among most men, despite documented improvements in health care access and behavioral health treatment availability for expansion populations. The research challenges assumptions about the relationship between Medicaid coverage and suicide prevention outcomes for male enrollees. The findings have implications for state Medicaid agencies and managed care organizations designing behavioral health interventions and measuring quality outcomes in expansion populations, particularly as states continue to evaluate the effectiveness of coverage expansions on mental health and mortality metrics.
- Managed Care
UnitedHealthcare Limits Lab Test Reimbursement Across Medicaid and Other Lines
UnitedHealthcare will implement new reimbursement limits on five categories of lab tests — allergen testing, liver fibrosis testing, in vitro chemotherapy sensitivity assays, testosterone blood tests, and vitamin B12 testing — effective September 1, 2026. The policies apply across the company's commercial, ACA exchange, Medicare Advantage, and Medicaid product lines. UnitedHealthcare Medicaid plans will be affected by the same utilization management criteria being applied to other lines of business. The changes will affect laboratory providers billing UnitedHealthcare Medicaid plans and could impact member access to certain diagnostic tests.
- Legal · PA
DOJ Charges 19 Defendants in $4M Medicare and Medicaid Home Health Fraud Scheme
The Department of Justice, in coordination with the U.S. Attorney's Office and Pennsylvania Attorney General, charged 19 defendants in a $4 million Medicare and Medicaid fraud scheme involving home health services. The alleged scheme included billing for services never rendered and submitting claims for unrealistic service hours. The charges were announced in early August 2026. The enforcement action signals continued federal and state scrutiny of home health billing practices, particularly phantom billing and time-based service inflation.
- Federal Policy
CMS Proposes Restrictions on Remote Patient Monitoring in 2027 Fee Schedule
CMS issued the CY 2027 Physician Fee Schedule Proposed Rule limiting remote patient monitoring and remote therapeutic monitoring services. The proposal restricts outsourced clinical staffing, imposes new billing requirements, and reduces reimbursement for certain services. Changes would take effect January 1, 2027. The restrictions reverse CMS's 2025 expansion of RPM/RTM access and could significantly affect Medicaid managed care organizations and providers using remote monitoring for chronic condition management, particularly for dialysis and other high-cost populations.
- Legal · ME
Maine Supreme Court Upholds $750M Medicaid Transport Contract with Modivcare
The Maine Supreme Court ruled Tuesday in favor of the state's 10-year, $750 million Medicaid non-emergency transportation contract with Denver-based Modivcare, ending a legal challenge by nonprofit provider Penquis. The decision allows Maine DHHS to proceed with the statewide contract, consolidating NEMT services under a single vendor. The ruling resolves a multi-year procurement dispute and establishes the operational framework for Medicaid transportation services statewide. The contract represents one of the largest NEMT procurements nationally and affects transportation access for Maine's Medicaid beneficiaries.
Tuesday, August 4 · 15 stories
- Federal Policy
HHS Secretary Kennedy Endorses Measles Vaccine Amid Outbreak Discussions
Health and Human Services Secretary Robert F. Kennedy Jr. endorsed the measles vaccine during a CNN interview on August 3, 2026, while making additional claims about other vaccines and RSV during ongoing measles outbreaks. The statement represents the Secretary's public position on measles immunization policy as the nation's top health official. The endorsement comes as federal and state health agencies manage measles outbreak response and vaccination campaigns. HHS guidance on childhood vaccinations influences state Medicaid EPSDT requirements, managed care quality metrics, and VFC program administration.
- Industry
MedCity News Publishes Sponsored Content on SNF Data Transparency for Health Plans
MedCity News published a sponsored article discussing how real-time clinical data sharing from skilled nursing facilities can help health plans identify member decline and prevent avoidable hospitalizations for long-stay residents. The piece frames SNF data transparency as a tool for earlier risk identification in long-term services and supports populations. No specific policy change, product launch, or implementation timeline is reported. This appears to be marketing content rather than news of a concrete development.
