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Monday, July 20 · 23 stories
- Federal Policy
Planned Parenthood Medicaid Funding Prohibition Excluded from GOP Reconciliation Framework
Republicans' reconciliation 3.0 framework omits language that would prohibit Medicaid funding from flowing to abortion providers like Planned Parenthood, prompting intensified activism from anti-abortion groups. The exclusion marks a potential shift in Republican legislative strategy on reproductive health provider funding within Medicaid. No timeline for final reconciliation language has been announced. The omission affects managed care organizations that currently contract with or reimburse Planned Parenthood affiliates for covered Medicaid services in states that have not already enacted provider exclusions.
- State Policy · KY
Kentucky to Cut Medicaid Rates 4% Affecting Disability Services
Kentucky is implementing a 4% Medicaid rate cut that will affect services for individuals with disabilities. Families and advocates are calling the reduction a threat to care access and urging state leaders to reverse the decision. The cut affects provider reimbursement rates across Medicaid services, with particular concern about impacts on disability and long-term services. Advocates are pressing the legislature and administration to identify alternative budget solutions before the reduction takes effect.
- Managed Care
State Medicaid Audit Reveals PBM Tactics That Inflate Drug Costs
A state Medicaid audit uncovered tactics pharmacy benefit managers use to obscure prescription drug costs, resulting in overcharges to taxpayers. The audit identified complicated claims processing methods that increased Medicaid spending beyond what would be expected under transparent pricing. The findings affect states contracting with PBMs directly or through managed care organizations for pharmacy services. The disclosure raises questions about PBM oversight requirements and potential recoupment of overpayments.
- Managed Care
Medicaid Eligibility Systems Face Increased Error Rates Amid Tax Law Implementation
State Medicaid eligibility determination systems are experiencing elevated error rates as they process changes required by recent federal tax and domestic policy legislation. Disabled beneficiaries report receiving erroneous coverage denials due to system malfunctions during the implementation period. The systems, which automate eligibility decisions for Medicaid managed care enrollment, have a documented history of technical failures that result in incorrect terminations or denials. State agencies are working to address the increased volume of system errors while maintaining beneficiary access to managed care coverage.
- Federal Policy
Final Medicaid Work Requirement Rules Mandate Medical Documentation for Exemptions
Final federal regulations on Medicaid work requirements require enrollees to regularly obtain documentation proving they are too sick to work, potentially from medical providers. The rules place physicians in the position of certifying functional capacity and work ability for program eligibility purposes. The regulations took effect immediately upon publication. The documentation requirements create new administrative workflows for managed care organizations coordinating member exemptions and provider interactions.
- State Policy
States Consider Publicly Naming Large Employers With Medicaid-Enrolled Workers
State legislators are proposing measures to publicly identify major companies whose employees rely on Medicaid coverage, a response to impending federal work requirements scheduled for January implementation. The proposals aim to highlight employer wage and benefit practices that result in government-subsidized healthcare coverage for low-income workers. These legislative efforts emerge as states face federal pressure to enforce work requirements while managing program costs. The focus on employer practices represents a shift in state Medicaid policy debates toward workforce participation and private sector responsibility.
Friday, July 17 · 29 stories
- Industry
UnitedHealth Raises 2026 Guidance on Q2 Profit Growth
UnitedHealth reported $5.5 billion in profit for Q2 2026, driven by earnings recovery in its insurance and value-based care delivery operations. The company raised its full-year 2026 financial guidance based on improved cost controls across its business segments. UnitedHealth's insurance arm, which includes Medicaid managed care operations, showed stronger performance alongside growth in its Optum value-based care division. The earnings beat reflects operational improvements following cost control measures implemented across the enterprise.
- Federal Policy
GAO Finds CMS Marketplace Controls Fail to Prevent Unauthorized Agent Enrollment Actions
A Government Accountability Office report released July 13, 2026 finds that CMS lacks adequate controls to prevent health insurance agents and brokers from making unauthorized enrollments and plan switches in the federal Health Insurance Marketplace. Consumer complaints of confirmed unauthorized activity grew more than fourfold from 2023 through 2025, with at least 160,000 applications in plan year 2024 showing likely unauthorized changes. While CMS implemented new consent procedures in 2024, GAO found they do not prevent all unauthorized actions because they are not consistently applied and identity verification is limited. CMS is exploring additional controls for the 2027 open enrollment period but has not finalized decisions.
- Federal Policy
Trump Administration Rescinds Nursing Home Staffing Rule, Shifts Inspection Priorities
The Trump administration has rescinded the Biden-era nursing home staffing rule, shifted federal inspection priorities from routine surveys to complaint-driven inspections, and suspended the deadline for nursing homes to report detailed ownership information. These policy changes affect federal oversight of nursing home safety and quality standards under Medicare and Medicaid certification. The changes are currently in effect. The shifts matter because many Medicaid managed care organizations contract for long-term care services in nursing facilities or operate programs with nursing home placement responsibility, making federal certification standards and inspection frequency directly relevant to network adequacy, quality oversight, and member safety obligations.
- Federal Policy
CMS Seeks Public Comment on Clinical Laboratory Improvement Amendments Regulations
On July 16, 2026, CMS and CDC announced they are seeking public input on regulations implementing the Clinical Laboratory Improvement Amendments of 1988 (CLIA), which have been in effect since 1992. The agencies are soliciting stakeholder feedback on various issues related to the current laboratory regulatory framework. The request for information signals potential modernization of CLIA regulations that govern clinical laboratory testing and quality standards. Public comments will inform whether CMS pursues regulatory changes to laboratory certification, personnel standards, quality control, or proficiency testing requirements.
- Federal Policy
CMS Proposes CY 2027 Physician Fee Schedule with QPP Updates
On July 14, 2026, CMS released the proposed rule for the calendar year 2027 Medicare Physician Fee Schedule, covering physician payment rates and Quality Payment Program policies. The proposed rule affects Medicare Part B physician reimbursement and MIPS/APM requirements. Comments are typically due 60 days after Federal Register publication. While the PFS primarily governs Medicare fee-for-service payments, changes to payment methodologies and quality measures often influence Medicaid managed care rate-setting, value-based purchasing arrangements, and provider network strategies.
- Federal Policy
340B Program Spending Reached $100 Billion in 2025, Federal Data Shows
Federal data shows 340B drug discount program spending reached $100 billion in 2025, marking continued growth despite regulatory efforts to limit program expansion. The spending increase reflects rising program enrollment and pharmaceutical costs. The growth trajectory affects Medicaid managed care organizations through potential impacts on pharmacy reimbursement rates, contract pharmacy relationships, and state efforts to recoup 340B savings through supplemental rebate programs. Regulators continue efforts to address program growth concerns.
- Federal Policy
CDC Nominee Schwartz Backs Vaccines at Confirmation Hearing
Erica Schwartz, President Trump's nominee to lead the Centers for Disease Control and Prevention, voiced support for vaccines, including COVID-19 shots, during her confirmation hearing. Her pro-vaccine position differs from that of Health and Human Services Secretary Robert F. Kennedy Jr., who has expressed skepticism about vaccine safety. The hearing did not produce a commitment from Schwartz to maintain independence from Kennedy's influence. If confirmed, Schwartz would oversee federal vaccination policy and public health guidance that affects Medicaid covered populations.
- Legal · NY
New York Ambulette Owners Indicted for Medicaid Transportation Fraud and Kickbacks
Two New York residents face federal charges in the Eastern District of New York for conspiracy to commit healthcare fraud related to Medicaid transportation services. The defendants allegedly paid kickbacks and submitted fraudulent claims to Medicaid and other government payors for ambulette services that were either not provided or included inflated mileage. The indictment was filed in federal court in Central Islip. The case demonstrates ongoing federal enforcement activity targeting non-emergency medical transportation fraud schemes.
- Industry
Home Health Providers Pursue Joint Ventures During CMS Enrollment Moratorium
CMS imposed a six-month moratorium on new Medicare home health enrollments, limiting traditional expansion paths for providers. Industry operators report that growth-minded agencies are pursuing organic growth, mergers and acquisitions, and joint ventures to scale operations despite enrollment restrictions. The moratorium affects provider capacity to enter new markets through new enrollments but does not prevent changes of ownership or partnerships with existing enrolled agencies. Providers are adapting expansion strategies to work within the temporary enrollment freeze.
- Federal Policy
CMS Proposes CY 2027 Physician Fee Schedule with Part B Payment and Quality Program Updates
CMS published a proposed rule updating the physician fee schedule for calendar year 2027, along with changes to Medicare Part B payment policies, Quality Payment Program requirements, and Medicare Shared Savings Program rules. The proposal also codifies the Medicare Prescription Drug Inflation Rebate Program established under the Inflation Reduction Act of 2022 and updates policies for rural health clinics, federally qualified health centers, ambulance services, and clinical laboratory fee schedules. While primarily Medicare-focused, the rule affects providers participating in both Medicare and Medicaid managed care networks, potentially impacting provider contracting, rate negotiations, and network adequacy for dual-eligible populations. Comments are due 60 days after Federal Register publication.
- Industry
ACA Marketplace Premiums Rise in 2027 Rate Filings
Health insurers have submitted 2027 rate filings to state regulators for individual market plans sold through ACA Marketplaces, showing premium increases. The filings detail insurer expectations and the factors driving rate changes for the coming plan year. Rate filings occur annually each spring and summer as part of the regulatory approval process. This development affects individual market plans, which operate separately from Medicaid managed care but may inform broader health plan pricing trends and cost drivers affecting the commercial insurance market.
- State Policy
Restrictive APRN Regulations Drive Nurse Migration Across State Lines
Advanced practice registered nurses (APRNs) are relocating from states with restrictive scope-of-practice regulations to states with more permissive practice authority. These nurses provide critical access to care in underserved areas where physician shortages exist. State-level variations in APRN regulations affect workforce availability and access to services. The migration patterns may exacerbate provider shortages in states with stricter regulations while benefiting states that grant APRNs greater practice independence.
- Industry
Commonwealth Fund Research Examines Private Equity Ownership in Four-State Hospital Analysis
The Commonwealth Fund is supporting new research analyzing private equity ownership patterns in hospitals and provider groups across four states. The research examines how private equity investments are affecting healthcare delivery organizations. The analysis provides state-level detail on ownership structures and operational changes. For Medicaid managed care organizations, private equity ownership of network providers can affect network stability, care continuity, service availability, and provider contracting dynamics.
- Federal Policy
CMS Seeks Comment on Generic Medicaid and CHIP Information Collection Activities
The Centers for Medicare & Medicaid Services is requesting public comment on proposed generic information collection activities under control number 0938-1148 (CMS-10398). The generic clearance process covers low-burden, voluntary collections related to Medicaid and CHIP state plan amendments, waivers, demonstrations, and reporting. Comments are due 60 days after publication in the Federal Register on July 16, 2026. The umbrella approval allows CMS to expedite certain data requests without full Paperwork Reduction Act review when collections do not raise substantive policy issues.