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Friday, July 17 · 29 stories
- Managed Care · CA
Kern Family Health Care Uses AI Outreach to Reduce Medi-Cal Renewal Churn
Kern Family Health Care deployed Careforce AI technology to conduct outreach to thousands of Medi-Cal enrollees at risk of losing coverage during renewals. The AI-powered system identified members who had not completed renewal paperwork and facilitated completion of the process. The initiative helped the health plan reduce disenrollment during California's post-pandemic redetermination period. This represents an operational approach to addressing procedural disenrollment that other Medicaid MCOs may consider as states continue eligibility redeterminations.
- Federal Policy
KFF Poll Shows Voter Focus on Health Costs, Republican Priority on Program Fraud
A new KFF Health Tracking Poll finds health care costs are the top health care priority for voters ahead of the 2026 midterm elections. More than half of Republican voters identify fraud in government health programs as an extremely important campaign issue, aligning with current Trump administration enforcement priorities. Most voters believe at least some fraud exists in government health programs, though voters perceive higher fraud levels in tax systems, defense spending, and foreign aid. The smallest share of voters perceives fraud in ACA marketplace programs.
- Federal Policy
Pharmacy Groups Warn Revised ACIP Charter Could Delay Vaccine Recommendations
Nine pharmacy organizations wrote to HHS Secretary Robert F. Kennedy Jr. on July 9, 2026, warning that CDC's revised charter for the Advisory Committee on Immunization Practices (ACIP), issued June 25, could undermine the evidence-based framework for U.S. immunization policy. The letter follows a year of ACIP restructuring. The groups expressed concern that changes to ACIP's charter and processes could delay vaccine access and recommendations. For Medicaid managed care organizations, ACIP recommendations determine vaccine coverage requirements under EPSDT and adult preventive services, making any disruption to the committee's timeline or evidentiary standards operationally significant.
- Federal Policy
CMS Launches Risk-Based Survey Process for High-Performing Nursing Homes Nationwide
CMS announced July 16 nationwide implementation of a risk-based survey process for high-performing nursing homes, effective September 2026 following state agency training. Approximately 12% of nursing facilities will initially qualify based on criteria including five-star ratings, zero harm citations, and accurate data submission. Qualifying facilities receive streamlined recertification surveys and a new Care Compare icon, though state agencies retain authority to use traditional surveys when safety concerns arise. All nursing homes continue receiving surveys at least every 15 months regardless of performance tier.
- Federal Policy
SNAP and Medicaid Eligibility Changes May Reduce School Meal Program Participation
Federal changes to SNAP and Medicaid eligibility could reduce the number of students qualifying for free school meals under USDA's Community Eligibility Provision. USDA uses enrollment in means-tested programs including Medicaid as a benchmark to determine which high-poverty school districts can offer universal free meals without collecting individual applications. Reductions in SNAP or Medicaid enrollment—whether through eligibility restrictions, administrative changes, or state policy decisions—could push schools below CEP thresholds, forcing districts to return to individual meal applications and potentially reducing meal participation among eligible low-income students. The timing of these changes depends on pending federal SNAP and Medicaid policy actions.
- Industry
TrumpRx Discount Website Covers Limited Share of Brand-Name Drugs After Six Months
The TrumpRx administration-backed prescription drug discount website has been operational for nearly six months but covers only a fraction of brand-name medications. The platform's limited formulary raises questions about its practical utility for consumers seeking prescription cost relief. The scope of coverage and actual impact on out-of-pocket costs remains unclear. For Medicaid managed care organizations, this development is relevant only if it affects member cost-sharing, supplemental benefit design, or pharmacy network strategies.
- Managed Care
Total GLP-1 Payments Rose Sharply Through 2022 Despite Lower Patient Cost-Sharing
A Northwestern University study published July 16 in the Journal of the American Heart Association found that average total payments for GLP-1 users without diabetes increased significantly between 2017 and 2022, even as patient out-of-pocket costs declined. The study documents the growing financial burden on payers during the period when GLP-1 utilization expanded beyond diabetes treatment. The findings reflect cost trends during a period that predates recent Medicare coverage expansion and current utilization management strategies. The research provides baseline data as Medicaid managed care organizations continue to face pressure to cover GLP-1s for weight loss and cardiovascular indications.
- State Policy · WI
Wisconsin APRN Modernization Act Removes Physician Collaboration Requirement September 1
Wisconsin's APRN Modernization Act takes effect September 1, 2026, eliminating the requirement that advanced practice registered nurses maintain collaborative arrangements with physicians or dentists to practice. The law modifies state licensure requirements for qualified APRNs. This change affects network adequacy and provider access strategies for Medicaid managed care organizations operating in Wisconsin, as APRNs gain independent practice authority. MCOs may need to update credentialing policies, provider contracts, and network composition to reflect the expanded scope of practice.
- Industry
Insurers to Pay $759 Million in MLR Rebates for 2024 Performance
Health insurers will pay an estimated $759.2 million in Medical Loss Ratio rebates in 2026 based on 2024 performance, according to KFF analysis of preliminary data filed with state regulators. The rebates go to individuals and employers in fully-insured plans where insurers failed to meet minimum MLR thresholds—80% for individual and small group markets, 85% for large group plans. This year's rebate total is lower than most prior years. Payments typically reach consumers by September 30, 2026.
- Industry
Peterson Health Technology Institute Examines AI Deployment in Prior Authorization and Medical Billing
The Peterson Health Technology Institute is evaluating how providers and payers are deploying artificial intelligence in administrative functions including prior authorization, medical coding, and billing. Providers are using AI tools to optimize revenue capture and documentation, while insurers deploy similar technology for claims review and utilization management. PHTI's executive director Caroline Pearson notes the central question is whether these technologies reduce total healthcare spending or simply accelerate existing reimbursement disputes. The institute previously found that digital diabetes management tools did not lower overall cost of care.
- Managed Care
Major Insurers Decline to Renew Trump Administration Prior Authorization Pledge
Several health insurers have declined to sign an updated version of the Trump administration's voluntary prior authorization reform commitment, less than one year after the original pledge. The commitment, signed by dozens of insurers in 2025, aimed to streamline prior authorization processes that require patients and physicians to obtain approval before treatment. The withdrawal of support from some plans signals uncertainty about industry-wide adoption of standardized prior authorization improvements. For Medicaid managed care organizations, this development indicates that voluntary reform efforts may not deliver consistent changes across all payers, potentially leaving MCOs navigating different standards and timelines for prior authorization requirements.
- State Policy · NY
Report Outlines Strategies to Expand New York Medicaid CHW Benefit
A new report from the Center for Health Care Strategies provides recommendations for expanding community health worker services under New York's Medicaid program. The analysis addresses opportunities for state policymakers, managed care organizations, and CHW stakeholders to strengthen implementation of the state's CHW benefit. Recommendations focus on enhancing access, improving reimbursement structures, and scaling CHW integration within Medicaid managed care networks. The report is published in July 2026.
- State Policy
KFF Tracker Compiles Section 1115 Medicaid Waiver Activity Across States
The Kaiser Family Foundation maintains an ongoing tracker of Section 1115 Medicaid waiver activity, cataloging approved and pending waiver provisions across states. The tracker covers waiver provisions affecting eligibility, benefits, social determinants of health initiatives, and other delivery system reforms. It provides a reference tool for monitoring state flexibility requests and approved demonstrations that deviate from standard Medicaid requirements. The resource is continuously updated as states submit new waiver applications and CMS issues approval decisions.
- Federal Policy
DHS Finalizes Public Charge Rule Tying Medicaid and CHIP Receipt to Immigration Bonds
The Department of Homeland Security on July 16 finalized a rule rescinding 2022 public charge regulations and establishing that receipt of Medicaid or CHIP will breach public charge bonds for immigrants. The final rule removes previous exemptions and the 2022 Public Charge Inadmissibility Framework definitions. It takes effect 60 days after Federal Register publication, likely in mid-September 2026. The change may reduce Medicaid and CHIP enrollment among eligible immigrant populations, affecting managed care plan membership and revenue.
- Federal Policy
CMS Issues Interim Final Rule Imposing Work Reporting Requirements on Medicaid Beneficiaries
CMS has published an interim final rule establishing work reporting requirements for certain Medicaid beneficiaries. The rule requires states to implement reporting systems for work activities as a condition of eligibility for non-exempt populations. The requirements take effect for state implementation planning immediately, with full compliance deadlines to be determined by state plan amendments. This marks a significant shift in Medicaid eligibility policy affecting managed care organizations' enrollment processes, member communication obligations, and systems for tracking beneficiary compliance with work requirements.
Thursday, July 16 · 20 stories
- Industry
KFF Analysis Examines Why Drug Prices Dominate Policy Debate Over Hospital Costs
KFF's Larry Levitt published a JAMA Health Forum post identifying four reasons why high drug prices receive more policy attention than hospital prices, despite hospitals accounting for 40% of national health spending growth from 2022 to 2024. The analysis explores barriers to hospital price restraint and potential policy interventions. The post provides context for understanding the political economy of health care cost containment efforts. No immediate policy changes are announced.
- Industry
Rural Hospitals Face Unique Payer Contracting Pressures from Geography and Payer Mix
Rural hospitals are confronting distinct challenges in managed care contracting driven by limited scale, geographic isolation, and constrained payer mix. These providers must navigate tighter margins than their urban counterparts while negotiating contracts that often fail to account for rural delivery realities. The article examines how rural facilities can strengthen their negotiating position despite structural disadvantages. These dynamics affect Medicaid managed care organizations with rural network obligations and rural health plan adequacy requirements.
- Federal Policy
CMS Proposes Payment Model Changes for Remote Patient Monitoring and Clinical AI
The Centers for Medicare and Medicaid Services has proposed significant changes to how it pays for remote patient monitoring (RPM) and clinical artificial intelligence tools. The proposal would restructure payment models for these technologies under Medicare. The changes affect how health plans and providers bill for AI-enabled clinical decision support and remote monitoring services. CMS has opened the proposal for public comment, with implementation timing to be determined following the comment period.
- State Policy
CHCS Reviews 15 Years of Medicaid Leadership Development Programs
The Center for Health Care Strategies published a retrospective analyzing over 15 years of Medicaid leadership development initiatives funded by the Robert Wood Johnson Foundation. The review examines programs designed to strengthen state Medicaid agency capacity through executive training, peer learning networks, and leadership support. The analysis documents approaches used to build technical and strategic capabilities among state Medicaid directors and senior staff. For managed care organizations, state agency leadership stability and expertise directly affect contract oversight quality, rate-setting processes, and the consistency of MCO performance requirements.
- Federal Policy
Senate Questions CDC and HHS Nominees on Vaccine Policy Alignment
Two Trump administration health nominees—Erica Schwartz for CDC Director and Sean Kaufman for an HHS position—faced Senate scrutiny on July 15, 2026, over their willingness to challenge administration positions on vaccines. Both Democrats and some Republicans expressed concern about the nominees' reluctance to break with administration policy. The hearing centered on whether the nominees would maintain agency independence on vaccine policy and public health guidance. Confirmation votes have not been scheduled.
