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Monday, October 5 · 64 stories
- State Policy · NC
NC Lawmakers Probe Claims Officials Falsified Medicaid Tech Funding Bids
GOP lawmakers in North Carolina say they are investigating allegations that state health officials used false information to obtain federal funding for a Medicaid technology overhaul. The allegations originated in a lawsuit that has since been dismissed, but the state auditor has revived a separate audit into the project. The scope and timeline of the legislative inquiry remain unclear, and no findings have been released. The matter raises questions about oversight of federal funding requests tied to the state's Medicaid IT modernization efforts.
- State Policy · MS
Mississippi Medicaid Requests $179M State Funding Increase
Mississippi's Division of Medicaid asked lawmakers for a roughly $179 million state funding increase for the fiscal year beginning July 2027, a 15% rise but far smaller than last year's nearly $390 million initial request. The agency also anticipates a $34 million shortfall in the current fiscal year. Executive Director Cindy Bradshaw told the Joint Legislative Budget Committee the figure will likely change, noting a slight federal matching-rate increase is expected to reduce the request by about $25 million. The agency's total projected budget, including federal funds, is $9.4 billion; cost-containment efforts include contractor and long-term care audits, prior authorization reviews, and reduced managed care profit margins. Lawmakers will issue budget recommendations in December ahead of the 2027 legislative session.
- State Policy · AR
Arkansas Families Press Lawmakers to Speed Disability Waiver Waitlist Fix
Families of Arkansans with disabilities testified before House and Senate committees urging faster relief for nearly 2,500 people on the Community and Employment Services Medicaid waiver waitlist, saying the state's planned 2027 timeline is too slow. Gov. Sarah Huckabee Sanders and DHS announced in September a roughly $17 million plan to have the managed-care Medicaid program begin covering non-medical in-home supportive living services by January, one of four services currently excluded for waitlisted families. DHS officials said the waitlist has ballooned because the agency's IT systems cannot keep pace with 400-500 annual applications, and the state must show CMS that home-based care saves money versus institutionalization. DHS plans to seek legislative approval this month for a customer-service vendor contract to streamline beneficiary access.
- Legal · CA
California Doctors, Health Plans Sue Newsom Over MCO Tax Hike
The California Medical Association and California Association of Health Plans filed suit Friday with the California Supreme Court against Gov. Gavin Newsom and the Legislature, alleging a June managed care organization (MCO) tax increase on private health plans violates Proposition 35, a 2024 voter initiative limiting healthcare taxes and dedicating revenue to Medi-Cal. The groups say the tax hike, prompted by federal changes to allowable healthcare tax structures, will raise individual premiums by about $100 annually ($400 for a family of four) as insurers pass costs to consumers. The state structured two competing tax versions for federal approval, one compliant with Prop 35 but likely to be rejected federally, and one that meets federal rules but largely bypasses the initiative, to preserve the revenue stream amid federal Medicaid funding cuts. No effective date or ruling timeline was given; the case is pending before the state Supreme Court.
- State Policy · MO
Missouri Forgoes Optional Hardship Exemptions From Medicaid Work Rules
Missouri's Department of Social Services will not adopt optional federal "short-term hardship" exemptions from Medicaid work requirements, covering hospitalization, medical travel, disaster areas, and high-unemployment regions, that states may use under the federal law requiring 80-hour monthly work, school, or volunteer activity for expansion adults starting Jan. 1, 2027. The department says it will instead rely on mandatory caregiver and "medically frail" exemptions to limit bureaucratic complexity, and will verify compliance based on just one month within each six-month reporting period. Advocates, including Legal Services of Eastern Missouri and the American Cancer Society Cancer Action Network, warn the mandatory exemptions require more verification and may not cover people with short-term acute conditions like cancer treatment or hospital stays. As of Sept. 25, 344,669 Missourians were enrolled in the adult expansion group subject to the new requirements.
- Managed Care · GA
Amerigroup Cuts Georgia Foster Children's Autism Therapy Rates 30%
Georgia's Medicaid managed care contractor for foster children, Amerigroup, cut reimbursement rates for applied behavior analysis (ABA) therapy by 30% starting September 1, while raising rates for parent-training services instead. Clinics say the cut, delivered via an August notice citing alignment across autism services, has already forced some providers to stop accepting new foster-child patients or drop existing ones, threatening access for a population with high rates of severe autism. State Rep. Lee Hawkins says industry surveys show 75% of affected clinics expect to reduce or stop serving foster children within three months, and over 90% expect to limit new patients. The Georgia Department of Community Health, which delegates foster-care Medicaid rate decisions to Amerigroup, says out-of-network providers must be secured when no in-network option exists, but families report no notification of that option.
Friday, October 2 · 48 stories
- Federal Policy
CMS Finalizes Major Updates to Medicare TAVR Coverage Rules
CMS issued a Decision Memorandum on September 10, 2026, finalizing a reconsideration of the National Coverage Determination for Transcatheter Aortic Valve Replacement, prompted by a request from device manufacturer Edwards Lifesciences. The updated NCD relaxes the 2019 rules by allowing asynchronous heart-team patient evaluations, eliminating the requirement for two operators from different specialties, replacing hospital-level volume requirements with operator-level thresholds (20 valve procedures annually, 15 of which must be TAVR), and ending coverage-with-evidence-development requirements for symptomatic severe aortic stenosis. CMS also created a new coverage pathway for asymptomatic severe aortic stenosis, limited to CMS-approved studies. Hospitals and physicians performing TAVR must comply with the revised conditions of Medicare payment, as noncompliance can trigger False Claims Act exposure.
- Industry
Hospital Revenue Cycle Leaders Flag 10 AI-Driven Payer Risks
In a Becker's Hospital Review roundup, revenue cycle executives from health systems including UC Davis Health, Harvard Medical Faculty Physicians, Rush University Medical Center, Carle Health, Lurie Children's Hospital, and Centerstone identify 10 top threats facing hospital billing operations. Leading concerns include payers using AI to review and deny claims faster than providers can respond, automation scaling existing workflow errors, governance gaps in AI-assisted coding creating compliance liability, silent "downcoding" that erodes revenue without appearing in denial reports, expanding prior authorization burdens, and organizational fragmentation that leaves no one accountable for end-to-end financial impact. The piece also highlights unmeasured "care abandonment" by patients unable to navigate administrative hurdles. No new regulation or enforcement action is reported; this is an industry survey of operational risks.
- Federal Policy
Analysis: Medicare Part D Plan Premiums Vary Widely for 2027
A new analysis of the 2027 Medicare Part D stand-alone prescription drug plan (PDP) market finds a modest reduction in the number of available plans alongside uneven premium changes. Many enrollees will see monthly premium increases of less than $10, but others face increases of $50 or more if they remain in their current plan rather than switching during open enrollment. The brief highlights that passive enrollees, those who don't actively shop plans each year, are most at risk of steep cost increases. This affects the millions of Medicare beneficiaries who rely on stand-alone PDPs for drug coverage, distinct from Medicare Advantage drug plans.
- Legal
Independence Blue Cross Pays $22.5M to Settle MA Fraud Claims
Independence Blue Cross agreed to pay $22.5 million to resolve allegations that it inflated diagnosis codes for Medicare Advantage beneficiaries to boost risk-adjustment payments. The insurer described the settlement, along with similar resolutions by other payers, as reflecting "industry-wide challenges" in applying Medicare Advantage risk adjustment standards. The matter concerns Medicare Advantage rather than Medicaid managed care directly, though risk adjustment practices and enforcement scrutiny often extend across both program types for payers operating in both markets.
- Industry
AARP Foundation: Senior Poverty Rate Climbs for Fifth Year
An AARP Foundation analysis of 2025 Census Bureau data found poverty among adults 65 and older has risen for five consecutive years, reaching 15.4% in 2025, up from 9.4% in 2020. The analysis uses the Supplemental Poverty Measure, which factors in government benefits, taxes, and cost of living. Among adults 50 and older, 17.2 million lived in poverty in 2025; those 50-64 had the lowest rate at 12.1%, while women over 65 faced higher poverty (16.8%) than men (13.7%). The report highlights a broader trend of rising poverty across age groups since a 2020 low point.
- Federal Policy
CDC Proposal Would Cut Disability Questions From Health Survey
CDC has proposed a major redesign of its National Health Interview Survey, set to take effect in 2028, shifting from in-person interviews to a "sequential mixed-mode" approach with shorter, simplified questionnaires. Many detailed topics fielded annually would be dropped, including a question asking whether a physician diagnosed the respondent with an intellectual or developmental disability or autism; only "foundational measures" based on the Washington Group Short Set on functional status would remain. Disability advocates, including The Arc's CEO Katy Neas, warn the change could worsen undercounting of people with disabilities and disrupt longitudinal tracking of disability prevalence, health outcomes, and funding decisions. The proposal, dated Aug. 20, is open for public comment until Oct. 19.
- Industry
Insurers Trim 2027 Medicare Advantage Plans, Shift Toward Special Needs Plans
Becker's Hospital Review reports that Medicare Advantage insurers are cutting plan offerings in 28 states for 2027, with total plan counts dipping from 5,553 to about 5,532, even as national enrollment projections hold roughly flat at 34 million. Twelve insurers that sold MA plans in 2026, including several health system-owned plans and some Blue Cross Blue Shield affiliates, will exit the market entirely, while large national carriers like Centene, UnitedHealthcare, and Aetna are each leaving over 100 counties. Growth is concentrated in special needs plans, which will grow 9.4%, with some insurers limiting new dual-eligible enrollment to members already in the insurer's affiliated Medicaid plan. CMS raised 2027 MA payments by 2.48% (4.98% counting risk score trends), which insurers say is insufficient to offset rising medical costs, setting up a second consecutive year of enrollment upheaval ahead of the Oct. 15–Dec. 7 annual enrollment period.
- Industry
Rural Surgeon Shortages Drive Worse Patient Outcomes, Data Show
Becker's Hospital Review compiles data showing rural surgical workforce shortages are worsening patient outcomes. Nationally there are 59.2 surgeons per 100,000 people, with a projected shortage of nearly 28,000 surgeons by 2038, and 30% of counties have no identified surgeon. Rural Medicare beneficiaries face higher 30-day mortality, complications and readmissions after common surgeries, and death rates from emergency conditions like appendicitis and hernias are now 86% higher in rural areas than urban ones. Responses include federal rural health transformation funding, state-funded workforce grants such as UNC System's rural surgery partnership, and new accreditation pathways from the American College of Surgeons for rural cancer programs.
- Legal · AZ
Arizona AG Sues Express Scripts, Optum Over Opioid Role
Arizona Attorney General Kris Mayes filed a consumer fraud lawsuit Oct. 1 against pharmacy benefit managers Express Scripts and Optum, alleging their formulary and rebate practices fueled the state's opioid epidemic over more than two decades. The complaint alleges the PBMs gave OxyContin unrestricted preferred formulary status in exchange for confidential payments from Purdue Pharma, avoided prior authorization and step-therapy controls, distributed misleading materials downplaying addiction risk, and sold prescriber data for targeted opioid marketing. Filed under the Arizona Consumer Fraud Act, the suit seeks restitution, civil penalties, injunctive relief, disgorgement and corrective programs. It closely mirrors a similar Arkansas lawsuit filed against the same two PBMs in June 2024, part of a broader wave of state litigation scrutinizing PBM business practices.
- Federal Policy · SD
CMS Awards $7.2 Million for South Dakota Ambulance Telemedicine
CMS announced $7.2 million in federal funding to expand ambulance-based telemedicine and upgrade emergency communications infrastructure across South Dakota. The funding will support rural emergency medical services, including equipment for real-time video consultation between ambulance crews and physicians during transport. South Dakota officials and providers will implement the upgrades, which aim to improve emergency care access in rural and underserved areas of the state. The announcement did not specify an implementation timeline or the funding mechanism involved.
- Federal Policy
HHS Picks 8 Communities for $96M Homelessness, Addiction Program
HHS Secretary Robert F. Kennedy Jr. announced in Houston that eight communities have been selected to receive funding through the new STREETS program, administered by SAMHSA. The program will distribute $96 million over four years to help selected communities build coordinated systems of care for people experiencing homelessness who have serious mental illness, substance use disorders, or co-occurring disorders. The announcement names the funding recipients but does not detail specific program start dates or application requirements for future rounds.
- Industry · RI
Brown University Health Cuts Jobs Citing Medicaid-Driven Cost Pressures
Brown University Health, Rhode Island's largest hospital system, announced buyouts for up to 200 non-clinical supervisors and layoffs of an unspecified number of executives, effective the start of its new fiscal year. CEO John Fernandez cited rising pharmaceutical, labor and supply costs alongside growing uncompensated care, insurer denials and bad debt. The system attributes much of the pressure to federal policy changes restricting Medicaid eligibility and ending exchange subsidies, projecting $346 million in charity care, denials and debt costs for fiscal 2027, $71 million more than the prior year, and a $64 million deficit. Despite the cuts, the system plans $210 million in capital facility upgrades and a January merit increase, and will end employee health plan coverage of GLP-1 drugs for weight loss starting Jan. 1.
- Industry
Mintz Quarterly Update Surveys PBM Policy Developments Through June 2026
In its Fall 2026 PBM Policy and Legislative Update, Mintz's Managed Care, PBMs & Pharmacies practice compiles federal and state developments affecting pharmacy benefit managers and the drug supply chain from mid-February through June 2026. The quarterly digest covers legislative and regulatory activity relevant to PBMs, health plans, and pharmacies operating across commercial and government-sponsored programs, including Medicaid. It serves as a reference roundup rather than a report on a single event, consolidating multiple developments tracked over the period. No specific effective dates apply since the piece is a periodic summary rather than a new rule or action.
- Legal · SC
OIG Finds SC Underreported $108.6M in Medicaid COVID FMAP Collections
HHS OIG found that South Carolina failed to report approximately $108.6 million of the federal share of Medicaid and CHIP collections subject to the temporary increased FMAP authorized during the COVID-19 public health emergency. The finding stems from an audit examining whether the state properly identified and returned collections tied to the enhanced federal match rate. The report affects South Carolina's Medicaid agency, which will likely need to refund the unreported federal share to CMS and correct its reporting processes. The audit underscores broader compliance risk for states that received the temporary FMAP bump and must accurately reconcile collections against the higher match rate.