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Wednesday, July 8 · 37 stories
- Federal Policy
Partnership for Medicaid Issues H.R. 1 Community Engagement Implementation Guidance
The Partnership for Medicaid released recommendations for CMS and states on implementing community engagement requirements under H.R. 1. The guidance addresses operational considerations for managed care organizations tasked with verifying beneficiary compliance and coordinating exemptions. Implementation timelines and specific federal guidance remain pending. This matters because MCOs will likely bear responsibility for tracking work requirements, exemption processes, and related reporting — operational burdens that require system changes, vendor coordination, and potential contract amendments.
- Federal Policy
MHPA Warns Senate Against Budget Reconciliation Provisions Affecting Medicaid MCOs
Medicaid Health Plans of America sent a letter to Senate leadership urging caution on specific provisions in the House-passed budget reconciliation bill. The trade association outlined concerns about how reconciliation measures could affect Medicaid managed care operations and beneficiaries. The letter was addressed to Senate Majority Leader John Thune, Minority Leader Chuck Schumer, and Finance Committee leadership. The reconciliation bill is now under consideration in the Senate, with potential modifications before final passage.
- Federal Policy
Modern Medicaid Alliance Urges Congress to Reject Proposed Medicaid Cuts
The Modern Medicaid Alliance has issued a statement urging Congress to reject proposed cuts to Medicaid currently under consideration. The advocacy coalition warns the cuts would directly affect Medicaid beneficiaries' access to care. The statement comes as Congress debates budget reconciliation proposals that could significantly reduce federal Medicaid spending. Timing and specific legislative vehicles remain subject to ongoing negotiations.
- Federal Policy
MHPA Coalition Urges Congress to Protect Medicaid and CHIP Funding
Medicaid Health Plans of America led a coalition letter to Senate Finance and House Energy & Commerce leadership on March 3, 2025, expressing support for Medicaid and CHIP programs. The letter was sent to committee chairs and ranking members as Congress considers budget and program changes. The coalition advocates for preserving funding and program integrity during legislative discussions. This signals organized industry pushback against potential Medicaid cuts or restructuring under consideration in the 119th Congress.
- Federal Policy
House Subcommittee Considers Bipartisan Medicaid HCBS Strengthening Legislation
The House Energy & Commerce Health Subcommittee held a hearing on April 30, 2024, to consider legislative proposals addressing Medicaid access and program integrity. The Medicaid Health Plans of America submitted a statement for the record supporting bipartisan policy to strengthen home and community-based services and make related changes permanent. The hearing covered multiple proposals affecting Medicaid program operations and access to care. MHPA's statement signals managed care industry support for HCBS policy changes under congressional consideration.
- Industry
MHPA Submits Congressional Testimony on Generic Drug Shortage Legislation
Medicaid Health Plans of America (MHPA) provided testimony to Congress regarding legislative proposals to address drug shortages and ensure access to affordable generic drugs, with particular focus on sterile injectable medications. The trade association representing Medicaid managed care organizations weighed in on pending federal legislation aimed at stabilizing the generic drug supply chain. MHPA's position supports congressional efforts to resolve shortages that affect Medicaid beneficiaries' access to essential medications.
- Federal Policy
MHPA Urges Changes to Draft Dual Eligible Care Integration Legislation
Medicaid Health Plans of America submitted recommendations on draft federal legislation aimed at improving care coordination and outcomes for dually eligible beneficiaries. The trade association expressed support for the bill's integration goals while raising concerns about specific provisions and requesting clarification on implementation details. The legislation seeks to better align Medicare and Medicaid services for the approximately 12 million Americans enrolled in both programs. MHPA's feedback reflects managed care industry priorities around dual eligible special needs plans (D-SNPs) and integrated care models.
- State Policy · CO
Colorado Issues Medicaid Outreach Toolkit, Polis Signs Healthcare Bills
The Colorado Department of Health Care Policy and Financing released a communications toolkit for partners to help Medicaid enrollees understand upcoming program changes. The toolkit is part of a new resource hub offering ready-to-use materials for outreach efforts. Governor Jared Polis also signed several healthcare bills into law this week, including SB26-178, which creates sustainable funding for an unspecified program. The document does not provide details on when the Medicaid changes take effect or what they entail.
- Managed Care
CMS Proposes Limits on State Directed Payments Under New Statutory Authority
On May 20, 2026, CMS released a proposed rule implementing statutory limits on state directed payments (SDPs) enacted under H.R.1 (Public Law 119-21). The rule establishes new caps and requirements for SDPs that states use to direct managed care organization payments to providers. The proposed changes would affect how states structure supplemental payments within capitation rates and require new CMS preapproval processes. Public comments are due 60 days from Federal Register publication. The rule directly impacts MCO rate setting, provider payment arrangements, and state contract negotiations for managed care plans participating in SDP arrangements.
- Federal Policy · CA
H.R. 1 Imposes Federal Medicaid Work Requirements, Cuts $1 Trillion Over Decade
In July 2025, President Trump signed H.R. 1 into law, reducing federal Medicaid funding by $1 trillion over ten years and establishing a federal work requirement for certain adult enrollees. The law mandates that covered adults work, attend school, or volunteer to maintain eligibility. The requirements apply to non-exempt adult populations and represent a fundamental shift from prior waiver-based work requirement approaches to a statutory federal mandate. States must implement compliance tracking and reporting systems, affecting MCO enrollment verification, eligibility redeterminations, and coverage continuity processes.
- State Policy · CA
California Health Care Foundation Publishes Medi-Cal HCBS Fact Sheet Series
The California Health Care Foundation released a fact sheet series explaining the essential components of Medi-Cal Home and Community-Based Services. The series covers how HCBS programs help older adults and people with disabilities live independently in California. The fact sheets are designed as educational resources for stakeholders working with or seeking to understand California's HCBS delivery system. While timing is not specified, this reflects ongoing state efforts to expand community-based alternatives to institutional care under Medicaid.
- Managed Care
Some Health Plans Exclude Manufacturer Copay Assistance from Deductible and Out-of-Pocket Maximums
Health insurers are implementing policies that exclude manufacturer copay assistance from counting toward patient deductibles and out-of-pocket maximums, a practice known as copay accumulator programs. When drugmakers provide financial assistance to help patients afford expensive medications, these programs prevent those payments from reducing the patient's cost-sharing obligations under the plan. Patients effectively pay twice — once through the manufacturer assistance that does not count toward their deductible, and again when they must meet the full deductible out of their own pocket. This practice affects managed care plans' pharmacy benefit design and patient access to high-cost specialty medications.
- Industry
FDA Approves Over-the-Counter CGM for Childhood Obesity Management
The FDA has approved an over-the-counter continuous glucose monitor (CGM) for use in young children, including toddlers as young as two years old, as a tool for childhood obesity management. The approval represents a significant shift in glucose monitoring technology from prescription diabetes management to preventive wellness applications in the pediatric population. Medical experts are evaluating the clinical benefits of real-time glucose data for obesity prevention against potential risks including device-related anxiety, misinterpretation of normal glucose fluctuations in non-diabetic children, and the appropriateness of medical device use in very young children. The approval takes effect immediately with retail availability expected in the coming months.
- Managed Care
GLP-1 Weight Loss Use Jumps to 11% of Americans in Two Years
A Gallup survey released Tuesday shows 11 percent of Americans now take GLP-1 medications for weight loss, up from 3 percent in 2024. An additional 15 percent report considering use. The sharp uptick in utilization represents significant pharmacy cost pressure for Medicaid managed care plans, which face coverage mandates in some states and growing member demand. Plans must manage prior authorization protocols, medical necessity criteria, and budget forecasts as obesity prevalence grows among Medicaid populations.
- Industry
Four Health Plans Expand Specialty Pharmacy Strategies to Address Drug Cost Growth
Four health insurers are implementing new specialty pharmacy approaches in 2026 to address rising prescription drug costs, a major driver of overall cost growth. Strategies include expanding service offerings, entering healthcare delivery, and pursuing partnerships to increase cost discipline. The initiatives reflect broader industry efforts to manage high-cost specialty medications through vertical integration and improved utilization management. Specific plan names and implementation details were not provided in the source material.
Tuesday, July 7 · 24 stories
- State Policy · CA
California Launches Birthing Care Pathway to Improve Medicaid Maternity Outcomes
California's Department of Health Care Services has implemented a Birthing Care Pathway as part of a multi-pronged state initiative to improve maternity care delivery. The pathway is one of three current California programs targeting maternal health outcomes, alongside the Transforming Maternal Health Model and Rural Health Transformation Program. The initiative affects Medicaid managed care organizations operating in California and their contracted maternity care providers. This is part of California's broader strategy to address maternal mortality and morbidity through structured care delivery frameworks.
- Legal
5,000 Independent Pharmacies Sue Prime Therapeutics for Alleged Antitrust Violations
Nearly 5,000 independent pharmacies filed a federal antitrust lawsuit on July 2, 2026, in the U.S. District Court for the Western District of Washington against Prime Therapeutics, alleging the PBM conspired with Express Scripts to suppress pharmacy reimbursement rates and increase fees. The complaint claims violations of federal antitrust law through coordinated pricing practices. The lawsuit targets PBM reimbursement methodologies that affect pharmacy network economics. This litigation follows broader scrutiny of PBM pricing practices and their impact on pharmacy access.
- Federal Policy
CMS Launches Medicare GLP-1 Bridge Program with Fixed-Cost Access
The Centers for Medicare & Medicaid Services launched its Medicare GLP-1 Bridge program on July 1, 2026, offering select beneficiaries fixed-cost access to GLP-1 medications including Foundayo and Wegovy. The program arrives as GLP-1 use among US adults reached 11% in 2026, up from 3% in 2024, according to a July 7 Gallup poll. The new Medicare benefit structure establishes precedent for coverage of anti-obesity medications that could influence Medicaid managed care pharmacy benefits and prior authorization protocols. Medicaid MCOs should monitor whether states adopt similar fixed-cost or expanded coverage models for their programs.
- Industry
Yale Study Finds Most Telehealth GLP-1 Vendors Skip Live Clinician Visits
A secret shopper study published July 6 in JAMA found that most telehealth platforms prescribing GLP-1 medications do not require real-time clinician interaction with patients before prescribing. Yale researchers documented prescribing practices across online vendors selling these weight-loss and diabetes medications. The study raises questions about appropriateness of care, patient safety, and adherence to clinical practice standards in the rapidly growing direct-to-consumer telehealth market for high-cost specialty drugs. Implications for Medicaid managed care organizations include potential utilization management concerns and pharmacy benefit oversight challenges.
- Industry
MedCity News Op-Ed Calls for Unified Governance in Health Data Exchange
A MedCity News opinion piece argues that while technical infrastructure for nationwide health data exchange exists, fragmented governance and inconsistent enforcement threaten its sustainability. The author contends that patients, providers, and innovators require unified oversight to maintain trust in interoperability frameworks. The piece does not announce new policy or enforcement actions. For Medicaid managed care organizations, the commentary reflects ongoing industry concern about the durability of federal interoperability requirements under the CMS Interoperability and Patient Access Rule and related ONC standards.