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Friday, June 26 · 9 stories
- Federal Policy
MACPAC Releases 2026-2027 Meeting Agenda on Program Integrity and Federal Oversight
The Medicaid and CHIP Payment and Access Commission (MACPAC) has published its analytic agenda for the 2026-2027 meeting cycle. The agenda includes program integrity, the federal role in Medicaid oversight, and other policy areas that will be examined through public meetings and research over the next two years. MACPAC's work typically informs congressional deliberations and CMS policy development. Managed care organizations should monitor MACPAC proceedings as the Commission's recommendations often lead to regulatory or legislative changes affecting MCO operations, compliance requirements, and payment policy.
- State Policy
Young Children's Uninsurance Rises Faster Than School-Age Peers Pre-2025
Analysis shows young children experienced faster uninsurance growth compared to school-aged children prior to 2025 Medicaid enrollment declines. The trend emerged before recent federal policy changes including Trump administration actions and H.R. 1 proposals. The data suggests underlying coverage gaps for young children independent of current redeterminations. States may need targeted outreach and enrollment strategies for families with young children to reverse the trend.
- Industry
Proposed Legislation Would Restructure Federal 340B Drug Pricing Program
Congressional legislation has been introduced to overhaul the 340B drug discount program, which requires pharmaceutical manufacturers to provide discounted outpatient drugs to eligible healthcare providers. The bill would restructure eligibility requirements and oversight mechanisms for the program that currently serves safety-net providers including some Medicaid managed care organizations and federally qualified health centers. If enacted, the changes would affect how covered entities access discounted medications and could alter prescription drug cost structures for Medicaid plans contracting with 340B-eligible providers. The proposal comes amid ongoing disputes between manufacturers and covered entities over contract pharmacy arrangements and duplicate discount prohibitions.
- Federal Policy
House Hearing Surfaces Partisan Split on CMS Medicaid Funding Deferrals
A House subcommittee hearing Thursday revealed sharp partisan divides over recent CMS actions deferring or threatening Medicaid funding in multiple states. State Medicaid directors defended program integrity efforts while Democratic members questioned why only Democratic-led states have faced funding actions despite administration claims the crackdown applies nationwide. The hearing focused on CMS's authority to withhold federal matching funds and the criteria used to identify states for enhanced scrutiny. The dispute centers on whether recent enforcement actions reflect objective program integrity standards or politically motivated targeting.
- State Policy · CT
Connecticut Medicaid Spending Rose in 2024 but Remained Lowest Per-Member Cost
Connecticut's Medicaid program experienced spending increases in 2024 while maintaining the lowest per-enrollee costs compared to commercial insurance markets in the state. The data shows Medicaid's cost efficiency persisted despite upward spending pressure. The comparison encompasses all insurance market segments operating in Connecticut. Medicaid managed care organizations in the state continue to deliver care at lower per-member costs than commercial carriers, though absolute spending grew year-over-year.
- Industry
Jails Face Medetomidine-Laced Opioid Withdrawal Crisis Without Treatment Protocols
Correctional facilities are increasingly encountering severe withdrawal cases from opioids contaminated with medetomidine, a veterinary sedative, but lack established treatment protocols for this emerging threat. The drug causes life-threatening withdrawal symptoms distinct from traditional opioid withdrawal, including extreme cardiovascular instability. Jails serve as unintentional frontline medical facilities as individuals enter custody experiencing these dangerous withdrawal episodes. Many facilities remain unprepared with limited access to specialized medical staff or evidence-based treatment approaches for this substance combination.
- Legal
Federal Court Orders Unsealing of Decade-Old False Claims Act Filings in HCR ManorCare Case
A federal court in Pennsylvania ordered the unsealing of nearly ten years of False Claims Act filings in U.S. ex rel. Compton v. HCR ManorCare, Inc., ruling that the government failed to justify continued sealing under the strong presumption of public access to judicial records. The decision, issued April 17, 2026, requires disclosure of qui tam complaint materials that have been under seal since 2016. The ruling reflects growing judicial scrutiny of extended seal periods in FCA cases, which typically remain sealed while the government investigates allegations of fraud against federal health programs including Medicaid.
- Legal
UPIC Audits Target Medicare and Medicaid Provider Billing Compliance
Unified Program Integrity Contractors (UPICs) are CMS-hired auditors that review healthcare provider medical and billing records to identify improper payments and pursue recoupments in Medicare and Medicaid programs. UPICs operate as part of CMS's broader program integrity enforcement infrastructure. The article provides a procedural overview for providers facing UPIC audits, covering response strategies and compliance steps. This guidance is relevant for any Medicaid managed care organization or provider subject to program integrity review.
- Federal Policy
CMS Prioritizes IRA Implementation and PBM Reform in Drug Pricing Agenda
The Trump administration has placed drug pricing at the top of its health policy agenda, with CMS focusing on implementing Inflation Reduction Act provisions and pursuing pharmacy benefit manager reforms. The agency is working on Medicare price negotiation, inflation rebates, and Part D redesign while exploring PBM transparency and reform measures. These initiatives affect how Medicaid managed care organizations negotiate drug prices, manage pharmacy benefits, and coordinate with Medicare for dual-eligible beneficiaries. The timeline for specific regulatory actions remains under development.
Thursday, June 25 · 15 stories
- Federal Policy
KFF Tracker Compiles Federal Medicaid Program Integrity Actions by State
The Kaiser Family Foundation maintains an ongoing tracker of federal Medicaid program integrity developments and their state-specific implications. The resource documents CMS enforcement actions, audit findings, and compliance initiatives as they emerge across different states. The tracker serves as a reference for monitoring federal oversight activity affecting state Medicaid programs. It compiles information on federal actions rather than reporting a single policy change or rulemaking.
- Federal Policy
Cassidy Introduces Bill to Limit Hospital 340B Drug Discount Eligibility
Senator Bill Cassidy has introduced legislation to restrict eligibility for the 340B drug discount program, which allows certain hospitals and health centers to purchase outpatient drugs at steep discounts. The proposal comes as hospitals face broader federal funding pressures. While specific provisions are not detailed in the brief article, any 340B restrictions typically target hospital eligibility criteria, contract pharmacy arrangements, or program oversight. The timing is significant as hospitals already navigate budget constraints and prior 340B enforcement actions.
- Legal
Court Permits End to TPS Protections for Syrian and Haitian Nationals
A federal court ruled that the Trump administration may terminate Temporary Protected Status (TPS) for nationals from Syria and Haiti. The decision affects approximately 7,000 Haitians and 6,700 Syrians currently residing in the U.S. under TPS. The ruling follows years of litigation challenging the administration's 2018 decision to end these protections. Affected individuals will face potential deportation unless they adjust their immigration status through other means or Congress acts to provide alternative relief.
- State Policy · IL
Illinois Law Restricts Out-of-State Access to Abortion, Gender Dysphoria Records
Illinois Governor J.B. Pritzker signed the Reproductive Health Records Privacy Act on June 24, 2025, requiring abortion services and gender dysphoria diagnoses to be separated from patients' electronic medical records and limiting disclosure to out-of-state entities. The law takes effect July 1, 2027. Healthcare providers, including Medicaid managed care organizations, must implement new record-keeping protocols to segregate these specific health information categories and establish controls preventing out-of-state disclosure.
- State Policy · CA
California Replaces Mental Health Services Act with New Behavioral Health Services Act
California has replaced the Mental Health Services Act (MHSA) with the Behavioral Health Services Act (BHSA), changing how counties allocate mental health funding. The BHSA modifies funding allocation requirements and county spending priorities for mental health and substance use disorder services. The change affects how counties structure behavioral health programs and redirect existing MHSA revenues. California Health Care Foundation has published resources detailing the differences between the two funding frameworks.
- State Policy · KY
Kentucky Directs Opioid Settlement Funds to Rural Substance Use Services
Eastern Kentucky is using opioid settlement funding to support programs addressing substance use disorders, housing instability, and food insecurity in rural communities. The initiative targets regions heavily affected by the opioid crisis with integrated support services. No specific implementation timeline or funding amount is provided in the reporting. This represents Kentucky's approach to deploying settlement resources for behavioral health infrastructure in underserved areas.
- Managed Care
National Health Law Program Calls for Expanded Menopause Coverage in Medicaid
The National Health Law Program identifies significant barriers to menopause care for Medicaid enrollees, including coverage gaps and access challenges. Approximately 6,000 people enter menopause daily in the U.S., experiencing symptoms like hot flashes, bone loss, sleep disturbances, and cognitive changes that can be disabling but treatable. The organization highlights that Medicaid beneficiaries, low-income individuals, and people of color face disproportionate obstacles in accessing menopause treatment. The article advocates for improved coverage policies to address these disparities.
- Federal Policy
Bipartisan Bill Would Allow Direct Methadone Prescribing for Opioid Use Disorder
A bipartisan bill in Congress would end the requirement that methadone for opioid use disorder be dispensed only through specialty opioid treatment programs, allowing qualified practitioners to prescribe it directly like buprenorphine. The legislation would enable office-based prescribing and pharmacy dispensing of methadone, dramatically expanding access beyond the current clinic-only model. If enacted, the change would remove a longstanding barrier to medication-assisted treatment that has limited access particularly in rural and underserved areas. The timing and specific requirements for prescriber qualifications remain unclear pending legislative details.
- Legal · NY
Federal Judge Blocks DOJ Subpoenas for Transgender Patient Records at NYC Hospitals
A federal district court issued a temporary restraining order blocking the Justice Department from obtaining medical records of transgender patients treated at New York City hospitals. The ruling halts an ongoing DOJ investigation into gender-affirming care provided at these facilities. The order provides immediate protection for patient records while the case proceeds. The decision affects hospitals treating Medicaid beneficiaries receiving gender-affirming services and raises questions about federal enforcement priorities and patient privacy protections.
- Industry · AR
Arkansas nonprofit launches GME center to expand physician training in rural areas
Heartland Whole Health Institute, a nonprofit founded by Alice Walton, has launched a statewide Graduate Medical Education Technical Assistance Center in Arkansas focused on expanding physician residency training in rural and underserved communities. The institute released a report outlining strategies to grow the physician pipeline through GME program development. The center aims to address provider shortages that affect care access in areas where Medicaid managed care organizations operate networks.
- Federal Policy
CMS Projects U.S. Health Spending to Reach $5.7T in 2025, Driven by Utilization Growth
CMS actuaries project total U.S. health spending will reach $5.7 trillion in 2025, with growth primarily driven by increased utilization rather than unit cost increases. Prescription drug spending is accelerating sharply, particularly for GLP-1 medications used for diabetes and weight management. The utilization trend affects all payers including Medicaid managed care plans, which face rising pharmacy costs and member demand for high-cost specialty drugs. CMS expects spending growth to moderate in subsequent years as utilization patterns stabilize.