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Thursday, June 4 · 12 stories
- Legal · HI
HHS OIG Defunds Hawaii Medicaid Fraud Control Unit After Four Years Without Indictments
The HHS Office of Inspector General will not recertify Hawaii's Medicaid Fraud Control Unit, cutting off $3 million in federal funding after the unit failed to produce any indictments or convictions over four years. Inspector General March Bell notified Hawaii Attorney General Anne Lopez of the decision in a letter. The decertification means Hawaii loses federal matching funds for its MFCU operations. This is the first known instance of OIG defunding a state MFCU for performance failure.
- Legal
Federal Trial Links Fake Nursing Diploma Mill to Patient Death in Florida Fraud Case
Federal prosecutors opened trial in Fort Lauderdale on June 1 for the final contested case from Operation Nightingale, a fraud scheme that sold approximately 15,000 fake nursing credentials over three years. For the first time, prosecutors are connecting the diploma mill scheme to a patient death. The trial represents the conclusion of a federal enforcement action that exposed thousands of individuals with fraudulent nursing degrees working in healthcare facilities nationwide.
- State Policy · LA
Louisiana Immigration Reporting Law Reduces Medicaid Enrollment Among Eligible Families
Louisiana enacted a law one year ago requiring state agencies to report undocumented immigrants to federal authorities, which has resulted in eligible immigrant families avoiding Medicaid applications for themselves and their qualifying children. The law applies broadly to state benefit programs including Medicaid. Eligible children, including U.S. citizens in mixed-status families, are reportedly foregoing enrollment due to fear of family separation or deportation. The chilling effect has reduced uptake of services among populations with legal eligibility, creating coverage gaps and uncompensated care risk.
- Federal Policy
CMS Interprets Medicaid Cuts Law Without Cancer Patient Protections Advocates Expected
CMS has issued guidance interpreting recent Medicaid legislation in a manner that cancer patient advocates argue fails to deliver promised protections from coverage cuts. Blood Cancer United's Gwen Nichols warns that vulnerable oncology patients face exposure to benefit reductions or coverage limitations despite congressional assurances. The interpretation affects how states and managed care organizations implement Medicaid changes affecting cancer treatment access and continuity of care. The guidance creates immediate operational uncertainty for MCOs managing oncology benefits and prior authorization protocols.
- State Policy · WI
Wisconsin APRN Modernization Act Grants Full Practice Authority Effective September 1, 2026
Wisconsin's APRN Modernization Act, passed in August 2025, takes effect September 1, 2026, granting Advanced Practice Registered Nurses full practice authority without requiring collaborative arrangements with physicians. Wisconsin becomes one of approximately two dozen states with full practice authority for APRNs. The change affects how Medicaid managed care organizations credential, contract with, and reimburse APRNs as independent practitioners. MCOs must update provider networks, credentialing policies, and reimbursement methodologies to reflect APRNs' expanded scope of practice.
- Industry · NY
Westchester Medical Center Partners with MVP Health Care on Care Coordination
Westchester Medical Center Health Network in New York has launched a partnership with MVP Health Care to improve care coordination for hospitalized patients and during discharge transitions. MVP clinical care managers will be embedded in hospital care teams and will continue supporting members after they return home. The partnership aims to reduce readmissions and improve care continuity. The arrangement reflects growing collaboration between health systems and payers on care transition programs.
Wednesday, June 3 · 6 stories
- State Policy
2026 Maternal Mental Health State Report Cards Find No State Earns Overall F Grade
The Policy Center for Maternal Mental Health and George Washington University released the 2026 Maternal Mental Health State Report Cards, showing improvement in state-level performance with no states receiving an overall failing grade for the first time. The report evaluates state policies addressing maternal mental health conditions, which affect one in five mothers and impose significant financial costs when untreated. A new assessment category for parental support reveals widespread deficiencies across states. The report cards provide a framework for states to benchmark their maternal mental health infrastructure and identify policy gaps.
- Industry
Providers and Insurers Deploy AI Tools for Prior Authorization and Claims Battles
Healthcare providers and insurers are increasingly using artificial intelligence to automate prior authorization requests and claims denials, creating an escalating technological arms race in medical billing. Providers use AI to generate documentation and appeals, while payers deploy AI to review and deny claims at scale. The automation may reduce administrative burden but also risks accelerating denials without human clinical judgment. This trend affects Medicaid managed care organizations that already face scrutiny over prior authorization delays and denial rates.
- Legal · TX
Texas Appeals Court Denies Novartis Petition to Halt Medicaid Fraud Qui Tam Case
The Fifteenth Court of Appeals in Texas denied Novartis Pharmaceuticals' request for mandamus relief to halt a Medicaid qui tam action brought under the Texas Medicaid Fraud Prevention Act (TMFPA). While the court acknowledged "weighty" constitutional questions raised by Novartis regarding the TMFPA's qui tam provisions, it ruled that these challenges must be addressed through ordinary appellate review rather than through extraordinary mandamus relief. The decision allows the underlying fraud case to proceed. The ruling affirms that constitutional challenges to state Medicaid fraud statutes, even when substantial, do not automatically warrant immediate appellate intervention before trial court resolution.
- Legal
DOJ Announces Faster False Claims Act Reviews and Expanded Federal Program Fraud Enforcement
The Department of Justice issued a May 27 memorandum accelerating False Claims Act enforcement timelines and expanding focus on federal benefits programs. The new policy directs faster qui tam case reviews, earlier enforcement decisions, and more aggressive fraud identification in federal health programs including Medicaid. The changes take effect immediately and apply to all pending and future FCA matters. This shift means managed care organizations should expect shorter review periods before DOJ intervenes or declines qui tam cases, with heightened scrutiny of billing practices and program integrity across all federal healthcare programs.
- Federal Policy
CMS Administrator Oz to Lead White House Press Briefing
Dr. Mehmet Oz, Administrator of the Centers for Medicare and Medicaid Services, will conduct the White House press briefing on Tuesday. He is filling in for press secretary Karoline Leavitt during her maternity leave, joining other Cabinet officials who have taken on briefing duties. The briefing may provide insight into CMS priorities and policy direction under the current administration. Managed care organizations should monitor for any announcements regarding Medicaid policy, regulatory changes, or administrative guidance that could affect program operations.
- State Policy · HI
Hawaii Launches $28M Rural Health Workforce Program With Service Commitments
Hawaii is launching a $28 million full-tuition program for healthcare students who commit to practicing in rural communities. The Hawai'i Outreach for Medical Education in Rural Under-resourced Neighborhoods program will cover tuition and fees for students pursuing healthcare and Health IT training beginning in September. In exchange, participants must work in designated rural areas after graduation. The program aims to address persistent provider shortages in Hawaii's underserved communities.
Tuesday, June 2 · 13 stories
- Federal Policy
OIG Reports Fourth Quarter 2025 Drug Pricing Comparison Shows ASP-AMP Spreads
The HHS Office of Inspector General released its quarterly comparison of Average Sales Prices (ASP) and Average Manufacturer Prices (AMP) for drugs in the fourth quarter of 2025. This routine report identifies drugs where ASP exceeds AMP by specified thresholds, which triggers potential Medicaid reimbursement adjustments under federal law. The data covers Medicare Part B drugs and provides transparency into pharmaceutical pricing differentials that affect both Medicare and Medicaid programs. CMS uses these comparisons to determine when Medicaid best price penalties may apply.
- State Policy
State Medicaid Work Requirements Data Now Being Tracked Under 2025 Reconciliation Law
A tracking initiative is monitoring state-level implementation of Medicaid work requirements mandated by the 2025 Reconciliation Law. The effort compiles detailed state and national data on how states are operationalizing work requirements, including eligibility verification processes, exemption categories, reporting systems, and compliance mechanisms. Implementation timelines and specific state policies vary as states develop infrastructure to meet federal mandates. For Medicaid managed care organizations, this creates new administrative responsibilities around member eligibility tracking, reporting coordination with state agencies, and potential enrollment fluctuations as work requirements take effect.
- Federal Policy
Lilly Threatens to End 340B Discounts for Hospitals That Don't Submit Claims Data
Eli Lilly issued a five-day ultimatum to hospitals participating in the 340B drug discount program, demanding they submit claims data or lose access to discounted pricing. The move escalates pharmaceutical manufacturers' ongoing efforts to restrict 340B eligibility and impose new compliance requirements on covered entities. Hospitals that fail to comply by the deadline will see their 340B discounts suspended. This follows similar manufacturer-led restrictions that have drawn pushback from HRSA and advocacy groups representing safety-net providers.
- State Policy
Medically Tailored Meal Programs Reduce Hospital Use in State Medicaid Population
A state Medicaid program demonstrated that medically tailored meal interventions reduced hospital utilization and healthcare costs among high-need beneficiaries. The program provided nutrition services targeting members with diet-sensitive chronic conditions. Results showed measurable decreases in inpatient admissions and emergency department visits among participating members compared to controls. The findings support growing interest in addressing social determinants of health through Medicaid managed care benefit design.
- State Policy
States Target Corporate Practice of Medicine in Telehealth Crackdown
Multiple states are introducing legislation to restrict corporate ownership structures that underpin most direct-to-consumer telehealth platforms. The legislative push focuses on corporate practice of medicine doctrine, which prohibits non-physician entities from employing physicians or controlling medical decisions. These state actions could force telehealth companies to restructure their business models or exit certain markets. The timing coincides with increased regulatory attention on telehealth prescribing practices following pandemic-era flexibilities.
- State Policy · NJ
New Jersey Hospital System Mobilizes to Retain 500,000 Medicaid Patients Facing Disenrollment
Hackensack Meridian Health is launching an outreach campaign to educate approximately 500,000 New Jersey Medicaid beneficiaries at risk of losing coverage, with $3.5 billion in reimbursement at stake for the 18-hospital system. The health system president cited concerns about increased emergency department utilization if patients lose coverage and delay care. The disenrollment threat appears connected to federal legislation referenced as the One Big Beautiful Bill Act. Hackensack Meridian is working to help eligible patients maintain enrollment through education and assistance with renewal processes.
- Legal
DOJ Launches West Coast Strike Force Targeting Health Care Fraud in Three Districts
The Department of Justice announced the creation of the West Coast Health Care Fraud Strike Force on April 30, 2026, combining fraud enforcement operations across the District of Arizona, District of Nevada, and Northern District of California with a focus on Silicon Valley. The strike force will coordinate investigations and prosecutions across these three federal districts. This expanded enforcement capacity increases audit and investigation risk for Medicaid managed care organizations operating in the western states, particularly those with behavioral health, telehealth, or technology-enabled care delivery models that have drawn recent DOJ scrutiny.
- State Policy · CA
California Implements Emergency Psychiatric Hospital Staffing Ratios With Financial Penalties
California's Department of Public Health implemented emergency regulations on June 1, 2025, establishing minimum nurse-to-patient ratios for psychiatric hospitals and imposing financial penalties for noncompliance. The regulations were developed in response to a February 2025 San Francisco Chronicle investigation documenting dysfunction, abuse, and understaffing at California behavioral health facilities. The emergency rules apply to all psychiatric hospitals operating in California. Facilities must meet the new staffing standards immediately or face state-imposed penalties.