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Tuesday, June 2 · 13 stories
- Industry
Eli Lilly Threatens to Cut 340B Discounts for Hospitals Refusing Data Sharing
Eli Lilly has issued an ultimatum to certain 340B hospitals requiring them to share data proving they are not duplicating drug discounts by Monday or face loss of 340B pricing. The pharmaceutical company claims some hospitals refuse to provide documentation showing compliance with program requirements prohibiting duplicate Medicaid and 340B discounts on the same claim. Hospitals are pushing back and requesting federal government intervention. The dispute centers on manufacturer attempts to limit 340B discounts amid concerns about program integrity and duplicate discounting.
- Industry · NC
Trump Rural Health Fund Excludes Closed Hospital Reopening Efforts
A proposed $50 billion rural health funding package championed by Congressional Republicans is not expected to support efforts to reopen closed rural hospitals, including Martin County, North Carolina's shuttered facility. The funding structure appears focused on operational support for existing facilities rather than capital investment for reopening closed hospitals. Rural hospital closures have accelerated over the past decade, leaving gaps in access to emergency and inpatient services. The exclusion raises questions about how federal rural health investment will address communities that have already lost their hospitals.
- Legal · MA
Massachusetts AG Sues UnitedHealthcare for $100M MassHealth Risk Score Fraud
The Massachusetts Attorney General filed suit against UnitedHealthcare alleging the insurer improperly inflated health risk scores for MassHealth members to obtain at least $100 million in excess capitation payments. The complaint accuses UnitedHealthcare of manipulating diagnosis coding to secure higher risk-adjusted payments from the state Medicaid program. The lawsuit seeks recovery of overpayments and penalties. This case signals increased state enforcement of risk adjustment integrity in Medicaid managed care and may prompt heightened scrutiny of diagnosis coding practices and chart review audits across other states.
- Federal Policy
CMS Issues Interim Final Rule Imposing 80-Hour Monthly Work Requirement for Adult Medicaid Beneficiaries
CMS released an interim final rule Monday requiring certain adult Medicaid beneficiaries to meet an 80-hour monthly work requirement. The rule takes effect as an interim final rule, meaning it is immediately enforceable while CMS accepts public comments. Experts warn the requirement could reduce health coverage for home care workers, potentially disrupting LTSS workforce stability and service continuity for Medicaid managed care beneficiaries who rely on home-based services. The rule affects adult beneficiaries in non-expansion populations, though specific exemptions and state implementation timelines remain unclear from this brief announcement.
- Legal
Court Vacates Gender Identity Protections in Section 1557 Nondiscrimination Rule
On October 22, 2025, the U.S. District Court for the Southern District of Mississippi vacated provisions of HHS's May 2024 Section 1557 final rule that expanded Title IX's sex discrimination definition to include gender identity discrimination. The vacated provisions are legally void. All other provisions of the Section 1557 nondiscrimination rule remain in effect. The ruling affects how Medicaid managed care organizations must handle gender identity-related coverage determinations, prior authorization policies, and grievance procedures under federal nondiscrimination requirements.
Monday, June 1 · 18 stories
- Industry
Telehealth Companies Expand GLP-1 Access Amid Safety and Screening Concerns
Telehealth platforms have rapidly scaled access to GLP-1 weight loss medications in response to surging patient demand. Researchers and physicians have raised concerns that some online providers may not adequately screen patients for contraindications or provide appropriate clinical monitoring during treatment. The safety questions emerge as telehealth prescribing of these high-cost medications expands outside traditional clinical settings. The controversy affects how managed care organizations evaluate telehealth vendor networks and pharmacy benefit management for GLP-1 drugs.
- Federal Policy
GAO Finds HUD Cannot Track Service Coordinators Due to Data Quality Failures
A GAO report found that HUD lacks uniform data entry procedures for service coordinators in multifamily housing and cannot determine how many properties employ them or whether properties comply with program requirements. HUD also does not routinely analyze performance reports from service coordinators. Stakeholders reported service coordinators help residents avoid eviction and apply for Medicaid, but five studies showed mixed results on health, financial, and housing outcomes. Rural challenges include managing multiple funding sources, limited service providers, and long distances to services.
- State Policy
Uninsurance Rate for Children Under 6 Hits Decade High, Up 220,000 Since 2022
A new report shows uninsurance among children birth through age 5 has reached its highest level in nearly a decade, with more than 220,000 young children losing coverage between 2022 and 2024. The increase follows the end of Medicaid continuous enrollment protections and state redetermination processes. The trend represents a reversal of coverage gains achieved during the public health emergency. Young children are predominantly enrolled in Medicaid and CHIP, making these coverage losses directly relevant to state program performance and managed care plan enrollment.
- Federal Policy
Uninsured Rate for Children Under 6 Jumped 23% Since 2022 Medicaid Unwinding Began
The number of uninsured children under age 6 increased 23% between 2022 and 2024, reaching the highest level in nearly a decade, compared to a 17% increase for school-aged children. The sharper rise among younger children coincides with Medicaid redeterminations that began after the end of the continuous enrollment provision in spring 2023. Young children face higher procedural disenrollment risk due to more frequent address changes and verification requirements. The data suggests gaps in ex parte renewal processes and family communication strategies that disproportionately affect families with infants, toddlers, and preschoolers.
- Federal Policy
Trump Administration's $50 Billion Rural Health Fund Will Not Reopen Closed Hospitals
The Trump administration's $50 billion rural health initiative will not fund hospital reopenings, despite Republican campaign messaging around rural healthcare access. The fund's structure focuses on operational support for existing facilities rather than capital investment to restore shuttered hospitals. Rural hospital closures disproportionately affect Medicaid beneficiaries, who comprise a significant share of patient populations in these areas. The policy gap means communities that have already lost hospital access will not see facility restoration through this federal initiative.
- Federal Policy
Federal Arbiters Finalize Dispute Resolution Rule for Surprise Medical Bills
Federal regulators released a final rule Thursday governing how health plans and providers resolve payment disputes over out-of-network emergency and certain non-emergency services under the No Surprises Act. The rule refines the independent dispute resolution process that applies when plans and providers cannot agree on payment rates for surprise bills. Health plans criticized the rule for not doing enough to prevent providers from exploiting the arbitration system, while the rule's proponents say it balances provider and plan interests. The changes take effect upon publication in the Federal Register.
- Federal Policy
CDC Reports 8% Uninsured Rate, 800,000 More Uninsured in 2025
The Centers for Disease Control and Prevention reported that the U.S. uninsurance rate remained stable in 2024 compared to the prior year. The data provides a baseline before anticipated coverage losses from federal healthcare spending cuts included in recent budget legislation. Medicaid managed care organizations may see enrollment declines if federal funding reductions lead to eligibility restrictions or benefit changes. The timing of any coverage losses will depend on how states implement budget cuts and whether Medicaid programs face disproportionate reductions.
- Industry · MN
Minnesota Hospitals Provide Limited Charity Care Despite Growing Uninsured Population
An investigation of Minnesota hospital data reveals most facilities provide minimal financial assistance to uninsured patients and create barriers to accessing charity care programs. The analysis examined hospital charity care spending and program accessibility as the state's uninsured population grows. The findings highlight systemic gaps in the healthcare safety net that affect uninsured individuals who may be eligible for Medicaid but face enrollment barriers or fall into coverage gaps. These charity care shortfalls increase the likelihood that uninsured patients delay care or accumulate medical debt, potentially affecting downstream Medicaid enrollment and emergency department utilization patterns.
- Legal
Mifepristone Mailing Access Faces Monday Deadline Amid Legal Uncertainty
Physicians may lose the ability to mail mifepristone starting Monday due to ongoing legal challenges, though abortion advocates indicate alternative distribution channels will remain available. The restriction would affect direct-to-patient telemedicine abortion services that expanded during the pandemic. The timing suggests a court-imposed deadline or regulatory change taking effect. While this primarily affects private abortion providers and retail pharmacy channels, Medicaid managed care organizations covering abortion services in states where it remains legal may see members redirected to in-person dispensing or alternative medication abortion protocols.
- Federal Policy
CMS Adds 10 States to CCBHC Medicaid Demonstration Program
HHS announced that 10 states—Alaska, Colorado, Hawaii, Louisiana, Maryland, Mississippi, Montana, North Dakota, Washington, and West Virginia—will join the Certified Community Behavioral Health Clinic (CCBHC) Medicaid Demonstration Program. The demonstration, operated jointly by CMS and SAMHSA, tests an alternative payment model for comprehensive community behavioral health services. CCBHCs provide a defined scope of crisis, mental health, and substance use disorder services under a prospective payment system. For participating states, managed care organizations will need to contract with CCBHCs and adjust payment methodologies to comply with the demonstration's requirements.
- Federal Policy
SAMHSA Awards $255 Million Contract to Administer 988 Suicide & Crisis Lifeline
The Substance Abuse and Mental Health Services Administration awarded $255 million to Vibrant Emotional Health to continue administering the 988 Suicide & Crisis Lifeline. The contract supports a national network of over 200 local crisis contact centers that have handled more than 25 million contacts since the lifeline's launch. The funding sustains federal infrastructure for crisis response services that increasingly intersect with Medicaid-funded behavioral health benefits. Medicaid managed care organizations often coordinate with 988 for crisis intervention and may face network adequacy requirements tied to crisis services availability.
- Federal Policy
HHS Announces Action Plan to Reduce Psychiatric Overprescribing
The Department of Health and Human Services announced an action plan targeting psychiatric overprescribing and promoting deprescribing when clinically appropriate. HHS Secretary Robert F. Kennedy, Jr. outlined the initiative at a mental health summit focused on overmedicalization. The announcement did not specify implementation timelines, enforcement mechanisms, or how the plan would apply to Medicaid managed care organizations. HHS has not released detailed guidance on prescribing standards, prior authorization changes, or utilization management requirements that would affect MCO behavioral health benefit administration.
- Managed Care
Pregnant Women with Gum Disease Face 3-4x Higher Pre-Eclampsia Risk
Pregnant women with gum disease are three to four times more likely to develop pre-eclampsia, an emergency condition that poses serious maternal and fetal health risks. The finding underscores the clinical importance of integrating oral health into prenatal care delivery models. Growing evidence linking dental health to maternal outcomes is prompting ob-gyns, state Medicaid programs, and health plans to reconsider care coordination and benefit design. No specific policy action or timeline is described.
- Industry
Gene Therapy Medications Pose Financial Challenges for Health Plans
Metabolic gene therapies are creating new financial pressures for health plans and benefits managers. These treatments offer clinical benefits for patients with serious conditions but carry high costs that require specialized coverage and payment strategies. The article discusses how plans must prepare benefits structures to manage these emerging high-cost therapies. No specific implementation timeline or regulatory action is described.
- Industry
Home-Based Care Providers Diversify Payer Mix Amid Reimbursement Pressure
Home-based care providers are restructuring their business models in response to sustained reimbursement cuts and policy changes across payers. Providers report cumulative financial strain from incremental rate reductions and inconsistent payment structures. In response, agencies are diversifying their payer portfolios and forming local partnerships to maintain financial viability. These strategic shifts are occurring now as providers adapt to what industry leaders describe as accumulating incremental cuts rather than single policy changes.