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Thursday, September 3 · 1 story
- Managed Care · FL
Florida Health Plan Highlights Operational Requirements for Self-Directed Care Programs
Independent Living Systems, a Florida-based health plan serving Medicaid long-term care enrollees, discussed the operational complexities of administering self-directed care when it transitioned to plan status in 2018. The plan required specialized administrative partnerships to support participant-directed services within Florida's Medicaid LTSS program. Self-directed care allows enrollees to manage their own services and supports, but requires health plans to build infrastructure for enrollment, budgeting, and compliance. The article addresses common misconceptions and operational realities for plans administering these programs.
Wednesday, September 2 · 2 stories
- Managed Care
UnitedHealthcare, Aetna, BCBS Plans Implement Lab Testing and Provider Reimbursement Policy Changes
Six major health insurers implemented reimbursement policy changes effective September 1, 2026. UnitedHealthcare is tightening lab testing reimbursement across commercial, Medicare Advantage, and Medicaid plans, with Medicaid rollouts staggered by state from August through December. Changes include caps on allergen testing (20 allergens per year for patients 20+), limits on hepatic fibrosis testing to once every six months, and vitamin B12 testing restrictions to once every three months. BCBS Michigan is phasing out incident-to billing starting September 1, requiring enrollment-eligible clinicians to add modifier SA; by March 2027, clinicians with their own NPI must bill directly or face 80% fee schedule reimbursement. Molina Healthcare of Ohio is implementing new specialty medication administration site-of-care policies and revised buy-and-bill pharmacy policies for several drugs.
- Managed Care · LA
Elevance Health Exits Louisiana Medicaid, Affecting 290,000 Members
Elevance Health and Blue Cross Blue Shield of Louisiana will terminate their Healthy Blue Medicaid plan in Louisiana effective 2027. The exit affects approximately 290,000 Medicaid enrollees who will need to select a new managed care plan. The withdrawal continues a pattern of MCO exits from the Louisiana Medicaid market. Affected members will receive transition notices and have opportunities to enroll in remaining plans before their current coverage ends.
Monday, August 31 · 5 stories
- Managed Care · MA
New England Senior Care Provider Discusses Immigration and Medicaid Policy Impacts on Long-Term Care
Adam Scott, leader of New England's largest nonprofit senior care and housing provider, discussed how immigration policy changes and Medicaid program shifts are affecting long-term care operations during a Harvard T.H. Chan School of Public Health interview. The discussion addressed rising demand driven by Massachusetts' aging population and workforce challenges in the long-term care sector. Scott outlined how policy changes at the federal and state level are creating operational pressures for providers serving Medicaid beneficiaries in residential and community-based settings. The conversation highlights staffing shortages and reimbursement adequacy as key concerns for nonprofit LTSS providers.
- Managed Care · RI
Rhode Island Launches Phone Consultation Program Connecting Primary Care to Behavioral Health
Rhode Island has implemented a phone-based consultation program that allows primary care physicians to connect directly with behavioral health specialists to support patient care. The program addresses the challenge of integrating behavioral health services into primary care settings, where physician shortages mean every visit carries increased clinical weight. The initiative aims to improve access to behavioral health treatment by enabling real-time specialist consultation without requiring separate referrals or appointments. For Medicaid providers and managed care organizations, this represents a care coordination model that can reduce emergency department utilization and improve outcomes for members with co-occurring physical and behavioral health needs.
- Managed Care
Drug-Resistant Fungal Infections Reported in 3,500 Patients Across 28 States
Twenty-eight states reported over 3,500 clinical cases of candida auris, a drug-resistant fungus, as of August 1, 2026, according to CDC surveillance data. The infection primarily affects severely ill patients in healthcare and long-term care facilities, particularly those with breathing tubes, feeding tubes, or catheters. California reported the highest number of clinical cases at 887, followed by Texas (437) and Tennessee (293). The fungus is resistant to multiple antifungal drugs and spreads easily in healthcare settings, with an additional 3,325 screening detections of patients who are colonized but not yet ill.
- Managed Care · CA
Kaiser Mental Health Workers Report Patient Access Delays Tied to Algorithmic Triage Systems
Mental health clinicians at Kaiser Permanente and Rogers Behavioral Health report that automated triage tools have coincided with reduced staffing and delays in patient access to appropriate care. At Kaiser's Walnut Creek facility, triage staff dropped from nine to three clinicians over three years as algorithmic systems took over some functions. Workers report increased patient frustration, missed diagnoses, and treatment delays, prompting union demands for transparency and limits on AI use in triage decisions. California has pending legislation to create safeguards around AI in medical settings.
- Managed Care · CA
Health Net Cancels Assisted Living Benefit for 3,500 California Medi-Cal Members
Health Net will terminate its optional assisted living benefit under CalAIM effective December 31, 2026, affecting approximately 3,500 Medi-Cal enrollees, most elderly with dementia or cognitive impairments. CalViva Health and Community Health Plan of Imperial Valley have also notified the state of their intent to discontinue the benefit. The benefit covers 24-hour care costs at board-and-care homes and memory care facilities, with members paying room and board. Advocates report some residents have already been dropped at emergency rooms and warn that members may face homelessness or hospital cycling without alternative placement options.
Saturday, August 29 · 7 stories
- Managed Care
CMS Guidance Addresses Medicaid Provider Enrollment and MCO Credentialing Standards
Chapter 7 of a CMS guidance document covers Medicaid provider enrollment and managed care organization credentialing requirements. The guidance addresses processes designed to ensure enrollees receive care from qualified providers while preventing enrollment of providers with criminal records related to federal health programs or histories of fraud, waste, or abuse. The content applies to state Medicaid agencies administering provider enrollment and managed care plans conducting credentialing. It clarifies federal expectations for screening and enrollment standards that affect provider network composition and compliance obligations.
- Managed Care
MACPAC Report Recommends Strengthening State Oversight Tools for Medicaid MCOs
The Medicaid and CHIP Payment and Access Commission released recommendations to improve accountability mechanisms for Medicaid managed care plans. The report identifies gaps in current state oversight practices and proposes enhanced tools for state Medicaid agencies to ensure MCO performance and compliance. MACPAC notes that despite managed care being the predominant delivery system, little is known about the accountability tools states actually deploy. The recommendations aim to strengthen both CMS and state-level oversight of managed care programs.
- Managed Care
MACPAC Brief Examines Children's Behavioral Health Service Use in Medicaid and CHIP
MACPAC published a brief analyzing behavioral health service utilization among children enrolled in Medicaid and CHIP, who experience higher rates of conditions like anxiety, depression, autism spectrum disorder, and ADHD compared to privately insured children. The brief reviews state coverage requirements for pediatric behavioral health benefits under Medicaid and CHIP. It provides context for managed care organizations and state agencies on access patterns and coverage obligations for this population.
- Managed Care
KFF Brief Examines PBM Role in Medicaid Drug Spending and Distribution
KFF published an issue brief analyzing pharmacy benefit managers' role in Medicaid drug distribution and their potential impact on program spending. The brief responds to recent policymaker and stakeholder concerns that PBM practices may be driving increased Medicaid drug costs. The analysis comes as states and CMS scrutinize PBM contracts with managed care organizations, including spread pricing, rebate retention, and formulary management practices. The brief provides background for state Medicaid agencies and health plans evaluating PBM contract terms and transparency requirements.
- Managed Care
MACPAC Examines AI and Automation in Medicaid Prior Authorization Processes
MACPAC's Chapter 2 report examines how Medicaid payers and providers are incorporating artificial intelligence and automation into prior authorization workflows. The analysis covers automated systems using algorithms or AI to conduct portions of the PA process, which may reduce administrative burdens for plans and providers. The report assesses both the potential efficiency gains and risks associated with automated PA decision-making in Medicaid managed care and fee-for-service programs. MACPAC's findings inform federal and state policymakers considering guardrails or standards for PA automation technology.
- Managed Care
MACPAC Comments on CMS Proposed Rule for State Directed Payments and Targeted Practitioner Payments
The Medicaid and CHIP Payment and Access Commission submitted comments to CMS Administrator Dr. Mehmet Oz on a proposed rule governing state directed payments in managed care and targeted practitioner payments in fee-for-service. MACPAC supports CMS efforts to align Medicaid payments with statutory requirements for economy and efficiency. The comment letter addresses proposed changes to how states can direct managed care organizations to make specific payments to providers and how states structure targeted payments in FFS arrangements. The proposed rule affects state Medicaid agencies' flexibility to use payment strategies that support provider rates and access while meeting federal oversight requirements.
- Managed Care
NAMD Issues Comments on CMS State Directed Payment Proposed Rule
The National Association of Medicaid Directors has submitted formal comments on CMS' 2026 proposed rule governing state directed payments in Medicaid managed care and targeted fee-for-service payments. NAMD's recommendations address regulatory changes CMS proposed for how states structure supplemental payments to providers through managed care contracts and direct Medicaid payments. The comments reflect state Medicaid directors' operational concerns about implementing potential new federal requirements for these payment arrangements, which states use to address provider rates, access, and delivery system reforms.
Friday, August 28 · 2 stories
- Managed Care
States Consider Value-Based HCBS Contracts to Avoid Benefit Cuts During Economic Downturn
Industry leaders at Home Health Care News' PAYER Summit in June said state Medicaid programs facing budget pressure from economic downturns could pursue value-based contracts with home- and community-based services providers rather than restricting benefits or cutting services outright. The strategy shifts financial risk to providers while preserving access. No specific states or implementation timelines were identified. This approach matters for HCBS providers and managed care organizations managing LTSS populations as states seek budget-neutral alternatives to traditional cost containment.
- Managed Care
NASHP Reviews State Models for Specialized Children's Medicaid Managed Care Programs
The National Academy for State Health Policy published an analysis of how states structure specialized Medicaid managed care programs for children and youth with chronic and complex conditions. The review examines state design choices including eligibility criteria, carved-in versus carved-out services, care coordination requirements, and specialized plan contracting approaches. The analysis is intended to help state Medicaid agencies considering or refining specialized programs for medically complex pediatric populations. No federal policy change or state-specific implementation timeline is reported.
Tuesday, August 25 · 1 story
- Managed Care
Medicare Advantage Plans Denied 12% of Prior Authorizations in 2025, KFF Finds
Medicare Advantage, Medicaid managed care, and ACA Marketplace plans denied between 12% and 18% of standard prior authorization requests in 2025, according to a KFF study. Denial rates varied widely among the largest insurers. The study highlights prior authorization burdens on providers, including home health agencies. The findings are current as of 2025 data.
Monday, August 24 · 2 stories
- Managed Care
CMS Webinar Addresses Health and Justice Needs for Children with Special Health Care Needs
The Centers for Medicare & Medicaid Services hosted a webinar on serving the 15 million children and youth with special health care needs (CSHCN) who have chronic physical, developmental, or behavioral health conditions requiring services beyond typical pediatric care. The session focused on coordination between health and justice systems for this population, which represents one in five children under age 18. The webinar covered strategies for Medicaid programs to better serve CSHCN involved in or at risk of justice system contact, addressing care coordination, behavioral health access, and cross-system collaboration.
- Managed Care
Trump Administration Medicaid Obesity Drug Coverage Pledge Faces Implementation Hurdles
President Trump's commitment to expand Medicaid coverage for weight loss medications has not materialized in practice. The pledge aimed to make expensive obesity drugs accessible to low-income beneficiaries, but implementation has stalled. The development affects Medicaid agencies planning pharmacy benefits and managed care organizations managing pharmacy carve-ins. The gap between the announced policy intent and actual coverage expansion leaves states without federal guidance on obesity medication coverage requirements or financing mechanisms.