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Friday, September 18 · 34 stories
- State Policy · VT
Vermont Regulator Cuts Hospital Commercial Rates 1.2%, Expects $1.94B Revenue Cap
Vermont's Green Mountain Care Board issued budget orders Monday reducing commercial insurance rates charged by hospitals by approximately 1% statewide, with collective commercial revenue capped at $1.94 billion for fiscal year 2027 beginning October 1, 2026. The University of Vermont Medical Center faces the steepest reduction at 4.4%, while only Northwestern Medical Center and Springfield Hospital received 2% rate increases. The orders aim to slow health insurance premium growth in a state where residents pay among the nation's highest premiums, but hospital leaders warn the cuts will destabilize facilities already projecting collective deficits this fiscal year and next. Vermont hospitals have cut $57 million from projected fiscal 2026 expenses as part of a broader plan to reduce spending by $330 million by 2028.
- State Policy · GA
Georgia Remains Among 10 States Without Medicaid Expansion Despite Public Support
Georgia has not expanded Medicaid eligibility under the Affordable Care Act, remaining one of 10 non-expansion states. Public polling shows strong support for expansion among Georgia residents. The article discusses whether recent state proposals represent genuine expansion efforts or delay tactics. The continued non-expansion affects coverage for low-income adults in the coverage gap who earn too much for traditional Medicaid but cannot afford marketplace plans.
- State Policy
Colorado Medicaid Projects Service and Funding Cuts Amid Budget Overruns
Colorado’s Medicaid program is forecasting service reductions and funding cuts as the program significantly overspends its budget. State lawmakers attribute rising costs to multiple converging factors creating financial pressure on the program. The forecast signals potential cuts affecting the state's Medicaid beneficiary population. Specific timing, affected services, and dollar amounts were not detailed in available information.
- Industry · AZ
Ascension Transfers Mercy Care Ownership Stake to Aetna
Ascension has agreed to transfer its ownership stake in Mercy Care, an Arizona managed care health plan, to Aetna (CVS Health). Ascension co-owns the plan with CommonSpirit's Dignity Health. The transaction is subject to regulatory approval. The deal represents consolidation in the Arizona managed care market, with a national commercial insurer acquiring equity from health system owners.
- State Policy · CA
California Medicaid Rate Increase Expected to Shift Pediatric Care to Home Settings
California implemented a Medicaid rate increase for home-based pediatric care, prompting Aveanna Healthcare to raise caregiver wages and plan January recruiting expansion. The company anticipates hundreds of families will transition medically complex children from institutional settings to home care as a result of improved reimbursement. The rate adjustment addresses longstanding workforce shortages in California's home health sector by enabling providers to offer competitive wages. This shift affects California's Medicaid program, pediatric providers, managed care organizations with LTSS responsibilities, and families of children with complex medical needs.
- Legal · VT
Vermont Provider Settles Medicaid Fraud Allegations for $390,000
Health Care & Rehabilitation Services of Southeastern Vermont will pay $390,000 to resolve allegations it mishandled Medicaid funds. The settlement also requires the provider to adopt new compliance policies. The case involved claims that the organization improperly managed federal Medicaid dollars. The settlement demonstrates continued state and federal enforcement activity targeting Medicaid billing and fund management practices at community-based providers.
- State Policy · MA
Massachusetts Reduces Estimate of Members Subject to Work Requirements by 50,000
MassHealth has lowered its projection of members who will be affected by upcoming Medicaid work and education requirements by approximately 50,000 individuals. The revised estimate reflects a recalculation of the member population subject to community engagement rules. The requirements will impose work, education, or volunteer obligations on non-exempt adult Medicaid beneficiaries. The reduction in projected impact suggests either narrower implementation scope or expanded exemption categories compared to initial projections, which will affect state administrative planning and managed care organizations' member engagement strategies.
- State Policy · PA
Pennsylvania Families Sue Shapiro Administration Over Medicaid Caregiver, Travel Restrictions
Four Pennsylvanians with intellectual and developmental disabilities filed a class action lawsuit challenging new Medicaid waiver rules that limit paid hours for family caregivers to 40–60 per week and restrict out-of-state travel support. The Shapiro administration imposed the limits through participation agreements after Commonwealth Court struck down nearly identical policies in February 2026 for failing to follow required rulemaking procedures. The administration gave participants an Aug. 6 deadline to sign new agreements or face involuntary service terminations; over 8,300 beneficiaries had signed by early September. Plaintiffs argue the state is bypassing the regulation process and forcing families to choose between uncompensated caregiving or institutional care.
- Managed Care · LA
Louisiana Proposes Higher Capitation Rates as Two MCOs Exit Medicaid Program
The Louisiana Department of Health has proposed new contract extensions with increased capitation rates for the four Medicaid managed care organizations remaining in the program after two plans exit by year-end. The departures will affect up to 580,000 enrollees who must be reassigned to the remaining plans. The proposed contracts were presented to state legislators on September 17, 2026. The rate increases reflect the state's need to retain existing plans and ensure adequate network capacity as the program consolidates from six to four MCOs.
Thursday, September 17 · 30 stories
- State Policy · CA
California Prop 36 Treatment Mandates Vary Widely by County, Leaving Gaps in Drug Treatment Access
Two years after California voters passed Proposition 36 requiring drug treatment for certain theft and drug offenses, counties are implementing treatment-mandated felony provisions inconsistently — with treatment durations ranging from three months in Ventura County to two years in San Luis Obispo County. Officials who supported the measure acknowledge gaps in the state's treatment infrastructure, with people waiting for services while charges remain pending. Defendants entering plea deals face challenges securing employment with felony convictions on record during court-mandated treatment periods that can extend well beyond residential program completion. The lack of state-funded treatment capacity and standardized implementation protocols has left some individuals the law intended to help falling through the cracks, according to state and local officials.
- Legal
OIG Finds Humana and UnitedHealth MA Plans Generated $180M in Upcoding Overpayments
HHS OIG audits released September 17, 2026 found that HumanaChoice and UnitedHealthcare of Wisconsin overstated member health conditions in Medicare Advantage risk adjustment submissions, resulting in nearly $180 million in overpayments over a two-year period. The audits concluded both plans frequently exaggerated health needs to inflate capitation payments. OIG has referred the findings to CMS for recovery action. While these audits focus on Medicare Advantage, they signal heightened federal scrutiny of risk adjustment practices that could extend to Medicaid managed care plans using similar diagnosis-driven payment models.
- Industry
Health Systems Lease SNF Beds to Address Patient Boarding and Discharge Delays
Hospitals are leasing skilled nursing facility beds to reduce emergency department boarding and expedite patient discharges as SNF capacity tightens. Four health systems report success using bed leasing arrangements that include value alignment with SNF partners, transparent patient selection criteria, and regular operational check-ins. The approach addresses growing pressure from an aging population and declining overall SNF bed supply. Systems largely exited the SNF business years ago but are now contracting for guaranteed bed access.
- Industry
FTC Tightens Failing Firm Defense Standards for Hospital Acquisitions
The Federal Trade Commission is applying stricter standards to the failing firm defense in hospital merger reviews, even as rural and critical access hospitals face documented financial pressures from low reimbursements, high Medicaid and Medicare volumes, uninsured patient populations, and expired pandemic relief funding. Hospitals seeking acquisition approval must now meet heightened thresholds to demonstrate they cannot remain independent or find alternative purchasers. The guidance affects health systems pursuing distressed hospital acquisitions, including those serving significant Medicaid populations.
- Legal
CMS Affiliation Rule Enables 10-Year Medicare Enrollment Bars for Physicians Without Direct Violations
Under current Medicare enrollment regulations, physicians can face up to 10-year exclusions from treating Medicare patients based solely on affiliation with another provider or supplier that has compliance issues, even when the physician has no personal history of fraud, improper billing, or disciplinary actions. The affiliation rule allows CMS to deny or revoke enrollment based on an individual's relationship with an entity that has been sanctioned or excluded. This administrative action does not require proof that the physician submitted improper claims or engaged in wrongdoing. The rule particularly affects hospice medical directors and other physicians in administrative or leadership roles where formal affiliations are documented.
- Managed Care
Eighteen Health Plans Score 5 Stars in NCQA 2026 Ratings, No For-Profits Included
Eighteen health plans achieved perfect 5-star ratings in NCQA's 2026 standards ratings, up from 11 in the previous cycle. None of the top-scoring plans are for-profit entities. The ratings measure plan performance across quality, access, and member experience metrics. The results highlight a continuing performance gap between nonprofit and for-profit health plans on nationally standardized quality measures.
- Industry
FDA Faces Staff Shortage That Hampers Agency's Ability to Expand Workforce
The Food and Drug Administration is experiencing a hiring bottleneck due to insufficient staffing resources to recruit and onboard new employees. This operational constraint affects the agency's ability to scale up its workforce even when funding and positions are authorized. The staffing limitation comes as FDA faces increasing regulatory responsibilities across drug approvals, medical device oversight, and food safety. While not directly a Medicaid story, this affects the broader regulatory environment in which Medicaid operates, particularly for drug approvals and medical device reviews that impact Medicaid coverage and spending decisions.
- Federal Policy · CT
CMS Awards Connecticut $50 Million for Rural Hospital Infrastructure and Care Delivery
CMS announced $50 million in federal funding to Connecticut to support rural hospital infrastructure improvements and optimize care delivery systems. The funding targets rural hospital facilities and care coordination in underserved areas. Implementation timing and specific program requirements were not detailed in the announcement. The funding represents significant federal investment in rural healthcare capacity, potentially affecting Medicaid beneficiaries who rely on rural hospital access for both inpatient and emergency services.
- Federal Policy
HHS Secretary Kennedy Appoints Eight Members to U.S. Preventive Services Task Force
HHS Secretary Robert F. Kennedy Jr. appointed eight new members to the U.S. Preventive Services Task Force on September 17, 2026, through the Agency for Healthcare Research and Quality, bringing the panel to 16 total members. The task force issues evidence-based recommendations on clinical preventive services including screenings, counseling, and preventive medications. These recommendations directly affect Medicaid coverage requirements under the Affordable Care Act, which mandates coverage of USPSTF Grade A and B services without cost-sharing for certain populations.
- Federal Policy · SC
CMS Awards $167 Million to South Carolina for Rural Infrastructure and Health Technology
CMS announced $167 million in federal funding to South Carolina for rural health care infrastructure, health technology upgrades, and prevention programs. The funding will support construction of rural care sites and modernization of health IT systems. The announcement did not specify eligibility or implementation timelines. This matters for South Carolina Medicaid providers and health plans operating in rural service areas, as infrastructure investments may affect network capacity and care delivery models.
- Legal · NC
OIG Finds North Carolina Medicaid Fraud Control Unit Compliant in 2025 Inspection
The HHS Office of Inspector General conducted an onsite inspection of North Carolina's Medicaid Fraud Control Unit in 2025 and found the unit in compliance with federal certification standards. The inspection reviewed the unit's investigative capacity, case management procedures, staffing levels, and coordination with state Medicaid agencies and law enforcement partners. MFCU certification is required for states to receive federal matching funds for fraud control activities. The findings confirm North Carolina maintains adequate resources and protocols to investigate and prosecute Medicaid provider fraud and beneficiary abuse.