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Monday, July 13 · 13 stories
- Federal Policy
SAMHSA Awards $1.5 Billion in State and Tribal Opioid Response Grants
HHS through SAMHSA announced more than $1.5 billion in FY25 continuation funding for State Opioid Response (SOR) and Tribal Opioid Response (TOR) grants on September 22, 2025. The funding supports states and tribal communities in addressing the overdose crisis through prevention, overdose reversal medications, treatment including medications for opioid use disorder (MOUD), and recovery support services. These are continuation awards, meaning recipients were previously awarded these grants and are receiving ongoing funding for existing programs.
- Federal Policy
SAMHSA Awards $19M in Block Grant Funding for SMI Housing Programs
The Substance Abuse and Mental Health Services Administration announced $19 million in supplemental Community Mental Health Services Block Grant funding to strengthen housing capacity for homeless individuals with serious mental illness. The funding addresses the intersection of homelessness and SMI through state-administered block grant programs. States will receive allocations to expand housing-related services and supports for this population. This matters for Medicaid managed care organizations because behavioral health plans often coordinate with state housing programs and provide wraparound services for members experiencing homelessness with SMI diagnoses.
- Federal Policy
SAMHSA Awards $45 Million to States for Young Adult Sober Housing Under SOR Program
SAMHSA announced more than $45 million in supplemental funding to State Opioid Response (SOR) program recipients to support sober and recovery housing services for young adults. The funding supplements existing state SOR grants to expand residential treatment options for young adults with substance use disorders. States that currently receive SOR funding are eligible to apply for these supplemental awards. The funding addresses a gap in sober housing options for young adults, a population with elevated overdose risk and barriers to traditional treatment settings.
- Federal Policy
SAMHSA Awards $19 Million to States for Housing for Homeless with Serious Mental Illness
The Substance Abuse and Mental Health Services Administration awarded $19 million in supplemental funding to 51 states, territories, and jurisdictions to build housing capacity for homeless individuals with serious mental illness. The funding provides additional resources for state programs serving this population. The announcement was made September 18, 2025. For Medicaid managed care organizations with behavioral health carve-ins or whole health responsibilities, these state funds may complement or require coordination with MCO housing-related supports and services for members experiencing homelessness.
- Federal Policy
HHS Secretary Kennedy Blocks Preventive Services Task Force Meetings, Fires Leadership
HHS Secretary Robert F. Kennedy Jr. has prevented the U.S. Preventive Services Task Force from meeting, declined to replace members whose terms have expired, and fired the panel's leaders in May 2026. The task force determines which preventive medical services insurers must cover without cost-sharing under the Affordable Care Act. The disruption affects coverage recommendations for screenings, counseling, and preventive medications that Medicaid managed care plans must cover as essential health benefits. The timeline for new coverage recommendations and the panel's future composition remain uncertain.
- Federal Policy
HHS Develops Guidance to Reduce SSRI Antidepressant Prescribing
The Department of Health and Human Services is working with mental health professionals to develop guidance aimed at reducing the use of selective serotonin reuptake inhibitor (SSRI) antidepressants. HHS officials convened a private meeting to advance this effort. The timing and scope of any formal guidance release remain unclear. For Medicaid managed care organizations, this could signal future prior authorization requirements, utilization management changes, or quality measure adjustments affecting behavioral health pharmacy benefits and member care protocols.
Friday, July 10 · 3 stories
- Federal Policy
CMS Issues Claims Attachment Rule Establishing HIPAA Standards for Electronic Documentation
CMS finalized a claims attachment rule establishing HIPAA standards for electronic submission of supporting documentation with health care claims. The rule requires standardized submission using the Health Level 7 (HL7) framework and covers digital signature requirements. This applies to all entities submitting electronic claims under HIPAA transaction standards, including Medicaid managed care organizations. Implementation timelines and compliance deadlines are set by CMS for covered entities to transition to the standardized format.
- Federal Policy
New Medicaid Work Requirements Threaten Farmworker Coverage
Federal Medicaid work requirements are being implemented that may disqualify farmworkers from coverage despite their employment status. Farmworkers, who often work seasonally or through labor contractors, face documentation challenges proving work hours to satisfy new verification requirements. The policy affects states that have received CMS approval for work requirement waivers. Compliance officers at Medicaid managed care organizations operating in affected states will need updated eligibility verification processes and member communication strategies to address coverage disruptions for this population.
- Federal Policy
CMS Approves Joint Commission for Continued HHA Accreditation Through 2026
CMS has approved The Joint Commission for continued recognition as a national accrediting organization for home health agencies seeking Medicare or Medicaid participation. The approval is effective July 10, 2026. Joint Commission-accredited HHAs are deemed to meet Medicare Conditions of Participation and Medicaid provider standards. This decision maintains the existing accreditation pathway for home health agencies providing services under managed care contracts and fee-for-service arrangements.
Thursday, July 9 · 3 stories
- Federal Policy
ACS Data Shows Direct Care Worker Demographics Amid Federal Policy Shifts
Analysis of 2024 American Community Survey data examines demographic and socioeconomic characteristics of direct care workers, including home health aides, personal care aides, and nursing assistants across long-term care settings. The workforce profile covers workers in nursing facilities, residential care, home health, and nonresidential services for older adults and people with disabilities. Federal policy changes affecting workforce stability, reimbursement, and recruitment directly impact Medicaid managed care organizations' ability to build adequate LTSS provider networks and meet access standards.
- Federal Policy
Medicaid and ACA Enrollment Drops 5 Million in 12 Months
Medicaid and Affordable Care Act marketplace enrollment declined by more than 5 million individuals over the past year, according to a new report. The decline is attributed to federal Medicaid funding cuts implemented under the Trump administration and the expiration of enhanced ACA premium subsidies. The enrollment losses affect both traditional Medicaid populations and marketplace coverage, with implications for managed care organizations' membership and revenue projections. The timing and scope of these reductions represent a significant shift in coverage patterns following the post-pandemic enrollment peak.
- Federal Policy
CMS Ends Fast-Track Review Process for Medicaid 1115 Waiver Extensions
CMS announced July 7 that it is eliminating the fast-track review process for certain Medicaid section 1115 demonstration extensions, formally rescinding 2015 guidance that established the expedited pathway. The change stems from a July 2025 reconciliation bill requirement that the CMS chief actuary certify budget neutrality for all 1115 demonstrations, effective January 1, 2027. CMS stated the fast-track process would make it difficult to evaluate renewal applications under the new budget neutrality certification requirements. The bulletin did not specify when the elimination takes effect, but states should anticipate longer review timelines for waiver extensions.
Wednesday, July 8 · 12 stories
- Federal Policy
CMS Requests State Medicaid Provider Revalidation Strategies in April Administrator Letter
CMS Administrator Dr. Mehmet Oz sent a letter to State Medicaid Directors on April 23, 2026, requesting each state develop and submit a comprehensive two-year provider revalidation strategy focused on high-risk providers. The letter, identified as an SMD (State Medicaid Director letter), is not published on the official Medicaid.gov site but is available through Fox News. Minnesota's early implementation offers initial lessons for states responding to the directive. The request affects all state Medicaid agencies and their managed care partners responsible for provider enrollment and network adequacy.
- Federal Policy
FDA Approves Gene Therapy for Children with Sickle Cell Disease
The FDA has approved a new gene therapy treatment for children aged 2 and older with sickle cell disease. The approval expands treatment options for pediatric patients with this serious inherited blood disorder, which disproportionately affects Medicaid beneficiaries. Sickle cell disease affects approximately 100,000 Americans, with the majority covered by Medicaid. Managed care organizations will need to evaluate coverage policies, establish prior authorization criteria, and assess the financial impact of this high-cost specialty therapy on capitation rates and medical loss ratios.
- Federal Policy
Health Care Coalition Seeks HHS Clarification on SUD Community Engagement Exemptions
ACAP and a coalition of health care organizations submitted a letter to HHS on February 7, 2026, requesting clarification on how Medicaid managed care plans should verify and document substance use disorder (SUD) treatment exemptions from community engagement requirements. The letter addresses operational challenges MCOs face in implementing exemption processes without clear federal guidance on documentation standards, member privacy protections, and coordination with SUD providers. The coalition seeks guidance on verification procedures to ensure eligible beneficiaries receive exemptions while maintaining compliance with federal requirements.
- Federal Policy
State Health Associations Urge Congress to Fully Fund Territory Medicaid and CHIP Programs
The Association of State and Territorial Health Officials (ASTHO) and the National Association of Medicaid Directors (NAMD) jointly called on Congress to provide full federal funding for Medicaid and CHIP programs in U.S. territories. Unlike states, territories receive capped federal Medicaid funding rather than open-ended matching funds, creating coverage gaps and program instability. The organizations advocate for parity in federal funding treatment between states and territories. This call comes as territories face recurring funding cliffs that threaten coverage for vulnerable populations.
- Federal Policy
CMS Proposes Rule Codifying Medicare Drug Price Negotiation Program
On June 16, 2026, CMS published a proposed rule to codify the Medicare Drug Price Negotiation Program established by the Inflation Reduction Act of 2022. The rule would formalize existing program guidance, introduce new policy proposals, and establish the regulatory framework for drug selection, negotiation, re-negotiation, compliance monitoring, and civil monetary penalties. The proposed rule affects Medicare Part D plans and manufacturers. Public comments on the proposed rule are due approximately 60 days after publication in the Federal Register.
- Federal Policy
Partnership for Medicaid Issues H.R. 1 Community Engagement Implementation Guidance
The Partnership for Medicaid released recommendations for CMS and states on implementing community engagement requirements under H.R. 1. The guidance addresses operational considerations for managed care organizations tasked with verifying beneficiary compliance and coordinating exemptions. Implementation timelines and specific federal guidance remain pending. This matters because MCOs will likely bear responsibility for tracking work requirements, exemption processes, and related reporting — operational burdens that require system changes, vendor coordination, and potential contract amendments.
- Federal Policy
MHPA Warns Senate Against Budget Reconciliation Provisions Affecting Medicaid MCOs
Medicaid Health Plans of America sent a letter to Senate leadership urging caution on specific provisions in the House-passed budget reconciliation bill. The trade association outlined concerns about how reconciliation measures could affect Medicaid managed care operations and beneficiaries. The letter was addressed to Senate Majority Leader John Thune, Minority Leader Chuck Schumer, and Finance Committee leadership. The reconciliation bill is now under consideration in the Senate, with potential modifications before final passage.
- Federal Policy
Modern Medicaid Alliance Urges Congress to Reject Proposed Medicaid Cuts
The Modern Medicaid Alliance has issued a statement urging Congress to reject proposed cuts to Medicaid currently under consideration. The advocacy coalition warns the cuts would directly affect Medicaid beneficiaries' access to care. The statement comes as Congress debates budget reconciliation proposals that could significantly reduce federal Medicaid spending. Timing and specific legislative vehicles remain subject to ongoing negotiations.