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Tuesday, September 15 · 19 stories
- State Policy
States Struggle to Define Disability Under Medicaid Work Requirements
State Medicaid agencies are determining which medical conditions qualify beneficiaries for exemptions from work requirements, creating inconsistent disability determinations. Some beneficiaries, including cancer survivors, are losing coverage after states conclude they are able to work despite ongoing health issues. The issue affects states implementing community engagement requirements and illustrates the operational challenges of administering medical exemptions at scale. These determinations directly impact coverage continuity for vulnerable populations and create administrative burden for states and health plans managing exemption processes.
- State Policy · NJ
New Jersey Bill Would Increase Medicaid Personal Needs Allowance for Nursing Home Residents
New Jersey legislators advanced a bill to add a cost-of-living adjustment to the monthly personal needs allowance for nursing home residents enrolled in Medicaid. The legislation would increase the allowance that residents retain for personal expenses after Medicaid pays for their care. The bill has moved forward in the legislature but timing for final passage and effective date remain unclear. The change would affect Medicaid long-term care financing and could modestly increase state Medicaid spending while improving residents' ability to cover incidental expenses.
- Federal Policy
Trump Drug Price Initiative Narrows to One or Two Drugs as State Opt-In Deadlines Extended Twice
The Trump administration's initiative to deliver lower drug prices in Medicaid has contracted from an original promise covering all drugs to just one or two products, with state opt-in deadlines pushed back twice. States maintain voluntary participation in the scaled-back program. The repeated delays and scope reductions suggest implementation challenges and potentially limited uptake among states.
- Legal · MD
Maryland Sues Optum for $126 Million Over Allegedly Defective Medicaid Behavioral Health Claims System
Maryland filed suit against Optum and UnitedHealth Group alleging Optum collected over $126 million while operating a behavioral health Medicaid claims system the state contends was never fully functional during the five-year contract period. The lawsuit asserts fraud and breach of contract related to the system's performance failures. The timing of the suit is current as of September 2026, though the underlying contract issues span multiple years. This represents significant state-level enforcement against a major managed care and technology vendor, potentially signaling increased scrutiny of Medicaid administrative service contracts and vendor performance accountability.
Monday, September 14 · 28 stories
- State Policy
NASHP Hosts Webinar on EMS Post-Overdose Response Partnerships October 14
The National Academy for State Health Policy (NASHP) will host a webinar on October 14, 2026, from 3:00–4:00 p.m. ET focused on expanding emergency medical services partnerships to reduce opioid deaths through post-overdose response strategies. The session will likely address how state Medicaid agencies and health plans can collaborate with EMS providers to implement follow-up interventions after overdose events. For states implementing Section 1115 substance use disorder waivers or managing behavioral health through Medicaid managed care, this webinar may provide operational models for care coordination and overdose prevention initiatives.
- State Policy · VT
Vermont Commentary Calls for Tax Law Changes to Fund Healthcare Coverage Expansion
A Vermont advocacy commentary argues that state tax laws allow wealthy property owners to avoid proposed higher taxes on second homes intended to fund expanded healthcare coverage, including Medicaid. The author proposes closing loopholes that permit married couples to claim separate primary residences in different states and imposing progressive income taxes on earnings over $500,000. The piece responds to Governor Phil Scott's opposition to wealth taxes and broader property tax increases. No specific legislative action is pending, but the commentary frames the debate over how Vermont could finance healthcare expansion.
- Federal Policy · GA
CMS Approves Georgia CHOICE Arrangements for Small Business Health Coverage
CMS, in coordination with the Small Business Administration, has formally recognized Georgia's CHOICE arrangements as an approved model for small business health coverage. The arrangements allow small businesses to pool resources for health benefits while maintaining compliance with federal standards. The approval takes effect immediately and provides a compliance pathway for Georgia small businesses seeking affordable coverage options. This matters for Medicaid stakeholders because CHOICE arrangements may intersect with Medicaid eligibility and coverage coordination, particularly for low-wage workers in small businesses who may cycle between employer coverage and Medicaid.
- Industry
Johnson & Johnson Requires Claims Data Sharing for 340B Discounts
Johnson & Johnson is requiring 340B-covered entities to share claims data as a condition of receiving 340B drug discounts. The company joins other pharmaceutical manufacturers implementing reporting requirements, citing concerns about duplicate discounts. The policy affects safety-net providers that rely on 340B pricing, including federally qualified health centers and disproportionate share hospitals that serve Medicaid populations. The requirement takes effect immediately for providers seeking to maintain access to J&J's discounted pricing under the 340B program.
- State Policy · CA
California Adopts 3.5% Hospital Spending Growth Cap Through 2029
California's Office of Health Care Affordability has adopted a 3.5% annual spending growth cap for hospitals, physician groups, and insurers, effective through 2029. Entities exceeding the cap will face penalties. The framework applies to all payers, including Medicaid managed care organizations contracting with hospitals and physician groups in California. This marks California's first enforceable cost growth benchmark, directly affecting Medi-Cal managed care contract negotiations and capitation rate development.
- Industry
Addus HomeCare to Acquire AccentCare Personal Care Division for $275 Million
Addus HomeCare Corporation will acquire AccentCare's personal care division outside New York for approximately $275 million. The transaction covers operations in 10 states serving approximately 13,700 clients daily and expands Addus into six new states: Colorado, Georgia, Minnesota, Pennsylvania, Tennessee, and Washington. The acquisition consolidates personal care market share among home and community-based services providers serving Medicaid beneficiaries, particularly in long-term services and supports programs. Financial and regulatory closing terms were not disclosed in the announcement.
- Federal Policy · KS
CMS Awards $17M to Rural Kansas Hospitals for Technology and Patient Transport
CMS announced nearly $17 million in funding for rural Kansas hospitals to adopt emerging healthcare technologies and improve patient transportation between facilities. The awards target infrastructure improvements in underserved rural areas. The funding is available immediately for qualifying hospitals. This matters for Medicaid providers serving rural beneficiaries, as improved transport and technology can enhance access to care for Medicaid patients who represent a significant share of rural hospital volume.
- Federal Policy
NAMD Proposes Federal Tools to Strengthen Medicaid Program Integrity Infrastructure
The National Association of Medicaid Directors has outlined federal-level program integrity enhancements for Medicaid, including modernizing the national provider identifier system, creating a national claims and provider data view, developing service-specific toolkits, and vetting IT solutions. The proposals address shared federal-state responsibilities for fraud prevention and program oversight. The recommendations aim to provide state Medicaid agencies with standardized tools and data infrastructure to improve provider screening, claims monitoring, and cross-state coordination.
- Federal Policy
22 States Sue DHS Over Public Charge Rule Affecting Immigrant Access to Benefits
A coalition of 22 Democratic-led states and Washington, D.C., filed suit against the Department of Homeland Security to block implementation of the public charge rule. The rule restricts green card eligibility for immigrants who use or are likely to use public benefits. The litigation challenges whether DHS exceeded its authority and whether the rule violates statutory requirements. For state Medicaid agencies, the rule affects enrollment and coverage decisions for lawfully present immigrants, particularly in states that extend Medicaid eligibility beyond the federally required minimum.
- Legal · AL
OIG Inspects Alabama Medicaid Fraud Control Unit Operations in 2025
The HHS Office of Inspector General conducted an inspection of Alabama's Medicaid Fraud Control Unit in 2025. These periodic inspections assess MFCU compliance with federal certification standards, including case management, staffing, prosecution capabilities, and coordination with state Medicaid agencies. The inspection reviewed the unit's investigative procedures, conviction rates, and financial recoveries. Results inform OIG's ongoing oversight of state fraud control operations and federal funding decisions for MFCUs.
- Managed Care
NASHP Releases Overview of State Medicaid Maternity Value-Based Payment Models
The National Academy for State Health Policy published an overview examining how states are implementing maternity-focused value-based payment models in their Medicaid programs. The report documents strategies states are using to link payment to quality metrics, care coordination, and improved perinatal outcomes. These payment reforms target maternal and infant health outcomes while aiming to control rising costs associated with pregnancy and childbirth care covered by Medicaid. The overview provides state Medicaid agencies and managed care organizations with comparative information on design approaches currently in use.
- Federal Policy
CMS Issues Three-Tier Medical Frailty Verification Model for Medicaid Work Requirements
On September 8, CMS released a three-tier verification framework for states implementing the medical frailty exclusion from Medicaid work reporting requirements. The model allows states to exclude individuals based on diagnosis alone (Tier 1), diagnosis plus utilization or pharmacy data (Tier 2), or individualized review with documentation (Tier 3). This guidance follows CMS's June Interim Final Rule requiring states to assess whether conditions "significantly impair" work ability — a functional standard that expanded beyond diagnosis-based exclusions and created operational challenges for states that had developed automated data strategies. CMS emphasizes the framework is a model, not a mandate, leaving states to select their own methodologies and code sets with clinical teams.
- State Policy · NC
North Carolina Tailored Plans Integrate Care for Children with Complex Needs
North Carolina's Tailored Medicaid managed care plans provide integrated physical health, behavioral health, and I/DD services for children and youth with chronic and complex conditions. The Tailored Plans, which launched statewide, aim to coordinate care across multiple service systems for beneficiaries with intellectual and developmental disabilities and serious behavioral health needs. The model assigns these members to specialized managed care organizations designed to address their unique needs. This approach represents North Carolina's strategy to improve care coordination and outcomes for its most vulnerable pediatric Medicaid population through specialized managed care delivery.
- Federal Policy
Rural Communities at Greater Risk of Harmful Impacts from New Medicaid Work Reporting Requirements
In 2025, Congress enacted H.R. 1, requiring work reporting as a condition of Medicaid eligibility in the 41 states that expanded coverage to low-income adults under the ACA, plus Wisconsin and Georgia. The law affects Medicaid expansion populations in those states. Rural communities face heightened risk of coverage loss due to barriers in meeting reporting requirements. The policy represents a significant shift in Medicaid eligibility standards, imposing new administrative and compliance obligations on state agencies and creating potential churn for health plans managing expansion populations.
- State Policy · NC
CMS Approves North Carolina Medicaid Expansion for School-Based Behavioral Health Services
CMS approved North Carolina's request to expand Medicaid coverage for preventive and behavioral health services delivered in schools, with a focus on rural areas. The approval allows the state to reimburse schools for services provided to Medicaid-enrolled students, expanding access to mental health counseling, substance use disorder screening, and preventive care in educational settings. The expansion takes effect immediately and applies statewide with targeted outreach to rural school districts. This matters for North Carolina Medicaid managed care plans and providers because it creates new service delivery sites, reimbursement pathways, and network adequacy considerations for pediatric behavioral health in school settings.
- Industry
CMS Health Technology Ecosystem Falls Short on Interoperability Promise
President Trump's 2025 pledge to eliminate redundant patient paperwork through CMS's Health Technology Ecosystem has not been fully realized. Healthcare providers still face significant barriers to seamless record exchange across appointments and care settings. The initiative aimed to reduce administrative burden through improved data interoperability, but implementation challenges persist. For Medicaid managed care organizations and providers, gaps in health information exchange continue to drive care coordination inefficiencies and administrative costs.