All stories
Jump to date
Monday, June 1 · 11 stories
- 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.
- 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.
- Federal Policy
DOL Rescinds 2024 Overtime Rule, Reverts to 2019 Salary Thresholds
The U.S. Department of Labor formally rescinded the 2024 overtime rule and returned to the 2019 salary threshold framework. The 2024 rule would have expanded overtime eligibility for home care workers, but courts vacated it after the first threshold increase took effect. The rescission provides immediate relief to home health and home care providers who faced increased labor costs under the 2024 standards. Providers operating under Medicaid managed care contracts can now plan staffing and budgets using the lower 2019 thresholds.
- Federal Policy
Democratic Senators Propose Medicare Home Care Benefit and Medicaid HCBS Expansion
A group of Democratic senators released a policy framework Wednesday to create a new Medicare home care benefit and expand Medicaid home- and community-based services. The proposal represents a significant shift in federal long-term care policy, potentially affecting how both Medicare and Medicaid fund home-based care. Details on implementation timelines, eligibility criteria, and financing mechanisms have not yet been specified. If enacted, the framework could reshape payment structures and access requirements for home health and HCBS providers serving dual-eligible and Medicaid-only populations.
- Federal Policy
Rep. Van Duyne Introduces Bill to Strengthen Medicare Home Health and Hospice Oversight
Rep. Beth Van Duyne (R-Texas) introduced the Protecting Seniors and Stopping Fraudsters Act on Wednesday to increase Medicare oversight of home health and hospice services. The bill aims to crack down on fraudulent providers and enhance beneficiary protections in these sectors. The National Alliance for Care at Home has expressed support for the legislation. While the bill targets Medicare, Medicaid managed care organizations that contract with home health and hospice providers should monitor this legislation, as federal fraud enforcement standards often inform state oversight approaches and MCO network adequacy requirements.
Saturday, May 30 · 1 story
- Federal Policy
Trump Executive Order Endorses HHS Reduction in Required Childhood Vaccinations
President Trump signed an executive order Friday endorsing HHS's decision to reduce required childhood vaccinations. The order cites religious liberty and parental rights as justification for adjusted immunization requirements. The policy change affects federally recommended vaccine schedules that states and health plans use for EPSDT and well-child care compliance. Medicaid managed care organizations must monitor whether state Medicaid agencies adjust their EPSDT screening requirements in response, which could impact quality metrics, HEDIS measures, and contractual performance standards tied to childhood immunization rates.
Friday, May 29 · 1 story
- Federal Policy
MACPAC Seeks Contractor for T-MSIS Data Analysis Services
The Medicaid and CHIP Payment and Access Commission issued a request for proposals for an indefinite delivery indefinite quantity contract to provide computing and data analysis services using the Transformed Medicaid Statistical Information System and other datasets. The contract will support MACPAC's ongoing research and policy analysis work. Proposals are being solicited through SAM.gov. This procurement reflects MACPAC's continued reliance on T-MSIS data for assessing Medicaid program performance, payment policy, and beneficiary access — research that informs Congressional action and CMS guidance affecting managed care plans.
Thursday, May 28 · 13 stories
- Federal Policy
USCIS Tightens Adjustment of Status Rules for Green Card Applicants
On May 21, 2026, USCIS issued a policy memo restricting adjustment of status applications, requiring applicants to demonstrate extraordinary circumstances to obtain lawful permanent residence without consular processing. The memo recharacterizes adjustment of status as discretionary relief rather than a routine pathway. This change affects healthcare organizations that sponsor foreign-born clinical staff and may complicate workforce planning for Medicaid managed care plans that rely on immigrant physicians, nurses, and behavioral health providers in shortage areas. Plans should review existing sponsorship pipelines and anticipate longer credentialing timelines.
- Federal Policy
Child Medicaid and CHIP Enrollment Drops by 2 Million Since January 2025
Medicaid and CHIP enrollment among children declined by 2 million between January 2025 and April 2026, according to state-by-state enrollment data. The drop suggests a rising child uninsured rate during this period. The enrollment decline affects managed care organizations through reduced membership and capitation revenue, particularly in states with high CHIP and Medicaid managed care penetration. Plans should monitor monthly enrollment reports and assess financial impacts from membership losses in pediatric populations.
- Federal Policy
Trump Administration Pharmaceutical Pricing Agreements Face Implementation Questions
The Trump administration's most favored nation (MFN) pricing agreements with pharmaceutical manufacturers remain under scrutiny as implementation details emerge. These agreements aim to tie U.S. drug prices to lower international reference prices. Medicaid managed care organizations may see indirect effects through pharmacy benefit design and supplemental rebate negotiations, though the agreements primarily target Medicare Part B and Part D. The timing and scope of implementation remain uncertain, creating planning challenges for health plans managing pharmacy benefits across multiple programs.
- Federal Policy
CMS Proposes Payment Limits on State Directed Payments and Targeted Fee-for-Service Rates
CMS published a proposed rule on May 22, 2026, that would impose payment limits on additional state directed payments in Medicaid managed care and establish new limits for targeted fee-for-service payments. The rule draws authority from section 71116 of H.R. 1 (the "One Big Beautiful Bill Act") and presidential directives. State directed payments allow states to require managed care organizations to adopt specific provider payment arrangements, and new limits could constrain state flexibility in setting enhanced reimbursement rates for hospitals, nursing facilities, and other providers. The proposal would affect how states design rate strategies and could require MCOs to renegotiate provider contracts if existing SDP arrangements exceed new federal limits.
- Federal Policy
CMS Proposes FY 2027 IPPS Payment Updates, Quality Measures, Joint Replacement Model Expansion
CMS released the FY 2027 Inpatient Prospective Payment System proposed rule updating Medicare hospital payment rates, uncompensated care payments, and graduate medical education residency program definitions. The rule expands the CJR-X joint replacement payment model and solicits comment on new quality measures. While IPPS primarily governs Medicare fee-for-service hospital payments, changes to quality measures and payment methodologies often influence Medicaid managed care quality programs and hospital contract negotiations. The comment period timeline was not specified in the excerpt.
- Federal Policy
OIG Clears Limited Free Orthodontic Services in Advisory Opinion 26-09
On May 1, 2026, OIG issued Advisory Opinion 26-09 addressing a pediatric dental and orthodontic provider's proposal to offer free orthodontic treatment to one patient annually at each of its three practice locations. The opinion provides guidance on how such charitable arrangements may comply with federal anti-kickback statute and beneficiary inducement provisions. For Medicaid managed care dental plans and MCOs with dental benefits, this opinion clarifies acceptable parameters for provider charitable care arrangements that could affect network adequacy and access strategies, particularly for orthodontic services where cost barriers are common.
- Federal Policy
CMS pauses Medicare enrollment for home health and hospice providers
CMS has temporarily halted new provider enrollment for home health and hospice services in Medicare, though specific details on duration and scope are not provided in the brief announcement. The enrollment pause likely reflects heightened scrutiny of fraud vulnerabilities in these sectors, which have been subjects of recent OIG investigations. Medicaid managed care organizations with delegated or integrated home health and hospice networks should monitor whether similar restrictions emerge in their contracts or state programs, particularly for dual-eligible populations where Medicare enrollment status affects network adequacy.
- Federal Policy
CMS Recharters Medicare Lab Test Advisory Panel, Announces July 2026 Meeting
CMS has rechartered the Medicare Advisory Panel on Clinical Diagnostic Laboratory Tests and appointed five new members. The panel will meet July 14-15, 2026, to advise HHS and CMS on clinical diagnostic laboratory test issues under Medicare. While focused on Medicare, decisions on laboratory test coverage and payment often influence Medicaid managed care plan policies for diagnostic services, particularly for dual-eligible populations and carve-in lab benefits. State Medicaid programs frequently align lab fee schedules and coverage criteria with Medicare determinations.