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Monday, September 28 · 9 stories
- Federal Policy
CMS Strengthens Federal ACA Marketplace Anti-Fraud Efforts
In its Health Care Week in Review, Alston & Bird reports that CMS has strengthened anti-fraud efforts for the federal ACA marketplace. The changes affect health plans participating in the federal exchange and brokers or agents facilitating enrollment. The timing and specific measures were not detailed in the available summary. The action reflects CMS's continued focus on program integrity in marketplace operations, with potential compliance implications for participating insurers and enrollment entities.
- Federal Policy · TX
CMS Awards $51 Million for Rural Texas Nutrition and Chronic Disease Prevention Programs
CMS announced a $51 million federal funding award for nutrition and chronic disease prevention programs targeting rural Texas communities. The award aims to address health disparities in rural areas through improved access to nutrition services and chronic disease management. The programs will affect Medicaid beneficiaries in rural Texas counties through expanded community-based health interventions. This funding matters for state Medicaid agencies and managed care organizations operating in rural Texas markets, as it may create new care coordination requirements and community partnership opportunities to address preventable chronic conditions among Medicaid populations.
- Federal Policy
CMS Launches Quality Partnership With 37 States to Shift Medicaid Measures Toward Health Outcomes
CMS announced a new quality measurement partnership with 37 states to refocus Medicaid quality metrics on health outcomes rather than process measures. The initiative launches immediately and will develop and test outcome-based measures over the next 18 to 24 months. The shift affects how state Medicaid agencies and managed care plans will be evaluated for quality performance, requiring changes to quality strategies, managed care contracts, and potentially capitation rate methodologies. States participating in the partnership will pilot new outcome measures before broader adoption across the Medicaid program.
Friday, September 25 · 8 stories
- Federal Policy
Census Bureau Proposes Eliminating Race and Ethnicity Data Collection
In September 2026, the Census Bureau issued a proposed rule that would prohibit the collection of race and ethnicity data in the decennial census and exclude many noncitizen immigrants from the apportionment count. The changes would affect how Medicaid programs identify disparities in access, quality, and outcomes for beneficiaries. If finalized, the rule would limit state Medicaid agencies' and managed care organizations' ability to stratify performance data, target interventions, and comply with federal health equity reporting requirements that rely on census-based demographic benchmarks. The proposed changes matter because Medicaid programs use census race and ethnicity data to establish stratified quality measures, identify underserved populations for outreach and enrollment, and allocate resources for programs addressing maternal health, behavioral health, and chronic disease disparities.
- Federal Policy
New Customs Requirements Set to Disrupt Canadian Prescription Imports October 22
The Wall Street Journal reports that new customs requirements taking effect October 22, 2026, could disrupt access to prescription drugs for millions of Americans who purchase medications from Canadian and other foreign mail-order pharmacies. The change affects individuals who rely on imported pharmaceuticals for cost savings. The timing and scope of enforcement will determine how many consumers and which medication categories face immediate supply interruptions. For Medicaid programs, this could increase formulary pressure if beneficiaries who previously self-paid for imported drugs now seek coverage through state plans, and may affect dual-eligible populations managing Medicare Part D coverage gaps.
- Federal Policy
AHA Urges Permanent Ban on 340B Rebate Models in SECURE 340B Act Comments
The American Hospital Association submitted comments on September 23 supporting the bipartisan SECURE 340B Act introduced in July, urging Congress to permanently prohibit rebate models in the 340B drug pricing program. The legislation combines hospital-sought protections with new program requirements. AHA stated it shares the bill's goals while seeking the rebate ban provision. This affects how safety-net hospitals and Medicaid providers access discounted pharmaceuticals under 340B, with potential implications for pharmacy carve-outs and drug purchasing arrangements in Medicaid managed care.
- Federal Policy
NAMD Submits Comments on CMS Medicaid Enterprise Systems IT Standards RFI
The National Association of Medicaid Directors submitted comments to CMS in response to a request for information on Medicaid Enterprise Systems IT standards. The RFI solicited stakeholder input on technical standards and interoperability requirements for state Medicaid IT systems. State Medicaid agencies are directly affected as these standards will shape future MES certification requirements and enhanced federal funding eligibility. The timing matters because CMS is gathering input to inform future rulemaking on MES modernization and MITA framework requirements.
- Federal Policy
CMS Issues Federal Funding Methodology for Basic Health Program Year 2027
CMS released an informational bulletin outlining the federal funding methodology for the Basic Health Program (BHP) in program year 2027. The guidance details how CMS will calculate federal payments to states operating BHPs — currently Minnesota and New York — for coverage of low-income individuals ineligible for Medicaid but below 200% of the federal poverty level. The methodology takes effect for the program year beginning in 2027. This matters for the two BHP states because the federal payment formula directly determines their program budgets and affects whether BHP remains financially sustainable compared to Marketplace coverage.
- Federal Policy
CMS Seeks Comment on Generic Clearance for State Plan Amendments and Waiver Information Collections
CMS has published a Federal Register notice requesting public comment on one or more information collection requests under its existing Paperwork Reduction Act generic clearance umbrella (control number 0938-1148). The umbrella, approved in April 2021, covers Medicaid and CHIP state plan amendments, waivers, demonstrations, and reporting requirements. Comments are due 60 days from publication. The generic clearance process allows CMS to expedite approval of voluntary, low-burden information collections that do not raise substantive policy issues, streamlining the agency's ability to request information from states without full PRA review for each individual collection.
- Federal Policy
CMS Re-Establishes Data Match With Treasury Do Not Pay System
CMS has re-established a computer matching program with the U.S. Department of the Treasury's Do Not Pay Working System, administered by the Bureau of Fiscal Service. The match enables CMS to verify payment eligibility and prevent improper payments across Medicare and Medicaid by cross-referencing beneficiary and provider data against federal databases tracking death records, excluded parties, and debarred entities. The re-establishment continues an existing fraud prevention tool used by CMS to support program integrity efforts. The match affects CMS payment operations and supports state Medicaid agencies' ability to identify ineligible providers or payments flagged through federal screening.
- Federal Policy
Senate Finance Committee Advances Chris Klomp Nomination for HHS Deputy Secretary
The Senate Finance Committee on September 24, 2026, advanced Chris Klomp's nomination for deputy secretary of the Department of Health and Human Services by a 15-12 vote, sending it to the full Senate. Klomp currently serves as director of Medicare and deputy administrator at CMS. The nomination now awaits a floor vote. If confirmed, Klomp would hold the second-highest position at HHS, with oversight authority spanning CMS, including Medicaid and CHIP operations, along with other departmental programs.
Thursday, September 24 · 11 stories
- Federal Policy
CMS Halts ACA Broker Registrations for 2027, Terminates 760,000 Enrollments
CMS announced Tuesday it is freezing new broker registrations for the 2027 marketplace open enrollment period and terminating coverage for more than 760,000 individuals the agency has identified as unauthorized enrollees. The broker registration pause aims to reduce fraud in the exchanges; the agency did not specify which populations or enrollment circumstances triggered the coverage terminations. The registration freeze affects brokers seeking new marketplace access for plan year 2027. The actions reflect heightened federal scrutiny of marketplace enrollment integrity following reports of unauthorized sign-ups and agent misconduct in certain states.
- Federal Policy
KFF Analysis Finds TrumpRx Prices Below OECD Average for 17 of 32 Brand-Name Drugs
A Peterson-KFF Health System Tracker analysis compared prices for 32 brand-name drugs on TrumpRx.gov—a federal portal launched in February 2026 offering medications from manufacturers that signed voluntary pricing agreements with the White House—to publicly listed prices in 11 wealthy OECD countries. TrumpRx prices were lower than the OECD peer average for 17 drugs and higher for 15; TrumpRx had the lowest price for 5 drugs and the highest for 13. The analysis does not assess whether these negotiated prices affect Medicaid or Medicare reimbursement, whether domestic prices outside TrumpRx have changed, or how the retail prices compare to net costs after rebates in Medicaid or other public programs.
- Federal Policy · DE
CMS Awards $23 Million to Delaware for Rural Health Center Modernization and Mobile Care
CMS announced nearly $23 million in federal funding to Delaware for rural health center modernization, mobile care expansion, and chronic disease management infrastructure. The award supports facility upgrades, mobile health units, and technology improvements in underserved rural areas. The funding is available immediately for eligible health centers and state agencies to draw down for approved projects. For Medicaid, this matters because rural health centers serve significant Medicaid populations, and improved infrastructure and mobile capacity can expand access for beneficiaries in areas where provider shortages limit care availability.
- Federal Policy
CMS Administrator Oz Predicts AI Will Drive Up Healthcare Costs Before Reducing Them
CMS Administrator Dr. Mehmet Oz stated Wednesday that artificial intelligence will initially increase healthcare costs by accelerating medical billing before delivering long-term savings. He described AI as likely to "turbocharge" billing processes in the near term. The comments suggest CMS anticipates cost pressure from AI adoption across the healthcare sector, including Medicaid programs and managed care plans investing in AI-driven administrative tools. No timeline or policy response was specified.
- Federal Policy · AR
CMS Awards Arkansas $54.6 Million for Chronic Disease, Maternal Health, and Rural Workforce
CMS awarded Arkansas $54.6 million in federal funding to support chronic disease management, maternal healthcare services, and rural health workforce development. The funding will flow to Arkansas Medicaid and other state programs to expand access to care in underserved areas and improve health outcomes for vulnerable populations. The award takes effect in federal fiscal year 2027. This matters for Arkansas Medicaid stakeholders because it will fund network expansion, provider recruitment, and care coordination for high-need populations, potentially affecting managed care plan responsibilities and provider contracting requirements.
- Federal Policy
Trump Administration Claims All States Accepted GENEROUS Drug Pricing Model, Several States Deny Enrollment Decision
Trump administration officials announced that all states have agreed to participate in the GENEROUS model, a federal initiative designed to provide lower drug prices to state Medicaid programs. However, officials in multiple states say they have not committed to participation and are still evaluating whether GENEROUS offers better value than existing manufacturer rebate arrangements. Pricing details for the GENEROUS model remain unavailable to the public. The discrepancy raises questions about enrollment claims and creates uncertainty for state Medicaid agencies making coverage and financial planning decisions.
- Federal Policy
GAO: Five State MMRCs Drove 12-Month Postpartum Medicaid Extensions Through Mortality Reviews
In a report released September 24, 2026, the Government Accountability Office found that Maternal Mortality Review Committees in five states successfully recommended extending Medicaid postpartum coverage to 12 months, which those states subsequently adopted. GAO reviewed 10 MMRCs and found all consider federal and state laws as factors affecting maternal mortality, with committees commonly making recommendations on care coordination, mental health and substance use, health equity, reproductive health, and health care workers. CDC provides approximately $134 million over 2024-2029 to support 52 state and territorial MMRCs and monitors performance through regular meetings, required reports, and site visits. The findings demonstrate how state-level mortality review processes directly influence Medicaid coverage policy decisions aimed at reducing preventable maternal deaths, particularly those linked to chronic conditions like severe hypertension in the postpartum period.
- Federal Policy
OIG Finds CMS Medical Loss Ratio Data Validation Process for Medicaid MCOs Has Gaps
The HHS Office of Inspector General found that CMS's process for verifying the accuracy of medical loss ratio data submitted by states for Medicaid managed care organizations has limitations that may affect oversight. The report identifies weaknesses in how CMS validates state-reported MLR data used to determine whether MCOs meet federal standards requiring at least 85% of capitation payments go toward medical care and quality improvement. OIG's findings affect CMS's ability to ensure compliance with MLR requirements and identify MCOs that may owe remittances to states. The report matters for state Medicaid agencies responsible for collecting and reporting MLR data and for managed care plans subject to MLR requirements and potential remittance obligations.
- Federal Policy
Federal Rules Expected to Cut Medicaid Provider Payments by $50 Billion Across 36 States
A peer-reviewed Health Affairs analysis estimates that new federal rules will force 36 states to reduce annual Medicaid payments to doctors and hospitals by more than $50 billion in total. The payment cuts could reduce the number of providers willing to participate in Medicaid. The analysis warns of significant implications for provider network adequacy and beneficiary access to care across affected states.
