All stories
Jump to date
Friday, August 21 · 1 story
- Managed Care · NY
EmblemHealth Issues Cease-and-Desist to Mount Sinai Over Government Plan Patient Access
EmblemHealth sent a cease-and-desist letter to Mount Sinai Health System's independent practice association on August 19, 2026, after the provider stopped accepting new patients from some of the insurer's government-backed plans. The action targets Mount Sinai's restriction on new patient intake, which appears to affect publicly-funded health plan enrollees. The cease-and-desist letter suggests the insurer views the access limitation as a potential contract violation. This development highlights ongoing network adequacy and access tensions between major health systems and Medicaid and Medicare Advantage plans in New York's competitive managed care market.
Thursday, August 20 · 1 story
- Managed Care · NY
Mount Sinai Stops Accepting New Patients with Centene Medicaid and Medicare Plans
Mount Sinai Health System in New York City has stopped accepting new patients enrolled in Centene's Fidelis Care Medicaid, exchange, and Medicare Advantage plans, as well as Wellcare Medicare Advantage plans. The health system removed public notices about the change from its website after initially posting them. The effective date and whether existing patients are affected remain unclear from available information. The move raises questions about network adequacy and access for Medicaid and Medicare Advantage enrollees in New York City, particularly those covered by Centene products.
Wednesday, August 19 · 1 story
- Managed Care
CHCS Report Examines Social Media Effects on Children's Behavioral Health
The Center for Health Care Strategies published a discussion with Stephanie Marcello, PhD exploring how social media and technology affect children's behavioral health. The report addresses concerns relevant to Medicaid managed care organizations that cover behavioral health services for children and adolescents. It builds on ongoing policy discussions about youth mental health and digital technology exposure. The analysis may inform MCO strategies for addressing behavioral health needs in pediatric populations.
Monday, August 17 · 1 story
- Managed Care
Prior Authorization Denial Rates Range from 2% to 25% Across Health Plans
Prior authorization denial rates varied from 2% to 25% among health insurers in 2025, according to a KFF analysis of newly released data mandated by CMS. The analysis reveals significant variation in how plans approve or deny coverage requests for medical services and drugs. This represents the first time CMS has required health insurers to publicly disclose prior authorization denial data, providing unprecedented transparency into plan-level utilization management practices. The data allows Medicaid managed care plans, state agencies, and regulators to benchmark denial patterns and assess whether authorization practices align with medical necessity standards and contract requirements.
Saturday, August 15 · 1 story
- Managed Care
Utah Mindfulness Therapy for Opioid Misuse Shows Cost Savings in Economic Analysis
A new economic analysis of a University of Utah mindfulness-based treatment for opioid misuse found potential savings of hundreds of thousands of dollars per patient when accounting for healthcare, criminal justice, and lost productivity costs. The study builds on earlier research demonstrating the therapy's clinical effectiveness in reducing opioid misuse. The analysis did not specify implementation timelines or whether the intervention is currently covered by Medicaid in any state.
Thursday, August 13 · 1 story
- Managed Care
Medicaid MCOs Denied at Least 1 in 8 Prior Authorization Requests in 2025
Analysis of 2025 prior authorization data shows Medicaid managed care organizations denied at least 12.5% of standard prior authorization requests, with denial rates varying significantly across insurers. The data, which also covers Medicare Advantage and ACA Marketplace plans, reveals inconsistencies in insurer practices but includes methodological limitations that complicate interpretation. The findings come as state Medicaid agencies and CMS face pressure to improve prior authorization transparency and oversight of MCO utilization management practices.
Tuesday, August 11 · 1 story
- Managed Care · AL
Black Midwife Addresses Maternity Care Access Gaps in Alabama Rural Counties
More than half of U.S. counties lack labor and delivery hospitals, according to new March of Dimes research, creating maternity care deserts that disproportionately affect rural populations. A Black midwife in Alabama is working to fill these access gaps by providing services across underserved counties. The delivery system gaps are particularly acute for Black mothers, who face significantly higher maternal mortality and morbidity rates. For Medicaid managed care plans covering pregnant beneficiaries, this highlights ongoing network adequacy challenges in maternal health, particularly in rural service areas where most deliveries are Medicaid-financed.
Monday, August 10 · 1 story
- Managed Care
Home Care Providers Focus on Caregiver-Client Matching to Reduce Turnover
Home care providers are emphasizing precise caregiver-client matching to address workforce retention challenges. Strong matches improve caregiver satisfaction and reduce turnover, while mismatches contribute to burnout and service disruptions. The approach targets operational stability amid ongoing labor shortages in home care. For Medicaid managed care plans and home and community-based services providers, improved matching strategies may reduce network instability and service continuity issues affecting LTSS members.
Friday, August 7 · 1 story
- Managed Care
ACAP CEO Defends Medicaid Program Following Senate Budget Committee Hearing
Margaret A. Murray, CEO of the Association for Community Affiliated Plans, issued a statement on August 4, 2026, following a Senate Budget Committee hearing titled "Medicaid: The Reality." Murray defended Medicaid as a pillar of the U.S. health care system. The statement responds to congressional scrutiny of the Medicaid program. The timing suggests potential legislative attention to Medicaid financing or structure, with implications for managed care organizations and safety-net plans represented by ACAP.
Thursday, August 6 · 1 story
- Managed Care
Emergency Department Bias Against Addiction Patients Limits Access to Evidence-Based Treatment
A ProPublica investigation documents how emergency department staff frequently dismiss patients with substance use disorders, withholding evidence-based addiction medications like buprenorphine despite their proven safety and effectiveness. The report highlights systemic bias among clinical staff who view addiction patients with suspicion rather than as individuals requiring medical treatment. This treatment gap has direct implications for Medicaid managed care plans and providers, as substance use disorder benefits are mandatory Medicaid services and many states now require MCOs to cover medication-assisted treatment without prior authorization.
Wednesday, August 5 · 2 stories
- Managed Care · MD
Baltimore Launches Alternative 911 Response for Health Crises
Baltimore is creating a new 911 response service designed to address health crises before they escalate. The city will deploy alternative responders when people call 911 for certain health-related emergencies. The initiative aims to connect individuals to appropriate health services rather than traditional emergency response. For Medicaid managed care organizations and behavioral health providers, this represents a shift in crisis intervention that may affect emergency department utilization, care coordination requirements, and community-based crisis response networks.
- Managed Care
UnitedHealthcare Limits Lab Test Reimbursement Across Medicaid and Other Lines
UnitedHealthcare will implement new reimbursement limits on five categories of lab tests — allergen testing, liver fibrosis testing, in vitro chemotherapy sensitivity assays, testosterone blood tests, and vitamin B12 testing — effective September 1, 2026. The policies apply across the company's commercial, ACA exchange, Medicare Advantage, and Medicaid product lines. UnitedHealthcare Medicaid plans will be affected by the same utilization management criteria being applied to other lines of business. The changes will affect laboratory providers billing UnitedHealthcare Medicaid plans and could impact member access to certain diagnostic tests.
Tuesday, August 4 · 1 story
- Managed Care · CA
California Health Plan Deploys AI to Prevent Medicaid Disenrollment Ahead of Work Requirements
A California Medicaid health plan is using artificial intelligence to automate appointment scheduling and paperwork reminders for enrollees facing new work requirements, aiming to reduce coverage losses during the compliance transition. The plan reports the AI system performs work equivalent to 40 staff members at significantly lower cost. The deployment comes as states prepare to implement work requirements that historically trigger coverage loss for eligible members who fail to complete verification processes. The approach raises questions about AI reliability, member experience, and whether automation adequately supports vulnerable populations navigating new administrative hurdles.
Monday, August 3 · 1 story
- Managed Care · VA
Sentara Health to Drop Anthem Networks Dec. 31 Without New Rates
Sentara Health has notified Anthem that it will terminate commercial, Medicare, and Medicaid contracts effective December 31, 2026, unless the parties reach a new rate agreement. The contract dispute affects an estimated 380,000 Virginians enrolled in Anthem plans. Sentara has indicated it will not renew under current rate terms. The termination would force Anthem Medicaid managed care enrollees in Virginia to find new in-network providers or face out-of-network costs if the impasse continues through year-end.
Tuesday, July 28 · 1 story
- Managed Care · CT
Connecticut Hospitals Redesign Emergency Departments for Behavioral Health Crises
Hospitals in Connecticut are redesigning emergency rooms to better accommodate patients experiencing behavioral health crises. Physicians and hospital leaders report the specialized units create calmer, more therapeutic environments compared to traditional ERs. The redesigns address growing demand for mental health crisis services in emergency settings. The changes affect how Medicaid managed care organizations coordinate behavioral health emergency services and may influence network adequacy and crisis stabilization requirements.
Monday, July 27 · 1 story
- Managed Care · CA
California Managed Care Plans Deploy Chief Health Equity Officers Under Medi-Cal Mandate
Medi-Cal managed care plans are required to employ chief health equity officers as part of California's strategy to address health disparities. These officers are implementing initiatives to reduce inequities in care delivery and outcomes across plan populations. The requirement affects all Medi-Cal MCOs operating in California. This represents a structural shift in how managed care plans address social determinants of health and health equity, requiring dedicated executive leadership and resources for disparities reduction.
Friday, July 24 · 1 story
- Managed Care
Survey Finds 62% of Family Caregivers View Home Care as Long-Term Solution
A 2026 report from A Place for Mom found that 62% of family caregivers view home care as a long-term or permanent solution for aging in place, suggesting families are more likely to adjust home care hours than transition to institutional settings. The finding indicates sustained demand for home and community-based services. While the brief article does not provide detailed methodology or timing, the trend reflects ongoing caregiver preferences that influence LTSS utilization patterns and Medicaid HCBS program design.
Tuesday, July 21 · 1 story
- Managed Care
Health Insurers Report Progress on Prior Authorization Simplification One Year After Voluntary Pledge
In June 2025, major health insurers committed to simplifying and reducing prior authorization requirements for plans covering 257 million Americans. One year later, payers report progress on their voluntary commitments, though implementation remains incomplete. The initiative affects commercial, Medicare Advantage, and potentially Medicaid managed care plans. For Medicaid MCOs, this signals industry-wide movement toward streamlined utilization management practices that may inform state contract requirements and CMS managed care rules.
Monday, July 20 · 5 stories
- Managed Care
Dementia Care Facilities Face Resident-on-Resident Violence Despite Oversight
An examination of health inspection reports and court records by KFF Health News reveals recurring violence between residents with dementia in nursing homes and assisted living facilities, including fatal assaults. The review documents patterns where facilities miss warning signs and fail to implement adequate safeguards to prevent resident-on-resident incidents. The findings highlight systemic gaps in dementia care protocols and supervision practices across long-term care settings. For Medicaid managed care organizations contracting with these facilities for long-term services and supports, the findings underscore quality oversight and member safety obligations.
- Managed Care
Specialty Pharmacy Economics Require Comprehensive Cost Management Beyond Drug Trend
Specialty drug costs continue rising, but traditional specialty drug trend metrics fail to capture the full economic picture for payers. A comprehensive view of specialty pharmacy economics includes rebates, dispensing fees, patient assistance programs, and site-of-care differentials that significantly affect net costs. Managed care organizations that analyze total cost of care rather than gross trend alone can identify opportunities to steer utilization to lower-cost sites and negotiate more favorable arrangements with specialty pharmacies and manufacturers. The analysis suggests payers should evaluate specialty pharmacy performance using net cost metrics that account for all payment flows, not just claims data.