All stories
Jump to date
Monday, July 20 · 5 stories
- Managed Care · MS
Mississippi Delta Hospital Closure Spurs Local Reopening Campaign After Maternal Death
Local leaders in Mississippi's Delta region are attempting to reopen a closed rural hospital following the 2021 roadside death of Harmony Ball-Stribling, a pregnant woman, and her unborn daughter. The closure left the community without nearby obstetric and emergency services. The effort faces substantial obstacles, as rural hospital closures are rarely reversed once facilities shut down. The campaign highlights ongoing maternal health access challenges in rural Medicaid populations, particularly in states with limited maternity care infrastructure.
- Managed Care
State Medicaid Audit Reveals PBM Tactics That Inflate Drug Costs
A state Medicaid audit uncovered tactics pharmacy benefit managers use to obscure prescription drug costs, resulting in overcharges to taxpayers. The audit identified complicated claims processing methods that increased Medicaid spending beyond what would be expected under transparent pricing. The findings affect states contracting with PBMs directly or through managed care organizations for pharmacy services. The disclosure raises questions about PBM oversight requirements and potential recoupment of overpayments.
- Managed Care
Medicaid Eligibility Systems Face Increased Error Rates Amid Tax Law Implementation
State Medicaid eligibility determination systems are experiencing elevated error rates as they process changes required by recent federal tax and domestic policy legislation. Disabled beneficiaries report receiving erroneous coverage denials due to system malfunctions during the implementation period. The systems, which automate eligibility decisions for Medicaid managed care enrollment, have a documented history of technical failures that result in incorrect terminations or denials. State agencies are working to address the increased volume of system errors while maintaining beneficiary access to managed care coverage.
Friday, July 17 · 3 stories
- Managed Care · CA
Kern Family Health Care Uses AI Outreach to Reduce Medi-Cal Renewal Churn
Kern Family Health Care deployed Careforce AI technology to conduct outreach to thousands of Medi-Cal enrollees at risk of losing coverage during renewals. The AI-powered system identified members who had not completed renewal paperwork and facilitated completion of the process. The initiative helped the health plan reduce disenrollment during California's post-pandemic redetermination period. This represents an operational approach to addressing procedural disenrollment that other Medicaid MCOs may consider as states continue eligibility redeterminations.
- Managed Care
Total GLP-1 Payments Rose Sharply Through 2022 Despite Lower Patient Cost-Sharing
A Northwestern University study published July 16 in the Journal of the American Heart Association found that average total payments for GLP-1 users without diabetes increased significantly between 2017 and 2022, even as patient out-of-pocket costs declined. The study documents the growing financial burden on payers during the period when GLP-1 utilization expanded beyond diabetes treatment. The findings reflect cost trends during a period that predates recent Medicare coverage expansion and current utilization management strategies. The research provides baseline data as Medicaid managed care organizations continue to face pressure to cover GLP-1s for weight loss and cardiovascular indications.
- Managed Care
Major Insurers Decline to Renew Trump Administration Prior Authorization Pledge
Several health insurers have declined to sign an updated version of the Trump administration's voluntary prior authorization reform commitment, less than one year after the original pledge. The commitment, signed by dozens of insurers in 2025, aimed to streamline prior authorization processes that require patients and physicians to obtain approval before treatment. The withdrawal of support from some plans signals uncertainty about industry-wide adoption of standardized prior authorization improvements. For Medicaid managed care organizations, this development indicates that voluntary reform efforts may not deliver consistent changes across all payers, potentially leaving MCOs navigating different standards and timelines for prior authorization requirements.
Thursday, July 16 · 2 stories
- Managed Care
Transportation Access Shapes Health Outcomes for Older Adults in Medicaid Programs
Transportation barriers significantly affect health care access and outcomes for older adults enrolled in Medicaid. Lack of reliable transportation limits ability to attend medical appointments, access prescriptions, and maintain preventive care, leading to worse health outcomes and potentially higher costs. Medicaid managed care organizations increasingly recognize non-emergency medical transportation (NEMT) as a critical social determinant of health requiring strategic intervention. Organizations are exploring enhanced NEMT benefits, partnerships with rideshare services, and integration of transportation coordination into care management protocols.
- Managed Care
Home Health Providers Reject 63% of Referrals Due to Workforce Shortages
A Homecare Homebase report found that 63.3% of home health providers are turning down referrals, with referral conversion rates declining 13%. Providers cite staffing shortages as the primary reason for rejections. Documentation burden and scheduling friction are identified as key drivers of workforce turnover in home-based care settings. The findings indicate growing constraints on home health capacity despite rising demand for services.
Wednesday, July 15 · 2 stories
- Managed Care
AI Will Not Resolve Prior Authorization Disputes, MedCity Analysis Argues
A MedCity News analysis argues that artificial intelligence will not eliminate prior authorization conflicts between providers and payers, but will instead reshape an already imbalanced system that has existed for three decades. The piece contends that framing AI as a solution to prior authorization burden misses the fundamental structural issues. For Medicaid managed care organizations, the analysis suggests AI deployment may accelerate review processes but will not reduce provider pushback or change the underlying tension between cost control and access. The commentary does not reference specific policy changes or implementation timelines.
- Managed Care
Dual-Eligible Beneficiaries Show Higher Chronic Condition Rates Driving Spending Patterns
A new issue brief analyzes enrollment and spending patterns for dual-eligible individuals enrolled in both Medicare and Medicaid, focusing on how chronic condition prevalence drives higher average per-person costs. The analysis uses recent data on chronic conditions to profile this population's health status and associated expenditures. Dual-eligible beneficiaries represent a disproportionately high-cost, high-need segment often served through integrated Medicare-Medicaid plans (D-SNPs and FIDE SNPs). The findings provide context for managed care organizations managing dual-eligible populations on how chronic disease burden correlates with spending.
Tuesday, July 14 · 3 stories
- Managed Care
PBM Reform Drives Need for Automated Claim Reconstruction and Real-Time Financial Alignment
Pharmacy benefit manager reform efforts require health plans to implement automated systems capable of reconstructing claim logic on demand and providing real-time alignment between pricing, rebates, and financial outputs. The regulatory changes are described as directional rather than temporary, signaling sustained compliance expectations. Managed care organizations relying on PBM arrangements must assess whether their current operational infrastructure can meet these transparency and reporting requirements. The shift affects MCO pharmacy benefit operations, financial reconciliation processes, and regulatory compliance capabilities.
- Managed Care
Home-Based Care Providers Address Social Determinants Without Direct Payment
Home-based care providers are addressing social determinants of health despite lacking direct financial incentives. Providers report that removing barriers like food insecurity, housing instability, and transportation gaps improves care outcomes and enables frontline workers to deliver contracted services more effectively. The activity reflects growing provider investment in upstream interventions that affect utilization, quality metrics, and total cost of care. Medicaid managed care organizations increasingly rely on home-based providers for complex populations where social determinants directly affect clinical outcomes and plan performance.
- Managed Care
Substance Use and Suicide Combined Ranked Third Leading Cause of U.S. Death in 2024
A new brief reports that substance use and suicide deaths collectively became the third leading cause of death in the United States in 2024, reflecting continued behavioral health mortality trends. The analysis examines demographic patterns and temporal trends in these deaths. For Medicaid managed care organizations, this data underscores the scale of behavioral health needs among enrollees, as Medicaid covers a disproportionate share of individuals with substance use disorders and mental health conditions. The findings reinforce the importance of MCO investments in crisis intervention, medication-assisted treatment, and integrated behavioral health services.
Monday, July 13 · 3 stories
- Managed Care
Medicaid Plans Face Performance Pressure on Member Outreach for High-Need Enrollees
Medicaid managed care organizations are under scrutiny for their ability to locate and engage high-need members who require intensive services. The core challenge is not service availability but systematic outreach failures that prevent members from accessing existing benefits. Plans are increasingly held accountable for proactive member contact and engagement, particularly for populations with complex needs. This shift represents a growing emphasis on MCO responsibility for population health outcomes beyond passive claims payment.
- Managed Care
ACAP Report Details MCO Rate Adequacy Amid Federal Funding Pressures
The Association for Community Affiliated Plans released a report examining actuarially sound rate-setting for Medicaid managed care organizations as states anticipate federal funding reductions. The report addresses how rate adequacy affects MCO financial stability, network adequacy, and access to care during periods of fiscal constraint. It provides guidance for states and plans navigating rate-setting requirements under potential budget pressures. The analysis comes as states prepare budgets amid uncertainty about federal Medicaid funding levels.
- Managed Care
Plan Switching Creates Continuity of Care Barriers for Medicaid Enrollees
Americans switching health plans to find affordable coverage face disruptions in provider networks and medication access. These continuity-of-care challenges affect patient outcomes and care coordination when enrollees move between health plans. The barriers include prior authorization requirements for existing medications, loss of established provider relationships, and administrative complexity in maintaining treatment regimens. For Medicaid managed care organizations, member churn and plan transitions create operational challenges in maintaining quality metrics and member satisfaction while managing care continuity requirements.
Thursday, July 9 · 2 stories
- Managed Care
Contraceptive Implant Use Rising Despite Remaining Below Other Birth Control Methods
Contraceptive implants, the most effective reversible birth control method available, are seeing increased provision and utilization in the United States, though adoption rates remain lower than other contraceptive methods. The growth in implant use reflects evolving clinical practice patterns and improved access channels. For Medicaid managed care organizations, implants represent a covered preventive service under federal requirements, with reimbursement structures varying by state. The shift toward long-acting reversible contraceptives has implications for pharmacy benefit management, provider network adequacy, and quality metrics related to reproductive health access.
- Managed Care
Medically Tailored Meals Reduce Hospital Use for Medicaid Enrollees, Study Finds
A new study shows that medically tailored meal programs — home-delivered meals customized by dietitians for people with diabetes, heart disease, and other chronic conditions — significantly improve health outcomes and reduce hospital visits for Medicaid enrollees. Approximately 12 states currently offer these programs through their Medicaid programs. The findings provide evidence for managed care organizations considering value-based arrangements or enhanced benefits that include nutrition services. The study results are relevant as MCOs evaluate supplemental benefit strategies to manage high-cost, chronically ill populations.
Wednesday, July 8 · 8 stories
- Managed Care
CHCS Report Examines Long-Term Care Financing and Family Cost Burden
The Center for Health Care Strategies published a report analyzing long-term care financing in the United States, examining payment sources and financial strain on older adults and families. The report addresses who pays for long-term care services and why the current system creates significant cost burdens. Medicaid is the largest payer of long-term care services nationally, covering approximately 60% of nursing home residents and funding home and community-based services for individuals who meet financial and functional eligibility requirements. The analysis is relevant for managed care organizations operating long-term services and supports (LTSS) programs under Medicaid managed care contracts.
- Managed Care · MA
MassHealth Designs Primary Care Risk Adjustment Model for Population-Based Payment
MassHealth developed a primary care-specific risk adjustment model to support population-based payment arrangements with primary care practices. The model accounts for patient complexity factors relevant to primary care settings, distinct from traditional encounter-based or specialty-focused risk scores. The Center for Health Care Strategies published lessons learned from MassHealth's design process to inform other states and Medicaid managed care organizations implementing similar value-based payment structures. The work provides operational guidance for payers structuring capitation or shared savings arrangements with primary care providers.