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Saturday, August 29 · 64 stories
- Managed Care
MACPAC Comments on CMS Proposed Rule for State Directed Payments and Targeted Practitioner Payments
The Medicaid and CHIP Payment and Access Commission submitted comments to CMS Administrator Dr. Mehmet Oz on a proposed rule governing state directed payments in managed care and targeted practitioner payments in fee-for-service. MACPAC supports CMS efforts to align Medicaid payments with statutory requirements for economy and efficiency. The comment letter addresses proposed changes to how states can direct managed care organizations to make specific payments to providers and how states structure targeted payments in FFS arrangements. The proposed rule affects state Medicaid agencies' flexibility to use payment strategies that support provider rates and access while meeting federal oversight requirements.
- Managed Care
NAMD Issues Comments on CMS State Directed Payment Proposed Rule
The National Association of Medicaid Directors has submitted formal comments on CMS' 2026 proposed rule governing state directed payments in Medicaid managed care and targeted fee-for-service payments. NAMD's recommendations address regulatory changes CMS proposed for how states structure supplemental payments to providers through managed care contracts and direct Medicaid payments. The comments reflect state Medicaid directors' operational concerns about implementing potential new federal requirements for these payment arrangements, which states use to address provider rates, access, and delivery system reforms.
- Federal Policy
CMS Releases State Toolkit for ABA Oversight and Autism Service Protections
CMS published a new toolkit to help states strengthen oversight of Applied Behavior Analysis (ABA) services for children with autism in Medicaid and CHIP. The toolkit provides guidance on monitoring provider qualifications, service quality, and care coordination to prevent harmful practices and ensure medically necessary treatment. States can use the resources immediately to enhance program integrity and beneficiary protections. This matters because ABA is a significant behavioral health expenditure across state Medicaid programs, and inconsistent oversight has led to quality concerns and potential fraud.
- Federal Policy · WA
CMS Announces Emergency Flexibilities for Washington State Public Health Crisis
CMS has announced emergency resources and regulatory flexibilities to assist Washington state in responding to a declared public health emergency. The flexibilities allow the state to modify service delivery requirements, adjust provider enrollment procedures, and access expedited waiver authority. These measures take effect immediately and remain in place for the duration of the emergency declaration. The announcement provides operational relief for Washington's Medicaid program, enabling rapid response to urgent health system needs without standard administrative timelines.
- State Policy · SD
CMS Approves $90 Million for South Dakota Medicaid IT System Modernization
CMS approved $90 million in enhanced federal matching funds for South Dakota to modernize its Medicaid Management Information System (MMIS) and improve data interoperability. The funding will support system upgrades to meet federal certification requirements, enhance provider and beneficiary portals, and improve claims processing and data exchange capabilities. The approval follows South Dakota's Advanced Planning Document submission and supports the state's transition to a modular, standards-based MMIS architecture required under federal Medicaid IT regulations. The modernization will affect all South Dakota Medicaid stakeholders including managed care organizations, providers, and state agency operations through improved data exchange, faster claims adjudication, and enhanced reporting capabilities.
- Federal Policy · ND
CMS Awards North Dakota Funding for Coordinating and Connecting Care Initiative
CMS has approved funding for North Dakota to launch the Coordinating and Connecting Care Initiative, a program designed to improve care coordination and integration across Medicaid services. The initiative targets beneficiaries with complex medical and behavioral health needs, including those requiring long-term services and supports. Implementation details, effective dates, and specific funding amounts were not provided in the available information. The program aims to reduce fragmentation in care delivery and improve health outcomes for high-needs Medicaid populations.
- State Policy
California Allocates $56M for Gender-Affirming Care After Federal Rule; Colorado Deploys AI Fraud Detection
California announced $56 million in state funding over three years to cover gender-affirming care and abortion services excluded from federal Medicaid reimbursement under a new Trump administration rule, plus network stabilization investments. Colorado received CMS certification for AI-powered fraud detection technology analyzing provider, member, claims, and financial data to identify program integrity outliers. Maryland launched a $3 million workforce fund offering zero-interest nursing student loans and is seeking public comment on adding nutrition services as In Lieu of Services in 2028. Maine approved 2027 commercial health insurance rate increases of 14.8% individual and 13.5% small group, effective January 1. Massachusetts scheduled six public listening sessions on healthcare cost reduction regulations.
- Federal Policy
CMS Updates SSI and Spousal Impoverishment Standards for 2026
CMS released updated Supplemental Security Income (SSI) and spousal impoverishment standards effective for 2026. The bulletin provides revised income and resource thresholds that states must apply when determining Medicaid eligibility for aged, blind, and disabled individuals, as well as protections for spouses of institutionalized individuals. These standards affect eligibility determinations for coverage of long-term services and supports. State Medicaid agencies must implement these updated figures in their eligibility systems and processes.
- Federal Policy
CMS Issues 2026 Federal Poverty Level Standards for Medicaid Eligibility
CMS released the 2026 Federal Poverty Level standards in an informational bulletin dated January 23, 2026. The updated income thresholds apply to Medicaid and CHIP eligibility determinations starting February 2026. States must update their eligibility systems and Modified Adjusted Gross Income (MAGI) conversion tables to reflect the new FPL amounts. The guidance affects income-based eligibility for millions of Medicaid and CHIP beneficiaries nationwide, requiring states to adjust eligibility thresholds and redetermination processes.
- Federal Policy
MACPAC June 2026 Report Addresses Community Engagement, Prior Authorization Automation, MCO Accountability
The Medicaid and CHIP Payment and Access Commission released its June 2026 Report to Congress covering seven policy areas. Key chapters examine community engagement requirements in Medicaid, automation in prior authorization processes, managed care accountability mechanisms, access to residential treatment services for Medicaid-enrolled youth, and transitions to adult coverage for children and youth with special health care needs. The report provides policy recommendations and analysis for congressional consideration on these topics. MACPAC reports typically inform federal legislative and regulatory activity in Medicaid and CHIP.
- Federal Policy
CMS Delays HCBS Fee-For-Service Grievance System Enforcement Until December 2027
CMS will not enforce the federal requirement for states to establish fee-for-service grievance systems for home and community-based services until December 31, 2027. The enforcement discretion applies to 42 CFR 431.205(d), which requires states to implement grievance procedures for HCBS beneficiaries in FFS arrangements comparable to managed care protections. States must still comply with all other due process and fair hearing requirements under existing federal rules. The delay gives states additional time to develop compliant systems while CMS considers whether regulatory modifications are needed.
- Federal Policy
Budget Reconciliation Act Mandates Medicaid Community Engagement Requirements for States
The 2025 Budget Reconciliation Act (P.L. 119-21) requires states to condition Medicaid eligibility on participation in qualifying community engagement activities for certain applicants and beneficiaries. A new report recommends states develop transparent monitoring and evaluation plans for implementing these requirements. The law creates operational obligations for state Medicaid agencies to establish verification systems, track compliance, and determine eligibility impacts. This represents a significant administrative burden for states and managed care organizations that will need to operationalize work reporting, exemption processes, and disenrollment protocols.
- Federal Policy
NAMD Submits Comments on CMS Community Engagement Interim Final Rule
The National Association of Medicaid Directors submitted formal comments on July 31, 2026, regarding CMS's interim final rule imposing community engagement requirements on certain Medicaid beneficiaries. The rule was issued with a comment period, allowing state Medicaid agencies and stakeholders to provide feedback before final implementation. NAMD's comments reflect state perspectives on operational feasibility, administrative burden, and compliance requirements associated with implementing work or community engagement mandates. The comment period signals that states will need to prepare for potential implementation depending on the final rule's provisions.
- Federal Policy
CMS Issues Guidance on Medicaid Eligibility After DHS Ends Parole Programs for Four Countries
CMS issued an informational bulletin on July 14, 2026, addressing how state Medicaid and CHIP agencies should handle eligibility and verification after DHS terminated parole programs for Cuban, Haitian, Nicaraguan, and Venezuelan nationals. The guidance clarifies that individuals who entered under these programs and whose parole has been terminated no longer meet the qualified non-citizen immigration status required for Medicaid eligibility in most categories, though emergency Medicaid remains available. States must update verification processes and eligibility determinations to reflect the changed immigration status of affected individuals. The guidance affects states with significant populations who entered under these parole programs and requires immediate attention to systems and procedures.
- Federal Policy
CMS Rescinds Fast-Track Review Process for Section 1115 Demonstration Extensions
CMS issued an informational bulletin on July 7, 2026, rescinding the fast-track federal review process for Section 1115 demonstration extensions. States seeking to extend existing Section 1115 demonstrations must now follow standard CMS review timelines and procedures, which typically require full public notice and comment periods and can take six months or longer. The rescission is effective immediately and applies to all pending and future extension requests. This change affects states with demonstrations expiring soon that planned to use expedited procedures, requiring them to build additional lead time into their extension planning and potentially delaying implementation of continuation authority.
- Federal Policy
CMS Issues Guidance on Medicaid Managed Care Monitoring and Oversight Requirements
CMS released an informational bulletin clarifying state agency responsibilities for monitoring and overseeing Medicaid and CHIP managed care organizations. The guidance addresses network adequacy monitoring, financial solvency review, quality performance measurement, and corrective action protocols that states must implement. States should review existing oversight processes against the CIB framework and adjust monitoring practices as needed to align with federal expectations. The bulletin provides operational direction for state Medicaid agencies on maintaining program integrity and beneficiary protections in managed care delivery systems.
Friday, August 28 · 11 stories
- Federal Policy
Home Health Providers Submit Comments on CY 2027 Rate Rule
Home health providers and advocates are submitting comments on CMS's proposed home health payment rule for calendar year 2027 as the comment period closes. Stakeholders have expressed support for the proposed rate increase while raising concerns about specific provisions. The rule would take effect January 1, 2027. For Medicaid managed care plans contracting with home health agencies, rate changes at the Medicare level often influence provider cost expectations and contracting leverage in Medicaid networks, particularly for dual-eligible populations and states with integrated care models.
- State Policy · TX
Democrats Target Medicaid Cuts in South Texas House Races
Healthcare has emerged as a central issue in South Texas' battleground House races, with Democratic candidates focusing campaign messaging on lapsed insurance subsidies and Republican-backed Medicaid cuts. The political emphasis reflects rising healthcare costs and their electoral significance in the state's most competitive districts. Democrats are using Medicaid funding reductions as a key contrast point in races that could determine state legislative control. This development signals that Medicaid policy decisions are becoming flashpoints in Texas electoral politics, potentially affecting future state budget negotiations and Medicaid program direction.
- Managed Care
States Consider Value-Based HCBS Contracts to Avoid Benefit Cuts During Economic Downturn
Industry leaders at Home Health Care News' PAYER Summit in June said state Medicaid programs facing budget pressure from economic downturns could pursue value-based contracts with home- and community-based services providers rather than restricting benefits or cutting services outright. The strategy shifts financial risk to providers while preserving access. No specific states or implementation timelines were identified. This approach matters for HCBS providers and managed care organizations managing LTSS populations as states seek budget-neutral alternatives to traditional cost containment.
- Managed Care
NASHP Reviews State Models for Specialized Children's Medicaid Managed Care Programs
The National Academy for State Health Policy published an analysis of how states structure specialized Medicaid managed care programs for children and youth with chronic and complex conditions. The review examines state design choices including eligibility criteria, carved-in versus carved-out services, care coordination requirements, and specialized plan contracting approaches. The analysis is intended to help state Medicaid agencies considering or refining specialized programs for medically complex pediatric populations. No federal policy change or state-specific implementation timeline is reported.