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Wednesday, July 8 · 8 stories
- Managed Care
ACAP Report Documents Safety Net Health Plan Chronic Disease Programs
The Association for Community Affiliated Plans released a report on January 15, 2026 documenting chronic disease management initiatives deployed by safety net health plans. The report highlights member-focused programs addressing conditions prevalent in Medicaid and dual eligible populations. Safety net health plans serving Medicaid beneficiaries can review documented approaches and potentially adapt models for their own populations. The report provides examples of operational interventions currently in use across ACAP member organizations.
- Managed Care
ACAP Proposes Five Dual SNP Demonstration Programs to Improve Care Coordination
The Association for Community Affiliated Plans released a report proposing five demonstration programs to leverage Dual Eligible Special Needs Plans (D-SNPs) for improved care coordination. The proposals target Medicare beneficiaries enrolled in D-SNPs, which serve individuals eligible for both Medicare and Medicaid. The report comes as CMS and states continue to pursue integrated care models for dually eligible populations. The proposals matter for Medicaid managed care organizations operating D-SNPs or seeking to expand dual-eligible programs, as they outline potential policy pathways for enhanced integration and coordination between Medicare and Medicaid benefits.
- Managed Care
NAMD Discusses Medicaid Coverage of GLP-1 Weight Loss Drugs
The National Association of Medicaid Directors addressed Medicaid coverage considerations for new anti-obesity medications in a discussion with VeryWellHealth reporters. The conversation focused on access and policy implications for Medicaid enrollees. As GLP-1 drugs like Wegovy and Zepbound gain FDA approval for weight loss, state Medicaid programs face coverage decisions affecting millions of beneficiaries. Medicaid managed care plans must navigate utilization management, prior authorization requirements, and budget impact as states determine whether and how to cover these high-cost medications.
- Managed Care
CMS Proposes Limits on State Directed Payments Under New Statutory Authority
On May 20, 2026, CMS released a proposed rule implementing statutory limits on state directed payments (SDPs) enacted under H.R.1 (Public Law 119-21). The rule establishes new caps and requirements for SDPs that states use to direct managed care organization payments to providers. The proposed changes would affect how states structure supplemental payments within capitation rates and require new CMS preapproval processes. Public comments are due 60 days from Federal Register publication. The rule directly impacts MCO rate setting, provider payment arrangements, and state contract negotiations for managed care plans participating in SDP arrangements.
- Managed Care
Some Health Plans Exclude Manufacturer Copay Assistance from Deductible and Out-of-Pocket Maximums
Health insurers are implementing policies that exclude manufacturer copay assistance from counting toward patient deductibles and out-of-pocket maximums, a practice known as copay accumulator programs. When drugmakers provide financial assistance to help patients afford expensive medications, these programs prevent those payments from reducing the patient's cost-sharing obligations under the plan. Patients effectively pay twice — once through the manufacturer assistance that does not count toward their deductible, and again when they must meet the full deductible out of their own pocket. This practice affects managed care plans' pharmacy benefit design and patient access to high-cost specialty medications.
- Managed Care
GLP-1 Weight Loss Use Jumps to 11% of Americans in Two Years
A Gallup survey released Tuesday shows 11 percent of Americans now take GLP-1 medications for weight loss, up from 3 percent in 2024. An additional 15 percent report considering use. The sharp uptick in utilization represents significant pharmacy cost pressure for Medicaid managed care plans, which face coverage mandates in some states and growing member demand. Plans must manage prior authorization protocols, medical necessity criteria, and budget forecasts as obesity prevalence grows among Medicaid populations.
Tuesday, July 7 · 3 stories
- Managed Care
States Urged to Modernize Program Integrity in Medicaid Self-Directed Care Programs
An analysis calls on states to redesign program integrity approaches for self-directed Medicaid services by focusing on four priorities that allow oversight to scale with program growth. Self-directed care models, where beneficiaries manage their own long-term services and supports budgets, have expanded rapidly but present unique fraud and compliance risks. The recommendations address how states can maintain effective oversight without constraining beneficiary choice and flexibility. For managed care organizations administering or overseeing self-directed options, this highlights evolving state expectations for program integrity infrastructure in LTSS programs.
- Managed Care
NASHP Publishes Behavioral Health Integration Resource for Medicaid MCOs
The National Academy for State Health Policy released a resource examining behavioral health integration strategies in Medicaid managed care contracts. The snapshot covers care coordination approaches, quality measurement frameworks, and payment methodologies states are using to advance integrated behavioral health delivery through MCO contracts. The resource is intended for state Medicaid programs and managed care plans developing or refining behavioral health integration requirements.
- Managed Care · AR
Centene Exits Arkansas Medicaid Expansion Program in 2027
Centene Corporation will discontinue participation in Arkansas' ARHOME Medicaid expansion program in 2027, according to the state Department of Human Services. The withdrawal affects one of the state's major managed care organizations serving the expansion population. Arkansas receives billions in federal Medicaid dollars annually, and Centene's exit will require the state to reassign covered members to remaining health plans or adjust its managed care delivery system. The decision reflects ongoing commercial considerations in state Medicaid managed care markets.
Monday, July 6 · 1 story
- Managed Care
KLAS Spotlight Profiles RAAPID's AI-Driven Risk Adjustment Coding Platform
KLAS Research published an Emerging Company Spotlight on RAAPID, a vendor offering neuro-symbolic AI solutions designed to improve risk adjustment coding defensibility for health plans. The report includes customer satisfaction ratings and performance assessments from RAAPID clients in 2026. Risk adjustment coding accuracy directly affects capitation payments and audit exposure for Medicaid managed care organizations, particularly as CMS and state agencies intensify oversight of diagnosis reporting and hierarchical condition categories. The spotlight provides comparative data for MCOs evaluating technology vendors to support compliant coding practices.
Wednesday, July 1 · 1 story
- Managed Care
Hurricane Flooding Extends Home Health Treatment Times by Two Weeks
New research finds that hurricanes and related flooding cause significant disruptions to home health services, adding nearly two weeks to treatment times and reducing rates of successful discharge to the community. The decentralized structure of home health care makes both providers and payers particularly vulnerable to extreme weather events. The findings highlight operational and quality risks for managed care organizations that contract for home-based services, especially those serving dual-eligible populations and members with complex care needs who rely on consistent in-home support.
Tuesday, June 30 · 3 stories
- Managed Care
Cityblock CEO: Most Health Care AI Invests in Billing, Not Care Delivery
Dr. Toyin Ajayi, CEO of Cityblock Health, argues that approximately 60 percent of health care AI investment focuses on billing, coding, and risk adjustment rather than care delivery. Cityblock serves over 100,000 Medicaid and dual-eligible members across ten states. Ajayi contends that redirecting AI investment toward care delivery for high-need populations can lower costs while improving outcomes. She discusses how Cityblock currently uses AI to enhance care and patient experience for Medicaid managed care enrollees.
- Managed Care · IL
Chicago Safety-Net Hospital Faces Closure Over Medicaid MCO Payment Delays
Roseland Community Hospital on Chicago's South Side is struggling to make payroll due to delayed payments from CountyCare, Cook County's largest Medicaid managed care organization. The facility barely met its June 30 payroll and CEO Tim Egan described the financial situation as critical. The hospital serves a predominantly Medicaid population in an underserved area. Payment delays from Medicaid MCOs threaten the facility's ability to remain operational.
- Managed Care · CO
Denver Health CEO Discusses Housing Program for Medicaid, Uninsured Patients
Denver Health CEO Donna Lynne describes the health system's Housing Outreach, Partnerships and Engagement (HOPE) program, which provides 34 apartments to patients experiencing homelessness or housing insecurity. The program, which won the 2026 AHA Dick Davidson NOVA Award, includes 20 recuperative care units with average 2-3 day stays and 14 longer-term apartments for up to six months. Denver Health serves a patient population that is 47% Medicaid and 15% uninsured; the program reduces length of stay and readmissions for homeless patients, who typically stay 2.5 times longer than housed patients. The health system partners with Colorado Coalition for the Homeless and Denver Housing Authority to transition patients to permanent housing.
Monday, June 29 · 2 stories
- Managed Care
988 Suicide Hotline Expands LGBTQ-Specific Services
The 988 Suicide and Crisis Lifeline is expanding specialized services for LGBTQ+ populations. The expansion addresses higher rates of crisis calls and mental health needs among LGBTQ+ individuals, particularly youth. For Medicaid managed care organizations, this development affects crisis service coordination and behavioral health network adequacy requirements, as many states require MCOs to integrate 988 into their crisis response systems. MCOs should assess whether their behavioral health networks can support LGBTQ-competent follow-up care for individuals diverted from emergency departments through 988.
- Managed Care
Home-Based Care Payment Models Focus on Value, Risk, and Coordination
Industry leaders at the PAYER Summit identified three payment trends reshaping home-based care delivery: value-based payment arrangements replacing fee-for-service, increased provider risk-sharing with managed care organizations, and stronger payment incentives for care coordination across post-acute settings. These shifts affect how MCOs structure home health and home-based primary care contracts. The trends reflect broader movement toward outcomes-based reimbursement in Medicaid managed long-term services and supports. Payer executives and providers agreed these payment changes will determine which home-based care organizations remain viable partners for health plans.
Thursday, June 25 · 1 story
- Managed Care
National Health Law Program Calls for Expanded Menopause Coverage in Medicaid
The National Health Law Program identifies significant barriers to menopause care for Medicaid enrollees, including coverage gaps and access challenges. Approximately 6,000 people enter menopause daily in the U.S., experiencing symptoms like hot flashes, bone loss, sleep disturbances, and cognitive changes that can be disabling but treatable. The organization highlights that Medicaid beneficiaries, low-income individuals, and people of color face disproportionate obstacles in accessing menopause treatment. The article advocates for improved coverage policies to address these disparities.
Wednesday, June 24 · 2 stories
- Managed Care · MA
Massachusetts Hospitals Drop Youth Gender-Affirming Care Amid Federal Pressure
Several hospitals in Massachusetts have voluntarily discontinued gender-affirming care services for minors despite state laws protecting such access, responding to anticipated federal enforcement actions from the Trump administration. The service reductions affect families currently receiving care and represent a significant network adequacy challenge for Medicaid managed care organizations that contract with these facilities. Massachusetts had previously enacted protective legislation and joined multi-state litigation to defend access to these services. The hospital decisions create immediate coverage gaps for MCOs required to provide comprehensive behavioral health and specialized pediatric services under their state contracts.
- Managed Care
Health Plan Appeals Activity Signals Operational Performance Under Pressure
Health plans experience relatively low appeal volumes, which serves as an indicator of operational effectiveness and case prioritization processes. The pattern of appeals and grievances reveals how plans identify high-priority cases and resolve member concerns before they escalate. For Medicaid managed care organizations, appeal rates and resolution practices are tracked by state agencies and CMS as quality metrics. Understanding why appeals remain infrequent — whether due to effective member services, barriers to access, or successful early intervention — matters for contract compliance and quality ratings.
Monday, June 22 · 1 story
- Managed Care
Health Plans Urged to Maintain Integrated Pharmacy Benefits Over Disaggregation Models
Industry commentary argues that health plans should retain integrated pharmacy benefit management rather than disaggregate services to separate PBMs or carve-out arrangements. The piece contends integrated models provide better coordination between medical and pharmacy benefits, improved utilization management, and stronger cost control compared to disaggregated approaches. No specific policy change or implementation timeline is involved; this represents strategic guidance for plan decision-making. For Medicaid MCOs facing increasing pharmacy costs and state pressure on benefit design, the integration versus disaggregation question affects contract performance, quality metrics, and administrative complexity.