All stories
Jump to date
Friday, August 14 · 14 stories
- State Policy · AZ
Arizona Audit Finds AHCCCS Failed to Implement Parent Caregiver Payment Limits
A state audit found that Arizona's Medicaid agency (AHCCCS) has not implemented legally required payment limits for parents who serve as paid caregivers for their developmentally disabled children, more than a year after the regulations became law. Auditors estimate the delay has cost the state hundreds of millions of dollars as program costs continue to escalate. The audit flags ongoing failure to enforce standardized payment guardrails designed to control expenditures in the state's long-term services and supports program for individuals with developmental disabilities.
- Legal
DOJ’s 2026 Health Care Fraud Takedown Signals Medicaid Enforcement Priorities
The Department of Justice announced its annual Health Care Fraud Takedown on June 23, 2026, with Medicaid and state health care programs representing a central enforcement focus. The takedown reflects DOJ's heightened scrutiny of fraud and abuse affecting state programs, not just Medicare. Medicaid providers, managed care organizations, and state agencies face increased risk of federal enforcement action. This enforcement prioritization signals that DOJ views Medicaid fraud as a critical target area requiring robust compliance programs and internal controls.
- State Policy · NE
Nebraska Medicaid Director Resigns Amid Work Requirement Implementation
Drew Gonshorowski has resigned as director of Nebraska's Division of Medicaid and Long-Term Care after less than two years, as the state became the first to implement more aggressive Medicaid work requirements. The leadership change comes at a critical juncture for Nebraska's program. The timing and circumstances of the resignation were not detailed in available reporting. A new director will need to oversee ongoing implementation of the work requirement policy and address any operational challenges in the state's Medicaid program.
- Legal
Federal Government Refers Hospitals, PBMs to DOJ Over Gender-Affirming Care Billing
The Vice President and HHS Secretary have referred dozens of hospitals, pharmacy benefit managers, and pharmacies to the Department of Justice and HHS Office of Inspector General for investigation of potentially fraudulent billing related to pediatric gender-affirming care. The referrals follow a new HHS report identifying organizations for scrutiny. The investigations will focus on billing practices for these services. This represents a significant enforcement action affecting hospitals and pharmacies providing or processing claims for pediatric gender-affirming treatment.
Thursday, August 13 · 24 stories
- Federal Policy
Physician Advocates for Site-Neutral Payment Reform in Medicare
A physician is arguing that Congress should enact site-neutral payment reforms in Medicare to reduce healthcare spending driven by hospital consolidation. Site-neutral payments would eliminate higher Medicare reimbursement rates for services provided in hospital outpatient departments compared to physician offices. The physician contends this reform would lower costs without compromising patient care quality. While the article focuses on Medicare policy, site-neutral payment discussions often influence Medicaid policy development, particularly as states manage their own fee schedules and provider networks.
- Federal Policy
CMS Proposes RAPID Pathway for Breakthrough Device Coverage Under Medicare
On August 7, 2024, CMS issued a notice with comment period proposing the Regulatory Alignment for Predictable and Immediate Device (RAPID) Coverage Pathway. The pathway would accelerate Medicare coverage for medical devices receiving FDA breakthrough designation by aligning CMS coverage review with FDA premarket review before market authorization. The proposal aims to reduce the gap between FDA approval and Medicare coverage determinations for qualifying devices. Comments are due following standard notice procedures.
- Federal Policy
CMS Sets October 13 Deadline for APM Participants to Update Billing Information or Forfeit 2026 Payments
CMS issued an advisory requiring certain alternative payment model participants to update taxpayer identification numbers by October 13, 2026, to receive APM incentive payments for the 2026 payment year based on 2024 performance. The agency could not identify valid TINs for some participants after processing payments. Clinicians who fail to submit updated billing information by the deadline will forfeit their APM incentive payments for this payment period.
- Industry
Bipartisan Senate Pressure on Insurers Intensifies Ahead of 2027
Senators Elizabeth Warren (D-Mass.) and Josh Hawley (R-Mo.) have introduced legislation targeting health insurers amid mounting bipartisan criticism over contracting practices, vertical integration, and prior authorization policies. The legislative effort reflects escalating tensions between insurers, lawmakers, employers, and patients heading into 2027. While the article does not specify effective dates or comment periods, it signals a legislative environment increasingly hostile to insurer business practices across both commercial and government-sponsored programs.
- Industry
Physician Shortage Projected to Reach 86,000 by 2036, Rural Areas Most Affected
A new AMN Healthcare report projects a U.S. physician shortage of 86,000 by 2036, with rural communities experiencing the most severe workforce gaps. The report warns that healthcare spending cuts could accelerate rural hospital closures in areas already struggling with provider access. The shortage affects all specialties but is most acute in primary care and behavioral health, sectors critical to Medicaid beneficiaries who disproportionately rely on rural safety-net providers.
- Industry
Nonprofit Hospital Operating Margins Improved in 2025 but Face Federal Funding Cuts
Nonprofit hospitals saw overall operating margin improvement in 2025, but some providers experienced declining performance, according to Fitch Ratings. The sector faces looming major federal funding cuts that threaten recent gains. The analysis indicates the recovery trajectory may have reached its peak, with financial pressures mounting for certain hospital systems. This development matters for Medicaid managed care networks as hospital financial instability can affect network adequacy, contract negotiations, and care delivery capacity for Medicaid enrollees.
- State Policy · PA
Pennsylvania Budget Excludes Home Health Nurse Rate Increase Despite Workforce Shortages
Pennsylvania's enacted budget does not include funding increases for home health nursing services, despite workforce shortages in the sector. Industry representatives report that current Medicaid reimbursement rates make it difficult to recruit and retain home health nurses. The budget outcome means existing rate structures will continue, affecting access to home-based nursing care for Medicaid beneficiaries. Home health agencies serving Medicaid populations face ongoing challenges competing for nursing staff without enhanced reimbursement.
- Industry
Big Five Medicaid MCOs Report Q2 2026 Earnings Results
The five largest publicly-traded Medicaid managed care organizations — Centene, CVS Health/Aetna, Elevance Health, Molina Healthcare, and UnitedHealth Group — have released second-quarter 2026 financial results. These companies collectively serve approximately half of all Medicaid enrollees nationwide. The earnings reports provide insight into revenue trends, medical loss ratios, enrollment changes, and profitability across the Medicaid managed care sector during the quarter ending June 30, 2026.
- Federal Policy
CMS Clarifies Custodial Parents Largely Exempt from Medicaid Work Reporting Requirements
The Centers for Medicare and Medicaid Services released an Interim Final Rule clarifying exemptions from new Medicaid work reporting requirements set to take effect in January 2027. The guidance confirms that most custodial parents and caretaker relatives are excluded from work reporting mandates, addressing widespread confusion as 28 states prepare implementation. The clarification affects state planning and system development currently underway. The IFR provides critical operational guidance for state Medicaid agencies navigating compliance with federal work reporting provisions while minimizing improper coverage terminations for exempt populations.
- Federal Policy
CMS Opens Comment Period for RAPID Device Coverage Pathway, Due October 10
CMS released a notice with comment period on August 7, 2026, establishing the framework for the Regulatory Alignment for Predictable and Immediate Device (RAPID) Coverage Pathway. The pathway aims to accelerate Medicare coverage for innovative medical devices following FDA market authorization. Comments are due October 10, 2026. The pathway creates a streamlined process that shortens the gap between FDA approval and national Medicare coverage for qualifying devices.
- Industry · ND
Altru Health System Closes Home Health Line in North Dakota Citing Regulatory Burdens
Altru Health System will close its home health service line effective September 1, 2026, citing regulatory burdens as the reason. The Grand Forks, North Dakota-based health system serves 230,000 residents across northeast North Dakota and northwest Minnesota with 3,100 staff. Patients who continue to qualify for home health services will need alternative providers. The closure reflects ongoing operational challenges in the home health sector that may affect Medicaid beneficiaries' access to home-based care in the region.
- State Policy
Cato Institute Report Finds Certificate of Need Laws Restrict Healthcare Access
The Cato Institute released a report analyzing nearly 130 studies on certificate of need (CON) laws, which require healthcare providers to obtain state approval before constructing new facilities or adding services. The report concludes that CON laws restrict healthcare access and competition. CON laws remain in effect in approximately 35 states and directly affect Medicaid beneficiaries' access to nursing homes, dialysis centers, home health agencies, and other services that require state approval before expansion. The analysis adds to ongoing state-level debates over repealing or reforming CON requirements.
- Industry
St. Luke's and UnitedHealthcare Automate 88% of Claim Status Updates via Epic
St. Luke's University Health Network and UnitedHealthcare have automated claim status updates for 88% of claims exchanged between them using Epic's Payer Platform. The automation gives St. Luke's staff real-time visibility into claim processing status. Epic reported this implementation in its 2026-2027 Almanac as an example of administrative efficiency gains through electronic data exchange between providers and payers.
- Industry
Hospital M&A Activity Surges in Early 2026 After Multiyear Slowdown
Hospital and health system merger and acquisition activity reached its highest level since early 2020, with 22 transactions announced in Q1 2026 and 18 more in Q2, following a multiyear slowdown that hit a decade-low in 2025. The rebound follows a period when hospital boards delayed deals amid federal policy uncertainty. Industry observers characterize the current wave as proactive strategic positioning rather than distress-driven consolidation, suggesting financially stronger systems are pursuing market expansion and service line integration opportunities.
- Industry
Medicare Value-Based Payment Programs Raise Hospital Administrative Costs, Study Finds
A study published August 7 in JAMA Health Forum found that participation in mandatory CMS value-based payment programs is associated with significantly higher annual administrative costs for hospitals. Researchers at Brown University School of Public Health analyzed Medicare cost report data from 2006 to 2020 covering 4,332 hospitals, including 2,820 participating in value-based arrangements. The findings suggest that administrative burden from quality reporting, performance tracking, and program compliance may offset financial benefits hospitals seek from value-based contracting.
- Federal Policy
HRSA Launches Framework to Modernize National Newborn Screening Panel Review Process
The Health Resources and Services Administration announced a new framework on August 11, 2026, to streamline how conditions are evaluated for addition to the national newborn screening panel. The initiative aims to update a review process that officials say has not kept pace with advances in genetic medicine. The framework establishes a standardized pathway for assessing which screenable conditions should be recommended for inclusion. This affects state Medicaid programs and CHIP, which finance newborn screening for the majority of U.S. births and must determine coverage for newly recommended tests.