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Friday, June 19 · 1 story
- Managed Care
Half of U.S. Counties Lack OB-GYN Despite Declining Birth Rates
Nearly half of U.S. counties have no practicing obstetrician or gynecologist, creating maternity care deserts despite declining fertility rates. The shortage stems from systemic workforce and reimbursement issues rather than demand pressures. Many rural and underserved areas lack adequate prenatal and delivery services, forcing pregnant beneficiaries to travel long distances for care. The gap affects Medicaid managed care organizations' ability to meet network adequacy standards and HEDIS measures for prenatal and postpartum care.
Thursday, June 18 · 1 story
- Managed Care
California, New York, Ohio Account for 26% of National Medicaid Drug Spend in FY 2024
California, New York, and Ohio led all states in gross Medicaid prescription drug spending in fiscal year 2024, representing more than a quarter of national expenditures, according to a KFF analysis of federal data. The figures reflect gross spending before manufacturer rebates on covered outpatient drugs under the Medicaid Drug Rebate Program. The data provides a state-by-state breakdown of prescription drug costs, highlighting geographic variation in Medicaid pharmacy spending patterns. This information is relevant for managed care organizations operating in multiple states to benchmark their pharmacy spending and assess market-specific cost drivers.
Wednesday, June 17 · 3 stories
- Managed Care
CDC Reports Infant Mortality Rate Falls to Record Low in 2025
The CDC's National Vital Statistics System reported that infant mortality rates in the United States reached an all-time low in 2025, based on provisional death and birth data. The infant mortality rate measures deaths under age one per 1,000 live births. Final figures will be released later this year. The decline continues a multiyear trend in improved birth outcomes, though racial and geographic disparities persist.
- Managed Care
National Survey Finds Medicaid Patients Report Worse Pregnancy Outcomes Than Privately Insured
A nationwide survey of over 3,800 people who gave birth in 2023-2024 found Medicaid enrollees reported worse pregnancy and delivery outcomes compared to those with private insurance. The Listening to Mothers survey documented limited access to care, with pregnant Medicaid patients frequently reporting feeling unheard and disregarded during pregnancy and labor. The findings highlight persistent quality and access gaps in maternal care delivery for Medicaid-covered pregnancies. Survey results reflect care delivered across 2023-2024.
- Managed Care
Medicaid MCOs Prepare for 2027 Community Engagement Requirements Under HR 1
The Reconciliation Act (HR 1) established community engagement requirements for non-elderly, nonpregnant Medicaid adults effective 2027. CMS has released an implementation framework detailing how states must operationalize work requirements for beneficiaries aged 19-64. Health plans cannot contract directly with states to administer these requirements, but managed care organizations are developing member engagement and support strategies to maintain enrollment and help beneficiaries comply. The requirements will affect eligibility determination, member outreach, and care coordination workflows across Medicaid MCOs.
Tuesday, June 16 · 1 story
- Managed Care
Rural Healthcare Access Requires Transportation Infrastructure Investment
Rural communities face significant healthcare access barriers due to transportation fragmentation. The article argues for reframing transportation as critical healthcare infrastructure rather than an ancillary support service, requiring standardization and investment comparable to other care delivery components. This shift would establish consistent quality standards, accountability measures, and integration with care coordination systems. For Medicaid managed care organizations serving rural populations, this perspective highlights the need to elevate non-emergency medical transportation from administrative function to strategic infrastructure investment.
Monday, June 15 · 2 stories
- Managed Care
Health Plans Deploy Analytics to Cut Maternal Care Costs and Improve Outcomes
Health plans are using predictive analytics and risk stratification to identify high-risk pregnancies earlier and reduce avoidable emergency department visits and NICU admissions. Analytics platforms enable plans to stratify members by social determinants of health, clinical complexity, and prior utilization patterns to target care management resources. Plans report reduced preterm births, lower cesarean section rates, and decreased total cost of care when analytics guide prenatal care coordination and postpartum follow-up. The approach addresses maternal health quality measures increasingly tied to MCO star ratings and value-based payment arrangements.
- Managed Care
Home-Based Care Providers Limit Medicare Advantage, Medicaid Admissions Amid Payment and Administrative Pressures
A recent survey of home-based care providers reveals that Medicare Advantage and Medicaid payment rates, administrative burden, prior authorization delays, and denials are driving some providers to restrict admissions for certain payers. Providers cite these factors as top operational concerns. The trend affects access to home-based care for Medicaid managed care enrollees and Medicare Advantage beneficiaries. This reflects broader tensions between managed care plans and home health providers over reimbursement adequacy and administrative requirements.
Friday, June 12 · 3 stories
- Managed Care
Transportation Insecurity Drives Missed Appointments Among Cancer Patients
Cancer patients face higher rates of transportation insecurity compared to the general population, leading to missed medical appointments and delayed care. Transportation barriers represent a social determinant of health that directly affects treatment adherence and outcomes for oncology patients. For Medicaid managed care organizations, this underscores the importance of non-emergency medical transportation (NEMT) benefits and supplemental transportation services in ensuring member access to cancer care. MCOs may need to strengthen NEMT networks and monitoring to reduce no-show rates and improve quality outcomes for members with cancer diagnoses.
- Managed Care
AMA and Lawmakers Target AI-Driven Prior Authorization Denials by Health Plans
The American Medical Association and members of Congress are pushing back against health insurers' use of artificial intelligence to deny prior authorization requests and coverage determinations. The scrutiny follows an HHS Office of Inspector General report documenting denial patterns by Medicare Advantage plans. Lawmakers are considering legislation to increase transparency and oversight of AI-driven utilization management tools. The controversy affects all payer types, including Medicaid managed care organizations that increasingly rely on automated systems for prior authorization and care management decisions.
- Managed Care
Healthcare Leaders Urge CMS to Extend Medicaid Eligibility Implementation Timeline
At the AHIP 2026 conference, healthcare industry leaders expressed concerns about CMS' new Medicaid eligibility requirements and called for extended state implementation timelines. The industry is pushing for additional time to operationalize the new eligibility standards. The request reflects concerns about states' and health plans' capacity to implement the requirements within the current timeframe. MCOs will need to monitor whether CMS grants an extension and adjust enrollment systems and operations accordingly.
Thursday, June 11 · 1 story
- Managed Care · CA
CalOptima Health Allocates $430M for Hospital and Specialist Rate Increases Through 2027
CalOptima Health's board approved $429.6 million from reserves to increase hospital and specialist rates over the next 30 months, bringing total provider rate increases to nearly $1 billion since 2024. The Orange County Medi-Cal plan is using reserve funds to address provider payment adequacy. The rate increases will be implemented through 2027. This reflects ongoing pressure on Medicaid managed care organizations to maintain network adequacy and provider participation amid rising costs.
Monday, June 8 · 2 stories
- Managed Care
UnitedHealthcare Changes Lactation Counseling Reimbursement Policy
UnitedHealthcare is revising its reimbursement methodology for lactation counseling services, a change that is expected to reduce payment rates for many providers. The policy modification affects how the nation's largest health insurer compensates lactation consultants and counselors who provide services to new mothers. The timing and specific payment methodology changes were not detailed in available reporting. The adjustment comes as maternal health services remain under scrutiny, particularly given federal emphasis on improving maternal health outcomes and access to postpartum care.
- Managed Care
Health Plans Miss Surgical Cost Savings by Focusing Only on Avoidance
Health plans are neglecting significant cost savings opportunities in surgical care by focusing primarily on avoidance rather than optimizing outcomes for necessary procedures. Plans that concentrate solely on reducing surgical volume miss larger savings from complications, readmissions, and poor outcomes when surgery does occur. The shift to value-based care and risk-based contracts makes surgical outcomes optimization financially critical for managed care organizations. Strategies include directing members to high-performing surgeons, implementing episode-based payments, and using decision support tools to ensure appropriate care pathways.
Friday, June 5 · 2 stories
- Managed Care
CMS 72-Hour Prior Authorization Rule Exposes Payment Cycle Delays in Healthcare Billing
The CMS rule requiring 72-hour prior authorization decisions for urgent requests is creating operational friction by accelerating approvals without corresponding improvements in billing and payment cycles. Health plans and providers now face misaligned timelines where clinical decisions move faster than claims processing and reimbursement. The policy change, which took effect for most payers in 2024, highlights gaps in interoperability and revenue cycle infrastructure. Managed care organizations are experiencing the downstream effects as prior authorization reform outpaces backend payment modernization.
- Managed Care
OB Billing Codes Shift from Bundled to Unbundled in January
Beginning in January, physician billing codes for pregnancy care will transition from a bundled reimbursement model to fee-for-service billing for individual visits and services. Obstetricians say the new codes will more accurately capture variation in care delivery. However, the shift from global maternity packages to unbundled billing creates risk for overutilization and increased costs. Medicaid managed care organizations should review their maternity care contracts and utilization management protocols to address potential volume increases under the new coding structure.
Thursday, June 4 · 1 story
- Managed Care
H.R. 1 Medicaid Work Requirements, ACA Changes to Drive 14 Million Coverage Losses by 2036
The One Big Beautiful Bill Act (H.R. 1) and expiration of enhanced ACA premium tax credits will result in an estimated 14 million coverage losses over the next decade, according to CBO projections. Medicaid work reporting requirements and six-month redeterminations for expansion adults begin January 1, 2027, with retroactive coverage cuts and new cost-sharing starting October 2028. The law cuts $1 trillion in federal and state Medicaid spending over 10 years, 95% in expansion states, while creating a $50 billion Rural Health Transformation Program. Marketplace enrollment could drop 17-26% in 2026 with morbidity increasing up to 6.5%, as healthier members disenroll following ePTC expiration.
Monday, June 1 · 1 story
- Managed Care
Pregnant Women with Gum Disease Face 3-4x Higher Pre-Eclampsia Risk
Pregnant women with gum disease are three to four times more likely to develop pre-eclampsia, an emergency condition that poses serious maternal and fetal health risks. The finding underscores the clinical importance of integrating oral health into prenatal care delivery models. Growing evidence linking dental health to maternal outcomes is prompting ob-gyns, state Medicaid programs, and health plans to reconsider care coordination and benefit design. No specific policy action or timeline is described.
Friday, May 29 · 1 story
- Managed Care
UnitedHealthcare Eliminates Two-Thirds of Pediatric Prior Authorization Requirements by Year-End
UnitedHealthcare announced it will remove prior authorization requirements for the majority of pediatric services for members under age 18 by the end of the year, eliminating two-thirds of current authorization requirements. The change affects commercial and Medicare Advantage plans with pediatric enrollment. The policy takes effect by December 31, 2024. This reflects growing pressure on health plans to reduce administrative burden and aligns with broader industry and regulatory momentum toward prior authorization reform, potentially setting a benchmark other Medicaid MCOs may need to match.
Thursday, May 28 · 3 stories
- Managed Care · CA
Shasta County Measles Response Offers Community Engagement Model for Health Plans
Shasta County, California successfully contained a measles outbreak by partnering with teachers, church leaders, and other trusted community members to promote vaccination and public health measures in a vaccine-skeptical population. Infectious disease specialists say the approach demonstrates how health plans and public health agencies can engage non-traditional messengers to reach hesitant communities. The strategy is particularly relevant for Medicaid managed care organizations responsible for immunization rates and quality metrics in populations with low vaccine uptake. No immediate policy changes, but the model offers practical guidance as measles cases rise nationally.