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Friday, July 24 · 26 stories
- Federal Policy
CMS Proposes Medicare Payment Category for Clinical Decision Support Software
CMS released proposed rules on July 2 and July 14, 2026 establishing a new Medicare payment category called Software as a Medical Service (SaMS) for software that supports clinical decision-making through algorithmic analysis. The proposals appear in the CY 2027 Hospital Outpatient Prospective Payment System and Physician Fee Schedule proposed rules. This represents CMS's first structured approach to paying separately for clinical decision support software under Medicare. Comments on the proposed rules are typically due 60 days after publication in the Federal Register.
- Legal
CMS Proposes Sweeping Medicare Home Health Enrollment Enforcement Tools in 2027 Rule
CMS released the calendar year 2027 Home Health Prospective Payment System proposed rule, combining payment updates with expanded program integrity enforcement authority. The rule introduces new enrollment enforcement mechanisms targeting home health agencies participating in Medicare. While the rule focuses on Medicare home health, the enforcement framework may signal CMS's broader compliance and enrollment oversight direction. Comments on the proposed rule are due 60 days after Federal Register publication.
- State Policy
NASHP Examines State Use of Community Health Workers for Oral Health Access
The National Academy for State Health Policy published an analysis of how states are deploying community health workers to expand oral health access in rural areas. The publication explores state-level strategies for integrating these workers into care delivery models where dental provider shortages limit access. The approach is particularly relevant for states addressing dental health disparities through Medicaid program design, as community health workers can connect beneficiaries to preventive services and coordinate care in underserved regions.
- Federal Policy
House Bill Proposes EHR Implementation Grants for Home Health and Post-Acute Providers
The Connecting Health and Records Technology for Seniors (CHARTS) Act has been introduced in the U.S. House of Representatives to provide up to $500,000 grants for home health, long-term care, and post-acute care providers to implement electronic health records and improve health information sharing. The legislation aims to reduce implementation costs and administrative burden for providers serving Medicare and Medicaid beneficiaries. If passed, the grants would support interoperability efforts critical to care coordination for dual-eligible and Medicaid long-term services and supports populations. The bill is in the early legislative stage with no timeline for passage.
- State Policy
Political Dispute Over Medicaid Payment Deferrals Threatens Home Care Provider Stability
Political tensions are escalating around states' use of Medicaid payment deferrals, with home care providers caught in the crossfire. The dispute centers on whether states can delay payments to manage budget cycles, a practice that disproportionately affects home- and community-based services providers operating on thin margins. Home care advocates warn that payment timing conflicts threaten provider solvency and beneficiary access to HCBS. The controversy reflects broader partisan divisions over Medicaid financing and state flexibility in program administration.
- Federal Policy
CMS Halts Premium Tax Credit Reconciliation Enforcement After Court Injunction
CMS issued implementation guidance July 22 following a federal district court injunction that blocked eight provisions of its 2027 notice of benefit and payment parameters final rule. The injunction, issued July 16, prevents enforcement of provisions set to take effect July 20. CMS directed exchanges to immediately stop removing or denying advance premium tax credits for applicants who failed to file and reconcile prior years' credits, effective for plan years 2026 and 2027. The agency also reinstated the automatic 60-day extension for resolving household income data inconsistencies.
- Legal
OIG Advisory Opinion Finds Hospital Discharge Referral Software Creates Anti-Kickback Risk
The HHS Office of Inspector General issued Advisory Opinion 26-15 concluding that a subscription-based referral management software platform used in hospital discharge planning could generate prohibited remuneration under the Federal Anti-Kickback Statute. OIG determined that providers paying subscription fees to use the platform may receive improper referrals in exchange for those payments. The opinion affects hospitals, post-acute care providers, and technology vendors involved in discharge planning and care coordination arrangements. The advisory opinion provides immediate compliance guidance for similar arrangements nationwide.
- Federal Policy
Poll Shows Most Americans Reject Claims of Widespread Medicaid Beneficiary Fraud
A new poll finds that most Americans do not believe Medicaid beneficiaries are the primary source of program fraud, contradicting recent allegations from some Republican leaders. Respondents view current fraud enforcement rhetoric as politically motivated rather than substantive. The poll results come amid ongoing congressional and administrative debates over program integrity measures, oversight authority, and enforcement resource allocation. Public perception could influence state Medicaid agency priorities and federal oversight emphasis as policymakers weigh beneficiary-focused versus provider-focused fraud detection strategies.
Thursday, July 23 · 14 stories
- State Policy
Rhode Island and Hawaii Enact Healthcare AI Laws; Arizona Governor Vetoes Chatbot Bill
Rhode Island and Hawaii enacted healthcare AI legislation in June and July 2026, while Arizona's governor vetoed a similar chatbot disclosure bill. Rhode Island Governor Dan McKee signed two AI-related healthcare bills into law. The measures reflect divergent state approaches to regulating artificial intelligence in healthcare settings. These laws may affect how Medicaid managed care organizations deploy AI tools for utilization management, care coordination, or member services in these states.
- Federal Policy
KFF Brief Reviews U.S. Abortion Data Trends Through 2026
A KFF brief examines U.S. abortion data sources and trends before and after the Dobbs decision, analyzing factors affecting abortion rates and projecting potential policy changes under the current administration and Congress. The analysis covers state-level variations in access and utilization following the overturning of Roe v. Wade. The brief provides context for understanding how federal and state policy changes may continue to shape abortion access and Medicaid coverage decisions.
- Industry
Elder Law Firm Highlights Long-Term Care Cost Burden on Middle-Class Families
A law firm analysis describes how long-term care expenses deplete family savings, noting Medicare's limited coverage and Medicaid's spend-down requirements. The piece emphasizes that middle-class households face significant financial exposure before qualifying for Medicaid long-term services and supports. No new policy change is reported. The content reflects ongoing challenges in the LTSS financing landscape that affect Medicaid eligibility and enrollment dynamics.
- Industry
Molina Healthcare Plans Additional ACA Exchange Cuts in 2027
Molina Healthcare announced plans to further reduce its participation in ACA marketplace exchanges in 2027 following second-quarter financial challenges in that segment. While the company reported stable Medicaid performance and stronger-than-expected Medicare Advantage results, ACA exchange operations underperformed expectations. CEO leadership characterized the ACA exchange trend as "unfortunate." The insurer did not specify which states or exchanges would face reductions. Molina's Medicaid operations, which represent a significant portion of its business, showed stability during the quarter.
- Legal
DOJ Secures Six Healthcare Fraud Convictions in Three Weeks, $1.1B in Alleged Losses
The Department of Justice's National Fraud Enforcement Division obtained six jury trial convictions between May 13 and June 1, 2026, across five federal districts. The defendants include a software platform executive and a rural nurse practitioner, among others spanning multiple healthcare settings. Total alleged losses exceed $1.1 billion to Medicare, Medicaid, and other health benefit programs. The convictions demonstrate DOJ's sustained enforcement activity across the healthcare sector, with direct implications for Medicaid managed care organizations' fraud, waste, and abuse compliance programs.
- Federal Policy
CMS Proposes Provider Enrollment Changes Across All Provider Types in 2027 Home Health Rule
CMS published a proposed rule on July 6, 2026, that includes provider enrollment changes applicable to all provider and supplier types, not just home health agencies. The changes are designed to strengthen program integrity across Medicare and Medicaid. The rule appears in the Calendar Year 2027 Home Health Prospective Payment System Proposed Rule. Comments are due 60 days after publication in the Federal Register.
- Federal Policy
Urban Institute Finds Postpartum Coverage Gains Stalling Among New Mothers
The Urban Institute reports that health insurance coverage for new mothers in the first year postpartum has improved in recent years but progress has stalled, according to Census Bureau American Community Survey data. The analysis examines uninsured rates among women ages 19 and older who gave birth within the past year. The findings come as states navigate the end of Medicaid continuous enrollment and implementation of the American Rescue Plan's optional 12-month postpartum coverage extension. The report signals potential erosion of maternal coverage gains that have reduced coverage gaps during the critical postpartum period.
- State Policy · KY
Kentucky Governor Reverses 4% Medicaid Provider Rate Cuts
Kentucky Governor Andy Beshear announced a reversal of the state's previously enacted 4% Medicaid provider rate cuts. The move follows criticism of the original cuts' impact on disability services and other providers. Beshear cautioned that the reversal would not immediately resolve all provider concerns, saying the change is not "a magic wand" or "a magic bullet." Managed care organizations operating in Kentucky should expect updated rate schedules reflecting the restored funding levels.
- Federal Policy · VA
Virginia Hospitals Project $31B Medicaid Loss Under Proposed CMS Rule
A proposed CMS rule implementing last summer's reconciliation bill includes Medicaid payment cuts to healthcare facilities that Virginia hospitals say go beyond what Congress authorized. Hospital systems contend the rule would reduce state Medicaid funding by $31 billion. The public comment period closed this week. The rule affects facility reimbursement under Medicaid and represents CMS's interpretation of reconciliation bill directives that hospital chains argue exceeds legislative intent.
- Federal Policy
CMS Proposes CY 2027 Hospital Outpatient Payment and ASC Policy Changes
CMS issued the Calendar Year 2027 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center proposed rule affecting hospitals participating in Medicare. The proposed rule includes significant payment and policy changes for hospital outpatient services and ASCs. The rule establishes payment rates and updates operational policies for calendar year 2027. While focused on Medicare payment systems, managed care organizations contracting with hospitals for Medicaid services should monitor for potential cost-shifting effects and policy precedents that states may adopt.
- Federal Policy
Partnership for Medicaid Issues Statement Opposing Coverage Reduction Policies
The Partnership for Medicaid released a statement on May 9, 2025, expressing concerns about unspecified policy changes that could reduce Medicaid coverage and access to care. The statement does not identify specific rules, proposals, or effective dates. No federal guidance or rulemaking is referenced in the brief announcement. The Partnership for Medicaid is a coalition that includes Medicaid Health Plans of America among its members.
- Industry
Choice Health at Home Plans National Expansion Amid Regulatory Uncertainty
Choice Health at Home, which serves 15,000 patients, is pursuing national expansion despite regulatory challenges including a federal enrollment moratorium and Medicaid policy changes under the One Big Beautiful Bill Act (OBBBA). CEO David Jackson outlined the company's westward growth strategy for 2026. The expansion comes as home-based care providers navigate heightened federal scrutiny, enrollment restrictions, and uncertain Medicaid reimbursement. The company's plans signal continued private investment in home health despite regulatory headwinds affecting the sector.