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Thursday, July 23 · 14 stories
- Federal Policy
CMS Clarifies Home Health Acceptance-to-Service Requirements in Survey Guidance
CMS issued updated survey guidance on July 16, 2026, clarifying home health agencies' obligations under the acceptance-to-service standard in the Home Health Agency Conditions of Participation. The standard, which took effect in January 2025, requires agencies to develop, implement, and maintain policies governing patient acceptance. The guidance provides surveyors and agencies with clearer expectations for compliance. For Medicaid managed care organizations contracting with home health providers, this guidance affects network adequacy assessments and provider compliance monitoring.
- Federal Policy
CMS Announces Public Data Release Under OPEN Government Data Act
CMS will release new public data assets in machine-readable formats under the OPEN Government Data Act, part of the Foundations for Evidence-Based Policymaking Act of 2018. The data release aims to support fraud, waste, and abuse identification while promoting transparency and accountability. CMS states it has balanced transparency objectives with protection of sensitive information. The notice does not specify which datasets will be released or when they will become available.
Wednesday, July 22 · 13 stories
- Industry
988 Lifeline In-State Call Answer Rate Data Unavailable Due to Access Restrictions
This content is password-protected and cannot be accessed for analysis. The title suggests it may contain data on in-state answer rates for the 988 Suicide and Crisis Lifeline. Without access to the underlying content, it is not possible to determine what information is presented, when any reported data applies, or whether it contains actionable intelligence for Medicaid managed care organizations. The 988 Lifeline, launched nationally in July 2022, is relevant to Medicaid MCOs that cover behavioral health crisis services, but the specifics of this protected content remain unknown.
- Industry
Commentary Argues Behavioral Health Needs Better Prescribing Infrastructure Over Deprescribing Focus
A MedCity News commentary argues that the behavioral health policy conversation should shift from deprescribing initiatives to building clinical infrastructure for consistent, high-quality care. The piece challenges the current policy emphasis on reducing prescriptions and instead advocates for systematic improvements in prescribing practices. The commentary does not announce specific policy changes or requirements but contributes to ongoing discussions about behavioral health quality in managed care settings.
- Federal Policy
Trump Announces 100% Tariff on Imported Generics Effective August 2028
President Trump announced Tuesday via social media that imported generic drugs will face a 100 percent tariff beginning in August 2028 unless manufacturers relocate production to the United States. The tariff is described as a penalty designed to reshore generic pharmaceutical manufacturing. Generic drugs constitute the majority of Medicaid pharmacy spending, and most generics dispensed in the U.S. are manufactured overseas or contain active pharmaceutical ingredients from foreign suppliers. The two-year implementation timeline provides MCOs and state programs time to assess potential pharmacy cost impacts and supply chain disruptions.
- Legal · TX
AstraZeneca Pays Texas $34M to Settle Medicaid Kickback Claims
AstraZeneca Pharmaceuticals LP agreed to pay $33,998,000 to Texas to resolve allegations that it provided illegal remuneration to healthcare providers in connection with prescriptions for drugs covered by the state's Medicaid program. The settlement addresses potential violations of anti-kickback statutes related to inducements tied to Medicaid prescribing. Texas Medicaid managed care organizations that reimbursed claims for the implicated drugs during the alleged period may have paid inflated costs tied to these arrangements. The settlement follows state enforcement action under Texas Medicaid fraud statutes.
- Federal Policy
CMS Proposes Tighter Remote Patient Monitoring Requirements in 2027 Physician Fee Schedule
CMS published a proposed rule on July 16, 2026, that would tighten requirements for remote patient monitoring (RPM) services in the Calendar Year 2027 Medicare Physician Fee Schedule. The changes respond to Office of Inspector General reports flagging program integrity concerns about RPM billing. The proposed rule affects how providers document and bill for remote monitoring services under Medicare. Comments on the proposed rule are typically due 60 days after publication in the Federal Register.
- Federal Policy
Webinar Examines H.R.1 Impact on Medicaid Maternal and Infant Health Programs
A webinar titled 'Medicaid Connections: Maternal and Infant Health and Justice' addresses how H.R.1 legislation affects Medicaid-funded maternity care. The session focuses on reproductive justice and optimizing Medicaid to fund holistic, culturally centered care including midwifery and doula services. As the nation's largest payer for maternity care, Medicaid plays a central role in addressing systemic health inequities for maternal and infant populations. The webinar provides guidance for policymakers on funding structures that support comprehensive perinatal services.
- Legal
D.C. Circuit Rules Drugmakers Need HHS Approval for 340B Rebate Models
The U.S. Court of Appeals for the D.C. Circuit ruled July 21, 2026, that pharmaceutical manufacturers cannot implement 340B rebate models without prior approval from the HHS secretary. The decision upheld lower court rulings against Novartis, Johnson & Johnson Health Care Systems, Bristol Myers Squibb, and Eli Lilly. The ruling reinforces federal authority over 340B program administration and blocks manufacturer attempts to unilaterally restructure drug discount delivery mechanisms. For Medicaid managed care organizations with provider networks that include 340B-eligible entities, the decision preserves existing 340B purchasing pathways and prevents disruption to contract pharmacy arrangements that affect covered entity participation and pharmacy network stability.
- Federal Policy
CMS Proposes Ban on Medicare Payment for Third-Party Remote Patient Monitoring
CMS has issued a proposed rule that would prohibit Medicare payment for remote patient monitoring services delivered by third-party vendors. Health systems, physician groups, and telehealth trade associations are opposing the proposal, citing concerns about disrupted RPM programs and unclear reimbursement alternatives. The proposal has prompted some organizations to pause RPM expansion plans and appears to conflict with congressional support for broader telehealth access. If finalized, the policy would require Medicare providers to deliver RPM services directly rather than through vendor arrangements.
- Federal Policy
Rural Hospital CEO Criticizes $50B Federal Rural Health Transformation Program Structure
A rural hospital CEO has publicly criticized the $50 billion Rural Health Transformation Program, which launched last year following Medicaid cuts under HR-1. Rural health executives are questioning the program's design, citing concerns that states control funding distribution, eligible uses are narrowly defined, and the structure may not adequately address care access challenges in communities affected by Medicaid reductions. The criticism reflects broader implementation concerns among rural providers about whether federal support will effectively reach facilities serving Medicaid populations.
- State Policy · CO
Colorado Medicaid Owes $8 Million in Federal Funds for HCBS Claims
An Office of Inspector General audit found Colorado Medicaid improperly claimed at least $8 million in federal funds for in-home disability care services. The OIG identified an additional $45 million in federal payments requiring further review. State officials acknowledged billing errors but stated no fraud occurred. The audit examined home and community-based services claims, a program area where improper billing has drawn increased federal scrutiny. Colorado must repay the federal share of identified improper payments.
- Federal Policy
AHA Urges CMS to Scale Back Medicaid State-Directed Payment Limits in Proposed Rule
The American Hospital Association submitted comments July 21, 2026, opposing portions of a CMS proposed rule implementing reconciliation-mandated changes to Medicaid state-directed payments. The rule proposes new limits on targeted fee-for-service payments and SDP design that exceed statutory requirements. CMS projects the rule would reduce Medicaid payments by $510.1 billion over 10 years—more than triple the Congressional Budget Office estimate of $149.4 billion. AHA argues the cuts would reduce care access, worsen workforce shortages, and threaten hospital financial viability, urging CMS to rescind provisions beyond what Congress required and mitigate SDP reductions.
- Federal Policy
CMS Proposes New Provider Tax Thresholds, Phases Out 6% Hold Harmless Rule
CMS released a proposed rule updating Medicaid provider tax policies following the July 2025 reconciliation law. The rule replaces the current 6% indirect hold harmless threshold with state- and provider class-specific thresholds based on taxes enacted as of July 4, 2025, and implements phased reductions for Medicaid expansion states starting in fiscal year 2028. CMS proposes to sunset the current 75/75 compliance test and establishes a new "Services of Health Insurers" provider tax class, bringing existing state taxes on health insurers under federal oversight. Comments are due 60 days after Federal Register publication.
- Legal
23 States Sue CMS Over Medicaid Work Requirements Rule Exemptions
On June 29, 2026, twenty-three states, two governors, and the District of Columbia filed suit in U.S. District Court for Massachusetts challenging CMS implementation of Medicaid work requirements under the One Big Beautiful Bill Act. Plaintiffs allege CMS unlawfully narrowed exemptions for medically frail beneficiaries. The litigation seeks to block enforcement of the work requirements rule pending judicial review. This lawsuit directly affects managed care organizations responsible for identifying medically frail populations, verifying exemptions, and ensuring compliance with work requirement reporting.
Tuesday, July 21 · 15 stories
- Industry
Novo Nordisk Sues Eli Lilly Over Obesity Drug Advertising Claims
Novo Nordisk has filed a lawsuit against Eli Lilly alleging misleading advertising of Lilly's GLP-1 obesity medications. The suit, which follows a cease-and-desist demand, claims Lilly is using deceptive advertisements to portray its products as broadly superior to Novo's competing medicines. Lilly has responded that its marketing campaign is truthful. The legal action comes as both manufacturers compete intensively in the rapidly growing obesity treatment market.
- Federal Policy
Senate Democrat Proposes Medicare Enrollment for All Children Under Age 26
Sen. Andy Kim (D-N.J.) introduced legislation to automatically enroll all American children in Medicare from birth through age 25, calling the proposal MediKids. The bill would create universal federal coverage for children regardless of family income. No timeline for committee consideration or floor action has been announced. The proposal would fundamentally restructure pediatric coverage currently delivered through Medicaid, CHIP, and commercial insurance, though passage prospects remain uncertain given divided government.
- Federal Policy
Four House Republicans Join Democratic ACA Discharge Petition
Four Republican members of the U.S. House of Representatives joined a Democratic discharge petition related to the Affordable Care Act on December 17, 2025. The Association for Community Affiliated Plans issued a statement from CEO Margaret A. Murray responding to this development. A discharge petition can force a floor vote on legislation if it receives 218 signatures. The bipartisan support suggests potential movement on ACA-related legislation that could affect Medicaid expansion states and marketplace programs.
- State Policy · NM
New Mexico Lawmakers Criticize Slow Rollout of Behavioral Health System Reforms
Bipartisan New Mexico legislators voiced frustration over delays in implementing the state's behavioral health system overhaul during a Monday legislative session. The criticism focuses on the pace of program deployment intended to rebuild behavioral health infrastructure and service delivery. The concerns come amid ongoing challenges in the state's behavioral health network, which affects Medicaid managed care organizations responsible for coordinating behavioral health services for enrollees. The delays may impact MCO network adequacy requirements and care coordination for members with behavioral health needs.
- Federal Policy · CA
HHS Defers $1 Billion in Federal Medicaid Payments to Two States
HHS and CMS announced Tuesday they deferred over $1 billion in federal Medicaid payments to two states, including $867.5 million to California, citing high-risk claims including home-based services. The deferrals represent a federal payment hold while CMS reviews claims for potential fraud, waste, or abuse. The action takes effect immediately. This is significant because payment deferrals can strain state budgets and delay provider payments, potentially disrupting network adequacy and access to home and community-based services that many MCOs coordinate or manage under managed long-term services and supports contracts.