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Thursday, July 16 · 20 stories
- Federal Policy
CMS Proposes Standardized Payment Structure for Clinical Software and AI Tools
The Centers for Medicare & Medicaid Services announced plans to develop a standardized payment framework for clinical software and artificial intelligence tools that incorporates patient outcome measures. The proposed structure would establish consistent reimbursement methodology across Medicare and Medicaid for digital health technologies currently paid through fragmented billing codes or bundled into other services. CMS has not specified an implementation timeline or comment period. For Medicaid managed care organizations, this signals potential changes to how digital therapeutics, clinical decision support tools, and AI-driven care management platforms are covered and reimbursed under capitated arrangements.
- Federal Policy
Acting AG Pledges Federal Action to Restrict Mail Order Mifepristone
Acting Attorney General Todd Blanche told Republican senators he will prioritize stopping abortion medication from being mailed to patients if confirmed. Blanche specifically opposes the Biden-era policy that permitted mail distribution of mifepristone but did not detail enforcement mechanisms or timeline. The commitment signals potential federal action against telehealth abortion services and mail-order pharmacy dispensing of medication abortion. Any DOJ enforcement action could affect Medicaid managed care plans that cover telehealth reproductive services and pharmacy benefits including mifepristone.
- Managed Care
Home Health Providers Reject 63% of Referrals Due to Workforce Shortages
A Homecare Homebase report found that 63.3% of home health providers are turning down referrals, with referral conversion rates declining 13%. Providers cite staffing shortages as the primary reason for rejections. Documentation burden and scheduling friction are identified as key drivers of workforce turnover in home-based care settings. The findings indicate growing constraints on home health capacity despite rising demand for services.
- Legal · NV
Nevada AG Prosecutes 40% of Medicaid Fraud Referrals, Double National Average
Nevada Attorney General Aaron Ford prosecutes 40% of Medicaid fraud referrals received by his office, double the national average for state attorneys general, according to federal data. The prosecution rate has drawn criticism from Governor Joe Lombardo and state legislators who argue the acceptance rate is too low. The data indicates Nevada's fraud enforcement activity significantly exceeds typical state performance, though a substantial majority of referrals still do not result in prosecution. This reflects broader challenges states face in Medicaid program integrity enforcement.
- Federal Policy
AHA Urges CMS to Preserve Essential Health Benefits Coverage Standards in RFI Response
The American Hospital Association submitted comments July 15 responding to a CMS request for information on potential modifications to the Affordable Care Act's Essential Health Benefits framework. AHA supported updating EHBs to reflect changes in healthcare delivery but warned against changes that would reduce coverage adequacy. The association emphasized that affordability requires adequate benefits, not just lower premiums, and cautioned that reduced benefits, narrower standards, or increased cost-sharing would increase patient financial exposure. CMS is reviewing the EHB framework, which establishes minimum coverage requirements for comprehensive insurance.
- Legal
CMS and OIG Increase Payment Suspensions Against Home Health Agencies
The Centers for Medicare & Medicaid Services and HHS Office of Inspector General are escalating enforcement actions against home healthcare providers suspected of fraud, including payment suspensions, recoupments, and criminal prosecution. Both Medicare and Medicaid suspensions are being deployed more frequently against home health agencies. The article outlines procedural steps for providers facing suspension. This enforcement trend affects Medicaid managed care organizations that contract with home health agencies and rely on them for post-acute and long-term services and supports delivery.
- State Policy · CA
California Psychiatric Hospital Staffing Mandate Shows Early Implementation Challenges
California's nurse-to-patient staffing ratios for acute psychiatric hospitals took effect June 1, 2026, establishing mandated minimums for freestanding psychiatric facilities for the first time in over 20 years. Hospital leaders report concerns about workforce turnover and potential impacts on behavioral health access six weeks into implementation. The mandate applies to acute psychiatric hospitals previously exempt from state staffing ratio requirements. The early implementation period reveals operational challenges as facilities adjust to the new requirements.
- State Policy
KFF Tracker Compiles State Medicaid Postpartum Coverage Extension Actions
This tracker compiles state-level activity on Medicaid postpartum coverage extensions beyond the federal 60-day minimum. It documents approved and pending Section 1115 waivers, state legislation requiring federal approval through state plan amendments or waivers, submitted and approved SPAs, and coverage financed entirely with state funds. The tracker provides a centralized reference for monitoring which states have extended postpartum coverage and through what mechanisms. It reflects ongoing state implementation of the American Rescue Plan Act option that allows states to extend Medicaid postpartum coverage to 12 months.
- Federal Policy
KFF Poll Finds Fraud in Government Health Programs Resonates with Republican Voters Ahead of Midterms
A KFF Health Tracking Poll released July 16, 2026, shows that 55% of Republican voters consider addressing fraud in government health programs, including Medicaid and Medicare, extremely important for candidates in the 2026 midterms. Most voters perceive at least some fraud in government health programs, though voters report higher fraud concerns in the tax system, defense, and foreign aid. The poll indicates health care costs remain the top health priority overall. The findings suggest fraud and program integrity messaging may gain prominence in congressional campaigns as midterm elections approach.
- State Policy · IA
Iowa Attorney General Launches Medicaid Fraud Elimination Task Force
Iowa Attorney General Brenna Bird convened the newly created Medicaid Fraud Elimination Task Force for its inaugural meeting on Wednesday. The 11-person task force established five working groups charged with developing recommendations to prevent and eliminate fraud in Iowa's Medicaid program. Bird emphasized a zero-tolerance approach to Medicaid fraud. The task force will develop policy recommendations affecting program integrity oversight for Iowa's Medicaid managed care organizations and providers.
- State Policy · PA
Pennsylvania AG Appeals Commonwealth Court Ruling Striking Down Medicaid Abortion Ban
Pennsylvania Attorney General Dave Sunday has appealed a Commonwealth Court ruling that struck down the state's ban on Medicaid-funded abortions, after the court found 4-3 in April 2026 that the ban violates the state constitution's Equal Rights Amendment. The state Supreme Court agreed in mid-July to hear the case again. Sunday intervened in February 2025 to defend the law after the Department of Human Services, which had initially defended it, reversed position and sided with plaintiffs challenging the ban. Sunday cited the Commonwealth Attorneys Act, which requires attorneys general to defend state statutes absent a controlling court decision, though legal experts disagree on whether that obligation extends to appeals.
Wednesday, July 15 · 14 stories
- State Policy · OH
Ohio AG Candidate Suggests Cuts to State Medicaid Program
Ohio Auditor Keith Faber, a Republican candidate for attorney general, made statements in recent media appearances suggesting support for ending portions of Ohio's Medicaid program. His campaign declined to clarify which aspects of Medicaid he would target, stating only that he supports lawful use of Medicaid dollars. The comments come as Ohio operates Medicaid managed care plans covering behavioral health, long-term care, and traditional acute care services. No specific timeline or legislative proposal has been announced.
- Industry
Children's Hospitals Face 16 Active Pediatric Drug Shortages Including Six IV Products
Pediatric drugs represent the therapeutic category most affected by active drug shortages, with 16 ongoing shortages including six involving IV fluids and additives. Children's hospitals face unique challenges managing these shortages compared to adult health systems due to weight-based dosing, limited alternative formulations, and smaller patient volumes that reduce purchasing leverage. The article examines operational strategies pediatric hospitals use to manage supply disruptions, though specific policy interventions or effective dates are not detailed.
- Managed Care
AI Will Not Resolve Prior Authorization Disputes, MedCity Analysis Argues
A MedCity News analysis argues that artificial intelligence will not eliminate prior authorization conflicts between providers and payers, but will instead reshape an already imbalanced system that has existed for three decades. The piece contends that framing AI as a solution to prior authorization burden misses the fundamental structural issues. For Medicaid managed care organizations, the analysis suggests AI deployment may accelerate review processes but will not reduce provider pushback or change the underlying tension between cost control and access. The commentary does not reference specific policy changes or implementation timelines.
- Industry
720 Rural Hospitals at Risk of Closure as Surgical Access Gaps Widen
A Center for Healthcare Quality and Payment Reform report finds that roughly one-third of rural hospitals — 720 facilities — face closure risk, raising questions about surgical access in underserved areas. As rural hospitals retreat from operating room services, the analysis highlights growing surgical care deserts. The report does not specify a timeline for closures but underscores ongoing financial instability in rural provider markets. For Medicaid managed care organizations with rural network obligations, this trend signals potential network adequacy challenges and increased need for alternative surgical access strategies.
- Legal
Glenmark Settles State Price-Fixing Claims for $29.6 Million
Glenmark Pharmaceuticals agreed to pay $29.6 million to settle price-fixing allegations brought by multiple states. The settlement resolves a multi-year investigation into alleged anti-competitive conduct involving drug pricing. The agreement covers claims from dozens of states that alleged Glenmark engaged in collusion to fix prices on generic pharmaceuticals. This settlement follows a pattern of similar enforcement actions against generic drug manufacturers over the past several years.
- Managed Care
Dual-Eligible Beneficiaries Show Higher Chronic Condition Rates Driving Spending Patterns
A new issue brief analyzes enrollment and spending patterns for dual-eligible individuals enrolled in both Medicare and Medicaid, focusing on how chronic condition prevalence drives higher average per-person costs. The analysis uses recent data on chronic conditions to profile this population's health status and associated expenditures. Dual-eligible beneficiaries represent a disproportionately high-cost, high-need segment often served through integrated Medicare-Medicaid plans (D-SNPs and FIDE SNPs). The findings provide context for managed care organizations managing dual-eligible populations on how chronic disease burden correlates with spending.
- Legal
OIG Releases Updated Corporate Integrity Agreement Template with Enhanced Compliance Requirements
On April 30, 2026, the HHS Office of Inspector General unveiled a revised Corporate Integrity Agreement template at the Health Care Compliance Association's annual conference, using the Kinex Medical Company CIA as the model. The updated template retains core compliance program elements while introducing enhanced compliance obligations for health care organizations entering into settlement agreements with OIG. CIAs are typically imposed on providers and health plans that resolve fraud and abuse allegations, requiring heightened compliance measures for three to five years. The new template will apply to future CIA settlements and affects any Medicaid managed care organization facing potential OIG enforcement actions.
- Industry
Elevance Health Plans Further Medicaid Portfolio Exit Amid High Costs
Elevance Health, the nation's second-largest health insurer, announced plans to reduce its Medicaid managed care footprint over the next year as medical costs remain elevated. The exit comes as states prepare to implement Medicaid work requirements. Elevance operates Medicaid plans in multiple states under its Anthem and Wellpoint brands. The decision reflects ongoing profitability challenges in Medicaid managed care following the end of pandemic-era continuous enrollment provisions.
- Industry
Providers Report Rising Denial Rates Despite Revenue Cycle Automation Gains
Health systems have invested heavily in revenue cycle automation over two decades, with the 2025 CAQH Index estimating $258 billion in avoided administrative costs in 2024. Despite these efficiency gains, denial rates continue to climb, with 41 percent of providers now reporting at least one in ten claims denied—a figure that has increased annually. The trend suggests automation alone has not resolved underlying issues driving claim denials, including prior authorization requirements, documentation standards, and payer policies.