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Wednesday, July 15 · 14 stories
- Industry
FTC Settles with CVS Caremark Over Insulin Price Manipulation Claims
The Federal Trade Commission has settled a lawsuit against CVS Caremark over allegations the company artificially inflated insulin prices and restricted access to diabetes treatment. The settlement resolves FTC charges related to the pharmacy benefit manager's pricing practices for insulin products. The action follows broader federal scrutiny of PBM practices affecting drug pricing and access. Terms of the settlement were not disclosed in the initial report.
- Industry
CVS Caremark Settles FTC Insulin Suit, Must End Rebate-Driven Formulary Preferences
CVS Caremark reached a settlement with the Federal Trade Commission over insulin pricing practices. The terms mirror the FTC's earlier settlement with Express Scripts and prohibit the pharmacy benefit manager from favoring higher-cost drug versions on standard formularies based on rebate arrangements. The settlement takes effect immediately upon court approval. For Medicaid managed care plans that contract with CVS Caremark or operate integrated PBM arrangements, this settlement signals continued federal scrutiny of rebate-driven formulary design and may preview future enforcement against similar practices affecting Medicaid populations.
- Federal Policy
Latham & Watkins Publishes July 2026 Drug Pricing Digest
Latham & Watkins LLP released its July 2026 Drug Pricing Digest, a recurring compilation tracking developments in the Medicaid Drug Rebate Program, 340B Program, Medicare drug pricing policy, and state pharmaceutical law. The digest appears to be a monthly or periodic roundup of regulatory and legislative activity affecting prescription drug pricing and market access. No specific policy changes or rulemakings are described in the brief excerpt provided. The digest serves as a reference tool for stakeholders monitoring evolving drug pricing regulations across federal programs including Medicaid.
- State Policy · OR
Oregon Faces Hundreds of Millions in Medicaid Cuts from Federal Tax Bill
Oregon's Medicaid program is confronting substantial funding reductions stemming from federal tax legislation enacted a year ago. The cuts total hundreds of millions of dollars and affect multiple safety net programs including SNAP and Medicaid. State officials have not yet determined how they will address the funding shortfall. The reductions create immediate pressure on Oregon's Medicaid budget and could affect coverage, provider payments, or eligibility determinations depending on state response.
- Federal Policy
HHS Abandons Proposed Rule Threatening Medicare and Medicaid Funding Cuts Over Gender-Affirming Care
The Department of Health and Human Services will not finalize a proposed rule that threatened to withhold Medicare and Medicaid funding from states and providers offering gender-affirming care to minors. The decision ends what would have been the most aggressive federal attempt to restrict such care nationally through payment policy. The withdrawal means existing Medicaid coverage policies for gender-affirming services remain governed by state discretion and existing federal non-discrimination requirements. No timeline for future rulemaking has been announced.
Tuesday, July 14 · 17 stories
- Federal Policy
CMS Requests Technical Input on PBM Compensation and Affiliate Practices
On June 18, 2026, CMS published a Request for Information seeking stakeholder input on pharmacy benefit manager services, compensation structures, affiliate relationships, and data collection practices. The RFI aims to gather technical details that will inform future rulemaking on PBM operations under Medicare Part D. Comments are due approximately 60 days from publication in the Federal Register. While focused on Part D, PBM transparency requirements and data standards developed through this process could eventually extend to Medicaid managed care pharmacy operations.
- Industry
HHS Secretary Kennedy Advances Initiative to Reduce SSRI Antidepressant Use
U.S. Health and Human Services Secretary Robert F. Kennedy Jr. is moving forward with an initiative aimed at helping Americans discontinue selective serotonin reuptake inhibitor (SSRI) antidepressants. The effort represents a significant policy shift at the federal level regarding mental health treatment approaches. The initiative's specific implementation mechanisms, timeline, and scope remain unclear from available reporting. For Medicaid managed care organizations, any federal guidance or directives affecting prescription psychiatric medications could have major implications for behavioral health benefit design, formulary management, prior authorization protocols, and member continuity of care.
- Federal Policy
Home Care Workers Face Pay Cuts as Medicaid Reimbursement Rates Fall
Home care workers providing services to Medicaid beneficiaries are facing potential pay reductions that could affect workforce stability in the home and community-based services sector. The pay cuts stem from changes in Medicaid reimbursement rates, threatening the financial security of direct care workers who provide essential LTSS services. The workforce disruption could affect continuity of care for Medicaid managed care enrollees who rely on home care services. For MCOs with LTSS contracts, caregiver turnover and recruitment challenges may increase as workers leave the sector.
- Industry
HCA Reports Lower Profits as Uninsured Patient Volume Rises After ACA Subsidy Expiration
Hospital chain HCA Healthcare reported declining profits attributed to increased uninsured patient volume following the expiration of enhanced Affordable Care Act subsidies. The company cited rising uncompensated care costs as patients lost marketplace coverage. This represents an early signal of coverage losses affecting provider revenues after the federal government allowed pandemic-era ACA premium subsidies to lapse. The trend may accelerate Medicaid enrollment as individuals lose private coverage and income-qualify for state programs.
- Federal Policy
988 Lifeline Volume Up 15% Year-Over-Year as States Answer More Calls In-State
The 988 Suicide and Crisis Lifeline handled 15% more contacts in March 2026 compared to March 2025, and volume is nearly 50% higher than two years prior. States are increasingly routing calls to in-state crisis centers, where counselors have better knowledge of local mental health and substance use resources. The growth reflects sustained demand for crisis services as the lifeline enters its fourth year of operation. For Medicaid managed care organizations, rising 988 utilization signals growing behavioral health crisis service needs and potential downstream impacts on emergency department use and member engagement.
- State Policy
NASHP Examines State Strategies for Primary Care SUD Treatment Referrals
The National Academy for State Health Policy published analysis on how states strengthen referral pathways from primary care settings to substance use disorder treatment and recovery services. The report focuses on state-level approaches to improve care coordination between primary care providers and SUD treatment systems. It appears to document ongoing state policy strategies rather than announce a specific new regulatory change or deadline. The findings are relevant to managed care organizations that contract with both primary care networks and behavioral health providers, particularly those operating integrated or carved-in SUD benefits.
- Legal
National Health Law Program Examines Crisis Pregnancy Center Medicaid Billing Practices
The National Health Law Program has published analysis examining the relationship between crisis pregnancy centers and Medicaid reimbursement. CPCs, which typically do not provide abortion, contraception, or comprehensive reproductive health services, may seek Medicaid payment for limited services such as pregnancy tests and ultrasounds. The analysis raises questions about billing practices, scope of services, and regulatory oversight of these facilities within Medicaid programs. The issue affects managed care organizations that may receive claims from CPCs or face questions about network adequacy and covered services for reproductive health.
- Legal
HHS Section 504 Rule Mandates Accessible Medical Diagnostic Equipment for Medicaid-Funded Providers
The U.S. Department of Health and Human Services published a final rule in May 2024 revising Section 504 of the Rehabilitation Act of 1973, which is now in effect. The rule requires healthcare systems receiving federal financial assistance, including Medicaid funding, to ensure medical diagnostic equipment is accessible to patients with disabilities. All entities that accept Medicaid payments are subject to these nondiscrimination requirements. The regulation imposes new compliance obligations on providers and health systems that contract with Medicaid managed care organizations.
- Managed Care
PBM Reform Drives Need for Automated Claim Reconstruction and Real-Time Financial Alignment
Pharmacy benefit manager reform efforts require health plans to implement automated systems capable of reconstructing claim logic on demand and providing real-time alignment between pricing, rebates, and financial outputs. The regulatory changes are described as directional rather than temporary, signaling sustained compliance expectations. Managed care organizations relying on PBM arrangements must assess whether their current operational infrastructure can meet these transparency and reporting requirements. The shift affects MCO pharmacy benefit operations, financial reconciliation processes, and regulatory compliance capabilities.
- Managed Care
Home-Based Care Providers Address Social Determinants Without Direct Payment
Home-based care providers are addressing social determinants of health despite lacking direct financial incentives. Providers report that removing barriers like food insecurity, housing instability, and transportation gaps improves care outcomes and enables frontline workers to deliver contracted services more effectively. The activity reflects growing provider investment in upstream interventions that affect utilization, quality metrics, and total cost of care. Medicaid managed care organizations increasingly rely on home-based providers for complex populations where social determinants directly affect clinical outcomes and plan performance.
- Managed Care
Substance Use and Suicide Combined Ranked Third Leading Cause of U.S. Death in 2024
A new brief reports that substance use and suicide deaths collectively became the third leading cause of death in the United States in 2024, reflecting continued behavioral health mortality trends. The analysis examines demographic patterns and temporal trends in these deaths. For Medicaid managed care organizations, this data underscores the scale of behavioral health needs among enrollees, as Medicaid covers a disproportionate share of individuals with substance use disorders and mental health conditions. The findings reinforce the importance of MCO investments in crisis intervention, medication-assisted treatment, and integrated behavioral health services.
- Industry
AIDS Activists Obtain Biden-Gilead HIV Prevention Patent Settlement R&D Agreement
AIDS activists have obtained a research and development agreement that formed the basis of a settlement between the Biden administration and Gilead Sciences concerning patents for HIV prevention drugs. The activists are criticizing the terms of the settlement deal. The agreement relates to pre-exposure prophylaxis (PrEP) medications used to prevent HIV transmission. This development follows years of dispute over whether the federal government held patent rights to Gilead's HIV prevention drugs and the terms under which those drugs should be made available.
- State Policy · CA
California Defers Medi-Cal Budget Decisions to Incoming Governor
California lawmakers finalized the 2026-27 state budget without resolving major Medi-Cal policy questions, leaving decisions on coverage, workforce, and program financing to the incoming governor who takes office in January 2027. The budget action affects California's Medi-Cal managed care program, which serves over 15 million enrollees through contracted health plans. Deferred issues include provider payment rates, eligibility and enrollment policies, behavioral health funding structures, and workforce development initiatives that directly impact MCO operations and financial performance.
- State Policy
CBPP Database Compiles State Eligibility and Enrollment Practices Across Safety Net Programs
The Center on Budget and Policy Priorities maintains a database tracking eligibility criteria, enrollment procedures, and operational practices for Medicaid, SNAP, TANF, and WIC across all 50 states and the District of Columbia. The resource provides state-by-state comparisons of program rules, application processes, and enrollment outcomes. It is updated on an ongoing basis as states modify their policies. The database serves as a reference tool for monitoring cross-program alignment and administrative practices that affect coverage continuity.
- Legal
HHS OIG Excludes Over 1,200 People and Entities from Federal Programs in Six Months
The HHS Office of Inspector General excluded more than 1,200 individuals and entities from participating in federal healthcare programs between October 2025 and March 2026. The exclusions are part of increased enforcement activity under the Trump administration targeting fraud in Medicaid and Medicare Advantage. Excluded providers and entities cannot receive payment from federal programs, and managed care organizations are prohibited from contracting with or employing excluded individuals. MCOs must screen their networks against the OIG exclusion list monthly to maintain compliance and avoid penalties.