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Monday, July 13 · 34 stories
- State Policy · WV
West Virginia Survey Finds 55% of Medicaid Recipients Unaware of 2027 Work Requirements
A new survey reveals that 55% of West Virginia Medicaid recipients are unaware of work requirements set to begin in 2027, affecting more than 161,000 enrollees. The requirements will condition eligibility on work or qualifying activities for certain adult beneficiaries. Implementation begins next year, requiring managed care organizations to support member communications and coordinate exemption verification processes. Low awareness levels signal potential enrollment disruptions and administrative burden for MCOs managing eligibility transitions.
- State Policy · GA
Georgia Democrats Campaign on Medicaid Expansion Despite Federal Legislative Changes
Democratic candidates in Georgia's 2026 primary are campaigning on Medicaid expansion despite federal legislative changes enacted in 2025 that may complicate implementation. Healthcare affordability remains a top voter concern, with majority support for expansion across party lines according to KFF polling—72% of Democrats, 63% of independents, and 47% of Republicans. The candidates' expansion pledges must now account for new federal requirements or constraints passed in the previous year. The timing and feasibility of expansion will depend on how state officials navigate the altered federal framework.
- State Policy
States Cut Immigrant Health Coverage Amid Budget Pressure from Federal Medicaid Reductions
Several states that use state-only funds to cover healthcare for undocumented immigrants are reducing or eliminating those programs due to budget constraints. The cuts follow federal Medicaid funding reductions and the expiration of enhanced Affordable Care Act subsidies. States affected include those that previously expanded coverage beyond federal eligibility requirements using state general funds. The reductions take effect as states finalize their fiscal year 2027 budgets, with some changes beginning as early as July 2026.
- State Policy · MO
Missouri Rural Hospitals Say $216M Federal Grant Insufficient to Offset Medicaid Cuts
Rural hospitals in Missouri are warning that a $216 million federal grant awarded in December 2025—part of a five-year, $50 billion rural healthcare investment—will not offset upcoming federal Medicaid reimbursement cuts. The hospitals say the reductions will further strain already fragile rural healthcare systems. Missouri received the funding as part of a broader Rural Health initiative, but providers argue the grant falls short of mitigating the financial impact of federal Medicaid payment reductions affecting hospital operations statewide.
- State Policy · CA
California Health Care Foundation Report Examines County-Administered Medicaid Eligibility Friction
The California Health Care Foundation published a paper analyzing structural and programmatic challenges in state-supervised, county-administered Medicaid eligibility systems. The report identifies inefficiencies inherent in the governance model where states oversee eligibility determination but counties execute it, and proposes policy considerations for modernization. This governance structure exists in several states including California, Colorado, Minnesota, New York, North Carolina, North Dakota, Ohio, and Wisconsin. The analysis is relevant for states considering eligibility system reforms and for managed care organizations operating in counties with persistent enrollment and renewal friction.
- Managed Care
ACAP Report Details MCO Rate Adequacy Amid Federal Funding Pressures
The Association for Community Affiliated Plans released a report examining actuarially sound rate-setting for Medicaid managed care organizations as states anticipate federal funding reductions. The report addresses how rate adequacy affects MCO financial stability, network adequacy, and access to care during periods of fiscal constraint. It provides guidance for states and plans navigating rate-setting requirements under potential budget pressures. The analysis comes as states prepare budgets amid uncertainty about federal Medicaid funding levels.
- Legal
CMS Revises Medicare Overpayment Rule on Identification Timeline and Investigation Requirements
CMS has revised regulations governing Medicare and Medicaid overpayments, modifying the definition of when an overpayment is considered "identified" and updating requirements for investigating related overpayments. The revisions affect how providers determine the 60-day deadline to report and return overpayments under the Affordable Care Act. While the changes offer some additional flexibility in compliance timelines, they reinforce the need for robust internal auditing and monitoring systems. Failure to comply with revised timelines and investigation standards may result in False Claims Act liability and other enforcement actions.
- State Policy · NH
New Hampshire Enacts Budget With Medicaid Copays, Premiums, and DHHS Cuts
In June 2025, Governor Kelly Ayotte signed New Hampshire's two-year budget cutting $51 million from the Department of Health and Human Services and imposing new Medicaid copays and premiums on certain recipients. The budget also reduced Department of Corrections funding by $10 million and cut support for the state university system. The policy changes affect Medicaid beneficiaries and state health services delivery. Managed care organizations operating in New Hampshire will need to implement the new cost-sharing requirements and adapt to reduced state DHHS capacity.
- Managed Care
Plan Switching Creates Continuity of Care Barriers for Medicaid Enrollees
Americans switching health plans to find affordable coverage face disruptions in provider networks and medication access. These continuity-of-care challenges affect patient outcomes and care coordination when enrollees move between health plans. The barriers include prior authorization requirements for existing medications, loss of established provider relationships, and administrative complexity in maintaining treatment regimens. For Medicaid managed care organizations, member churn and plan transitions create operational challenges in maintaining quality metrics and member satisfaction while managing care continuity requirements.
- Legal
Bankrupt Omnicare Settles DOJ Fraud Case for $440 Million
Omnicare has reached a $440 million settlement with the Department of Justice to resolve fraud charges related to improper billing of government health programs. The settlement follows Omnicare's bankruptcy filing last year after a court ordered the company to pay nearly $950 million for fraudulent billing practices. The reduced settlement amount reflects negotiations during the bankruptcy process. The case represents one of the largest False Claims Act settlements in the pharmacy services sector and concludes years of litigation over alleged improper billing to Medicaid and Medicare.
- Industry
Home Health Care News Profiles Six Home Care Companies for 2026
Home Health Care News published a profile of six home care companies navigating operational challenges in 2026. The article cites Medicaid reimbursement pressures, proposed 80-hour work requirements, fraud enforcement, technology adoption, and mergers and acquisitions as key factors shaping the sector. The publication does not report specific policy changes or enforcement actions, but rather frames the operating environment for home care providers. No effective dates or comment periods are provided because this is an industry profile rather than a policy document.
- State Policy · PA
Pennsylvania Delays $1.3 Billion in Medicaid MCO Payments to Balance Budget
Pennsylvania adopted a $50.8 billion budget that delays $1.3 billion in payments to Medicaid managed care organizations as part of accounting maneuvers to preserve an $8 billion rainy day fund. The legislature passed the budget two weeks late, using delayed MCO payments along with more than $500 million from special funds to close the gap. House Appropriations Chair Jordan Harris told reporters the approach ensures Medicaid enrollees still receive care but shifts the timing of MCO reimbursements. The budget includes $900 million in new education spending but no new revenue sources.
- Federal Policy
HHS Secretary Kennedy Blocks Preventive Services Task Force Meetings, Fires Leadership
HHS Secretary Robert F. Kennedy Jr. has prevented the U.S. Preventive Services Task Force from meeting, declined to replace members whose terms have expired, and fired the panel's leaders in May 2026. The task force determines which preventive medical services insurers must cover without cost-sharing under the Affordable Care Act. The disruption affects coverage recommendations for screenings, counseling, and preventive medications that Medicaid managed care plans must cover as essential health benefits. The timeline for new coverage recommendations and the panel's future composition remain uncertain.
- State Policy · CA
California Governor Defends Medicaid Spending on Housing and Food Amid GOP Fraud Claims
California Governor Gavin Newsom is defending the state's use of Medicaid funds for housing and food services for high-cost patients, as Republican lawmakers characterize these expenditures as waste, fraud, and abuse. The state has incorporated social determinants of health services into its Medicaid program to address needs of complex, high-utilizing enrollees. Newsom acknowledges concerns about potential federal funding cuts but maintains the state's holistic care approach is appropriate. This political tension creates uncertainty for managed care organizations operating California's CalAIM program, which relies heavily on these non-traditional service categories.
- Federal Policy
HHS Develops Guidance to Reduce SSRI Antidepressant Prescribing
The Department of Health and Human Services is working with mental health professionals to develop guidance aimed at reducing the use of selective serotonin reuptake inhibitor (SSRI) antidepressants. HHS officials convened a private meeting to advance this effort. The timing and scope of any formal guidance release remain unclear. For Medicaid managed care organizations, this could signal future prior authorization requirements, utilization management changes, or quality measure adjustments affecting behavioral health pharmacy benefits and member care protocols.
- State Policy
States Consider Wage Cuts for Family Caregivers of People with Disabilities
Multiple states are considering significant wage reductions for family caregivers who provide care to people with disabilities through Medicaid programs. These proposed cuts respond to state budget pressures following recent Medicaid funding reductions. The wage cuts would directly affect family members who serve as paid caregivers under state long-term services and supports programs. The changes threaten the financial stability of thousands of family caregivers who depend on these wages while providing essential home and community-based services.
Friday, July 10 · 26 stories
- Industry
Sturgis Hospital Closes After 101 Years as 720 U.S. Hospitals Face Closure Risk
Sturgis Hospital in Michigan closed June 19, 2026, after 101 years of operation, following a 13% volume decrease over two years. An estimated 720 hospitals nationwide are at risk of closure. The closures disproportionately affect rural facilities facing declining patient volumes and financial pressures. For Medicaid managed care organizations, rural hospital closures threaten network adequacy, emergency access, and continuity of care for beneficiaries in underserved areas.
- Industry · IA
CommonSpirit Closes Labor and Delivery Services at Iowa Hospital
CHI Health Mercy Council Bluffs will end labor and delivery and Level 2 NICU services on August 31, 2026. CommonSpirit Health will consolidate these services at its Omaha birth centers, located approximately 15 minutes away, which currently deliver over 4,460 babies annually. Patients will transition to the Omaha facilities for obstetric care.
- Industry
Dementia Costs Projected at $818 Billion in 2026, Threatening Home Health Workforce
Dementia and Alzheimer's disease are projected to cost the United States $818 billion in 2026, with families and individuals bearing more than 80% of the economic burden according to a study in Alzheimer's & Dementia. Flournoy Health Systems CEO warns this growing cost pressure could further strain the home health workforce. The projections come as managed care organizations face increasing demand for long-term services and supports, particularly home and community-based services for members with cognitive impairment. The workforce impact threatens network adequacy for LTSS benefits.
- Federal Policy
CMS Issues Claims Attachment Rule Establishing HIPAA Standards for Electronic Documentation
CMS finalized a claims attachment rule establishing HIPAA standards for electronic submission of supporting documentation with health care claims. The rule requires standardized submission using the Health Level 7 (HL7) framework and covers digital signature requirements. This applies to all entities submitting electronic claims under HIPAA transaction standards, including Medicaid managed care organizations. Implementation timelines and compliance deadlines are set by CMS for covered entities to transition to the standardized format.