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Friday, July 10 · 26 stories
- Legal · OH
Federal and Ohio Officials Highlight Individual Medicaid Fraud Cases While Corporate Enforcement Lags
In early June 2026, Trump administration officials traveled to Ohio to publicize investigations into individuals suspected of Medicaid fraud totaling tens of millions of dollars. The enforcement focus excluded corporate contractors holding large state Medicaid contracts, despite recent lawsuits against several companies and two settlements. The disparity raises questions about enforcement priorities when corporate entities with substantial Medicaid business face fraud allegations but receive less public attention than individual providers. The timing and scope of corporate enforcement actions remain unclear.
- Legal · NC
North Carolina Woman Pleads Guilty to $1.7 Million Medicaid Urine Testing Fraud
A North Carolina woman pleaded guilty to defrauding Medicaid of $1.7 million through fraudulent urine testing claims. The scheme involved billing for unnecessary or unperformed laboratory testing services. The case represents ongoing federal and state enforcement activity targeting laboratory billing fraud in Medicaid programs. Medicaid managed care organizations that reimburse laboratory services should review utilization patterns and billing practices for urine drug testing to identify potential fraud.
Thursday, July 9 · 11 stories
- Federal Policy
ACS Data Shows Direct Care Worker Demographics Amid Federal Policy Shifts
Analysis of 2024 American Community Survey data examines demographic and socioeconomic characteristics of direct care workers, including home health aides, personal care aides, and nursing assistants across long-term care settings. The workforce profile covers workers in nursing facilities, residential care, home health, and nonresidential services for older adults and people with disabilities. Federal policy changes affecting workforce stability, reimbursement, and recruitment directly impact Medicaid managed care organizations' ability to build adequate LTSS provider networks and meet access standards.
- Managed Care
Contraceptive Implant Use Rising Despite Remaining Below Other Birth Control Methods
Contraceptive implants, the most effective reversible birth control method available, are seeing increased provision and utilization in the United States, though adoption rates remain lower than other contraceptive methods. The growth in implant use reflects evolving clinical practice patterns and improved access channels. For Medicaid managed care organizations, implants represent a covered preventive service under federal requirements, with reimbursement structures varying by state. The shift toward long-acting reversible contraceptives has implications for pharmacy benefit management, provider network adequacy, and quality metrics related to reproductive health access.
- Industry
ACA Marketplace Insurers Propose 14% Premium Increase for 2027
Insurers participating in ACA Marketplaces are proposing a median premium increase of 14% for 2027, based on preliminary rate filings analyzed in 16 states and DC. This follows steep increases in 2026, bringing total premium growth to over one-third between 2025 and 2027. The analysis reflects preliminary filings subject to final regulatory review. Final rates will be determined later in 2026 ahead of the 2027 plan year.
- Industry
Menopause Complications Drive Utilization in Chronically Ill Populations
Menopause destabilizes chronic disease management in high-risk populations, leading to increased healthcare utilization and costs that are often not recognized in care planning. For patients already managing chronic conditions, menopause-related changes can complicate treatment adherence and clinical stability. The effects manifest over time in higher utilization rates and worse outcomes. Medicaid managed care organizations serving populations with high chronic disease burden may see increased costs and poorer quality metrics if menopause-related care gaps are not addressed in care management protocols.
- Legal
Court Dismisses False Claims Act Case on Medicare Advantage Marketing Practices
A federal court dismissed a sealed False Claims Act case alleging Medicare Advantage marketing violations. The relator attempted to characterize patient acquisition and outreach activities as fraudulent claims for payment. The dismissal demonstrates judicial skepticism toward FCA theories targeting marketing conduct rather than false billing. The outcome matters for Medicare Advantage plans facing similar qui tam allegations linking enrollment practices to improper payment.
- Federal Policy
Medicaid and ACA Enrollment Drops 5 Million in 12 Months
Medicaid and Affordable Care Act marketplace enrollment declined by more than 5 million individuals over the past year, according to a new report. The decline is attributed to federal Medicaid funding cuts implemented under the Trump administration and the expiration of enhanced ACA premium subsidies. The enrollment losses affect both traditional Medicaid populations and marketplace coverage, with implications for managed care organizations' membership and revenue projections. The timing and scope of these reductions represent a significant shift in coverage patterns following the post-pandemic enrollment peak.
- Industry
External Audit Finds 97% of UnitedHealth HouseCalls Diagnoses Supported by Medical Records
An external audit of UnitedHealth's HouseCalls program found that nearly 97% of diagnoses identified during senior home visits were supported by patients' medical records. The audit was conducted amid scrutiny of home visit programs used to identify conditions for Medicare Advantage risk adjustment. UnitedHealth released the findings to validate the program's integrity following questions about diagnosis coding practices in home-based assessments. The results address ongoing concerns from regulators and policymakers about the accuracy of diagnosis reporting in value-based care arrangements.
- Managed Care
Medically Tailored Meals Reduce Hospital Use for Medicaid Enrollees, Study Finds
A new study shows that medically tailored meal programs — home-delivered meals customized by dietitians for people with diabetes, heart disease, and other chronic conditions — significantly improve health outcomes and reduce hospital visits for Medicaid enrollees. Approximately 12 states currently offer these programs through their Medicaid programs. The findings provide evidence for managed care organizations considering value-based arrangements or enhanced benefits that include nutrition services. The study results are relevant as MCOs evaluate supplemental benefit strategies to manage high-cost, chronically ill populations.
- State Policy · VA
Virginia Budgets $15M for Medicaid Sickle Cell Gene Therapy Coverage
Virginia lawmakers allocated nearly $15 million over two years to help the state Medicaid program cover gene therapy treatments for sickle cell disease patients. The funding connects to a federal payment model designed to help Medicaid programs manage the high cost of cell and gene therapies. The initiative aims to improve patient access to these treatments, which can cost over $2 million per patient. Providers indicated the funding could reduce barriers to obtaining complex gene therapy services through Medicaid.
- State Policy · OK
Oklahoma Shifts State Behavioral Health Services to Four Private Providers
The Oklahoma Department of Mental Health and Substance Abuse Services has awarded one-year contracts to four private providers to deliver behavioral and mental health services in portions of the state, transitioning from direct state operations to a privatized model. The shift affects regional service delivery and represents a structural change in how Oklahoma delivers public behavioral health care. Contract terms and implementation timelines were not specified in the announcement. This change may create new network and coordination requirements for Medicaid managed care organizations operating behavioral health programs in Oklahoma.
- Federal Policy
CMS Ends Fast-Track Review Process for Medicaid 1115 Waiver Extensions
CMS announced July 7 that it is eliminating the fast-track review process for certain Medicaid section 1115 demonstration extensions, formally rescinding 2015 guidance that established the expedited pathway. The change stems from a July 2025 reconciliation bill requirement that the CMS chief actuary certify budget neutrality for all 1115 demonstrations, effective January 1, 2027. CMS stated the fast-track process would make it difficult to evaluate renewal applications under the new budget neutrality certification requirements. The bulletin did not specify when the elimination takes effect, but states should anticipate longer review timelines for waiver extensions.
Wednesday, July 8 · 37 stories
- Federal Policy
CMS Requests State Medicaid Provider Revalidation Strategies in April Administrator Letter
CMS Administrator Dr. Mehmet Oz sent a letter to State Medicaid Directors on April 23, 2026, requesting each state develop and submit a comprehensive two-year provider revalidation strategy focused on high-risk providers. The letter, identified as an SMD (State Medicaid Director letter), is not published on the official Medicaid.gov site but is available through Fox News. Minnesota's early implementation offers initial lessons for states responding to the directive. The request affects all state Medicaid agencies and their managed care partners responsible for provider enrollment and network adequacy.
- Federal Policy
FDA Approves Gene Therapy for Children with Sickle Cell Disease
The FDA has approved a new gene therapy treatment for children aged 2 and older with sickle cell disease. The approval expands treatment options for pediatric patients with this serious inherited blood disorder, which disproportionately affects Medicaid beneficiaries. Sickle cell disease affects approximately 100,000 Americans, with the majority covered by Medicaid. Managed care organizations will need to evaluate coverage policies, establish prior authorization criteria, and assess the financial impact of this high-cost specialty therapy on capitation rates and medical loss ratios.
- Industry
Safety Net CIOs Tighten IT Spending Amid Medicaid Budget Reductions
Public safety net systems like Valleywise Health in Maricopa County are applying stricter financial scrutiny to technology investments as Medicaid funding reductions take effect. Chief information officers are requiring business cases for every technology decision, intensifying pre-existing budget discipline. The approach reflects broader operational adjustments underway at safety net providers preparing for sustained Medicaid cuts. The article does not specify timing of cuts or which technology investments are being deferred or prioritized.
- Legal
Four Major Pharmacy Litigation Tracks Progress: PBM Ownership, 340B, Antitrust, Fraud
Pharmacy litigation is proceeding on four major fronts. State laws banning PBM ownership of pharmacies face constitutional challenges. Drugmakers are challenging state 340B protections in multiple jurisdictions. PBMs face antitrust claims over reimbursement practices. Federal fraud enforcement actions target rebate and claims manipulation by PBMs. These cases are ongoing with varying timelines across federal and state courts.
- Industry
UnitedHealth HouseCalls Program Reduces Hospitalizations by 5%, ER Visits by 4%
UnitedHealth Group reported that its HouseCalls in-home health program resulted in up to 5% fewer inpatient stays and 4% fewer emergency room visits for older adults with chronic conditions like diabetes and hypertension in the year following their visit. The findings come from an external analysis of initial program results announced Tuesday. The program targets Medicare Advantage and dual-eligible beneficiaries with in-home preventive visits. Results suggest potential value for managed care organizations exploring home-based interventions to reduce acute care utilization among high-risk populations.
- Managed Care
CHCS Report Examines Long-Term Care Financing and Family Cost Burden
The Center for Health Care Strategies published a report analyzing long-term care financing in the United States, examining payment sources and financial strain on older adults and families. The report addresses who pays for long-term care services and why the current system creates significant cost burdens. Medicaid is the largest payer of long-term care services nationally, covering approximately 60% of nursing home residents and funding home and community-based services for individuals who meet financial and functional eligibility requirements. The analysis is relevant for managed care organizations operating long-term services and supports (LTSS) programs under Medicaid managed care contracts.
- Managed Care · MA
MassHealth Designs Primary Care Risk Adjustment Model for Population-Based Payment
MassHealth developed a primary care-specific risk adjustment model to support population-based payment arrangements with primary care practices. The model accounts for patient complexity factors relevant to primary care settings, distinct from traditional encounter-based or specialty-focused risk scores. The Center for Health Care Strategies published lessons learned from MassHealth's design process to inform other states and Medicaid managed care organizations implementing similar value-based payment structures. The work provides operational guidance for payers structuring capitation or shared savings arrangements with primary care providers.