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Wednesday, July 8 · 37 stories
- Industry
MHPA Submits Congressional Testimony on Generic Drug Shortage Legislation
Medicaid Health Plans of America (MHPA) provided testimony to Congress regarding legislative proposals to address drug shortages and ensure access to affordable generic drugs, with particular focus on sterile injectable medications. The trade association representing Medicaid managed care organizations weighed in on pending federal legislation aimed at stabilizing the generic drug supply chain. MHPA's position supports congressional efforts to resolve shortages that affect Medicaid beneficiaries' access to essential medications.
- Federal Policy
MHPA Urges Changes to Draft Dual Eligible Care Integration Legislation
Medicaid Health Plans of America submitted recommendations on draft federal legislation aimed at improving care coordination and outcomes for dually eligible beneficiaries. The trade association expressed support for the bill's integration goals while raising concerns about specific provisions and requesting clarification on implementation details. The legislation seeks to better align Medicare and Medicaid services for the approximately 12 million Americans enrolled in both programs. MHPA's feedback reflects managed care industry priorities around dual eligible special needs plans (D-SNPs) and integrated care models.
- State Policy · CO
Colorado Issues Medicaid Outreach Toolkit, Polis Signs Healthcare Bills
The Colorado Department of Health Care Policy and Financing released a communications toolkit for partners to help Medicaid enrollees understand upcoming program changes. The toolkit is part of a new resource hub offering ready-to-use materials for outreach efforts. Governor Jared Polis also signed several healthcare bills into law this week, including SB26-178, which creates sustainable funding for an unspecified program. The document does not provide details on when the Medicaid changes take effect or what they entail.
- Managed Care
CMS Proposes Limits on State Directed Payments Under New Statutory Authority
On May 20, 2026, CMS released a proposed rule implementing statutory limits on state directed payments (SDPs) enacted under H.R.1 (Public Law 119-21). The rule establishes new caps and requirements for SDPs that states use to direct managed care organization payments to providers. The proposed changes would affect how states structure supplemental payments within capitation rates and require new CMS preapproval processes. Public comments are due 60 days from Federal Register publication. The rule directly impacts MCO rate setting, provider payment arrangements, and state contract negotiations for managed care plans participating in SDP arrangements.
- Federal Policy · CA
H.R. 1 Imposes Federal Medicaid Work Requirements, Cuts $1 Trillion Over Decade
In July 2025, President Trump signed H.R. 1 into law, reducing federal Medicaid funding by $1 trillion over ten years and establishing a federal work requirement for certain adult enrollees. The law mandates that covered adults work, attend school, or volunteer to maintain eligibility. The requirements apply to non-exempt adult populations and represent a fundamental shift from prior waiver-based work requirement approaches to a statutory federal mandate. States must implement compliance tracking and reporting systems, affecting MCO enrollment verification, eligibility redeterminations, and coverage continuity processes.
- State Policy · CA
California Health Care Foundation Publishes Medi-Cal HCBS Fact Sheet Series
The California Health Care Foundation released a fact sheet series explaining the essential components of Medi-Cal Home and Community-Based Services. The series covers how HCBS programs help older adults and people with disabilities live independently in California. The fact sheets are designed as educational resources for stakeholders working with or seeking to understand California's HCBS delivery system. While timing is not specified, this reflects ongoing state efforts to expand community-based alternatives to institutional care under Medicaid.
- Managed Care
Some Health Plans Exclude Manufacturer Copay Assistance from Deductible and Out-of-Pocket Maximums
Health insurers are implementing policies that exclude manufacturer copay assistance from counting toward patient deductibles and out-of-pocket maximums, a practice known as copay accumulator programs. When drugmakers provide financial assistance to help patients afford expensive medications, these programs prevent those payments from reducing the patient's cost-sharing obligations under the plan. Patients effectively pay twice — once through the manufacturer assistance that does not count toward their deductible, and again when they must meet the full deductible out of their own pocket. This practice affects managed care plans' pharmacy benefit design and patient access to high-cost specialty medications.
- Industry
FDA Approves Over-the-Counter CGM for Childhood Obesity Management
The FDA has approved an over-the-counter continuous glucose monitor (CGM) for use in young children, including toddlers as young as two years old, as a tool for childhood obesity management. The approval represents a significant shift in glucose monitoring technology from prescription diabetes management to preventive wellness applications in the pediatric population. Medical experts are evaluating the clinical benefits of real-time glucose data for obesity prevention against potential risks including device-related anxiety, misinterpretation of normal glucose fluctuations in non-diabetic children, and the appropriateness of medical device use in very young children. The approval takes effect immediately with retail availability expected in the coming months.
- Managed Care
GLP-1 Weight Loss Use Jumps to 11% of Americans in Two Years
A Gallup survey released Tuesday shows 11 percent of Americans now take GLP-1 medications for weight loss, up from 3 percent in 2024. An additional 15 percent report considering use. The sharp uptick in utilization represents significant pharmacy cost pressure for Medicaid managed care plans, which face coverage mandates in some states and growing member demand. Plans must manage prior authorization protocols, medical necessity criteria, and budget forecasts as obesity prevalence grows among Medicaid populations.
- Industry
Four Health Plans Expand Specialty Pharmacy Strategies to Address Drug Cost Growth
Four health insurers are implementing new specialty pharmacy approaches in 2026 to address rising prescription drug costs, a major driver of overall cost growth. Strategies include expanding service offerings, entering healthcare delivery, and pursuing partnerships to increase cost discipline. The initiatives reflect broader industry efforts to manage high-cost specialty medications through vertical integration and improved utilization management. Specific plan names and implementation details were not provided in the source material.
Tuesday, July 7 · 24 stories
- State Policy · CA
California Launches Birthing Care Pathway to Improve Medicaid Maternity Outcomes
California's Department of Health Care Services has implemented a Birthing Care Pathway as part of a multi-pronged state initiative to improve maternity care delivery. The pathway is one of three current California programs targeting maternal health outcomes, alongside the Transforming Maternal Health Model and Rural Health Transformation Program. The initiative affects Medicaid managed care organizations operating in California and their contracted maternity care providers. This is part of California's broader strategy to address maternal mortality and morbidity through structured care delivery frameworks.
- Legal
5,000 Independent Pharmacies Sue Prime Therapeutics for Alleged Antitrust Violations
Nearly 5,000 independent pharmacies filed a federal antitrust lawsuit on July 2, 2026, in the U.S. District Court for the Western District of Washington against Prime Therapeutics, alleging the PBM conspired with Express Scripts to suppress pharmacy reimbursement rates and increase fees. The complaint claims violations of federal antitrust law through coordinated pricing practices. The lawsuit targets PBM reimbursement methodologies that affect pharmacy network economics. This litigation follows broader scrutiny of PBM pricing practices and their impact on pharmacy access.
- Federal Policy
CMS Launches Medicare GLP-1 Bridge Program with Fixed-Cost Access
The Centers for Medicare & Medicaid Services launched its Medicare GLP-1 Bridge program on July 1, 2026, offering select beneficiaries fixed-cost access to GLP-1 medications including Foundayo and Wegovy. The program arrives as GLP-1 use among US adults reached 11% in 2026, up from 3% in 2024, according to a July 7 Gallup poll. The new Medicare benefit structure establishes precedent for coverage of anti-obesity medications that could influence Medicaid managed care pharmacy benefits and prior authorization protocols. Medicaid MCOs should monitor whether states adopt similar fixed-cost or expanded coverage models for their programs.
- Industry
Yale Study Finds Most Telehealth GLP-1 Vendors Skip Live Clinician Visits
A secret shopper study published July 6 in JAMA found that most telehealth platforms prescribing GLP-1 medications do not require real-time clinician interaction with patients before prescribing. Yale researchers documented prescribing practices across online vendors selling these weight-loss and diabetes medications. The study raises questions about appropriateness of care, patient safety, and adherence to clinical practice standards in the rapidly growing direct-to-consumer telehealth market for high-cost specialty drugs. Implications for Medicaid managed care organizations include potential utilization management concerns and pharmacy benefit oversight challenges.
- Industry
MedCity News Op-Ed Calls for Unified Governance in Health Data Exchange
A MedCity News opinion piece argues that while technical infrastructure for nationwide health data exchange exists, fragmented governance and inconsistent enforcement threaten its sustainability. The author contends that patients, providers, and innovators require unified oversight to maintain trust in interoperability frameworks. The piece does not announce new policy or enforcement actions. For Medicaid managed care organizations, the commentary reflects ongoing industry concern about the durability of federal interoperability requirements under the CMS Interoperability and Patient Access Rule and related ONC standards.
- Legal · NY
HHS-OIG Denies Recertification for New York Medicaid Fraud Control Unit, Freezes $60 Million
The HHS Office of Inspector General denied recertification for New York's Medicaid Fraud Control Unit and froze $60 million in annual federal funds effective July 1, 2026. This action came one week after DOJ's National Health Care Fraud Takedown announced partnerships with all 50 state MFCUs. The denial represents an unprecedented enforcement step against a state fraud control unit that typically partners with federal authorities on Medicaid provider fraud investigations. For Medicaid managed care organizations in New York, this creates uncertainty around ongoing fraud investigations, referral processes, and coordination with state enforcement authorities on provider integrity matters.
- State Policy · IN
Indiana to Implement Medicaid Work Requirements Starting January 2027
The Indiana Family and Social Services Administration released implementation details for Medicaid work requirements affecting able-bodied adults ages 19-64 enrolled in the Healthy Indiana Plan. Requirements begin January 1, 2027, with early compliance rules for new applicants and an 80-hour monthly work obligation for current enrollees. The policy applies to HIP members without exemptions such as disability, pregnancy, or caregiver status. Indiana becomes one of the first states to move forward with work requirements following recent federal policy shifts, requiring managed care organizations to track and report member compliance.
- Federal Policy
HHS Postpones Preventive Services Task Force Meetings, Plans August Reboot with Eight New Members
The Department of Health and Human Services will announce eight new members of the U.S. Preventive Services Task Force and schedule the panel's first meeting in 17 months for late August. HHS canceled four prior meetings, removed two vice chairs in May, and allowed the 16-member panel to shrink to eight as terms expired without replacement. The task force grades preventive services that Medicaid expansion programs and most private insurers must cover without cost-sharing when rated A or B. Recommendations on prostate cancer screening, weight loss counseling, cervical cancer screening, perinatal depression, and alcohol abuse await votes or formal publication.
- State Policy · CO
Colorado Maternal Health Initiative Leader Discusses Perinatal Care Transformation Under Medicaid
Elephant Circle founder Indra Lusero discusses Colorado's comprehensive maternal health initiatives under Medicaid in a Q&A format. Colorado was among the first states to pursue broad perinatal care reforms aimed at improving outcomes for pregnant and postpartum enrollees. The interview covers the state's maternal health strategy during a period described as involving recent federal funding constraints. The discussion addresses how Colorado's Medicaid program has approached perinatal care delivery and payment reform.
- Federal Policy
Proposed Medicaid Work Requirements Face Rural Service Delivery Challenges
A proposed federal rule implementing H.R. 1's Medicaid work and volunteer reporting requirements faces operational challenges in rural areas where postal service limitations may prevent beneficiaries from meeting documentation deadlines. The law, projected to result in 10 million Americans losing coverage, requires monthly work or volunteer activity reporting to maintain eligibility. Rural beneficiaries may face particular difficulty submitting timely verification due to mail delays and limited internet access. The rule remains in proposed form with implementation timing not yet finalized.