All stories
Jump to date
Monday, June 29 · 16 stories
- Federal Policy
Ten States Enter CCBHC Medicaid Demonstration as H.R. 1 Threatens Funding
Ten additional states have joined the Certified Community Behavioral Health Clinic (CCBHC) Medicaid demonstration program, expanding access to comprehensive community-based behavioral health services that meet federal certification standards. The expansion occurs as pending legislation H.R. 1 threatens the demonstration's continued funding. CCBHCs provide integrated behavioral health and physical health screening, crisis services, and care coordination under enhanced Medicaid payment structures. The timing creates uncertainty for managed care organizations with CCBHC network arrangements and for states planning implementation.
- State Policy
NASHP Releases Model Legislation Tying State Drug Pricing to Medicare Negotiated Rates
The National Academy for State Health Policy published revised model legislation allowing states to reference Medicare Maximum Fair Prices negotiated under the Inflation Reduction Act when setting prescription drug payment rates for state programs. The model act would apply to state-funded programs including Medicaid fee-for-service and potentially managed care pharmacy benefits. States can adapt the model to tie reimbursement rates to Medicare's negotiated prices for high-cost drugs, creating potential benchmark pricing constraints. The legislation offers states a mechanism to leverage federal negotiating power for prescription drug cost containment.
- Federal Policy
Senators Pursue $35 Insulin Cap for Private Insurance and Uninsured
U.S. senators are advancing legislation to extend the $35 insulin cost cap beyond Medicare to cover private insurance and uninsured individuals. The Medicare cap, enacted under the Inflation Reduction Act, currently applies only to Medicare Part D beneficiaries. The proposed expansion would affect Medicaid managed care organizations that coordinate care for dual-eligible beneficiaries and states with Medicaid pharmacy carve-ins where commercial insulin pricing dynamics affect beneficiary access. No effective date or legislative timeline is specified in the report.
- Managed Care
988 Suicide Hotline Expands LGBTQ-Specific Services
The 988 Suicide and Crisis Lifeline is expanding specialized services for LGBTQ+ populations. The expansion addresses higher rates of crisis calls and mental health needs among LGBTQ+ individuals, particularly youth. For Medicaid managed care organizations, this development affects crisis service coordination and behavioral health network adequacy requirements, as many states require MCOs to integrate 988 into their crisis response systems. MCOs should assess whether their behavioral health networks can support LGBTQ-competent follow-up care for individuals diverted from emergency departments through 988.
- Legal
DOJ Antitrust Settlements Target Hospital Steering Restrictions in Commercial Payer Contracts
The U.S. Department of Justice Antitrust Division filed civil complaints against hospital systems for using contract provisions that require health insurers to include them in nearly all commercial networks at preferred benefit tiers. These steering restrictions limit insurers' ability to design narrow network products. The OhioHealth settlement reflects DOJ's increased enforcement focus on payer contracting practices that constrain network design flexibility. While the cases involve commercial insurance, the enforcement trend signals heightened scrutiny of similar anti-steering and anti-tiering provisions that may appear in Medicaid managed care contracts.
- State Policy · CA
California Grants Staffing Waivers to 23 Psychiatric Hospitals After New Nurse Ratio Rules
California's Department of Public Health approved temporary waivers for 23 of 35 psychiatric hospitals required to comply with new nurse-to-patient ratios that took effect June 1, 2026. The regulations mandate one nurse per six adult patients and one nurse per five youth patients in psychiatric units. The waivers allow non-compliant facilities to continue operating while they work toward meeting staffing requirements. This affects Medicaid managed care organizations with behavioral health carve-ins or delegated inpatient psychiatric contracts, as network adequacy and access standards depend on participating hospitals maintaining operational capacity.
- Federal Policy
CMS Final Rule on Prior Authorization Leaves Core Automation Challenges Unresolved
CMS has finalized rule CMS-0053-F addressing prior authorization processes, but the regulation does not solve the underlying interoperability and standardization problems that have prevented automation. The rule requires electronic submission of prior authorization requests, moving away from fax-based workflows. However, it does not establish the data standardization or system integration needed for true automation. Medicaid managed care organizations will need to implement new electronic workflows while still handling manual review processes, creating a compliance obligation without the operational efficiency gains the industry expected.
- Federal Policy
Latham & Watkins Digest Tracks June 2026 Drug Pricing and Rebate Developments
Latham & Watkins LLP published its third June 2026 digest tracking developments in drug pricing policy, including the Medicaid Drug Rebate Program, 340B Program, Medicare reforms, and state-level legislative activity. The digest compiles recent regulatory actions, guidance, and policy changes affecting pharmaceutical pricing and market access. The publication serves as an ongoing reference for tracking federal and state drug pricing policy developments. This tracker does not report a single new event but aggregates multiple developments from the period.
- Federal Policy
KFF Tracker Compiles Monthly Medicaid and CHIP Enrollment Data
The Kaiser Family Foundation maintains an ongoing tracker of monthly Medicaid and CHIP enrollment figures across states. The tracker aggregates enrollment data reported by states and CMS, providing a centralized resource for monitoring program size and trends. It is updated as new monthly data becomes available from state and federal sources. The tracker serves as a reference tool for analyzing enrollment patterns following policy changes such as the end of continuous coverage provisions.
- Federal Policy
GAO Faults HHS for Lacking Near-Term Goals in National Alzheimer's Project
The Government Accountability Office found that HHS has not set near-term, measurable goals for the National Alzheimer's Project despite having long-term objectives like reducing Alzheimer's risk. Without these goals, HHS cannot effectively collect performance data, assess progress across the multi-agency initiative, or communicate results to stakeholders. GAO acknowledged the project has contributed to achievements including FDA-approved disease-modifying treatments and diagnostic advances. The report recommends HHS adopt key performance management practices to better track federal investments spread across multiple agencies through 2035, when the project's current authorization expires.
- Federal Policy
Sanders Releases HHS Emails Showing Kennedy Pressured CDC on Vaccine Messaging
Senator Bernie Sanders released internal HHS emails indicating that HHS Secretary Robert F. Kennedy Jr. pressured the CDC to alter vaccine messaging and directed the CDC's vaccine advisory panel to restrict vaccine access. The emails document direct intervention in CDC communications and advisory processes. The release comes amid ongoing scrutiny of the administration's vaccine policy direction and its potential impact on public health programs.
- Managed Care
Home-Based Care Payment Models Focus on Value, Risk, and Coordination
Industry leaders at the PAYER Summit identified three payment trends reshaping home-based care delivery: value-based payment arrangements replacing fee-for-service, increased provider risk-sharing with managed care organizations, and stronger payment incentives for care coordination across post-acute settings. These shifts affect how MCOs structure home health and home-based primary care contracts. The trends reflect broader movement toward outcomes-based reimbursement in Medicaid managed long-term services and supports. Payer executives and providers agreed these payment changes will determine which home-based care organizations remain viable partners for health plans.
- State Policy · ID
Idaho Behavioral Health Council Recommends Rural Opioid Funding Priority
Idaho's Behavioral Health Council is recommending that the state legislature direct opioid settlement funds toward rural communities in upcoming funding decisions. The council, which includes representatives from all three branches of state government, will present project proposals prioritizing rural areas. This recommendation comes as Idaho determines allocation of settlement funds received from opioid litigation. The focus on rural communities reflects ongoing challenges in accessing behavioral health services in non-urban areas of the state.
- Federal Policy
Advocates Warn Federal Support for Home and Community-Based Services at Risk
Advocates for people with disabilities and older adults warn that federal support for home and community-based services (HCBS) may be weakening, 25 years after the Supreme Court's Olmstead decision established the right to receive long-term care at home rather than in institutions. The concern centers on potential policy changes that could reduce federal backing for community-based care options. This comes as Medicaid HCBS programs have grown substantially, with managed care organizations increasingly responsible for delivering and coordinating these services. Any reduction in federal support would directly affect MCO LTSS programs, reimbursement structures, and member access to community-based alternatives.
- State Policy · CA
California Report Examines Undocumented Residents' Medi-Cal Access Under Enforcement Climate
A California Health Care Foundation report based on interviews with 39 undocumented Californians analyzes how recent Medi-Cal eligibility expansions interact with heightened immigration enforcement concerns. The qualitative research explores coverage enrollment decisions, trust barriers, and healthcare access patterns among undocumented individuals now eligible for Medi-Cal under California's eligibility expansions. The report documents how immigration policy uncertainty affects enrollment behavior and continuity of coverage even when individuals are legally eligible for benefits. Findings inform outreach strategies and enrollment retention efforts for managed care plans serving this population in California.
Friday, June 26 · 9 stories
- Federal Policy
MACPAC Releases 2026-2027 Meeting Agenda on Program Integrity and Federal Oversight
The Medicaid and CHIP Payment and Access Commission (MACPAC) has published its analytic agenda for the 2026-2027 meeting cycle. The agenda includes program integrity, the federal role in Medicaid oversight, and other policy areas that will be examined through public meetings and research over the next two years. MACPAC's work typically informs congressional deliberations and CMS policy development. Managed care organizations should monitor MACPAC proceedings as the Commission's recommendations often lead to regulatory or legislative changes affecting MCO operations, compliance requirements, and payment policy.
- State Policy
Young Children's Uninsurance Rises Faster Than School-Age Peers Pre-2025
Analysis shows young children experienced faster uninsurance growth compared to school-aged children prior to 2025 Medicaid enrollment declines. The trend emerged before recent federal policy changes including Trump administration actions and H.R. 1 proposals. The data suggests underlying coverage gaps for young children independent of current redeterminations. States may need targeted outreach and enrollment strategies for families with young children to reverse the trend.
- Industry
Proposed Legislation Would Restructure Federal 340B Drug Pricing Program
Congressional legislation has been introduced to overhaul the 340B drug discount program, which requires pharmaceutical manufacturers to provide discounted outpatient drugs to eligible healthcare providers. The bill would restructure eligibility requirements and oversight mechanisms for the program that currently serves safety-net providers including some Medicaid managed care organizations and federally qualified health centers. If enacted, the changes would affect how covered entities access discounted medications and could alter prescription drug cost structures for Medicaid plans contracting with 340B-eligible providers. The proposal comes amid ongoing disputes between manufacturers and covered entities over contract pharmacy arrangements and duplicate discount prohibitions.
- Federal Policy
House Hearing Surfaces Partisan Split on CMS Medicaid Funding Deferrals
A House subcommittee hearing Thursday revealed sharp partisan divides over recent CMS actions deferring or threatening Medicaid funding in multiple states. State Medicaid directors defended program integrity efforts while Democratic members questioned why only Democratic-led states have faced funding actions despite administration claims the crackdown applies nationwide. The hearing focused on CMS's authority to withhold federal matching funds and the criteria used to identify states for enhanced scrutiny. The dispute centers on whether recent enforcement actions reflect objective program integrity standards or politically motivated targeting.
- State Policy · CT
Connecticut Medicaid Spending Rose in 2024 but Remained Lowest Per-Member Cost
Connecticut's Medicaid program experienced spending increases in 2024 while maintaining the lowest per-enrollee costs compared to commercial insurance markets in the state. The data shows Medicaid's cost efficiency persisted despite upward spending pressure. The comparison encompasses all insurance market segments operating in Connecticut. Medicaid managed care organizations in the state continue to deliver care at lower per-member costs than commercial carriers, though absolute spending grew year-over-year.