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Thursday, June 18 · 11 stories
- Legal · IL
PCMA Files Lawsuit Challenging Illinois PBM Reform Law
The Pharmaceutical Care Management Association (PCMA) has filed a lawsuit seeking to exempt pharmacy benefit managers from an Illinois law reforming the PBM industry. This marks the second major legal challenge PCMA has launched against state PBM reform legislation since Monday. The lawsuit targets Illinois's attempt to regulate PBM practices, though specific provisions challenged are not detailed in the article. The legal action follows a pattern of PBM industry opposition to state-level regulatory efforts through preemption and other legal arguments.
- State Policy · MS
Mississippi Medicaid Seeks Court Approval to Withhold $2.4M Payment to Greenwood Leflore Hospital
The Mississippi Division of Medicaid filed a motion in bankruptcy court Wednesday requesting permission to withhold a scheduled $2.4 million payment to Greenwood Leflore Hospital. The hospital, currently operating under Chapter 11 bankruptcy protection, has warned the payment withholding could force immediate closure. The dispute arises as the state Medicaid program exercises its authority to recoup or withhold payments from providers in financial distress. If approved, the action would remove critical operating revenue from a hospital serving a predominantly Medicaid-eligible population in the Mississippi Delta.
- Industry
Immigration Enforcement Creates Pediatric Mental Health Surge for Medicaid Plans
Hundreds of thousands of children, many U.S. citizens enrolled in Medicaid, are experiencing acute mental health crises following parental arrests in immigration enforcement operations. Children are presenting with developmental regression, somatic complaints including stomachaches, sleep disturbances, and academic decline. Research indicates these separations produce long-term behavioral health consequences requiring sustained clinical intervention. Medicaid managed care organizations face increased utilization in pediatric behavioral health services, emergency department visits for mental health crises, and demand for trauma-informed care coordination.
- Federal Policy
CMS Seeks Input on PBM Compensation Restrictions and Data Reporting for 2028 Implementation
CMS issued a request for information on pharmacy benefit manager compensation structures and business practices to inform implementation of new legislative requirements. The RFI focuses on two mandates taking effect in 2028: restrictions on remuneration PBMs and affiliates may receive for services related to Part D drug utilization, and new data reporting requirements. CMS is seeking technical input on PBM service arrangements, affiliate relationships, and compensation models. Comments will shape how CMS defines permissible PBM compensation and structures data collection requirements for Medicare Part D plans.
- Federal Policy
CDC Reports 1,415% Increase in Nitazene Overdose Deaths Since 2020
The CDC reported nitazene-involved overdose deaths increased from 27 in 2020 to 409 in 2024, marking a 1,415% rise in confirmed fatalities from these super-potent synthetic opioids. Nitazenes are spreading across the U.S. drug supply, often mixed with or sold as other substances. The sharp escalation indicates an emerging public health threat requiring enhanced overdose response capacity. This trend follows patterns seen with fentanyl's emergence in the illicit drug market over the past decade.
- Industry
STATus Report Episode Examines GLP-1 Weight Loss Drug Pipeline
STAT News published a video episode examining the future trajectory of GLP-1 weight loss medications. The segment, hosted by Alex Hogan, explores upcoming developments in the GLP-1 drug class, which includes medications like Ozempic and Wegovy. The episode appears to focus on market trends and pharmaceutical industry developments related to these medications. No specific policy changes, regulatory actions, or Medicaid coverage decisions are reported.
- State Policy · NC
North Carolina Proposes Stricter ABA Therapy Rules Amid $505M Medicaid Spending
North Carolina lawmakers are pursuing tighter regulatory requirements for applied behavioral analysis (ABA) therapy providers following combined state and federal Medicaid spending of over $505 million in 2025. The proposed rules aim to reduce fraud and abuse in the rapidly growing autism treatment sector. The legislation would impose additional credentialing, supervision, and documentation standards on ABA providers participating in Medicaid. This follows nationwide scrutiny of ABA billing practices and improper payments in state Medicaid programs.
- Federal Policy
Trump Administration Finalizes Rule Tightening Medicaid Work Requirement Medical Exemptions
The Trump Administration finalized a rule that restricts medical frailty exemptions from the Medicaid work requirement enacted in the 2025 reconciliation law. The rule narrows exemptions for blindness, disability, substance use disorder, disabling mental disorders, and physical, intellectual, or developmental disabilities that impair ability to perform daily activities. The work requirement takes Medicaid coverage from enrollees who do not meet the requirement and do not qualify for an exemption. The rule is now in effect following finalization.
Wednesday, June 17 · 12 stories
- Legal
Legal Aid Groups Convene on Medicaid Cuts and Automated Eligibility Denials
Legal advocates gathered at the ABA/NLADA Equal Justice Conference in Charlotte to address threats to Medicaid from proposed federal budget cuts and automated eligibility systems. The National Health Law Program highlighted concerns about the One Big Beautiful Bill Act, which proposes significant Medicaid spending reductions, and automated systems that are denying coverage to eligible beneficiaries. The conference focused on legal strategies to protect Medicaid access and eligibility processes. No specific implementation dates or regulatory actions were announced.
- Legal
Olmstead Decision Marks 27 Years as Community Integration Faces Medicaid Budget Threats
The 27th anniversary of Olmstead v. L.C. arrives as the landmark Supreme Court decision establishing the right to community-based services faces new challenges from proposed Medicaid cuts. The 1999 ruling required states to provide services in the most integrated setting appropriate to individuals' needs, fundamentally reshaping long-term services and supports delivery through Medicaid managed care. Current budget proposals threaten funding for home and community-based services that emerged from Olmstead's community integration mandate, potentially reversing decades of progress in moving individuals out of institutional settings.
- Industry · KS
Seven Rural Kansas Hospitals Form Clinically Integrated Network
Seven independent rural hospitals in Kansas have formed the Kansas High Value Network, a clinically integrated network serving approximately 190,000 patients. The founding member hospitals represent a combined net revenue of $545 million. The network aims to support value-based care delivery and reduce purchasing costs through collective contracting and operational coordination. The formation reflects broader consolidation trends among rural providers seeking scale to participate in value-based payment arrangements.
- Managed Care
CDC Reports Infant Mortality Rate Falls to Record Low in 2025
The CDC's National Vital Statistics System reported that infant mortality rates in the United States reached an all-time low in 2025, based on provisional death and birth data. The infant mortality rate measures deaths under age one per 1,000 live births. Final figures will be released later this year. The decline continues a multiyear trend in improved birth outcomes, though racial and geographic disparities persist.
- Federal Policy
HHS Announces $708 Million in Behavioral Health Funding Opportunities
HHS Secretary Robert F. Kennedy, Jr. announced $708 million in new funding opportunities for behavioral health programs, including $96 million for the STREETS (Safety Through Recovery, Engagement, and Evidence-based Treatment and Support) program targeting mental illness, addiction, and homelessness, plus $612 million for additional behavioral health initiatives. The funding opportunities are now posted and available for application. This represents significant new federal investment in community-based behavioral health infrastructure and services that Medicaid managed care organizations often coordinate or deliver.
- Managed Care
National Survey Finds Medicaid Patients Report Worse Pregnancy Outcomes Than Privately Insured
A nationwide survey of over 3,800 people who gave birth in 2023-2024 found Medicaid enrollees reported worse pregnancy and delivery outcomes compared to those with private insurance. The Listening to Mothers survey documented limited access to care, with pregnant Medicaid patients frequently reporting feeling unheard and disregarded during pregnancy and labor. The findings highlight persistent quality and access gaps in maternal care delivery for Medicaid-covered pregnancies. Survey results reflect care delivered across 2023-2024.
- State Policy · TN
Tennessee Pharmacies Dispense High-Dose Ivermectin Under Standing Order Law
Since Tennessee enacted the nation's first law in 2021 allowing pharmacies to sell ivermectin without patient-specific prescriptions, dozens of pharmacies now dispense highly concentrated ivermectin pills under standing orders, many facilitated by a single anti-vaccine physician. The law permits pharmacies to dispense prescription drugs through protocol agreements with physicians rather than individual patient prescriptions. This arrangement allows pharmacies to sell potent formulations of ivermectin directly to consumers under medical standing orders, bypassing traditional prescribing requirements.
- Federal Policy
Uninsured Population Grew in 2024, First Increase Since 2019
The number and share of Americans without health insurance increased in 2024, marking the first rise since 2019, according to KFF's analysis of American Community Survey data. The growth in uninsured individuals follows the end of Medicaid continuous enrollment protections that expired in March 2023, resulting in millions of eligibility redeterminations across states. The increase reverses a five-year trend of declining uninsurance rates and signals potential coverage losses that disproportionately affect low-income populations eligible for Medicaid. This shift has immediate implications for uncompensated care costs and emergency department utilization that MCOs and safety-net providers must absorb.
- Federal Policy
FDA Approves Third Over-the-Counter Naloxone Nasal Spray
The FDA approved Rextovy, a 4mg naloxone nasal spray, for over-the-counter sale in pharmacies, convenience stores, and online for emergency treatment of opioid overdose. This is the third OTC naloxone product approved by FDA. The approval expands consumer access to overdose reversal medication without a prescription. For Medicaid managed care organizations, this may affect pharmacy benefit management, member education strategies, and harm reduction program design, particularly for plans serving populations with substance use disorders.
- Managed Care
Medicaid MCOs Prepare for 2027 Community Engagement Requirements Under HR 1
The Reconciliation Act (HR 1) established community engagement requirements for non-elderly, nonpregnant Medicaid adults effective 2027. CMS has released an implementation framework detailing how states must operationalize work requirements for beneficiaries aged 19-64. Health plans cannot contract directly with states to administer these requirements, but managed care organizations are developing member engagement and support strategies to maintain enrollment and help beneficiaries comply. The requirements will affect eligibility determination, member outreach, and care coordination workflows across Medicaid MCOs.
- Legal · NY
DOJ Sues New York DOH and PPL Over CDPAP Fiscal Intermediary Fraud Allegations
The U.S. Department of Justice filed a lawsuit Tuesday against the New York Department of Health and Public Partnerships LLC (PPL), alleging fraud in the state's transition of the Consumer Directed Personal Assistance Program (CDPAP) to a single fiscal intermediary. DOJ claims the arrangement was designed to extract millions from New York's Medicaid program through improper payments. The lawsuit targets both the state agency that selected PPL and the fiscal intermediary itself. CDPAP allows Medicaid beneficiaries to direct their own long-term care services, with fiscal intermediaries handling payroll and administrative functions.
- State Policy · CT
Connecticut Faces Loss of 110,000 Adult Medicaid Enrollees
Connecticut anticipates approximately 110,000 low-income adults could lose Medicaid coverage, prompting state officials to develop strategies to prevent increased uninsured emergency department utilization. The coverage losses stem from ongoing Medicaid redeterminations following the end of continuous enrollment protections. State officials are working to transition affected enrollees to alternative coverage options and prevent gaps in care. The unwinding creates operational challenges for Connecticut managed care organizations managing member retention and care continuity.