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Tuesday, June 16 · 16 stories
- Federal Policy
CMS Proposes Rule to Codify Medicare Drug Price Negotiation Program
CMS has issued a proposed rule to codify the Medicare Drug Price Negotiation Program and establish new policies for both the Negotiation Program and the Medicare Prescription Drug Benefit Program as required by the Inflation Reduction Act of 2022. The rule also proposes modifications to the fixed combination drug policy. The Negotiation Program allows Medicare to negotiate prices for certain high-cost drugs, which could affect formulary dynamics and pricing strategies for Medicare Advantage plans that include prescription drug coverage. The proposed rule sets the framework for how negotiated prices will be implemented and administered.
- State Policy
State Reproductive Health Policies Create Unequal Access Across U.S., KFF Analysis Finds
A KFF analysis published in The Milbank Quarterly documents how state-level policy decisions create significant variation in reproductive healthcare access across the United States. The research examines state choices on contraception coverage, abortion restrictions, and maternal health programs that directly affect Medicaid beneficiaries. State policy differences impact managed care organizations' benefit design, network requirements, and care coordination obligations. The analysis highlights how states' Medicaid program structures and regulatory frameworks shape reproductive health service delivery and access for MCO enrollees.
- State Policy
States Propose Changes to Immigrant Health Coverage and Enforcement in 2025-2026 Sessions
Multiple states are introducing legislation affecting immigrants' access to state-funded health coverage and services during the 2025-2026 legislative sessions. The actions include both expansions and restrictions to coverage eligibility, with direct implications for Medicaid and CHIP programs that serve immigrant populations. Changes vary by state and may affect enrollment, eligibility verification processes, and state budget obligations. Medicaid managed care organizations should monitor state-level developments that could alter their member demographics, revenue streams, and compliance requirements for serving immigrant populations.
- Federal Policy
NHeLP Report Finds Electronic Asset Verification Creates Rural Medicaid Access Barriers
The National Health Law Program released a report examining how electronic asset verification systems in Medicaid create enrollment barriers for rural residents, particularly Black rural populations. The report identifies gaps in rural banking infrastructure and property transfer documentation that interfere with automated eligibility systems. The analysis focuses on how Medicaid agencies' reliance on electronic verification tools may disproportionately delay or deny coverage for applicants in areas with limited financial institution networks and informal property arrangements. The report provides recommendations for state Medicaid programs to address these verification challenges.
- Federal Policy
Medicare Coverage of Anti-Obesity Drugs Begins Next Month Under Temporary Program
Medicare will begin covering weight loss medications starting next month through a program designed as temporary but expected to face political pressure for permanence. The coverage represents a significant policy shift for Medicare, which has historically excluded anti-obesity drugs from its formulary. The program's implementation comes as GLP-1 medications like Wegovy and Zepbound have demonstrated clinical efficacy for weight management but carry substantial cost implications. While positioned as temporary, the coverage expansion may prove difficult to reverse once beneficiaries begin accessing these medications.
- Federal Policy
Senate Democrats Release Prescription Drug Pricing Policy Blueprint
Senate Democrats released a policy blueprint proposing measures to lower prescription drug costs ahead of the midterm elections. The proposals aim to address voter concerns about drug affordability and provide a counter-message to White House voluntary pricing initiatives. The blueprint reflects ongoing bipartisan interest in drug pricing reform but does not specify legislative text, implementation timelines, or comment periods. For Medicaid managed care organizations, potential reforms could affect pharmacy benefit management, capitation rate calculations, and prescription drug rebate programs.
- Legal · TN
Express Scripts, PCMA Sue Tennessee Over Law Requiring PBM-Pharmacy Separation
Express Scripts and the Pharmaceutical Care Management Association filed lawsuits challenging Tennessee's FAIR Rx Act, which mandates the separation of pharmacy benefit managers from retail pharmacies. The law, passed earlier this year over strong PBM industry opposition, aims to prevent vertical integration practices that critics argue drive up drug costs and limit pharmacy access. The litigation follows similar legal action by CVS Caremark. The outcome will affect how Medicaid managed care plans structure pharmacy benefits and contract with PBMs in Tennessee and potentially influence similar legislative efforts in other states.
- Managed Care
Rural Healthcare Access Requires Transportation Infrastructure Investment
Rural communities face significant healthcare access barriers due to transportation fragmentation. The article argues for reframing transportation as critical healthcare infrastructure rather than an ancillary support service, requiring standardization and investment comparable to other care delivery components. This shift would establish consistent quality standards, accountability measures, and integration with care coordination systems. For Medicaid managed care organizations serving rural populations, this perspective highlights the need to elevate non-emergency medical transportation from administrative function to strategic infrastructure investment.
- Federal Policy
MACPAC June 2026 Report Addresses Prior Authorization Automation and Managed Care Accountability
The Medicaid and CHIP Payment and Access Commission (MACPAC) released its June 2026 Report to Congress with recommendations on six policy areas affecting Medicaid managed care operations. The report addresses automation in prior authorization processes, managed care accountability measures, and access to residential treatment services, among other topics. The recommendations also cover community engagement requirements, services for youth with special health care needs, and the Program of All-Inclusive Care for the Elderly (PACE). These recommendations typically inform congressional legislation and CMS policy development over the following 12-24 months.
- Federal Policy · CO
FDA Approves Colorado Drug Importation Plan from Canada
The FDA approved Colorado's Section 804 importation program, allowing the state to import certain prescription drugs from Canada to reduce costs for residents. This marks the first operational approval under the 2020 FDA guidance that permits states to seek authorization for Canadian drug importation. The approval comes after years of state planning and federal review. Colorado must now finalize vendor contracts and operational logistics before importing drugs, with implementation timeline still uncertain.
- Federal Policy
HHS Secretary Kennedy Demands Explanation for Retracted Vaccine-SIDS Study
HHS Secretary Robert F. Kennedy Jr. sent a June 11 letter to the editor-in-chief of Toxicology Reports demanding justification for the removal of a 2021 study linking vaccines to sudden infant death syndrome. Kennedy has cited this research in support of proposed changes to childhood immunization schedules. The retraction raises questions about the scientific basis for potential federal policy shifts affecting Medicaid-covered pediatric vaccine programs. No timeline has been announced for HHS policy changes to childhood vaccination requirements.
- Industry
Centene Announces Voluntary Separation Program for Most Employees
Centene Corporation confirmed it is offering a voluntary separation program to most employees as part of a broader repositioning effort. The managed care giant stated the program aims to deliver a simpler experience for members and partners while adapting to current healthcare market conditions. The announcement affects Centene's workforce across its health plan operations, though specific numbers of affected employees and program details were not disclosed. The timing follows industrywide pressure on managed care margins and administrative cost reduction initiatives.
- Legal
Federal Judge Vacates Most of 2025 ACA Enrollment and Eligibility Rule
A federal judge on Friday vacated the majority of CMS's 2025 ACA enrollment and eligibility rule, delivering a win for insurance advocates who challenged the regulation. The vacated provisions included controversial changes to enrollment processes and eligibility verification requirements. However, many of the rule's provisions have been incorporated into the GOP's reconciliation bill currently moving through Congress, limiting the practical impact of the court decision. The ruling does not affect state-based marketplaces or Medicaid operations directly.
- Industry
Elevance Health Focuses AI Strategy on Member, Provider, and Employee Experience
Elevance Health has outlined three strategic priorities for artificial intelligence deployment: simplifying member interactions, improving provider workflows, and enabling employees to access timely information. The health plan is integrating AI tools across its operations to enhance user experience and operational efficiency. These initiatives reflect broader industry investment in technology to manage administrative burden and member engagement. The timeline and specific implementation details were not disclosed.
- State Policy · MO
Missouri Eliminates Medicaid Coverage for Chiropractic Services Due to Budget Cuts
Missouri has eliminated Medicaid coverage for chiropractic services following state budget cuts, reversing a 2018 legislative expansion that added chiropractors as covered providers. The change affects access to non-opioid pain management services for Medicaid enrollees. The elimination comes despite earlier projections that chiropractic coverage would reduce overall Medicaid costs. The policy change takes effect immediately as part of broader Medicaid budget reductions.
- State Policy · WA
Washington Sued Over Medicaid Assisted Living Funding Cuts
Washington state faces litigation over budget cuts that reduced tens of millions in state funding for assisted living facilities serving Medicaid patients. Democratic lawmakers made the cuts to address a budget shortfall this year. The lawsuit challenges the state's decision to reduce payments to these facilities. The cuts affect assisted living providers that rely on Medicaid reimbursement for long-term care services.
Monday, June 15 · 10 stories
- Industry
KFF Health News Journalists Discuss ICE Detention Medical Care, RFK Jr. Comments
KFF Health News journalists appeared on national and local media outlets to discuss recent stories on medical neglect in ICE detention facilities and comments by Robert F. Kennedy Jr. regarding antidepressants. The media appearances covered investigative reporting on healthcare conditions in immigration detention and public health policy commentary. These discussions occurred as part of KFF Health News's ongoing coverage of healthcare access and policy issues. The appearances reflect broader public interest in healthcare delivery in detention settings and federal health policy discourse.
- Federal Policy
Medicaid State Directed Payment Spending Analyzed Before Federal Caps Take Effect
A new issue brief examines state spending on Medicaid state directed payments (SDPs) requiring prior CMS approval, providing baseline data ahead of new federal limits. The reconciliation law imposes caps on SDP spending that will take effect in the coming fiscal year, fundamentally altering how states can direct managed care payments to providers. The analysis covers SDP utilization patterns across states and payment types, including directed payment arrangements for hospitals, nursing facilities, and other providers. This data establishes the spending landscape before federal restrictions reshape state flexibility in directing managed care plan payments.
- State Policy
State Medicaid Fraud Crackdowns Reduce Provider Access for Disability Services
States are implementing stricter fraud enforcement measures in Medicaid programs serving people with disabilities, following federal directives. The increased scrutiny has led to provider exits from Medicaid networks, creating access challenges for beneficiaries requiring home and community-based services and other disability supports. States are balancing program integrity goals against network adequacy concerns as providers cite compliance burdens and payment delays. The enforcement trend affects multiple states and continues to evolve as federal Medicaid policy emphasizes fraud prevention.
- Industry
Drug Shortage Confusion Leads to Preventable Congenital Syphilis Case in Arizona
A newborn in Arizona was diagnosed with congenital syphilis after the mother could not access penicillin through Pfizer's emergency allocation program during a national drug shortage. The case illustrates how supply chain disruptions and access barriers to penicillin — the only FDA-approved treatment for syphilis in pregnancy — are contributing to rising congenital syphilis rates. The CDC reported over 3,700 congenital syphilis cases in 2022, up from 335 in 2012. Medicaid covers approximately 42% of all births nationally and a disproportionate share of pregnancies affected by syphilis, making prenatal screening and treatment access critical managed care quality measures.