All stories
Jump to date
Thursday, June 11 · 10 stories
- Federal Policy
Federal Court Deadline Looms on Mailed Abortion Medication Access
A federal court deadline on Monday could make mailing abortion pills illegal nationwide. The ruling would affect telemedicine providers who prescribe mifepristone and misoprostol to patients across state lines, including for medication abortion and miscarriage management. Providers currently rely on FDA guidance allowing direct-to-patient mailing of abortion medications approved during the COVID-19 public health emergency and maintained afterward. If the deadline results in restrictions, it could eliminate a key access pathway for medication abortion in states where in-person abortion services are limited or banned.
- Federal Policy
SAMHSA Opens $40 Million in Grants for Addiction Prevention and Behavioral Health Workforce
SAMHSA announced eight grant programs totaling $40 million to fund addiction prevention, behavioral health workforce development, child trauma services, and suicide prevention efforts. The funding opportunities are now open for application by eligible providers and organizations. Awards will support expanding access to behavioral health services and building provider capacity in underserved areas. For Medicaid managed care organizations, these grants may strengthen network adequacy by increasing the supply of behavioral health providers and services in their markets.
- Federal Policy
CMS Establishes Office of Health Technology and Products to Oversee Technology Modernization
CMS has created the Office of Health Technology and Products (OHTP) to lead enterprise-wide healthcare technology modernization and digital transformation across Medicare, Medicaid, CHIP, and other CMS programs. The office will oversee digital products and platforms in coordination with the CMS Chief Information Officer, who retains governance authority over IT infrastructure, cybersecurity, and enterprise architecture. The organizational change takes effect immediately through this statement of delegations. The new structure may affect how states and managed care organizations interact with CMS technology systems and digital service delivery initiatives.
- State Policy
Child Medicaid and CHIP Enrollment Down 2 Million Since January 2025
Child enrollment in Medicaid and CHIP has declined by more than 2 million since January 2025, according to Georgetown University's Center for Children and Families. The declines vary significantly by state and affect children in working families who often lack access to affordable employer-sponsored coverage. The enrollment losses represent a continuation of coverage instability following the end of the Medicaid continuous enrollment provision. These drops matter because many affected children become uninsured rather than transitioning to other coverage.
- Federal Policy
Six States Report Higher-Than-Expected ACA Marketplace Attrition After Enhanced Subsidies Expired
State-level enrollment data through April 2026 from Arkansas, Colorado, Maryland, Massachusetts, New Mexico, and New York show significant coverage losses as enrollees canceled plans or stopped paying premiums following the expiration of enhanced ACA subsidies. Georgetown University analysis indicates attrition rates exceed initial federal projections. Congress did not renew the enhanced subsidies that had been in place, resulting in higher premium costs for marketplace enrollees. The coverage losses could affect Medicaid managed care organizations in states with integrated or coordinated care models between marketplace and Medicaid coverage.
- Managed Care · CA
CalOptima Health Allocates $430M for Hospital and Specialist Rate Increases Through 2027
CalOptima Health's board approved $429.6 million from reserves to increase hospital and specialist rates over the next 30 months, bringing total provider rate increases to nearly $1 billion since 2024. The Orange County Medi-Cal plan is using reserve funds to address provider payment adequacy. The rate increases will be implemented through 2027. This reflects ongoing pressure on Medicaid managed care organizations to maintain network adequacy and provider participation amid rising costs.
- State Policy · PA
Pennsylvania Lawmakers Push PBM Oversight After 1,000+ Pharmacy Closures Since 2020
Pennsylvania has lost over 1,000 pharmacies since 2020, prompting state lawmakers to pursue legislative action targeting pharmacy benefit managers. A Pennsylvania Department of Human Services official expressed skepticism about a legislative proposal to hire a PBM to oversee other PBMs. The legislative effort aims to address pharmacy closures attributed to PBM practices, though specific proposals and timelines are not detailed in the available information.
- State Policy · RI
Rhode Island Faces Decision on Medicaid Coverage for GLP-1 Weight Loss Drugs
Rhode Island is considering whether to maintain Medicaid coverage for GLP-1 medications used to treat obesity, amid national debate over cost and access. The state has historically prioritized public health initiatives addressing health disparities and nutrition. The decision affects coverage policy for medications like Wegovy and Zepbound for Medicaid beneficiaries with obesity. Rhode Island's choice will impact managed care organizations' pharmacy benefits and utilization management protocols for this high-cost drug class.
Wednesday, June 10 · 14 stories
- Federal Policy
GAO Identifies 38 Priority Recommendations for HHS, Including Medicare and Medicaid Program Integrity
The Government Accountability Office has identified 38 priority recommendations for the Department of Health and Human Services as of May 2026, with seven new recommendations added in the past year. HHS has implemented four recommendations since May 2025. GAO is prioritizing two areas: strengthening Medicare and Medicaid program integrity and oversight, and improving public health program oversight and coordination. The recommendations aim to increase efficiency, reduce fraud and waste, and improve federal health care program operations. GAO sends these priority letters to agencies whose implementation could save significant federal funds or address high-risk issues.
- Industry
Average Drug Shortage Duration Reaches 5.3 Years in 2025
A new analysis shows the average drug shortage in 2025 has lasted 5.3 years, up from 4.3 years in 2024. The extended duration reflects chronic supply chain instability affecting generic medications, many of which are used extensively in Medicaid populations. The analysis highlights growing challenges in maintaining formulary stability and managing therapeutic alternatives. For Medicaid managed care plans, prolonged shortages complicate prior authorization processes, increase member access issues, and drive utilization of more expensive therapeutic substitutes.
- Legal
USCIS Restricts Green Card Adjustments to Extraordinary Relief Cases
On May 21, 2026, USCIS issued a policy memo limiting green card issuance through adjustment of status to applicants demonstrating extraordinary circumstances. The memo recharacterizes adjustment of status as a discretionary measure rather than an expected benefit. This policy change affects the immigration pathways available to foreign-born healthcare workers, including those employed by Medicaid managed care organizations and provider networks. The restriction takes effect immediately and may impact MCO workforce planning and recruitment strategies for clinical and administrative staff.
- Federal Policy
ACOG Issues Maternal Vaccine Schedule Diverging from CDC Guidance
The American College of Obstetricians & Gynecologists released a recommended maternal vaccine schedule that differs from CDC guidance for the first time. ACOG recommends four vaccines during pregnancy: influenza, COVID-19, Tdap, and RSV. The new schedule affects prenatal care protocols and provider counseling for pregnant Medicaid beneficiaries. This divergence creates potential confusion for managed care organizations that must decide whether to align coverage policies and quality metrics with CDC or ACOG recommendations for their maternal health programs.
- Industry
Health Systems Expand In-House Specialty Pharmacy Operations Amid 340B Restrictions
Health systems are increasingly establishing their own specialty pharmacy operations in response to tightening reimbursement and manufacturer restrictions on 340B contract pharmacy arrangements. Hospitals and health systems now represent the fastest-growing segment of direct participants in the specialty pharmacy market. The shift is driven by both revenue generation goals and manufacturers' evolving 340B policies that limit contract pharmacy access. This infrastructure buildout allows health systems to capture specialty drug dispensing margins and maintain access to 340B savings despite manufacturer restrictions.
- State Policy
Planned Parenthood Closes 60 Clinics Amid State Funding Restrictions
Nearly 60 Planned Parenthood clinics have closed or consolidated since last year due to state-level funding restrictions, according to a KFF report. The closures affect access to family planning, STI testing, and preventive care services in affected communities. The timing and specific states are not detailed in the brief article, but the trend reflects ongoing state policy actions targeting reproductive health funding. For Medicaid managed care organizations, these closures may disrupt member access to covered family planning services and require network adequacy adjustments in affected service areas.
- State Policy · MN
Minnesota Issues Provisional Licenses to 433 Autism Service Providers Under New Oversight Law
Minnesota's Department of Human Services received provisional license applications from 433 of 481 autism service provider sites under a new state law requiring licensure for Medicaid-funded autism services. The licensing requirement was enacted to increase oversight following explosive program growth and fraud allegations in recent years. The high application rate suggests most providers are seeking to remain in the Medicaid program under the new regulatory framework. This represents a significant expansion of state oversight over previously less-regulated autism service delivery.
- State Policy · MO
Missouri Drops 333,000 Medicaid Enrollees in 14 Months, 92% Due to Paperwork Issues
Missouri terminated Medicaid coverage for 333,265 beneficiaries between January 2025 and February 2026, with 91.9% disenrolled for procedural reasons rather than ineligibility determinations, according to CMS data. The state's high procedural termination rate indicates systemic renewal and redetermination processing problems. This disenrollment pattern affects managed care organizations through membership loss, revenue reduction, and potential contractual quality metric penalties tied to continuity of coverage. MCOs operating in Missouri face continued enrollment volatility as the state processes redeterminations.
- State Policy · OH
Ohio Withdraws Proposal to Ban Family Caregivers Under Medicaid
Ohio lawmakers removed language from House Bill 795 that would have prohibited family members living with Medicaid recipients from serving as certified caregivers. The provision was withdrawn Monday following significant public opposition. The proposal targeted Ohio's Medicaid home healthcare program, which allows beneficiaries to hire family members as paid caregivers. The reversal preserves existing caregiver arrangements for Medicaid managed care plans operating in Ohio's home and community-based services programs.
- State Policy · CA
California Union Sponsors Ballot Measures to Cap Healthcare Executive Pay, Regulate Clinics
A major California healthcare union has introduced two ballot initiatives targeting community clinics and capping executive and managerial compensation at hospitals and physician groups. The measures have triggered widespread opposition from healthcare industry stakeholders. The initiatives emerge amid anticipated Medicaid budget reductions in California, intensifying long-standing labor-industry tensions. If approved by voters, the measures would impose operational and financial restrictions on healthcare entities that contract with Medicaid managed care organizations.
- Federal Policy
CMS Issues First Major EPSDT Guidance Update in a Decade
CMS released updated guidance on the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit in 2024, marking the first comprehensive policy update in approximately ten years. The guidance, issued through a state health official letter, provides states with revised operational and coverage requirements for Medicaid's mandatory pediatric benefit. This updated playbook affects how states structure EPSDT services, including screening schedules, diagnostic services, and treatment coverage for Medicaid-enrolled children. The guidance clarifies federal expectations for state compliance and likely impacts how managed care organizations implement and document EPSDT services in their contracts.
- Federal Policy
Federal Actions Prompt Debate Over Methadone and Buprenorphine Access
Recent federal actions and proposals have sparked renewed debate over the use of methadone and buprenorphine for opioid use disorder treatment. Addiction medicine experts and patient advocacy organizations have expressed concern about potential restrictions on medication-assisted treatment (MAT). The developments come as Medicaid managed care organizations cover the majority of MAT services nationally, with medication costs and behavioral health integration representing significant budget and network adequacy considerations. Any federal policy changes affecting MAT access would directly impact MCO formularies, prior authorization protocols, and substance use disorder program design.