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Monday, June 8 · 18 stories
- Industry
20% of U.S. Adults Report Denial of Doctor-Recommended Care
A new Commonwealth Fund study found that one in five U.S. adults were denied doctor-recommended care, leading to deteriorating health outcomes and financial strain. The research highlights increasing patient frustration with claims review processes and prior authorization barriers. Insurers maintain their utilization management protocols are medically appropriate. The findings come as regulatory scrutiny of managed care denial practices intensifies at both federal and state levels.
- State Policy
Abortion Access Varies Widely Across States Four Years After Dobbs
Four years after the Supreme Court's Dobbs decision returned abortion regulation to individual states, access to abortion services varies dramatically across the country. States have implemented divergent policies ranging from near-total bans to expanded protections and coverage. The patchwork of state laws affects Medicaid coverage of abortion services, maternal health outcomes, and health plan network adequacy requirements. Managed care organizations operating in multiple states must navigate conflicting state regulations on covered services, provider networks, and member access.
- Federal Policy
CMS Issues Final Rule Tightening Medicaid Work Requirement Exemption Standards
CMS has finalized new regulations governing exemptions from Medicaid work requirements, a policy change that healthcare advocates say will increase administrative complexity for both enrollees and state programs. The rule affects how states must document and verify exemptions for populations unable to meet work or community engagement requirements. Critics warn the changes could lead to coverage losses among eligible beneficiaries due to procedural barriers, even as work requirements themselves face ongoing legal challenges. The timing and implementation timeline remain unclear from the available information.
Friday, June 5 · 9 stories
- State Policy
NASHP Hosts Webinar on State Nursing Home Quality Improvement Strategies
The National Academy for State Health Policy will host a webinar on June 9, 2026, from 3–4 p.m. ET focusing on state strategies to improve nursing home care quality. The session will examine state-level policy approaches and interventions aimed at enhancing care delivery in nursing facilities. For Medicaid managed care organizations with long-term services and supports responsibilities, the webinar may cover quality oversight mechanisms, rate-setting considerations, and regulatory approaches that could affect MCO contracts with nursing facilities.
- Federal Policy
Trump Administration Removes Civil Service Protections for Thousands of HHS Policy Staff
The Trump administration has reclassified thousands of HHS employees who shape policy to Schedule F status, stripping civil service protections and making them easier to terminate. The change affects staff across HHS agencies including CMS who develop regulations, guidance, and policy implementation. This action mirrors a similar executive order from Trump's first term that was rescinded by the Biden administration. The reclassification takes effect immediately and could lead to significant turnover among career staff who oversee Medicaid policy development and managed care oversight.
- Federal Policy
CDC Reports Over 2,000 Measles Cases in 2026, 93% Outbreak-Related
The CDC confirmed 2,030 measles cases in the U.S. as of June 4, 2026, with 1,890 cases (93%) linked to outbreaks. This total is rapidly approaching the full-year 2025 count. Measles is a highly contagious vaccine-preventable disease that poses particular risks to immunocompromised populations and young children. For Medicaid managed care plans, rising case counts may trigger increased EPSDT screening requirements, higher utilization of pediatric acute care and emergency services, and potential quality measure impacts related to childhood immunization rates.
- Federal Policy
FDA Launches Safety Review of Abortion Drug Mifepristone
The Food and Drug Administration has initiated a safety review of mifepristone, the abortion medication, according to an administration official. The retrospective analysis could lead to restrictions on the drug's use and distribution channels. Anti-abortion groups view this as a significant development that may result in tighter federal controls over medication abortion access. The timing and scope of the review have not been disclosed.
- Managed Care
CMS 72-Hour Prior Authorization Rule Exposes Payment Cycle Delays in Healthcare Billing
The CMS rule requiring 72-hour prior authorization decisions for urgent requests is creating operational friction by accelerating approvals without corresponding improvements in billing and payment cycles. Health plans and providers now face misaligned timelines where clinical decisions move faster than claims processing and reimbursement. The policy change, which took effect for most payers in 2024, highlights gaps in interoperability and revenue cycle infrastructure. Managed care organizations are experiencing the downstream effects as prior authorization reform outpaces backend payment modernization.
- Legal · OH
Ohio Suspends 49 Home Health Providers for Billing Irregularities
The Ohio Department of Medicaid suspended payments to 49 home health providers on Thursday following identification of suspicious billing patterns. The action aligns with broader federal enforcement efforts targeting Medicaid-funded home-based care. The suspensions appear connected to a gubernatorial executive order, though implementation details were not specified in the announcement. Managed care organizations contracting with affected providers should review care continuity protocols and confirm any required network substitutions.
- Federal Policy
GOP Budget Law Cuts Threaten Coverage for Nearly 2 Million Children
The 2025 GOP budget law includes significant cuts to healthcare programs that are expected to result in higher premiums and changes to Medicaid eligibility rules. An estimated 2 million children could lose health insurance coverage as a result of these cuts. The changes are creating uncertainty around Medicaid coverage determinations and affordability challenges for families. The law represents a major shift in federal healthcare policy affecting both Medicaid and marketplace coverage.
- Managed Care
OB Billing Codes Shift from Bundled to Unbundled in January
Beginning in January, physician billing codes for pregnancy care will transition from a bundled reimbursement model to fee-for-service billing for individual visits and services. Obstetricians say the new codes will more accurately capture variation in care delivery. However, the shift from global maternity packages to unbundled billing creates risk for overutilization and increased costs. Medicaid managed care organizations should review their maternity care contracts and utilization management protocols to address potential volume increases under the new coding structure.
- Industry · NC
Novant Health Reports 1,595 Bed Days Saved Through Hospital-at-Home Program
Novant Health's 19-hospital system launched a hospital-at-home program at Hanover Regional Medical Center in Wilmington, North Carolina, saving 1,595 inpatient bed days. The health system is advocating for expanded private payer coverage of the care model and seeking federal legislation to make hospital-at-home a permanent option beyond current emergency waivers. The program allows acute-care patients to receive hospital-level services in their homes, reducing facility capacity strain while maintaining care quality.
Thursday, June 4 · 12 stories
- Managed Care
H.R. 1 Medicaid Work Requirements, ACA Changes to Drive 14 Million Coverage Losses by 2036
The One Big Beautiful Bill Act (H.R. 1) and expiration of enhanced ACA premium tax credits will result in an estimated 14 million coverage losses over the next decade, according to CBO projections. Medicaid work reporting requirements and six-month redeterminations for expansion adults begin January 1, 2027, with retroactive coverage cuts and new cost-sharing starting October 2028. The law cuts $1 trillion in federal and state Medicaid spending over 10 years, 95% in expansion states, while creating a $50 billion Rural Health Transformation Program. Marketplace enrollment could drop 17-26% in 2026 with morbidity increasing up to 6.5%, as healthier members disenroll following ePTC expiration.
- Federal Policy
States Deploy Rural Health Transformation Funding for Maternity Care Deserts
States are using federal Rural Health Transformation Program (RHTP) grants to address maternal health access gaps in rural counties, with a mandatory October 30, 2026 deadline to obligate first-year awards. Initiatives include financial supports to sustain low-volume labor and delivery units, emergency OB equipment for rural hospitals, and workforce expansion through doulas, community health workers, and certified nurse midwives. Over 130 rural labor and delivery units have closed since 2020, leaving one in three U.S. counties without hospital-based obstetric care. States including Alabama, Alaska, New Mexico, California, and Iowa are prioritizing maternal health infrastructure, telehealth-enabled prenatal care, and incentive payments for rural providers serving high-need populations.
- Federal Policy
Senator Cassidy Blames HHS Secretary Kennedy for Rise in Vaccine-Preventable Diseases
Sen. Bill Cassidy (R-La.) publicly blamed HHS Secretary Robert F. Kennedy Jr. for a resurgence in vaccine-preventable diseases, citing a New York Times report that hospitals are seeing illnesses previously controlled by childhood immunizations. The statement comes as doctors report increased cases of diseases they rarely encountered in recent years. The criticism targets Kennedy's well-documented skepticism of vaccines and his influence over federal health policy. No immediate policy change or enforcement action has been announced.
- Federal Policy
HHS Secretary Kennedy Pursues Access to Patient Medical Records Through State Health Information Exchanges
HHS Secretary Robert F. Kennedy Jr. is working with state health information exchanges to access Americans' medical records as part of an initiative examining autism and vaccine data. In Nebraska, a state nonprofit health information organization receiving federal funding is cooperating with the project. The effort involves collecting and analyzing health data from multiple states through existing health information sharing infrastructure. The scope and timeline of data access remain unclear, as does whether patient consent protocols or HIPAA safeguards will apply to the federal review.
- Federal Policy
Trump Administration Moves to Eliminate Federal DEI Initiatives
The Trump administration has taken action to eliminate diversity, equity, and inclusion (DEI) initiatives across federal agencies. The brief examines the status of these actions and their potential impact on racial health disparities. For Medicaid managed care organizations, these changes may affect federal health equity requirements, data collection mandates, and program priorities that have shaped health plan operations and reporting obligations. The brief does not specify effective dates for all changes, though the administration's directives are already underway.
- Federal Policy
GAO Finds Seven Agencies Failed to Meet Payment Integrity Reporting Requirements for High Improper Payment Rates
The Government Accountability Office identified seven federal agencies with programs reporting improper payment rates of 10 percent or higher for 2-4 consecutive years from fiscal years 2021-2024, including HHS Medicaid programs. Five of seven agencies lacked documented policies to ensure timely reporting to Congress as required under the Payment Integrity Information Act of 2019. GAO found that OMB guidance does not direct noncompliant agencies to submit required annual reports, limiting congressional oversight. The report recommends agencies establish formal procedures to ensure compliance with PIIA reporting requirements for programs with persistent improper payment issues.
- Legal · HI
HHS OIG Defunds Hawaii Medicaid Fraud Control Unit After Four Years Without Indictments
The HHS Office of Inspector General will not recertify Hawaii's Medicaid Fraud Control Unit, cutting off $3 million in federal funding after the unit failed to produce any indictments or convictions over four years. Inspector General March Bell notified Hawaii Attorney General Anne Lopez of the decision in a letter. The decertification means Hawaii loses federal matching funds for its MFCU operations. This is the first known instance of OIG defunding a state MFCU for performance failure.
- Legal
Federal Trial Links Fake Nursing Diploma Mill to Patient Death in Florida Fraud Case
Federal prosecutors opened trial in Fort Lauderdale on June 1 for the final contested case from Operation Nightingale, a fraud scheme that sold approximately 15,000 fake nursing credentials over three years. For the first time, prosecutors are connecting the diploma mill scheme to a patient death. The trial represents the conclusion of a federal enforcement action that exposed thousands of individuals with fraudulent nursing degrees working in healthcare facilities nationwide.