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Monday, June 1 · 18 stories
- Federal Policy
Democratic Senators Propose Medicare Home Care Benefit and Medicaid HCBS Expansion
A group of Democratic senators released a policy framework Wednesday to create a new Medicare home care benefit and expand Medicaid home- and community-based services. The proposal represents a significant shift in federal long-term care policy, potentially affecting how both Medicare and Medicaid fund home-based care. Details on implementation timelines, eligibility criteria, and financing mechanisms have not yet been specified. If enacted, the framework could reshape payment structures and access requirements for home health and HCBS providers serving dual-eligible and Medicaid-only populations.
- Federal Policy
Rep. Van Duyne Introduces Bill to Strengthen Medicare Home Health and Hospice Oversight
Rep. Beth Van Duyne (R-Texas) introduced the Protecting Seniors and Stopping Fraudsters Act on Wednesday to increase Medicare oversight of home health and hospice services. The bill aims to crack down on fraudulent providers and enhance beneficiary protections in these sectors. The National Alliance for Care at Home has expressed support for the legislation. While the bill targets Medicare, Medicaid managed care organizations that contract with home health and hospice providers should monitor this legislation, as federal fraud enforcement standards often inform state oversight approaches and MCO network adequacy requirements.
Saturday, May 30 · 2 stories
- State Policy
KFF Launches Medicaid Unwinding Tracker With State-Level Renewal and Disenrollment Data
The Kaiser Family Foundation has published a tracker providing state-by-state data on Medicaid renewals, disenrollments, and monthly enrollment during the unwinding period following the end of the COVID-19 public health emergency continuous coverage requirement. The tracker compiles the most recent available data from each state, allowing comparison of disenrollment rates and renewal outcomes across states. This tool enables managed care organizations to monitor enrollment trends in their service areas and assess the impact of unwinding on member populations. The data is updated as states report new figures.
- Federal Policy
Trump Executive Order Endorses HHS Reduction in Required Childhood Vaccinations
President Trump signed an executive order Friday endorsing HHS's decision to reduce required childhood vaccinations. The order cites religious liberty and parental rights as justification for adjusted immunization requirements. The policy change affects federally recommended vaccine schedules that states and health plans use for EPSDT and well-child care compliance. Medicaid managed care organizations must monitor whether state Medicaid agencies adjust their EPSDT screening requirements in response, which could impact quality metrics, HEDIS measures, and contractual performance standards tied to childhood immunization rates.
Friday, May 29 · 5 stories
- Managed Care
UnitedHealthcare Eliminates Two-Thirds of Pediatric Prior Authorization Requirements by Year-End
UnitedHealthcare announced it will remove prior authorization requirements for the majority of pediatric services for members under age 18 by the end of the year, eliminating two-thirds of current authorization requirements. The change affects commercial and Medicare Advantage plans with pediatric enrollment. The policy takes effect by December 31, 2024. This reflects growing pressure on health plans to reduce administrative burden and aligns with broader industry and regulatory momentum toward prior authorization reform, potentially setting a benchmark other Medicaid MCOs may need to match.
- State Policy
NASHP Hosts Webinar on State Prescription Drug Cost Data and Policy Strategies
The National Academy for State Health Policy will hold a webinar on June 25, 2026, from 1–2 p.m. ET focusing on how states use prescription drug cost data to inform policy decisions. The session will examine state-level approaches to managing pharmaceutical spending. For Medicaid managed care organizations, state prescription drug cost initiatives can lead to new reporting requirements, formulary restrictions, or supplemental rebate negotiations that affect pharmacy benefit management and claims administration.
- State Policy
NASHP Summarizes State Medicaid Reentry Initiatives from Two-Year Learning Network
The National Academy for State Health Policy published findings from a two-year collaborative examining how states expand Medicaid access for individuals reentering communities after incarceration. The report highlights state approaches to enrollment, care coordination, and coverage continuity during the transition from correctional facilities. States face operational challenges linking justice systems with Medicaid eligibility systems and coordinating behavioral health and substance use disorder services. The work is relevant for MCOs operating in states implementing reentry initiatives, which may require dedicated care management protocols and cross-agency data sharing.
- Federal Policy
MACPAC Seeks Contractor for T-MSIS Data Analysis Services
The Medicaid and CHIP Payment and Access Commission issued a request for proposals for an indefinite delivery indefinite quantity contract to provide computing and data analysis services using the Transformed Medicaid Statistical Information System and other datasets. The contract will support MACPAC's ongoing research and policy analysis work. Proposals are being solicited through SAM.gov. This procurement reflects MACPAC's continued reliance on T-MSIS data for assessing Medicaid program performance, payment policy, and beneficiary access — research that informs Congressional action and CMS guidance affecting managed care plans.
- State Policy · NC
North Carolina Prepares to Implement 2025 Reconciliation Law Medicaid Provisions Amid Budget Shortfalls
North Carolina is developing plans to implement Medicaid provisions from the 2025 reconciliation law while facing budget constraints. The state is preparing policy changes that will affect Medicaid coverage and beneficiary access to care. Implementation details are emerging as North Carolina managed care organizations and state officials work through operational and financial implications. The reconciliation law's Medicaid provisions, combined with state budget pressures, will require MCOs to adjust operations, network management, and benefit administration.
Thursday, May 28 · 36 stories
- Federal Policy
USCIS Tightens Adjustment of Status Rules for Green Card Applicants
On May 21, 2026, USCIS issued a policy memo restricting adjustment of status applications, requiring applicants to demonstrate extraordinary circumstances to obtain lawful permanent residence without consular processing. The memo recharacterizes adjustment of status as discretionary relief rather than a routine pathway. This change affects healthcare organizations that sponsor foreign-born clinical staff and may complicate workforce planning for Medicaid managed care plans that rely on immigrant physicians, nurses, and behavioral health providers in shortage areas. Plans should review existing sponsorship pipelines and anticipate longer credentialing timelines.
- Federal Policy
Child Medicaid and CHIP Enrollment Drops by 2 Million Since January 2025
Medicaid and CHIP enrollment among children declined by 2 million between January 2025 and April 2026, according to state-by-state enrollment data. The drop suggests a rising child uninsured rate during this period. The enrollment decline affects managed care organizations through reduced membership and capitation revenue, particularly in states with high CHIP and Medicaid managed care penetration. Plans should monitor monthly enrollment reports and assess financial impacts from membership losses in pediatric populations.
- State Policy · ID
Idaho Seeks Waiver to Move Medicaid Enrollees to ACA Marketplace Coverage
Idaho has submitted a waiver application requesting federal approval to transition certain Medicaid enrollees to ACA Marketplace plans while maintaining Medicaid-specific requirements, including work requirements. If approved, affected enrollees would face higher out-of-pocket costs and reduced benefit protections compared to traditional Medicaid coverage. The proposal would impact thousands of Idaho residents currently enrolled in Medicaid. Managed care organizations operating in Idaho should monitor this waiver for potential impacts on enrollment, member cost-sharing, and program design if the administration approves the state's request.
- Federal Policy
Trump Administration Pharmaceutical Pricing Agreements Face Implementation Questions
The Trump administration's most favored nation (MFN) pricing agreements with pharmaceutical manufacturers remain under scrutiny as implementation details emerge. These agreements aim to tie U.S. drug prices to lower international reference prices. Medicaid managed care organizations may see indirect effects through pharmacy benefit design and supplemental rebate negotiations, though the agreements primarily target Medicare Part B and Part D. The timing and scope of implementation remain uncertain, creating planning challenges for health plans managing pharmacy benefits across multiple programs.
- Federal Policy
CMS Proposes Payment Limits on State Directed Payments and Targeted Fee-for-Service Rates
CMS published a proposed rule on May 22, 2026, that would impose payment limits on additional state directed payments in Medicaid managed care and establish new limits for targeted fee-for-service payments. The rule draws authority from section 71116 of H.R. 1 (the "One Big Beautiful Bill Act") and presidential directives. State directed payments allow states to require managed care organizations to adopt specific provider payment arrangements, and new limits could constrain state flexibility in setting enhanced reimbursement rates for hospitals, nursing facilities, and other providers. The proposal would affect how states design rate strategies and could require MCOs to renegotiate provider contracts if existing SDP arrangements exceed new federal limits.
- Industry
CVS Restores Lilly Obesity Drug to Formularies After Prior Removal
CVS Health has returned Eli Lilly's obesity medication to its formularies after previously removing it. This formulary reinstatement affects Medicaid managed care organizations that contract with CVS Caremark for pharmacy benefit management services, potentially expanding access to GLP-1 medications for Medicaid enrollees. The decision reverses a prior coverage restriction and may influence pharmacy spending and prior authorization protocols. Managed care plans should review their pharmacy contracts and assess budget impact from potential increased utilization of high-cost obesity treatments.
- Federal Policy
CMS Proposes FY 2027 IPPS Payment Updates, Quality Measures, Joint Replacement Model Expansion
CMS released the FY 2027 Inpatient Prospective Payment System proposed rule updating Medicare hospital payment rates, uncompensated care payments, and graduate medical education residency program definitions. The rule expands the CJR-X joint replacement payment model and solicits comment on new quality measures. While IPPS primarily governs Medicare fee-for-service hospital payments, changes to quality measures and payment methodologies often influence Medicaid managed care quality programs and hospital contract negotiations. The comment period timeline was not specified in the excerpt.
- Industry
Health Care REITs Shift Investment Focus from Nursing Homes to Senior Housing Communities
Health care real estate investment trusts are increasingly pivoting away from nursing home investments toward senior housing communities offering independent living options. The shift reflects broader real estate market trends over the past two years, with potential implications for hospital system partnerships in the senior housing sector. The article outlines strategic considerations for hospital systems exploring senior housing collaborations. This trend may affect Medicaid managed care organizations with long-term services and supports responsibilities, particularly those managing dual-eligible populations transitioning between care settings.
- Legal
DOJ Launches AI-Driven False Claims Act Enforcement Initiative Targeting Health Care Fraud
The Department of Justice launched the Fraud Oversight through Careful Use of Statistics (FOCUS) initiative on April 7, 2026, deploying artificial intelligence and large-scale data analytics to identify and pursue False Claims Act violations in health care. The initiative marks a fundamental shift in federal enforcement methodology, using statistical modeling to flag potential fraud patterns across provider billing data. Medicaid managed care organizations should anticipate increased scrutiny of claims patterns, particularly in high-risk service categories, and may face FCA exposure for delegated utilization management and provider oversight functions. MCOs should review fraud detection protocols and ensure compliance with federal program integrity requirements.
- Industry
CMS Pauses Hospice, Home Health Medicare Enrollments in Fraud Crackdown
CMS has paused new Medicare enrollments for hospice and home health agencies as part of a fraud prevention initiative. The enrollment moratorium affects providers seeking to enter Medicare in these categories while CMS implements enhanced screening measures. The action reflects heightened federal scrutiny of post-acute care billing practices. Medicaid managed care plans with Medicare-Medicaid dual eligible members or LTSS carved-in arrangements may see network disruptions if moratorium extends or existing providers face termination.
- Federal Policy
OIG Clears Limited Free Orthodontic Services in Advisory Opinion 26-09
On May 1, 2026, OIG issued Advisory Opinion 26-09 addressing a pediatric dental and orthodontic provider's proposal to offer free orthodontic treatment to one patient annually at each of its three practice locations. The opinion provides guidance on how such charitable arrangements may comply with federal anti-kickback statute and beneficiary inducement provisions. For Medicaid managed care dental plans and MCOs with dental benefits, this opinion clarifies acceptable parameters for provider charitable care arrangements that could affect network adequacy and access strategies, particularly for orthodontic services where cost barriers are common.