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Friday, October 2 · 1 story
- Managed Care · NC
NC's Four Medicaid MCOs Launch Joint Fraud Task Force
North Carolina's four Medicaid managed care organizations, AmeriHealth Caritas, Healthy Blue, UnitedHealthcare and Carolina Complete Health, formed a joint task force in August through the North Carolina Association of Health Plans to combat fraud, waste and abuse. The task force unites each plan's special investigative units and government relations staff so investigators can share billing data and coordinate on providers that contract across multiple MCOs. The effort emerged from a meeting with State Auditor Dave Boliek amid heightened federal and state scrutiny of Medicaid spending, including recent fraud cases involving a substance abuse treatment center and a nursing home. Organizers say applied behavioral analysis therapy billing is a top area of concern given rapidly rising spending.
Tuesday, September 29 · 1 story
- Managed Care
Yale Researchers Propose 10 Policies to Cut Healthcare Spending
Yale University researchers published 10 policy proposals aimed at reducing U.S. healthcare spending, touching Medicare Advantage payment methodology, site-neutral payment policy, drug pricing, and nursing home care. Nine of the proposals come with combined annual savings estimates ranging from roughly $70 billion to $84 billion; the tenth is not quantified in the same way. The proposals target federal payers and providers broadly rather than Medicaid specifically, though several areas, drug costs and nursing home/LTSS spending, overlap with state Medicaid programs. No implementation timeline or legislative vehicle is specified; these are research recommendations, not enacted policy.
Monday, September 28 · 1 story
- Managed Care
Utilization Management Emerges as Key Challenge for Healthcare AI Adoption
Healthcare AI developers face significant technical and operational barriers in applying artificial intelligence to utilization management and prior authorization processes. The challenge lies in predicting reimbursement outcomes before denials occur, requiring AI systems to navigate complex medical necessity criteria, payer-specific coverage policies, and claims adjudication logic that varies across health plans and service categories. For Medicaid managed care organizations, this affects the feasibility of AI-driven automation in authorization workflows, claims processing, and appeals management. The difficulty stems from the need to replicate payer decision-making logic across thousands of procedure-diagnosis combinations and benefit design variations.
Wednesday, September 23 · 2 stories
- Managed Care
Commonwealth Fund Reviews State Options for Addressing Medicaid MCO Performance Issues
The Commonwealth Fund published guidance on how state Medicaid agencies can address underperforming managed care plans through contractual tools and staff oversight strategies. The analysis covers corrective action plans, financial penalties, contract suspension, and systematic performance monitoring approaches states can deploy when plans fail to meet quality, access, or administrative standards. The guidance emphasizes strategic prioritization of enforcement resources and graduated remedies. State Medicaid agencies managing MCO contracts gain a framework for structuring performance oversight and escalating interventions when plans fall short of contractual obligations.
- Managed Care
Nursing Home Bed Supply Declining as Baby Boomers Age Into Peak Need Years
Nursing home bed capacity is shrinking as the oldest baby boomers reach age 80, raising concerns about availability for long-term care services. Researchers warn that facility supply may not meet demand from an aging population entering the years when institutional care is most likely. The article does not specify implementation timelines or immediate policy changes. The capacity gap threatens access for Medicaid beneficiaries who rely on nursing facility services, potentially forcing states and managed care plans to accelerate community-based alternatives or face waitlists.
Tuesday, September 22 · 2 stories
- Managed Care
ACAP Launches Innovation Fund for Medicaid Health Plans
The Association for Community Affiliated Plans (ACAP) announced September 22, 2026, the launch of the ACAP Innovation Fund in partnership with Innovation Fund Management. The initiative is designed to drive innovation in Medicaid managed care, though specific investment focus areas, funding amounts, and eligibility criteria were not detailed in the announcement. The fund targets ACAP member plans, which are safety-net health plans serving Medicaid and other vulnerable populations. Details on application timelines and fund deployment are expected to follow.
- Managed Care
Safety Net Health Plans Achieve Record Performance in NCQA Quality Ratings
Safety Net Health Plans, members of the Association for Community Affiliated Plans (ACAP), achieved record performance in the National Committee for Quality Assurance's (NCQA) 2026 health plan ratings. The announcement, released September 21, 2026, indicates improved quality measures among plans serving predominantly Medicaid and dual-eligible populations. These ratings affect star ratings, quality bonus payments, and auto-enrollment assignments for Medicaid managed care plans. The results suggest safety net plans—which disproportionately serve low-income and complex populations—are closing quality gaps with commercial-focused plans.
Monday, September 21 · 1 story
- Managed Care
Reconciliation Law Creates Rate Setting Uncertainty, Raises MCO Exit Risk
The 2025 reconciliation law has introduced uncertainty in Medicaid managed care rate setting, affecting MCO contracting and operations. State Medicaid agencies face challenges developing actuarially sound capitation rates under new federal constraints, while managed care organizations reassess market participation. The rate-setting ambiguity stems from changes to federal matching requirements and allowable rate components. MCO exits could disrupt coverage continuity in states already operating narrow plan markets, particularly affecting beneficiaries in rural areas and those requiring specialized LTSS or behavioral health services.
Friday, September 18 · 3 stories
- Managed Care
Health Systems Report Claims Automation Gap with Payers Creating Revenue Cycle Pressure
Revenue cycle executives at 17 health systems report that payers are now reviewing and denying claims at volumes and speeds that providers cannot match, creating what they describe as an unsustainable financial asymmetry. The automation gap affects providers' ability to respond to denials and prior authorization requests in real time. The imbalance is intensifying as payers deploy AI and automation tools faster than health systems can adopt corresponding technology. For Medicaid managed care organizations and their provider networks, this dynamic accelerates existing tensions over claims processing, prior authorization burden, and network adequacy tied to provider financial stability.
- Managed Care
ECRI Finds 73% of Medication Reconciliation Errors Occur During Care Transitions
ECRI reported September 16 that 73% of medication reconciliation errors occur when patients move between care settings, based on analysis of 10,000 safety events. The findings highlight care transitions as a high-risk period for medication safety failures. The report emphasizes the need for improved handoff protocols and communication systems between settings. For Medicaid managed care plans, this underscores operational risk in care coordination programs, particularly for high-utilizing populations moving between hospital, SNF, home health, and outpatient settings.
- Managed Care · LA
Louisiana Proposes Higher Capitation Rates as Two MCOs Exit Medicaid Program
The Louisiana Department of Health has proposed new contract extensions with increased capitation rates for the four Medicaid managed care organizations remaining in the program after two plans exit by year-end. The departures will affect up to 580,000 enrollees who must be reassigned to the remaining plans. The proposed contracts were presented to state legislators on September 17, 2026. The rate increases reflect the state's need to retain existing plans and ensure adequate network capacity as the program consolidates from six to four MCOs.
Thursday, September 17 · 2 stories
- Managed Care
Eighteen Health Plans Score 5 Stars in NCQA 2026 Ratings, No For-Profits Included
Eighteen health plans achieved perfect 5-star ratings in NCQA's 2026 standards ratings, up from 11 in the previous cycle. None of the top-scoring plans are for-profit entities. The ratings measure plan performance across quality, access, and member experience metrics. The results highlight a continuing performance gap between nonprofit and for-profit health plans on nationally standardized quality measures.
- Managed Care
National Health Law Program Calls for State Enforcement of Behavioral Health Network Adequacy Standards
The National Health Law Program is urging states to strengthen enforcement of network adequacy requirements for behavioral health services in Medicaid managed care plans. The organization highlights gaps in provider networks that leave enrollees unable to access timely mental health and substance use disorder treatment. States have existing authority under federal Medicaid managed care regulations to monitor network adequacy through time and distance standards, appointment wait times, and secret shopper surveys. The recommendation comes as states face ongoing challenges ensuring adequate behavioral health provider networks in managed care arrangements.
Wednesday, September 16 · 4 stories
- Managed Care
New Guide Details Health Plan-Community Development Partnership Models
The Build Healthy Places Network and Association for Community Affiliated Plans released a guide for health plans and community development organizations on structuring partnerships and investments addressing social determinants of health, particularly housing. The guide provides frameworks for identifying partners, building trust, and aligning investments with community priorities. It arrives as federal housing policy creates new opportunities for cross-sector collaboration. The resource targets Medicaid health plans seeking to operationalize social determinants investments beyond traditional medical services.
- Managed Care
Psychedelic-Assisted Therapy Poses Coverage and Implementation Questions for Medicaid Programs
As psychedelic-assisted therapies move toward FDA approval and market entry, Medicaid programs face emerging policy and operational questions around coverage criteria, administration protocols, and workforce requirements. These therapies, being developed for treatment-resistant depression and PTSD, differ from traditional pharmaceuticals in requiring intensive clinical supervision and specialized settings. Medicaid leaders must consider prior authorization frameworks, benefit design, provider network adequacy, and reimbursement models as these treatments enter the behavioral health landscape. Early planning is necessary given Medicaid's role as the largest payer of behavioral health services and the complex operational requirements these therapies will demand.
- Managed Care
Webinar Announcement on Medicaid Substance Use Services and Justice System Integration
A webinar titled 'Medicaid Connections: Substance Use Health & Justice' has been announced, focusing on how 21st-century legislative and system changes have shifted substance use disorder treatment from punitive systems toward health-based responses through Medicaid. The webinar will examine the evolving role of Medicaid in providing substance use services and the ongoing inequities in access. An audio transcript is available for download.
- Managed Care
Network Health Launches Epic Prior Authorization API Ahead of 2027 CMS Deadline
Network Health has implemented Epic's prior authorization application programming interface (API) in advance of CMS's January 1, 2027 interoperability rule deadline. The rule requires insurers to deploy APIs for patient access, provider access, provider directory, payer-to-payer data exchange, and prior authorization. Network Health is among the early adopters working with Epic to meet these requirements before the mandate takes effect. The implementation aims to streamline prior authorization processes between the health plan and providers using Epic's electronic health record system.
Monday, September 14 · 1 story
- Managed Care
NASHP Releases Overview of State Medicaid Maternity Value-Based Payment Models
The National Academy for State Health Policy published an overview examining how states are implementing maternity-focused value-based payment models in their Medicaid programs. The report documents strategies states are using to link payment to quality metrics, care coordination, and improved perinatal outcomes. These payment reforms target maternal and infant health outcomes while aiming to control rising costs associated with pregnancy and childbirth care covered by Medicaid. The overview provides state Medicaid agencies and managed care organizations with comparative information on design approaches currently in use.
Wednesday, September 9 · 1 story
- Managed Care · CA
California Orders Health Net to Extend Assisted Living Benefits Through December After Termination Violations
California's Department of Health Care Services issued a corrective action plan requiring Health Net to extend assisted living and home care services for approximately 3,500 Medi-Cal members through December 31, 2026, after finding eight deficiencies in how the insurer handled benefit terminations. The state cited failures to submit transition plans, move members to appropriate care, and improper service denials that endangered vulnerable members. Health Net faces potential fines of $25,000 per member per day for non-compliance. The insurer, which operates Medi-Cal plans in 10 counties, still plans to end the optional CalAIM benefit in January 2027, leaving members at risk of nursing home placement or homelessness.
Tuesday, September 8 · 1 story
- Managed Care
GLP-1 Prescriptions for Children Rose 30,000 Percent Since 2019
Prescriptions of GLP-1 medications for children increased more than 30,000 percent between 2019 and present, according to new data. Children with obesity-related conditions such as high cholesterol or sleep apnea were substantially more likely to receive GLP-1 prescriptions than those without these comorbidities. The dramatic rise in pediatric GLP-1 use reflects growing clinical acceptance of these medications for weight management in children with obesity-related health complications. This trend has significant implications for Medicaid managed care pharmacy budgets and prior authorization protocols, as GLP-1s are high-cost specialty medications and children represent a growing share of Medicaid enrollment.
