Weekly Roundup -
June 3, 2026
Smart. Strategic. Essential.
Unmatched Healthcare Insights from 量子资源网,
Leavitt Partners & Wakely.
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Webinar Replay – Summer Webinar Series: The Future of Medicaid State Directed Payments听
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Treatment-Resistant Depression: Costs, Caregiving, and Gaps in Care
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Medicaid State Directed Payments: CMS Proposes Major Changes to Financing and Oversight
The Centers for Medicare & Medicaid Services (CMS) proposed changes to state directed payments mark a significant inflection point for Medicaid financing. For states, plans, and providers, the coming months will be critical in understanding the rule鈥檚 final shape鈥攁nd how they can position themselves for a more constrained and standardized payment environment.
Federal Medicaid policy is entering a period of rapid change. Policymakers are advancing a series of interconnected proposals鈥攊ncluding Medicaid community engagement (work) requirements, program integrity initiatives, and new scrutiny of financing mechanisms that shape how dollars flow through the program.听
Among the most significant developments:听the听CMS鈥檚听proposed changes to Medicaid state听directed payments (SDPs). As outlined in听量子资源网鈥檚 recent听Issue听Brief, the proposal signals a meaningful shift in how federal policymakers approach provider reimbursement, managed care financing, and oversight of supplemental payment arrangements.听
量子资源网 (量子资源网)听will听further听examine these developments in听future articles, briefs, and听its Medicaid summer听webinar听series, which will focus on听SDPs, work requirements, and program integrity鈥攖hree policy areas now moving in parallel and reshaping the Medicaid landscape.听This article听provides an executive overview of the听SDP rule.听
What听are Medicaid State听Directed Payments?听
State听directed payments (SDPs)听are a key Medicaid financing tool that allows states to direct how managed care organizations reimburse providers.听
States use SDPs to:听
- Increase provider payment levels听
- Target specific provider types or services听
- Support delivery system reforms听
Over time, SDPs have become听a central component听of Medicaid managed care financing. As the听量子资源网 issue brief听emphasizes, their growing scale and complexity have drawn increased federal scrutiny.听
What听Does听CMS Propose听to Change?听
The听CMS proposed听rule听implements the statutory changes approved in听the 2025 budget reconciliation act (P.L.听119-21,听which CMS refers to听as the Working听Families听Tax Cut听Act,听or听WFTCA). The rule听introduces a new framework for how SDPs are structured, regulated, and reviewed. Based on 量子资源网鈥檚 analysis, the proposal听advances听several core policy shifts:听
- Expanded听Federal Limits on Payment Levels.听CMS proposes new constraints on how much states can direct plans to pay providers, extending payment limits across a broader range of services and delivery systems. Specifically, CMS proposes to lower the payment ceiling for all SDPs to either 100 percent of Medicare for states administering Affordable Care Act (ACA) expansion programs or 110 percent of Medicare for states without an ACA expansion program. CMS plans to grandfather certain SDPs at levels above Medicare and provide a transition period with an annual 10 percent reduction until the payments are reduced to Medicare levels. In addition, this rule proposes limiting SDPs to the total published Medicare payment rate at the service level鈥攁 departure even from Medicaid fee-for-service (FFS) upper payment limits, which are limited to a reasonable estimate of what Medicare would pay but are calculated at the aggregate level by ownership class.听
- Extends Limits听Across Programs听and Delivery Systems.听The proposal听seeks听to align听the limitations on practitioner payments under听fee-for-service听with the new limitations on SDPs. If a state makes payments to a subset of targeted practitioners, the new proposed limit would be actual Medicare payment rates applicable to the practitioner or provider for the same听time period听as the Medicaid state plan rate year.听The crosswalk of Medicaid payment rates to Medicare will听likely be听administratively burdensome鈥攅specially for states that set Medicaid rates using an entirely different听methodology听than Medicare鈥檚. Applying the Medicare payment limit at the service level will limit states鈥� ability to incentivize certain service types that may need enhanced reimbursement amounts to preserve access to care (e.g., primary care, neonatal, etc.).听
- Broader Applicability Across Providers.听The changes extend beyond a narrow set of provider types, affecting a wider range of stakeholders听participating听in Medicaid financing and delivery.听For example, the WFTCA听called for the reduced payment ceiling to be applied to the specified four classes of providers. This rule proposes that all providers be limited to the same ceiling and that the revised limits also apply to US territories.听
Why Is CMS Focusing on State听Directed Payments Now?听
As highlighted in the 量子资源网听Issue听Brief, federal policymakers are increasingly focused on the growth and complexity of SDPs听as well as the role of SDPs in broader Medicaid financing strategies.听In addition,听CMS policy officials are听prioritizing program integrity and fraud, waste,听and abuse and have couched the current SDP policies听as inefficient use of taxpayer dollars.听
These priorities align with a broader shift toward tighter federal oversight of Medicaid funding mechanisms.听
What Are the Implications for States, Plans, and Providers?听
The proposed changes have wide-ranging implications across the Medicaid ecosystem.听
States:听SDPs have been a flexible tool for shaping payment policy and directing resources. New federal parameters may limit听that flexibility听and require states to reassess existing financing strategies.听
Health Plans:听Plans may face a more standardized and regulated environment for implementing SDP arrangements, with less variation driven by state policy choices.听
Providers:听Many providers rely on SDPs to supplement base Medicaid payment rates. Changes to these payments could affect reimbursement levels and financial stability, particularly for organizations serving large Medicaid populations.听
As the听量子资源网 brief听underscores, the impact will vary significantly by state, depending on how SDPs are currently structured.听
How This Fits into Broader Medicaid Policy Changes听
CMS is advancing a听broader recalibration of how SDPs fit within Medicaid policy.听However, the SDP proposal is听also听part of a larger set of federal Medicaid policy developments, including:听
- Medicaid community engagement (work) requirements听and other changes to eligibility and redetermination rules听included in听a June 1, 2026,听interim final rule听
- Program integrity and oversight initiatives听
- Changes to financing structures and supplemental payments听
Taken together, these policies signal a transition toward听greater federal standardization听and increased oversight of funding flows.听
What Should Stakeholders Watch Next?听
CMS鈥檚 proposed changes to Medicaid state听directed payments mark a turning point in Medicaid financing policy.听
Stakeholders should expect continued movement toward greater oversight, tighter payment parameters, and increased consistency across the program. They听should begin planning now for a more constrained and standardized payment environment.听Key questions听center on:听
- How CMS will implement and phase in payment limits across states听
- The extent to which existing arrangements will be grandfathered听in听or phased down听
- How states respond in redesigning Medicaid payment strategies听
The proposed SDP rule is open for public comment听through听July听21,听2026, with final policy decisions expected following federal review. As听pending听issues are resolved, stakeholders across the Medicaid landscape will need to reassess financial models, policy approaches, and operational strategies.听
Stakeholders should begin evaluating potential impacts now, as the policy direction is clear,听even if final details are still evolving.听
Staying Ahead of Medicaid Financing Changes听
Given the pace and breadth of these developments, staying informed is critical. 量子资源网鈥檚听upcoming听Medicaid听summer webinar series听will provide听timely听analysis of the听SDP proposal alongside related policy changes, including community engagement and work requirements and program integrity听initiatives.听These sessions are designed to help states, plans, and providers understand policy changes and prepare for operational and financial implications,听identify听compliance gaps, and address sustainability issues.听Register for one听or multiple webinars here.听听
To听understand听how听these Medicaid听policy changes affect your organization,听contact听one of听量子资源网鈥檚听Medicaid experts.听
Health-Related Social Needs in Medicaid: Opportunities Remain Despite Policy Shifts
This鈥痑rticle听was鈥痑dapted based on a blog听written鈥痓y Laura Pence and Sara Singleton鈥痮n behalf of鈥疦ASDOH,鈥痑n alliance managed by Leavitt Partners. NASDOH is鈥痑 multi-sector coalition of stakeholders鈥痵eeking鈥痶o make a material improvement in the health of individuals and communities by advancing the adoption of effective policies and programs to address upstream drivers of health, such as food insecurity, housing instability, interpersonal safety, and transportation insecurity.鈥痀ou can find the full blog post听 and learn more about the鈥痑lliance鈥痑t .鈥�
Medicaid programs are the primary provider of healthcare benefits to tens of millions of Americans with limited incomes and resources, many of whom鈥痬ay鈥痚xperience food and nutrition insecurity and other鈥痟ealth-related social needs (HRSNs), which have a significant impact on healthcare spending and health outcomes.鈥疉lthough鈥痬ore鈥痗ould鈥痓e done, there has been bipartisan recognition鈥痠n recent鈥痽ears that improving health outcomes and lowering healthcare costs鈥攊ncluding in the Medicaid population鈥攔equires addressing鈥痶he underlying causes of poor health outcomes.鈥�听
As a result鈥痮f鈥痮ngoing鈥痜ederal and state鈥痚fforts鈥痑s well as鈥痯rivate sector innovations, a鈥痝rowing body of evidence shows that interventions addressing nutrition, housing, and other social drivers measurably improve health outcomes and reduce costly healthcare utilization.
Medicaid Policy Context: Authorities Supporting Health-Related Social Needs听
In 2021, the first Trump Administration鈥痳eleased a鈥�鈥痶o鈥痵tate鈥痟ealth鈥痮fficials outlining the key authorities and consolidating state guidance around how these authorities may be used to address social needs, including:
- in lieu of services鈥�(ILOS);鈥��听
- Medicaid managed care rule provisions鈥痶hat鈥痚ncourage or require Medicaid managed care organizations (MCOs) to address social needs;鈥��听
- Section 1915 Home-鈥痑nd Community-Based Services (HCBS) waivers, which鈥痬ay鈥痓e used to address non-medical needs of individuals to鈥痜acilitate鈥痶heir opportunity to live and work in the community if they would otherwise need institutional care;鈥��听
- 1915(i) state plan amendments that can be used to鈥痯rovide HCBS to鈥痯eople鈥痺ho meet state-defined needs-based criteria that are less stringent than institutional criteria;鈥痑nd鈥��听
- Section 1115 Demonstration waivers,鈥痺hich provide states flexibility to address or incorporate social needs interventions into their Medicaid programs.鈥�听
The Biden Administration鈥痚xpanded on this by issuing guidance on how states could use鈥�1115听demonstrations 鈥� commonly called 1115 waivers 鈥撎齮o听address HRSNs in Medicaid.鈥疢ore than 20鈥痵tates have ongoing鈥�鈥痶hat include efforts to address HRSNs鈥痵uch as鈥痟ousing, nutrition, and employment鈥痵upports.鈥疉lthough the鈥�1115 waiver鈥痝uidance鈥痠ssued during the Biden Administration have now been rescinded, 1 several underutilized opportunities to address HRSNs still exist within the Medicaid program.
Key Medicaid Opportunities to Address Health-Related Social Needs听
Although鈥�1115 waivers have become a prominent mechanism among states to advance efforts to screen for and address HRSNs, states and other听stakeholders鈥痵hould鈥痗onsider鈥痯reviously underutilized authorities,鈥痠ncluding鈥痠n lieu of services (ILOS),鈥痵tate plan amendments,鈥痑nd managed care contracts.鈥�听
碍贵贵鈥檚鈥�Survey鈥痮f Medicaid听officials鈥痠ndicate听that states are already using these tools to:听
- Screen enrollees for behavioral health and social needs听
- Provide referrals to social services听
- Partner with community-based organizations听
- Require providers to capture听SDOH听
States are also increasingly using听听to address specific needs such as nutrition, while continuing to rely on state plan amendments to expand coverage pathways for preventive services, case management, rehabilitative services, and听HCBS.听
As states negotiate with CMS over expiring 1115 waivers,听it will be critical to consider听how these听听can support continuation of interventions with听demonstrated听impact, including:听听
- The听CMS Accountable Health Communities (AHC)鈥痬odel found that connecting Medicaid beneficiaries with unmet social needs to community resources led to a 3鈥痯ercent鈥痳eduction in鈥痟ospitalizations, a 3鈥痯ercent鈥痳eduction in avoidable emergency department visits, and overall cost savings of more than $200 million.鈥�听
- 鈥�鈥痮n medically tailored meals, which several states cover through Medicaid authorities including ILOS, estimates that these interventions can avert millions of hospitalizations nationally and generate net healthcare savings, while improving management of chronic conditions such as diabetes and heart disease.鈥�听
- States听can consider听proposing new HRSN interventions within 1115 waivers.鈥疭ection 1115 waivers are鈥痠ntended to support 鈥�,鈥濃�痗reating鈥痑n opportunity for proposing innovative interventions rather than carrying out鈥痯rograms that have already developed an evidence鈥痓ase.鈥疐or interventions that already have an evidence base, funding them through the other mechanisms described鈥痺ill鈥痚nsure continued authority to provide them.鈥�听
Medicaid Innovation and Value-Based Models Continue to Support HRSN Strategies听
Beyond the听Medicaid-specific authorities and flexibility, the CMS Innovation Center鈥痗ontinues to听advance听models听that听integrate听HRSNs听into听value-based care that improves health outcomes.鈥疊uilding on听efforts such as the听AHC鈥疢odel听and the听Medicare Advantage听Value-Based Insurance Design听(VBID)鈥痬odel,鈥痶he Innovation Center has developed听numerous听frameworks鈥痶hat address HRSNs and SDOH. Upcoming models 鈥� including听,鈥�,鈥痑苍诲鈥�鈥�� provide听opportunities to address HRSNs.鈥�听
The Innovation Center鈥痗ontinues to provide鈥痮pportunities鈥痜or听research听and鈥痚vidence鈥痝athering on screening for and addressing HRSNs as a part of value-based care. Participation in voluntary models that involve screening for and addressing HRSNs听provides an opportunity for stakeholders听to receive reimbursement for these activities while generating data and resources to support other entities.鈥疭tates, providers, and community-based organizations can听participate听in鈥疘nnovation Center鈥痬odels to advance efforts鈥痶hat鈥痑ddress SDOH.鈥�听
Rural Health Transformation Fund鈥�听
The Rural Health Transformation Fund also鈥痚ncourages鈥痵tates and stakeholders to address SDOH.鈥疶he鈥�鈥痠nstructions from CMS require states to describe SDOH in rural鈥痗ommunities, including income levels, employment sectors, unemployment rates, education attainment, and availability of public transportation.鈥�听
In response, many states鈥痠ncluded proposals for addressing HRSNs in rural communities.鈥疐or example,鈥疉laska鈥檚鈥�鈥痳ecognized a need for 鈥渘utrition programs addressing food insecurity and teaching healthy eating habits鈥� and proposed to use funding to support community wellness centers to create dedicated spaces for physical activity and nutrition education.鈥疐urther,鈥疓eorgia鈥�鈥痠ncreasing access to nutrition services for children with autism spectrum disorder and dietitian/nutritionist support for women aged鈥�19鈥�44 who meet certain clinical requirements.鈥�听
The Rural Health Transformation Fund鈥�(RHTF)鈥痑llows鈥痵tates to pilot innovative interventions鈥痑nd鈥痑ddress HRSNs that could鈥痩ater鈥痓e included in the state鈥檚 Medicaid program.鈥��听
Why Addressing Health-Related Social Needs Matters for Medicaid Outcomes听
Opportunities to address听HRSN and SDOH听in Medicaid, CMMI鈥痙emonstrations, and the Rural Health Transformation Fund听remain significant, even as federal policy evolves.听States and stakeholders have a听variety of authorities and programs听they can consider听to address听SDOH.鈥疘n addition, CMS should develop more guidance on activities that align with the agency鈥檚 goals,鈥痑s well as examples for states to adopt.鈥疉ppropriately addressing individual social鈥痙rivers鈥痮f health will require collaborative and innovative approaches across the private and public sectors.鈥�听
You can read the听original听 and听learn more about the鈥痑lliance鈥痑t听.鈥�听
Federal Policy News
Fueled By Weekly Health Intelligence
CMS Details State Requirements for Medicaid Community Engagement Compliance
On June 1, CMS released the 鈥�鈥� Interim Final Rule with Comment (IFC) (CMS-2454).听
鈥疷nder the FY 2025 budget reconciliation law (), individuals covered under the Medicaid expansion are subject to 鈥渃ommunity engagement鈥� requirements with statutory exceptions for individuals who are pregnant, postpartum, disabled, medically frail, American Indian or Alaska Native, parents or caregivers of young children and people with disabilities, and those who are already complying with similar requirements through the Supplemental Nutrition Assistance Program (SNAP) or the Temporary Assistance for Needy Families (TANF) program.听
In the IFC, CMS defined medically frail as 鈥渁n individual whose physical, mental, or other behavioral health condition significantly impairs the individual鈥檚 ability to comply with the community engagement requirement in this subpart and who is blind or disabled; with an SUD; with a disabling mental disorder; with a physical, intellectual, or developmental disability that significantly impairs their ability to perform one or more ADLs; or with a serious or complex medical condition. Individuals only need to fit within one of these categories to qualify for the medically frail exclusion to the community engagement requirement.鈥�听
鈥疌MS does not provide States with the option to add additional categories of people to the definition of medical frailty for community engagement purposes, out of concern 鈥渢hat there may be more of an incentive for some States to include individuals who would not reasonably be considered medically frail.鈥�听
鈥疕owever, the rule will permit states to accept 鈥渁 statement or other information under penalty of perjury that provides sufficient information, as determined by the State, to verify an applicant or beneficiary is medically frail or otherwise has special medical needs, each time the State verifies an individual鈥檚 medical frailty鈥� through January 1, 2028, 鈥渨hen there is no reliable information available to the State or the reliable information is not reasonably compatible with the information provided by or on behalf of the individual.鈥� As such, for 2027, states may accept self-declarations from individuals that they meet the exemption for medical frailty.鈥�听
鈥疊eginning on January 1, 2028, States 鈥渕ay only use a statement or other information provided under penalty of perjury one time during an individual鈥檚 period of enrollment, to verify eligibility as a specified excluded individual on the basis of medical frailty or having other special medical needs.鈥�听
鈥疌MS will require states to provide individuals for which they cannot verify compliance 鈥渁t least鈥澨�30 days听to show the state that they meet the听requirement听or that they are exempt, with CMS allowing states to provide more time.听
鈥疉dditionally, in the rule, CMS specifies the process for a State to request a temporary good faith effort exemption from compliance with timely implementation of the community engagement requirements, and the criteria by which it will evaluate such requests. CMS states that it will issue a template for states to use in听submitting听their requests.听
鈥疭tates must implement the requirements by January 1, 2027, and comments are due by July 31, 2026.听
OMB Proposes Major Changes to Federal Grantmaking Rules
On May 29, OMB issued a proposed rule titled, 鈥�,鈥� to make changes to the federal grantmaking process in line with previous Executive Orders (EOs) intended to ensure federal funding is used to align with the Administration鈥檚 priorities and activities and programs currently authorized by law.听The proposed rule would introduce several provisions of recent EOs into federal regulation, such as requiring agencies to designate one or more senior appointees to conduct a pre-issuance review of all discretionary awards, require that discretionary awards must, where applicable, demonstrably advance the President’s policy priorities, and that 鈥渁ll else being equal, preference for discretionary awards should be given to institutions with lower indirect cost rates.鈥� Additionally, the rule includes proposals to:听
- Establish OMB鈥檚 authority to require agencies to听submit听reports detailing the specific recipients or types of recipients that received federal awards from the agency over a specific听time period. OMB noted that this is to 鈥減rovide OMB with oversight tools to ensure funding is not inappropriately concentrated among a narrow set of recipients.鈥�听
- Allow agencies to 鈥渃onsider an applicant’s history of questionable practices based on publicly available and verifiable information鈥� and 鈥渁ffiliations with organizations engaged in activities that violate Federal law, undermine public safety or national security, or advocate for the overthrow of the United States Government鈥� in awarding grants.听听
- Require that all discretionary federal funding opportunities (not just those that will be openly competed) be posted on听Grants.gov, except when publicly announcing an opportunity would pose a national security risk, and to require the use of Statements of Interest as a part of NOFOs 鈥渨hen high application volume or lengthy proposals are expected.鈥�听
- Require that federal agencies or pass-through entities 鈥渕ust ensure that the Federal award is not used to fund, promote, encourage, subsidize, or facilitate鈥� DEI, gender ideology, or gender transition as those terms have been defined in recent EOs.听
- In the proposed rule, OMB also proposes that these OMB policies be considered a regulation rather than guidance.听听
Stakeholders should consider the impacts the proposed regulation could have on current funding, as well as how to respond to future NOFOs. The comment period is open until July听13听but stakeholders may consider sharing with members of Congress potential impacts of the proposed rule should it be听finalized, including for their communities and districts.
White House Issues Executive Order on Childhood Vaccine Recommendations
On May 29, the White House issued听an听听titled, 鈥淩ealigning United States Core Childhood Vaccine Recommendations with Best Practices from Peer, Developer Countries.鈥� The EO directs the CDC and Advisory Committee on Immunization Practices (ACIP) to review the 鈥�,鈥� a report developed under direction of a December 2025听 and released by the HHS earlier this year. The report, authored by Dr. Tracy Beth H酶eg, acting director for FDA鈥檚 Center for Drug Evaluation and Research, and Dr. Martin Kulldorff, Chief Science and Data Officer for ASPE, in consultation with experts at key agencies, stated, 鈥淭he U.S. is a global outlier among peer nations in the number of target diseases included in its childhood vaccination schedule and in the total number of recommended vaccine doses.鈥� It recommended several changes to the schedule, which were subsequently听听by then-acting CDC Director Jim O鈥橬eill in a听听from the heads of NIH, FDA, and CDC. This included shifting vaccines for RSV, hepatitis A, hepatitis B, and meningococcal disease from a recommendation for all children, to vaccines recommended for those at听high risk. Additionally, under the revised schedule, vaccines for rotavirus, COVID-19, influenza, meningococcal disease, hepatitis A, and hepatitis B were moved to a recommendation based on 鈥渟hared clinical decision-making.鈥澨�听
鈥疕owever, in March, the revised schedule was听听by a federal district court judge, following a motion led by several public health groups, who argued that the changes to the childhood immunization schedule violate the Administrative Procedure Act, as acting CDC Director O鈥橬eill issued the January 2026 Decision Memo without sufficiently consulting ACIP.听
鈥疶he EO revisits the Trump Administration鈥檚 effort to revise the childhood vaccine schedule by directing the CDC and ACIP to review the report and 鈥渢he latest clinical data鈥� and 鈥渢ake any appropriate steps to update the U.S. childhood and adolescent vaccine schedule,鈥� while considering ways recommendations can provide 鈥渕aximum flexibility to parents and doctors for timing and sequencing of the administration of routine immunizations.鈥�听
鈥疐urther, the EO directs all executive departments and agencies to ensure that 鈥渁ll actions, regulations, funding, and coverage related to child and adolescent immunizations align with the schedule recommended by the ACIP and adopted by the CDC,鈥� while explicitly stating that 鈥渁ll the immunizations that are in any category on the schedule recommended by the ACIP and adopted by the CDC should continue to be covered without cost sharing by private insurance and covered by Medicaid, the Children鈥檚 Health Insurance Program, and the Vaccines for Children Program.鈥�听
FDA Issues Draft Guidance on Streamlined Safety Testing for Oncology Biologics
On May 29, FDA released听听titled, 鈥淥ncology Pharmaceuticals: Streamlined Nonclinical Safety Studies for Biologics and Conjugated Products,鈥� advancing听its听听to reduce animal testing and increase efficiency in drug development. In line with these goals, FDA is providing guidance on recommendations for general toxicology studies used for certain oncology drugs in development. The draft guidance reflects FDA analyses of historical toxicology data, as well as lessons learned from modified testing approaches used during the COVID-19 pandemic. It outlines recommendations in which traditional toxicology requirements for oncology drugs may be reduced or refined, such as using a single animal species or听leveraging听alternative, evidence-based approaches. These approaches may be supplemented with听听(NAMs), which offer non-animal, innovative testing strategies to assess the safety and effectiveness of FDA-regulated products. The agency is seeking听听ahead of finalization, with comments due by July 30, 2026.
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State Policy News
New York Medicaid Budget Grows to $40 Billion as State Extends Managed Care Tax
The New York Department of Health鈥檚 Medicaid budget grew to听$40 billion听in the听听approved by lawmakers. The fiscal 2027 spending plan also includes听$1.5 billion听in new Medicaid funding for healthcare facilities, including $706 million for hospitals, $480 million for nursing homes, $80 million for federally qualified health centers, and $20 million for assisted living centers. The budget makes the state鈥檚 tax on Medicaid managed care organizations permanent beginning January 1, 2027, with a uniform tax of 0.35 percent of total premium revenue, pending federal approval. However, the budget does not include specific relief for the听roughly 450,000听New Yorkers expected to lose Essential Plan coverage at the start of July.听
Ohio Medicaid Announces Behavioral Health Prior Authorization Standards
The Ohio Department of Medicaid鈥痑nnounced鈥痮n May 28, 2026, that it will require managed care plans to apply new statewide听听for community behavioral health, mental health, and substance use disorder services as part of a broader program integrity initiative. The new framework will require plans to use standardized authorization forms, apply prior authorization only when services exceed defined thresholds, and improve monitoring of unusual听utilization听patterns. The initiative is intended to support clinical care coordination, reduce duplicative or inappropriate services, improve documentation of medical necessity, and expand value-based payment partnerships with behavioral health providers.听
Oregon Secures Federal Approval for Rural Maternity Care Payments
Oregon Health Authority鈥�鈥痮n May 28, 2026, that the Centers for Medicare & Medicaid Services (CMS) approved its state directed payment proposal to support rural maternity care services, unlocking a total investment of up to $37.5 million for 21 rural hospitals across 17 counties. The payments build on a one-time $25 million state investment authorized in 2025 and are intended to help hospitals hire or retain maternity care staff, purchase clinical equipment, and expand outreach, navigation, or perinatal supports for Oregon Health Plan members. Rural hospitals that currently offer maternity services will receive payments automatically, with Oregon Health Authority coordinating the payment schedule with coordinated care organizations and hospitals.
Pennsylvania Releases MLTSS Reprocurement RFI
The Pennsylvania Department of Human Services鈥�released鈥痮n June 1, 2026, the听. CHC is the state鈥檚 mandatory Medicaid managed long-term services and听supports program听for dually eligible individuals and individuals with physical disabilities. The听previous听procurement and awards were canceled by the Commonwealth Court of Pennsylvania in April 2026 following protests from managed care organizations (MCOs). The state is seeking feedback on the number of MCOs in the program, regional versus statewide breakdown, length of term, strategies to further align Medicare and Medicaid coordination, artificial intelligence, and any other program recommendations. The current incumbents are AmeriHealth Caritas, Centene, and UPMC.听
Washington Releases Preliminary Medically Frail Billing Codes for Public Comment
The Washington Health Care Authority鈥�鈥痮n May 29, 2026, that it is seeking public feedback on a set of medical billing codes and conditions to identify Medicaid enrollees that would be exempt from the Medicaid work requirements approved under the 2025 budget reconciliation act (P.L 119-21, OBBBA) due to medical frailty. Comments are due by June 19, 2026.听
Private Market News
Fueled By
Hospitals Sue CVS for Allegedly Siphoning $250M In 340B Funds
The May 28 edition of the听听included an article addressing听lawsuits filed by hospitals听owned by Mount Sinai, University of Michigan Health, and the University of Kansas accusing CVS and its pharmacy subsidiaries of manipulating reimbursement rates for 340B drugs and keeping the difference as profit. The hospitals claim CVS听identified听claims as 340B-eligible only after insurers had already paid full rates, then reduced hospital reimbursement through affiliated PBM and pharmacy operations. The lawsuits add to broader scrutiny of PBMs and ongoing debates over transparency and reform in the drug pricing system.
艑耻谤补 Files for IPO Amid Healthcare Push
The听听featured coverage of听potential new applications for听艑耻谤补鈥檚听wearables听which听already track health metrics such as temperature, heart rate, and sleep. The听company is pushing further into health monitoring听and听working with the听US Food and Drug Administration (FDA)听on a study for a feature that could help听identify听early signs of hypertension. The IPO filing also comes as the company scales quickly: in October,听艑耻谤补听said it had sold more than 5.5 million devices and expected 2025 revenue to exceed听$1 billion.
Nevada to Hold Public Meeting on 鈥楶ublic Option鈥� 1332 Waiver Progress
The Nevada Health Authority (NVHA)听announced听on May 27, 2026, that it will hold a public meeting听regarding听the听听(BBSPs) and Market Stabilization Program Section 1332 State Innovation Waiver on June 15, 2026. BBSPs are qualified health plans designed to reduce premium costs by at least 15 percent compared to reference benchmark plans over a four-year period. The Market Stabilization Program includes a state reinsurance program, targeted premium relief for some Marketplace enrollees, a quality incentive payment program, and the Practice in Nevada provider retention program. The meeting will give NVHA a platform to discuss the progress of the waiver and collect public听comment.
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Fueled By Experts Across Our 量子资源网 Companies
量子资源网
Proposed Changes to Medicaid State Directed Payments and Targeted Practitioner Payments
On May 20, 2026, the Centers for Medicare & Medicaid Services (CMS) released the Medicaid Managed Care State Directed Payments and Medicaid Fee-For-Service Targeted Medicaid Practitioner Payments Proposed Rule.听The proposed changes to Medicaid听state directed听payments are听highly complex. The 量子资源网 consulting team is actively analyzing the regulatory text and stands ready to听assist听organizations with impact evaluations, policy interpretation, and strategic response planning.听To help healthcare organizations, state agencies, and health plans navigate these complex regulatory shifts,听量子资源网听experts have developed a comprehensive compliance and impact overview.
Treatment-Resistant Depression: Costs, Caregiving, and Gaps in Care
量子资源网鈥檚 report examines the clinical, economic, and caregiving burden of treatment-resistant depression (TRD), a condition affecting听nearly one听in three individuals with major depressive disorder. Drawing on a comprehensive literature review and analysis of Medicare data, the report highlights the substantial costs associated with TRD, including higher rates of hospitalization, increased healthcare听utilization, and approximately $8,000 in听additional听annual spending per Medicare beneficiary compared to individuals with well-controlled depression.听听
The findings also underscore the broader economic impact, with prior research estimating that TRD accounts for tens of billions of dollars annually in national costs. In addition, the report details the significant demands placed on families and caregivers, who often provide more than 23 hours of care per week and face considerable financial and emotional strain.听
A Summer Webinar Series (June 10): The Future of Medicaid State Directed Payments
As federal regulators听seek to reshape the Medicaid landscape, states, providers, and insurers across the country are facing intense pressure to adapt to changing eligibility and enrollment rules and financing policies while sustaining access to services and improving outcomes. This webinar series will deliver timely analysis and actionable insights on the evolving policy and operational environment affecting Medicaid funding, enrollment, and access to services.
A Summer Webinar Series (July 15): Understanding Work and Community Engagement Requirements
This听webinar听series will deliver听timely听analysis and actionable insights on the evolving policy and operational environment affecting Medicaid funding, enrollment, and access to services. Each session will feature up-to-the-moment information and perspectives from our subject matter experts, with content tailored to reflect the latest federal guidance, waiver activity, litigation, state implementation decisions, and market developments.
A Summer Webinar Series (August 12): How New Program Integrity Expectations Affect Medicaid Payments
This听webinar听series will deliver听timely听analysis and actionable insights on the evolving policy and operational environment affecting Medicaid funding, enrollment, and access to services. Each session will feature up-to-the-moment information and perspectives from our subject matter experts, with content tailored to reflect the latest federal guidance, waiver activity, litigation, state implementation decisions, and market developments.
Ground Ambulance Payment Landscape: Challenges and Policy Options
Ground ambulance transport is a critical piece of the US healthcare infrastructure and is currently facing several challenges, threatening patient access to care. Often, at critical and tense moments before the patient reaches hospital care, ground ambulance paramedics and emergency medical technicians (EMTs) are the first point of healthcare contact for the patient. To address the challenges that the ground ambulance industry is experiencing today and lessen the impact of the various emerging issues, this report offers several recommendations for policymakers and stakeholders to consider.
Leavitt Partners
Opportunities to Address Health-Related Social Needs in Medicaid Remain Possible and鈥疨revalent鈥�
Medicaid programs are the primary provider of healthcare benefits to tens of millions of Americans with limited incomes and resources, many of whom鈥痬ay鈥痚xperience food and nutrition insecurity and other鈥痟ealth-related social needs (HRSNs), which have a significant impact on healthcare spending and health outcomes.鈥疉lthough鈥痬ore鈥痗ould鈥痓e done, there has been bipartisan recognition鈥痠n recent鈥痽ears that improving health outcomes and lowering healthcare costs鈥攊ncluding in the Medicaid population鈥攔equires addressing鈥痶he underlying causes of poor health outcomes.鈥�This鈥痓log post听explores听丑辞飞鈥痮迟丑er Medicaid authorities听鈥�听beyond Section 1115 demonstrations 鈥撎�can听be used鈥痶o continue work that has鈥�an appropriate evidence鈥痓ase for lowering costs and improving health outcomes.鈥�听
Vital Viewpoints Podcast
The Coverage Gap Grows: ACA Changes Reverberate Across Healthcare
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RFP Calendar
RFP Calendar
| Date | State/Program | Event | Beneficiaries |
|---|---|---|---|
| Date: February 2026 - DELAYED | State/Program: Illinois | Event: Awards | Beneficiaries: 2,400,000 |
| Date: June 24, 2026 | State/Program: Wisconsin LTC GSR 3 | Event: Awards | Beneficiaries: 56,000 (all GSR) |
| Date: Summer 2026 | State/Program: Illinois Foster Care | Event: RFP Release | Beneficiaries: 33,000 |
| Date: July 1, 2026 | State/Program: Hawaii Community Care Services | Event: Implementation | Beneficiaries: 5,500 |
| Date: July 28, 2026 | State/Program: Nevada Children's Specialty | Event: Awards | Beneficiaries: NA |
| Date: August 2026 | State/Program: Indiana | Event: RFP Release | Beneficiaries: 1,400,000 |
| Date: January 1, 2027 | State/Program: Illinois | Event: Implementation | Beneficiaries: 2,400,000 |
| Date: January 1, 2027 | State/Program: Nevada CO D-SNP | Event: Implementation | Beneficiaries: 88,000 |
| Date: January 1, 2027 | State/Program: Wisconsin LTC GSR 3 | Event: Implementation | Beneficiaries: 56,000 (all GSR) |
| Date: January 1, 2027 | State/Program: Illinois Tailored Care Management Program | Event: Implementation | Beneficiaries: 22,400 |
| Date: July 1, 2027 | State/Program: Nevada Children's Specialty | Event: Implementation | Beneficiaries: NA |
| Date: January 1, 2028 | State/Program: Wisconsin LTC GSR 4,6 | Event: Implementation | Beneficiaries: 56,000 (all GSR) |
| Date: Fall 2027 | State/Program: Oregon | Event: RFP Release | Beneficiaries: 1,200,000 |
| Date: 2028 | State/Program: North Carolina | Event: RFP Release | Beneficiaries: 2,200,000 |
| Date: 2029 | State/Program: California | Event: RFP Release | Beneficiaries: NA |