This bill requires the establishment of standards for the settlement of health insurance claims in Alaska. In the absence of a contract between health care insurers and providers, the director will set regulations for allowable charges for health care services and supplies. These charges must be based on a statistically credible methodology using the most current data reflecting amounts charged by providers over a 12-month period, ensuring uniformity across the state. The allowable charge cannot be less than the 75th percentile of charges for similar services, with specific provisions for primary care providers, who will receive a minimum of 450 percent of the federal Medicare fee schedule.

This bill establishes minimum standards for health insurance provider networks in Alaska. It requires health care insurers to include all licensed hospitals, skilled nursing facilities, and mental health or substance abuse facilities, as well as all licensed physicians, physician assistants, and advanced practice registered nurses employed by these facilities, in their provider networks. Additionally, the bill mandates that insurers maintain a sufficient number of providers in each contracting region to meet specific percentage thresholds based on the total actively practising providers in various specialities.

This final rule establishes the reimbursement framework and participation requirements for Applied Behavior Analysis (ABA) therapy services under Arkansas Medicaid, effective January 1, 2025. Reimbursement uses a fee schedule methodology, aligning payments with the lower of the billed charge or the maximum allowable reimbursement. Amendments include updated credentialing standards for providers, enhanced documentation requirements for service delivery, and expanded prior authorization protocols to ensure medical necessity. These changes emphasize compliance and align treatment plans with measurable goals, improving accountability in provider reimbursement practices.

This proposed regulation outlines the process for Medicare crossover billing to ensure proper reimbursement for services under both Medicare and Medicaid. Additionally, providers must follow specific guidelines for billing Medicare and Medicaid, including the submission of detailed documentation and proper claim forms to ensure compliance and prompt processing.

This bill proposes amendments to the California Health Care Quality and Affordability Act by requiring the Office of Health Care Affordability to adjust healthcare cost targets when prescription drug costs are projected to increase faster than the established cost targets. It mandates the board to modify cost targets for providers or fully integrated delivery systems to reflect rising prescription drug expenditures. The bill also makes minor, technical changes to existing law related to the State Department of Public Health’s perinatal care system goals, which aim to reduce perinatal, maternal, and infant mortality and morbidity.

This bill outlines provisions for "street medicine" under the Medi-Cal program for individuals experiencing homelessness. It mandates that street medicine services coexist with other Medi-Cal provisions, such as community health worker services and enhanced care management. The bill requires the implementation of presumptive eligibility for full-scope Medi-Cal benefits for homeless individuals, allowing Medi-Cal providers to make eligibility determinations. It also requires Medi-Cal managed care plans to allow homeless beneficiaries to access services from any participating provider off-site, with related reimbursement requirements. The bill facilitates data-sharing between Medi-Cal and the California Statewide Automated Welfare System to identify homeless applicants and beneficiaries, ensuring better coordination. The bill also requires federal approval for these provisions and addresses new duties for counties related to eligibility determinations and data sharing, with reimbursement for costs mandated by the state.

This bill requires pharmacy benefit managers (PBMs) contracting with health care service plans or insurers in California to obtain a license from the Department of Managed Health Care beginning January 1, 2027, or when the licensing process is established, whichever is later. PBMs must submit an application and reimburse the department up to $25,000 for processing costs. Licensed PBMs must regularly submit confidential financial statements and drug pricing data to the Department of Health Care Access and Information (HCAI). The bill authorizes license suspension or revocation, with reinstatement possible through a petition and a fee of up to $500. It creates two state funds to hold PBM-related fees, fines, and penalties. Additionally, PBMs must report specified data to HCAI starting with contracts issued or renewed on or after January 1, 2026, and must pay biannual fees to support PBM oversight and HCAI’s Health Care Payments Data Program, which now includes PBMs on its advisory committee.

This bill expands the California Health and Human Services Agency’s (CHHSA) authority to form partnerships aimed at increasing competition, lowering prices, and addressing shortages for generic and brand-name drugs, vaccines, medical supplies, and devices. It updates Medi-Cal managed care plan requirements to cover COVID-19 screening, testing, immunizations, and therapeutics, while allowing cost sharing and utilization management for these services under Medi-Cal. The bill also revises prior authorization rules for drugs under Medi-Cal by allowing beneficiaries to continue receiving previously prescribed medications if prior authorization is approved, replacing the previous “continuing care” status. Additionally, it increases the minimum required state rebate from pharmaceutical manufacturers on Medi-Cal drugs to at least 25% of the average manufacturer price, strengthening cost controls.

This public notice from the Colorado Department of Health Care Policy and Financing announces several Medicaid reimbursement rate changes effective July 1, 2025. First, the Department will increase fee-for-service provider rates by 1.6% for a wide range of services, resulting in an estimated expenditure increase of over $152 million in FFY 2025 and $160 million in FFY 2026. Second, it will reduce the mileage reimbursement rate for non-emergency medical transportation from $6.10 to $3.00 per mile, decreasing expenditures by approximately $47 million in FFY 2025 and $49 million in FFY 2026. Third, it will rebalance Community First Choice (CFC) rates to align with the State Plan, leading to modest increases in expenditures. These changes are aligned with the 2025 Long Bill (SB25-206), and updated fee schedules will be posted online. Comments may be submitted to the Department, and copies of the proposed changes are available at various county human services offices.

This final rule establishes methodologies for calculating hospital and healthcare provider reimbursement rates under the Colorado Option standardized health benefit plans. It sets reimbursement floors tied to percentages of Medicare rates, ensuring hospitals receive at least 155% and providers at least 135% of aggregate Medicare rates. Adjustments for hospitals include increases for independent, essential access, and efficient hospitals, as well as those serving a high proportion of Medicare/Medicaid patients. The rule impacts Medicaid/Medicare reimbursement by standardizing rate floors to support premium reductions and access to care.

The Delaware Pre-Authorization Reform Act of 2025 establishes new requirements for pre-authorization procedures in both individual and group health insurance plans regulated under Chapters 33 and 35 of Title 18. The Act mandates that changes to utilization review terms, such as clinical criteria, apply only upon re-authorization and require at least six months’ advance notice to covered individuals, with limited exceptions. It sets qualifications for decision-makers, timelines for determinations and appeals, and standards for utilization review entities. The bill accelerates deadlines for notifying providers of pre-authorization decisions: within 5 business days for non-urgent requests submitted manually, 3 business days if submitted electronically, and within 24 hours for urgent requests submitted electronically. By January 1, 2027, all parties must process electronic requests via the same platform used to submit them. The Act extends pre-authorizations' validity from 60 to 90 days and ensures that only one authorization is needed per episode of care, including bundled services. It also applies the same reforms to group health insurance, requires compliance by state employee health plans and Medicaid carriers, and applies to insurance policies issued, modified, or renewed after December 31, 2026.

This bill amends Section 4 of the Medicaid Provider Fraud Prevention Amendments Act of 1984 to update language and establish a new special fund. It replaces references to the “Corporation Counsel” with the “Attorney General” and creates the Medicaid Provider Fraud Reimbursement Fund, administered by the Mayor. Funds recovered from Medicaid provider fraud or from payments that should have been covered by third-party insurers will be deposited into this Fund and used to reimburse the Medicaid program. Any remaining balance at the end of the fiscal year will be transferred to the District’s General Fund.

The Department of Health Care Finance (DHCF) has announced updates to the Medicaid fee schedule for CPT-HCPCS codes, effective July 1, 2025. These changes align with quarterly HCPCS code updates and Medicare fee schedule revisions for services such as physician care, lab tests, physician-administered drugs, and durable medical equipment. Most services will be reimbursed at 80% of the Medicare rate, except for physician-administered drugs, primary care, and select DME items. While DHCF cannot publish the full list of changes 30 days in advance due to timing constraints, a comprehensive update will be available on the DC Medicaid website and via transmittal by July 31, 2025.

The Department of Health Care Finance (DHCF) has announced updates to the Medicaid reimbursement rates for services under the Home and Community-Based Services Waiver for Persons who are Elderly and Individuals with Physical Disabilities (EPD), effective July 1, 2025. These adjustments align with annual increases under the Living Wage Act of 2006. Reimbursement rates will increase for seven EPD Waiver services: Personal Care Aide, Respite, Homemaker, Chore Aide, Assisted Living, Adult Day Health, and Case Management Services. Rates for Community Transition Services remain unchanged. The updated rates will be published on the DHCF website's Medicaid Fee Schedule for the EPD Waiver.

The Department of Health Care Finance (DHCF) has announced updates to the Medicaid reimbursement rates for Personal Care Aide (PCA) services provided by Home Health Agencies, effective July 1, 2025. These rate adjustments align with annual changes required by the District’s Living Wage Act of 2006.

This final rule implements amendments to increase Medicaid reimbursements for specific services. The rule provides annual lump-sum supplemental payments to home health agencies, supported employment provider agencies, and adult day health programs for services rendered from October 1, 2022, to March 31, 2025. These payments, set at 17.6% above the District's living wage, aim to ensure that funds are used to compensate direct care workers at this higher wage rate. Financially, the DHCF anticipates additional Medicaid expenditures of approximately $25.6 million for Fiscal Year 2024 and $32.8 million for Fiscal Year 2025. The supplemental payments are part of temporary measures to enhance support for direct care workers during the COVID-19 public health emergency, with the authority for the payments extending through May 11, 2024.

This proposed rule (59G-6.009) from the Florida Agency for Health Care Administration establishes the framework for implementing the Training, Education, and Clinicals in Health (TEACH) Funding Program, as authorized by section 409.91256, Florida Statutes. The rule applies to federally qualified health centers, rural health clinics, community mental health centers, and certified community behavioral health clinics that operate clinical training programs for health care students and residents. It outlines the application and agreement process for participation, sets reimbursement rates (up to \$75,000 annually or \$100,000 for accredited residency programs), and details eligible costs and required quarterly reporting on program metrics such as enrollment, demographics, and outcomes. Facilities must maintain accreditation, meet preceptorship standards, and comply with data reporting requirements to remain eligible. The TEACH Program is set to expire by July 1, 2034. A rule development workshop is scheduled for June 11, 2025.

This final rule significantly impacts the healthcare industry, especially medical, dental, and behavioral health services by setting reimbursement rates and eligibility criteria for Florida Medicaid.

This proposed rule amends Rule 59G-4.002, F.A.C., to update Florida Medicaid provider reimbursement schedules and billing codes. The revision impacts how Medicaid providers bill for services and receive reimbursement. A workshop will address potential regulatory effects under Florida law.

The rule applies to providers offering services to Florida Medicaid recipients. Florida Medicaid reimburses providers in the fee-for-service system based on a fee schedule, cost report, or contract. Fee schedules and billing codes are available on the Agency for Health Care Administration’s website.

This bill requires pharmacy benefits managers (PBMs) to reimburse pharmacies for prescription drugs at no less than the national average drug acquisition cost plus a professional dispensing fee, with annual adjustments based on inflation. It prohibits PBMs from offering lower reimbursements to nonaffiliated pharmacies compared to affiliated ones. The bill exempts certain state health plans and Medicaid services reimbursed directly by the Department of Community Health but applies to Medicaid care management programs. It also mandates that contracts with Medicaid care management organizations comply with these reimbursement requirements.

This bill authorizes the Georgia Department of Community Health to submit a Section 1115 waiver request to CMS, allowing for potential Medicaid program modifications. It also expands qualifying activities under the waiver, provides new definitions, and includes provisions for the implementation and repeal of conflicting laws. The bill establishes an effective date upon passage.

This bill directs the Department of Human Services (DHS) to adopt rules to expand Medicaid eligibility in Hawaii to all children from birth to age five, regardless of household income. It appropriates $317,000,000 for fiscal years 2025-2026 and 2026-2027 to support this expansion.