FULL SUMMARY

The bill makes Alabama’s “hospital provider privilege tax” regime for privately operated hospitals permanent for the state fiscal years 2026, 2027, and 2028 by continuing and extending the existing hospital assessment and Medicaid financing/payment structure in the Code of Alabama. It does so by revising multiple sections governing the assessment base (net patient revenue), creation and use of the Hospital Assessment Account, hospital payment methodologies (inpatient and outpatient base and access payments), conditions for assessment/tax takeoff and refunds, and the treatment of federal participation.

Key changes include: (1) the assessment imposed on each privately operated hospital remains 6.00% of net patient revenue for state fiscal years 2026–2028, using Medicare cost report data for fiscal year ending 2023/2024/2025 as applicable (with annual review/update) and a mechanism for the Medicaid Agency to report adverse Medicaid reimbursement impacts that would prompt proposed legislative changes; (2) refinements to net patient revenue determination logistics, including use of CMS Healthcare Cost Report Information System data and a requirement that hospitals submit a copy to the department if CMS data is not available, or if a hospital commenced operations after the applicable Medicare cost-report due date; and (3) continuing the “Hospital Assessment Account” structure within the Health Care Trust Fund, specifying allowable sources and uses of funds, separation from the State General Fund, restrictions against supplanting Medicaid general revenues, exemptions from certain budget cuts, and limits on carrying over balances through fiscal year 2028, after which remaining funds are refunded proportionally if there is no new assessment beginning October 1, 2028.

For Medicaid hospital payments, the bill preserves/continues the payment framework for fiscal years 2026–2028: the agency must pay inpatient and outpatient “base” amounts calculated from per diem (or a specified 2019 inpatient payments-to-patient-days methodology) and outpatient fee schedules (with potential updates subject to Hospital Services and Reimbursement Panel approval). It also keeps “access payments” tied to the upper payment limit (UPL) structure: all eligible hospitals receive access payments so that total payments (including base payments) aggregate to the UPL for each category (public/state-owned vs. privately operated) until the Hospital Assessment Account is exhausted; inpatient and outpatient access payments are required on a quarterly basis; and hospital access payments cannot be used to offset other Medicaid hospital payments. The bill also maintains provisions that: assessment take effect/continuation can cease with triggers such as reduced hospital reimbursement performance, CMS-approved rate changes, loss of federal matching eligibility for the financing mechanisms, or certain alternative-care-provider contracting arrangements; and the entire article becomes ineffective if federal financial participation under Title XIX is not available at the approved FMAP for 2026–2028.

The bill also repeals Section 40-26B-88 (the existing statutory termination provision for the Hospital Provider Privilege Tax), and it sets an effective date of October 1, 2026.

FULL SUMMARY

The regulation amends Alabama Medicaid Agency Rule 560-X-6-.01 (Physician Program-General) to clarify Medicaid payment rules for services provided by certified physician assistants (PAs) and certified registered nurse practitioners (CRNPs).

Key provisions retained but clarified in the PA/CRNP payment framework specify that Medicaid payment may be made for professional services of PA and CRNP employed practitioners when they are (1) legally authorized to furnish services and (2) render services under the supervision of an employing physician. Payment is made to the employing physician’s billing group, not directly to the PA or CRNP, and the employing physician must be an Alabama Medicaid provider in active status. The PA or CRNP must enroll with Alabama Medicaid, obtain an Alabama Medicaid provider number, and be listed with the employing physician as the payee.

The rule also describes operational and billing constraints tied to PA/CRNP services, including: covered services must be billed under the PA/CRNP’s name and NPI; PA/CRNP-approved services include certain injectable drugs, CLIA-certified laboratory services, and select CPT codes listed in specified appendices; PA/CRNP office visits count against the recipient’s yearly benefit limitation; the PA/CRNP must submit a copy of the prescriptive authority granted by the licensing board to the Medicaid fiscal agent; PA/CRNPs cannot make physician-required hospital/institutional visits solely to qualify as physician visits; and PA/CRNPs cannot sign or place the initial prescription/order for home health services or certain medical supplies/equipment/appliances (only the ordering physician may do so). Additionally, the employing physician is responsible for the PA/CRNP’s professional activities, medically necessary and appropriate care, and there is no independent unsupervised practice by PAs or CRNPs.

An “intended action” notice establishes the amendment process and solicitation of public input: written or oral comments are accepted at the Alabama Medicaid Agency address during business hours, with a final comment date of Friday, March 6, 2026. The notice provides no stated economic impact and frames the amendment’s purpose as clarifying PA/CRNP payment language.

FULL SUMMARY

The document provides notice that Alaska’s Department of Health intends to seek CMS approval for a Medicaid State Plan Amendment (SPA) with a July 1, 2026 effective date. The SPA’s stated purpose is to update the effective dates of rates shown on the frontispiece (page 1) of Attachment 4.19-B to the most current fiscal year rate. It also makes targeted edits to rate description language to remove redundant wording and to point to the frontispiece effective date.

For services with inflationary adjustments, the notice states that the frontispiece rates include preplanned annual percentage increases for specified service categories: ambulatory surgical clinical services (3.1%), licensed behavior analysts & substance use rehabilitation services combined with mental health clinic (3.2%), personal care services (3.2%), personal care services for the Community First Choice option (3.2%), and chore services for the Community First Choice option (3.2%), along with LTSS Targeted Case Management (3.2%). It also states that in-home peritoneal service reflects a rebasing adjustment and that physician services reflect updated Medicare rates plus a revised conversion factor of 46.513. The notice includes estimated cost increases for federal/state funds for SFY 2027 (and one item for SFY 2026) tied to these adjustments.

The notice further specifies language/reference clarification updates to reduce redundancy in several rate descriptions by changing the operative effective-date phrasing. Examples include (1) revising ambulatory surgical clinic services language to state rates are effective for services “on or after the date listed on Attachment 4.19-B, page 1,” (2) revising Community First Choice personal care services and chore services descriptions to change the effective-date language to provider reimbursement language tied to the Attachment 4.19-B frontispiece date, (3) updating Justice Involved Youth (JIY) – Targeted Case Management to replace fee-schedule/effective-date wording with an Attachment 4.19-B-based effective date, and (4) correcting other redundant references where the description also states rates are effective on or after the Attachment 4.19-B frontispiece date.

The notice states the proposed amendments will not affect how Alaska Medicaid provides or reimburses EPSDT services. A public comment period is announced through 5:00 PM on Thursday, July 30, 2026; comments may be submitted by email to christal.hays@alaska.gov with subject “2026 Fee Schedule Updates” and must include the sender’s full name and email address. Accommodation requests for people with disabilities must be submitted no later than Wednesday, July 15, 2026. Comments that cannot be emailed must be mailed/submitted to the DOH Commissioner’s Office (c/o Christal Hays, 3601 C Street, Suite 902, Anchorage, AK 99503).

FULL SUMMARY

The bill establishes minimum standards for health insurance provider networks and directs the Alaska Director of Insurance to account for certain “limited network” requirements when setting or approving covered-person benefits or related contractual requirements.

For provider networks, a health care insurer must include (1) every in-state hospital, skilled nursing facility, and licensed mental health or substance abuse facility, and (2) in-state physicians, physician assistants, or advanced practice registered nurses employed or contracted by those facilities, plus analogous requirements for facilities and clinicians operated/employed/contracted by Alaska tribal health organizations. The insurer must also include a sufficient number of in-region clinicians in each contracting region (and only clinicians meeting specified licensing/credentialing and principal-practice-location conditions may be counted under defined circumstances), with all included clinicians shown as in-network in the insurer directory.

The bill divides Alaska into six contracting regions and imposes percentage minimums for inclusion of actively practicing physicians/PA/APRNs by specialty and provider groups, using Centers for Medicare and Medicaid Services Medicare Advantage “network adequacy” specialty/provider-group categories. The required percentages vary by region: 70% for Anchorage; 75% for the Matanuska-Susitna Borough and the Fairbanks North Star Borough/Southeast Fairbanks Census Area; and 80% for the Kenai Peninsula Borough, the Juneau/Ketchikan Gateway/Sitka region, and the remainder of the state. The Director may grant exceptions from the minimum network standards for limited periods (not exceeding 36 months), subject to procedures/regulatory standards, and insurers must annually attest compliance and, if they do not meet a specific standard, submit a corrective-action plan; the Director may also adopt additional higher standards by region.

Separately, the bill creates standards for settlement of health insurance claims in the absence of a contract setting allowable charges. The Director must set regulations requiring insurers to use a statistically credible methodology to establish “allowable charges” for in-state services/supplies, based on the most current 12-month provider-charged data, uniformly applied statewide, and at least 345% of the applicable federal CMS physician fee schedule for the state in effect at delivery. The Director must periodically audit/validate insurer methodology. Insurers must review/update allowable charges no more often than every three years and at least every five years unless otherwise directed. The bill also requires uniform and equal reimbursement-rate application for a given service/supply type and authorizes definitions for “allowable charge,” “health care insurer,” and “health care provider.” A transition rule requires allowable charges for calendar year 2027 to use the most current data based on 12-month periods beginning in 2024 or earlier, and takes effect January 1, 2027; it also repeals AS 21.07.020(3).

FULL SUMMARY

The bill establishes an “Emergency Medicine Study Committee” tasked with reviewing Arizona’s emergency medical services system and the state of emergency medicine, focusing on delivery challenges, capacity and rural/urban adequacy, uncompensated care’s effects on financial viability, and factors affecting the stability of emergency medicine providers.

The committee’s membership includes three House members (appointed by the Speaker; one designated chair), three Senate members (appointed by the President), the director of the Arizona Department of Health Services (or designee), two emergency department operators split by county population (under vs. at least 500,000), three emergency medicine physicians split by county population plus a medical director of an emergency medical services agency, one emergency-medicine registered nurse or nurse practitioner, and two pre-arrival EMS providers split by the same county population thresholds; appointment authority is divided between the Speaker and Senate President for the listed public members.

The committee must (1) review EMS system delivery and obstacles to sustainability, (2) analyze emergency medicine capacity including factors affecting adequacy in rural and urban areas, (3) review the financial impact of uncompensated care on the practice of emergency medicine, (4) identify factors impacting provider entity stability, and (5) solicit stakeholder and patient input on both service delivery and emergency medicine financial viability. It may hold public hearings, conduct fact-finding tours, request data from the Department of Health Services, and take testimony; the legislature and the Department of Health Services must provide staffing and support. Members receive no compensation, but are eligible for expense reimbursement under Arizona law.

The bill requires an initial report by December 31, 2026 and annual reports thereafter to the Governor, President of the Senate, and Speaker of the House, with a copy provided to the Secretary of State. The committee is set to be repealed effective after June 30, 2029 (i.e., on or after that date the study committee no longer exists).

FULL SUMMARY

The proposed amendments revise AHCCCS Administration rules governing the AHCCCS Differential Adjusted Payment (DAP) initiatives for hospitals and hospital-based freestanding emergency departments (FSEDs). The changes focus on clarifying eligibility and the operational requirements needed to qualify for increased reimbursement for specified contract years, including DAP requirements tied to participation in value-based care programs and performance/quality measures.

Key changes occur in rules R9-22-712.35, R9-22-712.61, R9-22-712.71, and R9-22-712.90. For the outpatient and inpatient DAP payment framework, the amendments extend/adjust the eligibility criteria and milestone obligations for hospital subtypes across contract years (e.g., CYE 2025/2026/2027), including continuing/maintaining connections to designated HIE platforms, submitting required agreements/SOWs, completing integration and testing milestones, and meeting data-quality profile/improvement requirements. The HIE-related requirements include specific timelines and obligations to submit patient identifiable information elements (e.g., ADT, lab/radiology, medications, immunizations, discharge summaries) and to complete required data-quality profiles and improvement plans tied to specified percentage thresholds, with exceptions when data-quality results exceed 90% for each measure.

The amendments also add/clarify qualification and implementation requirements for additional DAP program components. These include:
(1) DAP activities tied to the Maternal Syphilis Program, requiring timely submission of Letters of Intent (LOIs), development/submission of facility policies meeting ADHS standards, initiation of testing, and submission of baseline and subsequent metrics (including testing counts, positive/negative results, treatment initiation, pregnancy status, and opt-out data), plus a narrative reporting requirement for the following year’s outcomes (public sharing).
(2) DAP activities tied to the Medications for Opioid Use Disorder (MOUD) Enhancement Program, requiring LOIs, attested participation in a statewide clinical opioid workgroup, development of facility MOUD program policies, completion of designated project types (e.g., recognition/diagnosis, medical coding/documentation, MOUD utilization rate, EHR buildout/clinical decision support, expanding prescribers, or bridge/connector programs), and defined stakeholder engagement.
(3) DAP activities tied to Naloxone Distribution Program (NDP) for hospital emergency department–related settings, requiring LOIs, facility policy development ensuring naloxone is purchased through standard routine pharmacy ordering, initiation of distribution by specified dates, and submission of program attestation; also includes different eligibility timing for facilities that did vs. did not participate in prior contract-year NDP DAP.

Procedurally, the notice establishes the public comment and hearing schedule: written comments accepted in person or via email; mailed comments postmarked within 30 days of publication; and an oral proceeding scheduled for August 11, 2026, 2:00 p.m. (virtual), with the comment period and close of record both ending August 11, 2026 at 5:00 p.m. The agency estimates about $55 million in additional payments for the contract year October 1, 2026 through September 30, 2027 to 116 hospitals under the DAP-related initiative framework.

FULL SUMMARY

The document establishes updated Arkansas Medicaid State Plan payment-rate provisions (Attachment 4.19-B, “Methods and Standards for Establishing Payment Rates—Other Types of Care”) by revising the “Physician Services” section to adjust several specific reimbursement components, with an Effective Date of June 1, 2026 and approval on June 9, 2026 (TN: 26-0006, superseding TN 25-0003).

For dates of service beginning January 1, 2021, it sets a 3% increase to the maximum reimbursement rates for evaluation and management (E/M) codes, calculated as 3% of the July 1, 2020 fee-for-service rate for each E/M code; it further reiterates that state-developed fee schedule rates apply equally to governmental and private providers and that the fee schedule rate was set as of January 1, 2021.

For dates of service beginning July 1, 2025, it increases reimbursement rates for obstetrical care (including prenatal care, delivery, and postpartum care) by 70%, with the increase based on an analysis of private-pay rates from state fiscal years 2023 and 2024 (Arkansas Blue Cross Blue Shield and Centene), while again stating state-developed rates are the same for governmental and private providers.

It also specifies immunization-related administration fee rules: for dates of service on or after July 1, 2020, the influenza immunization administration fee is set using the 2020 Medicare flu vaccine administration fee, and other immunization administration fees are based on the Medicare 2020 physician fee schedule for Arkansas; and for dates of service on or after June 1, 2026, the administration fee for RSV (immunization or monoclonal antibody) for infants and toddlers is $19.54 (equal to 100% of the maximum Arkansas VFC regional administration fee published in the Federal Register).

FULL SUMMARY

The bill establishes two new requirements/authorizations in California’s Medi-Cal system and creates a new state workgroup. First, it adds Section 14197.85 to the Welfare and Institutions Code to govern situations where a Medi-Cal managed care plan enrollee also has other health care coverage and Medi-Cal is the payer of last resort.

Under Section 14197.85, when an enrollee in a Medi-Cal managed care plan also has other health care coverage (excluding Medicare in the fee-for-service provider contracting rule), the department must ensure that a non-contracted provider that bills the Medi-Cal managed care plan for Medi-Cal allowable costs not paid by the other coverage does not face administrative requirements significantly more burdensome than those for billing the same costs to Medi-Cal fee-for-service. In the same payer-of-last-resort scenario (excluding Medicare), a Medi-Cal fee-for-service participating provider is not required to contract as an in-network provider with the Medi-Cal managed care plan in order to bill the plan for Medi-Cal allowable costs for covered services. The bill allows, in specified circumstances, a Medi-Cal managed care plan to require a letter of agreement (or similar agreement) with a non-contracted provider: (1) where the service needs prior authorization or where the other coverage does not cover the service but the plan covers it, and the letter is tied to that service; and (2) where continuity of care/completion of covered services applies under existing continuity-of-care provisions, permitting an agreement for the applicable services. The bill further specifies that, absent the letter/agreement in circumstance (1), providers may be responsible for billed amounts exceeding the Medi-Cal fee-for-service allowable rate (or applicable service limits), and it reiterates that providers may not bill the Medi-Cal managed care enrollee for excess amounts not paid by the Medi-Cal managed care plan.

Section 14197.85 also requires the department to take actions it deems necessary to clarify billing conditions for providers rendering services to Medi-Cal managed care enrollees with other coverage, with examples that may include regulatory updates, revised guidance, increased reporting, and enforcement. It states legislative intent that the department offer educational resources to enrollees needing assistance coordinating Medi-Cal and other coverage when requested. It requires annual reporting to the Assembly and Senate health committees from 2027 through 2030 on effectiveness of implementation, and authorizes implementation through all-county letters, plan letters, bulletins, information notices, or similar instructions without additional regulatory action. Implementation is conditioned on obtaining necessary federal approvals and having federal financial participation available and not jeopardized.

Second, the bill adds Division 110.5 (Section 130350) to the Health and Safety Code, requiring the California Health and Human Services Agency to convene a workgroup to explore the use and effectiveness of functional, hormonal, integrative, and metabolic health and medicine. The workgroup must meet at least four times per year and report findings to the Senate Health and Human Services Committee and the Assembly Health Committee.

FULL SUMMARY

AB 125 establishes a replacement Medi-Cal managed care organization (MCO) provider tax regime to generate nonfederal funding for Medi-Cal and to meet federal permissibility requirements. It creates the Medi-Cal Stability Fund in the State Treasury, continuously appropriates deposited tax revenues (and retained interest/dividends) to the Department of Health Care Services (DHCS), and prioritizes uses including: DHCS administrative costs (capped at $4 million annually), the nonfederal share of increased Medi-Cal managed care capitation payments driven by the tax, the nonfederal share of certain specified Medi-Cal payments, and at least $2 billion annually of the nonfederal share of specified Medi-Cal managed care rates for children/adults/seniors/people with disabilities and dually eligible individuals.

AB 125 amends Section 14105.201 by changing how reimbursements and directed payments for specified services (primary care, obstetric care and doula services, and certain outpatient mental health services) are funded and administered during the relevant period. It continues a methodology that sets reimbursement rates based on a Medicare “lowest maximum allowance” standard and related adjustments, requires DHCS to annually review/revise rates (or develop methodology where no Medicare maximum exists), and requires DHCS to seek federal approvals so the provisions operate only when approvals are obtained and federal financial participation is available and not jeopardized. It also removes an existing inoperative community health worker eligibility provision from the reimbursement rate framework by deleting the inoperative reference described in the bill.

The bill adds Article 7.2 (Sections 14199.90–14199.97) to the Welfare and Institutions Code to impose an MCO provider tax for calendar years 2027–2029 (subject to federal approval conditions). The tax is assessed per “countable enrollee” at $8.85 per enrollee per month unless DHCS determines an alternative tax amount is needed to meet the funding goal (with caps on how far alternative amounts can deviate from the base amount). DHCS computes and collects the tax in quarterly installments; it may not collect until either (1) DHCS certifies the tax meets federal broad-based/uniformity and hold-harmless requirements, or (2) DHCS receives written CMS approval. The bill sets procedures for notice to plans, payment timing requirements (including that the first payment cannot be due earlier than 20 calendar days after notice and that installment payments are at least one month apart), interest/penalties for late payment (10% per annum interest; penalties after 60 days overdue), and potential waiver of interest/penalties upon a showing of undue financial hardship or significant difficulty providing services (conditioned on an alternative payment schedule). It also allocates tax responsibility in mergers/acquisitions/establishment transactions.

Operationally, Article 7.2 becomes operative on July 1, 2026 (or chaptering date, whichever is later), is intended to take effect for tax purposes no earlier than January 1, 2027 (or later if federal approval is necessary and obtained), and generally becomes inoperative on January 1, 2031 with repeal on January 1, 2032 (except that Section 14199.92 continues to function to the extent not in conflict with federal law). It includes mechanisms to cease operability and refund amounts if federal approvals are rejected, the tax cannot be implemented, or final judicial/federal administrative determinations require ending the tax, while keeping accrued taxes/interest/penalties due and payable until fully satisfied. The bill also declares legislative intent to ensure the new tax is not subject to an earlier initiative-based MCO provider tax structure (Protect Access to Health Care Act of 2024), and it includes requirements for DHCS to request any necessary CMS waivers (e.g., broad-based/uniformity).

The California Health Care Quality and Affordability Act establishes a framework for analyzing health care costs and setting statewide cost targets for various health care entities, including providers, integrated delivery systems, and pharmaceutical companies. The legislation aims to address the rising costs of health care by implementing measures that promote affordability and quality.

Key provisions of the act include the adjustment of cost targets based on projected increases in prescription drug costs and organized labor costs for nonsupervisory employees. This approach is designed to ensure that health care entities can manage their expenditures while adhering to the established targets, which will be informed by historical cost data, economic indicators, and demographic changes.

The act emphasizes the importance of collaboration among health care entities to minimize fragmentation within the system. By establishing specific targets for different health care sectors, the legislation encourages cooperation and transparency in cost management.

Overall, the act seeks to create a more sustainable health care system in California by promoting accountability and informed decision-making regarding health care spending. Through comprehensive data analysis and stakeholder engagement, the legislation aims to enhance the quality and affordability of health care for all Californians.

FULL SUMMARY

The bill establishes a revised state process for setting and negotiating Medi-Cal Program of All-Inclusive Care for the Elderly (PACE) capitation rates under Welfare and Institutions Code Section 14301.1.

It changes the PACE capitation rate methodology requirements in Section 14301.1(n): the department must negotiate capitation rates with each contracting PACE organization (consistent with federal requirements) and make a good-faith effort to reach agreement, rather than engaging in the prior consultation requirement in developing the rate methodology. Before submitting negotiated rates to the federal Centers for Medicare and Medicaid Services (CMS) for approval, the department must notify the contracting PACE organization of the proposed rates at least 60 days in advance. The department may set a reasonable deadline for the PACE organization to submit written questions or feedback, and must respond in writing to those questions or feedback no later than 30 days before submitting the rates to CMS; upon request, the department must provide rationales for assumptions or calculations used in the proposed rates (including the underlying data/methodologies, the experience-based rate range, and the capitation rate for the PACE organization).

The bill also retains/continues the existing federal-law-aligned requirements that capitation rates be actuarially certified and that the department calculate an upper payment limit for PACE payments, with corrections to applicable data and consideration of nursing home placement risk for comparable populations. Implementation of the PACE rate provisions is limited to receipt of necessary federal approvals and availability of federal financial participation, and applies only for rates implemented no earlier than January 1, 2017.

All other aspects of Section 14301.1 shown in the bill text (including additional Medi-Cal managed care rate-setting subsections and CalAIM-related provisions) are carried as context rather than being substantively changed in the portions reproduced.

FULL SUMMARY

The bill requires Medi-Cal copayments for “newly eligible beneficiaries” with income above 100% and up to 138% of the federal poverty level (with the specified 5% disregard). It sets a $0.01 copayment for defined nonemergency services in an emergency department/emergency room when those services do not result in treatment of an emergency medical condition or inpatient admission, limits where copayments apply by excluding a broad list of service categories (including emergency services, family planning, certain inpatient/hospice/age/pregnancy populations, COVID-19 testing, specified vaccines, Indian Health Service/referrals, primary care, and mental health/substance use disorder and several clinic types), prohibits providers from denying care solely for nonpayment, exempts visits/services/devices/items when Medi-Cal payment is $10 or less, and caps total family cost-sharing/deductions (aggregate) at 5% of monthly family income.

The bill also modifies Medi-Cal retroactive eligibility procedures. It provides that, upon request, assistance is made available for care and services during the three months immediately before the month of application if the individual was (or would have been) eligible for medical assistance, and makes conforming changes specifying that these three months may be federally funded or state funded with federal reimbursement sought to the maximum extent allowable. In addition, it amends county Medi-Cal redetermination-related provisions (including eligibility during the redetermination process, notice and information-gathering requirements, timelines for obtaining information, and processes for termination or continuation when sufficient information cannot be obtained) and includes provisions related to redeterminations involving MAGI-based methods and non-MAGI situations.

For Medi-Cal eligibility systems and the broader insurance affordability programs (including the Exchange/CHIP context), the bill strengthens requirements around eligibility application usability, verification, and system integrity. It requires a single standardized application to be user-tested for accuracy/readability in Medi-Cal threshold languages and operational by the date required by the federal Secretary (including ahead of certain federal change effective dates). It also expands rules on self-attestation and limits what information the application/supplemental forms may request, allows/structures use of the application to determine compliance with federal work/community engagement requirements (including exemptions) without seeking additional information, requires accessible/plain-language forms, and requires that eligibility system stakeholder processes address functionality/accuracy/legal appropriateness of electronic eligibility systems and public websites, including regular (at least quarterly) user-testing and user-centered design, tracking defects/enhancements, and monitoring screening/evaluation.

Finally, it provides implementation conditions for the Medi-Cal copayment provision (only with federal approvals and federal financial participation, and no sooner than October 1, 2028), and includes a mechanism for state-mandate cost reimbursement if the Commission on State Mandates determines the bill imposes reimbursable costs on local agencies/school districts.

FULL SUMMARY

The bill establishes a new “Facility Fees” article in California’s Health and Safety Code (Chapter 2.5, Division 107) that limits when facility fees may be charged for outpatient services and requires patient-facing notice and reporting. Beginning January 1, 2028, it prohibits specified facility fees in several circumstances (off-campus hospital-based CPT/assessment-and-management outpatient locations; telehealth; and preventive services), while clarifying that these prohibitions do not bar billing professional fees.

For health care providers, hospitals, and health systems, the bill requires notice at scheduling and at check-in when a facility fee may be charged, including: (1) an express statement that a facility fee may be charged; (2) a good-faith estimate of the facility fee amount; (3) an explanation distinguishing professional fees from facility fees; and (4) whether the facility fee for the scheduled service is prohibited under the article. It also requires providers/hospitals to (a) post on their internet websites a list of services for which a facility fee may be charged (if permitted), and (b) separately itemize any allowed facility fee on patient bills. It then creates substantive prohibitions: no facility fee for outpatient CPT E/M or A/M services furnished at physician practices/clinics/outpatient locations that are hospital facilities located offsite from a hospital campus (regardless of Medicare provider-based designation, place-of-service code, ownership/affiliation, or fee terminology); no facility fee for any health care services furnished via telehealth; and no facility fee for preventive services identified by cross-references to specific preventive-service mandates.

The bill adds an enforcement and remedy scheme in the new Health and Safety Code article: the Director of the Department of Health Care Access and Information must impose an administrative penalty for each noncompliance, with multiple violations found during the same investigation treated as a single violation for penalty purposes. It also requires reimbursement to patients of any amount actually paid for a prohibited facility fee, tied to an existing reimbursement process reference. It authorizes the department to adopt (including emergency) regulations and makes the article operative January 1, 2028. It separately requires hospitals and health systems (under the new facility-fee definitions) to file facility-fee reports with DHCAI containing facility-level and service-level fee and revenue information, with authorization to incorporate reporting into an existing requirement to minimize costs; the reporting requirement is also operative January 1, 2028.

Finally, the bill adds parallel restrictions in the Insurance Code (operative January 1, 2028) enforced by the Insurance Commissioner: health plans/insurers may not reimburse, pay, or otherwise provide coverage for prohibited facility fees; may not include in contracts/provider agreements terms permitting payment of prohibited facility fees; must deny payment of claims that include prohibited facility fees; and may not pass through or shift prohibited facility fees to insureds. It also includes a state-mandate reimbursement carveout (no reimbursement required) because the act is connected to changes affecting local agency/school district costs via creation/elimination/changing of crimes or infractions/penalties or crime definitions under referenced constitutional provisions.

FULL SUMMARY

The bill (1) revises Medi-Cal reimbursement methodology for certain primary care, obstetric/doula, and outpatient mental health services funded through directed payments, and (2) creates a new, federally conditional Managed Care Organization (MCO) provider tax structure for calendar years 2027–2029, with revenues deposited to a new Medi-Cal Stability Fund and continuously appropriated for specified Medi-Cal purposes. It also establishes intent that the new tax be designed to avoid conflict with the Protect Access to Health Care Act of 2024 and to meet federal requirements for permissible health care-related taxes.

For Section 14105.201, the bill updates the statute governing reimbursement rates and managed care directed payments for: (A) primary care; (B) obstetric and doula services; and (C) specified outpatient mental health services. It keeps the existing “greater of” reimbursement framework tied to Medicare lowest maximum allowance (with inclusions for exemption from Medi-Cal payment reductions and specified Proposition 56-funded supplemental payments/rate increases in effect as of Dec. 31, 2023), and requires annual departmental review/revisions. It also clarifies that the directed payment structure must be supported by revenues from the new MCO provider tax (Article 7.2) or other appropriated state funds, and includes a transition that discontinues other fee-for-service supplemental payments and managed care directed payments for the identified services once the payments under subdivisions (a) and (b) are effective.

The bill adds Article 7.2 (Sections 14199.90–14199.97) establishing the continuation framework and operational mechanics of the new MCO provider tax. It defines key terms (including countable enrollees and base-year/data sources), creates the Medi-Cal Stability Fund in the State Treasury, and continuously appropriates tax revenues (net of refunds) to the Department of Health Care Services in a priority order: up to $4 million annually for administrative costs; the nonfederal share of increased capitation payments; the nonfederal share of payments described in Section 14105.201; and at least $2 billion annually in the nonfederal share of Medi-Cal managed care rates for specified populations/services. It then imposes a $8.85 per countable enrollee per month tax for 2027, 2028, and 2029, with Department discretion to adjust via alternative amounts/tax tiers (bounded by specified percentage limits for alternative tax amounts) and to modify parameters to secure or maintain federal approval and financial participation, while constraining changes that would significantly increase projected aggregate collections.

Collection and operability are conditioned on federal permissibility: the Department cannot collect until the Director certifies federal compliance (including broad-based/uniformity and hold-harmless requirements) or until CMS approves in writing, after which the Department issues notice to health plans with tax due dates. The bill sets interest (10% per annum) and penalties for late payment (with additional monthly penalties after 60 days overdue), allows the Director to waive interest/penalties upon a finding of likely undue financial hardship or significant difficulty in providing Medi-Cal services, and addresses transactions transferring tax responsibility in mergers/acquisitions/establishment events. The tax becomes effective and operative on January 1, 2027 (or later upon certified federal approval if approval is necessary), ceases to be operative if federal approvals are denied/conditions fail or under specified final judicial or federal administrative determinations (with refunds of tax for affected periods, subject to continued payment obligations until fully paid). Provisions in the article generally become inoperative January 1, 2031 and are repealed January 1, 2032, except that the Medi-Cal Stability Fund provisions (Section 14199.92) persist to the extent not conflicting with federal law. The bill takes effect immediately.

The document outlines significant changes to the Medi-Cal program concerning reimbursement rates for clinical laboratory services, particularly those related to the diagnosis and treatment of sexually transmitted infections. These changes primarily impact clinical laboratory service providers and healthcare services in this area.

Under the new provisions, Medi-Cal reimbursement for clinical laboratory services will be capped at the lowest of four specified metrics, including the amount billed and the charge to the general public. Importantly, the previous requirement for a 10% payment reduction for these services has been eliminated.

The new reimbursement rates for clinical laboratory services associated with sexually transmitted infections will take effect for services rendered on or after July 1, 2027, or when funding is appropriated, whichever occurs first. Additionally, data reporting exemptions for these services will apply for dates of service on or after January 1, 2027, or when funding is appropriated.

The department is tasked with publishing updated reimbursement rates and related datasets in conjunction with these changes. Overall, the bill aims to align Medi-Cal reimbursement rates with those of other payers while ensuring compliance with state and federal laws.

FULL SUMMARY

The bill changes Colorado’s out-of-network health-care dispute-related provisions in CRS 10-16-704 to modify how the state division enforces carrier payment requirements and how carriers provide payment and related transparency information to providers.

The bill updates CRS 10-16-704(13) by directing the General Assembly’s stated intent for subsection (13): (1) streamline out-of-network dispute resolution by granting the Division additional enforcement authority within the out-of-network complaint process, including requiring prompt payment by carriers when underpayment is identified; (2) require “jurisdictional transparency” by mandating that carriers clearly state on a remittance advice when a patient’s health benefit plan is governed by state law; and (3) empower data-driven enforcement by requiring carriers to disclose specific methodologies used to determine out-of-network reimbursement and by granting the Commissioner authority to order corrective payments and impose fines for noncompliance.

Operationally, when a carrier makes a payment pursuant to specified provisions of the section, providers may request—and the Commissioner must collect—data from the carrier to evaluate compliance in paying the highest rate required, including the methodology used to determine the carrier’s median in-network rate and corresponding reimbursement for each service in the same geographic area. The data submitted are characterized as proprietary/traet secret/confidential under the referenced confidentiality statute. In addition, beginning January 1, 2027, when making such payments, the carrier must provide a remittance advice identifying when the health benefit plan is regulated by state law and that the payment was made pursuant to the specified subsections. The bill also requires that each remittance advice include the carrier’s median in-network reimbursement rate for out-of-network claims.

The act becomes effective after the statutory referendum-petition period, specifically at 12:01 a.m. on the day following expiration of the 90-day period after final adjournment (August 12, 2026 if adjournment sine die is May 13, 2026), unless a referendum petition is filed and the act is approved by voters in November 2026; if approved, it takes effect upon official declaration of the vote by the governor. It applies to payments owed by health insurance carriers on or after the applicable effective date.

FULL SUMMARY

The rule establishes Colorado Medicaid and Children’s Basic Health Plan (CHP+) eligibility requirements tied to federal financial participation (FFP) eligibility for “qualified non-citizens,” effective October 1, 2026, by aligning state citizenship/immigration categories and related verification and exception processes with federal requirements under OBBBA provision 71109 and related federal Medicaid/CHIP rules.

It revises 10 CCR 2505-10 Sections 8.100.3.G and 8.100.4.G to update the definition and eligibility categories of lawfully residing non-citizens and to conform the state’s verification workflow. The rule requires that for Medicaid eligibility determinations, legal immigration status must be verified using the Verify Lawful Presence (VLP) interface connected to the federal Systematic Alien Verification for Entitlements (SAVE). If electronic verification is unsuccessful, a “Reasonable Opportunity Period” is triggered: the applicant receives a Notice of Action and has 90 days to submit required documentation; benefits must not be delayed, denied, reduced, or terminated during the Reasonable Opportunity Period if the applicant is otherwise eligible. The Reasonable Opportunity Period applies to MAGI, Adult, and Buy-In programs, with the rule listing the applicable program categories.

The rule also makes specific changes to the Reasonable Opportunity Period-related policy alignment language (Section 8.100.3.G.3) to better track federal regulatory text (42 CFR 435.956(a)(5)) regarding how a Reasonable Opportunity Period is handled when an applicant or member declares new or updated satisfactory immigration status that the department cannot verify electronically. In addition, it revises the “Legal Immigrant Prenatal” (LIP) policy in Section 8.100.4.G.6 to add additional exception reasons for maintaining eligibility beyond the guaranteed eligibility period; the rule states this will not change current LIP logic in the eligibility system (CBMS), but clarifies when exception requests/applications may be made.

Operationally, the department must implement system and process updates (including CBMS updates, verification procedures, and increased use of manual SAVE queries) to ensure benefits are provided only when immigration status qualifies for FFP and to avoid noncompliant eligibility decisions. The filing indicates no temporary/emergency rule is required (emergency adoption is not justified as imperatively necessary in the submission), and the rule is set to take effect October 1, 2026.

FULL SUMMARY

The document establishes Colorado’s Workers’ Compensation “Rule 18 Fee Schedule” for services rendered on or after January 1, 2027, setting maximum reimbursement amounts, reimbursement rules, and numerous billing/documentation requirements across professional services, facilities, and ancillary services. It limits reimbursement to the fee schedule unless the Director approves an exception to exceed maximum allowances, and it is intended to be read together with Rule 16 (Utilization Standards) and Rule 17 (Medical Treatment Guidelines). It also incorporates by reference multiple CMS/AMA/other pricing and coding manuals (with specified edition dates) and adopts specific code systems and hierarchy rules (Division-created codes supersede standard codes; certain status codes require prior authorization or are non-payable).

The fee schedule sets the core payment methodology for professional services: maximum allowances are calculated from RBRVS RVUs multiplied by conversion factors that vary by CPT section (e.g., E/M, anesthesia, SRPM, PM&R). It specifies provider-level reimbursement (generally 100% for most providers; APPs generally paid at 85% unless specified conditions apply, including rural-area definitions and certain accreditation/credential scenarios), and it defines RBRVS status codes/payment designations that determine whether services are separately payable, bundled, priced by report, non-payable, or payable only under specified conditions (including multiple specific HCPCS/CPT ranges and dentistry rules).

For professional services, the document contains detailed policies and limits for evaluation & management (including documentation standards, what constitutes new vs. established patient within workers’ comp claims, visit frequency limits, telephone/online treating physician billing documentation, and consult/transfer/IME billing rules), anesthesia (eligible provider types, medical direction requirements, required modifiers, time reporting, physical-status add-on units, qualifying circumstance add-on RVUs, and non-time-based billing modifier use), surgery payment adjustments (global surgical package inclusions/exclusions, assistant surgeon and co-surgeon/team surgery modifiers and payment apportionment, multiple/bilateral/reduced-discontinued procedure rules), radiology accreditation and interpretation rules (technical component accreditation requirement and limits on multiple interpretations), pathology/lab (CLIA waiver vs compliance rules, lab reimbursement percentages and component splitting), medicine (e.g., biofeedback qualifications/requirements; EMG classification references; manipulation prior authorization and therapy limits), physical medicine & rehab (PT/OT/AT evaluation rules, PM&R plan-of-care functional objectives, modality/procedure time and unit caps, special tests and prior-authorization thresholds, and therapy billing modifiers), and telemedicine (covered services only with prior authorization unless otherwise specified, required modifier 95 for synchronous services, originating site and HIPAA security requirements, and originating-site fee criteria). The rule also establishes extensive ancillary-service payment frameworks including DMEPOS rental/purchase caps and invoice/servicing rules, drug reimbursement methodology (AWP-based with DAW and prior authorization triggers, compounding/topical/OTC/injectable rules, and repackaged drug billing rules), home care service limits and hourly/per-15-minute caps, app-based interventions payment limits, and ambulance and facility reimbursement methodologies.

In addition to the overall fee schedule, it establishes multiple “division-established” fee items and reimbursement structures for meetings, reports (including WC164 initial/progress/closing forms with distribution timing and countersignature requirements when completed by NP/PA), independent medical examinations (RIME/CIME/DIME definitions, report service timing, audio recording obligations, and cancellation/rescheduling payment treatment), permanent impairment ratings (Level II accreditation requirements, limits on number of whole-person ratings per claim with specified circumstances for additional ratings), missed appointments, interpreter services (certification/qualification requirements and billing/cancellation treatment), guardian ad litem/conservator services (authorization and reasonableness factors), and deposition/testimony preparation/payment rules (including ALJ authority for certain reimbursement above the fee schedule). It also includes quality initiatives payment provisions (opioid management review codes, definitions of acute/subacute/chronic opioid use, drug testing/PDMP expectations for coverage, QPOP provider qualifications, required tools/documentation, and billing frequency constraints) and provides exhibits: E/M decision-making tables (with time-based coding instructions and scoring definitions), hospital base rates and cost-to-charge ratios used for MS-DRG facility payments, and a comprehensive dental fee schedule. The fee schedule is effective January 1, 2027 (and applies to services rendered on/after that date); where applicable, it specifies additional effective/coverage constraints within specific subsections.

FULL SUMMARY

SPA 26-0025 would be submitted to CMS to update Connecticut’s Medicaid payment methodologies in Attachments 4.19-A (inpatient hospital supplemental payments) and 4.19-B (outpatient hospital supplemental payments and practitioner supplemental payments), effective on or after July 1, 2026 (SFY 2027). The stated purpose is to implement reimbursement changes added to Connecticut General Statutes section 17b-239e by Public Act 26-68, and to maintain sufficient access to inpatient and outpatient hospital services and specified physician and mid-level practitioner services for Medicaid members.

It revises inpatient hospital supplemental payment pools for non-governmental short-term general hospitals not receiving DSH payments (and related tiering criteria) by setting SFY 2027–SFY 2031 pool amounts and eligibility/distribution rules using hospital characteristics as of January 1, 2025 and Medicaid revenue/other measures based on FFY 2024 or specified OHS-reported data. Key pool categories and SFY 2027–2031 total pool amounts include: a general inpatient supplemental pool ($202,823,819; $220,864,276; $239,696,267; $258,122,646; $277,597,027); a small hospital inpatient pool (tiers by Medicaid revenue with $3,425,000/$9,675,000 for SFY 2027, growing through SFY 2031); a midsized hospital inpatient pool (tiers by Medicaid revenue with totals $9,250,000/$19,000,000 for SFY 2027, increasing through SFY 2031); a midsized inpatient independent hospital pool (tiers by Medicaid revenue with $2,225,000/$6,700,000 for SFY 2027, increasing through SFY 2031); and a large inpatient hospital supplemental pool (tiers by Medicaid revenue with $63,000,000/$117,000,000 for SFY 2027, increasing through SFY 2031). The SPA also provides additional DSH changes for certain private acute care hospitals meeting specified uncompensated care/DSH criteria, including municipality/population and Medicaid-charge-percentage thresholds, with annual DSH pool amounts for SFY 2027–SFY 2031 (e.g., $45,792,235; $45,648,705; $45,516,217; $45,395,510; $45,282,754 for one category, and $7,706,981; $8,541,956; $9,393,031; $10,260,616; $11,146,556 for another). DSH payments remain subject to hospital-specific DSH limits calculated under federal requirements.

It revises outpatient hospital supplemental payment pools similarly for nongovernmental hospitals not receiving DSH payments, establishing SFY 2027–SFY 2031 pool amounts and tiered criteria based on Medicaid outpatient revenue/FFY 2024 OHS reporting and emergency-department visit thresholds for midsized/independent groups. The general outpatient pool totals are $194,995,425 (SFY 2027) through $305,623,328 (SFY 2031). The midsized outpatient supplemental pool totals are $65,425,000 (SFY 2027) through $80,025,000 (SFY 2031), and include tiering by Medicaid revenue (less than $30 million vs. $30 million or more). There is also an “independent” midsized outpatient supplemental pool with smaller tiered amounts ($2,225,000/$6,700,000 for SFY 2027, increasing to $2,875,000/$8,400,000 for SFY 2031).

For practitioner supplemental payments, the SPA creates/expands hospital-based and hospital-affiliated-group supplemental pools effective July 1, 2026, funded annually at $72,750,000 (gross) for eligible hospital-affiliated medical groups and their physician/APRN/PA services, and $32,250,000 (gross) annually for eligible faculty practice plans; eligibility and distribution use a “funding gap” methodology comparing Medicaid payments for physician/APRN/PA services during the Medicaid period (SFY 2025) to what would have been paid under the calendar-year 2026 Medicare physician fee schedule. It also updates existing UConn and children’s hospital-related practitioner supplemental provisions: (1) the UConn physician group/advanced practice nurse group supplemental methodology is effective for dates on or after July 1, 2026 and uses an ACR-based “Medicare equivalent” calculation to pay the difference between Medicaid payments and ACR-to-Medicare-adjusted amounts; (2) Connecticut Children’s Medical Center’s physician group supplemental provision is likewise updated so that it applies to physician/APRN/PA employed by or under contract to CCMC (or its affiliated physician group) with the “difference vs. Medicare” approach effective July 1, 2026; and (3) mid-level practitioners affiliated with children’s hospitals are explicitly included in the existing federally approved practitioner supplemental authorization for medical groups affiliated with children’s hospitals, and UConn’s practitioner pool scope is expanded to include additional service categories (APRNs/PAs and certain provider types) as specified.

Public comment must be received no later than July 30, 2026 (submission via email or mail is provided). The SPA’s financial impact estimates include increased annual gross expenditures of approximately $359.1 million in SFY 2027 and $427.2 million in SFY 2028, including category increases for inpatient supplemental payments, DSH, outpatient supplemental payments, and practitioner supplemental payments.

The bill appropriates General Fund money to the Connecticut Department of Social Services to increase Medicaid reimbursement rates for private providers. It specifies that an appropriation amount is to be set in the bill (currently blank) for the fiscal year ending June 30, 2027.

The use of the funds is tied to “phase one of the Medicaid rate study,” directing that the increase in reimbursement rates occur in accordance with that phase of the study. No other program changes, eligibility requirements, or regulatory amendments are specified in the text provided.

The document’s operative content consists solely of this targeted appropriation and its purpose statement indicating the goal of funding Medicaid rate increases consistent with the Medicaid rate study.

FULL SUMMARY

The bill establishes Medicaid “peer support services” in the Connecticut Medical Assistance Program. It defines peer support services as recovery-focused behavioral health services that help an individual learn to manage their recovery with help from a “peer support specialist.” It defines a peer support specialist as a person with lived experience recovering from mental illness or a substance use disorder who is certified to provide peer recovery support under a Department of Mental Health and Addiction Services-administered program.

Beginning July 1, 2026, the Commissioner of Social Services must amend the Medicaid state plan to integrate peer support services into care teams funded under the medical assistance program and must provide Medicaid reimbursement to peer support specialists for providing those services.

By no later than August 1, 2027, the Commissioner of Social Services must report to the General Assembly’s joint standing committees with cognizance over human services and public health, in accordance with Conn. Gen. Stat. § 11-4a, including: (1) the number of peer support specialists who received Medicaid reimbursement; (2) the number of Medicaid enrollees served by those specialists; and (3) any outcome data on treatment provided to those enrollees. (See Section 1(c), pages 2–3.)

The bill requires the Commissioner of Social Services to amend Connecticut’s Medicaid state plan to increase reimbursement rates for pediatric care services by at least 5% compared to the rates in effect on June 30, 2026.

The bill also requires the Commissioner to file a report evaluating the impact of these pediatric rate increases on (1) provider participation in the Medicaid program, (2) access to care, and (3) the state budget.

FULL SUMMARY

The bill establishes a new statutory definition of “emergency medical condition” for purposes of Medicaid and directs the Commissioner of Social Services to expand “emergency Medicaid coverage” consistent with federal law for treatment of qualifying emergency conditions. It requires emergency Medicaid coverage to include emergency labor and delivery and defines emergency medical conditions as those manifesting acute symptoms severe enough that the absence of immediate medical attention could reasonably be expected to place the person’s health in serious jeopardy, seriously impair bodily functions, or cause serious dysfunction of any bodily organ or part.

It further requires the emergency Medicaid expansion to include (to the extent allowed by federal law) specified condition categories, including: high-risk pregnancy; type 1 diabetes in persons under age 21; diabetic emergencies (including diabetic ketoacidosis); renal failure requiring ongoing dialysis; certain skull/arm/neck/leg/spine/pelvis fractures occurring in the two months before a request; hypertensive emergencies with end-organ damage and specified blood pressure thresholds (SBP ≥180 or DBP ≥120); unstable seizure disorder with specified seizure duration/frequency and impaired consciousness; active cancer treatment; ventilator dependency; labor and delivery; and acute inpatient or outpatient psychiatric treatment.

By no later than July 1, 2027, the bill establishes an administrative process requiring the commissioner to provide a system allowing individuals to apply in advance for emergency Medicaid coverage when the emergency medical condition can be treated in outpatient settings rather than hospital emergency departments. It requires the Department of Social Services to publish a prominent link to the advance-application and a list of covered emergency medical conditions on its website, and to include information about advance applications and the covered-condition list in department forms and policy manuals.

The act takes effect July 1, 2026 (Section 1), with a requirement that the advance-application administrative system be established by July 1, 2027; a fiscal note indicates administrative costs to DSS of at least $250,000 in FY27 associated with implementing the advance-application registration system and anticipates at least $125,000 in federal reimbursement/grants revenue, while the cost impact of expanding the emergency-medical-condition definition is stated as not determinable at the time.

FULL SUMMARY

The bill establishes new requirements for contracts between health insurers (and similar entities) and health care providers entered into, renewed, or amended on or after July 1, 2026 for covered outpatient benefits. Contracts must require reimbursement for covered outpatient benefits billed using certain CPT E/M codes, CPT A/M codes, telehealth codes, or drug infusion codes in an amount that does not vary based on the facility where the provider furnishes the benefit, and must use equal reimbursement rates for all contracting providers in the same geographic region as determined by the Insurance Commissioner, regardless of employer or affiliation, for each covered outpatient benefit when reimbursement is fee-for-service or standardized bundled payment. Contracts must also include a conspicuous statement of compliance, and the Insurance Commissioner must adopt regulations to implement these provisions.

The bill updates the definition of “anti-steering clause” in Conn. Gen. Stat. § 38a-477i(a)(2) effective October 1, 2026 by clarifying that it includes provisions (including utilization management provisions) restricting a health carrier or plan administrator from encouraging enrollees to obtain services from competitors of a hospital or health system, including incentives to use specific providers (e.g., centers of excellence) or other pay-for-performance programs. It also requires the Insurance Commissioner, effective from passage, to conduct a study on revisions to insurance statutes, including excess insurance, the Health Care Cabinet, and outpatient health care services provided at off-site hospital facilities (not later than January 1, 2027, via a report to the relevant joint standing committee).

The bill adds new protections against “downcoding” for claims. Effective October 1, 2026, it defines “downcode” and prohibits health carriers from using software tools (including artificial intelligence or algorithms) to automatically downcode or deny a health insurance claim submitted by a provider without review by a clinical peer. It also removes a limitation on contract continuation during disputes: effective October 1, 2026, it repeals and replaces a notice-related provision in Conn. Gen. Stat. § 38a-472f(g)(1)(C), changing the circumstances under which reimbursement terms continue after termination or nonrenewal (the replacement removes the prior “sixty days”/timing framework and instead ties continuation to when the dispute is resolved or the policyholder’s renewal date).

Effective January 1, 2027, the bill strengthens utilization review and adverse determination processes for services ordered by providers in the highest tier of a tiered network by creating rebuttable presumptions of medical necessity for such services and shifting the burden of proof to the health carrier. It requires utilization-review and adverse-determination reviews to be conducted with clinical peer independence and impartiality, specifies that clinical peers cannot have been involved in the initial adverse determination, requires consideration of all relevant documents and information submitted by the covered person regardless of whether previously considered, and requires providing any new/additional documents, evidence, and scientific or clinical rationale free of charge before the carrier issues a decision. Finally, effective October 1, 2026, the bill revises both individual and group prescription drug step therapy prohibitions (Conn. Gen. Stat. §§ 38a-510(a) and 38a-544(a)) by removing a specific exception tied to stage IV metastatic cancer, and otherwise retains the general restrictions while keeping the provider’s ability to deem step therapy clinically ineffective and obtain an override/authorization for the prescribed drug. The bill’s effective dates are set by section across July 1, 2026 through October 1, 2026 and January 1, 2027, with the study requirement taking effect from passage.

FULL SUMMARY

The bill establishes a voluntary hospital financial assistance program effective October 1, 2026. Participating hospitals must provide inpatient and outpatient care for eligible patients by: (1) providing care at no cost to uninsured patients with income up to 200% of the federal poverty level (FPL); (2) providing subsidized care for uninsured patients with income above 200% but not exceeding 300% FPL; (3) providing subsidized care for patients with income up to 400% FPL who are enrolled in SNAP or WIC; and (4) for patients with household income under 200% FPL who are deemed ineligible for hospital financial assistance, billing on a payment schedule capped at no more than 2% of annual household income. After 36 cumulative months of payments under this capped schedule, participating hospitals must consider the patient’s hospital bill paid in full and permanently cease any collection activity on any remaining unpaid balance.

Participation triggers several eligibility/documentation limits. Participating hospitals may not count patient assets to determine eligibility and may not require proof that applications for specified public or other coverage (state medical assistance/Medicaid, Emergency Medicaid, Medicare, or Connecticut Health Insurance Exchange coverage) were denied. Hospitals must use software meeting industry standards for electronic income verification and may accept specified documents to verify income (recent tax return; W-2 and 1099s; two most recent pay stubs; or employer written verification for cash-paid patients). Hospitals must exempt patients experiencing homelessness or imminently at risk from providing documentation, while allowing self-attested information for screening and application. The bill also requires participating hospitals to make information about the program available in the top non-English languages spoken by at least 5% of the population in the hospital’s geographic service area, included in discharge paperwork and on the hospital website, with Office of the Health Care Advocate contact information and ADA-compliant effective communications.

The bill authorizes reimbursement of participating hospitals through Medicaid’s disproportionate share hospital payments (DSH). The Commissioner of Social Services must amend the Medicaid state plan to use DSH payments to compensate hospitals that participate in the hospital financial assistance program, and must establish criteria for participating hospitals to document financial assistance and receive timely payment. A hospital aggrieved by a final commissioner decision on the validity of the hospital’s bills for hospital financial assistance may pursue a rehearing and then appeal using the referenced existing process.

In addition to creating the hospital program and DSH reimbursement framework, the bill changes the rehearing/appeal procedure in the DSS payment/rate context by repealing and substituting a revised subsection 17b-238(b) (effective October 1, 2026) and further making a technical update to that subsection effective January 1, 2027. The bill sets an effective date of October 1, 2026 for the new sections (with the hospital rehearing provision taking effect January 1, 2027).

FULL SUMMARY

The bill establishes requirements for Medicaid provider rate increases and ongoing oversight beginning July 1, 2026. It defines “Medicaid rate study” as the study commissioned by the Department of Social Services (DSS) under section 1 of Public Act 23-186, and uses a “five-state rate benchmark” (the average of rates for the same health care services in Maine, Massachusetts, New Jersey, New York, and Oregon) and the “Medicare Economic Index” (MEI) as calculated by CMS for physician practice costs and wage levels.

Within available appropriations, the DSS Commissioner must phase in Medicaid provider rate increases starting July 1, 2026, so that by June 30, 2029 all provider rates are at least (1) 75% of the most recent Medicare rates for the same health care services, or (2) for services with no corresponding Medicare rates, a percentage of the five-state rate benchmark that produces an equivalent rate increase. On and after June 30, 2029, the Commissioner must adjust rates annually to maintain at least 75% of the most recent Medicare rates (or an equivalent percentage of the five-state benchmark for services without Medicare counterparts), or alternatively by increasing rates by the percentage change in MEI. Any review or rebasing of Medicaid rates must include (a) rates required to be studied under the Medicaid rate study and (b) rates with no corresponding Medicare rate or benchmark rate in that study; if any of the five benchmark states has a corresponding rate for the same or substantially similar service, that state’s rate must be used for comparison. The Commissioner is also required to streamline and consolidate Medicaid fee schedules so that every provider is reimbursed using the same fee schedule, incorporating the most recent Medicare fee schedule for services covered by Medicare to the extent applicable.

The bill also establishes an ongoing systemic review process for Medicaid provider reimbursement rates by the Council on Medical Assistance Program Oversight (MAPOC). MAPOC must develop and implement the review to ensure Medicaid provider rates are adequate to sustain a sufficient provider pool for high-quality care access, and must file annual reports to relevant General Assembly committees beginning no later than January 15, 2027. The report must include MAPOC’s recommendations for necessary appropriations to compensate Medicaid providers for services in accordance with the bill’s rate-setting requirements.

According to the fiscal and bill analysis materials included with the bill (pages 4–5 and 6–7), the rate phase-in is expected to create significant costs for DSS due to increases through June 30, 2029, and an example provided shows phase-in costs of $50.0 million per year across three years (total $150.0 million annualized by FY29), depending on provider groups and funding needed to meet the benchmarks and rate-update mechanisms.

FULL SUMMARY

The bill establishes and refines Delaware’s primary-care value-based delivery framework administered through the Health Care Commission (Title 16) and the Office of Value-Based Health Care Delivery (OVBHCD). It requires coordinated monitoring of provider uptake and compliance with value-based care delivery models (in coordination with the Primary Care Reform Collaborative), and it directs the OVBHCD/Commissioner to collect specified reporting and develop regulations that standardize primary-care performance measurement and program design elements.

The bill also changes insurer rate and coverage requirements by (1) creating/clarifying a set of “Medicare Reference-Based Pricing (RBP) Targets” used to limit costs per inpatient hospital service, outpatient service, and emergency department service for commercial and group coverage for plan years beginning in 2028 (with special treatment for Free-Standing Children’s Hospitals), including defined exemptions (e.g., Medicare-Dependent Rural Hospitals, Urban Medicaid DSH Hospitals, and participation in approved multi-payer global budget models); and (2) extending primary-care “spend-at-least” requirements—starting in 2026—for both commercial and state group insurance markets. Specifically, carriers must spend at least 11.5% of total cost of medical care on primary care, with at least 5% via prospective primary care management payments; carriers must offer value-based care programs meeting Department program design elements and may not deny participation to contracted providers willing to accept program terms on the same basis as other providers.

On enforcement and accountability, the bill modifies administrative penalty authority for violations tied to the primary-care and value-based care framework (Title 18 §329), including changing penalty treatment for specified violations to be equivalent to the monetary value associated with the violation, and establishing a Primary Care Fund. Penalty-related funds are directed for use by the Statewide Benefits Office and the Division of Medicaid and Medical Assistance for functions supporting implementation of Medicaid and related primary-care requirements under Title 29/31, subject to annual appropriations and a cap on the unencumbered carryover (with excess transferred to the OPEB Fund). The bill also extends the Commission’s ability to request insurer reports (removing a time limitation referenced in Title 16).

The bill applies parallel public-plan requirements: it amends primary-care spending and reporting obligations for the state’s group insurance for public officers/employees (Title 29 §5224) and creates a new primary-care coverage spending/reporting provision for entities providing health insurance under state public assistance (Title 31 §539). It also removes a sunset/expiration clause that would have repealed the specified insurer rate/primary-care sections effective January 1, 2027. Finally, the Department of Insurance must promulgate implementing regulations within 18 months of enactment, and must, on or before January 1, 2027, establish a methodology for annual inflationary/other adjustments to a hospital’s “Full Medicare Rate” not otherwise captured in the annual Medicare rate update.

FULL SUMMARY

The regulation establishes a new Medicaid beneficiary reimbursement framework in Chapter 9 (Title 29) of the District of Columbia Municipal Regulations by adding Section 933, “Beneficiary Reimbursement for Medicaid Covered Services.” It specifies when reimbursement may be requested, which types of out-of-pocket expenses are reimbursable (including “other services covered under the Medicaid State Plan” and other listed categories), circumstances under which reimbursement is available due to improper denial of coverage, and submission requirements for reimbursement requests, including a deadline. It also sets agency and Medicaid Managed Care Plan (MCP) responsibilities and timelines for processing claims and issuing final written determinations, including due-process appeal rights for beneficiaries.

Section 933.1 allows reimbursement to occur if a Medicaid covered expense was incurred and paid (on a date consistent with 29 DCMR 95) and the reimbursement requirements in § 933.2 are met. Section 933.2 lists reimbursable out-of-pocket expenses and adds a catch-all category for “Other services covered under the Medicaid State Plan” (covering services available to children through EPSDT, without naming EPSDT separately). It also defines additional reimbursement triggers where beneficiaries are improperly denied coverage, including when DHCF incorrectly determined ineligibility at renewal/recertification, when a provider seeks payment because the beneficiary was incorrectly identified as ineligible, for beneficiaries under age 21 required to pay for EPSDT services, and for dual eligibles where a third-party insurer does not cover the Medicaid covered portion. Section 933.3 extends the general reimbursement request window to 12 months from the date the expense was incurred or 12 months from the date of Medicaid eligibility determination, whichever is later.

Section 933.4 requires submission of a Medicaid Reimbursement Form (link provided) or equivalent information to the Department or to the beneficiary’s MCP based on enrollment status at the date of service. Each submission must include beneficiary and provider identifiers, service date, amounts paid/owed, amounts paid by other insurers (including Medicare), the amount the beneficiary seeks Medicaid to reimburse, and either a receipt showing payment to the provider or a signed statement explaining why a receipt cannot be presented. The “reasonable inability” standard for missing receipts includes specified provider-related circumstances and allows a Department case-by-case determination.

Sections 933.5 through 933.12 set claim routing and decision/processing timelines: DHCF identifies whether the beneficiary was enrolled in Medicaid fee-for-service (FFS) or an MCP on the service date; if MCP-enrolled, DHCF must within 30 calendar days provide written notice of MCP processing and the right to appeal/request a fair hearing (and forward the claim and notice). MCPs must issue final written determinations within 60 calendar days of receiving a claim from DHCF or the beneficiary. Final determinations must include full payment, partial payment with explanation, or denial with explanation and due process appeal rights; if MCPs miss the 60-day deadline, they must pay the full claim within 5 business days after the deadline. Additional safeguards provide for DHCF payment when DHCF fails to submit a claim to an MCP within 30 calendar days (resulting in longer downstream delay), and for DHCF payment when it fails to issue a determination within 90 calendar days for FFS claims. Section 933.11 allows appeals by both FFS and MCP enrollees pursuant to applicable appeal processes; Section 933.12 limits MCP appeals when a beneficiary prevails at fair hearing challenging an MCP denial.

The Director of DHCF took final action to adopt the rulemaking on April 1, 2026, and the rules become effective upon publication of the notice in the District of Columbia Register.

The document outlines a comprehensive series of legislative amendments and provisions aimed at enhancing various sectors in the District of Columbia, with a strong focus on economic development, community support, education, public safety, and healthcare. Key initiatives include funding flexibility for Advisory Neighborhood Commissions, support for small businesses through delayed sales tax increases, and the establishment of programs like Baby Bonds to assist families financially. Significant allocations for public safety and education are highlighted, including funding for immigrant legal services and adjustments to public school funding formulas.

In the realm of community development, the document emphasizes the transfer of jurisdiction over the Rock Creek Tennis Center to the District government and the establishment of a program to preserve historic burial grounds for African Americans. Community land trusts will benefit from tax exemptions, and business licensing regulations are updated to encourage compliance. Additionally, funding for educational programs, particularly for special education and early childhood initiatives, is set to increase, ensuring better support for at-risk students.

Healthcare provisions include changes to the medical cannabis industry and expanded criminal background checks for child services providers. The document also addresses environmental health by transferring responsibilities related to lead poisoning prevention to the Department of Health. Furthermore, amendments aim to improve youth services through grant programs focused on employment and recidivism reduction, while reforming child support systems to better support families in need.

Public benefits are enhanced through the expansion of the Health Care Ombudsman Program, and new regulations for body art establishments are introduced to ensure safety. Significant financial allocations are made for stormwater management and energy initiatives, including the establishment of a Sustainable Energy Trust Fund. Additionally, new regulations are introduced to enhance road safety and update vehicle for hire regulations.

Overall, these legislative changes reflect a systematic approach to fund management and reallocation, aiming to enhance service delivery and support critical programs in healthcare, housing, education, and public safety. The amendments are designed to ensure that surplus revenues are effectively utilized to address community needs and promote sustainable development, ultimately fostering economic growth and improving public services in the District of Columbia.

FULL SUMMARY

The regulation sets out proposed District of Columbia Medicaid changes to the eligibility and reimbursement framework for Private Duty Nursing (PDN) under 29 DCMR Chapter 9, Section 947. It would require PDN reimbursement to apply only when a beneficiary needs “complex and continuous medical intervention,” defined in the rule as either (1) individualized and continuous medically necessary care enabling the beneficiary to remain at home instead of a hospital or nursing facility, or (2) dependence on ventilator equipment/other technology where discontinuation is likely to cause immediate deterioration of vital signs. It also clarifies reimbursable PDN service requirements, including who may order PDN and how the plan-of-care must be developed, reviewed, signed, updated, and documented.

Key ordering, face-to-face, documentation, and plan-of-care changes include: PDN orders must include physician certification of medical necessity under Section 947.7 and must be submitted with documentation demonstrating medical necessity. Medicaid reimbursable PDN requires an R.N.-developed plan of care (signed by the R.N.) and a physician review/approval process: the physician must review and (if needed) amend and sign the initial plan within 30 days, and the physician must review/update and sign the plan every 60 calendar days. The ordering physician must also document that a relevant face-to-face encounter occurred within 30 days before the start of services and within 30 days before the order, conducted by the ordering physician, or an NP in collaboration with the ordering physician, or a physician assistant under the ordering physician’s supervision. The plan-of-care must be developed collaboratively (R.N., ordering physician, Home Care Agency, beneficiary, and caregiver) and “optimized” for effective home delivery.

The rule would update PDN reimbursement administration by: establishing prior authorization requirements for all PDN requests, with specific criteria DHCF (or its designee) must use (including eligibility under the complex/continuous standard; plan-of-care compliance; ability to meet needs safely in the home; cost-effective delivery; and documentation and clinical appropriateness standards). It would maintain a baseline Medicaid reimbursement limit of up to 12 hours per day, while allowing additional hours only if DHCF determines they are medically necessary under the complex/continuous criteria. It would add additional operational provisions: DHCF audit authority and provider recordkeeping/access for audits (records retained for 10 years or longer if audits are ongoing); expanded detail on PDN duties and progress-note expectations; service limitations excluding PDN billing for duties that are assessments/reassessments/supervisory components in computing the daily hour limit; rules preventing double billing when ADLs occur during assessments/supervisory/PDN visits; and restrictions on concurrent delivery with personal care aide services (only reimbursable if DHCF determines concurrency is necessary for health and safety). It also would bar concurrent PDN reimbursement where the beneficiary concurrently receives skilled nursing services under the State Plan.

The proposal would add definitions for “Continuous care,” “Home setting,” and “Complex health care” within Section 947.99. Public comments must be submitted in writing within 30 days after publication in the District of Columbia Register (submission via email, online at dcregs.dc.gov, or by mail to DHCF). The rule is tied to a State Plan amendment approved by CMS effective October 1, 2025, and the notice states DHCF projects no fiscal impact in FY 2026.

FULL SUMMARY

The document establishes eligibility criteria for employers/facilities, physicians, and employment contracts under Florida’s Conrad 30 program (rule 64W-1.003). It requires all sponsoring facilities/employers and practice site locations in Florida to accept and actively bill Florida Medicaid (whether fee-for-service or as a managed care provider), and it limits physician eligibility at the practice site to specific categories (e.g., free clinics as defined in statute, physicians funded 100% by government funds without charging patients, or physicians who accept Medicaid, with the condition that the applicant cannot be the only Medicaid-accepting physician at the site).

It further sets physician eligibility requirements for applicants, including that applicants (i) currently reside in the United States, (ii) have an active U.S. Department of State case number at the time of application, (iv) hold an unrestricted, active Florida license as an allopathic or osteopathic physician that is effective on or before October 31 (excluding residents, graduate assistants, interns, fellows, and house physicians), (v) agree to reside in Florida and treat only patients in Florida during the entire approved Conrad 30 employment period, and (vi) be ineligible if they are eligible to apply through the HHS Exchange Visitor Program.

For employment contracts to qualify, the rule specifies mandatory contract content and prohibits certain terms. Contracts must include signed physician and employer signatures with signature dates; must clearly list all practice locations and prohibit language that permits changing/adding locations without prior Department notification under Rule 64W-1.008; must state the physician will provide direct patient care for at least 40 hours per week, disallowing administrative duties, telemedicine, or being merely “available” to provide direct patient care as part of those 40 hours (and requiring an explanation if shift work is mentioned); must provide a minimum 3-year full-time term with stated start and end dates; must state that full-time employment starts within 90 days after USCIS approves the waiver (and disallow caveats to that statement); must require written notice to the Department Primary Care Office at least 60 days before termination by either party (or immediately for immediate termination); must contain no non-compete clauses; and must limit termination provisions to “for cause.” The rule also requires that legally binding provisions in an Offer of Employment letter be included in the contract (not used as a separate cover letter), and that any addendum/attachment altering contract terms be signed and dated by both parties.

The rule concludes with statutory authority/implementation citations (Rulemaking Authority 381.4018(3) FS; Law Implemented 381.4018 FS) and indicates its history (new in 8-12-21, amended 10-24-22, and amended 8-23-26).

FULL SUMMARY

The bill makes multiple changes to Florida’s Medicaid program, with an emphasis on (1) creating mandatory work/community engagement conditions for certain able-bodied adult Medicaid recipients, and (2) expanding and tightening Medicaid drug-policy, managed-care accountability, and program integrity processes. It also establishes new statutory sections and revises several existing Medicaid statutes related to drug pricing/rebates, managed care encounter data, integrity and overpayment determinations, and managed care plan governance.

Key Medicaid eligibility change: it creates a new requirement under new sections 409.9041/409.9041 (and related cross-references) requiring the Agency for Health Care Administration (AHCA), coordinated with the Department of Children and Families, to implement mandatory work and community engagement requirements for able-bodied adults as a condition of obtaining and maintaining Medicaid coverage. AHCA must seek federal approval to implement these requirements for specified populations. The bill specifies which Medicaid recipients ages 18–64 are subject (with listed exemptions including, among others, certain caregiving roles, medically frail/disabled categories, some SNAP-compliant individuals, participants in residential substance use disorder treatment, inmates of public institutions, and certain pregnancy/postpartum categories) and identifies the specific activities that can satisfy the requirement (e.g., paid employment, training, certain education and high-school-equivalency activities, and other designated work activities). Parents with children ages 6–18 must participate only during standard school hours. Medicaid recipients must demonstrate compliance at specified times to maintain coverage; the bill directs AHCA to develop compliance processes and to require the department to verify compliance at redetermination (or more often as determined). AHCA must conduct outreach, and if noncompliance is found, AHCA must notify the recipient and specify eligibility impacts. The notice must include a 30-day grace period to come into compliance or request an exemption, continued coverage during the grace period, and consequences thereafter (including denial and service termination timing) plus the right to request a fair hearing.

Drug policy and pharmacy reimbursement changes: the bill authorizes AHCA retrospective reviews/audits for certain emergency Medicaid claims (revising s. 409.904(4)). It also changes Florida’s Medicaid Pharmaceutical and Therapeutics framework by revising the committee’s purpose and revising Medicaid preferred drug list structure: it creates a set of preferred lists including a “preferred physician-administered drug list,” a “preferred product list,” and a “high-cost drug list,” and requires AHCA adoption upon committee recommendations, with review frequency requirements. Reimbursement for drugs not on the preferred lists (except antiretrovirals) becomes subject to prior authorization. AHCA must publish and disseminate the lists, including on the agency website, without needing chapter 120 rulemaking procedures for posted updates. Additional drug cost-control mechanisms are required/authorized within s. 409.912’s spending-control program (including prior authorization processes such as step-therapy and step-edit definitions, dispensing supply limits, return/reuse program parameters, 340B fiscal impact study requirements, and new or revised supplemental rebate negotiation provisions and preferred-list-linked rebate floors/limitations). The bill also establishes an alternative reimbursement methodology for long-acting injectables administered in a hospital setting for severe mental illness, and expands prescription drug management system authority.

Managed care governance, encounter data, integrity, and dental pilot program: the bill adjusts multiple statutes governing managed care plan accountability. It amends provisions on mandatory hospital inpatient service coverage purchasing practices and adds an expanded home- and community-based behavioral health program for adults with serious mental illness (subject to federal approval). It revises managed care plan requirements including (a) encounter data reporting/validation and uniform cost accounting, and (b) additional analysis and public reporting using encounter data (including an annual “Analysis of Potentially Preventable Health Care Events” report with defined inclusions and timing). Program integrity statutes are amended to clarify “overpayment” and to allow/require retrospective reviews, investigations, analyses, and audits, with random audit minimums and specific fraud-detection tracking/medical necessity methods. Managed care plan procurement/accountability provisions are strengthened by requiring a longer initial contract term structure and by imposing additional contract requirements on third-party administrative entities, including physician compensation benchmarks, electronic prior authorization acceptance, provider network standards with online searchable databases and feedback capability, enhanced quality improvement obligations (including HEDIS/core set behavioral measures stratified by demographics and disability determinations), accreditation timing and consequences, program integrity functions, grievance processes, and penalties/fines for encounter data noncompliance and for plan departures/noncompliance. The bill also creates a new statute defining “control” for affiliated entities and requires managed care plans to report affiliations and related party/controlled interests by specified dates, plus an AHCA public assessment by December 31, 2026 of affiliated entity payment transactions and deviations for medical and administrative costs. Finally, it creates an Integrated Managed Care Pilot Program for combined medical and state-plan dental services in designated regions (subject to federal approval), including contract amendments, timing, continuity-of-care requirements, minimum dental “medical loss ratio” standards, evaluation measures, and reports to the Governor/Legislature beginning December 1, 2028.

Effective date: the bill takes effect July 1, 2026.

The regulation establishes new standards for provider access and information transparency. It requires that at least 50% of primary care providers offer appointments outside of regular business hours, specifically outside of Monday through Friday 5 p.m. to 8 a.m., and on all day Saturday and Sunday. Additionally, plans must maintain an online, complete, and searchable provider database. These requirements are effective starting July 1, 2026.

FULL SUMMARY

The bill requires the Agency for Health Care Administration (AHCA) to establish network adequacy standards specifically for prepaid dental plans, including time and distance travel standards for each provider type and covered specialty service. It also requires sedation dentistry network standards to ensure sufficient capacity so that enrollees who require sedation dentistry can access at least two preventive or treatment appointments per year, with sedation dentistry travel standards no more than those for general dentistry.

The bill expands Medicaid managed care plan provider network database requirements by requiring contract/provider databases to identify whether providers are accepting additional Medicaid patients. For prepaid dental plans, it further requires online provider database fields that clearly identify sedation dentistry providers, list specialty providers separately from general dentists, and specify the specialty services offered by each provider; the database must also be available online to both AHCA and the public, allow comparison to network adequacy standards, and accept and display feedback from patients.

It requires AHCA to conduct, or contract for, systematic and continuous testing of plan-maintained provider network databases to confirm database accuracy, confirm behavioral health providers are accepting enrollees, and confirm enrollees have access to behavioral health services. The bill also adds/clarifies several managed care operational requirements: managed care plans must accept prior authorization requests electronically (including by their fiscal agents/intermediaries), and plans serving children in the custody of the Department of Children and Families must maintain complete medical, dental, and behavioral health encounter information and participate in making it available for coordinated case management, with an interagency agreement governing confidentiality, recipient, scope, format, and submission deadlines.

The act takes effect July 1, 2026.

The document introduces several significant changes to Florida's healthcare statutes and regulations. It repeals statutes related to the prohibition of using state funds for travel to other states for abortion services, sex-reassignment procedures, and protections for healthcare providers' conscience rights. It establishes new requirements for covered entities to adopt policies, submit lists of refused services, notify the Department of Health of changes, and include such lists in grant or contract applications, with a deadline of October 1, 2026. The Department is tasked with publishing current refused service lists, developing public education programs, and maintaining an online list of covered entities and their refused services by January 1, 2027.

The bill mandates that health care facilities disclose refused services to patients and the Department, with penalties for non-compliance up to $5,000 per day. It also clarifies that the section does not alter existing legal liabilities or rights related to health care service denials. Additionally, it requires the development of public education and awareness programs about service denials and their impacts.

A new requirement is added that pregnancy and parenting support services must constitute at least 85% of contract funds, replacing the previous 90% threshold. The bill also prohibits telehealth abortions and the mailing or couriering of medications for medical abortions, mandating in-person performance of pregnancy termination procedures by licensed physicians.

Legal definitions are introduced or clarified for sex-reassignment prescriptions or procedures, with specific exceptions for treatments related to genetic disorders, injuries, or illnesses posing imminent danger. Emergency jurisdiction is expanded to include cases where minors are subjected to or threatened with sex-reassignment procedures, allowing courts to issue custody warrants if serious harm is likely. Reimbursement policies for Medicaid are revised to allow retroactive recalculations based on updated cost reports, with full payment at the new rate, and provisions are included for adjusting reimbursement rates, fees, and service parameters to align with available funds and legislative intent. The bill also emphasizes increased reporting and transparency in Medicaid fraud prevention, including detailed fiscal analyses, performance standards, and educational materials for recipients, along with provisions for emergency license suspension of practitioners arrested for certain offenses, including sex-reassignment procedures for minors.

FULL SUMMARY

The bill makes multiple changes to Florida Department of Health-related programs and several health-professional statutes, including creating a new grant program for neurofibromatosis research, expanding/adjusting newborn metabolic screening requirements, revising dental shortage-area and loan-repayment eligibility definitions, and updating several medical marijuana and health care regulatory provisions.

Key changes include: (1) Dental Student Loan Repayment Program statutory definitions are revised by defining “Low-income” and removing reliance on “medically underserved area,” and eligibility requirements are adjusted by changing the program’s qualifying geographic/population criteria (Section 1, s. 381.4019). (2) Medical marijuana law is revised by updating the definition of “Low-THC cannabis” and revising requirements tied to department approval of qualified physicians and medical directors (s. 381.986), including deletion of obsolete language. The bill also extends an exemption related to marijuana rulemaking and adjusts provisions about the timeframe for certain medical marijuana rules (Sections 16–17 and related text changes). (3) A new “Neurofibromatosis Disease Grant Program” is created within the Department of Health (s. 381.994), requiring competitive, peer-reviewed grantmaking for scientific and clinical research, with specific application eligibility, peer review panel process and conflict-of-interest restrictions, and authorization for carryforward of obligated but undisbursed general revenue appropriations for up to five years (Sections 3 and related carryforward provision).

In addition, newborn screening is expanded: the Department of Health must require newborn screening for infantile Krabbe disease beginning January 1, 2027 (subject to legislative appropriation), and the bill adds Duchenne muscular dystrophy screening beginning January 1, 2027 (also subject to appropriation) (Section 4 amending s. 383.14). The bill also requires the Department to create and distribute an evidence-based educational pamphlet for parents/guardians of preterm infants treated in neonatal intensive care units, including specified nutritional-content topics, with electronic availability by January 1, 2027 to hospitals providing neonatal intensive care services (Section 4).

Other program and regulatory changes include: revisions to the Early Steps Program and Early Steps Extended Option related to statewide uniform transition protocols to education settings and local notice/conference procedures around a child’s move to age 3 (Sections 5–6, amending s. 391.308 and s. 391.3081); redesignation/expansion of pediatric trauma center designation authority to require level assignment based on American College of Surgeons verification (Section 7, amending s. 395.4025); emergency suspension of certain health care practitioners’ licenses for arrests involving murder (Section 8, amending s. 456.074); authorization under controlled-substance delegation rules for certain administration by home health aides for medically fragile children in an emergency seizure context (Section 9, amending s. 464.0156); new scope permissions for dental hygienists to use a dental diode laser under direct supervision with defined training, continuing education, documentation, and evidence requirements (Sections 10, adding to s. 466.023); exemptions for licensed cosmetologists performing specified aesthetic body contouring services, including defining “aesthetic body contouring services” (Section 11, amending s. 480.034); and a statutory change prohibiting certain incestuous marriages entered after July 1, 2026 (Section 13, amending s. 741.21). The bill also expands “health care provider/provider” definition for a governmental contractor relationship to include certain students in accredited programs preparing for licensure under specified professional categories (Section 14, amending s. 766.1115), updates University of Florida Center for Autism and Neurodevelopment micro-credential requirements (Section 15, amending s. 1004.551(1)(f)), and sets the bill’s effective date as July 1, 2026 (Section 19).

FULL SUMMARY

The bill changes Florida’s inmate welfare trust fund requirements for contractor-operated correctional facilities. It amends s. 945.215(3)(b), Florida Statutes, to require that “maintenance and repair deduction fees” collected from contractor-operated correctional facilities be deposited into the Contractor-Operated Institutions Inmate Welfare Trust Fund (in addition to other specified sources already directed to that fund). It also specifies how money in the fund may be used: funds must be used exclusively to provide or operate programs to aid inmates’ reintegration into society and to support environmental health upgrades to facilities, including fixed capital outlay for repairs and maintenance that improve environmental conditions.

The bill further requires that expenditures from the Contractor-Operated Institutions Inmate Welfare Trust Fund be made only pursuant to a legislative appropriation. To conform cross-references after the s. 945.215 change, it reenacts s. 944.72(1), Florida Statutes, so that the trust fund’s purpose (inmate benefit and welfare in contractor-operated facilities) and the statement that deposits and expenditures are handled as provided in s. 945.215 remains accurate.

The changes take effect July 1, 2026.

The document introduces new requirements for managed care plans and providers, including the obligation to negotiate mutually acceptable rates, methods, and terms of payment, with plans specifically required to pay dentists at rates equal to or higher than the agency's set rates. Managed care plans must accept electronic prior authorization requests and share complete medical, dental, and behavioral health encounter data for children in the care of the Department of Children and Families, establishing interagency data-sharing agreements. Additionally, statutes are amended to specify Medicaid provider agreement procedures for school districts, including certification of school-based services (excluding family planning, immunizations, and prenatal care) and the participation of lab schools in Medicaid programs. Procurement procedures for transportation services are revised to require negotiations with the transportation commission before contracting.

Furthermore, the bill mandates that managed care plans include essential Medicaid providers, including specific categories of statewide essential providers, and negotiate payment rates for non-contracted essential providers, with plans authorized to exclude certain providers after 12 months based on quality or performance, provided notice is given. It also establishes criteria for selecting plans in a pilot program for individuals with developmental disabilities, emphasizing experience, community partnerships, benefits, provider development, and person-centered planning, with a preference for plans meeting specific service standards. An effective date of July 1, 2026, is specified for these provisions.

FULL SUMMARY

The bill makes multiple changes to Florida’s Medicaid and food assistance programs, primarily by (1) creating a mandatory Medicaid work/community engagement framework (with federal approval and legislative-plan approval prerequisites), (2) strengthening Medicaid program integrity and oversight rules affecting overpayment determinations, audits, and notices, and (3) expanding Medicaid drug cost-control and preferred-drug-list administration through new/modified lists, prior authorization processes, and additional program requirements.

A new section (s. 409.9041) establishes Medicaid work and community engagement requirements for able-bodied adults ages 19–64 as a condition of obtaining and maintaining Medicaid coverage. The Agency for Health Care Administration (AHCA) must seek federal approval (via a Medicaid waiver) and may not implement the requirements until AHCA’s business plan is specifically approved by the Legislature. The business plan must include ongoing eligibility/exemption determination methods, an analysis of enrollment and expenditure effects, and an income-earning transition method modeled on temporary cash-assistance Medicaid continuity. The bill specifies which Medicaid recipients are subject to the requirements, the exemptions/exclusions (including a defined “family caregiver”), acceptable activities (80 hours/month), a school-hours-only rule for certain parents, and procedures for demonstrating compliance at enrollment/redetermination and at least every 6 months. It also requires agency outreach, a compliance process aligned to SNAP processes where possible, Department of Children and Families verification at set intervals, and notice procedures for noncompliance—including a 30-day grace period, consequences after the grace period (denial and service termination timing), fair-hearing rights, and reapplication instructions.

The bill amends Medicaid service and drug-related statutes. It allows AHCA, for a specified emergency Medicaid eligibility category, to conduct retrospective reviews/audits to validate the existence/duration of the emergency medical condition and necessity of services, regardless of whether prior authorization was obtained (s. 409.904(4)). It also removes a requirement that AHCA discontinue its hospital retrospective review program and clarifies that AHCA may still conduct retrospective reviews under the Medicaid integrity statute even after implementing hospital inpatient prior authorization. For optional Medicaid services, it adds a requirement for AHCA to seek federal approval to expand home- and community-based behavioral health services for adults 18+ with serious mental illness who are high utilizers in institutional settings, with a coordination requirement and a requirement that program cost estimates be appropriated before implementation.

The bill substantially revises Medicaid pharmaceutical governance. It changes the Medicaid Pharmaceutical and Therapeutics Committee’s purpose and directs AHCA, upon committee recommendations, to adopt (and publish) a Medicaid preferred physician-administered drug list, a preferred product list, and a high-cost drug list, reviewed on a 6–12 month cadence. It provides that reimbursement for drugs not on those lists (with an antiretroviral exception) is subject to prior authorization and adds detailed prior-authorization/step-edit process requirements, including timing/availability rules and limits on dispensing supply. It requires AHCA to establish and manage a broader drug spending-control program (including preferred lists, prior authorization and step-therapy processes for non-preferred drugs, and a return-and-reuse program for drugs dispensed to institutional recipients). It also requires (1) a detailed fiscal impact study of the federal 340B Drug Pricing Program, including data submission by specified entities and sanctions for noncompliance, and submission of results to the Governor and Legislature by June 30, 2027; and (2) further drug therapy management processes for recipients with high prescription utilization, including an agency program that may include comprehensive reviews and case evaluations. Separately, it modifies Medicaid integrity law (s. 409.913) to allow overpayment determinations to be based on retrospective reviews/investigations/analyses/audits and clarifies that “overpayment” includes certain amounts paid as a result of utilization review/prior authorization processes; it also updates confidentiality cross-references for supplemental rebate negotiation materials. The bill also adds new food assistance provisions: it limits eligibility to specified resident categories, requires documentation of shelter/utility expenses (and prohibits relying solely on self-attestation), creates a food assistance payment accuracy improvement plan with a target error-rate reduction and specified plan/reporting requirements (with repeal on Oct. 1, 2028), requires photographic identification on front of newly issued/reissued EBT cards to the maximum extent permitted by federal law, and revises SNAP employment/training participation criteria and related work requirement compliance rules (effective July 1, 2026).

FULL SUMMARY

The bill creates a Joint Legislative Committee on Medicaid Oversight and sets requirements for its membership, leadership (including alternating chair/vice chair appointments), subcommittees, meeting frequency, and staffing. It assigns the committee duties to evaluate Medicaid program financing, quality of care/health outcomes, administrative and operational functions; identify and recommend policies to limit Medicaid spending growth while improving outcomes; review Medicaid managed care plan data (including provider credentialing/payment timeliness, claim denial rates, prior authorizations, consumer complaints, and encounter data); review health outcomes (including HEDIS/National Committee for Quality Assurance and Medicaid managed care organization quality goals); and develop a plan of action for the Medicaid program’s future. The committee may issue periodic reports to the Legislature and is authorized to access records and compel testimony/evidence using specified subpoena-like procedures and powers consistent with joint legislative committee rules.

To support the committee, the bill requires the Auditor General and the Agency for Health Care Administration (AHCA) to enter and maintain a data sharing agreement by July 1, 2026, to ensure full access to data needed by the committee, and requires AHCA to notify the committee before implementing changes to Medicaid managed care capitation rates, including appearing with specified capitation-rate and cost/expense trend reporting. It also requires AHCA to provide the committee copies of other required legislative reports related to the Medicaid program. It further expands Medicaid managed care accountability in multiple areas: it revises Medicaid encounter data requirements by specifying plan submission of encounter data including denied and capitated reimbursed encounters, requiring AHCA validation and ongoing analysis (adjusting for plan enrollee characteristics) to detect overspending, above-market payments, underutilization/denials, inappropriate utilization, and potential fraud/waste/abuse; requiring use of this analysis in capitation rate setting; requiring quarterly reporting of provider assignment counts by plans and systematic continuous testing of network databases to confirm accuracy and behavioral health access; and requiring annual reporting by AHCA of potentially preventable health care events, due October 1 each year.

The bill strengthens managed care contract and pricing oversight. It updates contract procurement and contract/accountability provisions by requiring a 6-year contract structure for managed care plans (beginning with specified procurement activity) and revising numerous contract standards, including network access/provider database requirements, electronic prior authorization requirements, continuous improvement requirements (including quality measurement and accreditation timelines), grievance processes with quarterly reporting, program integrity functions and minimum fraud/abuse controls, and additional penalties and termination procedures tied to noncompliance (including encounter data reporting fines and notice/termination triggers). It tightens achieved savings rebate calculations by revising prohibited items and—effective January 1, 2027—changing the income-sharing ratios used to compute achieved savings rebates (shifting retention/refund percentages across income thresholds). It also revises the medical loss ratio (MLR) framework by requiring calculation as applicable and changing reporting timing and classification rules; it requires AHCA to report MLRs quarterly and annually for each contracted managed care plan within a set timeframe. Finally, it adds affiliated entities and related-party oversight by creating new reporting and transparency requirements: managed care plans must report controlled/affiliated persons and certain investment/ownership or common-control relationships by March 31, 2027 and annually thereafter, report changes within 60 days, and AHCA must calculate/analyze and publicly report on affiliated entity payment transactions and related administrative costs beginning by December 31, 2026 and annually thereafter.

The bill also modifies pharmacy benefit manager (PBM) and related insurer statutes. It amends PBM transparency/accountability provisions by defining “affiliated manufacturer,” revising the definition of “pharmacy benefits plan or program,” expanding required contract terms between PBMs and participating pharmacies (including prohibitions on certain financial clawbacks/reconciliations/offsets and specified exceptions), adding/clarifying an administrative appeal process for maximum allowable cost pricing (including electronic spreadsheet submission options, minimum filing time after updates/adjudications, PBM response deadlines, and required outcomes if upheld), and requiring periodic quarterly reporting by PBMs starting August 15, 2026 for denied appeals by drug. It amends PBM prohibited practices to add specific restrictions (including limits on recoupment and affiliate-related reimbursement practices). It also updates a cross-reference in the prior authorization law definition of “health insurer.” The act takes effect July 1, 2026 except for provisions with specified earlier effective timing (including those tied to enactment, and one provision effective January 1, 2027).

The document clarifies the definition of "outside of regular business hours" for the purpose of establishing provider access standards in Medicaid managed care plans. Specifically, it defines these hours as Monday through Friday from 5 p.m. to 8 a.m. local time, and all day Saturday and Sunday. This new definition aims to ensure consistent application of provider access standards during non-standard hours and on state holidays. The operative change is a replacement of the previous or undefined term with this specific, detailed time frame, effective July 1, 2026.

The document repeals sections 286.31, 286.311, and 381.00321, which previously restricted the use of state funds for travel related to abortion services, sex-reassignment procedures, and protected healthcare providers' conscience rights. It establishes new requirements for healthcare entities to provide written notices of refused services, submit lists of such services to the Department of Health, and maintain publicly accessible information on refused services, with policies to be adopted by October 1, 2026, and enforcement mechanisms including fines up to $5,000 per day. The department is tasked with developing rules, publishing lists of refused services, and overseeing compliance.

Additionally, the bill mandates that providers promote childbirth exclusively, ensure informational materials are current and cite sources, and deliver services that are noncoercive and free of religious content. It introduces detailed reporting obligations on service provision and expenditures, and restricts third-trimester abortions to specific conditions such as physician certification, emergencies, fetal abnormalities, or cases involving rape, incest, or trafficking, with documentation requirements. In-person physician performance of abortions is required, while telehealth and mailing of medications for medical abortions are prohibited. The bill grants the agency authority to regulate abortion clinics, including licensing, inspections, and record-keeping, and repeals section 395.3027.

The definition of "sex" is clarified to be based on reproductive anatomy, chromosomes, and hormones present at birth, and "sex-reassignment procedures" are clarified to exclude treatments for genetic or physical disorders, infections, injuries, or illnesses that could be caused or worsened by such procedures. Telehealth providers are prohibited from performing abortions via telehealth, including medical abortions. Statutes related to emergency jurisdiction and child custody enforcement are amended to include protections concerning sex-reassignment procedures. Medicaid reimbursement policies are modified to include protections for gender-affirming care, with specific provisions for hospital services and local government funding.

Finally, the bill enhances oversight of Medicaid fraud and abuse by establishing detailed reporting requirements, including annual reports to the Legislature, policy recommendations with fiscal analyses, and performance standards. It also updates provisions related to Medicaid recipient communication, the licensing deadline for Medicaid mental health service providers (set for December 31, 1998), and authorizes Medicaid payments for gender-affirming care.

FULL SUMMARY

The document issues a notice of changes to a previously proposed Florida Medicaid rule establishing the drug reimbursement methodology in Rule 59G-4.251 (Prescribed Drugs Reimbursement Methodology). It specifies that certain subsections of the proposed rule remain unchanged while revising particular reimbursement details, including the 340B reimbursement provision and the reimbursement basis for practitioner-administered drugs in an office setting.

In subsection (6), Florida Medicaid reimbursement for drugs purchased under the 340B program is clarified/adjusted to be the actual purchased drug price, not to exceed the 340B ceiling price, plus a $10.24 dispensing fee. The provision applies only to covered entities, Indian Health Services, tribal organizations, urban Indian pharmacies, and federally qualified health centers that dispense drugs at prices authorized under section 340B of the Public Health Services Act.

In subsection (8), Florida Medicaid reimbursement for prescribed drugs administered by a licensed practitioner in an office setting is set at 106% of ASP as provided by CMS in quarterly drug pricing files (with specific CMS pricing file locations listed). If no ASP rate is available, reimbursement is at WAC.

In subsection (11), Florida Medicaid reimbursement for DRG and EAPG exempt high-cost drugs is specified as reimbursement at AAC.

FULL SUMMARY

The document contains a notice of development of rulemaking for Florida Medicaid’s provider reimbursement and billing codes in Rule 59G-4.002, Florida Administrative Code. It announces an update intended to revise the fee schedules and billing codes incorporated by reference so that the rule uses reference materials effective January 1, 2026, while also listing additional fee schedule reference materials effective July 1, 2025; July 8, 2025; and October 1, 2025. It also lays out a rule development workshop and public comment/participation deadlines for that proposed update (workshop April 10, 2026; workshop requests by April 8, 2026; official comments due April 13, 2026).

Operative content changes are confined to the “preliminary text of the proposed rule development,” which updates the incorporated-by-reference fee schedule and billing code links for their effective dates. Specifically, it provides a revised set of “Florida Medicaid Fee Schedules Effective January 1, 2026” reference links (covering multiple categories such as assistive care, behavior analysis, behavioral health overlay, birth center, community-based substance abuse county match, dental general, DME/medical supplies, and many others). It also lists fee schedule reference links for later effective dates (July 1, 2025; July 8, 2025; and October 1, 2025).

In addition, the proposed preliminary text updates “Florida Medicaid Billing Codes Effective January 1, 2026,” replacing/setting new incorporated-by-reference billing code reference links for multiple provider/service groups (including county health department, federally qualified health center, hospice, hospital outpatient services, intermediate care facility for individuals with intellectual disabilities, nursing facility services, prescribed drugs physician administered, rural health clinic, statewide inpatient psychiatric program services, and additional specified categories). It also states an “Effective July 1, 2025” billing codes reference link for prescribed drugs physician administered billing codes.

The notice does not specify effective or compliance dates for the rule change itself within the text provided; rather, it identifies the incorporated reference schedules/codes that will be effective on specific calendar dates (January 1, 2026; July 1, 2025; July 8, 2025; October 1, 2025). The document identifies Medicaid’s rulemaking authority and law implemented (409.919 FS; and implemented provisions including 409.902, 409.905, 409.906, 409.907, 409.908, 409.912, 409.913 FS).

FULL SUMMARY

The regulation sets the Florida Medicaid fee schedules and Medicaid billing code sets that are incorporated by reference and made available on the Agency for Health Care Administration (AHCA) website, specifying the effective dates for each schedule/code group.

It establishes fee schedules effective January 1, 2025 (including assistive care, behavior analysis, behavioral health overlay services, birth center, several community match/behavioral health services, county health department match, dental general, durable medical equipment and medical supplies for all Medicaid recipients, early intervention, family home health aide, hearing, home health visits, licensed midwife, Medicaid certified school match, medical foster care, occupational therapy, personal care, physical therapy, physician pediatric surgery, prescribed drugs immunization, and private duty nursing), and it also lists additional fee schedules effective July 1, 2025 (independent laboratory, practitioner, practitioner laboratory, and prescribed pediatric extended care services) and July 8, 2025 (specialized therapeutic services). It further specifies fee schedules effective October 1, 2025 (independent laboratory, practitioner, practitioner laboratory, and targeted case management services).

It establishes billing code sets incorporated by reference with effective dates: January 1, 2025 billing codes for multiple provider categories (county health department, federally qualified health center, hospice, hospital outpatient, intermediate care facility for individuals with intellectual disabilities, and nursing facility services); July 1, 2025 billing codes for additional provider categories and service groups (including rural health clinic and statewide inpatient psychiatric program services, plus a separate set for prescribed drugs physician administered billing codes). The document also reflects later-extending coverage on page 2 by listing other July 1, 2025 billing code categories (rural health clinic and statewide inpatient psychiatric program services).

Operatively, the document is structured as a single rule (59G-4.002) with incorporated-by-reference links to the AHCA/Rulemaking Gateway reference documents. No public comment, hearing, or delayed compliance dates are stated in the provided text; the key effective dates are January 1, 2025, July 1, 2025, July 8, 2025, and October 1, 2025. Rulemaking authority and law implemented are listed for references to Florida Statutes 409.919 and 409.902–409.913, and the rule’s history indicates it was newly created in 2005 and amended multiple times through 2026.

FULL SUMMARY

The bill establishes the “Georgia Medicare for All Program” as a universal single-payer healthcare system for all Georgia residents, to be administered by a newly created Georgia Medicare for All Board and funded through a newly created “Georgia Medicare for All Trust Fund.” The program is required to be established and implemented by no later than July 1, 2029, and the bill authorizes the Board to organize, administer, market, and contract for program services, while also seeking federal waivers/approvals and submitting state plan amendments to secure federal funding and federal program integration.

The bill creates an eligibility and enrollment structure under which every Georgia resident is automatically enrolled as a program member (unless disenrolled/disqualified). It prohibits members from paying enrollment fees and disallows member cost-sharing (premiums, copayments, coinsurance, deductibles, or other cost-sharing) for covered benefits. Covered benefits are broadly defined to include a wide range of medical services, ancillary services, care coordination, prescription drugs, and—explicitly—reproductive healthcare and gender-affirming care, as well as benefits that the bill requires to be covered regardless of the prior source (including Medicaid/PeachCare/Medicare and certain other state-covered services) and essential health benefits mandated as of January 1, 2026 under the federal Affordable Care Act. The bill requires participation rules for licensed healthcare providers and introduces an out-of-state service concept for medically necessary care furnished while a member is temporarily out of state.

A key program design feature is mandatory care coordination: the bill requires each member to enroll with a care coordinator before receiving services that the program pays for, and it defines care coordination to include administrative tracking and medical recordkeeping subject to state and federal privacy and record-retention requirements. The bill also authorizes and regulates “healthcare organizations” (nonprofit/governmental entities approved by the Board) that can provide program care coordination and ancillary services, and it establishes standards for care coordinators and healthcare organizations, including approval, renewal, and potential limitation/suspension/revocation for specified grounds.

The bill further creates data transparency requirements (including inpatient, emergency/ambulatory surgery, and detailed hospital financial data) and restricts law enforcement from using program money/property or program information to investigate/enforce certain violations. It also includes payment and reimbursement rules, including: payment rates must be reasonable and related to the cost of efficiently providing services; healthcare services (other than care coordination) default to fee-for-service unless/ until the Board establishes other methodologies; integrated delivery systems/essential community providers/group practices may choose specified budget-based reimbursement; participating providers may not charge amounts above the program’s payment rates or solicit/accept extra payment from members/third parties (subject to federal-program exceptions); and payments are “considered payment in full.” It also adds a collective negotiation framework allowing healthcare providers to negotiate terms for contracts through an authorized providers’ representative, with limits on concerted actions outside the representative framework.

Separately from the single-payer program, the bill repeals and replaces Georgia abortion-related statutes by creating a “Reproductive Freedom Act” in Title 31 (including explicit state protections for the right to choose abortion and refuse contraception/sterilization), establishes prohibitions on state/local law enforcement interference with abortion rights when performed in accordance with the new chapter, and sets limits on disclosure of reproductive-health information by covered entities without consent. It repeals related earlier gender-dysphoria/minors provisions in multiple titles (Title 31 for minors’ treatment rules; Title 42 for certain prohibited inmate treatment categories as revised; Title 43 for certain gender-dysphoria-related professional restrictions) and repeals a Medicaid expansion prohibition provision by amending prior Medicaid-related statutes. Finally, it makes numerous conforming statutory changes across Titles 1, 15, 16, 19, 31, 33, 43, 45, 48, and 49, including revising definitions to include “unborn child” as a “natural person,” revising juvenile court reporting provisions related to abortion without disclosure under open-records rules, and adding a Medicaid payment requirement for abortion/abortion-related services for medical assistance recipients.

The bill includes a contingent effective date for Part II (the Medicare for All program) that applies only upon the effective date of a specific appropriation item in the state’s General Appropriations Act referencing the bill, while Parts III–VI become effective upon approval by the Governor or upon becoming law without such approval.

FULL SUMMARY

The bill adds a new statutory section to Georgia’s pharmacy benefits manager (PBM) regulation chapter requiring PBMs to ensure final reimbursements to certain “eligible pharmacies” for prescription drugs follow specified minimum pricing formulas tied to drug acquisition costs plus a professional dispensing fee.

The new section defines “affiliate pharmacy” (based on ownership/investment ties to a licensed PBM), “eligible pharmacy” (a pharmacy not owned by an entity/natural person with ownership interests in more than 10 pharmacies), “rural area” (counties with population under 50,000 per the 2020 decennial census or any future such census), and “rural pharmacy” (eligible pharmacies located in rural areas). It then requires that, after accounting for all fees/charges/adjustments/reductions (including direct/indirect renumeration fees, administrative/performance-based/network access fees, and similar constructs), the final reimbursement equals the national average drug acquisition cost at dispensing plus a professional dispensing fee equal to the current Georgia Medicaid professional dispensing fee determined by the Department of Community Health. If the national average drug acquisition cost is unavailable, the PBM must reimburse at the wholesale acquisition cost (as defined in 42 U.S.C. §1395w-3a(c)(6)(B)) as of January 1, 2026, plus the same Medicaid-determined professional dispensing fee, and must exclude reimbursements made under the new subsection from any “effective rate guarantees” (defined as contract provisions that permit adjusting reimbursement rates so overall reimbursement averages out to a predetermined rate).

The section includes applicability limits: it does not apply to a “state health plan” (as defined in O.C.G.A. §45-18-22) and does not apply to Medicaid under Chapter 4 of Title 49, including Medicaid managed care programs administered through care management organizations. It also clarifies that PBMs are not prohibited from reimbursing a rural pharmacy above the required national average acquisition cost plus the Medicaid dispensing fee; however, that rural-upcharge exception does not apply to affiliate pharmacies, mail-order pharmacies, and specialty pharmacies. The bill sets an effective date of July 1, 2027, and repeals conflicting laws.

FULL SUMMARY

The bill establishes a restructuring of Hawaii’s Medicaid delivery and administration away from risk-based managed care and toward a managed fee-for-service model with separate funding for care coordination. Beginning July 1, 2026, the Department of Human Services (DHS) is prohibited from initiating, renewing, or extending any contract with a “financial risk-bearing entity” to administer Medicaid services for all DHS Medicaid programs, including Med-QUEST and successors; existing managed care organization contracts must terminate no later than December 31, 2026.

To operationalize the new model, DHS must contract with one or more “administrative services organizations” to perform non-risk administrative functions for Medicaid administration. These functions include prior authorization review (used judiciously and only for demonstrated risk of unnecessary use), provider credentialing/recruitment (with DHS retaining participation-status authority and permitting exclusion for specified misconduct), customer service and grievance resolution, data analytics and utilization monitoring, claims processing, and administrative support for care coordination programs. DHS retains primary responsibility and oversight; administrative services organizations may not create separate provider networks and must operate within a unified statewide, publicly managed network. Contracts must include transparency and data-sharing obligations, and DHS must ensure public reporting of performance metrics, audit results, and stakeholder feedback.

The bill requires DHS to create a Medicaid care coordination program that contracts with community-based interdisciplinary teams to provide culturally responsive patient navigation, transportation, care planning, chronic disease management, specialist consultations to primary care, specialized programs (including for serious mental illness and substance use disorders), geriatric needs programming, behavioral health integration, and culturally competent outreach. DHS must provide fixed, predetermined care coordination payments to primary care practices designated by enrollees as their coordinated-care source, and care coordination program funding must come from program budgets (not capitation) to avoid shifting insurance risk to providers. DHS must also develop and publish performance metrics. DHS must establish regional health hubs in each county (with quarterly meetings and specified community representation) to monitor community needs, disparities, and service gaps, recommend best practices, and support care coordination strategies; hubs receive operational funding and must submit annual reports to DHS and the legislature. The bill further requires transparency and data ownership: DHS contracts for administrative functions must comply with Hawaii’s Uniform Information Practices Act and related public-record laws, the State must retain exclusive ownership of Medicaid-related data, and DHS must maintain a quarterly public data dashboard (de-identified data) plus an annual data report.

Public health functions (vaccination programs, disease surveillance, emergency response coordination, and health education) must remain under the direct administration of DHS’s Department of Health and cannot be delegated to administrative services organizations or other contractors; DHS must integrate public health operations with Medicaid where appropriate using its own staffing, infrastructure, and funding without reliance on privatized intermediaries. DHS must convene a Medicaid stakeholder advisory group during the transition. DHS is directed to seek any necessary amendments to the state Medicaid plan or Medicaid waivers from CMS to implement the above operational changes. The bill appropriates general funds for FY 2026–2027 for transition and administrative systems, care coordination fund activities, regional health hubs, and provider recruitment/training/retention, and sets the effective date as July 1, 2026, except that Sections 2–7 take effect only upon CMS approval of the Hawaii Medicaid state plan. It also includes a standard severability clause and provides definitions for key terms including administrative services organization, financial risk-bearing entity, managed fee-for-service, care coordination, and regional health hub.

FULL SUMMARY

The bill establishes a shift in Hawaii’s Medicaid delivery and administration model away from risk-based managed care toward (1) fee-for-service payment for clinical services directly by the State and (2) separately funded, non-risk care coordination and administrative functions. It creates requirements for contracting with administrative services organizations that do not assume financial risk, sets up a statewide Medicaid care coordination program, requires direct provider payment, and establishes county-based regional health hubs and a statewide Medicaid stakeholder advisory group to guide and monitor implementation.

Beginning July 1, 2026, the Department of Human Services may not initiate, renew, or extend contracts for Medicaid administration with “financial risk-bearing entities,” and all existing managed care organization contracts must terminate no later than December 31, 2026. The bill also prohibits a fiscal intermediary from receiving capitated payments or assuming financial risk for Medicaid enrollees; Medicaid health care services must be paid directly from the State to providers on a fee-for-service basis, with care coordination funded separately (except that capitation is not used for direct care other than a fixed, predetermined monthly care coordination fee paid to a provider/practice designated by the beneficiary as the coordinator of care).

The bill requires the Department to contract with one or more administrative services organizations to perform defined non-risk administrative functions, including judicious prior authorization review (focused on services with demonstrated risk of non-medically necessary use), provider credentialing and recruitment (with the State retaining authority over participation status, subject to disqualification for material professional misconduct), customer service and grievance resolution, data analytics and utilization monitoring, claims processing, and administrative support for care coordination program operations. Administrative services organizations must not maintain separate provider networks; each enrollee must access care through a unified statewide publicly managed provider network inclusive of safety-net and culturally competent providers, and contracts must require compliance with Hawaii’s Uniform Information Practices Act and other public-record/data transparency laws, with the State retaining exclusive ownership of Medicaid-related data.

The bill establishes the Medicaid care coordination program through community-based interdisciplinary teams providing patient navigation, transportation, interdisciplinary care planning, chronic disease management, specialist consultations to primary care, specialized programs for serious mental illness and substance use disorders, geriatric-focused care, behavioral health integration, and culturally competent outreach. It sets direct compensation terms: physicians and independent practitioners are paid directly by the State on a fee-for-service basis at least 100% of applicable Medicare rates (adjusted for geographic and practice-specific factors), and eligible providers receive a fixed, predetermined care coordination fee drawn from the care coordination program. Hospitals and institutional providers must also be reimbursed directly via fee-for-service methodologies designed to promote stability and access. Regional health hubs must be established in each county, convene at least quarterly, include specified stakeholder representation, and submit annual reports; public health functions (vaccination, surveillance, emergency response coordination, and health education) must remain under the Department of Health and cannot be delegated to non-risk administrative contractors. The Department must apply to CMS for Medicaid plan amendments or waivers needed to implement sections 2 through 7, publish a quarterly publicly accessible de-identified data dashboard and an annual data report, and provide legislative reporting: an annual report due at least 40 days before each regular session beginning with 2027, plus a detailed budget and implementation timeline due by December 1 (year not fully displayed in the text). The bill appropriates general funds for fiscal year 2026–2027 for transition and infrastructure, the care coordination fund, regional health hubs, and provider recruitment/training/retention, and it takes effect July 1, 2026 with sections 2–7 effective upon CMS approval of the state Medicaid plan.

The bill directs the Hawaii Department of Human Services (DHS) to adopt rules under Hawaii’s administrative procedures (chapter 91, Hawaii Revised Statutes) to expand eligibility for the State’s Medicaid programs to all children statewide from birth through age five years, with no income requirement.

The bill appropriates general funds for fiscal year 2026–2027 to support the Medicaid eligibility expansion, to be expended by DHS for the purposes of the Act.

The Act’s effective date is December 31, 2050.

FULL SUMMARY

The bill establishes a new Medicaid operating model for Hawaii based on non-risk administration and separate funding for clinical services versus care coordination. It prohibits the Department of Human Services (DHS) from initiating, renewing, or extending contracts with financial risk-bearing entities for Medicaid administration and requires that existing managed care organization contracts end by December 31, 2026, with DHS support for a smooth transition. It also bars a fiscal intermediary from receiving capitated payments or assuming financial risk for Medicaid enrollees; Medicaid clinical payments must be made directly from the State to providers on a fee-for-service basis, while care coordination is funded through a separate mechanism.

DHS is required to contract with one or more “administrative services organizations” (ASOs) to perform non-risk administrative functions, including judicious prior authorization (only where non-medically necessary use is demonstrated risk), provider credentialing and recruitment, customer service and grievance resolution, data analytics/utilization monitoring, and claims processing. ASOs must not establish separate provider networks; care must be accessed through a unified statewide provider network that DHS manages and that includes safety-net, culturally competent, and geographically distributed providers. DHS must retain primary responsibility for Medicaid administration, provider payment, and oversight of ASOs, and DHS must impose transparency and data-sharing requirements, including public reporting of performance metrics, audit results, and stakeholder feedback. The bill also requires DHS to establish a Medicaid care coordination program that contracts with community-based interdisciplinary programs to provide patient navigation, transportation for health care, interdisciplinary care planning, chronic disease management, specialist consultations to primary care, programs for serious mental illness and substance use disorders, geriatric care needs, behavioral health integration, and culturally competent outreach.

The bill requires direct provider payment: physicians and other independent practitioners must be paid fee-for-service by the State Medicaid agency at not less than 100% of applicable Medicare rates for the same services, adjusted for geographic and practice-specific factors set by DHS. Hospitals and other institutional providers must be reimbursed directly through fee-for-service payments using methodologies intended to promote financial stability, access, and alignment with the bill’s goals. Separately, DHS must provide a fixed, predetermined care coordination fee to primary care practices formally designated by a Medicaid enrollee as their source of coordinated care; care coordination is funded through care coordination program budgets (not capitation) and DHS must develop and publish performance metrics covering patient satisfaction, reductions in avoidable hospitalizations, improved chronic disease management, and culturally appropriate service delivery.

The bill creates county-based “regional health hubs” as localized oversight bodies that monitor community health needs and disparities, identify service gaps, recommend culturally responsive best practices, facilitate continuous provider/patient feedback, and provide quarterly meetings with specified stakeholder representation. It mandates transparency and data ownership: contracts with ASOs must comply with Hawaii’s Uniform Information Practices Act and other open-records laws; the State retains exclusive ownership of Medicaid-related data; and DHS must maintain a publicly accessible, de-identified data dashboard updated quarterly plus an annual data report. It also keeps public health functions under the direct control of the Department of Health and prohibits delegation of vaccination, disease surveillance, emergency response coordination, and health education to ASOs or other third parties. Additionally, DHS must convene a Medicaid stakeholder advisory group to monitor implementation during the transition. DHS must submit legislative reports (beginning 40 days before the 2027 regular session) with detailed financial, provider participation/quality metrics, challenges, and recommendations, and must also submit a detailed budget and implementation timeline by December 1 (with a fill-in in the text). DHS must apply to CMS for any Medicaid plan amendments or waiver authority necessary to implement sections 2 through 7. The bill appropriates general funds for FY 2026–2027 for transition infrastructure/system shifts, care coordination funding, regional health hubs, and provider recruitment/training/retention, and it takes effect July 1, 2026, except that sections 2 through 7 take effect upon CMS approval of the Hawaii Medicaid state plan.

FULL SUMMARY

The bill establishes a new Idaho “Prior Authorization Reform Act” within Title 41 (new Chapter 35) creating requirements governing how health insurance issuers and contracted utilization review organizations administer prior authorization for health benefit plans and stand-alone dental benefit plans.

Key changes and requirements include: (1) defining “prior authorization,” “complete prior authorization request,” “adverse determination,” and “expedited prior authorization request,” and setting chapter purposes (reduce unreasonable interference, prevent disruption of medical judgment, and require transparency); (2) requiring issuers to maintain and publicly post complete, current prior authorization service lists and access to clinical review criteria (including Idaho-specific effective/termination dates and, when applicable, access to standardized electronic submission processes); (3) requiring clinical review criteria to meet evidence- and standards-based consistency, accreditation alignment, and annual physician-directed updates; (4) establishing notice and timing rules for new or amended prior authorization requirements (generally 60 days advance notice to impacted enrollees and providers, with limited exceptions such as fraud/abuse findings, scarcity, FDA-authorized clinical trials, legal changes in <60 days, or removal of requirements); and (5) requiring issuers to report prior authorization approval/denial and appeal statistics to the Department of Insurance.

Operational process requirements include: (1) an electronic prior authorization API by January 1, 2027, conforming to CMS interoperability standards and supporting electronic request/response exchange; (2) rules for what makes a prior authorization request “complete,” including that minor clerical/technical errors not materially affecting adjudication cannot prevent “complete” status and that completeness is presumed unless additional specific information is requested within one business day; (3) standard prior authorization decisions within 7 calendar days after receipt of a complete request (with only reasonably necessary additional information and limit on requests for additional information to once per request absent materially new clinical information); (4) expedited decisions for urgent health care services within 72 hours after receipt of a complete expedited request (and requiring trained, appropriately licensed physician consultation mechanisms); and (5) adverse determination notices that must include reasons/evidence-based criteria and appeal rights, plus instructions for filing appeals, documentation needed for appeal, and the right to independent external review under Idaho law.

The bill also establishes appeal personnel and insurer and continuity rules: appeals must be peer reviewed by appropriately licensed and specialty-qualified professionals not directly involved in the adverse determination; insurers must periodically review prior authorization requirements and consider removal; issuers are limited in revoking or further restricting valid prior authorization approvals except for defined circumstances (fraud/abuse, unavailability/need for alternative service, FDA safety alerts or public health emergencies, changes required by accepted standards, legal changes within 60 days, or documented material clinical change); approvals have set validity periods (generally 6 months, with potential extension by agreement); recurring chronic-condition approvals must remain valid for the lesser of 12 months or the treatment length determined by the treating professional; and the bill requires continuity of prior approvals for at least the initial 90 days after an enrollee moves to a new health plan upon receipt of documentation, while allowing issuer review during that continuity window. Enforcement and administration are assigned primarily to the Idaho Department of Insurance, including cease-and-desist authority, plans of correction, and administrative fines up to $10,000 per violation for specified failures; there is no private right of action. The bill includes mandatory annual issuer reports (first due by June 1, 2027, and each June 1 thereafter) and creates penalties for knowing false prior authorization requests by routing findings to relevant licensing oversight and prosecuting authority. Finally, it creates a de minimis exemption allowing issuers with prior authorization use on fewer than 1% of claims to elect exemption via annual Department attestation, subject to Department verification and potential revocation. The act becomes effective January 1, 2027.

FULL SUMMARY

The bill amends Idaho Code § 56-265 (Provider Payment) and nullifies specified Idaho Administrative Procedure Act (IDAPA) rules effective on and after July 1, 2026. It also contains an emergency clause making the act effective upon passage and approval.

The substantive statutory change is in § 56-265(2): for Medicaid home and community-based services (HCBS) without a Medicare-equivalent rate, the department must cost-survey annually and ensure at least 15% of responses are audited, using the cost survey and other sources to evaluate rate adequacy. The bill further requires payment rates to include allocations for direct care worker wages, employee-related expenses, program-related expenses, and general and administrative costs, with providers required each year to expend at least the allocated amounts for wages and employee-related expenses. Failure to meet that expenditure requirement can trigger department-approved corrective action plans, closure of intake, or termination of the provider agreement. The department must also summarize the audited cost-survey work by provider type and service in a publicly available report no later than December 31 each calendar year.

The bill also removes/overrules the continued effect of certain administrative Medicaid Plan Benefits rules identified as IDAPA 16.03.26, specifically Section 051 and Section 052. Those rules are declared null, void, and of no force and effect on and after July 1, 2026.

Finally, the bill includes an emergency declaration, so it takes effect on and after passage and approval, despite parts of the administrative-rule nullification being effective later (July 1, 2026).

FULL SUMMARY

The bill establishes a new “Emergency Care Affordability Act” within Title 41, creating insurance requirements to protect covered persons from high-cost billing for emergency services provided by out-of-network freestanding emergency rooms and out-of-network providers.

It defines key terms including “allowed amount,” “emergency medical condition,” “emergency services,” and—critically—“freestanding emergency room” (a 24-hour, physically separate facility that principally provides unscheduled emergency services and participates in the federal independent dispute resolution process; exclusions include critical access hospitals and certain hospital- and physician-owned facilities). It also defines “out-of-network provider/facility,” including affiliates and billing entities that submit or attempt to submit claims on their behalf.

For covered emergency services, an out-of-network freestanding emergency room must accept the health benefit plan’s “allowed amount” for the same specialty/type in-network service in the same geographic area as payment in full, and may not bill the covered person for amounts above that allowed amount (regardless of billing entity, coding modifiers, or use of affiliated third parties). The covered person’s cost-sharing must be calculated using the plan’s in-network benefit design; the plan must pay the provider directly (minus covered-person cost sharing) without regard to beneficiary assignment or similar agreements. Any contract or consent allowing excess billing/balance billing for covered emergency services is void and unenforceable.

The bill further requires specified disclosure when an out-of-network freestanding emergency room furnishing emergency services is not enrolled in Medicare, Medicaid, or TRICARE: a plain-language notice (given as soon as practicable after the medical screening exam, only when the patient is conscious/oriented/capable and without interfering with stabilization) stating the facility’s nonparticipation and that the covered person may be personally responsible for some/all charges. Failure to provide the required disclosure creates a rebuttable presumption the covered person was not informed and, absent contemporaneous compliance documentation, bars the facility from billing/collecting/seeking reimbursement for emergency-services charges, rendering violative bills/invoices/collection attempts void. It adds rules for self-funded plans: the chapter applies to self-funded health plans only if they elect to participate by annual notice to the Idaho Department of Insurance and the election applies for the plan year; the director must publish an annual list of participating self-funded plans. Enforcement includes attorney’s fees and costs for covered persons or plans to challenge violations, voiding any violative billing by out-of-network facilities and affiliated billing entities, authorizing the director (upon written request) to inquire with the patient’s health benefit plan to verify payment consistency, and treating each attempt to bill/collect in violation as a separate violation. The act takes effect July 1, 2026, and an emergency clause makes it effective that date.

FULL SUMMARY

The rulemaking proposes changes to 89 Ill. Adm. Code Part 148 (Hospital Services) by targeting two existing reimbursement provisions: Section 148.423 (Hospital Outpatient Adjustment) and Section 148.425 (Directed Payment Classifications).

For Section 148.423, the proposal lowers the Hospital Outpatient Adjustment Payment rates effective January 1, 2024. Specifically, for High Medicaid General Acute Care Hospitals, the rate would drop from $375 (through December 31, 2023) to $136 (effective on and after January 1, 2024). For Other General Acute Care Hospitals, the rate would drop from $325 (through December 31, 2023) to $118 (effective on and after January 1, 2024). The annual payment methodology (hospital’s 2019 outpatient claims multiplied by the applicable group rate) remains the same, with the qualifying criteria unchanged in the text provided.

For Section 148.425, the proposal adds a directed-payment classification election for certain hospitals. Beginning January 1, 2026, hospitals that were assigned to the High Medicaid Hospital class in the prior year and newly qualify as safety-net hospitals would be permitted to elect to remain in the High Medicaid Hospital class for directed-payment purposes for certain services. If a hospital makes this election, it must remain in the High Medicaid Hospital class for the entire calendar year. The rulemaking states that if the amendment cannot be adopted on January 1, 2026, the Department will reconsider emergency rulemaking at that time.

The notice requests written comments within 45 days after publication of the notice and indicates the Department will consider comments received during the first notice period as required by the Illinois Administrative Procedure Act. It also provides that there is no automatic repeal date and no incorporations by reference. The proposed changes are authorized under the Illinois Public Aid Code (305 ILCS 5), and the notice identifies public act authority including SPA IL-23-0032 (for the outpatient adjustment rate changes) and Public Act 104-0007 (for the safety-net election related to directed payments).

FULL SUMMARY

The rule establishes a new hospital reimbursement provision in 89 Ill. Adm. Code 148.200 to provide quarterly supplemental “Critical Access Hospital OB and Other Treatment Services Payment (CAHOOTS)” to publicly owned critical access hospitals in Illinois for perinatal and obstetrical or gynecological services and other specialty services. Payments are financed through an annual amount of $3,500,000 and are implemented under criteria tied to hospital location, eligibility as a Critical Access Hospital, and whether the hospital is owned or operated by an Illinois government body or municipality. The rule became effective May 20, 2026 and does not include an automatic repeal date or incorporations by reference.

The provision sets qualification requirements: (1) the hospital must be located in Illinois; and (2) it must meet the definition of a Critical Access Hospital in Section 148.25(g). For qualifying government/municipality-owned or -operated hospitals, the quarterly payment equals $875,000 multiplied by the lower of (a) a market-share quotient based on the hospital’s “adjusted outpatient claims” for the data quarter divided by the total “adjusted outpatient claims” for all qualifying hospitals in the same quarter, or (b) 10%. For qualifying hospitals not owned or operated by an Illinois government body or municipality, the quarterly payment equals $2,500,000 multiplied by the same “lower of” formula using adjusted outpatient claims, subject to the same 10% cap.

The rule also establishes a redistribution mechanism for any remaining funds after quarterly payments under the capped formula for the government-owned/municipality-owned group and the non-government group. Remaining funds are distributed in the payment quarter to qualifying hospitals that have not reached the 10% limitation, calculated as the product of (1) all remaining funds and (2) a quotient of the hospital’s total adjusted outpatient claims in the data quarter divided by the total adjusted outpatient claims for only those qualifying hospitals that have not reached the 10% limitation.

Definitions are included for key terms used in the payment methodology. “Data Quarter” is the quarter of the calendar year that begins six months and ends three months prior to the payment period; “Payment Quarter” is the quarter of the calendar year when payments will be made. “Adjusted Outpatient Claims” are defined as the number of paid MCO encounter outpatient claims for services covered under Title XIX of the Social Security Act, excluding days for individuals eligible for Medicare under Title XVIII (with additional definitional detail continuing in the section text). The rule’s adopted-action notice states that it was added by public act authority and that prior CMS-directed payment policy changes delayed implementation until after January 1, 2025; a provider notice issued June 16, 2025 set the methodology for the first two quarters of calendar year 2025.

FULL SUMMARY

HB4701 establishes the “Limitations on Facility Fees Act,” creating new limits on when health care providers may charge, bill, or collect “facility fees” for certain outpatient services and emergency-center settings.

Under the Act, a health care provider generally may not charge a facility fee except in three site-specific circumstances: (1) services provided on a hospital’s campus; (2) services provided at a facility that includes a licensed hospital emergency department; or (3) emergency services provided at a freestanding emergency center. In addition, the Act imposes service-specific limits: notwithstanding the site rules, no facility fee may be charged for outpatient evaluation and management services, or for other outpatient diagnostic or imaging services that the Department of Public Health identifies through its annual process.

The Department must annually identify which outpatient diagnostic or imaging services may reliably be provided safely and effectively in settings other than hospitals; the identified services are those for which facility-fee limitations do not apply under the Act’s service-specific restrictions. The Act also requires annual reporting by each hospital, health system, and freestanding emergency center to the Department about facility fees charged or billed during the preceding calendar year, including facility locations, patient-visit counts, Medicare/Medicaid/private insurance amounts and ranges, hospital-based facility and provider/system-wide revenue totals from facility fees, and detailed “top 10” procedures/services (by both fee gross revenue and patient volume) using CPT category I code groupings, plus other information the Department may require. Providers must also make relevant books, documents, records, or data available to the Department (or its designee) for audit purposes until four years after furnishing services for which a facility fee was charged, billed, or collected.

The Department may adopt rules to implement the Act, including reporting formats/content and penalties for noncompliance. Enforcement treats violations as unlawful practices under the Consumer Fraud and Deceptive Business Practices Act, and authorizes administrative penalties up to $1,000 per occurrence. The bill also: (1) amends the Fair Patient Billing Act’s Section 12 to align with the new facility-fee limits while retaining the requirement that hospitals develop patient-notification policies when charging facility fees separate and distinct from professional fees; and (2) adds a new provision to the Consumer Fraud and Deceptive Business Practices Act stating that any person who violates the Limitations on Facility Fees Act commits an unlawful practice.

FULL SUMMARY

The document contains a house resolution urging action by the Illinois Department of Healthcare and Family Services (HFS) regarding Medicaid managed care pharmacy reimbursement.

It resolves that HFS should ensure pharmacies participating in Medicaid managed care networks are reimbursed for covered outpatient prescription drugs at a rate no less than what pharmacies would receive under the Illinois Medicaid fee-for-service (FFS) pharmacy program, including both the ingredient cost methodology and the professional dispensing fee.

It further urges HFS to implement this reimbursement “parity” through Medicaid managed care organization (MCO) contracts and pharmacy benefit manager (PBM) agreements to promote consistent, transparent, and fair pharmacy reimbursement across the Medicaid program. The resolution also urges HFS to monitor and report to the General Assembly on the impact of reimbursement parity on pharmacy network participation, patient access to medications, and pharmacy closures in Illinois, and to evaluate how parity affects pharmacy deserts, rural health access, and Medicaid beneficiary access to pharmacist-provided patient care services (including medication counseling, chronic disease management support, HIV PrEP/PEP, contraception assessment, and preventive health services).

Finally, it directs delivery of a copy of the resolution to the Director of HFS.

FULL SUMMARY

The bill establishes the “Transparency in Downcoding Act” to regulate how Illinois health care payors (including group health plan sponsors, health insurance issuers, and Medicaid managed care organizations) adjust or reduce (“downcode”) submitted claim codes. It defines key terms (including CARCs and RARCs; “downcoding” and an exclusion for grouping/bundling required by integrity rules) and applies to specified health insurance policies/contracts and certain publicly issued coverage arrangements issued, amended, delivered, or renewed on or after the act’s effective date.

Beginning January 1, 2028, the bill prohibits (1) automatic downcoding that bypasses evaluation of billing provider information and requires downcoding determinations to be made or reviewed by a qualified natural person consistent with CPT coding guidance; and (2) downcoding solely based on reported diagnosis codes. When downcoding occurs, payors must notify billing health care professionals using appropriate CARCs/RARCs and must include the specific clinical/coding justification, the original and revised service codes and payment amounts, and the process to dispute the decision.

The bill requires a dispute process for downcoded claims, including clear written/electronic instructions, dispute contact information, and submission timelines no less than 90 days. It also requires that all downcoding disputes be reviewed by a natural person who is knowledgeable about the services under dispute, was not directly involved in the original decision, performs a documented review of supporting clinical information (including pertinent medical records and any medical literature provided by the billing professional), and follows CPT coding guidelines in effect at the time of service. The bill further requires that downcoding not be targeted or discriminatory against providers who routinely treat patients with complex or chronic conditions, and clarifies that the existence of the dispute process does not limit other available appeals under applicable state or federal utilization review law.

For enforcement, the Department of Insurance enforces payors’ compliance (including restrictions on automated downcoding and pattern/practice violations), while the Department of Healthcare and Family Services enforces Medicaid managed care organizations’ compliance subject to federal requirements. The bill adds a new provision to the Illinois Public Aid Code requiring all managed care organizations to comply with the act, includes severability, and sets the effective date as January 1, 2028.

FULL SUMMARY

The bill adds a new Section 368k to the Illinois Insurance Code establishing minimum reimbursement requirements for physicians in specified Illinois counties. It defines relevant terms (including “County” as Cook, DuPage, Lake, and Will; “covered health care service” as services for which a Medicare rate has been established at the time provided; “Medicare rate” as the applicable Medicare Physician Fee Schedule CPT rate in effect when services are rendered; and “physician” to include licensed physicians/osteopaths and advanced practice providers practicing under physician supervision).

Under the new Section 368k(b), a health insurance company must reimburse a physician for covered health care services provided in any of the covered counties at no less than 160% of the applicable Medicare rate for the same service. If Medicare establishes multiple payment rates for a service, subsection (c) requires calculating the reimbursement floor using the rate that most closely corresponds to the setting and type of service.

The bill makes lower-than-minimum reimbursement provisions void and unenforceable to the extent they conflict with the minimum reimbursement requirements. It also prohibits a physician from waiving the protections of the Section as a condition of participation in a health benefit plan or for any other reason. The Department of Insurance is directed to enforce the Section and may adopt rules to implement it.

Violations by a health insurance company subject the company to civil penalties up to $15,000 per individual violation, payment of restitution to the affected physician, and any additional remedies authorized by the Department.

FULL SUMMARY

The Department of Healthcare and Family Services proposes changes to 89 Ill. Adm. Code 140.71 governing C-13 invoice voucher advance payments and expedited claims payments. The proposal is tied to Public Act 104-0470 and adds/clarifies the Department’s authority and procedures to recoup unpaid advance balances when a provider fails to comply with advance payment agreement terms, including the methods and processes for recovery, notice, timing, and continued recoupment until the liability is satisfied.

The proposal establishes more detailed advance approval and repayment requirements for C-13 advance payments: C-13 advances remain an exception to the regular reimbursement process, limited to qualified providers under extraordinary circumstances. Eligibility criteria include enrollment with the Department, a defined emergency (severe and irreparable harm from withholding), and meeting “significant number of clients” thresholds by provider type; providers must also sign an agreement specifying reasons, amount, when recoupment begins, and recoupment method (e.g., percentage of payable amounts, fixed monthly amounts, warrant intercept, or combinations). For requests, the Department may require additional supporting financial documentation at its discretion, including lists of real/personal property and related liens/encumbrances, with provider certification and updates, and may also demand similar documentation upon default/breach/non-compliance and related renegotiation.

The proposal adds/clarifies recoupment terms and enforcement mechanics. For advance repayment agreements, the rule limits the recoupment period to a maximum of 36 months for properly certified/licensed/qualified providers, while stating recoupment should not exceed six months from the month payment is authorized; for providers not in good standing, recoupment proceeds from the next available payments and/or the designated recoupment methods. If the provider fails to comply, the remaining balance is subject to immediate recovery as specified in the recoupment provisions. It also maintains that prior agreements survive adoption/amendment of the section’s terms notwithstanding the new section.

Critically, the proposal establishes Department recoupment procedures upon default/breach/non-compliance: (1) notice requirements (a default/non-payment/breach notice, then an additional notice if non-compliance persists for 30 days); (2) a 30-day compliance window after which recovery actions begin, while clarifying that delay by the Department in initiating recoupment does not reduce provider liability or bar later action; (3) monthly recoupment of an agreed percentage (or Department-determined percentage if not listed), with an explicit option for the Department to immediately recoup the full remaining balance at any time after non-compliance; (4) recoupment sources in a specified order/availability approach (MCAPs/state-directed payments; FFS supplemental/GME supplementals; FFS Medicaid claims; MCO Medicaid claims; and other amounts payable by any State agency, including grants); (5) use of the Illinois Office of the Comptroller’s Offset System when applicable, and pursuit of other collection methods if no funds are available; (6) continued recoupment until the balance is satisfied with discretionary suspension/pausing if compliance is restored, and a limitation that after two recoupment initiations in a fiscal year the Department may terminate the agreement and collect the full remaining balance immediately; and (7) authorization to use any other collection remedies available under state or federal law.

The proposal also adds a limited-time renegotiation authorization for nursing facilities for advance repayment agreements involving nursing homes in effect prior to June 16, 2026: nursing facilities may enter renegotiated agreements only until August 15, 2026. If they do not renegotiate by that deadline, renegotiation is not reached, or the nursing facility fails to comply, the Department may immediately collect unpaid advance debts using the PA 104-0470 and other specified recoupment methods. Renegotiated agreements must provide repayment of the total amount owed over a 12-month period in equal increments, with payments beginning within 30 days of the signed agreement. Finally, expedited claims payments are retained as an acceleration mechanism under extraordinary circumstances with similar emergency and “significant number of clients” criteria, periodic Department review of continued need, and a written application requirement.

A public comment period is requested for 45 days after publication of the notice. (The notice text does not state an effective date or compliance deadline; it specifies only the comment submission deadline and review period.)

FULL SUMMARY

The rulemaking establishes four new Medicaid provider reimbursement sections within 89 Ill. Adm. Code 140, Subpart G (Maternal and Child Health Program): Section 140.925 (Doula Services), Section 140.926 (Lactation Consultation Services), Section 140.927 (Home Visiting Services), and Section 140.928 (Licensed Certified Professional Midwife (LCPM) Services). It also includes a new provider enrollment/payments framework for each service type and, for lactation and LCPM, replaces language from previously repealed sections.

Doula Services (140.925) requires doulas seeking enrollment to be certified by the Illinois Medicaid-Certified Doula Program administered by Southern Illinois University. Payment is made only when services are rendered by a certified and enrolled doula, recommended either by a physician/LPHA within scope per 42 CFR 440.130(c) or via the Illinois Department of Public Health standing recommendation, and provided to pregnant and birthing persons throughout the perinatal period (including labor and delivery) and up to 12 months postpartum regardless of how the pregnancy ends. Reimbursable doula services are limited to specified categories (e.g., perinatal counseling/education/support, labor support and birth attendance with birth plan development, coordination with community services, accompanying clients to clinician visits, emotional/physical support, and visits for basic infant care), and reimbursement is capped at the lesser of provider charges or the maximum fee schedule rate published by the Department.

Lactation Consultation Services (140.926) defines provider and credential requirements for Medicaid enrollment: lactation consultants must be certified and remain in good standing with one of several certifying pathways (IBCLCs, CLCs, or CLSs, as specified). Covered services must be performed within the scope appropriate to the credential and include comprehensive assessments and management of lactation-related conditions; evidence-based counseling on infant feeding decisions (including information about medications, alcohol/tobacco/addictive drugs, and herbs/supplements and impacts on milk production and child safety); development/implementation of personalized feeding plans; support to meet breastfeeding goals; and coordination to access other clinical and non-clinical supports (including WIC, primary care, and pediatric care and related services). Reimbursement is provided for the lesser of provider charges or the maximum fee schedule rate. The section also includes compliance and audit authority, with potential consequences for non-compliance (e.g., suspension/termination of provider status, recoupment of overpayments, and legal penalties) and an appeal right requiring submission within 30 days of Department decisions.

Home Visiting Services (140.927) establishes that “home visiting services” are prenatal, postpartum, and child home visits provided by a Home Visiting Organization to deliver informational support, facilitate screening, and provide care coordination for healthy outcomes. To enroll, organizations must demonstrate full accreditation or compliance with national standards for home visiting delivered under a state-approved evidence-based or research-informed model, as detailed in the Department-issued provider handbook. Payment is made when services follow the state-approved model standards, are delivered within the home visitor’s scope/credentialing, and are recommended by an LPHA within scope under 42 CFR 440.130(c) or using the Illinois Department of Public Health standing recommendation. Reimbursement is capped at the lesser of provider charges or the maximum fee schedule rate for the specific home visiting model. Licensed Certified Professional Midwife (LCPM) Services (140.928) establishes enrollment/credentialing: LCPMs must be licensed by Illinois (or equivalent out-of-state licensing body) and certified by the North American Registry of Midwives (NARM). Payment requires services to be delivered by the enrolled LCPM (or an assistant under direct supervision) and recommended by a licensed physician/PA/APRN under 42 CFR 440.130(c), with services provided to pregnant and birthing persons throughout pregnancy, birth, and postpartum. LCPM-covered services include comprehensive assessment/diagnosis/treatment across pregnancy through newborn care, physical exams, medication/device administration, ordering/interpreting allowable labs/diagnostic tests, and consultation/referral/linkage to other healthcare professionals; reimbursement is again limited to the lesser of provider charges or the maximum fee schedule rate.

Comment deadline and dates: the Department requests written comments within 45 days after publication of the notice; the notice itself does not specify an effective/compliance date for the proposed changes (it contains placeholders in the source sections). The rulemaking is stated to not replace an emergency rule and not include an automatic repeal date.

FULL SUMMARY

This notice sets proposed changes to Illinois’ Medical Payment rules for mental health services in 89 Ill. Adm. Code 140, specifically requesting amendments to Sections 140.424 and 140.453 and listing additional proposed new sections (140.925–140.928) elsewhere in the Part. The proposal is made pursuant to Public Act 102-0043 and Section 12-13 of the Illinois Public Aid Code, and it would broaden or clarify behavioral health provider eligibility and service definitions/qualifications for reimbursement under the Medical Assistance Program.

The proposed changes to Section 140.424 (Subpart D) revise the “Other Licensed Behavioral Health Practitioner” provider category to cover licensed clinical professional counselors (LCPC) and licensed marriage and family therapists (LMFT), not only licensed clinical social workers (LCSW). It defines “Other Licensed Behavioral Health Practitioner” to include LCSWs, LCPCs, and LMFTs, and specifies reimbursable services within each practitioner’s scope and clinical training: (1) developmental and behavioral health screening, (2) diagnostic evaluation, and (3) therapeutic services delivered in office, home, or community settings, including individual psychotherapy and family or group psychotherapy (with group psychotherapy required to meet referenced clinic guidelines in Section 140.462). Reimbursement is set at the lesser of provider charges or the maximum fee schedule rate published by the Department, and the section includes a provision that payment is not made for services identified in Section 140.6. It also reflects an effective dates concept for LCSWs (services effective for dates of service January 1, 2017 and after), while the notice text indicates the overall amended framework would incorporate the broader “Other Licensed Behavioral Health Practitioner” concept.

The proposed changes to Section 140.453 update community-based mental health service definitions and professional qualifications. The revised text reiterates that qualified professionals may provide only the services listed in the section within their scope of practice and includes expanded professional definitions relevant to reimbursement. Key qualification updates include explicit inclusion of licensed clinical professional counselors and marriage and family therapists within the “Licensed Practitioner of the Healing Arts (LPHA)” definition, and expansion of “Mental Health Professional (MHP)” to include additional credentialed roles, including (as listed) recovery support and family partnership professionals certified by the Illinois Alcohol and Other Drug Abuse Professional Certification Association, and a “veteran support specialist” who is certified by and in good standing with that Association. The “Peer Support Worker (PSW)” definition is also expressly retained/embedded with eligibility criteria (age 21, lived experience/caregiver experience, agency/teamwork and supervision participation, and completion of a Department-approved training/certification).

For timelines and process, interested parties may submit written comments within 45 days after publication of the notice; comments are considered during the first notice period as required by Section 5-40 of the Illinois Administrative Procedure Act. The notice does not replace an emergency rule and states there is no automatic repeal date. It also states there are other proposed rulemakings pending on this Part, referenced by new section numbers 140.925–140.928 with publication citations in the Illinois Register.

FULL SUMMARY

The Department of Healthcare and Family Services proposes to update 89 Ill. Adm. Code 147.310 (Implementation of a Case Mix System) to revise the STRIVE per diem staffing add-on methodology within the nursing facility rate for facilities licensed under the Nursing Home Care Act as skilled or intermediate care facilities. The proposal aligns the STRIVE staffing calculation with a PDPM-based STRIVE staffing ratio, includes a staged (four-quarter) transition to full PDPM implementation, and adjusts per diem add-on amounts tied to facility staffing performance relative to facility-specific targets.

Under the proposed changes, the variable per diem staffing add-on is linked to STRIVE study staffing percentages determined using PBJ staffing hours adjusted for acuity using MDS (and CMS Provider Information/COMPARED data sources). Facilities are subject to guardrails that limit minimum add-on eligibility (no add-on below 70% of STRIVE-indicated staffing after December 31, 2022) and constrain reductions across consecutive quarters (beginning April 1, 2023, reductions are limited to no more than 5% over two consecutive quarters). The rule also provides for rate corrections when PBJ data are missing/inaccurate or miscalculated, and continues to allow payment determinations to be appealed under referenced provisions.

The proposal updates the staffing-percentage denominator starting October 1, 2024 and revises it again starting January 1, 2025 by defining the “PDPM STRIVE Staffing Ratio,” including facility PDPM STRIVE staffing targets and a calculation that changes the facility target multiplier (e.g., 0.82 times Illinois adjusted facility case-mix hours per resident per day, and later 0.7122 times that measure). It specifies a transitional blend for the staffing percentage denominator for quarters from October 1, 2024 through September 30, 2025 (using weighted combinations of PDPM STRIVE staffing target and case-mix total nurse staffing hours), and it retains a planned schedule for full PDPM-based payment of the nursing component per diem starting October 1, 2023.

A Medicaid Access Adjustment is included in the surrounding 147.310 framework (effective July 1, 2022 through December 31, 2027) but the notice’s core focus is the STRIVE staffing add-on modernization and transition. Interested parties must submit written comments within 45 days after publication of the notice; comments will be considered during the first notice period under the Illinois Administrative Procedure Act. The notice states the proposal is not an emergency rule and contains no automatic repeal date and no incorporations by reference.

FULL SUMMARY

This interim rule temporarily supersedes specified Indiana Administrative Code provisions governing Hospital Assessment Fees (HAF) for both outpatient and inpatient services, and establishes a Medicaid fee-calculation framework based on each hospital’s Indiana net patient revenue. It applies to fee periods beginning after June 30, 2025 (Sections 1–14). A public comment period is provided with a deadline of August 28, 2026.

For outpatient HAF (Section 1), and inpatient HAF (Section 2), the rule directs the Family and Social Services Administration’s Office (OMPP) to collect an assessment fee from hospitals meeting statutory definitions and specific licensing criteria, and to exclude multiple hospital categories (e.g., long term acute care, state-owned, federally operated, freestanding rehabilitation; most freestanding psychiatric hospitals meeting a >90% admission composition test; out-of-state hospitals; certain hospitals governed by other statutes; physician-owned hospitals as defined in statute; and respite-care-only providers under specific age/medical-fragility limits). It also sets reduced assessment fee rates for designated hospital types: 50% for LIUR acute care and LIUR freestanding psychiatric hospitals; 80% for rural obstetrics hospitals; and for outpatient, 55% for Perinatal Level IV hospitals (inpatient is 70% for Perinatal Level IV). It specifies notice/reconsideration/appeal mechanics by cross-referencing Sections 13 and 14, payment collection methods (offset against Medicaid payments or otherwise as determined), allowance of payment plans (Section 9), interest on late payment, and additional enforcement including reporting to IDOH for potential license revocation after 120 days, plus Medicaid sanctions under IC 12-15-22.

Sections 3–12 and 15–14 establish the calculation mechanics and related definitions. The HAF is assessed, calculated, and paid on a state fiscal year basis and computed separately for inpatient and outpatient services. “Indiana net patient revenue” is defined as net patient revenue less the portion attributable to services to non-Indiana residents, determined using patient days; inpatient and outpatient Indiana net patient revenue are calculated separately (Section 4). Net patient revenue is generally based on cost reports for a hospital fiscal year ending in state fiscal year 2023, with discretionary Secretary authority to elect a more recent state fiscal year beginning after June 30, 2026, subject to uniform application and federal health-care-related tax compliance constraints (including broad-based/uniformity waiver and the B1/B2 redistributive statistical test requirements) (Section 5). The rule requires cost-report adjustments for non-12-month periods and exclusion of closed hospitals, excludes certain newly licensed hospitals lacking required cost report data, and authorizes data submissions by hospitals not certified for Medicaid participation that lack cost reports (Section 5).

The standard inpatient and outpatient rates are set each fee period so aggregate assessment fees do not exceed the lesser of (i) 6% of total inpatient/outpatient net patient revenue of assessed hospitals, or (ii) the maximum amount permitted under federal law for taxes on inpatient/outpatient hospital services (Sections 10 and 11). It further establishes base and incremental HAF components using Medicaid “state share” and DSH-related computations (Section 7), deposits base amounts into the hospital Medicaid fee fund and incremental amounts into a separate incremental hospital fee fund (Sections 7–8), and makes the adjustment authority explicit (Section 12), including refunds if an adjustment creates an overpayment (Section 12(c)). Eligibility and rate reductions interface with an outpatient hospital adjustment factor (for outpatient rates) designed to approximate the federal Medicare upper payment limit without exceeding it; inpatient rates similarly use an inpatient adjustment factor to approximate the relevant Medicare upper payment limit (Sections 1(n) and 2(o), and cross-referenced Sections 10–11). After calculating HAF, the office must provide written notice and a calculation explanation (Section 13), and hospitals may request administrative reconsideration within 45 days with a deemed denial if no timely decision is issued; subsequent appeal is permitted under IC 4-21.5-3 (Section 14). The interim framework expires 425 days after acceptance of the interim final rule for filing (Section 17).

FULL SUMMARY

The bill makes two main sets of insurance-related changes effective July 1, 2026. First, it expands hospital requirements in Indiana Code IC 16-21-9.5 by defining “collection action” and “payment assistance program,” and by creating a new hospital chapter requiring notice, signage, and electronic availability of payment assistance options (including charity care, financial assistance, and other payment plans). Hospitals must provide written notice of their payment assistance programs to patients (or representatives) during registration/intake, at discharge, and with the initial billing statement; the notice must include available program descriptions, eligibility criteria, application instructions, and contact information. Hospitals must also post conspicuous signage in registration areas and emergency departments, provide information electronically through any patient portal, and—before starting a collection action—make a reasonable effort to notify the individual and provide an application form. Nonprofit hospitals must annually report compliance in their community benefits plan report, and the state department may adopt rules and impose civil penalties up to $1,000 per violation, deposited in the state general fund.

Second, the bill creates new limits and process protections concerning “downcoding” of health benefits claims by insurers and health maintenance organizations (HMOs) under new IC 27-1-52 (effective July 1, 2026). The new chapter defines key terms (e.g., “downcode,” “health benefits claim,” “insurer/health maintenance organization,” and CARC/RARC) and generally prohibits practices that would prevent providers from submitting claims for actual services and collecting reimbursement for actual services performed. It prohibits insurers from using automated processes/system/tools (including AI) as the sole basis to downcode a medically necessary claim without review of the covered individual’s medical record by an insurer employee/contractor, and prohibits providers from submitting claims using automated tools without review by a provider or other claim-preparer. Insurers must disclose when AI is used to make adverse prior authorization determinations or to downcode; insurers may not downcode solely based on diagnosis codes; and if downcoding occurs, insurers must notify providers with appropriate CARC and RARC, provide the specific clinical reason and clinical criteria reference, list original and revised service codes and payment amounts, and include a notice of appeal rights. Providers must be afforded an appeal process with a submission timeline of at least 180 days and the ability to appeal in batches of substantially similar downcoding issues. The chapter also prohibits targeted/discriminatory downcoding against providers treating complex or chronic conditions and directs the department to adopt rules to implement it.

In addition to these new chapters, the bill makes related changes to existing claims adjustment and recoupment timing rules for both accident and sickness insurers and HMOs. For CPT code reimbursement rates, it adds restrictions that prevent retroactive reimbursement rate reductions for CPT codes and require at least 60 days’ written notice (mail/e-mail plus website posting) before prospectively reducing CPT reimbursement rates (for accident and sickness insurers and for HMOs). It also amends the existing insurer and HMO overpayment/recoupment and audit/correction timing limits by extending the referenced time periods (adding a “one hundred eighty (180) days” component to multiple thresholds). Finally, it adds new provisions in both the insurer and HMO chapters addressing recoupment due to coordination-of-benefits errors by allowing providers to submit claims to the appropriate insurer/HMO for the same services, while generally requiring submission within 90 days after recoupment (with documentation requirements for the original submission and the recoupment due to coordination-of-benefits errors, and allowing insurers/HMOs to grant more time). It includes applicability provisions limiting the new downcoding and rate/claim-adjustment protections to policies issued/renewed after specified dates, and it exempts Medicaid.

FULL SUMMARY

The bill (Senate Enrolled Act No. 1) (1) adjusts Indiana’s framework for accepting and appropriating federal funds; (2) expands and tightens Indiana requirements tied to federal SNAP and Medicaid eligibility and verification; and (3) creates/updates Medicaid managed-care and “Healthy Indiana” program rules, including new funding-account, cost-sharing, eligibility verification, and reporting requirements.

For federal fund handling, it updates IC 4-12-1-18 so that (retroactively effective January 1, 2026) federal funds received by an “instrumentality” remain appropriated for purposes specified by federal government and the General Assembly, subject to budget-agency allotment, and it reiterates applicability of grant/loan/gift processing provisions to instrumentalities. It also adds language to IC 4-12-1-18 via an earlier-enacted P.L.213-2025 change, and separately amends IC 4-12-1-18 and IC 12-8-15-related federal-funds allotment timing language (retroactively effective January 1, 2026) so federal funds received as revenue by a state agency/department generally are not available for expenditure until budget-agency allotment.

For SNAP, it (effective July 1, 2026) adds definitions of “candy” and “soft drink” (tied to IC 12-14-30-10) and prohibits SNAP recipients from using SNAP benefits to purchase candy or soft drinks, with a secretary duty to request any needed federal waivers/authorizations. It also adds a new SNAP eligibility verification section (IC 12-14-30-9, effective July 1, 2026) requiring the division to verify U.S. citizenship/eligible alien status using SSA’s database or SAVE during enrollment and recertification, requiring specified acceptable proof when verification fails, requiring DHS referral/enforcement handling for certain unverified/inadmissible status situations, and—if an individual is determined ineligible based on citizenship/immigration status—it restricts household income/resource treatment by requiring the division to consider the entire income/resources of ineligible individuals and disallow proration/exclusion under the referenced SNAP rules.

For Medicaid and the Healthy Indiana plan, the bill adds a new dedicated “Indiana Rural Health Transformation Fund” (IC 12-8-15, new Chapter 15, retroactively effective January 1, 2026) funded with specified federal Section 71401 funds, continuously appropriated, administered by the Office of the Secretary; requires that beginning December 1, 2026 allotments/expenditures be subject to budget committee review; imposes administrative-expense payment limits to what federal law allows; provides for investment and non-reversion of end-of-year balances; requires periodic benchmark/status reporting to the budget committee; and sunsets the fund at December 31, 2032. It further amends Medicaid program operations by adding new/expanded verification, eligibility redetermination, and data-matching rules (including ongoing eligibility redeterminations on specified schedules; monthly/quarterly/annual data sources to identify eligibility-changing circumstances; and termination-based actions such as ending enrollment when verified lottery/gambling winnings trigger ineligibility thresholds). It adds Medicaid rules addressing immigration-status income counting and new referral/enforcement steps tied to applicants/recipients’ citizenship/immigration status verification, including requirements to include immigration-status fields on Medicaid presumptive eligibility applications and to require verified immigration-status eligibility before approving presumptive eligibility.

For the Healthy Indiana plan (IC 12-15-44.5 series), it revises eligibility/work and participation rules (including changes to hours-based “work” criteria language), updates plan benefit package requirements and exclusions (e.g., no abortion/abortifacients under family planning benefits), and adds/adjusts patient cost-sharing and administration constraints: it adds/enforces health care accounts with required minimum annual deductibles, requires contributions/payment mechanics and initial-payment gating before benefits begin, conditions continued participation on making contributions, provides rules on benefit reduction/termination for failure to pay (with different effects depending on income relative to the federal poverty level), governs enrollment renewal timing, and adds eligibility verification limits (the secretary cannot rely on self-attestation or managed-care-designations as sufficient verification; compliance must be verified by the secretary). It also updates emergency-room nonemergency use restrictions by setting minimum copay amounts (with exceptions for sudden, severe conditions) and imposes a cap on total quarterly cost-sharing to 5% of family income. Operationally, it requires actuarial analysis submission to the budget committee, imposes limits on managed care organization fees/profit and administrative allocations of plan funds (including an 87%/13% allocation rule for certain plan funds), requires specified reporting/notice before plan extensions or material amendments to HHS (including notice to Indiana Hospital Association), and modifies how the secretary may negotiate/alter the plan subject to specific prohibitions on reducing minimum contribution/deductible/work-hour requirements and on removing certain penalties or account requirements.

Effective timing appears in multiple provisions: the rural health fund is effective retroactively January 1, 2026; SNAP-related definitions and the new SNAP eligibility/prohibition on purchases are effective July 1, 2026; Medicaid-related immigration and verification sections are effective July 1, 2026 and/or October 1, 2026 in specific subsections; Healthy Indiana plan changes are effective upon passage with some sections effective July 1, 2026 and others tied to January 1, 2027 for certain Medicaid process items. The act also contains an “emergency is declared for this act” clause.

FULL SUMMARY

The rule establishes and implements Indiana’s Hospital Assessment Fee (HAF) under a CMS-approved, broad-based and uniformity waiver methodology that shifts the assessment from a day-based framework to a net-patient-revenue (NPR) framework for both inpatient and outpatient hospital services. It also consolidates and coordinates the procedural requirements for notification, reconsideration, and adjustments so that hospitals follow a single set of processes tied to the updated HAF calculations.

The rule amends three Indiana Administrative Code provisions that together govern HAF methodology: it replaces the day-based, projected-cost approach in 405 IAC 1-22 and amends 405 IAC 1-8-5 (outpatient) and 405 IAC 1-10.5-7 (inpatient). Key changes include (1) redefining what triggers and how the assessment is calculated using inpatient and outpatient portions of a hospital’s Indiana net patient revenue, (2) replacing the inpatient/outpatient allocation approach and related “projection and annual true-up” with an NPR determination from cost report data, and (3) setting standard inpatient and outpatient assessment rates as the lesser of 6% of net patient revenue or the maximum amount permitted under federal law. It also adds/clarifies defined terms (including “fee period,” “Indiana net patient revenue,” and several rate/classification terms), clarifies “state share,” and formally recognizes base and incremental fee components, including a cap related to a DSH payment component used in calculating the base fee when the state-directed payment program operates.

The rule changes assessment applicability and exemptions. It adds exempt categories including county or municipal hospitals, physician-owned hospitals, and hospitals providing only respite care services (with an age limitation for individuals served) to the list of hospitals that are not assessed. It also adds or ties reductions to hospital classifications (including low-income utilization rate hospitals, rural obstetrics hospitals, and Perinatal Level IV acute care hospitals with specified reduced percentages for inpatient vs. outpatient services), and establishes that assessment notification, reconsideration/appeal, and adjustment requirements are governed by the consolidated 405 IAC 1-22 procedures. The rule also adds a cross-reference related to optional payment plans (up to 12 months) and includes nonpayment sanctions by reference to IC 12-15-22.

Operationally, FSSA is proposing an interim rule that takes effect on the date/time accepted for filing and applies retroactively to fee periods beginning after June 30, 2025, aligning with the waiver’s July 1, 2025 effective date; the rule is described as applying to fees for periods after June 30, 2025. Fiscal impacts described in the analysis estimate aggregate assessment revenue of about $2,007,125,426 for state fiscal year 2026 under the NPR methodology versus $1,642,566,604 in state fiscal year 2025 under the prior methodology (an increase of about $364,558,822). The fee is described as a dedicated non-federal-share funding mechanism, with no new fine or civil penalty created by the rule itself (the fee increase is presented as a cost to assessed hospitals), and no new administrative expenses are imposed on hospitals; hospitals generally continue to remit when due using data already on file (cost-report based rate-setting by FSSA/its contractor).

FULL SUMMARY

The document establishes Iowa Medicaid “conditions of eligibility” and related eligibility-factor rules within Iowa Administrative Code Chapter 75 (Human Services), covering both MAGI-related and non-MAGI-related eligibility pathways, definitions, eligibility categories, presumptive eligibility, medically needy eligibility and spenddown, and general requirements such as social security number, residency, citizenship/alienage verification, institutionalization rules, third-party liability, and estate recovery.

It contains an internal standards framework and operational details for multiple programs and eligibility mechanisms, including: family-related Medicaid categories (children, parents/caretakers, pregnant women, foster/subsidized guardianship/adoption groups, former foster care youth through age 26, and postpartum/continuous eligibility rules), breast/cervical cancer treatment coverage (including presumptive coverage), IHAWP eligibility and presumptive eligibility, refugee medical assistance (including extended coverage), SSI-related and other aged/blind/disabled pathways, medically needy coverage with defined spenddown methodology, and continuous eligibility rules for pregnant women and children. It also establishes presumptive eligibility processing through qualified entities using the Medicaid Presumptive Eligibility Portal, specifies attestation and verification rules for citizenship/qualified noncitizen status (including a 90-day “reasonable opportunity period” and limits on retroactive eligibility), sets conditions for public institution inmates, and provides extensive rules on third-party medical resources, medical assistance liens, and recovery.

Key program operations defined include: (1) transitional and extended coverage for certain FMAP discontinuations (up to 12 months transitional and up to four months extended, with fraud and income-change conditions), (2) MEPD (Medicaid for employed people with disabilities) with monthly premiums for specified income bands above 150% FPL, conditional eligibility requiring premium payment, due-date/cancellation rules, six-month retention when unable to work due to medical condition or job loss (with intent-to-return requirements), and (3) HIPP (health insurance premium payment) program rules governing cost-effectiveness thresholds, eligibility/payment timing, prohibited premium reimbursements for certain plan types/situations (including HDHP treatment), reporting/cancellation/reinstatement, and notice timing (including a 65-day decision deadline for cost-effectiveness).

The document also contains detailed asset-transfer and trust rules affecting Medicaid eligibility and/or long-term care services (e.g., disposal of assets for less than fair market value with look-back periods, penalty periods for institutional vs noninstitutionalized individuals, exceptions including home/spousal/disabled-child provisions, purchase of annuities/life estates/promissory notes treatment, and trust treatment for post–Aug. 10, 1993 trusts). It includes estate recovery and recovery/overpayment processes, specifying when debts arise (including estate recovery debt rules for members 55+ and for institutionalized members under 55 meeting criteria), possible waivers for undue hardship, and recovery appeals under Chapter 2506.

As indicated in the text for Chapter 75, it is part of a continuing regulation structure with recissions and editorial updates noted (e.g., multiple ARC entries and effective dates), and the text includes specific “effective” dates for referenced sections (notably including 1/1/26, with additional editorial changes and later effective dates such as 8/1/26 for certain ARC references).

FULL SUMMARY

The bill establishes a new Medicaid requirement limiting certain post-payment reviews of provider claims that are not tied to fraud or misrepresentation. It creates a new Iowa Code section (249A.42B) requiring that, for Medicaid fee-for-service and managed care administration paid claims without fraud/misrepresentation, any post-payment review may cover only claims paid within the prior 12 months.

For providers, the bill also bars recoupment for older overpayments: if an overpayment is identified for a claim where 12 months or more have elapsed since the date of payment, the overpayment is not subject to repayment and may not be recovered by offset against future reimbursement of claims by the provider.

The limitations do not apply to retroactive Medicaid cost settlements or to rate changes based on a Medicaid or Medicare cost report. Additionally, any improper payment identified through a covered review may be resubmitted by the provider as a claims adjustment (i.e., the provider is permitted to correct/adjust claims following the review).

The act takes effect upon enactment, and it is codified as the new section addressing limitations on activities related to paid claims (resubmission).

FULL SUMMARY

The bill creates new Iowa requirements governing health carriers’ (1) auditing of clean claims and (2) standards of conduct for interactions with health care providers, and it adds new, detailed rules governing prior authorization decisions by utilization review organizations (UROs) and health carriers, including clinical- and peer-review requirements, appeal procedures, and exemptions.

For claim audits, the bill establishes a new section requiring that if a health carrier audits a clean claim, it must reimburse the provider’s reasonable documented administrative costs to respond to the audit. The bill also sets timelines: the carrier must notify the provider within 15 calendar days after selecting the clean claim for audit; must complete the audit and issue an adverse determination within 45 calendar days after receiving all requested documentation; and must process an appeal initiated by the provider no later than 30 calendar days after receipt of the audit determination, issuing a final determination within 14 calendar days after notice of the appeal. If the carrier violates the audit timelines, the clean claim is automatically approved and promptly paid with interest at 10% per annum. The audit rules do not apply to claims under active fraud investigation by a state or federal authority or to federal programs where audits are mandated by federal law. Violations by a health carrier are treated as unfair or deceptive acts and may trigger civil penalties; providers may recover litigation costs, including reasonable attorney fees.

For standards of conduct, the bill adds new prohibitions for health carriers, including: (a) no financial penalties, reimbursement reductions, administrative fees, or network termination based on a provider’s referral to or affiliation with out-of-network providers; (b) no interference with a provider’s staffing and referral decisions (except as otherwise provided by law); and (c) no offering/enforcing contract terms requiring provider negotiation opportunity and no enforcement of provisions that impose unreasonable or unconscionable obligations (such terms are void and unenforceable). Violations constitute unfair or deceptive acts, can lead to civil penalties, and allow providers to recover litigation costs, including attorney fees.

For prior authorizations, the bill creates a new URO/health-carrier “peer review” framework. It defines key terms (e.g., clinical peer, qualified reviewer, downgrade) and provides that a URO may deny or downgrade only if decisions are made by an appropriately credentialed qualified reviewer (physician) or clinical peer (non-physician), with the organization supplying: a written reasons statement, an appeals process explanation, and a written attestation containing specified credentials/identifiers and specialty or experience requirements. It also requires, on provider request after denial, a consultation within seven business days. If the denial/downgrade is appealed, the appeal must be handled by a qualified reviewer or clinical peer not involved in the initial determination and must consider relevant clinical records and submitted medical literature. Violations are deemed unfair/deceptive practices subject to civil penalties and allow providers to recover litigation costs, including attorney fees. Separately, the bill creates exemptions preventing a health carrier from requiring prior authorization or imposing additional utilization review for (1) certain cancer-related screening/preventive services recommended under updated NCCN oncology clinical practice guidelines, and (2) life-threatening conditions that develop or become evident while a covered person is receiving inpatient care, unless immediate assessment and treatment is provided. Applicability limits apply to health benefit plans delivered/issued/continued/renewed on or after January 1, 2027, and to certain pending prior authorization requests made before that date but not finally determined by it.

FULL SUMMARY

The bill creates additional rate-review and reporting obligations for Iowa’s Department of Health and Human Services (HHS) covering three areas: shelter care and qualified residential treatment provider (QRT) costs/rates; medical assistance provider reimbursement rates; and home- and community-based services waiver provider rate limits.

First, it amends Iowa Code section 235.2 by adding a requirement that once HHS implements a uniform cost report for shelter care and QRT providers, HHS must conduct a biennial review comparing shelter care and QRT provider costs to current shelter care and QRT rates. HHS must then submit, on or before October 1 of the year immediately following the review, a report to the governor and the general assembly detailing the review results and recommendations for rate adjustments.

Second, it amends Iowa Code section 249A.4 by adding an annual review requirement for provider reimbursement rates for all medical and health services provided under the chapter. For each provider reimbursement rate, HHS must compare it to Medicaid reimbursement rates in (1) states contiguous to Iowa, (2) states with populations comparable to Iowa (based on the most recent decennial census), and (3) the federal Medicare program if applicable. HHS must submit an annual report summarizing this review to the general assembly on or before December 1.

Third, it adds a new section (249A.32C) establishing home- and community-based services waiver provider rate limits. Beginning July 1, 2026, HHS—using input from the public, providers, and other stakeholders—must conduct at least biennial reviews of provider reimbursement rates for services rendered under waivers during a review period specified by HHS. The review must include, at minimum, the aggregate cost to the state to reimburse providers for waiver services, utilization of waiver services by consumers, providers’ demonstrated capacity to meet consumer demand using available resources, and indicators of need for increased resources. Based on the review, HHS must develop proposed rate models and related changes to HHS policy and procedures, and must report to the general assembly on or before December 31 of the year the review is completed; the report must include the proposed rate models, the projected fiscal impact of implementing them, documentation supporting the actuarial soundness of the proposed models, and the proposed policy/procedure changes. The section also defines “consumer,” “provider,” and “waiver” by cross-reference to existing definitions in section 249A.29.

FULL SUMMARY

The bill creates a new Iowa statutory section, defining terms for “emergency services,” “out-of-network provider,” “participating facility/provider,” and “complicating factor,” and establishes new requirements for coverage and reimbursement of emergency care provided by out-of-network providers.

For policies, contracts, or plans providing third-party payment or prepayment of medical expenses, the bill requires coverage of services furnished by an out-of-network provider in two situations: (1) when the services are emergency services; or (2) when the services were provided at a participating facility and the covered person could not receive the services from a participating provider. It also limits patient billing by prohibiting an out-of-network provider from billing or collecting from the covered person any amount other than the covered person’s cost sharing under the health benefit plan.

The bill sets a claims and reimbursement process for out-of-network providers: the provider must submit a claim to the covered person’s health carrier within 60 calendar days after providing the services; the carrier must reimburse within 60 calendar days after receipt, and the reimbursement must be the greater of (a) the median amount that would have been paid to a participating provider in the same specialty (excluding cost sharing) or (b) 150% of the most recently published federal CMS fee schedule for the service (excluding cost sharing). For services involving a “complicating factor,” the out-of-network provider may seek additional reimbursement as part of the initial claim by submitting medical records/clinical documentation demonstrating the complicating factor; the carrier must either pay an additional amount equal to 25% of the initial reimbursement or issue a denial within 30 calendar days.

If the carrier denies the additional reimbursement, the provider may request binding arbitration with the commissioner, and the bill prescribes arbitration mechanics and timing: the commissioner notifies the parties within 30 days whether the request is accepted/denied; the carrier must submit reconfirmation or an alternative payment offer within 30 days after notice; the parties select an arbitrator from an approved list; and the arbitrator issues a written decision within 45 calendar days, considering specified documentation and payment offers. Arbitration costs must be split equally by the carrier and provider. The bill applies to enumerated types of specialized health-related insurance contracts/policies/plans delivered, issued, continued, or renewed in Iowa on or after January 1, 2027, and it excludes certain coverage types (e.g., accident-only, specified disease, short-term limited hospital/medical, disability income, workers’ compensation/similar supplements, and automobile medical payment insurance). The commissioner of insurance is authorized to adopt rules to administer the new section.

FULL SUMMARY

The bill creates a new Iowa statutory section, 514C.16A, establishing required insurance/health-plan coverage and a payment-and-dispute process for certain out-of-network emergency services. It defines key terms including “out-of-network provider,” “participating facility,” “emergency medical condition,” “emergency services,” “complicating factor,” “cost sharing,” and “arbitrator list” (a commissioner-approved list of arbitrators), and it requires coverage by a policy/contract/plan for services furnished by an out-of-network provider when the services are emergency services or when provided at a participating facility and the covered person could not receive equivalent services from a participating provider.

Under the new section, an out-of-network provider must submit a claim to the covered person’s health carrier no later than 60 calendar days after providing the services. Within 60 calendar days after receiving the claim, the health carrier must reimburse the out-of-network provider the greater of (1) the median amount that would have been paid to a participating provider in the same specialty for the same services (excluding cost sharing), or (2) 150% of the most recently published Medicare fee schedule amount for the service (excluding cost sharing). The bill prohibits the out-of-network provider from billing, attempting to collect from, or collecting from the covered person any amount beyond the cost sharing required by the covered person’s health benefit plan.

For out-of-network services involving a “complicating factor,” the provider may request additional reimbursement by submitting an initial claim that includes medical records and clinical documentation supporting the complicating factor and justifying the additional reimbursement. After receiving a claim for additional reimbursement, the carrier must, within 30 calendar days, either pay an additional amount equal to 25% of the initial-claim reimbursement or issue a denial letter explaining the denial basis. If denied, the provider may request binding arbitration with the insurance commissioner; the commissioner must notify both parties within 30 calendar days whether the request is accepted. The carrier then submits documentation within 30 calendar days reconfirming the denial or offering an alternative payment for arbitration consideration. The parties select an arbitrator from the commissioner’s arbitrator list, arbitration documentation is submitted, the arbitrator issues a written decision within 45 calendar days, arbitration costs are split equally between the carrier and provider, and the arbitrator considers specified documentation and the complicating factor.

The coverage/payment requirements apply to specified classes of third-party payment-provider contracts, policies, or plans delivered, issued, continued, or renewed in Iowa on or after January 1, 2027, including certain accident and sickness insurance, hospital/medical service contracts, health maintenance organization contracts, and public employee plans. The bill exempts specified specialized coverage types (e.g., accident-only, specified disease, short-term/hospital confinement indemnity, credit/dental/vision, Medicare supplement, long-term care, disability income, liability/worker’s compensation-related supplemental coverage, and automobile medical payment insurance) from the section’s requirements, and it authorizes the commissioner of insurance to adopt rules to administer the section. It also expressly allows private negotiation agreements that result in reimbursement greater than what the section requires.

FULL SUMMARY

The document establishes Iowa Medicaid provider payment procedure rules (IAC 5/27/26 Human Services, Chapter 80) covering submission of claims, payment rules (including third-party liability), time limits for submitting claims and claim adjustments, provider authorization/eligibility card practices, exceptions for payment to parties other than the provider, and the “health care data match” program requiring health insurers to provide eligibility/coverage information to the state under a signed data use agreement.

It also contains an internal update effective date tied to a specific rulemaking action (effective 7/1/26) for the cited Chapter 80 provisions, and it incorporates by reference a provider manual (Chapter IV, “Billing Iowa Medicaid,” as amended to July 1, 2026) for detailed claim submission procedures.

Key required changes/requirements reflected in the text include: mandatory electronic claim submission “whenever possible,” specific electronic claim forms for fee-for-service Medicare beneficiaries (UB-04 and CMS-1500, with EOMB required only if requested), “clean claim” and third-party liability rules including a “pay and chase” approach for certain categories, defined time limits (365 days for initial claims and for most adjustments/resubmissions; no payment if received beyond two years from date of service), rules on eligibility card issuance and validity tied to ELVS, limits/conditions for payments to clients/counties/business agents, and a health insurer data match obligation with confidentiality requirements consistent with HIPAA and its implementing regulations.

The document is intended to implement Iowa Code chapter 249A.

The document presents a resolution urging Congress to empower state insurance regulators with authority over Medicare Advantage plans. It raises concerns about the absence of state oversight since the Medicare Modernization Act was enacted in 2003, which has resulted in aggressive and misleading marketing practices within the Medicare private plan marketplace.

Key issues highlighted include reports from state departments of insurance and consumer advocacy organizations regarding misrepresentations in the marketing of Medicare Advantage plans, particularly concerning provider networks and benefits. The resolution points out that aggressive sales tactics often target seniors and vulnerable adults, making it difficult for them to make informed decisions about their healthcare options.

The resolution advocates for Congress to acknowledge that states are better positioned to oversee Medicare plans and safeguard consumers from fraudulent practices, similar to their regulation of other health plans. It calls for legislation that would enable states to enforce their own marketing and consumer disclosure laws for Medicare plans.

FULL SUMMARY

The bill proposes adding a new section to the Kentucky Constitution to entrench Medicaid expansion coverage for non-disabled, low-income adults aged 19 through 64 with income at or below 138% of the federal poverty level (as authorized by federal law). It requires Kentucky to provide Medicaid benefits to eligible individuals and to ensure that the coverage meets or exceeds the applicable benchmark or benchmark-equivalent requirements defined by federal law.

The bill limits Kentucky’s ability to increase eligibility or enrollment barriers for people eligible under the constitutional provision. Kentucky may not impose greater or additional burdens or restrictions on eligibility or enrollment standards, methodologies, or practices than those applied to other Medicaid-eligible persons under Kentucky law, except that Kentucky may impose a work requirement or cost-sharing requirement to the extent required by federal law or regulation.

The amendment is submitted to Kentucky voters for ratification or rejection at the next regular election according to constitutional and statutory procedures referenced in the bill. It directs the Secretary of State to publish (at least once) the question posed in the act and the full proposed constitutional amendment text, and to publish notice that the amendment will be voted on at the next regular election (with publication timing tied to the first Tuesday in August preceding the election). It also provides ballot-implementation timing and requires certification of the complete text for placement on ballots, with dates tied to the August/September schedule depending on whether a presidential election is occurring.

FULL SUMMARY

The bill makes targeted changes to Kentucky Medicaid statutes and adds process requirements tied to federal authorization.

It amends KRS 205.520 and KRS 205.6312: (1) updates the declared policy language in KRS 205.520, including how the Cabinet may use federal funds, how Medicaid eligibility is provided, and reaffirming Medicaid’s status as payor of last resort and the primacy of Medicaid’s third-party recovery rights; and (2) modifies a Medicaid copayment/cost-sharing prohibition so that the cabinet or managed care organizations may not institute copayments, cost sharing, or similar charges to recipients (and their spouses or parents) for assistance provided under the chapter, federal law, or a federal Medicaid waiver except to the extent federally required, explicitly including reference to 42 U.S.C. § 1396o(k).

It also requires the Governor, within 30 days after the Act’s effective date, to commission an independent third-party analysis of Kentucky’s current Medicaid expansion and the Kentucky Health Benefit Exchange, including investigation of Kentucky’s uninsured rate, access to care, and improvements in health indicators.

Finally, if the Cabinet for Health and Family Services or the Department for Medicaid Services determines that state plan amendment, waiver, or other federal authorization is necessary to implement the Medicaid changes, the bill mandates that within 90 days after the effective date the cabinet/department request the necessary federal authorization/approval, and it permits delaying implementation only for provisions where federal authorization/approval is deemed necessary until that approval is granted. Sections 1, 2, and 4 are specified as the authorization required under KRS 205.5372(1).

FULL SUMMARY

The bill establishes a proposed amendment to the Kentucky Constitution that would require the Commonwealth to exercise any federally available option (currently existing or later made available) to expand eligibility for the Medicaid program. It specifies that individuals qualifying under the new constitutional section must receive Medicaid coverage that meets or exceeds federal “benchmark” or “benchmark-equivalent” coverage requirements (as defined by federal law).

The bill also restricts Kentucky’s ability to add state-level obstacles to Medicaid eligibility or enrollment. It would prohibit the Commonwealth from imposing greater or additional burdens or restrictions on eligibility or enrollment standards, methodologies, or practices for people eligible under the new constitutional section than those applied to other Medicaid-eligible persons under Kentucky law. A limited exception permits Kentucky to impose, to the extent required by federal law or regulation, a work requirement or cost-sharing requirement on people eligible under the section.

The bill provides for submission of the constitutional amendment to Kentucky voters for ratification or rejection at the next regular election in the manner required by referenced constitutional and statutory provisions. It further directs the Secretary of State to publish the question and the full text of the proposed amendment in a statewide newspaper and to certify the complete text to county clerks in time to be printed on ballots, with specific timing rules keyed to whether the relevant election year includes a President and Vice President election.

FULL SUMMARY

The bill requires Kentucky’s Medicaid program to implement a federal “demonstrated community engagement” eligibility requirement for specified Medicaid individuals, sets timelines for imposing the requirement and providing notice, and prohibits seeking certain federal exemptions/delays unless the General Assembly authorizes them. It also expands the statutory definition of “applicable individuals” and defines “demonstrated community engagement” through qualifying monthly activities (including work, community service, education participation, combinations, and specified income thresholds) while enumerating categories excluded from the requirement.

It amends Medicaid cost-sharing rules to apply copayment cost sharing (starting October 1, 2028) only to Medicaid enrollees with income above 100% of the federal poverty line who are enrolled under a specified Medicaid eligibility pathway, and it exempts numerous services from cost sharing unless federal law requires otherwise. It also amends Medicaid presumptive eligibility procedures for hospitals (including training, notification, and limits on presumptive eligibility periods for pregnancy), modifies lottery/unemployment/vital statistics data-matching language for eligibility monitoring, and adds new requirements governing Medicaid managed care contracts and related managed care obligations. New provisions include: (1) semiannual Medicaid eligibility redeterminations beginning January 1, 2027 for specific non-exempt populations; (2) enhanced data systems usage and conditional “ineligibility” initial findings with appeal rights based on inconsistent data; (3) a programmatic framework to assess Medicaid nonemergency medical transportation (NEMT) eligibility determinations;

A major new NEMT section establishes a regional brokerage delivery model with capitated payments to regional brokers, regional medical-loss-ratio targets that increase over successive state fiscal years (from 85% beginning July 1, 2026 to 90% for 2029 and later), GPS-equipped vehicles at broker expense, performance-based withholds/recoveries (2%), and reporting requirements starting in 2027. It creates a Medicaid managed care organization compliance fund, financed by specified penalties/fines, and it tightens managed care obligations on claims processing, grievance/appeal timelines, internal appeals/grievances procedures, provider audit and recoupment rules, and required reporting to the Department of Insurance and legislative bodies. The bill also creates new Medicaid waiver administration requirements, including required waiver-specific level-of-care assessment tools, standardized waiver application contents (provider recommendation and provider attestation), a transitional 12-month deadline for certain existing waiver waitlist placements, and additional reporting obligations for waiver expenditures/utilization.

Finally, the bill creates or changes Medicaid governance/oversight mechanisms: it requires the Medicaid Oversight and Advisory Board to manage data access/transparent oversight via new provisions for continuous machine-readable access to Medicaid data and records by a legislative commission, and it creates a web-based healthcare transparency dashboard. It also directs the board to evaluate the NEMT program during the 2026 interim and to form a waiver waitlist management subcommittee with recommendations and a required cabinet report by October 1, 2026. Operationally, it extends existing managed care contracts through December 31, 2028 and prohibits initiating procurement for managed care delivery before January 1, 2028, establishes a future transition plan to an administrative services organization (ASO) for Medicaid-covered dental services beginning January 1, 2029, repeals specified statutory provisions, declares an emergency with immediate effect upon passage/approval, and includes provisions for requesting federal approvals when needed to implement enumerated sections while limiting the duration of any delayed implementation pending federal authorization.

FULL SUMMARY

The bill establishes a new Medicaid state-directed payment program within Kentucky’s Medicaid framework by requiring the Department for Medicaid Services (DMS) to develop Medicaid programs to improve quality of and access to care by increasing Medicaid reimbursement rates for specified “qualifying hospitals,” subject to federal law.

KRS 205.6412 is revised to require enhanced add-on payments from Medicaid managed care organizations to qualifying hospitals (1) that participate in the existing hospital rate improvement program under KRS 205.6406, (2) that are Level II, III, or IV trauma centers, (3) that are located in counties whose Medicaid enrollment percentage exceeds the statewide median for the prior calendar year as shown in a Cabinet report, and (4) that have agreements to train providers with specified graduate medical education programs (either university-affiliated or, in the pediatric teaching hospital path, with limitations described below). The revised statute also expands eligibility for “pediatric teaching hospitals” (as defined in KRS 205.565) by allowing enhanced add-on payments, but limits eligibility to services delivered to patients age 18 or younger. In addition, for a separate qualifying pathway authorized under federal approval, enhanced add-on payments may be based on an “equivalent Medicare rate” for certain physician and nonphysician professional services provided through affiliated or contracted physician groups or professionals, provided the hospital has an agreement to train providers with a state-owned university-affiliated graduate medical education program.

The program’s financing and implementation are conditioned on CMS requirements: the nonfederal share must come from an identified funding source separate from the KRS 205.6406 assessment and not from the general fund; qualifying hospitals must report quality measures tied to the state university teaching hospital Medicaid directed payment plan and existing applicable Medicaid directed payment plan measures; and reimbursement applies only to Medicaid managed care organization-covered patients. The new state-directed payment program must be separate and distinct from any state-directed payment program authorized under KRS 205.6406, and DMS may implement only after CMS approves the federal Medicaid documentation, agrees to consider the program through a dedicated CMS preprint without affecting other directed payment programs, and confirms the availability of compliant nonfederal/state match funding. If federal recoupment is sought after implementation, the state is not liable and qualifying hospitals are liable for any reimbursement owed to CMS or other federal agencies. DMS must promulgate administrative regulations under KRS Chapter 13A to implement the program.

Within 60 days after the Act’s effective date, DMS must submit a Medicaid preprint to CMS seeking authorization to implement the program with a January 1, 2026 effective date. If CMS approves the preprint with a retroactive effective date of January 1, 2026, DMS must direct contracted Medicaid managed care organizations to make retroactive enhanced add-on payments to qualifying hospitals for previously paid claims (beginning January 1, 2026) for physician and nonphysician professional services provided by the hospitals’ affiliated physician groups or contracted employed professionals.

FULL SUMMARY

The bill establishes requirements for a Kentucky Medicaid state-directed payment program administered by the Department for Medicaid Services. It requires (subject to federal approval under applicable Medicaid requirements) enhanced “add-on” payments funded through a non-general-fund nonfederal share source separate from the assessment authorized in KRS 205.6406, and it limits the program to services and patients meeting specified eligibility rules.

KRS 205.6412 is revised to direct the department to develop Medicaid managed-care-based enhanced add-on payments for qualifying hospitals. Eligibility to earn enhanced add-on payments includes hospitals that (a) participate in the KRS 205.6406 hospital rate improvement program, (b) are Level II, III, or IV trauma centers, (c) are located in counties where Medicaid enrollment exceeds the statewide median (as defined by a Cabinet posted “Monthly Medicaid Counts by County” metric for the prior calendar year), and (d) have agreements for clinical rotations to train providers with a university-affiliated graduate medical education program; or alternatively (e) are pediatric teaching hospitals (with an added age limitation). Under the pediatric teaching hospital pathway, enhanced add-on payments are restricted to services delivered to patients age 18 or younger.

For federal implementation, within 60 days after the Act’s effective date the department must submit a Medicaid preprint to the federal Centers for Medicare and Medicaid Services (CMS) seeking authorization to implement the program with a January 1, 2026 effective date. If CMS approves the preprint, the qualifying hospitals may earn enhanced add-on payments from Medicaid managed care organizations based on the hospitals’ equivalent Medicare rates for services, including physician and nonphysician professional services provided by affiliated physician groups/physicians or other professionals employed by or contracted with the qualifying hospital, provided the qualifying hospital has an agreement to train providers with a state-owned, university-affiliated graduate medical education program.

The bill also sets program design and implementation conditions: the state-directed payment program must be separate and distinct from any state-directed payment program authorized under KRS 205.6406; reimbursement applies only to patients covered by a Medicaid managed care organization; qualifying hospitals must report the same quality measures applicable under (i) the state university teaching hospital Medicaid directed payment plan and (ii) similarly approved payment programs active in Kentucky; and the department must promulgate administrative regulations under KRS Chapter 13A to implement the program. Finally, if CMS approves the required preprint with a retroactive effective date of January 1, 2026, the department must direct each contracted Medicaid managed care organization to make retroactive enhanced add-on payments to qualifying hospitals for previously paid Medicaid claims for physician and nonphysician professional services provided on or after January 1, 2026 by the qualifying hospital’s affiliated professionals.

FULL SUMMARY

The bill establishes a proposed constitutional amendment to Kentucky’s Constitution creating a new section that “enshrines and protect[s] the current expansion of Medicaid eligibility for non-disabled, low-income adults.” The proposed new constitutional language directs the Commonwealth, to the extent permitted by federal law, to provide Medicaid benefits to people aged 19 through 64 with income at or below 138% of the federal poverty level for the applicable family size, as authorized by federal law.

It requires that coverage provided under this constitutional eligibility group meets or exceeds the applicable Medicaid benchmark (or benchmark-equivalent) coverage requirements, as those terms are defined by federal law. It also prohibits Kentucky from imposing greater or additional burdens or restrictions on eligibility or Medicaid enrollment standards, methodologies, or practices for individuals eligible under the new constitutional provision than those imposed on other Medicaid-eligible persons under Kentucky law, except that Kentucky may impose, to the extent required by federal law or regulation, a work requirement and/or cost-sharing requirement on people eligible under the section.

The amendment is submitted to Kentucky voters for ratification or rejection at the next regular election at which General Assembly members are voted for, following the timing and voter-submission procedures tied to Sections 256 and 257 of the Kentucky Constitution, KRS 118.415, and Sections 4 and 5 of the Act.

Administrative election steps are added/modified for ballot and publication purposes: the Secretary of State must publish the question and the entirety of the proposed constitutional amendment at least once in a newspaper of general circulation and must publish notice that the amendment will be on the next regular election ballot; and the Secretary of State must certify the complete text and amendment to county clerks by specified deadlines so that the text is indicated on paper or electronic ballots used in each county or precinct.

FULL SUMMARY

The regulation sets Kentucky Medicaid reimbursement rules for physicians’ services, including baseline reimbursement methodology (lesser of usual and customary charge or the Medicaid Physician Fee Schedule), rate-setting formulas using relative value units and dollar conversion factors, and numerous service-specific reimbursement rules (e.g., Medicare Part B services, CPT modifiers, laboratory and venipuncture rules, delivery-related anesthesia caps, anesthesia direction limitations, vaccine reimbursement, physician assistant reimbursement, and other reimbursement limits and conditions such as E/M visit requirements and non-reimbursement for provider preventable conditions).

It also establishes reimbursement-related program rules and governance items: supplemental payments for qualifying medical school faculty physicians (and resident-provided services under their supervision) with conditions on licensure, enrollment/participation, employment by specified teaching entities, and assignment of Medicaid reimbursement; rules allowing managed care organizations to elect—though not being required—to reimburse the same amounts as the department; contingency on federal financial participation and CMS approval; and appeal rights tied to recipient, provider, and eligibility decisions.

The document contains an explicit amendment update with three targeted changes: it updates the timeline for Medicaid Physician Fee Schedule updates to align with CMS’ annual update schedule; revises the definition of “provider group” (changing it from a “group of at least two individually licensed physicians” concept to “at least one licensed physician” who is enrolled individually and as a group and shares a Medicaid group provider number when more than one physician is in the group); and updates which vaccinations are eligible for reimbursement by providers (including clarifying reimbursement for department-approved vaccines and maintaining flu vaccine reimbursement for any age).

For public process, the regulation provides for a public hearing if requested on March 23, 2026 at 9:00 a.m. (virtual), with notice of intent to attend due by March 16, 2026 and written public comments due by March 31, 2026.

FULL SUMMARY

The bill enacts the “Preservation Act for Other Rural Hospitals” by creating new Louisiana statutes (R.S. 40:1190.1 through 1190.5) to govern Medicaid reimbursement and potential directed/state supplemental payments for certain qualifying “other rural hospitals,” and to set implementation and funding guardrails for the Louisiana Department of Health (LDH).

It defines “other rural hospital” as a hospital licensed by LDH with no more than 60 beds (excluding certain distinct-part beds) as of October 1, 2024, located outside Louisiana metropolitan statistical areas, with an operational emergency room, located in a municipality with fewer than 23,000 residents, and not classified as a rural hospital under existing law, a long-term care hospital, a rehabilitation hospital, or a free-standing psychiatric hospital. The bill also defines key terms used in payment administration (including “prospective rate approximating cost” and “reasonable cost”) and assigns LDH authority and duties tied to Medicaid state plan implementation under Title XIX.

LDH must adopt regulations providing for Medicaid reimbursement upgrades for other rural hospitals. Specifically, LDH must (1) allow other rural hospitals to certify eligible expenditures as a contributing public agency for Medicaid federal financial participation; (2) maximize allowable funding and the use of intergovernmental transfers/certified expenditures for state match to increase access for Medicaid/LaCHIP beneficiaries and indigent individuals; and (3) by September 1, 2026 file a Medicaid state plan amendment with CMS to reimburse other rural hospitals at a rate comparable to rural hospitals, targeting approximately 110% of appropriate reasonable cost (with CMS-driven maximum reductions not below 100% of reasonable cost) for inpatient and outpatient services, including services from rural health clinics licensed as part of an other rural hospital. For inpatient acute and inpatient psychiatric services, the new methodology must use prospective rates approximating costs at the time of service; outpatient payments must ensure that outpatient services in the aggregate are paid at 110% of reasonable cost (or lower amounts approved by CMS but not below 100% of reasonable cost). The bill requires interim outpatient payment mechanisms, quarterly supplemental payment estimates, and final cost-settlement true-ups so outpatient services reach the required aggregate level.

For cost reporting periods ending after July 1, 2026, LDH must pay 75% of interim outpatient settlement amounts and pay 100% of final outpatient settlement amounts within 14 days after receipt of Medicaid audit contractor reports. The bill also requires LDH, effective for services on or after July 1, 2026 (or as soon as federal law permits), to develop and implement via emergency rule a payment methodology comparable to rural hospital payments (including directed payments) to optimize Medicaid inpatient/outpatient payments, distributing calculated payments to qualifying hospitals no less than quarterly (or as authorized by federal law). Eligibility for additional payments is conditioned on providing minimum documentation; no payments increase/supplements/directed payments/authorized payments are allowed for any other rural hospital that is not current on all assessment payments or is delinquent/in arrears, and LDH must withhold/offset/recoup payments until assessment obligations are satisfied. The bill further creates funding protections: annual funding for other rural hospitals must be separately appropriated by the legislature and must be sufficient to hold rural hospitals harmless from negative financial effects; other rural hospital funding must not be used to offset or substitute other hospital funding streams; and implementation must not reduce Medicaid reimbursement received by small rural hospitals. It adds an applicability provision tied to state plan amendment TN 24-0022 (ensuring net economic benefit for affected reconciliation periods) and provides procedural requirements for rulemaking and for submitting state plan amendments after CMS approval. The bill’s effective date is upon gubernatorial signature or, if not signed, upon lapse of time for enactment without signature; if vetoed and later approved by the legislature, it becomes effective the day after that approval.

The law amends and reenacts Louisiana Medicaid’s continuous glucose monitor coverage rule in R.S. 46:450.8(A)(1), expanding the covered enrollee conditions for which a continuous glucose monitor is provided.

Under the amended provision, the Louisiana Medicaid program must provide coverage for a continuous glucose monitor for an enrollee who has “any type of diabetes,” expressly including but not limited to gestational diabetes. Coverage is conditioned on either (1) the need for insulin use more than two times daily or (2) evidence of level 2 or level 3 hypoglycemia.

The enrolled text shown indicates the change occurs within R.S. 46:450.8(A)(1) by altering the eligibility criteria described above; the provision remains subject to an exception still referenced in the surrounding statute (Subsection B), but the operative coverage conditions in Subsection A(1) are the focus of the modification.

FULL SUMMARY

The act establishes Medicaid reimbursement “equality” between independent rural health clinics (type one) and provider-based rural health clinics (type two and three). It directs the Louisiana Department of Health (LDH) to increase, for fiscal years 2026–2027 and 2027–2028, the encounter rate in effect for independent type one clinics by $41.50 over the prior year’s encounter rate, and to apply the annual Medicare Economic Index inflationary adjustment to that rate.

The act also expands facility need review requirements by adding “types one and two rural health clinics” to the list of healthcare provider types subject to facility need review under Louisiana’s facility need review statute (R.S. 40:2116(B)(8)).

LDH must prepare a state plan amendment or promulgate and adopt any necessary rules to implement the new Medicaid reimbursement equalization and related changes, and the provisions are conditioned on approval by the Centers for Medicare and Medicaid Services (CMS). LDH must also provide a monthly report to the legislature including, for each individual type one clinic, the number of encounters per month and the total amount of monthly expenditures.

Implementation timing is set so that LDH must take necessary actions within 90 days after the act’s effective date. The act’s operative provisions take effect only when an act with a specific appropriation for implementation becomes effective; the remaining effectiveness provisions follow standard Louisiana timing based on gubernatorial signature (or lack of signature) and override approval, as provided in the Louisiana Constitution.

FULL SUMMARY

The bill establishes a new Louisiana statutory Chapter 2 in Title 28 (R.S. 28:301–308) focused on Medicaid behavioral health administrative requirements, including provider enrollment/credentialing standards and documentation and staffing rules intended to reduce administrative barriers while maintaining patient safety.

Key new requirements and prohibitions include: (1) prohibiting the Louisiana Department of Health (LDH) and Medicaid managed care entities from requiring pre-employment reference letters as a condition of provider enrollment, staff credentialing, or delivery of Medicaid behavioral health services (while allowing primary-source verification of employment history, licensure, education, and required work experience) (R.S. 28:303); and (2) prohibiting LDH and managed care entities from requiring CPR, first-aid certification, or seizure-assessment training for behavioral health staff as a condition of enrollment, credentialing, or reimbursement, except that LDH may require such training only for staff providing services in settings where federal law, state law, or applicable licensing rules require it (R.S. 28:304).

The Chapter also changes administrative alignment and documentation: (3) supervision of provisionally licensed or otherwise supervised staff is deemed to satisfy Medicaid clinical supervision requirements when it meets or exceeds applicable program standards, and LDH is barred from requiring duplicative supervision when licensing-board supervision overlaps program requirements (R.S. 28:305); and (4) LDH must revise Medicaid provider progress-note documentation requirements for CPST and PSR services to align with federal guidance requiring documentation to be completed during the service or as soon as practicable after service, allows a general timeliness standard with reasonable exceptions (including state or federal declared emergencies or other department-defined exceptions), and requires late-entry attestation (date of entry and reason for delay) when documentation is completed outside the general standard (R.S. 28:306).

Additional new staffing/clinical director rules require that when a CPST/PSR provider must maintain a nurse on staff or a written nursing-services agreement solely for medication administration, the requirement is satisfied by having a licensed physician, psychiatrist, advanced practice registered nurse, or physician assistant whose duties include medication administration—without authorizing practice outside the scope of professional licensure (R.S. 28:307). The bill also expands the allowable medical director options for CPST/PSR by permitting a medical director to be a physician, advanced practice registered nurse, medical psychologist, or physician assistant, subject to criteria including an unrestricted Louisiana license, at least two years of qualifying experience treating psychiatric disorders, and practice pursuant to a collaborative practice agreement or required supervision arrangement under state law (R.S. 28:308), and directs LDH to revise rules and provider manuals accordingly. LDH must promulgate implementing rules under the Administrative Procedure Act (Section 2) and must submit to CMS by October 1, 2026 any necessary state plan amendment, waiver, or other request to authorize reimbursement for psychosocial rehabilitation services delivered via telehealth, with CMS submission follow-up notice obligations to specified legislative committees (Section 3). The bill’s effective date is upon gubernatorial signature or, if unsigned, at the constitutional end of the bill-signing period, or the day after legislative approval if vetoed and overridden (Section 4).

FULL SUMMARY

The document promulgates a new Louisiana Administrative Code framework (Title 50, Part I, Subpart 5, Chapter 41–46) governing Medicaid program integrity fraud, waste, and abuse recovery. It repeals the existing Subpart 5 and replaces it with a new Subpart and chapter structure establishing definitions, rules on applicability/waivers, payment review and overpayment recovery, investigative and compliance review authorities, provider recordkeeping and reporting obligations, prohibited conduct, a sanctions regime (including exclusions, suspensions/withholding, and repayment rules), and related procedural protections (informal hearing and administrative appeal), plus confidentiality and severability provisions.

Key operational requirements include: (1) payment review authority allowing pre-payment, post-payment, and compliance reviews at the department’s discretion (including statistical sampling and extrapolation); (2) “materiality” of incorrect claim submissions at 5% or more of the reviewed claims universe when determining materiality; (3) provider obligations to maintain documentation supporting quantity, quality, medical necessity, authorization/qualified service delivery, sign/date requirements and correction rules for records, record retention, and cooperation with audits/investigations; (4) explicit time-bound provider reporting and repayment duties, including notifying the department of discovered overpayments within 60 days and repaying identified overpayments within 60 days of a final overpayment decision (or under an agreed longer schedule); and (5) presumptions that providers know applicable rules and that ignorance is not a defense.

The rule establishes mandatory and permissive exclusion and suspension/withholding mechanisms. It specifies a mandatory exclusion triggers list (e.g., certain criminal offenses tied to publicly funded healthcare programs, exclusions from publicly funded healthcare programs, patient abuse/neglect-related offenses, agreement to be excluded, and failure to meet payment-related agreement/judgment terms), with limited appeal rights (typically only to contest identity) and automatic/retroactive effect tied to the triggering event. It also creates payment withholding rules (including for credible allegations of fraud, failure to cooperate, suspected fraud/abuse, and written notice from a prosecuting authority) with notice content requirements and time limits on continuation, and it provides that exclusions and sanctions generally remain effective through administrative process subject to timing rules for when sanctions become “final.”

For enforcement, the document defines a broad prohibited-conduct list (e.g., failure to comply with Medicaid laws/enrollment terms, failure to disclose excluded persons, administrative/criminal/civil reporting failures within 10 business days, false statements during applications/claims reviews, various fraudulent billing conduct, failure to repay overpayments, record-audit noncompliance, failure to cooperate, systematic abusive billing, and abuse/neglect/exploitation). It establishes sanctions available for violations, including program prior authorization requirements, manual claim review, bonding/security, termination of associations, restrictions on tasks/locations/recipients/referrals, recovery, exclusion/suspension, monetary penalties up to $10,000 per violation, and administrative fines up to three times the overpayment, plus offsetting payment remedies. It also provides procedures for informal hearings (request within 15 calendar days; rebuttal/document access; non-adversarial process) and administrative appeals to the Division of Administrative Law (typically within 30 calendar days of notice or informal-hearing results), while clarifying that many corrective actions/education/warning letters/initial findings reports and certain actions (e.g., referrals to licensing or law enforcement, prepayment review, manual review placement, prior authorization requirements) are not treated as sanctions and are not subject to informal hearing or appeal. Finally, it adds confidentiality protections for investigatory/review contents until final sanction, a severability clause, and a supersession clause for conflicting departmental regulations.

The 132nd Maine Legislature has proposed legislation to increase the MaineCare reimbursement rate for ambulance services to 140% of the average allowable reimbursement rate under Medicare. This change is intended to address critical funding issues identified by recent blue ribbon commissions, which have raised concerns about the financial viability of emergency medical services providers.

To support this initiative, the bill includes a transfer of $15,000,000 from the Department of Public Safety's Emergency Medical Services Stabilization and Sustainability Program to the Department of Health and Human Services. Additionally, there will be a one-time allocation of $7,300,000 from the Federal Expenditures Fund and $5,000,000 from Other Special Revenue Funds for the fiscal years 2025-26 and 2026-27.

The overall financial impact on the Department of Health and Human Services is projected to total $12,300,000 across all funds for the same period. The urgency of this funding increase is underscored by an emergency clause in the legislation, allowing it to take effect immediately upon approval to ensure the preservation of public health and safety.

The regulation establishes an expanded uniform reporting system for financial data under Maine Health Data Organization (MHDO) Chapter 300. It changes the scope of entities required to report financial data by adding multiple facility types beyond the existing coverage for hospitals and parent entities. It also adds a new annual reporting template requirement for covered facilities, including patient counts and specific payor category financial data, and adds a specific filing obligation for hospitals to submit an IRS Form 990 copy to MHDO. The rule becomes effective Sunday, August 16, 2026.

FULL SUMMARY

The bill requires health maintenance organizations (HMOs) to pay certain nonparticipating (out-of-contract) health care providers within 30 days after receiving a claim and sets specific minimum reimbursement rates for covered services delivered to HMO enrollees by providers without a written contract.

For noncontract hospital services, the HMO must pay the rate approved by the Health Services Cost Review Commission. For trauma care, the bill sets a minimum payment standard for trauma physicians as the greater of (1) 140% of the Medicare rate for the same service to a similarly licensed provider, or (2) the HMO’s January 1, 2001 rate in the same geographic area, with both standards applying to the same covered service to similarly licensed providers. For other noncontract providers, reimbursement must be at least the greater of specified Medicare-inflated thresholds and/or Medicare-based thresholds: for evaluation and management services, no less than either (A) 125% of the HMO’s average contracted rate as of January 31, 2019 (rather than the previously referenced “January 1 of the previous calendar year”), inflated by the change in the Medicare Economic Index from 2019 to the current year, or (B) 140% of the Medicare rate as of August 1, 2008 inflated by the Medicare Economic Index from 2008 to the current year; and for services that are not evaluation and management services, no less than 125% of the HMO’s average contracted rate as of January 31, 2019 inflated by the Medicare Economic Index from 2019 to the current year.

The bill also clarifies how HMOs calculate the “average rate” for similarly licensed contracted providers: it requires summing the contracted rate across all occurrences of the relevant Current Procedural Terminology (CPT) code and dividing by the total number of occurrences. It maintains disclosure rights for noncontract providers by requiring HMOs, on request, to disclose the reimbursement rate required under the trauma provider and nontrauma provider minimum-payment provisions.

Beyond payment rules, the bill retains and/or adjusts operational and enforcement mechanisms applicable under the same section: HMOs may require trauma physicians to submit adjunct claims documentation and include an HMO-assigned provider number (with the HMO required to assign a provider number on request). It preserves restrictions on HMOs requiring referral or preauthorization for covered trauma services delivered by a trauma physician. It also maintains provider enforcement through complaints to the Maryland Insurance Administration or civil actions in court, attorney-fee awards when the provider’s complaint is sustained, annual compliance review and reporting by the Maryland Health Care Commission, enforcement authority for the Maryland Insurance Administration, and a civil penalty cap (up to $5,000) for violations that reflect a general business practice. The act takes effect October 1, 2026.

FULL SUMMARY

The bill requires the Maryland Medical Assistance (Medicaid) Advisory Committee to form workgroups and subcommittees as necessary to carry out the Committee’s duties. It also establishes a new “Workgroup to Study the Adoption of a Fee-for-Service Model for All Medicaid Services” to study the feasibility of implementing a direct care payment model statewide across Maryland’s Medicaid program.

The Medicaid Advisory Committee’s membership and general duties remain tied to managed-care advising, including advising the Secretary on implementation and evaluation of managed care programs, reviewing and recommending regulations and contract standards, reviewing oversight of quality assurance, reviewing managed-care performance and related data, promoting dissemination of performance information to enrollees, assisting with evaluation of enrollment processes, and reviewing ombudsman reports. The bill adds an explicit requirement that the Committee “form workgroups and subcommittees as necessary” to perform its duties.

The newly created Workgroup consists of designated legislative members (one Senate member appointed by the Senate President; one House member appointed by the Speaker), a Maryland Health Care Commission representative appointed by the Commission Chair, and appointees by the Governor including one Medicaid provider representative, one representative of a Medicaid advocacy organization, and any other member considered necessary. The Maryland Medicaid Advisory Committee must provide staff for the Workgroup. Workgroup members may not receive compensation but may receive expense reimbursement under State travel regulations. The Workgroup must (1) review Connecticut’s Medicaid experience with a fee-for-service model, including cost, provider participation, and access impacts; (2) review Maryland’s experience using fee-for-service rather than managed care; (3) examine other states’ fee-for-service or direct care model efforts in response to federal funding/enrollment changes; (4) review evidence-based studies on direct care payment model benefits and outcomes; (5) examine feasibility of implementing a direct care payment model throughout Maryland’s Medicaid program; and (6) propose a potential transition timeline.

By on or before January 1, 2027, the Workgroup must report its findings and recommendations to the Maryland Medicaid Advisory Committee and to specified recipients under State Government Article § 2–1257, including the President of the Senate, the Speaker of the House of Delegates, the Senate Finance Committee, and the House Health Committee. The Act takes effect July 1, 2026; Section 2 (the Workgroup provisions) remains effective for one year and is abrogated after June 30, 2027.

FULL SUMMARY

The bill revises the payment obligations of health maintenance organizations (HMOs) for covered services provided to enrollees by health care providers that are not under written contract with the HMO, specifically altering the reimbursement-rate requirements and the formulas used to determine them.

For noncontracted trauma care, the HMO must continue to pay a trauma physician (for trauma rendered to a trauma patient in a trauma center) at the greater of: (1) 140% of the Medicare program rate for the same covered service to a similarly licensed provider, or (2) the HMO’s rate as of January 1, 2001 (as published by CMS) for the same covered service to a similarly licensed provider.

For other noncontracted providers, the bill changes the “evaluation and management service” reimbursement floor and the benchmark date used for inflation calculations. Instead of using the HMO’s average rate paid as of “January 1 of the previous calendar year,” it uses the average rate paid as of “January 31, 2019.” For evaluation and management services, the HMO must pay no less than the greater of (A) 125% of that January 31, 2019 average rate, inflated by the change in the Medicare Economic Index from 2019 to the current year, or (B) 140% of the Medicare rate as of August 1, 2008 inflated by the change in the Medicare Economic Index from 2008 to the current year. For non-evaluation-and-management services, the HMO must pay no less than 125% of the January 31, 2019 average rate (inflated by the Medicare Economic Index change from 2019 to the current year).

An HMO must still disclose, on request of a noncontracted provider, the reimbursement rate required under the noncontracted-provider provisions, and it must continue using a defined method to calculate average contracted rates by summing contracted Current Procedural Terminology (CPT) code rates and dividing by total occurrences. The bill also retains enforcement and administration provisions, including provider enforcement through complaints to the Maryland Insurance Administration or civil action, annual compliance review by the Maryland Health Care Commission, regulatory implementation by the Maryland Insurance Administration, and civil penalties for HMO violations. The Act takes effect October 1, 2026.

FULL SUMMARY

101 CMR 614.00 establishes the rules governing Massachusetts Health Safety Net payments and funding for dates of service beginning October 1, 2025. It specifies that the Health Safety Net office may issue administrative bulletins to clarify policies and implementation documentation for these payment and funding requirements.

101 CMR 614.00 defines key terms used across Health Safety Net payment calculations, including eligibility-related payment concepts (allowable Health Safety Net payment, shortfall amount), provider and payer terms (acute hospital, community health center, Disproportionate Share Hospital (DSH), public payer mix), and clinical/service concepts (emergency services and urgent care; emergency bad debt; administrative days; medically necessary service). It also clarifies administrative-day and partially eligible day payment principles, and defines provider and fund concepts (Health Safety Net Trust Fund and Health Safety Net office).

For funding allocation, 101 CMR 614.03 sets a graduated shortfall allocation methodology that differs by fiscal-year period. Through fiscal year 2024, if projected Health Safety Net payments exceed available funding, the Health Safety Net office allocates the shortfall via a graduated payment system: DSH hospitals are paid the greater of 85% of allowable Health Safety Net payments or a revised amount calculated through a relative public payer mix adjustment factor, subject to limits based on allowable payments; non-DSH hospitals follow with an initial cap of 75% and similar relative public payer mix adjustments; remaining funding (if any) is distributed proportionally by remaining allowable payments. Beginning with fiscal years on or after October 1, 2024, the same core graduated approach is retained but applied to those fiscal years, and a further additional reserved “Payments from the Health Safety Net Trust Fund beginning Fiscal Year 2026” section is added that extends the funding allocation framework using a data-driven estimate of projected reimbursable services, medical hardship, emergency/urgent care bad debt, and administrative expenses. The regulation also authorizes (i) final reconciliation of Health Safety Net payments with acute hospitals and community health centers, to be completed no later than two fiscal years after the end of the reconciled fiscal year, including notification that no further adjustments occur after final reconciliation, and (ii) post-reconciliation recoupment of overpayments through payment offsets, with discretionary underpayment adjustments.

101 CMR 614.06 and 614.07 establish how Health Safety Net pays acute hospitals and community health centers, respectively. Acute hospital payment rules include: monitoring claim volume and withholding/adjusting payments for suspected billing maximization or substantial service pattern changes; specific payment types (primary/secondary payer rules, offsets for emergency bad debt recoveries and free care endowment investment income); inpatient pricing using Medicare IPPS for non-psychiatric claims and IPF-PPS for psychiatric claims (with specified alternative pricing for Critical Access Hospitals, PPS-exempt hospitals, hospitals with fewer than 20 discharges, sole community hospitals, and Medicare Dependent Rural Hospitals); outpatient per-visit pricing based on source-year adjudicated eligible claims with exclusions (e.g., low-dollar visits and visits closely preceding admission) and a hospital-specific Medicare payment on account factor, plus a transitional add-on for DSH and non-teaching acute hospitals; separate physician and other outpatient service pricing using Medicare fee schedule/rate methodologies; secondary payer payment limitations including a “95% Rule” and a payment cap tied to what would have been paid under primary payer rules; emergency bad debt pricing rules with special conditions for hospitals with fewer than 20 emergency bad debt claims and for what bad debt categories are payable; medical hardship payment reduction rules; and an “Other” provision authorizing an additional $3.85 million payment to freestanding pediatric hospitals with specified Medicaid discharges criteria.

Community health center payment rules (101 CMR 614.07) require payment based on claims submitted, reduced by cost sharing, with monitoring and withholding/adjustment for suspected billing maximization. Reimbursable services are generally paid using Medicare-based PPS per-patient-per-day rates with specified geographic adjustments and coverage for defined visit types only once per patient per day (subject to listed exceptions), while services not included in the PPS rate are paid using a service-specific table (e.g., urgent care, selected diagnostic technical components, behavioral health categories, radiology, lab, dental, 340B pharmacy services, vision care, family planning services, preventive services/risk factor reduction, immunization-related services, and vaccine administration with conditions). Reporting requirements (101 CMR 614.08) require providers to file or make available data reasonably necessary for administering 101 CMR 614.00, allow the office to revise data specifications by administrative bulletin, permit audits, and authorize payment denial for noncompliance after advance notice to acute hospitals or community health centers. A severability clause applies to 101 CMR 614.00, and regulatory authority is stated under M.G.L. c. 118E.

FULL SUMMARY

101 CMR 614.00 establishes the Health Safety Net payment and funding rules for acute hospitals and community health centers for dates of service beginning October 1, 2025, and includes the related payment mechanics, definitions, and provider reporting obligations. The regulation authorizes the Health Safety Net office to issue administrative bulletins to clarify policies, specify documentation needed to implement the rules, and clarify billing/payment specifications. It also provides a structured approach to eligibility-determined payments, severability, and a final reconciliation process with subsequent post-reconciliation adjustments (recoupments and potential underpayment true-ups).

The regulation defines key terms used throughout the payment framework, including “Allowable Health Safety Net Payment,” “Shortfall Amount,” “Disproportionate Share Hospital (DSH),” “Public Payer Mix,” and “Relative Public Payer Mix Adjustment Factor,” as well as provider/payment concepts such as “Bad Debt,” “Emergency Bad Debt,” and “340B Provider.” It sets payment-year mechanics for funding shortfalls (projected reimbursable services, medical hardship services, emergency/urgent bad debt, and administrative expenses) and establishes that acute-hospital payments may be adjusted for additional available funding or shortfall allocations, with the Health Safety Net office allowed to reserve up to 10% to ensure full-year funding.

Starting with fiscal years beginning on/after October 1, 2024 (covering the shift from FY2024 to FY2025 and beyond), the regulation changes how shortfall allocations are distributed: when projected acute-hospital payments exceed available funding, funding is allocated through a graduated payment system that first applies DSH caps (initially up to 85% of allowable payments) and then applies non-DSH caps (initially up to 75%), using relative public payer mix adjustment factors when total funding is insufficient to meet those caps. For FY2026 and later (i.e., fiscal years beginning on/after October 1, 2025), the regulation further specifies cap-and-redistribution methods for DSH and non-DSH and then distributes any remaining funding across all hospitals proportionally to remaining allowable Health Safety Net payments.

Operational payment rules are set out for acute hospitals (101 CMR 614.06) and community health centers (101 CMR 614.07), including claim monitoring/possible withholding for suspected billing maximization (e.g., unbundling, upcoding), pricing methodologies using Medicare payment systems (IPPS/IPF-PPS for inpatient; outpatient per-visit pricing based on source-year outpatient charges and a hospital-specific Medicare payment on account factor), exclusions/non-payments (e.g., claims for outpatient visits ≤ $20.00 are handled through a specific pricing rule; outpatient visits within 72 hours of inpatient admission are not payable; provider preventable conditions and certain serious reportable events are not paid), secondary-payer rules (including a 95% rule and a “payment not to exceed primary” limit), bad debt and medical hardship handling, and specific add-on/other payments (including an additional payment for certain freestanding pediatric hospitals). Community health center payments are set primarily on a Medicare-based rate per patient per day (or less-than-or-equal charge amount under the PPS framework), with rules for service-specific payments outside the PPS rate table (including separate pay for defined services) and bad debt urgent-care payments limited to emergency bad debt and urgent-care bad debt at 75% of the specified payment rates. Reporting requirements require each provider to file or make available data deemed necessary by the Health Safety Net office (with administrative bulletin authority to revise specifications/schedules) and authorize audits and payment adjustments; failure to comply can lead to payment denial after notice. Final reconciliations must be completed no later than two fiscal years after the end of the fiscal year reconciled, with a defined closure rule after which no further adjustments occur for that fiscal year.

FULL SUMMARY

The bill establishes a new reimbursement obligation for Massachusetts health care carriers regarding “uncollected” patient cost-sharing amounts (co-payments, co-insurance, and deductibles) that remain unpaid after specified provider collection efforts. It adds Chapter 176O, Section 7A, requiring carriers to reimburse health care providers at no less than 65% of each qualifying unpaid co-payment/co-insurance/deductible amount that is not collected after reasonable efforts.

Section 7A defines “co-payment” as a fixed dollar amount owed under a health benefit plan; “co-insurance” as a percentage of the allowed amount (after any co-payment); and “deductible” as a specific dollar amount owed before the plan’s obligation begins (excluding any portion of premiums). The bill deems reimbursement for qualifying unpaid amounts as recovery of an “uncollectible bad debt,” and permits providers to request reimbursement if (i) the claim derives from unpaid cost-sharing amounts under the insured’s plan, (ii) each claim is at least $250 and reflects a unique covered service for the insured, (iii) the provider made reasonable collection efforts with documentation, including that the claim is not subject to an ongoing payment plan for more than 120 days from the date the first bill was mailed, (iv) the provider submits an aggregate reimbursement request on or before May 1 for claims meeting criteria in the prior calendar year with specified documentation (insured identifiers, date of service, amounts collected, and contact details), (v) the carrier may audit eligibility/coverage and the provider’s collection-effort documentation, must complete audits and dispute notifications within 120 days of receipt, and pays 65% of “undisputed” amounts within 120 days, and (vi) any amounts recovered by the provider after carrier reimbursement must be offset against future submissions.

The bill also prevents a carrier from prohibiting providers from collecting the insured’s cost-sharing at the time of service. It requires the Division of Insurance to promulgate regulations within 90 days of the act’s effective date consistent with CMS rules for reasonable collection efforts; if the division does not issue regulations in time, Section 7A is self-implementing and carriers must use the CMS bad-debt collection-efforts process documented in the most recent Medicare Provider Reimbursement Manual (CMS Pub. 15-1 and 15-2 (HIM-15)) as in effect within 90 days of the act’s effective date. Finally, it requires each carrier to provide an annual public report (posted on the division’s website) identifying the total number and amount of reimbursed and denied uncollected co-payments, co-insurance, and deductibles.

FULL SUMMARY

The bill creates a new Section 3C in Massachusetts General Laws chapter 176D to govern how insurers must pay ambulance service providers for emergency ambulance services when the provider is not under contract with the insurer covering the insured.

In defining the rule, the bill specifies key terms for “ambulance service provider” (licensed by the Department of Public Health), “emergency ambulance services” (emergency services rendered under an ambulance service license where immediate medical attention is needed), “insurance policy”/“insurance contract” (coverage for ambulance transportation services issued within Massachusetts), “insured,” and “insurer” (a list of Massachusetts-regulated insurance and health plan entities).

Operationally, if an ambulance service provider furnishes emergency ambulance services to an insured but is not under contract with the insurer providing the insured’s policy/contract, the insurer must pay the ambulance service provider directly and promptly. Payment must occur even if the insured’s policy/contract prohibits benefit assignments, so long as the insured executes an assignment; if the insured cannot practically execute an assignment because the policy would otherwise prohibit it, payment is still required. The bill also provides that the provider is not considered paid if the insurer instead pays the insured for the emergency service, and it grants the provider a right of action against an insurer that fails to pay under this requirement.

Payment rate and billing consequences are set out: except for nonprofit corporations licensed to operate critical care ambulance services that do both ground and air transports, payment under the direct-pay rule must be at the rate established by the municipality where the patient was transported. The bill deems the provider paid in full once paid under these subsections and prohibits further billing of the insured for the ambulance service, except for amounts the insured remains responsible for under the policy (coinsurance, co-payments, or deductibles). The bill further clarifies that it does not limit an insured’s existing rights to ambulance coverage and does not create entitlement to ambulance coverage where the insured’s policy provides none.

FULL SUMMARY

The bill establishes a new Massachusetts public health insurance option administered through the Commonwealth Connector. It adds a new chapter 176S creating the “Public Health Insurance Option,” requiring the Commonwealth Connector Authority to offer a public health benefits plan exclusively through the Connector to eligible individuals and groups, alongside Connector “seal of approval” plans. The public option must meet the Connector’s seal-of-approval requirements, minimum creditable coverage standards, and applicable requirements from ch. 176Q; it is required for eligible individuals and eligible small groups by no later than January 1, 2027, and for eligible large groups by no later than July 1, 2027.

The bill sets administration and oversight requirements for the public option, including permitting the Connector’s executive director to contract with managed care organizations or other health benefits administrators. It requires collaboration among the executive director, the Secretary of Health and Human Services, and the Commissioner of Insurance so that (as of January 1, 2026) only Medicaid managed care organizations already under contract with the Commonwealth may administer aspects of the public option; it allows applications from non-Medicaid managed care organizations after January 1, 2027. It requires annual reporting in the Connector’s annual reports on activities, receipts, expenditures, and enrollments, with oversight by the Connector Board and the state auditor as specified in ch. 176Q. It directs the Connector to set premium rates sufficient to fully finance the costs of benefits and related administrative costs.

For provider reimbursement and participation, the bill requires the Connector Board to set payment rates for public-option services and providers based on Medicare parts A and B, with Board discretion to adjust those base Medicare rates to maintain fair reimbursement and a strong provider network. It provides an opt-out mechanism for health care providers participating in Medicare so that no provider faces a penalty for not participating, the Connector must provide information on how providers can opt back in, and there must be an annual provider enrollment period to decide participation.

The bill also creates a related financing and risk-adjustment structure by amending multiple provisions of Massachusetts law. It authorizes the Commissioner of Insurance (by inserting new ch. 26 §8K) to assess risk-adjustment payments among “risk-adjusted health plans” and to make payments when a plan’s actuarial risk exceeds the average actuarial risk across risk-adjusted plans; self-insured group health plans under ERISA are exempt. It requires the Commissioner to set criteria and methods, allows use of actuarial and utilization/diagnosis and cost data (in a confidentiality-limited way), and includes a technical amendment to remove two specified last sentences of a prior 2006 session law section. The bill creates a new “Public Health Insurance Option Trust Fund” in ch. 29, requiring that amounts credited to the fund be expended without further appropriation for operation of the public option, and requires an updated revenue report by the Comptroller not later than January 1 to multiple specified offices and committees. Finally, it amends ch. 176Q to add definitions and cross-references expanding Connector “seal of approval” and underwriting-related provisions to “eligible large groups,” and it requires that no later than July 1, 2026 the Connector Board extend its seal of approval to large group plans and offer such plans alongside the public health insurance option for large groups through the Connector.

FULL SUMMARY

The bill directs the Massachusetts secretary of health and human services to make monthly enhanced Medicaid payments to “eligible hospitals” through enhanced Medicaid payments, supplemental payments, or other mechanisms, overriding contrary state law.

Each enhanced payment to an eligible hospital must be equal to 5% of the hospital’s average monthly Medicaid payments for inpatient and outpatient acute hospital services as determined by the secretary for the preceding year (or the most recent year with available data). The bill bars using these enhanced payments in later years to recalculate the hospital’s average monthly payment, and it prohibits the enhanced payments from offsetting existing Medicaid payments the hospital would otherwise qualify to receive. It also caps total payments to all eligible hospitals under the section in any fiscal year at $35,000,000.

The secretary may impose reasonable payment conditions to help ensure the availability of federal financial participation, and the bill allows the secretary and comptroller to take payment-related actions in anticipation of expected federal participation. The executive office of health and human services is authorized to promulgate regulations necessary to carry out the section.

For purposes of the bill, an “eligible hospital” is defined as a non-profit or municipal acute care hospital licensed under specified law that received enhanced Medicaid payments under the 2020 act in calendar years 2021 and 2022.

FULL SUMMARY

The bill requires the Massachusetts Health Policy Commission, working with the Center for Health Information and Analysis and the Division of Insurance, to conduct an analysis and issue a report on the use of prior authorization for health care services and its impact on cost, quality, and access.

The required report must cover: (1) an inventory of admissions, items, services, treatments, procedures, and medications that require prior authorization, focusing on items with high approval/denial rates for both standard and expedited requests (including after appeal); (2) review and adjudication timelines for standard and expedited requests, including the time to adjudicate appeals; (3) total health care expenditures associated with submitting and processing prior authorization determinations, including appeals; and (4) how prior authorization affects patient access and cost by patient demographics, geographic region, and service type. It also requires identification of services with low utilization variation across providers/carriers, low denial rates across carriers, and chronic-disease-related prior authorization items that negatively impact chronic disease management.

In addition, the bill directs analysis of operational and policy mechanics of prior authorization, including the integration of standardized electronic prior authorization attachments, standardized forms, requirements, and decision support into electronic health records and practice management software to promote transparency and efficiency; and whether “gold-carding”/waiver of prior authorization based on a carrier’s standards or policies is available to all providers in a carrier’s network. The bill further requires recommendations to simplify health insurance prior authorization standards and processes to improve access and reduce provider burden.

The bill specifies that the report be informed by data and information carriers submit to the Division of Health Insurance and must include, for both standard and expedited requests and for standard denials/expedited denials at least through appeal outcomes: lists of all prior-authorization-required admissions/items/services/treatments/procedures/medications; approval and denial rates (including denials later approved after appeal); frequency of extended review timeframes and how often such requests were approved; and average and median processing times for initial determinations and for appeals for standard and expedited prior authorizations. The report (and any legislative recommendations) must be submitted to the chairs of the joint committee on health care financing and the House and Senate committees on ways and means within one year of the act’s effective date.

FULL SUMMARY

The bill creates a new licensing and participation framework for dentists seeking to practice in Massachusetts under MassHealth. It adds a new General Laws section (Chapter 112, Section 52H) requiring that no person be licensed to practice dentistry unless the dentist agrees to accept a minimum percentage of MassHealth patients as part of the dentist’s active patient base.

The minimum MassHealth patient requirement is set by the Department of Public Health in consultation with the Executive Office of Health and Human Services and may not be less than 5% of a dental provider’s total patient caseload; it is also adjusted based on regional needs and the dental provider’s capacity. Dentists must provide annual documentation to the department verifying compliance. The department must also establish an application process for hardship exemptions or adjustments based on factors including practice size, geographic location, and other department-determined considerations.

Noncompliance triggers enforcement and penalties: the Board of Registration of Dentistry may suspend a dentist’s license until compliance is achieved (pursuant to Section 52D), and/or the department may assess administrative penalties as determined by the department. The Executive Office must develop an online portal to help MassHealth recipients locate participating dental providers by region and to publish transparency information on participation rates and available services. To incentivize participation, the Executive Office must (subject to appropriation) offer student loan forgiveness to newly licensed dentists who meet or exceed the required MassHealth percentage for at least 3 years, and must increase reimbursement rates for services rendered to MassHealth patients to support participating dentists’ financial sustainability.

The bill provides an emergency-care exception: in emergencies (as defined by the department, including acute dental pain, infection, or trauma requiring immediate intervention to prevent significant complications), any licensed dentist may treat a MassHealth recipient regardless of participation status and will be reimbursed at the standard MassHealth rate plus 10% for services provided within 60 days. The Executive Office must promulgate implementing rules, and it must issue an annual report (due December 31 each year) including the number of participating dentists by region, the percentage of MassHealth patients served relative to the state’s dental care needs, and recommendations for addressing access gaps. The act takes effect 180 days after passage.

FULL SUMMARY

The bill adds new requirements across Massachusetts health insurance and healthcare settings to improve coverage and continuity of access to ostomy care supplies and related fistula management. It inserts new provisions in Chapter 32A (Group Insurance Commission), Chapter 111 (acute-care hospitals), Chapter 112 (physician licensing/clinical prescribing rules), Chapter 118E (Medicaid managed care), and the major commercial insurance statutes (Chs. 175, 176A, 176B, and 176G), with largely parallel requirements.

For insureds under the Group Insurance Commission and for Medicaid managed care and contracted insurers/administrators (Chs. 32A and 118E), the respective commissions/division must provide coverage of all medical supplies for management of surgically created or spontaneous fistulas and supplies related to ostomy care, and may not require “non-medical” supplies as a condition of coverage. Each entity must make publicly available information about its ostomy-supply coverage. The bill also requires transfer of ostomy care information, patient history, and prescriptions to a new insurer within 72 hours when a person obtains new health insurance coverage, and prohibits delaying ostomy supply orders/shipments during the transition period.

Across the physician and pharmacy/supplier workflow, the bill requires that an ostomy-related prescription issued by a licensed physician be valid for at least 1 year without disruption. It allows physicians to prescribe ostomy supplies in quantities exceeding any legal/regulatory/insurance-policy limits when the physician determines it is necessary and expedient for patient care. It prohibits delaying fulfillment based on approval/appeal processes and requires ostomy suppliers to provide 1 month of advanced notice of prescription expiration to both patients and prescribers.

It also limits substitution (“non-medical switching”) of ostomy supply brands/products: suppliers must dispense as written and provide 1 month of advanced notice of intended substitution by mail, with the notice including samples of the proposed substitute for the patient to try; if the substitute fails to meet or exceed the quality of the original and compromises ostomy care, the patient may return to the original product or receive a product that matches the original quality. In addition, healthcare payers must reimburse ostomy supply suppliers at a rate not less than the Medicare reimbursement rate, and the bill requires acute-care hospitals performing ostomy surgery to employ and provide access to certified healthcare professionals specializing in ostomy care, including appropriate outpatient follow-up with such specialists.