Following the receipt of New York Governor Kathy Hochul’s letter, CMS has admitted that it made an error in the calculations used to justify the investigation into the state’s Medicaid program. The federal agency had accused the state of fraud, waste, and abuse (FWA), claiming that New York had 75% of Medicaid beneficiaries enrolled in the personal care services (PCS) program, but in reality, only about 450,000 or about 6% to 7% were part of it. An agency spokesperson attests that CMS mischaracterized New York’s approach of applying billing codes and has since modified its methodology (AP News, April 10; Politico Pro, April 10).
In alignment with CMS’ drug interoperability rule release on April 10, the Office of the National Coordinator for Health Information Technology (ONC) proposed updates to its Health IT Certification Program. As part of the proposed rule, the ONC looks to update six HL7 Fast Healthcare Interoperability Resources (FHIR) standards and add one new standard. If approved, the older versions would expire in 2028. Additionally CMS released an inpatient payment proposed rule, which included proposals to update the definition of certified electronic health record technology under the Medicare Promoting Interoperability Program, as well as modify the Electronic Prior authorization measure, and modify reporting requirements for the Public Health and Clinical Data Exchange objective through the addition of Unique Device Identifiers for the Implantable Medical Devices measure (Inside Health Policy, April 10).
CMS has proposed a rule to expand electronic prior authorization requirements for prescription drugs, with the goal of reducing delays and improving access to medications. The proposal would apply to Medicare Advantage, Medicaid and CHIP programs, and marketplace plans, requiring these payers to use electronic processes for drug prior authorization requests. Beginning October 1, 2027, the rule would set more consistent timelines for decisions, including a 24-hour turnaround for urgent requests and up to 72 hours for standard requests, depending on the program.
It would also require payers to provide clear reasons for denials and make more detailed prior authorization data available, with new reporting requirements on approval and denial rates starting in 2028 based on 2027 data. Overall, the policy is intended to create greater consistency across programs, improve transparency for providers, and help patients receive prescriptions more quickly, building on earlier rules finalized in 2020 and 2024. Stakeholder groups, including America’s Health Insurance Plans and the Electronic Health Record Association, have generally supported expanding electronic prior authorization while suggesting additional implementation improvements (Inside Health Policy, April 10; Health Payer Specialist, April 13).
An updated charter for the Advisory Committee on Immunization Practices (ACIP) under HHS Secretary Robert F. Kennedy Jr. is drawing concern from public health experts. The revised charter places greater emphasis on vaccine safety, including identifying gaps in safety research and reviewing potential adverse effects, as well as newer technologies like mRNA vaccines. It also expands the range of expertise on the panel to include areas such as toxicology, pediatric neurodevelopment, recovery from vaccine injuries, and consumer perspectives. The changes follow earlier actions taken last June, when the previous ACIP panel was replaced with new members, some of whom have expressed skepticism about vaccines, leading to contentious meetings and legal challenges from groups including the American Academy of Pediatrics. While the U.S. Department of Health and Human Services maintains the update is routine, critics argue it could weaken confidence in vaccines and increase confusion. A court ruling last month found parts of the broader vaccine policy changes were implemented unlawfully, adding to ongoing scrutiny of the administration’s approach (Fierce Pharma, April 10).
CMS released a proposed rule for FY2027 updating Medicare payment policies for inpatient hospitals and long-term care hospitals. The rule includes a 2.4% payment increase for both hospital types, reflecting a 3.2% market basket update minus a productivity adjustment. Overall, hospital payments are expected to rise by about $1.4B, with an additional $464M tied to new medical technologies. Payments for long-term care hospitals are also projected to increase by about $55M, with no major structural changes beyond routine updates.
The rule would also expand the Comprehensive Care for Joint Replacement model into a mandatory nationwide model starting October 2027, covering more joint replacement procedures. CMS proposes several quality reporting updates, including adding new measures such as diabetes-related care and advance care planning, modifying mortality measures to include Medicare Advantage patients, and removing certain outdated measures. Hospitals that fail to report quality data would face payment reductions (CMS, April 10).
Additional provisions include:
On April 8, CMS issued a letter to state officials on the implementation of Section 71109 of the OBBBA, under which federal financial participation (FFP) for Medicaid and CHIP services must be limited to US citizens, green card holders, Cuban and Haitian entrants, and individuals eligible under the Compact of Free Association (COFA). While states will no longer be able to claim federal matching funds for non-citizens, the agency clarifies that funds will remain available for the treatment of emergency conditions. Due to the nature of this being a statutory change, states will be required to verify beneficiaries’ immigration status, first with electronic data sources and if needed to reach out to them (Inside Health Policy, April 9).
Following CMS’ decision to freeze about $260M in Minnesota’s Medicaid funding related to allegations of fraud, waste, and abuse (FWA) investigation in the state’s program, the state has begun to make strides to address CMS’ concerns. Part of the corrective action plan (CAP) approved by CMS is to revalidate the about 5,600 care providers that reside in the state; to date, 550 have been approved, 160 disenrolled, and 2,500 not yet responded or have not yet completed their application. The state estimates that it will be finished with the revalidation process by the end of May, but it remains unclear when CMS will release the withheld funds. The agency’s Administrator, Dr. Mehmet Oz, had initially stated that CMS would release the deferred funds once the state proposes and acts on their CAP, but they have not yet released the funds, with a federal judge recently declining to block the agency’s fund withhold (MPR News, March 20; MPR, April 10).
In Maryland’s attempt to deal with their projected $1.5B budget gap, the state’s Developmental Disabilities Administration (DDA) has been a target for cuts, with the Governor last week signing a budget that includes $127M funding reduction in FY2027. On April 10, the House approved SB 792, Maryland Protecting People With Disabilities Act, under which the state would address “procedural terminations” by repealing the 90-day time limit to appeal a threatened disenrollment, protecting Community Pathways waiver participants from being disenrolled from missing or incomplete documentation and disenrollments due to the department’s failure to process applications in a timely manner. The bill now awaits the Governor’s signature (News From the States, April 11).
Medicaid expansion has been linked to increased access to opioid use disorder treatment, particularly buprenorphine, according to recent research based on national pharmacy claims data. In eight states that expanded Medicaid after 2018, prescriptions increased by more than 21% between 2019 and 2023, with the largest gains in Maine, Oklahoma, and Virginia. Earlier expansion states also saw smaller increases as federal policy changes after 2018 made the medication more widely available, including through telehealth. The study highlights how expansion supports both affordability and provider capacity, leading to higher treatment rates across populations. These gains may be at risk as experts warn that potential federal Medicaid cuts could limit access to treatment. The Congressional Budget Office estimates nearly $886.8B in reduced Medicaid spending over the next decade, which could increase the number of uninsured individuals and reduce coverage. Medicaid remains the largest payer for opioid use disorder treatment, covering nearly half of nonelderly adults with the condition. While overdose deaths have declined from 81,806 in 2022 to 54,045 in 2024, disruptions in coverage could increase the risk of treatment discontinuation and mortality (News From the States, April 10).
Nebraska lawmakers approved a bill to preserve retroactive Medicaid coverage, preventing the state from moving forward with plans to eliminate it through a federal waiver. The policy allows certain medical expenses incurred before enrollment to be covered, currently up to 90 days prior to application, though federal changes from 2027 to 2029 will shorten that window to one or two months depending on eligibility group. The legislation requires the state to provide the maximum level of coverage allowed under federal law. The bill also adds requirements around transparency in disability determinations and places limits on changes to home and community-based services. It comes as the state moves ahead with other Medicaid changes, including implementing work requirements for some enrollees starting May 1 (Nebraska Public Media, April 10).
Tennessee (Effective January 1, 2026): Renews a uniform percentage increase for inpatient and outpatient hospital services for the rating period covering, January 1, 2026 through December 31, 2026, incorporated in the capitation rates through a separate payment term.
Wisconsin (Effective January 1, 2026): Renews a uniform percentage increase established by the state for eligible home and community-based services for the rating period covering January 1, 2026, through December 31, 2026, incorporated in the capitation rates through a risk-based rate adjustment.
Wisconsin (Effective January 1, 2026): Renews a uniform percentage increase established by the state for eligible home and community-based services for the rating period covering January 1, 2026 through December 31, 2026, incorporated in the capitation rates through a separate payment term.
Wisconsin (Effective January 1, 2026): Renews a uniform percentage increase established by the state for eligible home and community-based services for the rating period covering January 1, 2026 through December 31, 2026, incorporated in the capitation rates through a risk-based rate adjustment.
Wisconsin (Effective January 1, 2026): Renews a minimum fee schedule for home and community-based services for the rating period covering January 1, 2026 through December 31, 2026, incorporated in the capitation rates through a risk-based rate adjustment.
Michigan (Effective October 1, 2025): Renews a uniform increase established by the state for primary care and specialty physician services provided by practitioners employed or under contract with approved public entities, for the rating period covering October 1, 2025 through September 30, 2026, incorporated in the capitation rates through a separate payment term.
Oregon (Effective January 1, 2026): Renews a minimum fee schedule for behavioral health outpatient services furnished by qualified providers for the rating period covering January 1, 2026 through December 31, 2026,incorporated into the capitation rates through a risk-based adjustment.
Arizona (Effective October 1, 2025): Amends a uniform percentage increase established by the state for Differential Adjusted Payments (DAP) program eligible providers for the rating period covering October 1, 2025, through September 30, 2026, and incorporated in the capitation rates through a risk-based adjustment.
Illinois (Effective January 1, 2026): Renews a uniform increase established by the state for inpatient services at hospitals participating in delivery system transformation programs approved by the state for the rating period covering January 1, 2026 through December 31, 2026, incorporated in the capitation rates through a separate payment term.
Tennessee (Effective January 1, 2026): Renews a value-based payment and uniform percentage increase for professional services at an academic medical center for the rating period covering January 1, 2026 through December 31, 2026, incorporated in the capitation rates through a separate payment term.
Florida (Effective October 1, 2024): Renews a uniform percentage increase for inpatient and outpatient hospital services for rating periods covering October 1, 2024 through January 31, 2025, incorporated in the capitation rates through a separate payment term.
Florida (Effective February 1, 2024): Renews a uniform percentage increase for inpatient and outpatient hospital services for rating periods covering February 1, 2025 through September 30, 2025, incorporated in the capitation rates through a separate payment term.
Florida (Effective February 1, 2025): Renews a uniform dollar increase for primary care services and nursing facility services for rating periods covering February 1, 2025 through September 30, 2025, incorporated in the capitation rates through a separate payment term.
Florida (Effective October 1, 2024): Renews a uniform dollar increase for primary care services and nursing facility services for rating periods covering October 1, 2024 through January 31, 2025, incorporated in the capitation rates through a separate payment term.
New Jersey (Effective July 1, 2025): Establishes a uniform dollar increase for inpatient hospital services, outpatient hospital services and behavioral health inpatient services provided by general acute hospitals and a private acute psychiatric inpatient hospital in Union County for the rating period, July 1, 2025 through June 30, 2026, incorporated into the capitation rates through a separate payment term.
New Jersey (Effective July 1, 2025): Renews a uniform dollar increase for inpatient and outpatient hospital services and behavioral health inpatient and outpatient services provided by participating hospitals in Ocean County for the rating period covering July 1, 2025 through June 30, 2026, incorporated in the capitation rates through a separate payment term.
New Jersey (Effective July 1, 2023): Amends a uniform increase for inpatient hospital services provided by public and private acute care hospitals and freestanding psychiatric hospitals in Bergen County for the rating period covering July 1, 2023 through June 30, 2024, incorporated in the capitation rates through a separate payment term.
New Jersey (Effective July 1, 2023): Amends a uniform increase for inpatient hospital services, including behavioral inpatient hospital services, provided by participating hospitals in Ocean County for the rating period covering July 1, 2023 through June 30, 2024, incorporated in the capitation rates through a separate payment term.
New Jersey (Effective July 1, 2025): Establishes a uniform dollar increase for inpatient hospital services and outpatient hospital services provided by Gloucester County hospitals for the rating period covering July 1, 2025 through June 30, 2026, incorporated in the capitation rates through a separate payment term.
New Jersey (Effective July 1, 2025): Renews a uniform dollar increase for inpatient and outpatient hospital services provided by participating hospitals in Bergen County for the rating period covering from July 1,2025 through June 30, 2026, incorporated in the capitation rates through a separate payment term.
New Jersey (Effective July 1, 2025): Renews a uniform dollar increase for inpatient and outpatient hospital services provided by Middlesex County hospitals for the rating period, July 1, 2025 through June 30, 2026, incorporated in the capitation rates through a separate payment term.
New Jersey (Effective July 1, 2025): Renews a uniform dollar increase for inpatient and outpatient hospital services provided by Mercer County hospitals for the rating period, July 1, 2025 through June 30, 2026, incorporated in the capitation rates through a separate payment term.
New Jersey (Effective July 1, 2023): Amends uniform increase for inpatient hospital services provided by Middlesex County hospitals for the rating period covering July 1, 2023 through June 30, 2024, incorporated in the capitation rates through a separate payment term.
Pennsylvania (Effective July 1, 2024): Amends a quality payment/pay for performance (category 2 APM, or similar) and performance improvement initiative for nursing facility services for rating periods covering January1, 2024 through December 31, 2024, incorporated in the capitation rates through a separate payment term.
Pennsylvania (Effective January 1, 2026): Renews a uniform percentage increase for inpatient hospital and outpatient hospital services for rating periods covering January 1, 2026 through December 31, 2026, incorporated in the capitation rates through a separate payment term.
Pennsylvania (Effective January 1, 2026): Renews a uniform percentage increase for inpatient hospital and outpatient hospital services for rating periods covering January 1, 2026, through December 31, 2026, incorporated in the capitation rates through a separate payment term.
Virginia (Effective July 1, 2024): Amends a uniform percentage increase for professional services at an academic medical center for rating periods covering July 1, 2024, through June 30, 2025, incorporated in the capitation rates through a separate payment term.
Tennessee (Effective January 1, 2026): Renews a value-based purchasing model for behavioral health outpatient services for the rating period covering January 1, 2026 through December 31, 2028, incorporated in the capitation rates through a risk-based rate adjustment.
Illinois (Effective January 1, 2026): Renews a uniform increase for critical access hospitals established by the state for outpatient hospital services for the rating period, January 1, 2026 through December 31, 2026, incorporated into the capitation rates through a separate payment term.
Missouri (Effective July 1, 2025): Establishes a minimum and maximum fee schedule for inpatient and outpatient hospital services for children’s hospitals for the rating period covering July 1, 2025 through June 30, 2026, incorporated into the capitation rates through a risk-based adjustment.
Missouri (Effective July 1, 2025): Renews a minimum and maximum fee schedules established by the state for outpatient hospital services for the rating period covering July 1, 2025 through June 30, 2026, incorporated into the capitation rates through a risk-based adjustment.
Missouri (Effective July 1, 2025): Renews a minimum and maximum fee schedule for inpatient and outpatient hospital services for children’s hospitals for the rating period covering July 1, 2025 through June 30, 2026, incorporated into the capitation rates through a risk-based adjustment.
Oregon (Effective January 1, 2026): Renews a minimum and maximum fee schedules established by the state for inpatient hospital services for the rating period covering July 1, 2025 through June 30, 2026, incorporated into the capitation rates through a risk-based adjustment.
Nevada (Effective January 1, 2023): Amends a uniform increase for eligible professional services at designated academic medical centers for the rating period covering January 1, 2023 through December 31, 2023, incorporated in the capitation rates through a separate payment term.
Tennessee (Effective January 1, 2026): Renews a uniform dollar increase for emergency ground ambulance services for rating periods covering January 1, 2026 through December 31, 2026, incorporated in the capitation rates through a separate payment term.
Nebraska (Effective January 1, 2026): Renews a uniform increase for staff and faculty dental providers at an academic dentistry institution of a public university established by the state for dental services for the rating period covering January 1, 2026 through December 31, 2026, incorporated in the capitation rates through a risk-based rate adjustment.
Nebraska (Effective January 1, 2026): Renews a uniform increase for faculty or staff members of an academic medical institution of a public university established by the state for the rating period covering January 1, 2026 through December 31, 2026, incorporated in the capitation rates through a risk-based rate adjustment.
Oregon (Effective January 1, 2026): Renews a uniform dollar increase for governmental units providing ground emergency medical transportation, established by the state for the rating period covering January 1, 2026, through December 31, 2026, incorporated in the capitation rates through a separate payment term.
Colorado (Effective July 1, 2025): Renews a minimum fee schedule for behavioral health outpatient services for the rating period covering July 1, 2025 through June 30, 2026, incorporated in the capitation rates through a risk-based rate adjustment.
Missouri (Effective July 1, 2025) Renews a uniform percentage increase for the professional services of designated providers affiliated with one of the qualifying hospitals for the rating period covering July 1, 2025 through June 30, 2026, incorporated into the capitation rates through a separate payment term.
Ohio (Effective July 1, 2025): Establishes a uniform percentage increase for qualified practitioner services at an academic medical center, primary care and specialty physician services, and dental services, as well as a value-based performance payment to providers who attain quality performance target(s), starting July 1, 2025 for the rating period covering January 1, 2025 through December 31, 2025, incorporated into capitation rates via a separate payment term.
Florida (Effective October 1, 2025): Renews a uniform percentage increase for primary care services and specialty physician services for the rating period covering October 1, 2025, through September 30, 2026, incorporated in the capitation rates through a separate payment term.
Ohio (Effective January 1, 2026): Renews a uniform percentage increase for qualified practitioner services at a non-academic medical center and a value-based performance payment to providers who attain quality performance target(s), for the rating period covering January 1, 2026 through December31, 2026, incorporated into the capitation rates through a separate payment term.
Ohio (Effective January 1, 2026): Renews a uniform percentage increase for qualified practitioner services at a non-academic medical center and a value-based performance payment to providers who attain quality performance target(s), for the rating period covering January 1, 2026 through December31, 2026, incorporated into the capitation rates through a separate payment term.
Oregon (Effective January 1, 2026): Renews a uniform dollar increase for ground emergency medical transportation for privately-owned providers, established by the state for the rating period covering January 1, 2026 through December 31, 2026, incorporated in the capitation rates through a separate payment term.
Ohio (Effective July 1, 2025): Establishes a uniform percentage increase for inpatient and outpatient hospital services, and for qualified practitioner services at an academic medical center, and a value-based performance payment to providers who attain quality performance target(s), starting July 1, 2025 for the rating period covering January 1, 2025 through December 31, 2025, incorporated into capitation rates via a separate payment term.
Ohio (Effective January 1, 2026): Renews a uniform percentage increase for qualified practitioner services at a non-academic medical center and a value-based performance payment to providers who attain quality performance target(s), for the rating period covering January 1, 2026 through December31, 2026, incorporated into the capitation rates through a separate payment term.
Florida (Effective October 1, 2024): Renews a maximum fee schedule for inpatient hospital services and outpatient hospital services for the rating period covering October 1, 2024, through January 31, 2025, incorporated in the capitation rates through a risk-based rate adjustment.
Florida (Effective February 1, 2025): Renews a maximum fee schedule for inpatient hospital services and outpatient hospital services for the rating period covering February 1, 2025 through September 30, 2025, incorporated in the capitation rates through a risk-based rate adjustment.
Kentucky (Effective January 1, 2026): Renews a quality payment and uniform dollar increase for inpatient hospital services, outpatient hospital services, and professional services at an academic medical center for the rating period covering January 1, 2026 through December 31, 2026, incorporated in the capitation rates through a separate payment term.
Nevada (Effective January 1, 2026): Renews a uniform dollar amount for inpatient hospital and outpatient hospital services for rating periods covering January 1, 2026 through December 31, 2026, incorporated in the capitation rates through a separate payment term.
Georgia (Effective July 1, 2025): Renews a uniform percentage increase for inpatient hospital and outpatient hospital services for rating periods covering July 1, 2025, through June 30, 2026, incorporated in the capitation rates through a separate payment term.
Georgia (Effective July 1, 2025): Establishes a uniform percentage increase for inpatient hospital services and outpatient hospital services for rating periods covering July 1, 2025 through June 30, 2026, incorporated in the capitation rates through a separate payment term.
