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CMS Sets Final ACA Terms for 2027

The Centers for Medicare & Medicaid Services has issued its annual “Notice of Benefit and Payment Parameters for 2027; Basic Health Program,” which governs health plans offered through the federal health insurance exchange and state exchanges as established under the Affordable Care Act. Major provisions under the new final rule include: Eliminating the current requirement that insurers offer standardized health plans at each of the traditional plan levels (bronze, silver, gold, and platinum) in favor of permitting insurers to offer unlimited numbers of plans at each level. Introducing a new [...]

May 20, 2026|Categories: Affordable Care Act|Tags: Affordable Care Act, catastrophic health plans, health insurance exchanges, health insurance tax credits, health plan cost-sharing, non-network health plans, Notice of Benefit and Payment Parameters for 2027, state health insurance exchanges|

MACPAC Seeks Guardrails for AI Use in Medicaid Prior Authorization

While acknowledging the potential value of the use of AI in facilitating Medicaid prior authorization decisions, the agency that advises Congress on Medicaid and Children’s Health Insurance Program policy will recommend to Congress that the programs erect guardrails to protect those they serve. During a recent meeting of the Medicaid and CHIP Payment and Access Commission, members of that group discussed a staff report on the use of AI in Medicaid prior authorization decisions and endorsed the following principles for the use of AI in this manner: The Secretary of [...]

May 15, 2026|Categories: MACPAC, Medicaid, Medicaid managed care|Tags: AI use in Medicaid prior authorization, AI use in prior authorization, MACPAC, Medicaid and CHIP Payment and Access Commission, Medicaid prior authorization, prior authorization|

Federal Health Policy Update for May 14

The following is the latest health policy news from the federal government for May 8-14. Some of the language used below is taken directly from government documents. Congress The Ways and Means Committee has circulated a discussion draft of a bill that would require non-profit hospitals and health systems to report more of their community benefit-related spending activity. Under the draft bill, non-profit hospitals and health systems would be required to report on charity care spending, their process for patients to apply for financial assistance, and spending associated with community benefits. They also would be required to report on subsidized service [...]

May 14, 2026|Categories: hospitals, MACPAC, Medicaid, Medicaid and CHIP Payment and Access Commission, Medicaid and housing for the disabled, Medicaid managed care, Medicare, Medicare reimbursement policy|Tags: AI in Medicaid prior authorization, CDC and hantavirus, CMS and ELEVATE Model, CMS Electronic Prior Authorization initiative, CMS Medicare Wasteful and Inappropriate Service Reduction Model, CMS PEPPER program, CMS WISeR model, Early and Periodic Screening Diagnostic and Treatment program, EPSDT, excepted benefits for fertility services, Health and Human Services Inspector General report on inpatient rehabilitation facility documentation coverage and billing requirements, Health and Human Services Office of the Inspector General report on office-based peripheral vascular procedures, Health Care Advisory Committee, Information reporting for non-profit hospitals bill, MACMAC, Medicaid and CHIP Payment and Access Commission, Medicaid prior authorization, Medicaid state plan amendments, Medicare physician fee schedule, MLN Connects, moratorium on Medicare home health agency enrollment, moratorium on Medicare hospice provider enrollment, new moms.gov web site, non-profit hospitals community benefit bill, Organ Transplantation and Procurement Network, proposed CMS meeting request portal, section 504 of the Rehabilitation Act, state directed Medicaid payments|

A Closer Look at the Proposed Drug Prior Authorization Regulation

Last month, the Centers for Medicare & Medicaid Services proposed new requirements for the prior authorization of drugs for patients served by Medicare Advantage, Medicaid, CHIP, and qualified health plans in the federal marketplace. This proposal represented a next step to requirements CMS laid out in 2024 when it called on payers to offer electronic prior authorization for medical services and to respond to providers within required timeframes: seven days for standard requests and 72 hours for expedited requests. Now, CMS proposes requiring these payers to meet these standards through [...]

May 14, 2026|Categories: Centers for Medicare & Medicaid Services, Medicaid, Medicare|Tags: CMS and prior authorization, exchange plans and prescription prior authorization, Medicaid and prescription prior authorization, Medicare and prescription prior authorization, Prior authorization for prescriptions|

MACPAC Meets

Members of the Medicaid and CHIP Payment and Access Commission met last week in Washington, D.C. During the course of the deliberations, MACPAC’s staff made the following presentations to the commissioners: Automation in Medicaid Prior Authorization: Recommendations Exploring the Role of the State Medicaid Agency in the Program of All-Inclusive Care for the Elderly: Recommendations and Updated Implications Appropriate Access to Residential Services for Children and Youth with Behavioral Health Needs: Recommendations Implementing Community Engagement Requirements in Medicaid: Recommendation and Updated Implications Children and Youth with Special Health Care Needs [...]

May 13, 2026|Categories: MACPAC, Medicaid, Medicaid and CHIP Payment and Access Commission, Medicaid and housing, Medicaid and housing for the disabled, Medicaid regulations for the disabled|Tags: AI and Medicaid prior authorization, MACPAC, Medicaid and CHIP Payment and Access Commission, Medicaid and community engagement requirements, Medicaid prior authorization, Medicaid work requirements, Program of All-Inclusive Care|

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