Policy Updates

CMS Introduces First Prior Authorization Program for Traditional Medicare

Some Medicare-covered services will be subject to prior authorization in some parts of the country under a new model to be launched by the Centers for Medicare & Medicaid Services next year. To run from 2026 through 2031, the “Wasteful and Inappropriate Service Reduction Model,” or WISeR, will test a new process for determining whether enhanced technologies, including artificial intelligence, can expedite prior authorization for selected items and services that have been identified by CMS as particularly vulnerable to fraud, waste, abuse, or inappropriate use. The model will not include inpatient-only services, emergency services, and “…services that would pose a [...]

joe2025-07-01T17:06:55-04:00July 2, 2025|Centers for Medicare & Medicaid Services, CMMI, Medicare, Medicare reimbursement policy|

State Spending on Medicaid Rising – Fast

The states are experiencing almost unprecedented increases in their Medicaid spending – both more money and a larger share of their overall state budgets. According to a new Pew Research Center report, In fiscal year 2023, the combination of expiring federal COVID-19 pandemic aid, slowing tax revenue growth, and rising costs for Medicaid led to an increase in the share of state revenue dedicated to Medicaid of 17.8%, or $44.4 billion, over the previous year – the largest single-year rise in at least two decades. States spent 15.1% of every state-generated dollar on Medicaid, up 2.2 percentage points from the [...]

joe2025-06-26T15:53:22-04:00June 30, 2025|Medicaid|

Federal Health Policy Update for June 26

The following is the latest health policy news from the federal government for June 20-26. Some of the language used below is taken directly from government documents. Congress Senate Majority Leader Thune and House Speaker Johnson continue to press for passage of the “One, Big, Beautiful Bill” by July 4, the deadline set by President Trump. Leader Thune had hoped to bring the bill to the Senate floor early this week but continued disagreements over cuts to Medicaid have slowed progress. Earlier this week, in an attempt to assuage senators’ concerns that the bill’s Medicaid cuts would imperil rural hospitals, [...]

joe2025-06-26T16:56:14-04:00June 26, 2025|Uncategorized|

The Potential Impact of the Senate’s Proposed Medicaid Cuts

After the House passed its FY 2025 budget reconciliation bill the Senate took up its own bill, with the Senate Finance Committee proposing more than $800 billion in Medicaid cuts through a combination of reduced future Medicaid provider taxes, new limits on state directed payments made through Medicaid managed care plans, new Medicaid work requirements, more frequent redetermination of Medicaid eligibility, a shorter period of retroactive eligibility for Medicaid and the Children’s Health Insurance Program, and more. The Senate continues to debate these proposals, with some members believing they are necessary and appropriate and others arguing that they would have [...]

joe2025-06-25T12:53:57-04:00June 26, 2025|Congress, Medicaid|

Study Finds Differences in Medicare Advantage Hospitalization Trends

Patients who participate in Medicare Advantage plans spend more time as hospital inpatients but receive less post-acute care than those in traditional Medicare, a new study has found. According to NORC, a non-partisan research organization at the University of Chicago, Medicare Advantage patients had hospital stays that were 40% longer on average than those with Traditional Medicare, which comes to seven days versus five. In 2022, Medicare Advantage plans discharged fewer patients to post-acute care settings such as skilled nursing or home health compared to patients covered by Traditional Medicare. According to NORC, “These disparities suggest that Medicare Advantage beneficiaries [...]

joe2025-06-24T16:21:34-04:00June 25, 2025|Medicare, Medicare post-acute care|

Federal Health Policy Update for June 19

The following is the latest health policy news from the federal government for June 13-19. Some of the language used below is taken directly from government documents. Congress The Senate Finance Committee The Senate Finance Committee has released its portion of the FY 2025 budget reconciliation bill. Major proposals include: A freeze on the size of Medicaid provider taxes, phased down reductions of current taxes toward a new, lower limit for many states, and new terms under which provider taxes can be approved. New limits on the use of Medicaid state directed payments so they eventually will not exceed 100 [...]

joe2025-06-19T16:17:10-04:00June 19, 2025|Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, CMMI, Congress, Medicaid, Medicaid disproportionate share, Medicaid DSH, Medicaid DSH allotments, Medicaid managed care, Medicaid regulations, Medicare reimbursement policy|

Federal Health Policy Update for June 12

The following is the latest health policy news from the federal government for June 6-12. Some of the language used below is taken directly from government documents. Congress Republican senators continue to work on their version of a reconciliation bill with a goal of passage by July 4, although that deadline may slip. Some Senate committees have begun releasing their portions of the bill but the Finance Committee’s bill, with its tax and Medicaid provisions, has not yet been released. Among the majority party in the Senate, fault lines around the House-passed reconciliation bill remain around Medicaid provider taxes, state [...]

joe2025-06-12T16:32:26-04:00June 12, 2025|Centers for Medicare & Medicaid Services, hospitals, MACPAC, Medicaid, Medicaid managed care, Medicaid regulations, Medicare, Medicare post-acute care, Medicare regulations, Medicare reimbursement policy, MedPAC, Telehealth|

HHS Releases Proposed Budget

The Department of Health and Human Services has released a new, expanded version of its proposed FY 2026 budget. In some areas this version provides more detail than the administration shared in early May when it released a so-called “skinny budget” and some aspects of the budget proposal differ from the May release. Highlights of the most recent proposal include: A reduction of 25 percent, from $126 billion to $94.7 billion, in HHS’s overall discretionary (non-mandatory) spending. The consolidation of HHS’s 28 current operating divisions into 15 divisions. A reduction of $661 million, or 11 percent, in discretionary spending for [...]

joe2025-06-11T12:29:44-04:00June 12, 2025|340b, Centers for Medicare & Medicaid Services|

Administration Targets State Directed Medicaid Payments

The White House has issued a presidential memorandum on “Eliminating Waste, Fraud, and Abuse in Medicaid” that cites Medicaid “state-directed payments” as a form of waste, fraud, and abuse. According to the memorandum, states use state directed payments to pay more than Medicare rates for some Medicaid-covered services – something the memorandum suggests is contrary to current practice because “…billable costs for such care were historically capped at the same level that healthcare providers could receive from Medicare.” This assertion comes despite a 2024 regulation that set the payment limit for state directed payments at the average commercial rate and [...]

joe2025-06-11T10:22:01-04:00June 11, 2025|Medicaid, Medicaid managed care, Medicaid regulations|

CMS Charts Medicare’s Tech Future

In the wake of issuing a request for information asking stakeholders how the agency can better serve Medicare beneficiaries, the Centers for Medicare & Medicaid Services has begun charting its future use of technology by laying out some of the objectives of such an undertaking. In a recent news release, CMS identified the following objectives: Building a dynamic, interoperable national provider directory. Bringing modern identity verification processes to Medicare.gov to streamline credentials across the healthcare system. Expanding functionality of CMS’ Blue Button 2.0 patient access application programming interface (API). Transitioning CMS’s Data at the Point of Care pilot to general availability. [...]

joe2025-06-05T15:53:32-04:00June 10, 2025|Medicare|