Category: Curator

HHS Curator is our free research service published by our team. We read hundreds of Medicaid news items each week and highlight and summarize them for you to save you time.

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STATE NEWS – Losing bidders accuse state officials of mishandling Medicaid contracts

STATE NEWS – Losing bidders accuse state officials of mishandling Medicaid contracts


Alternative Headline: Georgia Medicaid Contract Controversy


[MM Curator Summary]: Georgia’s Medicaid contract awards face legal protests amid claims of misconduct, favoritism, and transparency violations.

==============================


A bidding war for a massive contract to manage the state’s multibillion-dollar Medicaid health insurance program has devolved into allegations of misconduct against state officials.

The losing companies, Amerigroup and Peach State Health Plan, filed complaints with the state’s contracting office and with the Fulton County Superior Court.

Peach State Health Plan accuses the former commissioner of the Department of Community Health, Russel Carlson, of violating a strict period of silence meant to keep all bidders on an even footing.

The companies also accuse the department of withholding documents that it should have produced under the state’s transparency laws.

At stake, they say, is the fairness and legality of doling out a major state contract.

“The State’s procurement was mismanaged, rife with errors and reckless practices,” Peach State said in a December letter protesting the decision.

State officials contacted by The Atlanta Journal-Constitution did not address the allegations or say whether the contract would be rebid, citing the pending procurement process.

Carlson, who recently left his job with the state for an outside position, did not answer AJC reporters’ questions about the contract. In a joint statement, he and DCH said his departure was unrelated to the contract.

Georgia insures about 2.3 million people under Medicaid, a state-federal health insurance program for poor children and some poor, elderly and disabled adults. Since 2006 Georgia has outsourced the operation of the critical program to private health insurance companies under a handful of contracts.

In December, DCH awarded the contracts to four companies: CareSource, Humana Employers Health Plan of Georgia, Molina Health Care and United Health Care of Georgia. But those companies have not taken over the work while the protest plays out.

Whichever companies ultimately end up with the contract will be responsible for signing up doctors and hospitals to the company’s Medicaid plan, writing the checks for patient care and coordinating care for patients.

Amerigroup and Peach State Health Plan have held those contracts since the outsourcing began in 2006. Amerigroup manages the Medicaid insurance for about 460,000 Georgians, and Peach State Health Plan does it for about 700,000. The contract includes children in foster care as well as adult Medicaid recipients.

A third company, CareSource, covers 380,000 Georgians under the current contract. That company was selected to continue with the state and is not part of the protest.

Peach State alleges Carlson texted with a lobbyist for one of the competing bidders and offered to call him about the timing of the award. The contracting process was at that moment still in a “blackout period,” the complaint claims, meaning state officials were forbidden from discussing the contract with any of the bidders except through designated intermediaries.

In addition, the insurance companies allege the DCH violated the Georgia Open Records Act by failing to produce any text messages until prodded by a court filing, and then producing so few that the company says it was not a good faith effort.

As part of its protest, Amerigroup has accused Candice Broce, the commissioner of the Department of Human Services, of smearing its reputation and scapegoating the company. DHS is separate from DCH and determines eligibility for Medicaid. Amerigroup had sought to win a separate Medicaid contract that would allow the company to manage health care for children in foster care or otherwise under state custody.

The company referenced a letter Broce wrote to then-DCH Commissioner Caylee Noggle saying, “Amerigroup is often difficult to reach, even during normal business hours” and providers complain they do not get paid in a timely manner, prompting many to leave the network.

The state has postponed the contract start date until to 2026 while the protest plays out.

https://www.ajc.com/politics/2025/07/losing-bidders-accuse-state-officials-of-mishandling-medicaid-contracts/


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STATE NEWS – Losing bidders accuse state officials of mishandling Medicaid contracts

STATE NEWS – Losing bidders accuse state officials of mishandling Medicaid contracts


Alternative Headline: Georgia Medicaid Contract Controversy


[MM Curator Summary]: Georgia’s Medicaid contract awards face legal protests amid claims of misconduct, favoritism, and transparency violations.

==============================


A bidding war for a massive contract to manage the state’s multibillion-dollar Medicaid health insurance program has devolved into allegations of misconduct against state officials.

The losing companies, Amerigroup and Peach State Health Plan, filed complaints with the state’s contracting office and with the Fulton County Superior Court.

Peach State Health Plan accuses the former commissioner of the Department of Community Health, Russel Carlson, of violating a strict period of silence meant to keep all bidders on an even footing.

The companies also accuse the department of withholding documents that it should have produced under the state’s transparency laws.

At stake, they say, is the fairness and legality of doling out a major state contract.

“The State’s procurement was mismanaged, rife with errors and reckless practices,” Peach State said in a December letter protesting the decision.

State officials contacted by The Atlanta Journal-Constitution did not address the allegations or say whether the contract would be rebid, citing the pending procurement process.

Carlson, who recently left his job with the state for an outside position, did not answer AJC reporters’ questions about the contract. In a joint statement, he and DCH said his departure was unrelated to the contract.

Georgia insures about 2.3 million people under Medicaid, a state-federal health insurance program for poor children and some poor, elderly and disabled adults. Since 2006 Georgia has outsourced the operation of the critical program to private health insurance companies under a handful of contracts.

In December, DCH awarded the contracts to four companies: CareSource, Humana Employers Health Plan of Georgia, Molina Health Care and United Health Care of Georgia. But those companies have not taken over the work while the protest plays out.

Whichever companies ultimately end up with the contract will be responsible for signing up doctors and hospitals to the company’s Medicaid plan, writing the checks for patient care and coordinating care for patients.

Amerigroup and Peach State Health Plan have held those contracts since the outsourcing began in 2006. Amerigroup manages the Medicaid insurance for about 460,000 Georgians, and Peach State Health Plan does it for about 700,000. The contract includes children in foster care as well as adult Medicaid recipients.

A third company, CareSource, covers 380,000 Georgians under the current contract. That company was selected to continue with the state and is not part of the protest.

Peach State alleges Carlson texted with a lobbyist for one of the competing bidders and offered to call him about the timing of the award. The contracting process was at that moment still in a “blackout period,” the complaint claims, meaning state officials were forbidden from discussing the contract with any of the bidders except through designated intermediaries.

In addition, the insurance companies allege the DCH violated the Georgia Open Records Act by failing to produce any text messages until prodded by a court filing, and then producing so few that the company says it was not a good faith effort.

As part of its protest, Amerigroup has accused Candice Broce, the commissioner of the Department of Human Services, of smearing its reputation and scapegoating the company. DHS is separate from DCH and determines eligibility for Medicaid. Amerigroup had sought to win a separate Medicaid contract that would allow the company to manage health care for children in foster care or otherwise under state custody.

The company referenced a letter Broce wrote to then-DCH Commissioner Caylee Noggle saying, “Amerigroup is often difficult to reach, even during normal business hours” and providers complain they do not get paid in a timely manner, prompting many to leave the network.

The state has postponed the contract start date until to 2026 while the protest plays out.

https://www.ajc.com/politics/2025/07/losing-bidders-accuse-state-officials-of-mishandling-medicaid-contracts/


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STATE NEWS – How federal policy changes will affect Access Health CT plans

STATE NEWS – How federal policy changes will affect Access Health CT plans


Alternative Headline: CT Faces ACA, Medicaid Cuts


[MM Curator Summary]: Connecticut residents face rising health costs and coverage losses under Trump’s health policy overhaul, affecting ACA plans, Medicaid, and immigrant access.

==============================

Connecticut’s Democratic elected officials have been crisscrossing the state to warn about the impacts of Medicaid cuts in President Donald J. Trump’s “One Big Beautiful Bill.” The measure, along with other federal policy changes, will also impact people who purchase plans through state-based exchanges established by the Affordable Care Act. These plans are often referred to as “qualified health plans,” “marketplace plans” or “ACA plans.”

Roughly 150,000 residents purchase health insurance through Access Health CT, the state’s health insurance exchange. Many of the cuts to the exchange plans will happen before the widely-discussed changes to Medicaid, with some changes to the ACA plans going into effect as soon as this year.

Here’s what you need to know about those upcoming changes.

Enhanced premium tax credits

Around 90% of Connecticut residents who purchase a plan on the exchange receive financial support to help cover the cost. At the end of 2025, one type of subsidy, known as “enhanced premium tax credits,” is set to expire. As a result, Connecticut residents with exchange plans could expect to pay $1,700 more on average every year for their health insurance, according to Access Health CT. Over 135,000 people will lose at least some financial support. A fifth of those people, or roughly 27,000, will no longer be eligible for any financial assistance.

The federal government originally passed the “enhanced” premium tax credits in 2021 as part of the American Rescue Plan Act and extended them through the end of 2025 as part of the Inflation Reduction Act. The Affordable Care Act already provided financial assistance to people with qualifying incomes who purchased exchange plans. The enhanced subsidies in ARPA and the IRA were meant to give more financial support during COVID-19 to people who already received it, as well as provide some to people who made a bit too much to qualify for subsidies under the ACA.

Unless Congress extends the enhanced subsidies before the end of the year, they will expire on Dec. 31. People who make over 400% of the federal poverty level annually and qualify for enhanced subsidies based on their income and household size will no longer receive financial support. People who make less than 400% of the federal poverty level will still receive financial support, but it will be reduced. In 2025, 400% of the federal poverty level for a family of four equates to an annual income of roughly $127,000.

The expiration of the enhanced subsidies will also deal a major blow to Covered Connecticut, a program that provides no-cost exchange plans to residents who make too much to qualify for Medicaid but still earn 175% or less than the federal poverty level. Covered Connecticut currently provides more than 40,000 residents with no-cost health and dental coverage. The Department of Social Services estimates it would cost the state $30 million annually to continue the program.

State budget officials recently projected last fiscal year’s spending plan closed out with an almost $2.2 billion surplus.

A spokesperson for DSS said the agency is awaiting more guidance from federal agencies before reviewing the information with Gov. Ned Lamont. Once “he has decided on a course of action, the administration will discuss next steps with legislators and other relevant stakeholders. Any changes to revenue or appropriations resulting from the Trump budget will require legislative approval.”

Coverage for immigrants

Federal policy changes will also impact access to exchange plans for people with certain immigration status, with some measures going into effect almost immediately.

Beginning in August 2025, recipients of the Deferred Action for Childhood Arrivals program, or DACA, will no longer be eligible to enroll in health coverage through the exchange. The federal policy allowing them to access ACA plans only went into effect in November 2024 and was overturned by a “final rule” issued by the Centers for Medicare and Medicaid Services, or CMS, in June. Less than 200 Connecticut residents will be impacted by this change, according to Access Health CT.

As a result of the “big beautiful bill,” green card holders who can’t qualify for Medicaid because they haven’t been residents for a minimum of five years will no longer receive tax credits that allow them to purchase discounted plans on the exchange. This change will go into effect in January 2026 and will impact roughly 4,855 enrollees in Connecticut, according to data provided by Access Health CT to the comptroller’s office.

Effective January 2027, financial assistance will only be available to certain types of immigrants, including legal permanent residents, as well as people who entered the U.S. through the Cuban-Haitian Entrant Program. Roughly 11,000 residents, including refugees, asylees, trafficking survivors and humanitarian parolees will no longer qualify for financial assistance.

Changes to enrollment and income verification timelines

There are also pending administrative changes.

Generally, people can only enroll in an exchange plan between Nov. 1 and mid-January, but a “special enrollment period” allows people with incomes at or below 150% of the federal poverty level to enroll in any month. The special enrollment period provision will be eliminated on Aug. 25 of this year.

Also beginning Aug. 25, CMS will be changing the ways in which people must verify their incomes for financial help, including shortening the time period to submit documents from 150 days to 90 days. 

Click here for a broader list of federal changes to Access Health CT plans. 

Correction: A previous version of this story incorrectly reported that the enrollment period for the exchange plan ended in mid-December. It ends in mid-January.

https://ctmirror.org/2025/07/23/access-health-ct-federal-policy-big-beautiful-bill/




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STATE NEWS – Medicaid advisory committee meets – Mississippi Today

STATE NEWS – Medicaid advisory committee meets – Mississippi Today


Alternative Headline: Mississippi Medicaid Panel Reconvenes


[MM Curator Summary]: Mississippi’s Medicaid Advisory Committee resumed meetings after 19 months, now including required input from Medicaid beneficiaries per new federal rules.

==============================


Cindy Bradshaw, executive director of the Mississippi Division of Medicaid, listens during a meeting of the Medicaid Advisory Committee at the Sillers Building, Friday, July 25, 2025, in Jackson. Credit: Vickie D. King/Mississippi Today

The committee tasked with advising the Mississippi Division of Medicaid met Friday for the first time in a year and a half. 

The meeting in Jackson was a primer on Medicaid programs and provided a financial update for new members, most of whom were appointed in 2024 but have not yet participated in a meeting. 

The Medicaid Advisory Committee offers expertise and opinions to the state Medicaid program about health care services. It is made up of doctors, hospital executives, managed care organization representatives and other Medicaid stakeholders. 

Medicaid Advisory Committee members during a meeting at the Sillers Building, Friday, July 25, 2025, in Jackson. Credit: Vickie D. King/Mississippi Today

It includes two members of the recently formed Beneficiary Advisory Council, a group of Medicaid members and their families who advise Medicaid on their experience with the program. 

New federal policy seeks to heighten the role that beneficiaries play in shaping Medicaid programs and policy by mandating that members of the council serve on the Medicaid Advisory Committee. Ten percent of the group must be composed of beneficiaries or their families, a proportion that will rise in the coming years. 

Both committees are mandated by the federal government to meet quarterly. 

The last Medicaid Advisory Committee meeting, formerly known as the Medical Care Advisory Committee, was held on Dec. 8, 2023. 

Meetings were first set back in 2024 because state leaders, who were formerly charged with selecting members, were slow to make appointments. A meeting scheduled for October was postponed after former executive director Drew Snyder announced his resignation. 

Medicaid Advisory Committee members during a meeting at the Sillers Building, Friday, July 25, 2025, in Jackson. Credit: Vickie D. King/Mississippi Today

Meetings were then delayed further while the agency worked to sort out a discrepancy between state law and new federal guidelines, which mandated that committee appointments be made by the executive director of Medicaid and include members of the then-unformed Beneficiary Advisory Council. The new guidelines took effect this month. 

State lawmakers proposed language in several bills earlier this year during the legislative session that would have conformed state law to federal regulations. Two such bills were vetoed by the governor. 

Medicaid Executive Director Cindy Bradshaw said the agency decided to “honor the language” of the vetoed bills, conforming to federal guidelines without updating state law. 

Medicaid Advisory Committee members during a meeting at the Sillers Building, Friday, July 25, 2025, in Jackson. Credit: Vickie D. King/Mississippi Today

The committee’s recommendations have played a crucial role in crafting state Medicaid policy in the past. In 2023, the advisory group’s recommendation contributed to the Legislature’s passage of extended Medicaid coverage for new mothers. 

Republish our articles for free, online or in print, under a Creative Commons license.

https://mississippitoday.org/2025/07/25/medicaid-advisory-committee-meets-for-the-first-time-since-2023/



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STATE NEWS – How federal policy changes will affect Access Health CT plans

STATE NEWS – How federal policy changes will affect Access Health CT plans


Alternative Headline: CT Faces ACA, Medicaid Cuts


[MM Curator Summary]: Connecticut residents face rising health costs and coverage losses under Trump’s health policy overhaul, affecting ACA plans, Medicaid, and immigrant access.

==============================


Access Health CT is Connecticut’s health insurance exchange. Credit: Jenna Carlesso / CT Mirror

This story has been updated.

Connecticut’s Democratic elected officials have been crisscrossing the state to warn about the impacts of Medicaid cuts in President Donald J. Trump’s “One Big Beautiful Bill.” The measure, along with other federal policy changes, will also impact people who purchase plans through state-based exchanges established by the Affordable Care Act. These plans are often referred to as “qualified health plans,” “marketplace plans” or “ACA plans.”

Roughly 150,000 residents purchase health insurance through Access Health CT, the state’s health insurance exchange. Many of the cuts to the exchange plans will happen before the widely-discussed changes to Medicaid, with some changes to the ACA plans going into effect as soon as this year.

Here’s what you need to know about those upcoming changes.

Enhanced premium tax credits

Around 90% of Connecticut residents who purchase a plan on the exchange receive financial support to help cover the cost. At the end of 2025, one type of subsidy, known as “enhanced premium tax credits,” is set to expire. As a result, Connecticut residents with exchange plans could expect to pay $1,700 more on average every year for their health insurance, according to Access Health CT. Over 135,000 people will lose at least some financial support. A fifth of those people, or roughly 27,000, will no longer be eligible for any financial assistance.

The federal government originally passed the “enhanced” premium tax credits in 2021 as part of the American Rescue Plan Act and extended them through the end of 2025 as part of the Inflation Reduction Act. The Affordable Care Act already provided financial assistance to people with qualifying incomes who purchased exchange plans. The enhanced subsidies in ARPA and the IRA were meant to give more financial support during COVID-19 to people who already received it, as well as provide some to people who made a bit too much to qualify for subsidies under the ACA.

Unless Congress extends the enhanced subsidies before the end of the year, they will expire on Dec. 31. People who make over 400% of the federal poverty level annually and qualify for enhanced subsidies based on their income and household size will no longer receive financial support. People who make less than 400% of the federal poverty level will still receive financial support, but it will be reduced. In 2025, 400% of the federal poverty level for a family of four equates to an annual income of roughly $127,000.

The expiration of the enhanced subsidies will also deal a major blow to Covered Connecticut, a program that provides no-cost exchange plans to residents who make too much to qualify for Medicaid but still earn 175% or less than the federal poverty level. Covered Connecticut currently provides more than 40,000 residents with no-cost health and dental coverage. The Department of Social Services estimates it would cost the state $30 million annually to continue the program.

State budget officials recently projected last fiscal year’s spending plan closed out with an almost $2.2 billion surplus.

A spokesperson for DSS said the agency is awaiting more guidance from federal agencies before reviewing the information with Gov. Ned Lamont. Once “he has decided on a course of action, the administration will discuss next steps with legislators and other relevant stakeholders. Any changes to revenue or appropriations resulting from the Trump budget will require legislative approval.”

Coverage for immigrants

Federal policy changes will also impact access to exchange plans for people with certain immigration status, with some measures going into effect almost immediately.

Beginning in August 2025, recipients of the Deferred Action for Childhood Arrivals program, or DACA, will no longer be eligible to enroll in health coverage through the exchange. The federal policy allowing them to access ACA plans only went into effect in November 2024 and was overturned by a “final rule” issued by the Centers for Medicare and Medicaid Services, or CMS, in June. Less than 200 Connecticut residents will be impacted by this change, according to Access Health CT.

As a result of the “big beautiful bill,” green card holders who can’t qualify for Medicaid because they haven’t been residents for a minimum of five years will no longer receive tax credits that allow them to purchase discounted plans on the exchange. This change will go into effect in January 2026 and will impact roughly 4,855 enrollees in Connecticut, according to data provided by Access Health CT to the comptroller’s office.

Effective January 2027, financial assistance will only be available to certain types of immigrants, including legal permanent residents, as well as people who entered the U.S. through the Cuban-Haitian Entrant Program. Roughly 11,000 residents, including refugees, asylees, trafficking survivors and humanitarian parolees will no longer qualify for financial assistance.

Changes to enrollment and income verification timelines

There are also pending administrative changes.

Generally, people can only enroll in an exchange plan between Nov. 1 and mid-January, but a “special enrollment period” allows people with incomes at or below 150% of the federal poverty level to enroll in any month. The special enrollment period provision will be eliminated on Aug. 25 of this year.

Also beginning Aug. 25, CMS will be changing the ways in which people must verify their incomes for financial help, including shortening the time period to submit documents from 150 days to 90 days. 

Click here for a broader list of federal changes to Access Health CT plans. 

Correction: A previous version of this story incorrectly reported that the enrollment period for the exchange plan ended in mid-December. It ends in mid-January.

https://ctmirror.org/2025/07/23/access-health-ct-federal-policy-big-beautiful-bill/



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CMS NEWS – CMS launches oversight of Medicaid, CHIP enrollees to ensure immigration status

CMS NEWS – CMS launches oversight of Medicaid, CHIP enrollees to ensure immigration status


Alternative Headline: CMS Tightens Medicaid Immigration Checks


[MM Curator Summary]: CMS is requiring states to verify immigration status more rigorously for Medicaid and CHIP enrollees through new monthly reports.

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The Centers for Medicare & Medicaid Services today announced a nationwide initiative aimed at reinforcing eligibility standards for Medicaid and the Children’s Health Insurance Program. This effort focuses on verifying enrollees’ immigration status.

Starting today, CMS will begin issuing monthly enrollment reports to states, flagging individuals whose immigration status could not be confirmed in federal databases. States are expected to promptly review the cases, request additional documentation if necessary and take appropriate actions to ensure compliance with federal eligibility rules. Individuals who do not meet immigration requirements may only receive limited services under specific circumstances.

https://www.aha.org/news/headline/2025-08-19-cms-launches-oversight-medicaid-chip-enrollees-ensure-immigration-status


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STATE NEWS – Alaska Law Implements Time Limits for Prior Authorization Decisions on Medication Coverage

STATE NEWS – Alaska Law Implements Time Limits for Prior Authorization Decisions on Medication Coverage


Alternative Headline: Alaska Caps Prior Authorization Delays


[MM Curator Summary]: Alaska passed a law requiring insurers to decide prior authorization requests within 72 hours, effective January 2026.

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The law has support from patients, health care providers, pharmacists,and the largest health insurance provider in the state.

Prior authorizations (PAs) are pervasive in the delivery of US health care. They are a tool used by government and private health insurers to control costs and to ensure resources are being optimally utilized. Although developed for good fiscal management practices, PAs have also been prone to abuse, which can lead to delays in necessary treatment. They have shifted an administrative burden onto medical practices and pharmacies to the degree that many physicians’ practices employ staff whose sole responsibility is to process PAs.1

In May 2025, the Alaska Legislature passed SB 133, which requires insurers to notify patients of PA decisions within 72 hours of the request submission. This law applies to PA requests for medical services and prescription drugs. Within this 72-hour range, the insurer can request additional information from the health care provider, which provides a limited extension of time for decision notification. The law includes a path for expedited requests, which must have a decision within 24 hours.2

The new legislation becomes effective January 1, 2026. The law is described as having support from patients, health care providers, pharmacies, and the largest health insurance provider in the state. In a statement, legislative sponsor Sen Jesse Bjorkman stated, “[T]his bill makes the process quicker, clearer, and fairer for everyone.”2

For several years, the American Medical Association has advocated for changes in medical service PAs, and a Centers for Medicare & Medicaid Services (CMS) final rule in 2024 implemented similar times for PA decisions.3 This policy is referred to as the Interoperability and Patient Access Final Rule. The CMS rule also required insurers to improve application programming interfaces (APIs). In simple terms, APIs are interfaces that increase communication between computer systems and enhance automation of decisions. The CMS interoperability rule streamlined administrative burden in medical practices, but the rule specifically excluded PA decisions regarding prescription medications.3 The American Pharmacists Association advocated for the CMS rule to cover medications.

Presently, there is a robust public discourse on drug pricing mechanisms and levels of transparency in decision-making processes. Although not under the same magnification as pharmacy benefit managers, PAs and API computer systems are poised to be an emerging strategy for patient advocacy and improvements in pharmacy operations and finances.

REFERENCES
1. O’Reilly KB. Survey quantifies time burdens of prior authorization. American Medical Association. January 30, 2017. Accessed July 21, 2025. https://www.ama-assn.org/practice-management/prior-authorization/survey-quantifies-time-burdens-prior-authorization
2. Rosen Y. New Alaska law establishes quick deadlines for insurers’ decisions on medical care. Alaska Beacon. July 18, 2025. Accessed July 21, 2025. https://alaskabeacon.com/briefs/new-alaska-law-establishes-quick-deadlines-for-insurers-decisions-on-medical-care/
3. Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Advancing Interoperability and Improving Prior Authorization Processes for Medicare Advantage Organizations, Medicaid Managed Care Plans, State Medicaid Agencies, Children’s Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges, Merit-Based Incentive Payment System (MIPS) Eligible Clinicians, and Eligible Hospitals and Critical Access Hospitals in the Medicare Promoting Interoperability Program. Fed Regist. 2024;89(27):8758-8988. 42 CFR §422, 431, 435, 438, 440, and 457 (2024); 45 CFR §156 (2024). Accessed July 21, 2025. https://www.federalregister.gov/documents/2024/02/08/2024-00895/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-advancing-interoperability
4. Re: [CMS-9123-P] Medicaid Program; Patient Protection and Affordable Care Act; Reducing Provider and Patient Burden by Improving Prior Authorization Processes, and Promoting Patients’ Electronic Access to Health Information for Medicaid Managed Care Plans, State Medicaid Agencies, CHIP Agencies and CHIP Managed Care Entities, and Issuers of Qualified Health Plans on the Federally-facilitated Exchanges; Health Information Technology Standards and Implementation Specifications, Proposed Rule [Email]. January 4, 2021. Accessed July 21, 2025. https://aphanet.pharmacist.com/sites/default/files/audience/APhACommentstoCMSonMedicaidPriorAuthorization_Final.pdf

https://www.pharmacytimes.com/view/alaska-law-implements-time-limits-for-prior-authorization-decisions-on-medication-coverage


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STATE NEWS – OMNES IPA and Northwinds IPA Join Forces to Create Expanded Healthcare Network Across New York State

STATE NEWS – OMNES IPA and Northwinds IPA Join Forces to Create Expanded Healthcare Network Across New York State


Alternative Headline: OMNES, Northwinds Form Mega IPA


[MM Curator Summary]: OMNES IPA and Northwinds IPA have merged to form a $800M behavioral health network serving 80,000 patients across 34 New York counties.

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OMNES IPA (Syracuse) and Northwinds IPA (Plattsburgh) today announced a strategic integration that will create one of New York State’s most geographically expansive independent provider associations (IPA). The affiliation, completed on August 1, 2025, combines the strengths of a for-profit LLC with a nonprofit 501(c)(3) organization to better serve patients, advocate for providers, and partner with health plans and hospital systems.

Operating under the OMNES IPA name with headquarters in Syracuse, the newly combined organization brings together 36 behavioral health providers serving approximately 80,000 patients across 34 counties with combined revenues over $800 million annually. This strategic alliance positions the organization as a major force in value-based care delivery for behavioral health and mental wellness at a critical time for Medicaid programs nationwide.

“By uniting our organizations, we’re creating a powerful hub for value-based care and innovation that can better advocate for providers, strengthen partnerships with health plans and managed care organizations, and deliver exceptional care across an unprecedented geographic footprint,” said Enrico Cullen, former Executive Director of Northwinds IPA and now CEO of the combined OMNES organization.

Both organizations bring complementary strengths to the partnership. Northwinds IPA has achieved Level 2 contracting capabilities to take on financial risk for value-based care and developed sophisticated methodologies for multivariate data analysis. OMNES IPA contributes significant technological infrastructure that will enhance operational efficiency and care delivery. The combined strengths offer an attractive foundation for future partnerships.

“This partnership represents exactly the kind of strategic thinking our healthcare system needs,” said Shawna Craigmile, Chief Growth Officer at Helio Health and OMNES Board Chair. “By combining the technological capabilities of OMNES with Northwinds’ proven value-based careexpertise, we’re creating a model that other regions and other providers can look to for guidance and hopefully inspiration.”

The new entity specifically strengthens the network’s expertise in vital care areas, including Certified Community Behavioral Health Clinics (CCBHC), opioid treatment programs, mental wellness services, whole-person care approaches, and social determinants of health initiatives.

“The healthcare landscape is evolving rapidly, and this strategic alliance ensures we can meet those challenges head-on,” said James Button, CEO of Citizen Advocates (DAXIA Integrated Health Network), Northwinds Board Chair, and one of the original founders of Northwinds IPA “Our combined resources and geographic reach will enable us to deliver more comprehensive, coordinated care while maintaining the community-focused approach that defines both organizations.”

Kate Budlong, interim Executive Director of OMNES IPA, emphasized the timing and cultural significance: “Cultural fit is an important aspect of any collaboration and vital for a strategic business endeavor. We have it. We’re bringing together two organizations with proven track records, shared values, and shared ways of operating at a moment when healthcare providers need to unite to navigate Medicaid challenges and continue serving our most vulnerable populations.”

The expanded geographic scope includes Plattsburgh, Malone, Watertown, Syracuse, Utica, Rochester, Ithaca, Binghamton, Elmira, and more, which uniquely positions OMNES IPA to address rural healthcare challenges while leveraging urban healthcare infrastructure and expertise. The affiliation follows OMNES IPA’s 2023 strategic merger with Your Health Partners (YHP) in the Rochester and Finger Lakes regions, which expanded its reach and added a strong data strategy.

The timing is critical given the challenging landscape facing Medicaid providers. Recent federal budget legislation projects reductions in federal Medicaid spending that will affect millions of beneficiaries nationwide. The enhanced scale, analytics acumen, and technological capabilities position OMNES IPA to navigate these funding pressures while maintaining community-based care delivery in behavioral health, addiction treatment, and whole-person care to address some of New York State’s most pressing healthcare needs.


https://fox40.com/business/press-releases/ein-presswire/841186684/omnes-ipa-and-northwinds-ipa-join-forces-to-create-expanded-healthcare-network-across-new-york-state/


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STATE NEWS – Financial relief incentive spiked CRC screening uptake in Florida Medicaid enrollees

STATE NEWS – Financial relief incentive spiked CRC screening uptake in Florida Medicaid enrollees


Alternative Headline: Florida Boosts Cancer Screening


[MM Curator Summary]: Florida Medicaid’s financial incentive program boosted colorectal cancer screening rates by 4.4 points in under a year, impacting over 100,000 enrollees.

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Key takeaways:

  • A Florida initiative helped improve colorectal cancer screening by 4.4 percentage points among Medicaid enrollees.
  • State had significant increases for individuals aged 45 to 55 years.

A Florida health initiative prompted a significant increase in colorectal cancer screening for eligible individuals with Medicaid within the state, demonstrating the strategy’s effectiveness and ability to target urgent public health needs.

Florida incentivized Medicaid managed care plans to focus on screening uptake with financial relief. The results included a 4.4 percentage-point increase in overall screening in less than a 

Christopher R. Cogle

“The results were larger than expected,” Christopher R. Cogle, MD, professor of medicine at University of Florida and founding director of Florida Health Policy Leadership Academy, told Healio. “In just 9 months, we brought 100,000 Floridians up to speed for colorectal cancer screening, and for many of them, this was their first encounter with health care.”

“When large health systems try new interventions at the practice level, they might only get a few hundred patients up to speed with colorectal cancer screening,” he added. “Florida tried something new. It aimed for system-level change and found a scale of improvement that was larger than even the largest hospitals in the state.”

Financial relief for better uptake

Colorectal cancer incidence continues to rise in the U.S.

Nationally, a projected 154,270 cases will be diagnosed, and 52,900 people will die of the disease this year, according to American Cancer Society’s Cancer Statistics 2025 report. Only lung/bronchial cancer will cause more mortality among malignancy types.

Patients enrolled in Medicaid have “disproportionally and persistently low” screening rates compared with those with private insurance, researchers wrote.

“Coming out of COVID, we saw a cancer screening gap,” Cogle said.

Approximately 70% to 80% of individuals enrolled in Medicaid are covered through managed care, private insurance companies contracted to help manage costs, Cogle said.

“Today’s managed care plans agree to handle both the medical needs of patients as well as their health-related social needs,” he added.

At the same time, state agencies wield significant “leverage” with these agreements.

“Every Medicaid managed care plan has clear performance measures in their state contracts,” Cogle said. “These plans aren’t just processing claims. They’re competing on quality, because that’s what drives their payment.”

In 2022, Florida used a financial relief, called alleviation of liquidated damages, to try and improve screening for colorectal cancer.

“Florida Medicaid created a new financing approach. It offered relief on other performance measures if plans made an extra push to raise cancer screening rates within the next 9 months,” Cogle said.

Cogle and colleagues conducted a comparative effectiveness analysis of Florida Medicaid enrollees eligible for colorectal cancer screening before and after the initiative to determine its efficacy.

The pre-initiative cohort included 187,295 individuals (54.5% aged 56-65 years; 30.5% white; 19.9% Hispanic; 19.4% Black) and the post-initiative cohort had 191,659 (52.6% aged 56-65 years; 30.3% white; 22% Hispanic; 19.2% Black).

The proportion of Medicaid enrollees who had up-to-date screening for colorectal cancer at the end of the policy served as the primary endpoint.

‘Encouraging example’

After accounting for attrition, the post-initiative cohort had a significantly higher proportion of individuals up to date with colorectal cancer screening compared with the pre-initiative cohort (51.3% vs. 46.9%; P < .001).

Screening significantly increased among individuals aged 45 to 55 years (31.3% to 38.6%; P < .001) and those aged 56 to 65 years (56.6% to 60.8%; P < .001).

“This trend suggests that the 2021 United States Preventative Services Task Force guideline update, which lowered the recommended screening age from 50 to 45, was being adopted early by physicians and embraced by patients, even within a Medicaid population that often faces significant barriers to preventive care,” Cogle said. “It’s a rare and encouraging example of rapid uptake of national guidelines in a resource-constrained environment.”

Conversely, screening decreased significantly for those aged 66 to 75 years (62% to 56.7%; P < .001).

Investigations into barriers to screening for this population deserve future investigations, researchers wrote.

However, the program’s overall success underscores the importance of long-term initiatives.

“The next step is to make successful policies durable,” Cogle said. “We also need to share results widely, through publications, conferences, and other forums, and explore how federal guidance can help scale proven models nationwide.”

Cogle emphasized this approach could be used to improve outcomes in other areas.

“We’ve used similar state-level financial incentives in Florida, and they consistently prompt health plans to focus intensely, at least for a time, on urgent health needs,” he said. “Cancer has shown us a new way to improve population health. This was an experiment in a high-priority cancer, but the lessons translate to maternal health, birth outcomes, adolescent mental health, and more.”

“This is much bigger than oncology,” he added. “Medicaid isn’t just a safety net. It’s the country’s largest public health laboratory. When you align quality goals, financing, and private sector engagement, you can achieve large-scale results and learn from it.”

https://www.healio.com/news/hematology-oncology/20250815/financial-relief-incentive-spiked-crc-screening-uptake-in-florida-medicaid-enrollees



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TECH – Drive Health Named Preferred Vendor by the Association for Community Affiliated Plans

TECH – Drive Health Named Preferred Vendor by the Association for Community Affiliated Plans


Alternative Headline: Drive Health Named ACAP Vendor


[MM Curator Summary]: Drive Health has been named a Preferred Vendor by ACAP to help its 85 member health plans serving 30M people leverage AI for improved care and efficiency.

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PHOENIX–(BUSINESS WIRE)–Today, digital health startup Drive Health announces that it has been named a Preferred Vendor by the Association for Community Affiliated Plans (ACAP). ACAP is the national trade association representing not-for-profit Safety Net Health Plans who serve their members through Medicare, Medicaid, and more.

With its new designation as a Preferred Vendor, Drive Health solidifies its unwavering dedication to member welfare and the optimization of the healthcare industry. Drive will use its resources and its team’s extensive knowledge of the public sector to support ACAP’s mission: to equitably improve the health and well-being of people with limited resources or significant health needs. This partnership comes at a particularly crucial time, as challenges like regulatory headwinds, industry-wide labor shortages, and rising acuity of member populations require increased attention and resources.

Drive Health’s mission is to create healthier communities through revolutionary technology and approachable artificial intelligence. Founded in 2022, Drive Health’s flagship product, Avery, a Personalized Agentic Caregiver, empowers clinicians to focus on direct members with the highest needs by automating routine tasks – helping plans deliver more personalized care, ultimately delivering higher patient satisfaction and improved outcomes.

Under the partnership, Drive Health will share its mission with ACAP’s network of health plans through numerous platforms, including ACAP’s newsletter, its CEO Summit, and its educational webinar series. These mediums will give Drive Health’s team the chance to speak in further detail about the impact artificial intelligence has on the healthcare industry, and how ACAP members can leverage emerging technology to address workforce challenges and optimize member outcomes.

James Stringham, CSO at Drive Health and former ACAP Board Member and Plan CEO, will host a webinar alongside Chief Nursing Officer Dr. Leeza Constantoulakis and Co-Founder Kevin Longoria in September.

“Partnering with ACAP was an absolute no-brainer for us. Drive Health is well equipped to deliver nonprofit organizations and members alike the tools to harness emerging technology. We’re dedicated to ensuring equitable healthcare outcomes for all, and we will utilize our expertise to help position and differentiate member health plans," said James Stringham, CSO at Drive Health and former ACAP Board Member and Plan CEO.

“ACAP is delighted to welcome Drive Health as a Preferred Vendor,” said ACAP CEO Margaret A. Murray. “Our member plans look forward to learning more about the ways Drive combines hands-on health care experience with innovative technology to offset potential financial and clinical challenges.”

ACAP’s 85 member Safety Net Health Plans provide coverage for more than 30 million people through Medicare, CHIP, Medicaid, and other public healthcare programs across the United States. Drive Health’s team of seasoned industry experts looks forward to helping ensure equitable, high-quality care for all.

About Drive Health

Drive Health makes healthcare simple and accessible – anytime, anywhere, for everyone. Its mission is to ease the burden on healthcare providers, build trust with consumers, and simplify healthcare through secure, AI-enabled solutions. For more information, visit DriveHealth.ai.


https://www.businesswire.com/news/home/20250819073391/en/Drive-Health-Named-Preferred-Vendor-by-the-Association-for-Community-Affiliated-Plans



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