Category: MM_Family_of_Companies

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CMS NEWS – A Framework for Scaling Palliative Care Via Medicaid

CMS NEWS – A Framework for Scaling Palliative Care Via Medicaid


Alternative Headline: Scaling Medicaid Palliative Care

[MM Curator Summary]: A study proposes a four-part EDIB model for states to expand Medicaid-based palliative care and improve outcomes.

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States can adopt a specific framework to help scale palliative care via Medicaid, according to a recent study published in Health Affairs.

Currently, the ability to scale palliative care nationally is limited by several obstacles. Among them are lack of awareness and workforce shortages. Another barrier is low reimbursement through Medicare that only covers physician and nurse practitioner services and does not pay for the full range of interdisciplinary care.

In the midst of this, some states have tried to improve palliative care access among their Medicaid populations in hopes of reducing unnecessary and expensive emergency room visits and hospital stays.

“Recognizing these challenges and federal inertia, states are increasingly implementing strategies to raise awareness, strengthen the palliative care workforce, and reform reimbursement to better support people living with serious illness …” the study authors wrote. “Over the past 15 years, states have increasingly adopted policies related to palliative care for people living with serious illness.”

As of 2024, nine states have implemented a comprehensive adult palliative care benefit, the study indicated. About 33 have established a serious illness task force to explore the issue, and eight states have established a pediatric palliative care benefit.

States can expand access further using a Engage, Design, Integrate, and Bundle (EDIB) methodology, the study authors contend.

This includes the following, according to the authors:

  • Engage: To scale community-based palliative care, states must engage patients, families, providers, and health systems.
  • Design: States should define palliative care elements including the core teams and services needed to support high-quality care for serious illness.
  • Integration: States should assess the state landscape to identify mechanisms for integrating aspects of palliative care into existing contracts.
  • Bundle: States should support specialty palliative care interdisciplinary teams through bundled reimbursement and standardized benefits across care settings.

States would also need to collect data on palliative care and quality measures.

“States can add language to managed care contracts to require data collection for palliative care-related quality measures, such as pain management and quality of life,” the authors wrote. “Other measures states may choose to incorporate include care manager skills training, care manager assessments, and referrals to palliative care.”

https://hospicenews.com/2025/06/25/a-framework-for-scaling-palliative-care-via-medicaid/


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CMS NEWS – HHS announces initiative with insurers to streamline prior authorizations  | AHA News

CMS NEWS – HHS announces initiative with insurers to streamline prior authorizations  | AHA News


Alternative Headline: HHS Overhauls Prior Authorization

[MM Curator Summary]: HHS and insurers launch a national initiative to modernize and streamline prior authorization with electronic systems and fewer delays — the initiative included commitments from insurers covering 257 million Americans. =============================

The Department of Health and Human Services June 23 announced an initiative coordinated with multiple health insurance companies to streamline prior authorization processes for patients covered by Medicare Advantage, Medicaid managed care plans, Health Insurance Marketplace plans and commercial plans. Under the initiative, electronic prior authorization requests would become standardized by 2027. HHS stated that these reforms complement ongoing regulatory efforts by the Centers for Medicare & Medicaid Services to improve prior authorization, including building upon the Interoperability and Prior Authorization final rule. 

The plan is expected to make the prior authorization process faster, more efficient and more transparent, the agency said. Participating insurers pledged to expand real-time responses by 2027. HHS said that the insurers would also commit to reducing the volume of medical services subject to prior authorization by 2026, including those for common procedures such as colonoscopies and cataract surgeries. 

During a news conference, HHS Secretary Robert F. Kennedy Jr. said unlike previous attempts by insurers, this initiative would succeed because the number of insurers participating represent 257 million Americans. “The other difference is we have standards this time,” he said. “We have … deliverables. We have specificity on those deliverables, we have metrics, and we have deadlines, and we have oversight.” 

Mehmet Oz, M.D., CMS administrator, said that the pledge “is an opportunity for industry to show itself.” Sen. Marshall, R-Kan., said that Congress could pursue codifying at least some portions of the initiative in the future. 

Additionally, participating insurers would honor existing prior authorizations during coverage transitions. 

https://www.aha.org/news/headline/2025-06-23-hhs-announces-initiative-insurers-streamline-prior-authorizations


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STATE NEWS – N.C. Medicaid pilot gets $30M approved by state Senate; bill now goes to House

STATE NEWS – N.C. Medicaid pilot gets $30M approved by state Senate; bill now goes to House


Alternative Headline: NC Medicaid Pilot Needs Funding

[MM Curator Summary]: North Carolina’s Medicaid pilot program, helping thousands with non-medical services, may end if $30 million in funding isn’t approved by July 1.

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A North Carolina pilot program focused on creating a better quality of life for Medicaid recipients could receive the funding it needs to continue.

This program is called the Healthy Opportunities Pilot. State senators approved $30 million in stopgap funding for the program, as part of a greater bill for a continuation of funds for many measures, to keep it operational. The state House must now take up the bill.

What You Need To Know

  • 36,442 people have received services through the N.C. Healthy Opportunities Pilot

  • The goal of the pilot is to reduce hospital stays and ER visits along with financial stress on members; there are more than 100 partner organizations across the state

  • The North Carolina Department of Health and Human Services previously reported the program would end by July 1 if more money cannot be secured

The measure, commonly known as HOP, is an innovative approach to health care that “buys health” for members of the program, according to the North Carolina Department of Health and Human Services.

The pilot administrators, called Network Leads, are spread out across the state, with two in the east and another in the west. Underneath Network Leads are the Home Service Organizations. 

It is through those organizations that these services flow.

The program is designed to offer members a variety of services, including farm fresh food, home repairs, rides to appointments, even safety from interpersonal violence.

One beneficiary in Winterville said her life would be upside down without the program.

“It’s not fast food. It’s not McDonald’s. It’s not Wendy’s. It’s not Taco Bell,” Evette said.

For confidentiality, Evette asked not to disclose her last name. 

She has two children who receive Medicaid, which qualified her family for the Healthy Opportunities Pilot.

The mother has received a food box packed with fresh fruits and vegetables every week.

“This program really does help,” she said.

The program took off in 2022 with federal support. 

A waiver gave North Carolina the freedom to use $650 million in Medicaid funding to pay for non-medical services with the goal of lowering stress over money.

The concept is to improve a person’s health by increasing access to community resources without billing Medicaid for expensive medical treatments. 

Evette said she had a rough time getting by before she joined the program last fall.

“I was struggling paycheck to paycheck,” she said.

It’s a struggle she worried will return. 

If more money is not added for the program to the budget by this fall, Deputy Secretary for N.C. Medicaid Jay Ludlam said that would be a death sentence.

“Without the General Assembly appropriating that, for now, we will have to stop the program,” Ludlam said.

Previously, the state health agency warned of the abrupt stop in operations across the constellation of providers by July 1.

Partners like the Catholic Charities of the Diocese of Raleigh in Greenville, sign up as Home Service Organizations. Catholic Charities delivers food boxes to members like Evette.

The Catholic Charities fall under Access East, a network lead that covers services for Beaufort, Bertie, Chowan, Edgecombe, Halifax, Hertford, Martin, Northampton and Pitt counties.

The Community Care of the Lower Cape Fear has 41 Home Service Organizations in its coverage area. 

Sarah Ridout is the program director for the Cape Fear Healthy Opportunities Pilot.   

“We are seeing a reduction in emergency department utilizations as well as a reduction in hospital admissions,” Ridout said.

That was one of the goals when the program was created.

An Asheville-based nonprofit, Impact Health, is also part of the Healthy Opportunities Pilot as a network lead. 

Laurie Stradley is the program director of Impact Health who said the Healthy Opportunities Pilot funding made it easier to quickly provide healthy meals to families in need after Hurricane Helene.

“It was just click, click, click and it was just incredible to see that come together,” Stradley said.

Since the expansion of the Healthy Opportunities Pilot, community partners have hired more employees. Kevion Dixon is one of them at Catholic Charities. 

“I love people. I love helping people,” Dixon said. Dixon is the food delivery program manager for the organization. “(I love) getting up every day, being driven to just help those around me. That’s why I wanted to be here.”

The community partner houses sliced carrots, oatmeal, bagged goods, seasonal crops and cultural ingredients for dishes like tortilla wraps.

After a box is packed for a member, Dixon or one of his employees will drive nutritious food to hungry families from as north as the Virginia state line to deep in rural eastern North Carolina.

“They’re just looking to make it day-to-day,” Dixon said.

The funding debate is based on the return on investment.

A Centers for Medicare and Medicaid analysis found cost savings of about $85 a year for each person in the program from mid-March 2022 to the end of November 2023. The savings roughly equate to a little more than $1,000 a year for each person. At the time this federal report was released to the public, 11,809 people had received services. 

For Evette, it’s make or break. 

“Oh, I would say I’m saving, like, at least $200 a month. When the program leaves, I’m going to be back to crunching the numbers,” Evette said.

An evaluation of the program last year also found that it decreased ER visits and hospital stays by a small margin.

https://spectrumlocalnews.com/nc/charlotte/news/2025/06/24/bill-to-fund-nc-medicaid-pilot-goes-to-house


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TECH – Walmart expands AI health platform to Medicaid, Medicare members

TECH – Walmart expands AI health platform to Medicaid, Medicare members


Alternative Headline: Walmart Launches Health Program

[MM Curator Summary]: Walmart and Soda Health launch a data-driven wellness program offering personalized nutrition guidance for Medicare and Medicaid members.

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Walmart Inc. is teaming with a startup to provide personalized nutrition and guidance to select Medicare Advantage and Medicaid members.

Walmart is partnering with health tech startup Soda Health Inc. to launch the Walmart Everyday Health Signals program to eligible Medicare Advantage and Medicaid members who opt in. 

Walmart Everyday Health Signals is designed to support day-to-day decisions for better health and wellbeing by utilizing real-time retail insights and targeted benefit delivery. The retailer also recently extended the offering to NationsBenefits members.

[READ MORE: Walmart combines its AI health platform with NationsBenefits services]

Members who enroll in the program can opt in to receive personalized nutrition and wellness insights based on their shopping patterns on Walmart.com. This includes key nutritional information for purchases like fruits and vegetables and identifying products to help reach wellness goals, along with customized healthy recipes and shopping lists. These data-driven insights are generated only when members opt in to participate.

Participating members who opt in receive direct access to real-time engagement tools powered by data driven insights:

  • After selecting a wellness objective, members will receive guidance tailored to their goals and personal shopping habits.
  • Members will be provided data-driven guidance to help navigate food choices and lifestyle change.
  • Information may also be used by health plans to identify additional benefits which support the members’ overall health and wellness. For example, insights may be used by plans to facilitate care coordination and identify additional benefits in support of the member’s overall health and wellness.

“At Walmart, we’re focused on making it easier for individuals and families to access the everyday foods that support their health and well-being," said Pravene Nath, MD, group director, consumer health and data solutions at Walmart. "Through our work with Soda Health, we’re helping members and other plan participants access personalized insights and groceries that align with their wellness goals. Together, we’re creating affordable, scalable solutions that address both individual health and broader community needs."

Walmart is co-launching this new program following the pullback of its Walmart Health service, which included brick-and-mortar clinics as well as virtual care options, in 2024.

Meanwhile, Soda Health also has existing partnerships with Hy-Vee and Kroger to personalize and deliver benefits down to the SKU level. 

"Our collaboration with Walmart demonstrates how the retail and healthcare sectors can work together to improve population health — starting with nutrition," said Robby Knight, co-founder and CEO of Soda Health. "Soda Health is helping to create connections between health plans and retailers to serve their members better by using opt in data to personalize interventions. As the focus increasingly turns toward the role of food as medicine, programs like this will help define better ways of improving outcomes and reducing the cost of care."

Based in Bentonville, Ark., Walmart Inc. operates more than 10,500 stores and numerous e-commerce websites in 19 countries.

https://chainstoreage.com/walmart-expands-ai-health-platform-medicaid-medicare-members



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STATE NEWS – Minnesota bill cutting free health care for illegal immigrants heads to governor – The Lion

STATE NEWS – Minnesota bill cutting free health care for illegal immigrants heads to governor – The Lion


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Alternative Headline: Minnesota Scales Back Immigrant Coverage

[MM Curator Summary]: Minnesota passed a bipartisan bill to end free health care for undocumented adults to curb spending, while keeping coverage for children.

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Minnesota is poised to repeal much of its free health care for illegal immigrants.

Both chambers of the Minnesota Legislature passed a bipartisan measure this week preventing illegal immigrant adults from receiving free, taxpayer-funded health insurance in Minnesota, Alpha News reports. The bill won’t impact access for illegal immigrant children.

The legislation passed 68-65 in the Republican-controlled House, with one Democrat joining 67 Republicans to provide the 68 votes needed to pass.

Additionally, the Democratic-controlled Minnesota Senate voted 37-30 in favor, with several Democrats joining the body’s Republicans.

“This is about being honest with Minnesotans about how their tax dollars are being spent,” Sen. Jordan Rasmusson, R-Fergus Falls, said on the Senate floor. “We cannot justify spending hundreds of millions on individuals who broke the law to enter the country while we face cuts to special education, nursing homes, and disability services.” 

The vote comes as the House, Senate and Gov. Tim Walz struck a budget deal last month that included repealing health care access for illegal immigrant adults. 

Walz and the then-Democratic-controlled Minnesota Legislature enacted legislation in 2023 making illegal immigrants eligible for the state’s Medicaid program, MinnesotaCare. Now this law will only apply to children. 

Walz is expected to sign the provision into law per the budget agreement. 

Even so, rank-and-file Democrats weren’t happy about it. 

“We didn’t think we were going to have this many people speaking up on the floor today,” state Rep. Maria Isa Perez-Vega, D-St. Paul, said on the House floor. “But thank you for those of you who have said ‘this bill sucks.’” 

However, Medicaid wasn’t invented to provide illegal immigrants with health care, noted state Rep. Jeff Backer, R-Browns Valley. 

“MinnesotaCare was never designed to be a comprehensive healthcare system for undocumented individuals. It was created to serve hardworking, lawful Minnesotans,” Backer said. “We must prioritize Minnesotans and protect their wallets and healthcare.” 

House Democrats attempted Monday to amend the proposal. Their provision would have let illegal immigrants ages 59 and older or those with certain health conditions stay enrolled in the program; it failed on a party-line vote. 

“Members, if we do not stop this, we are creating a deficit in the healthcare access fund,” said state Rep. Kristin Robbins, R-Maple Grove. 

“I know, Democrats, you had an $18 billion surplus that you turned into a $6 billion deficit,” she added. “Well, you are about to do it again for low-income Minnesotans. We cannot afford to create another deficit that will hurt our most vulnerable citizens.” 

https://readlion.com/minnesota-house-senate-send-legislation-cutting-free-health-care-for-illegal-immigrants-to-governor/





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CMS NEWS – AFSCME lab tech fights to save Medicaid for his patients — and his brother

CMS NEWS – AFSCME lab tech fights to save Medicaid for his patients — and his brother


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Alternative Headline: Lab Tech Defends Medicaid

[MM Curator Summary]: AFSCME member Ruben Bastell urged Congress to protect Medicaid, which supports both his patients and his brother.

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· Wednesday, June 18, 2025

Ruben Bastell knows what will happen to the patients he serves every day if Congress cuts Medicaid.  

“If there’s further delay in testing and diagnosis,” the senior laboratory technician and member of Local 860 (CSEA/AFSCME 1000) says, people won’t get timely treatment, “and there’ll be a lot more sickness.” 

Bastell recently travelled from New York to Washington. He joined a host of other AFSCME members who have visited the halls of Congress to urge House and Senate members to preserve funding for Medicaid, Medicare and a host of other programs people depend on. 

For Bastell, the fight is personal. His 24-year-old brother, born with kidney disease, has depended on Medicaid for years.  

“He’s able to live a full life because of the care that he receives through Medicaid,” says Bastell. 

https://www.afscme.org/blog/afscme-lab-tech-fights-to-save-medicaid-for-his-patients-and-his-brother





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STATE NEWS – Survey shows strong majority of Coloradans back Medicaid as GOP Congress weighs deep cuts to the program

STATE NEWS – Survey shows strong majority of Coloradans back Medicaid as GOP Congress weighs deep cuts to the program


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Alternative Headline: Coloradans Oppose Medicaid Cuts

[MM Curator Summary]:  A strong majority of Colorado voters oppose Medicaid cuts and support social safety programs amid GOP budget proposals.

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With millions of dollars in Medicaid on the table as Republicans solidify their budget bill, the majority of Coloradans say they don’t want the health program for low-income Americans to be cut.

Most Coloradans — 65 percent — oppose cuts to Medicaid, something that may happen if the budget bill passes, according to a new poll. The survey of 675 registered voters was conducted by Magellan Strategies for the health advocacy group Healthier Colorado.

“A majority have a positive regard for Medicaid. A majority think it’s important for their local community. A majority don’t want it cut,” said Jake Williams, Healthier Colorado’s CEO. “A majority are less likely to vote for a candidate who voted to cut Medicaid. So it’s a pretty clear result here.”

He said a proposal from President Donald Trump to raise taxes on those making over $2.5 million a year to help fund Medicaid is broadly popular among Coloradans.

Sixty-three percent of voters in hotly contested Congressional District 8 say they were less likely to vote for a candidate who voted to cut Medicaid, which is known as Health First Colorado.

“Cuts to Medicaid really aren’t showing any sort of support here, no matter really what the subgroup is,” said Courtney Sievers, Magellan’s director of survey research. 

The 8th district’s representative, Republican Gabe Evans, voted for the first version of the bill in the U.S. House, which makes deep cuts. He said he supports protecting Medicaid for vulnerable populations like pregnant women, kids and disabled people.

A spokesperson for Evans pointed out that it’s important to note that the polling also shows that some voters in the district who have an unfavorable view of Medicaid said there’s fraud, waste, and abuse in the Medicaid system and support undocumented people not receiving taxpayer-funded health care.

Pollsters wrote that “a dominant theme — especially among Republican and unaffiliated respondents — was anger or frustration over Medicaid being used for undocumented immigrants. Many said Medicaid should only be for U.S. citizens or legal residents, with some calling for stricter eligibility enforcement." 

Voters were asked if changes being proposed for Medicaid are “more about improving how the program works or more about taking money from Medicaid to use it for other purposes?” Sixty percent statewide and 51 percent in CD-8 said it was more about taking money to use for other purposes; that compared with 22 percent statewide and 29 percent in Evans’ district saying it was about improving how the program works for people.

“People aren’t buying the story that these Medicaid cuts are about making the program better, whether it’s work requirements or other forms of elimination of waste, fraud and abuse,” Williams said. 

Coloradans, including in CD-8, also expressed strong support for other government social safety net programs under threat from cuts in the Republican budget bill. Eighty-three percent statewide said they support the food assistance program called SNAP (Supplemental Nutrition Assistance Program). Eighty-two percent said they support Head Start, a free, federally funded program that provides early learning, health, nutrition, and support services to families with children from birth to age 5.

Most voters and those in CD-8 said they don’t want to see Congress make significant decreases in funding for those programs.

Voters weigh in on other issues

The poll also delved into other health-related questions on things like vaccines and social media.

  • 90% of voters in Colorado believe social media has had a negative impact on the youth mental health.
  • The percentage who believe the impact has been very negative has increased from 49% to 58% since December 2023.
  • 90% of Colorado voters believe there is a growing mental health crisis for children and youth.
  • The percentage who strongly agree has increased from 50% to 62% since December 2023.
  • 72% of voters in Colorado believe vaccines are safe and 76% believe they are effective; a majority (69%) said they do not believe that vaccines cause autism in children.
  • Just 5% of Colorado voters said the cost of childcare is affordable in their area.

https://www.cpr.org/2025/06/13/survey-strong-majority-coloradans-support-medicaid/




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STATE NEWS – Texas clarified when abortions are OK and aligned with RFK Jr. on health this legislative session

STATE NEWS – Texas clarified when abortions are OK and aligned with RFK Jr. on health this legislative session


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Alternative Headline: Texas Health Policy Shifts

[MM Curator Summary]: Texas passed major health bills in 2025, clarifying abortion rules, funding dementia research, and launching new Medicaid and nutrition initiatives.

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The 2025 Texas Legislature proved to be a session of re-calibration, where health care regulations were either tightened or loosened and attempts to delve further into some policy areas were left hanging until the next session.

The past two legislative sessions saw more seismic shifts: a near-total ban on abortion, a massive expansion of the state’s psychiatric hospital system, the teeniest of Medicaid expansions to offer one year of insurance coverage to new moms and a mental health budget boom following the tragic Uvalde school shooting.

That didn’t appear to leave much for the 89th Legislature to do on health, although lawmakers managed to approve a handful of intriguing bills and budget requests while killing other proposals.

Vaccine-hesitant parents successfully lobbied and won easier access to the vaccine exemption form and lawmakers narrowly clarified the state’s near-total abortion bans to give doctors more confidence in performing life-saving abortions.They also passed a historic $3 billion dementia research fund that awaits voter approval in November.

There were also a variety of bills signaling to the Trump administration, particularly U.S. Health Secretary Robert F. Kennedy Jr., that Texas was all on board his priorities to create transparency on food labeling and to stamp out chronic diseases.

The remaining health care cliffhanger is whether Gov. Greg Abbott signs or vetoes a hard-fought ban on THC products in the state. Abbott has until June 22 to veto any legislation passed this session. Otherwise, most of them will go into effect immediately or in September, even without his signature.

Here’s a rundown of how health care fared this past session.

Vaccine choice

House Bill 1586 allows anyone the ability to download a vaccine exemption vaccine exemption form at home. The form allows children to be exempted from being vaccinated to attend public schools. Currently, parents have to contact the Texas Department of State of Health Services and request the exemption form be mailed to them. Critics of the bill fear it would allow vaccine exemptions to flourish, as the state grapples with declining vaccination rates, but proponents say the bill is only meant to make it easier for parents to access a form.

Other vaccine skeptic measures that passed include HB 4076 which bars making patients ineligible as organ transplant recipients solely based on their vaccination status and Senate Bill 269 which requires providers to report patients’ vaccine complications to the national Vaccine Adverse Event Reporting System.

HB 4535 requires health care providers obtain informed consent from patients before a COVID-19 vaccine is administered and that patients receive notice about possible side effects.

Make Texas Healthy Again

Two nutrition bills dubbed Make Texas Healthy Again bills passed.

Texans who receive benefits through the federal Supplemental Nutrition and Assistance Program will no longer be able to purchase soda and candy with their Lone Star card following the passage of SB 379.

SB 25 requires food manufacturers to label foods by 2027 that contain any one of 44 additives or colorings not permitted in food sold in the United Kingdom, Australia, the European Union or Canada.

The state labeling requirements would take effect on Jan. 1, 2027 but a loophole exists that if on Dec. 31, 2026 a snack food producer wants to stick with its existing packaging for another decade, no warning label is needed because the new law “applies only to a food product label developed or copyrighted on or after January 1, 2027.”

The bill also requires elementary, secondary and postsecondary educational institutions to re-prioritize health and exercise. It also forces health professionals to take continuing education courses regarding nutrition and metabolic health. And it will require recess or physical activity for kids in charter schools – physical activity is already required in public schools.

HB 26 creates a pilot program within Medicaid to offer pregnant moms with nutritional counseling and medically-tailored meals.

Reproductive health

Texas banned all abortions three years ago, with a narrow exception that allows doctors to terminate a pregnancy only to save a pregnant patient’s life. Immediately, doctors and legal experts warned that this exception was too narrow and vaguely written, and the penalties were too severe, to ensure women could get life-saving care.

SB 31 says doctors need not wait until death is imminent to intervene, but affirms that the condition must be life-threatening to justify performing an abortion. It will also require doctors and lawyers to take continuing education courses on the nuances of the law.

Legislators passed a bill restricting cities, like Austin and San Antonio, from using taxpayer dollars to assist people who travel out-of-state to have an abortion. But the highest profile anti-abortion bill, SB 2880, which would have allowed anyone who manufactures, distributes, provides or prescribes abortion pills to be sued for $100,000 passed the Senate but stalled in the House.

Mental health

Lawmakers passed bills to expand crisis hotline services and provide loan reimbursement to address the mental health workforce shortage.

After a couple days of debate about the role of mental health professionals in Texas, lawmakers passed SB 646, which broadens eligibility for Texas’ loan repayment assistance program to include school counselors, marriage and family therapists, and other behavioral health professionals.

HB 5342 establishes the 988 Suicide and Crisis Lifeline Trust Fund, which will accept donations, grants and federal funds to maintain or improve the crisis line. Additionally, the bill mandates an annual report on the usage of the crisis centers participating in the 988 network.

Texas lawmakers imposed some restrictions on how minors accessed social media.

SB 2420 sets up requirements for age verification and parental consent before a minor is allowed to download or make purchases within software applications. Under this bill, developers must assign age ratings to their apps, disclose the reason for the rating, and notify the app stores of any significant changes.

Parental consent will not be required for specific emergency or educational applications, such as those providing access to crisis hotlines.

A bill to ban minors from social media altogether failed in the last few days of the legislative session.

Major budget items and agency changes

Several budget items involving health care and services for Texans were also approved.

Among them were an extra $100 million to fund child care scholarships to low income families on a waitlist for child care.

Nearly 95,000 Texas children are on a waitlist for child care scholarships at a time when facilities are closing and the cost of child care in Texas is making it difficult for working parents to make ends meet.

Last year, HHSC asked for $300 million worth of upgrades for its Medicaid and food stamps enrollment system but will? receive less than half that ask, about $139 million. The agency’s request came after Texas and the nation suspended Medicaid rules requiring participants to renew their applications more often during the pandemic and then removed nearly 2 million participants following the pandemic. The improvements will shorten the time between application for health care coverage and food assistance and activation of those benefits.

In Texas, Medicaid is mostly a children’s health insurance program. Only low income children, the elderly and new moms are covered by Medicaid in this state.

There is also a $18 million increase over the next two years for the state’s Early Childhood Intervention (ECI) services which assists families with children up to 36 months who have developmental delays, disabilities or certain medical diagnoses that may impact development.

A $60 million rider was put in to cover Texas’ costs of entering a federal summer lunch program in 2027. The 2023 program would give qualifying parents $120 over the summer months to help pay for lunches when school is out of session. More than 30 states now participate in the Summer Electronic Benefits Transfer program which also goes by the name Sun Bucks.

Lt. Gov. Dan Patrick championed the passage of Senate Bill 5, which creates the Dementia Prevention and Research Institute of Texas, to study dementia, Alzheimer’s disease, Parkinson’s disease and other brain conditions. Modeled after Texas’ cancer institute, the measure received bipartisan support. Abbott has signed the bill but the measure now goes before the voters to approve whether $3 billion in general revenue can be used to fund the project.

The Texas Health and Human Services Office of Inspector General’s office investigates health care and benefit fraud. This year, a handful of bills were passed to help streamline investigations by the office and update salary classifications for OIG officers to those of other Texas law enforcement officers, improving recruiting. This comes as the office has been instrumental in identifying fraud within some of the state’s health benefits systems, leading to firings of some agency employees.

https://www.newsfromthestates.com/article/texas-clarified-when-abortions-are-ok-and-aligned-rfk-jr-health-legislative-session





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FRAUD – Indian-origin pharma tycoon Tonmoy Sharma arrested in Los Angeles over $149 million healthcare fraud

FRAUD – Indian-origin pharma tycoon Tonmoy Sharma arrested in Los Angeles over $149 million healthcare fraud


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Alternative Headline: $149M Fraud by Rehab CEO

[MM Curator Summary]: Tonmoy Sharma was arrested for running a $149 million fraud scheme that lured in patients promising coverage, and then secretly using patient information to make false claims to Medicaid, and then the Affordable Care Act coverage.  


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Indian-origin doctor and businessman, the founder and former CEO of the now-defunct Sovereign Health Group, was recently arrested over $149 million medical fraud. The 61-year-old psychiatrist has been charged with four counts of wire fraud, one count of conspiracy and three counts of illegal remunerations for referrals to clinical treatment facilities.

    

What was the medical fraud? What was Sharma’s modus operandi?

Tonmoy Sharma’s Sovereign Health Group was a prominent addiction treatment provider throughout Southern California and several other states. According to court documents, the company billed private insurance companies for drug addicted and mentally ill patients at extremely high rates between 2014 and 2020.

Sovereign used to pursue patients aggressively through various forms of marketing forcing them to get admitted to the company’s treatment facilities. The patients were told that their treatment would be paid by a foundation funded by the donations from former SDpvereign patients. There was no such actual foundation and it was a ruse for Sovereign employees. They obtained patients’ names, date of birth and Social Security numbers and then obtained health insurance coverage on their behalf while the patients remained in the dark. Sovereign employees sometimes pretended to be the patients when calling into these insurance companies.


At Sharma’s direction, the court documents said, the employees claimed qualifying life events that had not happened in order to obtain new insurance outside the enrollment period and inflating or underreporting their income so the patients would qualify for Affordable Care Act government-subsidized private insurance instead of Medicaid, whose reimbursement rates were significantly lower than private insurers.

Sovereign also paid more than $21 million in illegal kickbacks for patient referrals to patient brokers.

Originally from Assam’s Dibrugarh, Sharma studied MBBS from Dibrugarh University. Sharma’s medical license was once revoked while he was practicing in the UK before he established his career in California.

https://www.msn.com/en-in/news/other/indian-origin-pharma-tycoon-tonmoy-sharma-arrested-in-los-angeles-over-149-million-healthcare-fraud/ar-AA1G9cyu






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PHARMA – The MAHA agenda won’t include expanding GLP-1 coverage — for now

PHARMA – The MAHA agenda won’t include expanding GLP-1 coverage — for now


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Alternative Headline: GLP-1 Coverage Faces Setback

[MM Curator Summary]:  PushbackThe Trump administration canceled a proposal to allow Medicare and Medicaid to cover GLP-1 obesity drugs, despite rising demand, but the discussion remains ongoing. 

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The GLP-1 boom isn’t slowing down anytime soon. Prescriptions for overweight or obese adults jumped almost 587% from 2019 to 2024, Healthcare Dive reported, and there’s still a huge untapped patient population representing more market upside.

As pharma’s pipeline explodes with more than 100 new drugs in various stages of development, one barrier to access has yet to be toppled. Medicare and Medicaid do not fully cover weight loss medications, with some exceptions, leaving out millions of potential users.

The Biden administration proposed ending this prohibition in late 2024, but the Trump administration recently axed the idea in April, stating it “did not intend to finalize” the proposed rule. A 2024 fact sheet about the proposal has also since been taken down by the Trump administration.

The move was a blow to the market, but health officials and the Centers for Medicare and Medicaid Services haven’t ruled out covering obesity medications at some point.

Obesity limitations

The government prohibition against covering obesity treatments has been the law of the land for the last 20 years, while states have been able to decide whether to cover these drugs in their Medicaid plans. Only 13 states covered GLP-1 drugs for obesity as of last year, but both Medicare and Medicaid cover GLP-1s for other approved indications, including diabetes or cardiovascular disease.

Allowing the expanded coverage would have cost the federal government $35 billion over 10 years, according to the Congressional Budget Office. Covering anti-obesity medications like GLP-1s would also result in some savings by preventing worsening health outcomes, but those savings would be less than the cost of the drugs, CBO said. 

Not everyone agrees the price isn’t worth it. 

“It does not align with the goal of reducing overall spending — it is penny wise but pound foolish.”

“Access to these drugs can meaningfully reduce the incidence of obesity, which is associated with significant improvements in overall health outcomes,” Wayne Winegarden, senior fellow and director of the Center for Medical Economics and Innovation at Pacific Research Institute, said via email. “Beyond the health benefits, some studies have found that covering obesity medications can reduce overall healthcare spending by reducing the need for expensive surgeries, hospital stays and other medical treatments.”


One 2023 estimate revealed Medicare could save between $175 billion to $245 billion in the first 10 years of covering weight loss drugs if private insurers similarly covered them. Another study found that average medical costs dropped by around $7,500 for patients after starting semaglutide drugs — well above the $5,600 that CBO estimated Medicare would spend on each weight loss drug user.

Market impact

Expanding GLP-1 coverage would also be a boost for obesity market leaders Eli Lilly and Novo Nordisk. Both pharma companies saw a dip in their stock prices when the Trump administration published its decision not to follow through on the proposal.

But that outcome was expected by some health policy experts and analysts, given the Trump administration’s short-term focus on cost-cutting measures across healthcare.

“It is not surprising in the sense that the administration appears to be under-appreciating the value created by innovative drugs,” Winegarden said. “It does not align with the goal of reducing overall spending — it is penny wise but pound foolish.”

Lilly has been pushing for broader coverage of its GLP-1 weight loss med Zepbound, which has helped the large pharma recently overtake Novo’s market leading position. Both companies have a list price of around $1,000 per month for their GLP-1s, making them hard to afford if insurers don’t offer coverage. The two companies are already competing head to head for market dominance by offering cheaper direct-to-patient vials via telehealth platforms and striking deals with pharmacy benefit managers.

Medicare also already has its sights on lowering costs for Novo’s suite of three semaglutide GLP-1 products, which were selected for its price negotiation program in 2027. But both companies are expanding their patient population through new indication approvals, including Novo’s nod for Ozempic in chronic kidney disease, while also developing new delivery methods through oral routes.

A path forward

While Medicare won’t be covering obesity meds in 2026, the Trump administration may take up the issue again down the road. CMS noted in April it was not finalizing the proposal, among others, “at this time,” but the agency also stated it “may address these proposals in future rulemaking, as appropriate.”

HHS Secretary Robert F. Kennedy Jr. also mentioned a potential “regulatory framework” to include coverage of these drugs in an April interview with CBS News. However, he said a change in diet and exercise would be a first-line treatment before people are entitled to an obesity medication. He also harped on the high cost of covering the drugs at the federal level.

But advocates have pointed out that Trump administration officials have made conflicting statements about their support of GLP-1s.

“To date, HHS leadership have sent mixed signals on the issue,” the American College of Gastroenterology said in April. “HHS Secretary [Kennedy] has criticized the drugs, while [Dr.] Mehmet Oz, administrator of [CMS], has praised the benefits of the treatments.”

FDA Commissioner Dr. Martin Makary, stated prior to taking the role that GLP-1s could cost Medicare “a fortune” and divert funds from other medical services, while Oz has promoted weight loss treatments, including GLP-1s, and stated it should be “easy” for people to access the medications.

If the recently published MAHA Commission report is any indication, the Trump administration won’t be pushing for a medication-first approach to tackle obesity anytime soon. While the report mostly focused on childhood chronic health issues, the sections regarding GLP-1s underscore the administration’s focus on dietary choices and food regulations as a first step.

The May report stated that “children are on too much medicine,” and included GLP-1s among a handful of drugs being more frequently used and potentially overtreated.

A handful of Democratic senators wrote to Kennedy in April urging him to reconsider Medicare and Medicaid coverage, calling such an expansion “a critical long-term investment” to improve obesity-related healthcare costs.

https://www.pharmavoice.com/news/maha-agenda-glp1-medicare-coverage-rfk-hhs/749455/