CMS updates prior authorization transparency requirements for health plans
As part of efforts to improve prior authorization, CMS has bolstered its transparency requirements for health plans. Based on 2024 regulations that partially took effect in 2026 and are intended to promote electronic prior authorization, new requirements apply to health plans in Medicare Advantage (MA), Medicaid managed care and the Affordable Care Act marketplaces, along with state…
Hospital cyberattacks underscore growing financial and operational risks
As seen in two incidents over the past month and in a newly issued warning, cyberattacks are a relentless threat to hospitals and their communities. The South Carolina-based health system AnMed and Texas-based JPS Health experienced disruptions that included implementation of downtime procedures and patient-diversion protocols. And in recent days, the American Hospital Association highlighted…
Court decisions on ACA marketplace rules affect key coverage provisions
As CMS moves ahead with Medicaid funding limits for gender-affirming care in minors, Democratic state leaders used litigation to block restrictions in the Affordable Care Act (ACA) insurance marketplaces. The ACA policy, established in 2025 regulations, would remove the essential health benefit (EHB) designation from gender-affirming care. EHB status allows ACA consumer protections, such as…
No Surprises Act QPA calculations set to change after appeals court ruling
An appeals court sided with providers in a case about the No Surprises Act’s qualifying payment amount (QPA), a key benchmark in out-of-network payment determinations. The U.S. Court of Appeals for the Fifth Circuit issued a ruling that QPA calculations must not include ghost rates, referring to non-negotiated rates listed in contracts for services a…
Guilty plea in UnitedHealthcare CEO killing comes amid sustained focus on obstacles to care
Luigi Mangione pleaded guilty Aug. 14 to federal stalking charges in the 2024 fatal shooting of UnitedHealthcare’s CEO, potentially bringing resolution to an incident that spurred introspection by insurers and the healthcare industry. The charges, stemming from the killing of Brian Thompson on Dec. 4, 2024, carry a maximum penalty of life in prison. Prosecutors…
HHS report raises scrutiny of gender-affirming care billing and coding
HHS followed up its final rule blocking Medicaid funding for gender-affirming care in minors by publishing a commissioned report alleging “potentially fraudulent” billing and coding among providers of the services. The report, released Aug. 13, alleges that financial incentives drove hospitals and physicians to expand access to the care, and that deceitful billing practices took…
CMS ends Medicaid coverage of gender-affirming care for minors
Federal Medicaid funding no longer will be available to cover gender-affirming healthcare for minors, according to a CMS final rule issued Aug. 11. The rule blocks Medicaid and Children’s Health Insurance Program (CHIP) federal matching funds from reimbursing providers for what the rule refers to as “sex-rejecting procedures” in beneficiaries younger than 18 in Medicaid…
CMS proposes new 340B reporting and HOPD attestation requirements
Recently published editions of two annual Medicare proposed rules both included provisions creating new administrative tasks for hospitals. CMS’s proposed rule for hospital outpatient care would formalize a system of required attestation for off-campus hospital sites starting in 2028, while the rule for physician payments would establish obligatory submission of 340B-related data to a centralized…
Medicare DSH payments ruling could boost hospital reimbursement under 1115 waivers
Hospitals obtained a victory in a case about Medicare disproportionate share hospital (DSH) payments, with potentially significant reimbursement implications. In a July 27 ruling in Covenant Medical Center v. Kennedy, a judge with the U.S. District Court for Northern Texas struck down an HHS rule that excluded certain patients from the DSH formula if they were…
Senate Medicaid hearing highlights the debate over federal spending cuts
Cuts to federal Medicaid spending are necessary to streamline the program and don’t necessarily portend tough times for providers, conservative policymakers and analysts argued during a Senate hearing. The Aug. 4 hearing of the Senate Budget Committee included discussion of whether healthcare policies in the One Big Beautiful Bill Act (OBBBA) should be scaled back…