All Insurance Policy Changes (Page 115)

Continuing from page 114. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

Medium impact
06-30-2026 H.R. 1 – Federal Payments to Prohibited Entities – Important Update: End of One-Year Restriction on Federal Payments – APL 26-013 IE LA SAC SD
Molina Healthcare·Effective Jul 4, 2026
Effective July 4, 2026, Molina Healthcare of California will resume processing and paying claims from providers previously classified as "Prohibited Entities" under Section 71113 of H.R. 1. Providers affected by the one-year federal payment restriction may resume normal claims and encounter submission for all Medi-Cal covered services. This change applies only to services with dates of service on or after July 4, 2026; prior claims remain subject to earlier guidance.
Medium impact
Medicaid Services Manual Chapter 2800 Updated
Nevada Medicaid·Effective Apr 29, 2026
Nevada Medicaid updated School Health Services (SHS) policy effective April 29, 2026. Key changes include: age eligibility expanded from 3–21 to under 21 years; a new limited exception to Ordering, Prescribing, and Referring (OPR) requirements for registered nurses (RN); clarified third-party liability (TPL) pay and chase requirements; and a new Program Compliance section. Billing teams must review the full Chapter 2800 to understand RN authorization changes and TPL processing impacts.
High impact
Colorectal Cancer Screening Program Transition
Blue Cross Blue Shield of North Dakota·Effective Jun 30, 2026
Blue Cross Blue Shield of North Dakota will cease administering claims, adjustments, appeals, and call center support for the Colorectal Cancer Screening Program effective June 30, 2026. All outstanding claims must be submitted to BCBSND by June 29, 2026, or they will be redirected to a new vendor (Mountain Pacific). After June 30, 2026, all program-related inquiries and claim submissions must go directly to Mountain Pacific.
Medium impact
Reminder: When to Mark an Appeal as Urgent
Blue Cross Blue Shield of North Dakota·Effective Jun 25, 2026
Blue Cross Blue Shield of North Dakota (BCBSND) issued a reminder on June 25, 2026 clarifying when appeals should be marked as urgent. Providers must only use the urgent designation when delay could seriously jeopardize patient life, health, or function. All urgent appeals now require clear clinical documentation explaining the time-sensitive risk and direct contact information to enable timely communication.
High impact
Risk Adjustment Data Validation (RADV) and The Department of Health and Human Services (HHS) Medical Records Request
Blue Cross Blue Shield of North Dakota·Effective Jun 25, 2026
Blue Cross Blue Shield of North Dakota is participating in a CMS-mandated Risk Adjustment Data Validation (RADV) audit for Medicare Advantage members. Providers will receive medical records requests from Cognisight (in-state) or Virtix Health (out-of-state) vendors and must provide requested records at no charge. All submitted medical records must be fully legible, signed with provider credentials, and dated to meet CMS requirements.
Medium impact
July 2026 Medicaid Information Bulletin
Utah Medicaid·Identified Jul 3, 2026
Failed to analyze policy change
Medium impact
R13849CP: Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2026.
Medicare/CMS - Transmittals·Identified Jul 3, 2026
Failed to analyze policy change
High impact
R13855CP: July 2026 Quarterly Update to the Clinical Laboratory Fee Schedule (CLFS) and ClinicalLaboratory Improvement Amendments (CLIA): Healthcare Common Procedure Coding System(HCPCS) Codes, Waived Tests, and Reasonable Charge Payments.
Medicare/CMS - Transmittals·Identified Jul 3, 2026
CRITICAL MISMATCH DETECTED: The policy title references R13855CP regarding July 2026 Clinical Laboratory Fee Schedule updates and HCPCS codes for laboratory testing. However, the actual document content provided is unrelated marketplace help desk contact information and agent/broker registration resources dated May 2024. The billing team cannot act on this policy because the actual fee schedule details, affected HCPCS codes, and reimbursement changes are not included in the provided content.
Medium impact
R13854OTN: Implementation of Editing for Programs of All-Inclusive Care for the Elderly (PACE) Inpatient Claims Submitted for Indirect Medical Education (IME) Payment
Medicare/CMS - Transmittals·Identified Jul 3, 2026
Failed to analyze policy change
Low impact
Register for HCS, TxHmL and PI Quarterly Webinar
Texas Medicaid·Effective Jul 27, 2026
HHSC Long-Term Care Regulation (LTCR) is hosting a quarterly educational webinar on July 27, 2026 for HCS, TxHmL, and PI providers. This is an informational/educational announcement with no billing or clinical workflow changes. Note: Internet Explorer users may experience registration issues and should use alternative browsers like Chrome or Edge.
High impact
Now Open: Nursing Facility Liability Insurance Rate Add-on: Required Annual Provider Attestation
Texas Medicaid·Effective Sep 1, 2026
Texas nursing facilities must now complete an annual Nursing Facility Liability Insurance Coverage Attestation (NFLAR) enrollment in the STEPS system to receive liability insurance rate add-on payments. This new attestation requirement begins for state fiscal year 2027 and replaces previous reimbursement methodology for liability insurance costs.
High impact
Correction to “Reimbursement Rate Updates for Certain CSHCN Procedure Codes Effective July 1, 2026”
Texas Medicaid·Effective Jul 1, 2026
TMHP has issued a correction to the July 1, 2026 CSHCN reimbursement rate updates, fixing incorrect information in the Clinical Laboratory Services spreadsheet. Billing teams must immediately download and implement the corrected reimbursement rates for Clinical Laboratory Services, Ear, Nose, and Throat, and Female Genital System Surgery procedure codes to avoid claim denials starting July 1, 2026.
High impact
KMAP BULLETIN: PPS Rebase for RHCs and FQHCs
Kansas Medicaid (KanCare)·Effective Jan 1, 2028
KMAP is implementing a Prospective Payment System (PPS) rebase effective January 1, 2028, for Rural Health Clinics (RHCs) and Federal Qualified Health Clinics (FQHCs). All RHC and FQHC facilities in Kansas must submit their 2024, 2025, and 2026 (if available) cost reports by July 1, 2027, to support this rebase calculation.
Medium impact
KMAP BULLETIN: Coverage Criteria Update for D8999
Kansas Medicaid (KanCare)·Effective Aug 1, 2026
KMAP is updating coverage criteria for dental code D8999, clarifying that the $1,900.80 maximum limitation can be exceeded when medically necessary and supported by appropriate documentation and prior authorization. This change allows for flexibility beyond the previous hard cap for qualifying cases.
Medium impact
PDS Transition Memo - Second Notice
Kentucky Medicaid·Effective Jul 1, 2026
Kentucky is transitioning oversight of Participant Directed Services (PDS) from the Department for Aging and Independent Living (DAIL) to waiver operating agencies. Critical incident reporting, mortality reviews, inability to access services, and involuntary termination tasks will transition to operating agencies effective July 1, 2026, with full PDS transition anticipated by January 1, 2027. Case managers must attend mandatory training on August 5, 2026 to learn revised PDS standard operating procedures.
High impact
BT2026111: IHCP discontinues use of JG modifier to indicate 340B drugs on medical claims
Indiana Medicaid (IHCP)·Effective Aug 1, 2026
The Indiana Health Coverage Programs (IHCP) is discontinuing the JG modifier for 340B drugs on medical claims effective August 1, 2026. Providers must use the TB modifier instead to identify 340B-acquired drugs on physician-administered drug claims for IHCP members. Claims submitted with the JG modifier for DOS on or after August 1, 2026 will no longer be accepted.
Medium impact
BT2026112: IHCP posting FFS payment rates per final rule transparency requirements
Indiana Medicaid (IHCP)·Effective Jul 1, 2026
Indiana Medicaid (IHCP) has published all FFS payment rates and comparative payment rate analyses as required by federal transparency rules (effective July 1, 2026). All billing teams must verify current rates for their service lines on the IHCP Fee Schedules webpage or applicable partner sites (Myers and Stauffer, Optum Rx) to ensure accurate claim submission and reimbursement.
Medium impact
BT2026113: IHCP presents status of claim-processing payment for impacted CCBHC claims
Indiana Medicaid (IHCP)·Identified Jul 3, 2026
IHCP is processing system corrections for CCBHC claims affected by a January 28, 2026 system implementation. Two specific issues are being resolved: (1) Members with third-party liability for optical coverage experiencing erroneous claim denials, and (2) Members in the 590 Program receiving incorrect denials with EOB code 2033. Providers should NOT resubmit claims as IHCP will automatically reprocess them as system updates are completed.
High impact
BT2026114: IHCP clarifies FQHC and RHC billing procedures for vision services
Indiana Medicaid (IHCP)·Effective Jul 2, 2026
IHCP clarifies billing procedures for vision services at FQHCs and RHCs, requiring all vision services to be billed on professional claims with HCPCS code T1015 and a valid encounter code. When eyeglasses are picked up on a separate date from the eye exam, providers have two options: submit one combined claim (eligible for PPS rate) or submit separate claims for exam and materials (materials-only claim must be denied). Materials are limited to basic frames and lenses; upgrades and non-medically-necessary contact lenses are member responsibility with advance notification required.
High impact
Hospital Average Commercial Rate (ACR) Data Collection
Illinois Medicaid - HFS·Effective Jan 1, 2027
Illinois hospitals must submit Average Commercial Rate (ACR) data for their five highest-volume commercial payers to demonstrate compliance with federal Medicaid managed care payment limits. This data collection is required to maintain directed payment eligibility for calendar year 2027. Data submission is mandatory by July 31, 2026, through a secure portal managed by Milliman.
High impact
2026-07-02 - CY 2027 Hospital Outpatient Prospective Payment System & Ambulatory Surgical Center Proposed Rule
Medicare/CMS·Identified Jul 3, 2026
CMS issued a proposed rule for CY 2027 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) payment updates, including revised payment rates, expanded volume control methods, reduced 340B drug payments, elimination of the inpatient-only list, and new prior authorization requirements for botulinum toxin injection codes. This is a proposed rule requiring comment period completion before final implementation.
High impact
26-824 Follow New Maternity Care Requirements to Avoid Claim Delays
Health Net·Effective Jan 1, 2026
Medi-Cal has implemented new maternity care requirements effective January 1, 2026, requiring providers to complete risk assessments at initial visit, each trimester, and postpartum; document screening results and patient opt-outs for the California Prenatal Screening Program; and offer referrals to behavioral health, lactation, doula, and Community Health Worker services. Prior authorization is now required for basic prenatal, maternal, and preventive services with standard turnaround of 5 business days (not to exceed 7 calendar days) or 72 hours for urgent cases. Claims may be delayed if documentation and opt-out status are not properly recorded.
High impact
26-825 Follow New Maternity Care Requirements to Avoid Claim Delays
Health Net·Effective Jan 1, 2026
Medi-Cal maternity care requirements have been updated effective January 1, 2026, requiring providers to complete risk assessments at specific intervals, document screening results and patient opt-outs, provide prenatal education, and coordinate expanded support services (doula, lactation, behavioral health). Prior authorization is now required for basic prenatal, maternal, and preventive services with 5-7 business day standard timelines. Failure to comply will result in claim processing delays.
High impact
26-826 Follow New Maternity Care Requirements to Avoid Claim Delays
Health Net·Effective Jan 1, 2026
Medi-Cal maternity care requirements are now in effect requiring providers to complete risk assessments at initial visit, each trimester, and postpartum; document all screening results and patient opt-outs; provide prenatal screening education; and coordinate expanded support services (doula, lactation, behavioral health). Prior authorization is now required for basic prenatal, maternal, and preventive services with standard authorization timelines of 5 business days (max 7 calendar days). Failure to comply will result in claim processing delays.
Medium impact
MA11.015ah, Bioengineered Skin Substitutes
Independence Blue Cross·Identified Jul 3, 2026
Failed to analyze policy change

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Archive by year

2023 2024 2025 2026

06-30-2026 H.R. 1 – Federal Payments to Prohibited Entities – Important Update: End of One-Year Restriction on Federal Payments – APL 26-013 IE LA SAC SD

Medicaid Services Manual Chapter 2800 Updated

Colorectal Cancer Screening Program Transition

Reminder: When to Mark an Appeal as Urgent

Risk Adjustment Data Validation (RADV) and The Department of Health and Human Services (HHS) Medical Records Request

July 2026 Medicaid Information Bulletin

R13849CP: Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2026.

R13855CP: July 2026 Quarterly Update to the Clinical Laboratory Fee Schedule (CLFS) and ClinicalLaboratory Improvement Amendments (CLIA): Healthcare Common Procedure Coding System(HCPCS) Codes, Waived Tests, and Reasonable Charge Payments.

R13854OTN: Implementation of Editing for Programs of All-Inclusive Care for the Elderly (PACE) Inpatient Claims Submitted for Indirect Medical Education (IME) Payment

Register for HCS, TxHmL and PI Quarterly Webinar

Now Open: Nursing Facility Liability Insurance Rate Add-on: Required Annual Provider Attestation

Correction to “Reimbursement Rate Updates for Certain CSHCN Procedure Codes Effective July 1, 2026”

KMAP BULLETIN: PPS Rebase for RHCs and FQHCs

KMAP BULLETIN: Coverage Criteria Update for D8999

PDS Transition Memo - Second Notice

BT2026111: IHCP discontinues use of JG modifier to indicate 340B drugs on medical claims

BT2026112: IHCP posting FFS payment rates per final rule transparency requirements

BT2026113: IHCP presents status of claim-processing payment for impacted CCBHC claims

BT2026114: IHCP clarifies FQHC and RHC billing procedures for vision services

Hospital Average Commercial Rate (ACR) Data Collection

2026-07-02 - CY 2027 Hospital Outpatient Prospective Payment System & Ambulatory Surgical Center Proposed Rule

26-824 Follow New Maternity Care Requirements to Avoid Claim Delays

26-825 Follow New Maternity Care Requirements to Avoid Claim Delays

26-826 Follow New Maternity Care Requirements to Avoid Claim Delays

MA11.015ah, Bioengineered Skin Substitutes