All Insurance Policy Changes (Page 84)

Continuing from page 83. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

High impact
Medical Policy Updates
MVP Health Care·Effective Jun 1, 2025
MVP Health Care has issued a comprehensive medical policy update effective June 1, 2025, affecting 24 policy categories including cardiac monitoring, autism therapies, orthopedic procedures, sleep apnea surgery, and investigational treatments. The billing team must review detailed policy changes in the Provider FastFax Library to identify coverage determinations, prior authorization requirements, and billing code impacts for each affected service line.
Medium impact
Formulary Policy Updates
MVP Health Care·Identified Jul 19, 2026
MVP Health Care has updated its Q3 2025 formulary, removing prior authorization requirements for 9 medications (Crexont, Neffy, Ohtuvayre, Rytelo, Sofdra, Vafseo, Vigafyde, Voranigo, Zoryve 0.15% cream), excluding Nemluvio from coverage, and adding generic alternatives for several brand-name drugs. Changes take effect on each member's plan year start date and affect prescribing workflows and claim processing across Commercial, Marketplace, and Self-Funded plans.
High impact
Zepbound for Obstructive Sleep Apnea - Guidance
Alaska Medicaid·Effective Jul 17, 2026
Alaska Medicaid is clarifying coverage criteria for Zepbound (tirzepatide) when prescribed for Obstructive Sleep Apnea (OSA). Claims must be accompanied by documented sleep studies showing an Apnea-Hypopnea Index (AHI) ≥15 events/hour in patients with BMI ≥30 kg/m². Claims submitted without qualifying sleep study documentation will be subject to recoupment. Additionally, Zepbound prescribed for weight management alone remains non-covered per existing Alaska Medicaid policy.
Low impact
[Virginia] Network Relations Specialists for LTSS Providers — Virginia
Anthem BCBS·Effective Jul 17, 2026
HealthKeepers, Inc. (Anthem) has designated regional Network Relations Specialists for Long-Term Services & Supports (LTSS) providers across Virginia, effective immediately. This is a resource and contact directory update for LTSS providers (home/community-based services, nursing facilities, home health) to facilitate contracting, provider support, and navigation of LTSS resources.
High impact
Change in denial process for lack of prior authorization
Harvard Pilgrim Health Care·Effective Jul 1, 2026
Point32Health is implementing a cascading denial policy effective July 1, 2026 (September 1, 2026 for Harvard Pilgrim Commercial) where any ancillary or supporting services related to a denied prior authorization claim will also be denied, including medications and procedures billed separately. Ambulance services and radiology/lab report readings are excluded, and Maine providers are exempt from this policy.
Low impact
07-14-2026 Coming soon: Redesigned MolinaHealthcare.com launching August 14 IM IE LA OC SAC SD
Molina Healthcare·Effective Aug 14, 2026
Molina Healthcare of California is redesigning their provider website (MolinaHealthcare.com) launching August 14, 2026. The website will feature simplified navigation, enhanced search functionality, and faster access to provider tools. All existing provider resources, forms, and the Availity Essentials portal login remain unchanged and accessible via redirects.
Low impact
07-15-2026 Availity payer spaces patient care portlet enhancement IM IE LA OC SAC SD
Molina Healthcare·Effective Jul 15, 2026
Molina Healthcare of California has enhanced the Availity Provider Portal's Patient Care Portlet to improve operational efficiency. Providers can now select multiple locations/providers simultaneously, generate consolidated rosters, access larger roster reports, and receive email notifications when files are ready. No immediate billing team action is required, but staff should familiarize themselves with these portal enhancements to optimize roster and member information retrieval workflows.
Medium impact
NC Medicaid Managed Care Capitation Rates – Updated Care Management Assumptions for SFY 2027
NC Medicaid - NCDHHS·Effective Jul 1, 2026
NC Medicaid updated care management capitation rate assumptions effective July 1, 2026, establishing $11.34 PMPM as the expected average cost for whole-person care management staffing within NC Medicaid Managed Care Standard Plans and Advanced Medical Home (AMH) Tier 3 practices. This is a reference rate for negotiation purposes; NCDHHS has not set minimum care management fees and expects Standard Plans and practices to establish mutually agreeable rates based on care management intensity and breadth.
High impact
Changes to Pharmacy Network for Some Commercial Members, Effective Aug. 3, 2026
BCBS Illinois·Effective Aug 3, 2026
Blue Cross Blue Shield of Illinois is launching Pharmacy Match with Prime Therapeutics LLC, effective August 3, 2026, to expand the specialty pharmacy network for fully insured commercial members. Prescribers must now e-prescribe specialty and complex care medications to Free Market Health Pharmacy (NPI: 1366292880) instead of traditional pharmacies, with prior authorization still required through BCBSIL when needed.
Low impact
Talk with Members About Access to Contraceptive Care
BCBS Illinois·Effective Jul 17, 2026
This is an informational policy from Blue Cross Community Health Plans (BCCHP) emphasizing provider engagement in contraceptive care counseling and access. The policy highlights HHS quality measures for contraceptive provision (including long-acting reversible methods) for women ages 15-44 and postpartum contraceptive access within 3-90 days of delivery. It reminds providers that contraceptive care is a covered benefit under BCCHP Medicaid and recommends telehealth and same-day access when appropriate.
High impact
Nevada Private Hospital Assessment State Fiscal Year (SFY) 2027 Rate Levied
Nevada Medicaid·Identified Jul 18, 2026
Nevada has levied a 5.5% assessment on net patient revenue (less Medicare revenue) for inpatient and outpatient services provided by private hospitals in SFY 2027. Private hospitals must pay invoices from NVHA to enable corresponding Medicaid supplemental payments. Exact assessment percentages and payment amounts will be communicated in upcoming invoices.
High impact
[Ohio] Evaluation and Management (E/M) and Psychotherapy Add-On Billing Policy
CareSource·Effective Sep 1, 2026
CareSource Ohio Medicaid is implementing strict concurrent billing restrictions on psychotherapy add-on codes (90833, 90836, 90838) with high-level E/M services (99204, 99205, 99214, 99215). When billed together on the same date by the same provider, psychotherapy add-ons will be denied and only the E/M will be reimbursed. Providers must now document separate start/stop times, non-overlapping clinical effort, and ensure E/M levels are based on medical decision-making rather than time when billing these combinations.
High impact
Baylor Scott & White and FirstCare Health Plans Will End Participation in Texas Medicaid Managed Care
Texas Medicaid·Effective Sep 1, 2026
Effective September 1, 2026, Baylor Scott & White and FirstCare health plans will terminate participation in Texas Medicaid managed care programs (STAR, CHIP). Billing teams must stop accepting claims with service dates on or after September 1, 2026, under these plans and ensure all claims with DOS on or before August 31, 2026, are submitted by the federal deadline of August 31, 2028.
High impact
Reimbursement Rate Updates for DME and Enteral Supplies Procedure Codes Effective September 1, 2026
Texas Medicaid·Effective Sep 1, 2026
Texas Medicaid (TMHP) is implementing reimbursement rate changes for durable medical equipment (DME) and enteral supplies procedure codes effective September 1, 2026. Billing teams must obtain and review the updated fee schedules from linked spreadsheets to ensure accurate claim submission and reimbursement. Rates for these supply categories will change, requiring system updates and potential claim adjustments.
Medium impact
September 2026 TMPPM Update for Solid Organ Transplants
Texas Medicaid·Effective Sep 1, 2026
Effective September 1, 2026, TMHP is removing the reference to thymus transplant from section 9.2.51 of the TMPPM. However, thymus transplant remains covered by Texas Medicaid for medically necessary cases in children ages birth through 20 years via EPSDT coverage. Billing teams must understand that while the manual reference is being removed, the procedure is still a covered 1905(a) service and claims should not be denied based on the manual update alone.
High impact
Language Clarification: Proper Use of Modifier 25 When Billing for Allergy Testing and E/M Services on the Same Day
Texas Medicaid·Effective Sep 1, 2026
Texas Medicaid clarifies that modifier 25 must be appended to both allergy testing and E/M service codes when billed on the same day by the same provider. Additionally, supporting documentation proving a significant, separately identifiable E/M service must accompany the claim and be maintained in the medical record. Without proper documentation, the E/M service will be denied while allergy testing is reimbursed.
High impact
Reimbursement Rate Updates for Ambulance Procedure Codes Effective September 1, 2026
Texas Medicaid·Effective Sep 1, 2026
Texas Medicaid (TMHP) is implementing reimbursement rate changes for ambulance procedure codes effective September 1, 2026. Specific rate updates are contained in a linked spreadsheet that must be reviewed and integrated into billing systems. The policy also clarifies that MCOs may have different prior authorization and administrative requirements than traditional Medicaid.
Medium impact
Update to Acceptable Signatures in the CMS-1500 Paper Claim Form Instructions
Texas Medicaid·Effective Aug 1, 2026
Effective August 1, 2026, TMHP will remove the requirement for 'SOF' (Signature on File) notation from block 12 of CMS-1500 paper claim forms for Texas Medicaid and CSHCN Services Program claims. Providers may now submit either a signature on file or the legal signature of the client/authorized caregiver, with the requirement that last names must be spelled out (initials allowed only for first and middle names).
High impact
STEPS Planned System Outage – July 17, 2026 to July 19, 2026
Texas Medicaid·Effective Jul 17, 2026
The State of Texas Electronic Provider System (STEPS) will be offline for a planned system update from July 17, 2026 at 5 p.m. to July 19, 2026 at 9 p.m. CDT. External users will have no access to STEPS during this outage window, which may impact claim submissions, authorization requests, and provider account activities that depend on the system.
Medium impact
Updates to the Electronic Visit Verification Personal Care Services Bill Codes Table
Texas Medicaid·Effective Aug 1, 2026
HHSC has added three new Personal Care Services (PCS) bill codes to the Electronic Visit Verification (EVV) system for CMS Long-term Care Fee-for-Service claims: Primary Home Care PAS Level 1 (G0718), Family Care Agency Admin PAS (G0747), and Community Attendant Services PAS (G0750). All three codes are effective for EVV matching on August 1, 2026, and must be integrated into billing systems to ensure claims process correctly.
Low impact
OASIS for Clinicians Training Set for July
Texas Medicaid·Effective Jul 28, 2026
This is an educational webinar for clinicians on OASIS-E2 data collection, specifically covering hearing, speech, vision, and cognitive assessment sections. The training is scheduled for July 28, 2026, and targets registered nurses and therapists who collect OASIS data. This is not a billing policy change but rather clinical training guidance.
High impact
Attention FMSAs and CDS Employers: Services Added Requiring an EVV Visit
Texas Medicaid·Effective Aug 1, 2026
Three new personal attendant services (PAS) codes for Consumer Directed Services (CDS) require Electronic Visit Verification (EVV) matching beginning August 1, 2026. Claims with dates of service on or after 8/1/2026 that lack an EVV visit match will be denied payment. This affects FMSAs and CDS employers billing through the Claims Management System Long-term Care Fee-For-Service section.
Medium impact
New Login Process for All Texas Medicaid Providers Through TMHP IAMOnline and Provider MFA Registration for Transition Release 4
Texas Medicaid·Effective Aug 24, 2026
Effective August 24, 2026, Texas Medicaid providers must transition to a new unified login system called TMHP IAMOnline for accessing multiple portals including Long-term Care Online Portal, LTC Dashboard, Electronic Visit Verification Portal, and Care Forms. All providers, including those already using IAMOnline for STEPS cost reports, must activate their TMHP IAMOnline account and register for Multi-Factor Authentication (MFA) to maintain access to these applications.
Low impact
Long-Term Care Educational Opportunities Now Available
Texas Medicaid·Identified Jul 18, 2026
This is an educational announcement from Texas HHS and UT Austin School of Nursing offering free web-based modules and webinars on long-term care best practices (infection prevention, antipsychotic reduction, culture change, quality improvement, geriatrics, and related topics). The program provides continuing education credits for nurses, CNAs, and nursing facility administrators. This is informational only and does not change billing codes, coverage policies, or reimbursement rates.
Low impact
Join Us July 24 to Learn About New Arizona RHTP Funding Opportunities
Arizona Medicaid - AHCCCS·Identified Jul 18, 2026
This is a grant funding opportunity announcement from Arizona AHCCCS for rural healthcare providers to apply for competitive grants (up to $5M) to modernize medical diagnostic equipment, implement/upgrade EHR systems, enhance health information exchange, and strengthen cybersecurity. This is not a billing policy change affecting claims processing, reimbursement rates, or coding requirements—it is informational notice of available grant funding with application deadlines of July 17–August 14, 2026.

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Insurance Policy Changes Tracker: All Payer Updates (Page 84) | PolicyChanges.app

Medical Policy Updates

Formulary Policy Updates

Zepbound for Obstructive Sleep Apnea - Guidance

[Virginia] Network Relations Specialists for LTSS Providers — Virginia

Change in denial process for lack of prior authorization

07-14-2026 Coming soon: Redesigned MolinaHealthcare.com launching August 14 IM IE LA OC SAC SD

07-15-2026 Availity payer spaces patient care portlet enhancement IM IE LA OC SAC SD

NC Medicaid Managed Care Capitation Rates – Updated Care Management Assumptions for SFY 2027

Changes to Pharmacy Network for Some Commercial Members, Effective Aug. 3, 2026

Talk with Members About Access to Contraceptive Care

Nevada Private Hospital Assessment State Fiscal Year (SFY) 2027 Rate Levied

[Ohio] Evaluation and Management (E/M) and Psychotherapy Add-On Billing Policy

Baylor Scott & White and FirstCare Health Plans Will End Participation in Texas Medicaid Managed Care

Reimbursement Rate Updates for DME and Enteral Supplies Procedure Codes Effective September 1, 2026

September 2026 TMPPM Update for Solid Organ Transplants

Language Clarification: Proper Use of Modifier 25 When Billing for Allergy Testing and E/M Services on the Same Day

Reimbursement Rate Updates for Ambulance Procedure Codes Effective September 1, 2026

Update to Acceptable Signatures in the CMS-1500 Paper Claim Form Instructions

STEPS Planned System Outage – July 17, 2026 to July 19, 2026

Updates to the Electronic Visit Verification Personal Care Services Bill Codes Table

OASIS for Clinicians Training Set for July

Attention FMSAs and CDS Employers: Services Added Requiring an EVV Visit

New Login Process for All Texas Medicaid Providers Through TMHP IAMOnline and Provider MFA Registration for Transition Release 4

Long-Term Care Educational Opportunities Now Available

Join Us July 24 to Learn About New Arizona RHTP Funding Opportunities