Monday, June 29, 2026

CMS has formally reinstated a framework for states to apply Section 1115 waivers imposing community engagement, or 'work,' requirements on certain non-disabled, non-elderly, non-pregnant adult Medicaid enrollees. The rule, effective 30 days after publication, allows states to condition Medicaid eligibility on work, job training, or volunteer activity for 80 hours per month. Practices in states likely to seek these waivers should prepare for new eligibility verification workflows and potential coverage losses for patients, which can increase uncompensated care and denials. This action reverses a 2021 policy and follows a 2023 Supreme Court ruling that vacated a prior injunction. Monitor your state Medicaid agency's announcements and comment period if a waiver is proposed.

A major Medicare Advantage company agreed to a $342 million settlement with the federal government to resolve a longstanding investigation into its billing practices. The probe focused on risk adjustment coding and the submission of inaccurate diagnoses to inflate payments. This settlement highlights continued, intense federal scrutiny of Medicare Advantage plan coding and documentation requirements, which directly impacts providers who submit the underlying clinical data. While this is a plan-level settlement, it signals to all providers that accurate, specific, and well-documented coding is critical. Expect ongoing audits and enforcement in the MA space.

Despite the upcoming July 1 start of CMS's temporary Medicare GLP-1 bridge program, which offers weight-loss drugs for a $50 monthly copay, surveys indicate many beneficiaries are unaware of the new benefit. The program's enrollment window is limited, and a lack of patient awareness could lead to low uptake and patient inquiries at the point of prescribing. This information gap presents a downstream burden for practices, which may need to field questions and help eligible patients navigate enrollment.