Tuesday, July 7, 2026

KFF analysis reveals Medicare Advantage plans denied prior authorization requests for post-acute care at substantially higher rates than the overall denial rate in 2025. Denial rates for skilled nursing facilities reached 13%. Home health agency requests were denied 9% of the time. The overall MA prior auth denial rate was 5%. The data covers plans from UnitedHealthcare, Aetna, Blue Cross Blue Shield, Humana, and Kaiser Permanente. For practices managing transitions of care, these rates signal increased administrative burden and potential delays for patients moving to SNF or home health. Monitor your top MA plan denials for SNF and HHA admissions. Consider proactive pre-authorization for high-risk patients.

CMS is proposing new rules to expand its authority to revoke Medicare billing privileges and expedite enrollment revocation for providers deemed 'problematic.' The agency cites program integrity and fraud prevention as core goals. The proposal follows earlier signals CMS is targeting aggressive enrollment safeguards. If finalized, this would give CMS broader latitude to act on providers with patterns of problematic billing or compliance issues. The comment period will determine the final scope. This is part of a wider CMS push on program integrity. While aimed at fraud, practices should audit their own enrollment data in PECOS and ensure all practice locations and reassignments are current and accurate. The comment period is a key window to influence the final rule's definitions of 'problematic.'

A coalition of 26 states has filed a lawsuit in the District of Massachusetts challenging CMS's final rule that allows states to impose community engagement or work requirements on certain Medicaid beneficiaries. The rule, finalized on June 29, 2026, is the administration's latest attempt to permit states to mandate work or volunteer activities as a condition of Medicaid eligibility for non-elderly, non-pregnant adults. Legal challenges to earlier iterations of Medicaid work requirements were largely successful in federal courts, which found they were incompatible with the core objective of the Medicaid program to provide healthcare coverage. The outcome of this lawsuit will determine whether states like Arizona, Montana, and New York can proceed with planned or newly implemented requirements that could affect coverage for hundreds of thousands of beneficiaries. Monitor the docket for this case, as it will shape state Medicaid policy and patient access for years.