All Insurance Policy Changes (Page 10)

Continuing from page 9. 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 Mutual Transitioning from MedCommunity to Cohere Health for Inpatient Requests
Medical Mutual of Ohio·Identified Sep 9, 2026
Medical Mutual is transitioning inpatient prior authorization requests from MedCommunity to Cohere Health's web-based portal beginning early/mid-December 2026. Outpatient submissions through Cohere remain unchanged. Contracted providers must register with Cohere Health if not already registered and submit all inpatient acute, post-acute, and behavioral health authorization requests through the new portal starting on the transition date.
High impact
Total Gainwell System Outage for MMIS – Scheduled Maintenance
Alabama Medicaid·Effective Sep 25, 2026
The Gainwell Technologies MMIS system will undergo scheduled maintenance resulting in a complete outage from Friday, September 25, 2026 at 6:00 p.m. (non-pharmacy) / 9:00 p.m. (pharmacy) through Monday, September 28, 2026 at 6:00 a.m. Central Time. During this period, all claims submission, eligibility verification, prior authorization, and portal access will be unavailable. The CARES eligibility system will remain operational.
High impact
[California] Community Supports Short-Term Post-Hospitalization Housing service ending January 2027
Anthem BCBS·Effective Jan 1, 2027
Effective January 1, 2027, Anthem Blue Cross (Medi-Cal) will end the Community Supports Short-Term Post-Hospitalization Housing (STPHH) service. No new authorizations will be issued after December 1, 2026, and all existing authorizations expire December 31, 2026. Providers must identify affected members, continue services through authorized periods, and coordinate transition planning including connection to Housing Transition Navigation services, ECM care providers, and permanent housing resources.
Low impact
How modern living is fueling colorectal cancer in younger adults
Cigna·Identified Sep 9, 2026
This is an informational newsroom article from Cigna Healthcare about rising early-onset colorectal cancer rates in adults under 50 and the importance of provider screening. It emphasizes that Cigna typically covers colorectal cancer screenings at no cost when performed at in-network locations and references the Preventive Care Services (A004) administrative policy for billing codes. No billing workflow changes are required.
Medium impact
Cigna Specialty Care Options programs drug list changes
Cigna·Effective Sep 1, 2026
Cigna is expanding its Specialty Care Options (SCO and SCO+) programs to include additional specialty medications effective September 1, 2026, and January 1, 2027. These drugs will now require site-of-care review to determine if administration can occur in a less-intensive setting (office, home infusion, or ambulatory center) rather than hospital outpatient settings. Billing teams must identify claims for these medications and ensure prior authorization includes site-of-care medical necessity documentation.
Medium impact
instED in-home care offers ED visit alternative
Harvard Pilgrim Health Care·Identified Sep 9, 2026
Tufts Health Plan now offers instED, a mobile integrated health vendor service, as an alternative to emergency department visits for non-emergent clinical triage. This applies to Tufts Health Plan Senior Care Options and Tufts Medicare Preferred members in Massachusetts. Providers can request same-day in-home visits (8 a.m. to 10 p.m. daily) for conditions like flu, dehydration, and minor injuries when office appointments are unavailable.
High impact
Brain Stimulation Treatments - Medicare Advantage (Revised)
Humana·Effective Nov 3, 2025
This is a revised Medicare Advantage policy for brain stimulation treatments (effective 11/03/2025) that covers multiple neurological conditions including refractory epilepsy, Parkinson's disease, essential tremor, and dystonia. The policy consolidates coverage guidance for cortical stimulation, deep brain stimulation (DBS), directional DBS, thalamic stimulation, and magnetic resonance guided focused ultrasound (MRgFUS). Billing teams must ensure prior authorization aligns with specific MAC jurisdictions and applicable Local Coverage Determinations based on patient geography.
High impact
Cosmetic and Reconstructive Surgery - Medicare Advantage (Revised)
Humana·Effective Mar 2, 2026
This is a revised Medicare Advantage policy on cosmetic and reconstructive surgery effective March 2, 2026. The policy clarifies coverage criteria for multiple procedures including benign skin lesion removal, hair removal, keloid removal, panniculectomy, rhinoplasty/septoplasty, and scar revision. It establishes that reconstructive surgery requires documented functional impairment, and references jurisdiction-specific Local Coverage Determinations (LCDs) by Medicare Administrative Contractor (MAC) regions.
Medium impact
Pharmacogenomics Testing - MEDICAID - KENTUCKY (Revised)
Humana·Effective Sep 9, 2026
Humana Kentucky Medicaid updated its pharmacogenomics testing policy effective 09/09/2026, establishing coverage for molecular pathology testing (CPT 81479) when treating patients with medications having known FDA-labeled or CPIC Level A/B gene-drug interactions. The policy explicitly excludes coverage for six specific tests (IFNL3, RightMed variants, ChemoFx, Mind.Px, and SLCO1B1) due to insufficient evidence. Prior authorization is required for all pharmacogenomics testing.
Medium impact
Process Change for NC Medicaid Direct Private Duty Nursing Authorizations
NC Medicaid - NCDHHS·Effective Sep 1, 2026
NC Medicaid Direct is streamlining Private Duty Nursing (PDN) hour redistribution among service provider agencies. Previously approved shared PDN hours can now be redistributed without requiring a new provider-signed CMS-485 form or order—only the current signed CMS-485, Shared Case Form (DHB-3512), and a PA submission are needed. Total approved hours and authorization end dates remain unchanged.
High impact
Attention Provider Type 63 (Psychiatric Residential Treatment Facilities): Guidance for Requesting Complex Case Criteria
Nevada Medicaid·Effective Aug 1, 2026
Nevada Medicaid has activated a new revenue code 0120 (effective August 1, 2026) for complex case rates at Psychiatric Residential Treatment Facilities (PRTF) for children under 10 or those meeting complex criteria. Providers must use the FA-15 Prior Authorization form to request this rate and cannot bill revenue codes 0100 (flat rate) and 0120 simultaneously. If the wrong revenue code was initially submitted, providers have 5 business days to correct it using form FA-29 with supporting documentation.
Medium impact
Account registration for the new Provider Portal is still open
Priority Health·Effective Jan 1, 2027
Priority Health has launched a new Provider Portal with account registration still open as of January 1st. This is an operational/system change affecting provider access and administrative functions, not clinical billing. Site administrators must actively monitor affiliation requests in the portal, and all providers should complete registration and training to ensure continuity of operations.
High impact
Medicare Advantage Risk Adjustment Data Validation Audit
Florida Blue·Effective Sep 1, 2026
CMS is conducting a Risk Adjustment Data Validation (RADV) audit for Florida Blue Medicare Advantage plans covering 2023 service dates (payment year 2024). Providers will receive medical records requests between September 2026 and February 2027 and must submit requested documentation within 10 business days, with a hard deadline of 45 days from the request date.
Medium impact
HHSC Releases PL 2026-15 Acceptance-to-Service Requirement for Home Health Agencies and Updated Guidance
Texas Medicaid·Identified Sep 9, 2026
HHSC has released PL 2026-15 establishing new acceptance-to-service requirements for home health agencies in Texas. Two new G-tags (G990 and G992) have been added to the State Operations Manual Appendix B, and G1052 interpretive guidelines have been updated to clarify Administrator Standards. Home health agencies must review and update their referral acceptance processes to comply with CMS standards.
Low impact
September 9 Quarterly NF Webinar with HHSC LTCR
Texas Medicaid·Identified Sep 9, 2026
HHSC Long-term Care Regulation is hosting a quarterly nursing facility provider webinar on September 9, 2026, to cover regulatory updates including SB 457 disclosure requirements, immediate jeopardy resources, and risk-based survey overviews. Provider attendance is critical for staying current with NF compliance requirements.
Low impact
HHSC Submits Legislative Appropriations Request
Texas Medicaid·Identified Sep 9, 2026
The Texas Health and Human Services Commission has submitted its Legislative Appropriations Request for fiscal years 2028-29, outlining funding priorities for the 90th Legislature and identifying a required 3% base budget reduction. This is a legislative budget planning document with no immediate billing or coverage changes, but may signal future policy adjustments affecting Texas Medicaid programs.
Low impact
Members Sought for the Palliative Care Interdisciplinary Advisory Council
Texas Medicaid·Identified Sep 9, 2026
This is a recruitment announcement from Texas HHSC for qualified applicants to serve on the Palliative Care Interdisciplinary Advisory Council with terms expiring in 2029-2030. This is an informational/administrative policy requiring no changes to billing workflows, coding, or claims processing.
Low impact
Members Sought for the Hospital Payment Advisory Committee
Texas Medicaid·Identified Sep 9, 2026
The Texas Health and Human Services Commission (HHSC) is recruiting members for the Hospital Payment Advisory Committee (HPAC) to serve through December 31, 2032. This is a volunteer advisory board role focused on Texas hospital financing policies, disproportionate share hospitals, uncompensated care, and directed payment programs. Applications are due by October 1, 2026.
Low impact
Deadline Extended: for the Behavioral Health Advisory Committee
Texas Medicaid·Identified Sep 9, 2026
This is an advisory committee membership application announcement from the Texas Health and Human Services Commission (HHSC), not a billing policy change. The Behavioral Health Advisory Committee is seeking qualified applicants for terms expiring in 2028 and 2029, with applications due September 14, 2026. This does not affect medical billing, coding, reimbursement, or clinical operations.
Low impact
Deadline Extended: for the Behavioral Health Advisory Committee
Texas Medicaid·Identified Sep 9, 2026
The Texas Health and Human Services Commission (HHSC) is seeking qualified applicants for the Behavioral Health Advisory Committee (BHAC) with an application deadline of September 14, 2026. This is an informational announcement about committee membership opportunities and does not affect billing processes, coding, reimbursement, or claims processing for the medical billing team.
Medium impact
Updated: SDAs for Dates of Discharge on or After September 1, 2026
Texas Medicaid·Effective Sep 1, 2026
Texas Medicaid (TMHP) corrected reimbursement rates in the Standard Dollar Amount (SDA) Add-on spreadsheet that was initially published September 1, 2026. The corrected rates are now available, and TMHP will automatically reprocess all claims with discharge dates on or after September 1, 2026 that were paid at the previous incorrect rates. No action is required from the billing team beyond monitoring for reprocessed claims.
High impact
Updated: SDAs for Dates of Discharge on or After September 1, 2026
Texas Medicaid·Effective Sep 1, 2026
Texas Medicaid corrected erroneous reimbursement rates in the Standard Dollar Amount (SDA) Add-on spreadsheet that was initially published on September 1, 2026. Updated SDA rates are now available, and TMHP will automatically reprocess all claims with discharge dates on or after September 1, 2026, that were paid at the incorrect rates.
Medium impact
BT2026149: IHCP simplifies rendering provider linkage processes
Indiana Medicaid (IHCP)·Effective Sep 30, 2026
Effective September 30, 2026, IHCP is streamlining rendering provider linkage by eliminating the requirement for Rendering Provider Agreement and Attestation Forms when linking already-enrolled rendering providers to groups or during revalidations. The form remains required only for new rendering provider enrollments and OPR-to-rendering provider conversions. This reduces administrative burden for existing provider networks.
High impact
Federal Changes to Medicaid Eligibility
Illinois Medicaid - HFS·Identified Sep 9, 2026
Illinois Department of Healthcare and Family Services announces two major Medicaid eligibility changes: (1) Federal law eliminates Medicaid coverage for most lawfully present noncitizens effective October 1, 2026, with limited exceptions for green card holders, certain entrants from Cuba/Haiti, COFA migrants, and children under 19 and pregnant women; (2) New federal work requirements for ACA Adults (ages 19-64 with income up to 138% FPL) effective January 1, 2027, with specific exemptions for medically frail, caregivers, veterans, pregnant women, foster youth, and others. Billing teams must identify affected patient populations and implement eligibility verification procedures before both dates.
High impact
26-1056 Provider Communications Posted Online and Operations Manual Updates for August 2026
Health Net·Identified Sep 9, 2026
Health Net California issued a comprehensive policy update (26-1056) summarizing August 2026 operational and clinical policy changes across multiple lines of business. Key changes include: (1) Updates to prior authorization requirements for Medicare D-SNP members; (2) Clarification of services not requiring prior authorization for Medi-Cal; (3) Removal of cognitive health assessment training requirements for Medi-Cal; and (4) Updated payment guidelines for Medi-Cal Prohibited Entities following federal restrictions ending July 4, 2026.

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Archive by year

2023 2024 2025 2026

Medical Mutual Transitioning from MedCommunity to Cohere Health for Inpatient Requests

Total Gainwell System Outage for MMIS – Scheduled Maintenance

[California] Community Supports Short-Term Post-Hospitalization Housing service ending January 2027

How modern living is fueling colorectal cancer in younger adults

Cigna Specialty Care Options programs drug list changes

instED in-home care offers ED visit alternative

Brain Stimulation Treatments - Medicare Advantage (Revised)

Cosmetic and Reconstructive Surgery - Medicare Advantage (Revised)

Pharmacogenomics Testing - MEDICAID - KENTUCKY (Revised)

Process Change for NC Medicaid Direct Private Duty Nursing Authorizations

Attention Provider Type 63 (Psychiatric Residential Treatment Facilities): Guidance for Requesting Complex Case Criteria

Account registration for the new Provider Portal is still open

Medicare Advantage Risk Adjustment Data Validation Audit

HHSC Releases PL 2026-15 Acceptance-to-Service Requirement for Home Health Agencies and Updated Guidance

September 9 Quarterly NF Webinar with HHSC LTCR

HHSC Submits Legislative Appropriations Request

Members Sought for the Palliative Care Interdisciplinary Advisory Council

Members Sought for the Hospital Payment Advisory Committee

Deadline Extended: for the Behavioral Health Advisory Committee

Deadline Extended: for the Behavioral Health Advisory Committee

Updated: SDAs for Dates of Discharge on or After September 1, 2026

Updated: SDAs for Dates of Discharge on or After September 1, 2026

BT2026149: IHCP simplifies rendering provider linkage processes

Federal Changes to Medicaid Eligibility

26-1056 Provider Communications Posted Online and Operations Manual Updates for August 2026