All Insurance Policy Changes (Page 1309)

Continuing from page 1308. 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
BlueSpeak June 2026: Pharmacy Policy Updates
Blue Cross and Blue Shield of Kansas City·Effective Jul 1, 2026
Blue KC is implementing comprehensive pharmacy formulary updates across three commercial plan tiers (Premium, Select, and Essential Health Benefits) effective July 1, 2026. Changes include new prior authorization requirements for specific drugs, exclusions of certain medications with covered alternatives, exclusion of branded drugs with generic equivalents, and mandatory specialty pharmacy transition for three medications (Temozolomide, Fingolimod, Everolimus) through Lumicera Specialty Pharmacy.
High impact
Jan. 1, 2026, PCA and CFSS reimbursement rates and wage floor retroactive payment requirements
Minnesota Medicaid (MHCP)·Effective Jan 1, 2026
Minnesota DHS has implemented new tiered minimum wage floors for Personal Care Assistance (PCA) and Community First Services and Supports (CFSS) direct support workers, effective Jan. 1, 2026, with retroactive payment requirements. Providers must pay workers the enhanced minimum wages for all hours worked from Jan. 1, 2026 forward, and must make retroactive payments for hours already worked. New wage floor tiers were distributed to PCA Choice and FMS providers on May 28, 2026.
Low impact
COVID-19 PHE Audits for Free-Standing Skilled Nursing Facilities
Medi-Cal·Identified May 31, 2026
California DHCS has published updated audit instructions for Medi-Cal COVID-19 public health emergency expenses at free-standing skilled nursing facilities. Providers must submit COVID-19 PHE Reporting Schedules for expenses and revenues from January 1-December 31, 2023 by August 15, 2026.
High impact
[Ohio] Behavioral Health Service Frequency Guidelines
CareSource·Effective Jul 1, 2026
Effective July 1, 2026, CareSource Ohio Next Generation MyCare & Medicaid is implementing new service frequency thresholds for behavioral health services. Prior authorization will be required once members exceed specified unit/day limits for withdrawal management, intensive outpatient programs, psychiatric support, and therapeutic services. Billing teams must track member utilization across all providers and obtain prior auth before services exceed thresholds to avoid claim denials.
High impact
[Ohio] Vaccine for Children Program Administration Billing Guidance
CareSource·Effective Jul 1, 2026
Effective July 1, 2026, CareSource will reject vaccine administration claims billed with CPT codes 90471 or 90472 for VFC-covered toxoids when the provider is part of the VFC program. VFC providers must use CPT code 90460 instead for vaccine administration of covered toxoids.
Medium impact
[Indiana] Access and Availability | After Hours Standard Change
CareSource·Effective Jul 1, 2026
CareSource is expanding its after-hours availability requirement for Primary Care Providers to now include Behavioral Health (BH) providers effective July 1, 2026. BH providers must ensure patients can reach a provider or backup via phone after hours for triage, or refer patients to the 988 Suicide & Crisis Hotline. This is an operational/compliance requirement, not a billing code change.
High impact
[Georgia] Provider Revalidation by July 1, 2026
CareSource·Effective Jul 1, 2026
Georgia Medicaid providers who have not completed their required five-year enrollment revalidation must do so by July 1, 2026, or face automatic suspension from all Georgia Medicaid and PeachCare for Kids programs. Suspended providers cannot bill for services with dates of service on or after July 1, 2026, and all claims will be denied. Providers can check their revalidation status on the GAMMIS website and must submit revalidation applications before the deadline to avoid termination.
Low impact
Update My Personal Information
Tricare·Effective May 29, 2026
TRICARE has updated its policy outlining how patients should update their personal information in DEERS and with regional contractors. This is primarily a patient-facing resource that provides contact information and procedures for updating demographics, but billing teams should be aware of the updated contact numbers for coordination purposes.
Medium impact
[California] New specialty pharmacy medical step therapy requirements
Anthem BCBS·Identified May 30, 2026
California Anthem has implemented new specialty pharmacy medical step therapy requirements, meaning patients must try and fail on less expensive specialty medications before accessing higher-tier specialty drugs. This will affect prior authorization processes and may delay patient access to certain specialty pharmaceuticals.
Medium impact
[California] FAQ on transitioning to paperless remittances with Availity
Anthem BCBS·Effective May 29, 2026
Anthem Blue Cross is transitioning to paperless remittances through the Availity Essentials platform for California providers. Billing teams must enroll in electronic remittance advice (ERA), use the Availity Remit Viewer to access digital EOPs and 835 ERAs, and can request paper copies only through specific contact channels if needed. Electronic funds transfer (EFT) enrollment is also encouraged for faster payment processing.
Medium impact
[New York] New specialty pharmacy medical step therapy requirements
Anthem BCBS·Identified May 30, 2026
Anthem in New York has implemented new specialty pharmacy medical step therapy requirements, meaning certain specialty medications will now require patients to try and fail on less expensive alternatives before coverage is approved. This affects billing for specialty drug administration and may require additional prior authorization documentation.
Medium impact
[Ohio] New specialty pharmacy medical step therapy requirements
Anthem BCBS·Identified May 30, 2026
Ohio Anthem has implemented new specialty pharmacy medical step therapy requirements, meaning patients must try certain lower-cost or first-line specialty medications before coverage is approved for more expensive alternatives. This will affect billing for specialty pharmaceutical claims and may require additional prior authorization steps.
Low impact
[Ohio] Dedicated email address to support select provider types
Anthem BCBS·Effective May 29, 2026
Anthem Medicaid/MyCare Ohio has established a dedicated email address (ohmedicaidencpesupport@anthem.com) for administrative support for five specific provider types: SNFs, DME providers, independent hospice providers, independent home healthcare providers, and assisted living facilities. This creates a new communication channel to reduce administrative delays and improve issue resolution for these select providers.
Medium impact
[Virginia] Carelon Medical Benefits Management to manage PA reconsiderations; submit within 10 business days
Anthem BCBS·Effective Jul 11, 2026
Effective July 11, 2026, Carelon Medical Benefits Management will now handle reconsiderations of their own initial prior authorization determinations for Virginia commercial plans. Providers must submit reconsideration requests within 10 business days of the initial determination via the Carelon provider portal or by phone at 866-789-0158.
Medium impact
[Virginia] New specialty pharmacy medical step therapy requirements
Anthem BCBS·Identified May 30, 2026
Anthem Virginia has implemented new step therapy requirements for specialty pharmacy medications, requiring patients to try and fail on lower-cost alternatives before coverage is approved for certain specialty drugs. This affects prior authorization processes and may delay treatment approvals for specialty medications.
Medium impact
[Georgia] New specialty pharmacy medical step therapy requirements
Anthem BCBS·Identified May 30, 2026
Anthem in Georgia has implemented new step therapy requirements for specialty pharmacy medications, requiring patients to try specific lower-cost medications before accessing higher-tier specialty drugs. This policy affects prior authorization processes and may delay treatment approvals for specialty medications.
Medium impact
Reminder: Providers and RHCs Must Retain Medical Records for Specified Periods
Texas Medicaid·Identified May 30, 2026
Texas Medicaid providers must retain medical records for minimum periods: individual providers 5 years, freestanding RHCs 6 years, hospital-based RHCs 10 years from date of service. Records must be kept until all billing audits, appeals, investigations, or court cases are resolved, including for permanently closed practices.
Medium impact
Prescribing Provider Survey for the Texas PDMP Extended to June 10, 2026
Texas Medicaid·Identified May 30, 2026
The Texas PDMP prescribing provider survey deadline has been extended from May 11, 2026 to June 10, 2026. This survey is required by CMS for Texas Medicaid-enrolled prescribing providers who prescribe controlled substances and covers prescription data from federal fiscal year 2025.
Medium impact
Procedure Code Q5135 Updated to Include Valid Diagnosis Code M0529
Texas Medicaid·Effective Oct 1, 2024
Texas Medicaid corrected an invalid diagnosis code M0259 to valid code M0529 for tocilizumab-aazg (Tyenne) injection procedure code Q5135, effective for dates of service October 1, 2024 and later. TMHP will automatically reprocess affected claims and has waived the 120-day appeal deadline for this issue.
Medium impact
June 2026 TMPPM Update for Vaccine Services Procedure Code 90461
Texas Medicaid·Effective Jun 1, 2026
Effective June 1, 2026, Texas Medicaid clarifies that procedure code 90461 should be used for administering additional vaccine components, but will NOT reimburse this code when vaccines are eligible under the Texas Vaccines for Children (TVFC) programs. This creates a billing restriction for TVFC-eligible vaccines.
Low impact
Updated Texas Health Steps QRG Available June 1, 2026
Texas Medicaid·Effective Jun 1, 2026
TMHP will publish an updated Texas Health Steps Quick Reference Guide on June 1, 2026, with revised website links in the Contact Information section. This is an informational update to reference materials rather than a change to billing or coverage requirements.
Medium impact
HHSC Has Published IL 2026-13, Preparing for the Upcoming Fiscal Year 2026 Fee-for-Service Claims Billing Closeout
Texas Medicaid·Effective Aug 31, 2026
HHSC has published guidance for the fiscal year 2026 closeout ending August 31, 2026, requiring providers to promptly submit all unbilled claims for services already rendered. Additionally, inactive TMHP user accounts will be deactivated after 90 days of inactivity.
Medium impact
Vestronidase Alfa-Vjbk (Mepsevii) a Benefit in the Home Setting Effective July 1, 2026
Texas Medicaid·Effective Jul 1, 2026
Starting July 1, 2026, Texas Medicaid will cover vestronidase alfa-vjbk (Mepsevii) when administered in the home setting using procedure code J3397. The drug's information is also being moved to a different section in the provider manual.
Medium impact
[New York] Genetic testing claims for FEP members: medical records required for review
Anthem BCBS·Identified May 29, 2026
FEP (Federal Employee Program) members now require medical records to be submitted for genetic testing claim reviews. This affects all genetic testing claims for federal employees and requires additional documentation beyond standard claims submission.
High impact
[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (June 2026 Newsletter)
Anthem BCBS·Effective Jul 1, 2026
Carelon Medical Benefits Management has updated prior authorization and precertification requirements across multiple service categories (Genetic Testing, Sleep, Cardiovascular, Musculoskeletal, Radiology, and Radiation Oncology) for New York-based plans. Changes are staggered across three effective dates: July 1, 2026 (Medicaid); September 1, 2026 (Medicare Advantage); and October 1, 2026 (Commercial). One Cardiovascular article for Commercial plans was retracted on July 17, 2026.

Browse by payer Browse by state Browse by specialty Browse by billing code Browse & filter all changes

Get alerts for changes like this

Save a search and receive a daily digest whenever a new policy change matches your filters.

Create a free alert

Archive by year

2023 2024 2025 2026

BlueSpeak June 2026: Pharmacy Policy Updates

Jan. 1, 2026, PCA and CFSS reimbursement rates and wage floor retroactive payment requirements

COVID-19 PHE Audits for Free-Standing Skilled Nursing Facilities

[Ohio] Behavioral Health Service Frequency Guidelines

[Ohio] Vaccine for Children Program Administration Billing Guidance

[Indiana] Access and Availability | After Hours Standard Change

[Georgia] Provider Revalidation by July 1, 2026

Update My Personal Information

[California] New specialty pharmacy medical step therapy requirements

[California] FAQ on transitioning to paperless remittances with Availity

[New York] New specialty pharmacy medical step therapy requirements

[Ohio] New specialty pharmacy medical step therapy requirements

[Ohio] Dedicated email address to support select provider types

[Virginia] Carelon Medical Benefits Management to manage PA reconsiderations; submit within 10 business days

[Virginia] New specialty pharmacy medical step therapy requirements

[Georgia] New specialty pharmacy medical step therapy requirements

Reminder: Providers and RHCs Must Retain Medical Records for Specified Periods

Prescribing Provider Survey for the Texas PDMP Extended to June 10, 2026

Procedure Code Q5135 Updated to Include Valid Diagnosis Code M0529

June 2026 TMPPM Update for Vaccine Services Procedure Code 90461

Updated Texas Health Steps QRG Available June 1, 2026

HHSC Has Published IL 2026-13, Preparing for the Upcoming Fiscal Year 2026 Fee-for-Service Claims Billing Closeout

Vestronidase Alfa-Vjbk (Mepsevii) a Benefit in the Home Setting Effective July 1, 2026

[New York] Genetic testing claims for FEP members: medical records required for review

[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (June 2026 Newsletter)