All Insurance Policy Changes (Page 15)

Continuing from page 14. 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
Coverage of GLP-1s for Tufts Health RITogether members
Harvard Pilgrim Health Care·Effective Oct 1, 2026
Effective October 1, 2026, Tufts Health RITogether (Rhode Island Medicaid) will no longer cover GLP-1 medications when prescribed solely for weight loss, including Saxenda, Wegovy, Zepbound, and Foundayo. However, Wegovy and Zepbound remain covered for specific FDA-approved indications (cardiovascular risk reduction, MASH with advanced fibrosis, and moderate-to-severe sleep apnea). GLP-1s approved for type 2 diabetes treatment will continue to be covered. All existing prior authorizations for weight-loss use will be end-dated by September 30, 2026, and affected members will be notified.
Medium impact
Community Choices and HIV/AIDS 1915(c) Waiver Changes and Program Renewal Status
SC Medicaid - SCDHHS·Effective Jul 1, 2026
CMS has approved South Carolina's five-year renewal of the Community Choices (CC) and HIV/AIDS 1915(c) HCBS waiver programs, with all submitted changes approved. The renewal is retroactive to July 1, 2026. Billing teams should review the approved renewal applications and previously announced amendments on the SCDHHS website to identify any service coverage, benefit, or billing process changes.
High impact
Outpatient Hospital Drugs and Biologicals Payment Update
SC Medicaid - SCDHHS·Effective Oct 1, 2026
Effective October 1, 2026, South Carolina Medicaid will change how it reimburses outpatient hospital drugs and biologicals. These drugs will now be reimbursed using the same methodology as physician-administered drugs, and certain outpatient hospital drugs will be reimbursed as add-ons without the outpatient hospital multiplier applied. This affects billing methodology and reimbursement calculations for all outpatient drugs and biologicals at hospital facilities.
Medium impact
Attention Provider Type 33 (Durable Medical Equipment, Disposable, Prosthetics): Modifier RR is No Longer Required on Claims or Prior Authorization for Temporary Rental of Equipment for Recipient-Owned Item Being Repaired
Nevada Medicaid·Effective Sep 2, 2026
Nevada Medicaid no longer requires modifier RR on claims or prior authorization requests for HCPCS code K0462 (temporary replacement equipment rentals during repairs). This simplifies billing for durable medical equipment providers when recipient-owned items are being repaired. All other requirements in Web Announcement 650 remain in effect.
Medium impact
[Ohio] Resubmitted Claims Advisory
CareSource·Effective Aug 28, 2026
CareSource inadvertently retransmitted previously submitted claims to Ohio Medicaid on August 28, 2026, resulting in duplicate claim acknowledgements (277CA). Providers may receive new acknowledgement files for claims already processed. No action is required—providers should ignore duplicate responses, and CareSource will remove invalid transmissions from their systems.
Low impact
Residential Location Data Cleanup – Provider Guidance September 1, 2026
Texas Medicaid·Identified Sep 3, 2026
HHSC requires Home and Community-based Services (HCS) providers to clean up residential location data in the Long Term Care Online Portal (LTCOP) by October 31, 2026. Providers must remove duplicates, correct addresses, end-date inactive locations, and maintain only one administrative location per contract. This affects capacity reporting and placement accuracy but does not directly impact medical billing codes or claim processing.
Medium impact
Reimbursement Rate Updates for Dental Services Procedure Codes Effective September 1, 2026
Texas Medicaid·Effective Sep 1, 2026
Texas Medicaid & Healthcare Partnership (TMHP) has updated reimbursement rates for dental services procedure codes effective September 1, 2026, for the Children with Special Health Care Needs (CSHCN) Services Program. Billing teams must obtain the revised rates from the Dental Services spreadsheet and update their systems to ensure accurate claim submissions for all dates of service on or after September 1, 2026.
Medium impact
Reimbursement Rate Updates for MTP Procedure Code S0215 Effective July 1, 2026
Texas Medicaid·Effective Jul 1, 2026
Texas Medicaid has updated reimbursement rates for medical transportation program (MTP) procedure code S0215, effective July 1, 2026. TMHP will automatically reprocess affected claims, and providers should not appeal unless claims are denied for additional reasons after reprocessing. Billing teams must verify updated rates in the Medical Transportation Program spreadsheet and ensure claims submitted on or after July 1, 2026 reflect the new reimbursement amounts.
Medium impact
Updated Prior Authorization Criteria for Teplizumab-mzwv (Tzield)
Texas Medicaid·Effective Oct 1, 2026
Texas Medicaid updated prior authorization criteria for teplizumab-mzwv (Tzield) effective October 1, 2026. The policy now covers treatment for pediatric patients ages 8-17 with recently diagnosed stage 3 type 1 diabetes (in addition to existing stage 2 coverage for ages 1+). Prior authorization requires documentation of stage 3 T1D diagnosis with at least one positive pancreatic islet cell antibody and confirmation of residual beta cell function via C-peptide testing.
High impact
Update: MCO Providers Have 95 Days to Submit Claims With a DOS On or Before August 31, 2026, for Baylor Scott & White and FirstCare Health Plans
Texas Medicaid·Effective Sep 1, 2026
Effective September 1, 2026, Baylor Scott & White and FirstCare health plans will no longer participate in Texas Medicaid managed care. Providers have 95 days from the effective date to submit all claims with a date of service on or before August 31, 2026. Any claims with a DOS on or after September 1, 2026, will be rejected by TMHP.
High impact
KMAP BULLETIN: Rate Changes for Physician-Administered Drugs – October 2026
Kansas Medicaid (KanCare)·Effective Oct 1, 2026
Effective October 1, 2026, KMAP will update Medicaid reimbursement rates for physician-administered drugs (PADs) by aligning pure HCPCS codes with CMS Medicare Part B rates. Unlisted procedure code drugs will continue using WAC-based rates, while High Dollar Rare Disease Drugs follow existing MCO guidelines. LARC product price changes will be retroactive to their effective dates.
Medium impact
KMAP BULLETIN: Long-Acting Reversible Contraceptives Coverage in Mobile Clinics
Kansas Medicaid (KanCare)·Effective Oct 1, 2026
Effective October 1, 2026, Kansas Medical Assistance Program (KMAP) now covers Long-Acting Reversible Contraceptives (LARCs) when provided in mobile clinics and billed with Place of Service (POS) 15. Six FDA-approved LARC products are covered under the clinic benefit when specific operational and physician direction requirements are met. Billing teams must update systems to recognize POS 15 for LARC services and ensure mobile clinic eligibility requirements are documented.
High impact
KMAP BULLETIN: NCCI/MUE Editing – October 2026
Kansas Medicaid (KanCare)·Effective Oct 1, 2026
Kansas KMAP is implementing quarterly updates to National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUE) rules effective October 1, 2026. Billing teams must review and apply the updated NCCI/MUE editing files from the Medicaid website to ensure accurate claim processing and avoid denials. Implementation timing may vary by KanCare MCO.
High impact
Electronic Visit Verification (EVV) Update
Mississippi Medicaid (DOM)·Effective Aug 1, 2026
This is a Mississippi Medicaid administrative code document (Title 23, Part 200) that establishes general provider information requirements, including a new Electronic Visit Verification (EVV) rule (Rule 1.14). The document covers provider enrollment, claims and billing procedures, beneficiary information, and administrative requirements for Medicaid providers in Mississippi.
Medium impact
2026-09-03 - Arkansas: $149.3M to Expand Telehealth & Increase Access to Specialty Care and Preventive Screenings
Medicare/CMS·Effective Oct 1, 2026
This MLN Connects newsletter (Sept 3, 2026) contains multiple Medicare policy updates affecting billing and compliance. Key changes include: (1) CPT code 0421U for colorectal cancer screening will be available in HETS eligibility starting January 2027; (2) DMEPOS benefit category determinations updated in the Medicare Benefit Policy Manual; (3) October 2026 updates to Medicare Physician Fee Schedule Database and National Correct Coding Initiative (NCCI) effective October 1, 2026; (4) New National Coverage Determination 210.3 for non-invasive biomarker colorectal cancer screening tests effective June 8, 2026; and (5) Consolidated billing enforcement updates for skilled nursing facilities.
Low impact
Payment Policy Updates
CareFirst BlueCross BlueShield·Effective May 1, 2026
CareFirst issued three clarifying policy updates effective May 1, 2026: modifier 25 language was removed from PP CO 600.05, coding validation examples were added to PP CO 002.02 without logic changes, and consultation services policy PP CO 014.02 now includes cross-reference to PP CO 010.01. Additionally, CareFirst is investigating an issue where some providers received paper checks instead of ACH/EFT payments since May 10; no provider action is needed pending resolution.
Medium impact
Place of Service (POS) Assignment Updates
CareFirst BlueCross BlueShield·Effective Jul 1, 2026
Effective July 1, 2026, CareFirst is updating Place of Service (POS) code 02 (Telehealth Provided Other than in a Patient's Home) to reimburse at professional facility rates instead of previous rates. Billing teams must review updated Payment Policy PP CO 200.02 and the POS assignment grid to ensure correct claims submission for telehealth services.
Medium impact
2027 Maternity Coding Changes
CareFirst BlueCross BlueShield·Effective Oct 13, 2026
This policy contains three unrelated administrative notices from CareFirst: (1) an ongoing investigation into EFT payments being issued as checks instead of ACH deposits with no immediate action required, (2) a billing NPI verification reminder requiring that billing NPIs match records in CareFirst, NPPES, ePREP, and MPRIME (effective 10/13/2026), and (3) notification of a healthcare data breach. The policy title references '2027 Maternity Coding Changes' but the actual content does not address maternity coding.
Medium impact
26-985 Strengthening PPG Performance Standards and Oversight
Health Net·Identified Sep 3, 2026
Health Net has updated its Participating Physician Group (PPG) Performance Management processes by implementing a formal Corrective Action Plan (CAP) policy and renaming the oversight governance structure from 'Delegation Oversight Committee' to 'Delegated Provider Performance Governance.' These administrative changes strengthen accountability and clarify performance expectations for PPGs.
Low impact
26-986 Strengthening PPG Performance Standards and Oversight
Health Net·Identified Sep 3, 2026
CalViva Health has updated its Participating Physician Group (PPG) performance management processes, implementing a formal Corrective Action Plan (CAP) policy and renaming the oversight committee to 'Delegated Provider Performance Governance.' These changes strengthen accountability and performance monitoring for PPGs in the Medi-Cal program. Billing teams should review updated provider manuals for any workflow impacts related to performance reporting and JOM (Joint Operations Meeting) documentation requirements.
Medium impact
26-987 Strengthening PPG Performance Standards and Oversight
Health Net·Identified Sep 3, 2026
HealthNet California has updated its Participating Physician Group (PPG) Performance Management processes, implementing a formal Corrective Action Plan (CAP) policy and renaming the oversight committee structure. These governance and accountability changes strengthen performance expectations and require PPGs to align with new corrective action protocols and terminology.
Medium impact
05.00.81a, Osteogenic Stimulators (non-invasive, invasive/semi-invasive, electrical and ultrasound)
Independence Blue Cross·Effective Sep 2, 2026
Policy 05.00.81a regarding Osteogenic Stimulators (non-invasive, invasive/semi-invasive, electrical and ultrasound) has been reissued effective 09/02/2026. Without access to the full policy text content, the specific changes cannot be determined. The billing team must obtain and review the complete policy document to identify coverage changes, billing code updates, or prior authorization requirements.
Medium impact
Mandatory Medicaid Coverage of Routine Patient Costs in Qualifying Clinical Trials (for Tennessee Only)
UnitedHealthcare·Effective Sep 1, 2026
UnitedHealthcare Community Plan of Tennessee now mandates Medicaid coverage of routine patient costs (such as study visits, tests, and procedures) for patients enrolled in qualifying clinical trials, effective September 1, 2026. This expands coverage for trial-related services and may affect billing workflows for practices enrolling Medicaid patients in clinical research.
Medium impact
Tzield® (Teplizumab-Mzwv) (for Pennsylvania Only)
UnitedHealthcare·Effective Oct 1, 2026
UnitedHealthcare Community Plan of Pennsylvania has issued a revised medical policy for Tzield® (Teplizumab-Mzwv), a monoclonal antibody treatment for type 1 diabetes. This is a Medicaid-specific policy for Pennsylvania that becomes effective October 1, 2026. The billing team must implement coverage and authorization requirements for this newly updated policy.
Medium impact
Mandatory Medicaid Coverage of Routine Patient Costs in Qualifying Clinical Trials (for Pennsylvania Only)
UnitedHealthcare·Effective Sep 1, 2026
UnitedHealthcare Community Plan of Pennsylvania now mandates Medicaid coverage of routine patient costs (such as travel, lodging, and other non-medical expenses) for qualifying clinical trials effective September 1, 2026. This Pennsylvania-only policy expands coverage scope for Medicaid beneficiaries enrolled in eligible clinical trials. Billing teams must identify trial participants and ensure routine costs are processed as covered benefits rather than patient responsibility.

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2023 2024 2025 2026

Insurance Policy Changes Tracker: All Payer Updates (Page 15) | PolicyChanges.app

Coverage of GLP-1s for Tufts Health RITogether members

Community Choices and HIV/AIDS 1915(c) Waiver Changes and Program Renewal Status

Outpatient Hospital Drugs and Biologicals Payment Update

Attention Provider Type 33 (Durable Medical Equipment, Disposable, Prosthetics): Modifier RR is No Longer Required on Claims or Prior Authorization for Temporary Rental of Equipment for Recipient-Owned Item Being Repaired

[Ohio] Resubmitted Claims Advisory

Residential Location Data Cleanup – Provider Guidance September 1, 2026

Reimbursement Rate Updates for Dental Services Procedure Codes Effective September 1, 2026

Reimbursement Rate Updates for MTP Procedure Code S0215 Effective July 1, 2026

Updated Prior Authorization Criteria for Teplizumab-mzwv (Tzield)

Update: MCO Providers Have 95 Days to Submit Claims With a DOS On or Before August 31, 2026, for Baylor Scott & White and FirstCare Health Plans

KMAP BULLETIN: Rate Changes for Physician-Administered Drugs – October 2026

KMAP BULLETIN: Long-Acting Reversible Contraceptives Coverage in Mobile Clinics

KMAP BULLETIN: NCCI/MUE Editing – October 2026

Electronic Visit Verification (EVV) Update

2026-09-03 - Arkansas: $149.3M to Expand Telehealth & Increase Access to Specialty Care and Preventive Screenings

Payment Policy Updates

Place of Service (POS) Assignment Updates

2027 Maternity Coding Changes

26-985 Strengthening PPG Performance Standards and Oversight

26-986 Strengthening PPG Performance Standards and Oversight

26-987 Strengthening PPG Performance Standards and Oversight

05.00.81a, Osteogenic Stimulators (non-invasive, invasive/semi-invasive, electrical and ultrasound)

Mandatory Medicaid Coverage of Routine Patient Costs in Qualifying Clinical Trials (for Tennessee Only)

Tzield® (Teplizumab-Mzwv) (for Pennsylvania Only)

Mandatory Medicaid Coverage of Routine Patient Costs in Qualifying Clinical Trials (for Pennsylvania Only)