All Insurance Policy Changes (Page 50)

Continuing from page 49. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

Medium impact
Addition of Intercept for Intensive In-home Services
SC Medicaid - SCDHHS·Effective Aug 1, 2026
South Carolina Medicaid is adding coverage for Intercept, an evidence-based intensive in-home behavioral health service for at-risk youth ages up to 20, effective August 1, 2026. Providers must become licensed through Youth Villages and bill using new procedure code H0037-U2 with a bundled daily rate of $309.56 per diem, limited to 48 encounters over 120 days without prior authorization; additional encounters require prior authorization with medical necessity documentation.
Low impact
SCDHHS Announces Rural Health Transformation Program Notices of Intent to Award
SC Medicaid - SCDHHS·Identified Aug 1, 2026
SCDHHS issued award determinations for 712 applications under the Rural Health Transformation Program (RHTP), a $200M+ CMS-funded initiative. This is an informational announcement regarding grant funding opportunities for rural healthcare providers and organizations in South Carolina; it does not directly change billing codes, coverage, or reimbursement practices for medical practices.
High impact
Bevacizumab products (Revised)
Humana·Effective Jan 1, 2026
Humana Medicaid Ohio revised its Bevacizumab products prior authorization policy effective January 1, 2026, with updates on June 24, 2026. The policy establishes specific clinical criteria for coverage of six bevacizumab products (Avastin, Mvasi, Zirabev, Vegzelma, Alymsys, Jobevne) across 13 indications, including requirements that patients have intolerance/contraindication to preferred biosimilars before accessing alternative products for oncology indications. Billing teams must verify prior authorization requirements are met before claim submission for all bevacizumab products in Ohio Medicaid.
Medium impact
Cimerli® (ranibizumab-eqrn) (New)
Humana·Effective Aug 1, 2026
Humana has established a new prior authorization policy for Cimerli® (ranibizumab-eqrn), a VEGF inhibitor for retinal conditions, effective August 1, 2026. The policy requires step-therapy documentation showing contraindication/intolerance to bevacizumab and failure of prior VEGF inhibitor therapies before approval. This applies to Medicare, Kentucky Medicaid, and South Carolina Medicaid plans.
Medium impact
Cimerli® (ranibizumab-eqrn) (New)
Humana·Effective Aug 1, 2026
Humana Medicaid Indiana has established a new prior authorization policy for Cimerli® (ranibizumab-eqrn), a VEGF inhibitor for retinal conditions. Coverage requires documented diagnosis of one of five qualifying eye conditions AND either contraindication/intolerance to bevacizumab OR documented failure to achieve positive clinical response with prior bevacizumab therapy. All claims for this drug require prior authorization before dispensing.
High impact
Cimerli® (ranibizumab-eqrn) (New)
Humana·Effective Aug 1, 2026
Humana Medicaid Ohio has established a new prior authorization policy for Cimerli® (ranibizumab-eqrn), an intravitreal VEGF inhibitor for five retinal conditions. Coverage requires either a documented contraindication/intolerance to bevacizumab OR failure of prior bevacizumab therapy with provider attestation of lack of clinical response. This is a step-therapy requirement effective August 1, 2026.
Medium impact
Cimerli® (ranibizumab-eqrn) (New)
Humana·Effective Aug 1, 2026
Humana Medicaid Louisiana is implementing a new prior authorization policy for Cimerli® (ranibizumab-eqrn), an ophthalmic VEGF inhibitor for retinal conditions. The policy requires step therapy—patients must have a contraindication/intolerance to bevacizumab OR demonstrate lack of clinical response to prior bevacizumab therapy before Cimerli coverage is approved. This affects five ophthalmologic indications and requires documentation of failed or unsuitable prior therapy.
Medium impact
Avlayah™ (tividenofusp alfa-eknm) solution (New)
Humana·Effective Aug 1, 2026
Humana Medicaid (Ohio) has established a new prior authorization policy for Avlayah™ (tividenofusp alfa-eknm), an enzyme replacement therapy for Hunter Syndrome (MPS II) neurologic manifestations. Coverage requires three criteria: confirmed Hunter Syndrome diagnosis, treatment of presymptomatic or symptomatic neurologic manifestations prior to advanced impairment, and patient weight ≥5 kg. This is a brand-new policy effective August 1, 2026, requiring prior authorization before dispensing.
Medium impact
Avlayah™ (tividenofusp alfa-eknm) solution (New)
Humana·Effective Aug 1, 2026
Humana Medicaid-Louisiana has established a new prior authorization policy for Avlayah™ (tividenofusp alfa-eknm), an intravenous enzyme replacement therapy for Hunter Syndrome (MPS II) neurologic manifestations. Coverage requires three criteria: confirmed Hunter Syndrome diagnosis, treatment of presymptomatic or symptomatic neurologic manifestations prior to advanced impairment, and patient weight ≥5 kg. This is a brand-new policy effective August 1, 2026, requiring prior authorization for all claims.
Medium impact
Aldurazyme® (laronidase) (New)
Humana·Effective Aug 1, 2026
Humana Medicaid (Ohio) has implemented a new prior authorization policy for Aldurazyme® (laronidase) effective August 1, 2026. This enzyme replacement therapy requires prior authorization for patients with Hurler or Hurler-Scheie forms of MPS I, or Scheie form with moderate to severe symptoms. Billing teams must establish prior authorization workflows before claims submission.
High impact
Rate Increase for Personal Care Services and the Community Alternatives Program
NC Medicaid - NCDHHS·Effective Aug 1, 2026
Effective August 1, 2026, North Carolina Medicaid is implementing an 18% rate increase for all Personal Care Services (PCS) procedure codes across NC Medicaid Direct, CAP/C, CAP/DA, and CAP/CD programs. Billing teams must update fee schedules in their systems and ensure managed care plans load new rates within 45 days of DHB notification, with an additional 30-day claims reprocessing window.
High impact
Pharmacy Program Updates: Prior Authorization Changes Effective Sept. 15, 2026
BCBS Illinois·Effective Sep 15, 2026
This policy updates prior authorization (PA) criteria for 24 pharmacy programs administered by Prime Therapeutics, affecting multiple drug classes including biologics, cardiac medications, opioids, and specialty drugs. Changes are rolling out between September 15, 2026 and January 1, 2027 across multiple plan types (Basic, Enhanced, Performance, Jade, Balanced, Topaz, Select, HIM Annual). Billing teams must update PA protocols and alert providers to new clinical criteria requirements for affected medications.
High impact
Silver State Scripts Board Made Changes to the Preferred Drug List Effective August 1, 2026
Nevada Medicaid·Effective Aug 1, 2026
Nevada Medicaid (Silver State Scripts Board) has updated its Preferred Drug List effective August 1, 2026, with significant changes affecting pharmacy coverage across multiple drug classes. Key changes include: moving several drugs from preferred to non-preferred status (requiring prior authorization or becoming non-covered), adding new preferred options with prior authorization requirements, removing discontinued products, and establishing three new drug classes (Prolia/Biosimilars, Xgeva/Biosimilars, and DMD Corticosteroids). Billing teams must immediately update systems to reflect coverage and prior authorization requirements to avoid claim denials.
High impact
Attention Provider Type (PT) 93 (Substance Use Treatment): Substance Use Treatment/Outpatient Behavioral Health Authorization Request Form (FA-11D), Enrollment Checklists, and Billing Guidelines Updated
Nevada Medicaid·Effective Aug 1, 2026
Nevada Medicaid updated the Substance Use Treatment/Outpatient Behavioral Health Authorization Request Form (FA-11D) and related enrollment checklists and billing guides to align with ASAM 4th Edition standards. Providers must discontinue use of the previous FA-11D version and transition to the updated form by August 1, 2026. Submissions using the old form will be pended through August 30, 2026, and denied on or after September 1, 2026.
High impact
Web Announcement 3978
Nevada Medicaid·Effective Jul 31, 2026
Nevada Medicaid has published the top 5 prior authorization denial reasons from Q2 2026 and provided specific corrective actions. The billing team must implement preventive measures across five key areas: medical necessity documentation, portal monitoring for additional information requests, eligibility verification, timely filing compliance, and current form usage. This is a compliance alert rather than a new requirement, but addresses systemic denial patterns that require immediate workflow attention.
High impact
Fast Facts Newsletter - August (Special Edition) 2026
HealthPartners·Effective Jul 1, 2026
HealthPartners issued a comprehensive policy update affecting pharmacy formularies, medical coverage criteria, and administrative operations. Key changes include: (1) Chiropractic claims routing transition from Fulcrum Health to direct HealthPartners submission effective July 1, 2026; (2) SUD billing requirements alignment with Minnesota DHS Behavioral Health Fund Grid effective September 1, 2026; (3) Multiple drug formulary and pharmacy policy updates favoring biosimilars (Avtozma over Actemra, Mvasi/Vegzelma over Avastin); (4) Medical policy revisions for TMD diagnostics, wheelchair codes, and Cohere coverage criteria effective October 1, 2026.
High impact
2026.40 - Provider Bulletin - Documentation Required for Override of Claims Rejected for ProDUR
Connecticut Medicaid (HUSKY Health)·Effective Jul 1, 2026
Connecticut Medicaid (CMAP) now requires pharmacy providers to maintain contemporaneous, detailed documentation whenever they override a 'major' ProDUR (Prospective Drug Utilization Review) alert rejection on a paid claim. Documentation must include clinical justification, the intervention taken, contact information and authorization details from the prescriber/patient/other source consulted, and the pharmacist's name/initials. Failure to provide this documentation upon audit will result in claim recoupment by the state.
High impact
DSS Important Message - CoCM Frequently Asked Questions
Connecticut Medicaid (HUSKY Health)·Identified Aug 1, 2026
Connecticut CMAP has issued clarification on Psychiatric Collaborative Care Model (CoCM) billing requirements. Key points: Code 99484 (general BHI) is NOT reimbursed by CMAP—only specific CoCM codes are covered. Psychiatric consultants and behavioral health care managers may work in different practices but must be employed or contracted by the treating/billing practitioner. Both must meet specific HUSKY Health enrollment requirements. Claims must report place of service where the treating practitioner ordinarily provides face-to-face care.
High impact
DSS Important Message - Required Personal Care Attendant (PCA) Training
Connecticut Medicaid (HUSKY Health)·Identified Aug 1, 2026
The Connecticut Department of Social Services (DSS) requires all Home and Community Based Services (HCBS) providers and Homemaker/Companion agencies to ensure their Personal Care Attendant (PCA) staff complete free standardized PCA training modules with a minimum 70% passing score. New employees must complete training within 90 days of hire; existing employees must complete within one year. Training completion certificates and test scores must be maintained in personnel records and are subject to verification during provider audits.
High impact
DSS Important Message - CMAP Addendum B Updated
Connecticut Medicaid (HUSKY Health)·Effective Jul 1, 2026
Connecticut CMAP Addendum B Version 27.2 has been updated effective July 1, 2026, with APC payment rate changes for procedure codes with status indicators G, K, or K1, plus new, changed, or deleted procedure codes. Outpatient hospitals must implement these changes immediately, with claims submitted before the rate change adjusted in August and new/changed codes reprocessed in future cycles.
Medium impact
Reconsideration Filing Limit for Commercial NICU Claims With Ineligible Reason Code of CR1 is 180 days
BCBS Texas·Effective Nov 2, 2026
Beginning November 2, 2026, reconsideration requests for commercial NICU claims with CR1 reason code (level of care mismatch) must be filed within 180 days from claim finalization. This is a new filing deadline for postservice medical necessity reviews seeking higher level of care reimbursement. Required supporting documentation includes itemized bill, admission summary, discharge summary, and daily progress notes.
High impact
Pharmacy Policies Available Online
Blue Cross Blue Shield of North Dakota·Effective Oct 1, 2026
Blue Cross Blue Shield of North Dakota (BCBSND) is implementing substantial pharmacy policy changes effective October 1, 2026, including 10 new medical drug prior authorization policies, new retail pharmacy utilization management programs for multiple drugs, and updates to 80+ existing pharmacy programs affecting clinical criteria, quantity limits, and preferred product designations. Billing teams must update their prior authorization workflows, quantity limit edits, and formulary references in their billing systems before the October 1 effective date.
High impact
MMP 26-27: Update to Requirements for Fee-for-Service Claim Inquiries
Michigan Medicaid - MDHHS·Effective Sep 1, 2026
Effective September 1, 2026, Michigan Medicaid (including Healthy Michigan Plan and MOMS) is implementing a mandatory requirement that all written Fee-for-Service claim inquiries must include a service request number obtained from Provider Support. Claims submitted without a service request number will not be reviewed. This applies only to FFS programs; MCOs and HIDE-SNPs have separate requirements.
Medium impact
MMP 26-28: Home Help Services Prohibited Outside the United States
Michigan Medicaid - MDHHS·Effective Sep 1, 2026
Michigan Medicaid and Healthy Michigan Plan now prohibit payment for Home Help services provided outside the United States. Previously, temporary residence outside Michigan was allowed if intent to return could be demonstrated; this clarification adds a geographic restriction requiring services be delivered within U.S. borders. Claims for Home Help services outside the U.S. will be denied and subject to recoupment.
High impact
MMP 26-29: Certified Community Behavioral Health Clinic (CCBHC) Demonstration Direct Payment Transition
Michigan Medicaid - MDHHS·Effective Oct 1, 2025
Michigan Medicaid updates Certified Community Behavioral Health Clinic (CCBHC) Demonstration requirements effective October 1, 2025. CCBHCs must be certified by MDHHS, enroll with a Type 2 NPI under specialty programs, provide nine core behavioral health services (no prior auth required when medically necessary), and deliver 51% or more services directly rather than through contracted collaborators. The policy establishes new enrollment, certification, eligibility, and service delivery standards for Medicaid, Healthy Michigan Plan, and MIChild beneficiaries.

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Archive by year

2023 2024 2025 2026

Addition of Intercept for Intensive In-home Services

SCDHHS Announces Rural Health Transformation Program Notices of Intent to Award

Bevacizumab products (Revised)

Cimerli® (ranibizumab-eqrn) (New)

Cimerli® (ranibizumab-eqrn) (New)

Cimerli® (ranibizumab-eqrn) (New)

Cimerli® (ranibizumab-eqrn) (New)

Avlayah™ (tividenofusp alfa-eknm) solution (New)

Avlayah™ (tividenofusp alfa-eknm) solution (New)

Aldurazyme® (laronidase) (New)

Rate Increase for Personal Care Services and the Community Alternatives Program

Pharmacy Program Updates: Prior Authorization Changes Effective Sept. 15, 2026

Silver State Scripts Board Made Changes to the Preferred Drug List Effective August 1, 2026

Attention Provider Type (PT) 93 (Substance Use Treatment): Substance Use Treatment/Outpatient Behavioral Health Authorization Request Form (FA-11D), Enrollment Checklists, and Billing Guidelines Updated

Web Announcement 3978

Fast Facts Newsletter - August (Special Edition) 2026

2026.40 - Provider Bulletin - Documentation Required for Override of Claims Rejected for ProDUR

DSS Important Message - CoCM Frequently Asked Questions

DSS Important Message - Required Personal Care Attendant (PCA) Training

DSS Important Message - CMAP Addendum B Updated

Reconsideration Filing Limit for Commercial NICU Claims With Ineligible Reason Code of CR1 is 180 days

Pharmacy Policies Available Online

MMP 26-27: Update to Requirements for Fee-for-Service Claim Inquiries

MMP 26-28: Home Help Services Prohibited Outside the United States

MMP 26-29: Certified Community Behavioral Health Clinic (CCBHC) Demonstration Direct Payment Transition