All Insurance Policy Changes (Page 6)

Continuing from page 5. 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
Remind Blue High-Performance Network® Members To See In-Network Providers
BCBS Texas·Identified Sep 11, 2026
This policy clarifies that Blue High-Performance Network (BlueHPN) members have coverage ONLY when seeing in-network BlueHPN providers, except in emergencies. The billing team must verify BlueHPN membership via member ID card, check eligibility in real-time before rendering care, and remind members to use in-network providers to avoid unexpected out-of-pocket costs and claim denials.
Medium impact
[Ohio] Updated Clinical Practice Guidelines Released
CareSource·Identified Sep 11, 2026
CareSource has updated and approved five new Clinical Practice Guidelines (CPGs) effective immediately covering hypertension, blood cholesterol, coronary artery disease, hepatitis C, and maternal/postpartum care. These evidence-based guidelines will be used to measure member health outcomes and inform clinical care delivery across multiple CareSource plans in Georgia, Ohio, Nevada, North Carolina, West Virginia, and Wisconsin.
Low impact
[Indiana] Save The Date: 2026 Q3 Provider Friday Forum
CareSource·Identified Sep 11, 2026
CareSource Indiana is hosting a Q3 2026 Provider Friday Forum on September 25, 2026, to discuss BHIE (Behavioral Health Information Exchange) and SBIRT (Screening, Brief Intervention, and Referral to Treatment) updates. This is an informational event invitation with no billing policy changes, code updates, or coverage modifications.
High impact
Medical/Pharmacy Policy Updates Effective 12/15/2026
Blue Cross Blue Shield of Nebraska·Effective Dec 15, 2026
Blue Cross and Blue Shield of Nebraska (BCBSNE) has implemented a new step therapy requirement for six biologic drug classes effective 12/15/2026. Patients on non-preferred products (biosimilars and brand-name biologics) now require prior authorization and documented evidence of contraindication, intolerance, or failure to a preferred product before coverage. This affects denosumab, infliximab, rituximab, tocilizumab, and trastuzumab products across all patient populations.
Medium impact
FMAP and EFMAP to Change on October 1, 2026
Texas Medicaid·Effective Oct 1, 2026
Effective October 1, 2026, Texas Medicaid's Federal Medical Assistance Percentage (FMAP) will decrease from 59.83% to 58.54%, and the Enhanced EFMAP will decrease from 71.88% to 70.98%. Only providers that certify expenses and receive only the federal share will see reimbursement adjustments; EFMAP changes will not affect provider payments.
Low impact
Register for HCS, TxHmL and PI Quarterly Webinar
Texas Medicaid·Identified Sep 11, 2026
HHSC Long-term Care Regulation is hosting a quarterly webinar on October 27, 2026 for HCS, TxHmL, and PI providers to receive updates on long-term care regulations. This is an educational event, not a policy change affecting billing operations. Providers should register using Chrome or Edge browsers if Internet Explorer causes issues.
Medium impact
BT2026150: IHCP to adjust CCBHC claims
Indiana Medicaid (IHCP)·Effective Oct 14, 2026
IHCP is adjusting previously reimbursed CCBHC claims for QMB-only and SLMB-only Medicare beneficiaries to pay only Medicare coinsurance, copayments, or deductibles (not full service amounts). T1040 modifiers will no longer be required on these crossover claims. Mass claim adjustments will appear on remittance advices starting October 14, 2026.
High impact
BT2026151: IHCP clarifies billing guidance for providers enrolled as a CCBHC or CMHC
Indiana Medicaid (IHCP)·Identified Sep 11, 2026
IHCP clarifies NPI usage and billing requirements for community mental health centers (CMHC) and certified community behavioral health clinics (CCBHC) with multiple service locations. Providers must use the correct NPI based on service type and location, include accurate service location addresses and place of service codes on all claims, and follow specific submission rules to ensure proper identification of where services are delivered.
High impact
Applied Behavior Analysis (ABA) Policy Changes
Virginia Medicaid - DMAS·Identified Sep 11, 2026
Virginia Medicaid is implementing a 20-hour per week cumulative limit on Applied Behavior Analysis (ABA) services effective July 1, 2026, and requiring an autism spectrum disorder (ASD) diagnosis or provisional ASD diagnosis for children age 5 and younger. The effective date for these changes will be announced after Centers for Medicare and Medicaid Services (CMS) approval is obtained and the DMAS Mental Health Services Manual is updated. No changes to the current authorization process will occur until CMS approval and manual updates are finalized.
High impact
Physician Administered Drug Program Updates, Virginia Medicaid Drug Utilization Review Board Approved Updates and Preferred Drug List Effective October 1, 2026
Virginia Medicaid - DMAS·Effective Jul 23, 2026
Virginia Medicaid implemented a new service authorization (SA) program for physician-administered drugs (PADs) billed to the medical benefit, effective July 23, 2026 for certain drugs. Additionally, the Preferred Drug List (PDL) is being updated effective October 1, 2026 with changes to estrogen agents, glucocorticoids, phenylketonuria treatments, bronchodilators, intranasal rhinitis agents, antiemetic agents, HAE treatments, and PAH agents. Providers must submit SA requests via fax with complete clinical documentation to avoid claim denials.
High impact
Physician Administered Drug Procedure Code Rates Effective July 1, 2026
Virginia Medicaid - DMAS·Effective Jul 1, 2026
Virginia Medicaid is updating reimbursement rates for Physician Administered Drug procedure codes effective July 1, 2026. Rates are posted on the DMAS website and MCOs must increase reimbursement to match revised FFS rates. Providers should verify updated rates in their billing systems and be prepared for claim reprocessing once MCO systems are updated (30-60 days after posting).
High impact
Resource Based Relative Value Scale (RBRVS) Rates Effective July 1, 2026
Virginia Medicaid - DMAS·Effective Jul 1, 2026
Virginia Medicaid is updating physician reimbursement rates effective July 1, 2026, based on the CMS Physician Fee Schedule (CMS-1807-F). All providers billing Virginia Medicaid must use the new RBRVS rates found on the DMAS website. Managed Care Organizations (MCOs) will implement rate changes within 30-60 days and automatically reprocess claims paid under old rates.
High impact
Private Duty and Skilled Nursing Update Effective July 1, 2026
Virginia Medicaid - DMAS·Effective Jul 1, 2026
Effective July 1, 2026, Virginia Medicaid updates reimbursement rates for Skilled Nursing (S9123, S9124) and Private Duty Nursing (T1002, T1003) codes per the 2026 Appropriation Act. Managed Care Organizations (MCOs) must align their rates with the revised FFS rates and will automatically reprocess claims within 30 days of system updates; providers may bill immediately under old rates or delay billing until MCO systems are updated.
High impact
Waiver Rate Updates Effective July 1, 2026
Virginia Medicaid - DMAS·Effective Jul 1, 2026
Virginia Medicaid has updated reimbursement rates effective July 1, 2026, for select services under the Developmental Disabilities (DD) Waiver and Commonwealth Coordinated Care Plus (CCC+) Waiver, plus revised the billing unit for Adult Day Healthcare. Managed Care Organizations (MCOs) require 30-60 days to update their systems and will automatically reprocess claims paid at old rates. Providers may bill immediately at old rates or wait for MCO system updates.
High impact
Clinical Laboratory Services Procedure Code Rates Effective July 1, 2026
Virginia Medicaid - DMAS·Effective Jul 1, 2026
Virginia Medicaid (DMAS) is updating Clinical Laboratory Services procedure code rates effective July 1, 2026. Providers must access the new rates on the DMAS website and prepare for system updates from Managed Care Organizations (MCOs), which may take 30-60 days to implement. Claims paid under old rates will be automatically reprocessed once systems are updated.
High impact
Outpatient Rehabilitation Rates Effective July 1, 2026
Virginia Medicaid - DMAS·Effective Jul 1, 2026
Virginia Medicaid is updating Outpatient Rehabilitation rates effective July 1, 2026, with bulletin publication on August 18, 2026. Managed Care Organizations (MCOs) must align reimbursement rates to match the percentage changes in revised fee-for-service rates and may require 30-60 days to update systems; MCOs will automatically reprocess claims paid under old rates within 30 days after system updates. Providers should check the DMAS website for updated rates and ensure enrollment information is current in the Provider Services Solution (PRSS) portal to avoid payment disruptions.
High impact
Behavioral Health Services Redesign Implementation Dates
Virginia Medicaid - DMAS·Effective Jun 30, 2027
Virginia Medicaid is redesigning behavioral health services, retiring four Community Mental Health Rehabilitative Services (CMHRS) codes (H2012, H2016, H0046, H2017) effective June 30, 2027, and implementing five new behavioral health service codes (CPST-Adult, CPST-Youth Community, CPST-Youth School, CSC, Clubhouse) effective July 1, 2027. All current members receiving the retiring services must transition to alternative behavioral health services by the deadline. The practice must update provider enrollment, verify credentials, and prepare for service authorization transitions over the next 6-12 months.
High impact
Submitting Retrospective Service Authorization Requests for Retroactive Eligibility
Virginia Medicaid - DMAS·Effective Aug 24, 2026
Virginia Medicaid now requires providers to obtain retrospective service authorizations for services rendered to individuals approved for retroactive eligibility. Providers must submit these authorization requests within 90 calendar days of the member's Medicaid eligibility determination date and include them with claims submissions. Requests submitted after 90 days will be denied for timeliness.
Medium impact
Updates to Pharmacy Manual Chapter 7
Virginia Medicaid - DMAS·Effective Aug 27, 2026
Virginia Medicaid updated Pharmacy Manual Chapter 7 with revisions to the RetroDUR (Retrospective Drug Utilization Review) process and removed RetroDUR criteria for Nursing Facility members, along with minor grammatical corrections. The memo emphasizes that all providers must maintain current enrollment, contact information, and license information in the PRSS (Provider Services Solution) portal to avoid claim payment disruptions, as federal rules prohibit MCOs and DMAS from paying claims to non-enrolled network providers.
Medium impact
Updates to the Temporary Detention Orders Supplement
Virginia Medicaid - DMAS·Effective Aug 27, 2026
Virginia Medicaid updated the Temporary Detention Orders (TDO) Supplement to clarify when Community Service Boards can bill for prescreening assessments, added a required attestation form for TDO emergency custody services, and removed duplicative language. All providers must maintain current enrollment, contact information, and license details in the PRSS portal to avoid claim denials—MCOs and DMAS are prohibited from paying claims to providers not enrolled in PRSS.
High impact
CCC Plus Waiver Provider Manual Update, Chapters II and IV; New Appendix E, Extraordinary Care Guide; and DMAS-97A/B and DMAS-99 Forms Update
Virginia Medicaid - DMAS·Effective Sep 2, 2026
Virginia DMAS updated the CCC Plus Waiver Provider Manual (Chapters II and IV) with substantive changes to licensure requirements, criminal background checks, personal care documentation, and Plan of Care procedures. Two critical forms—DMAS-97A/B and DMAS-99—have been updated and must be adopted by October 1, 2026, or claims will be denied. Providers must also ensure enrollment information is current in the Provider Services Solution (PRSS) system to avoid claim payment disruptions.
High impact
H.R. 1 Federal Work Requirement, Six-Month Renewals, and Medicaid Eligibility Changes for Non-Citizen, Non-Pregnant Adults
Virginia Medicaid - DMAS·Effective Oct 1, 2026
Virginia Medicaid is implementing three major eligibility and enrollment changes under H.R. 1: (1) restricting full-benefit Medicaid for non-citizen, non-pregnant adults effective October 1, 2026; (2) imposing federal work requirements (80 hours/month work, school enrollment, or $580+ monthly income) for Medicaid Expansion adults ages 19-64 effective January 1, 2027; and (3) reducing Medicaid Expansion eligibility review cycles from 12 months to 6 months effective January 1, 2027. Additionally, retroactive coverage is reduced to 1 month for Medicaid Expansion and 2 months for other groups. Billing teams must verify eligibility before each service and update workflows to account for more frequent renewals and work requirement documentation.
Medium impact
Electronic Visit Verification—Live-In Requirement Effective 10/1/2026
Virginia Medicaid - DMAS·Effective Oct 1, 2026
Virginia Medicaid is eliminating the live-in caregiver exemption from Electronic Visit Verification (EVV) requirements effective October 1, 2026. All agency-directed aides and consumer-directed attendants performing personal care, respite care, or companion care services must now use EVV-compliant methods (F/EA mobile app or IVR system) to log and submit work shifts. The January 7, 2021 guidance permitting live-in caregiver exemptions is no longer valid.
High impact
Coverage of Wegovy for MACE and MASH, and Zepbound for OSA
Illinois Medicaid - HFS·Effective Oct 1, 2026
Effective October 1, 2026, Illinois Medicaid (both FFS and Managed Care) will cover Wegovy (semaglutide tablets and injection) for MACE reduction in adults with established cardiovascular disease and obesity/overweight, and for MASH treatment with moderate-to-advanced liver fibrosis (F2-F3). Zepbound (tirzepatide) is now covered for moderate-to-severe obstructive sleep apnea in adults with obesity. All three indications require prior authorization. Weight loss alone remains non-covered.
Low impact
AM Best reaffirms Regence plans’ financial strength
Regence BlueCross BlueShield of Oregon·Identified Sep 11, 2026
AM Best has reaffirmed Regence health plans' financial strength ratings (A/Excellent FSR and a/Issuer Credit Rating) across Idaho, Oregon, Utah, and Washington. This is a credibility announcement about plan solvency and financial stability with no direct impact on billing codes, prior authorization requirements, or reimbursement rates.

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Archive by year

2023 2024 2025 2026

Remind Blue High-Performance Network® Members To See In-Network Providers

[Ohio] Updated Clinical Practice Guidelines Released

[Indiana] Save The Date: 2026 Q3 Provider Friday Forum

Medical/Pharmacy Policy Updates Effective 12/15/2026

FMAP and EFMAP to Change on October 1, 2026

Register for HCS, TxHmL and PI Quarterly Webinar

BT2026150: IHCP to adjust CCBHC claims

BT2026151: IHCP clarifies billing guidance for providers enrolled as a CCBHC or CMHC

Applied Behavior Analysis (ABA) Policy Changes

Physician Administered Drug Program Updates, Virginia Medicaid Drug Utilization Review Board Approved Updates and Preferred Drug List Effective October 1, 2026

Physician Administered Drug Procedure Code Rates Effective July 1, 2026

Resource Based Relative Value Scale (RBRVS) Rates Effective July 1, 2026

Private Duty and Skilled Nursing Update Effective July 1, 2026

Waiver Rate Updates Effective July 1, 2026

Clinical Laboratory Services Procedure Code Rates Effective July 1, 2026

Outpatient Rehabilitation Rates Effective July 1, 2026

Behavioral Health Services Redesign Implementation Dates

Submitting Retrospective Service Authorization Requests for Retroactive Eligibility

Updates to Pharmacy Manual Chapter 7

Updates to the Temporary Detention Orders Supplement

CCC Plus Waiver Provider Manual Update, Chapters II and IV; New Appendix E, Extraordinary Care Guide; and DMAS-97A/B and DMAS-99 Forms Update

H.R. 1 Federal Work Requirement, Six-Month Renewals, and Medicaid Eligibility Changes for Non-Citizen, Non-Pregnant Adults

Electronic Visit Verification—Live-In Requirement Effective 10/1/2026

Coverage of Wegovy for MACE and MASH, and Zepbound for OSA

AM Best reaffirms Regence plans’ financial strength