All Insurance Policy Changes (Page 79)

Continuing from page 78. 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
Reminder: Requirements for Research-Based Behavioral Health Treatment Service Delivery
NC Medicaid - NCDHHS·Effective Apr 30, 2026
NC Medicaid issued a clarification bulletin on Research-Based Behavioral Health Treatment (RB-BHT) services for autism spectrum disorder, emphasizing strict requirements for covered treatments, diagnosis validation, assessment standards, treatment planning, provider credentials, telehealth restrictions, and monitoring for fraud/waste/abuse. Billing teams must ensure claims comply with specific coverage criteria and supervision requirements, as NC Medicaid will conduct random onsite visits and desk reviews to investigate inappropriate billing patterns.
Medium impact
Some Qualified Medicare Beneficiaries Now Have Coverage for Family Planning Services
NC Medicaid - NCDHHS·Identified Jul 22, 2026
NC Medicaid Direct has expanded coverage for Qualified Medicare Beneficiary (MQB-Q/B) individuals to now include Family Planning services—contraception, health screenings, STI testing/treatment, lab services, HPV vaccines, and sterilization procedures—in addition to their existing premium and cost-sharing coverage. Providers must verify eligibility in NCTracks and inform eligible patients of this new benefit.
High impact
Attention All Providers: New Personal Care Services (PCS) Initial Prior Authorization (PA) Submission Capability and Updated FA-24 Form
Nevada Medicaid·Effective Jul 21, 2026
Nevada Medicaid has updated the Provider Web Portal (PWP) and the FA-24 form to streamline Personal Care Services (PCS) initial prior authorization submissions. Effective immediately, providers can submit PCS Initial PA requests directly through PWP, and the updated FA-24 form (dated 07/21/2026) now consolidates both initial PA and provider transfer requests. The previous FA-24 version must be discontinued by September 21, 2026, after which requests on old forms will be rejected.
High impact
Reminder: first 2026 PIP supplemental data deadline is Nov. 1
Priority Health·Effective Nov 1, 2026
Priority Health has established two supplemental data submission deadlines for the 2026 PCP Incentive Program (PIP). The first deadline is November 1, 2026, for dates of service January 1–June 30, 2026. ACNs must submit all supplemental data (digitally via MiHIN, APS, HL7, EPP, or via medical records) by this deadline, with an exception allowing blood pressure and A1c results to be submitted year-round.
Medium impact
Reminder: Your payments will be delivered by ECHO starting Sept. 1
Priority Health·Effective Sep 1, 2026
Priority Health is transitioning payment delivery to ECHO starting September 1, 2026. This is an administrative change to the payment processing system that will affect how the practice receives claim reimbursements from Priority Health.
High impact
[Indiana] Out of Network Claims Filing Limit
CareSource·Effective Jan 1, 2026
CareSource Indiana Medicaid has reduced the out-of-network claims filing deadline from 180 calendar days to 90 calendar days from date of service or discharge, effective January 1, 2026. Claims filed after 90 days will be denied for timely filing, except when eligibility is updated. This change aligns with federal Medicaid regulations (42 CFR 447.45(d)(4)).
Medium impact
5160:1-6-03.2 - Medicaid: use of qualified income trusts (QIT). (Amend/Original File)
Ohio Medicaid·Effective Jul 21, 2026
This is a recent amendment to Ohio's Medicaid rule 5160:1-6-03.2 governing the use of Qualified Income Trusts (QITs) for Medicaid eligibility purposes. The policy appears to be a procedural or eligibility rule update rather than a clinical billing change. Without access to the full policy text detailing specific modifications, the exact billing impact cannot be determined from the metadata alone.
High impact
EVV Impacts: Baylor Scott & White and FirstCare MCOs End Participation in Texas Medicaid Managed Care Effective Aug. 31
Texas Medicaid·Effective Sep 1, 2026
Effective Sept. 1, 2026, Baylor Scott & White and FirstCare will end participation in Texas Medicaid STAR program. All members must transition to alternative MCOs (WellPoint or Superior) in their service area. Billing teams must identify each member's new MCO assignment, create new authorizations in the EVV system with updated plan codes, and bill the new payer for all dates of service on or after Sept. 1, 2026.
Low impact
HHSC LTCR Publishes PL 2026-14 Amendments to the Definitions of Abuse and Neglect
Texas Medicaid·Identified Jul 22, 2026
HHSC Long-term Care Regulation has published Provider Letter 2026-14 updating the definitions of child abuse and neglect for nursing facilities (NF) and portable/person-centered emergency care (PPECC) providers, based on Texas House Bill 1106 from the 89th Legislature. This policy clarifies regulatory compliance requirements for long-term care facilities in Texas but does not directly impact clinical billing codes or reimbursement workflows for most medical practices.
High impact
BT2026119: IHCP updates reimbursement percentage for anesthesia medical direction with modifier QK
Indiana Medicaid (IHCP)·Effective Apr 1, 2024
Indiana Health Coverage Programs (IHCP) is increasing reimbursement for anesthesia medical direction claims billed with modifier QK from 30% to 50% of the fee schedule, effective retroactively for dates of service on or after April 1, 2024. This change corrects an omission from the HIP Rate Equalization Project and clarifies duplicate billing rules when multiple anesthesia providers bill the same procedure codes.
High impact
BT2026120: IHCP reminds providers of specific directions requirement for all prescriptions
Indiana Medicaid (IHCP)·Identified Jul 22, 2026
IHCP (Indiana Medicaid) reinforces requirement that ALL prescriptions must include specific dosing and directions—not vague language like 'as directed' or 'PRN'. Pharmacists must contact prescribers for clarification if directions are insufficient, and billing must reflect actual verified directions. Claims submitted with vague directions are subject to audit and recovery.
High impact
DMAS-80 and DMAS 421A Fax Retirement
Virginia Medicaid - DMAS·Effective Jun 30, 2026
Virginia DMAS is retiring the fax submission process (804-452-5456) for DMAS-80 nursing facility admission/discharge forms, DMAS-421A, and admission packages effective June 30, 2026. All submissions must transition to email (nfportalentries@dmas.virginia.gov) with secure encryption and required portal error screenshots. Providers must also ensure enrollment information is current in the PRSS provider portal to avoid claims payment disruptions.
High impact
Updated Private Duty Nursing Regulations and Forms
Virginia Medicaid - DMAS·Effective Mar 26, 2026
Virginia Medicaid has updated private duty nursing regulations and authorization requirements effective March 26, 2026, clarifying that PDN is only a covered service when authorized as an EPSDT or 1915(c) waiver service. A new regulation (12VAC30-50-132) and revised DMAS-62 Medical Necessity Assessment form (required for all requests on or after June 5, 2026) establish service descriptions, provider qualifications, service limits, and a new Medical Needs Assessment algorithm. Billing teams must transition to the new DMAS-62 form and submit requests through Atrezzo portal (non-waiver FFS), Waiver Management System (waiver-enrolled members), or directly to the MCO depending on member enrollment status.
Medium impact
Home and Community-Based Services (HCBS) Grievance System
Virginia Medicaid - DMAS·Effective Jun 10, 2026
Virginia Medicaid is implementing a new Home and Community-Based Services (HCBS) Fee-for-Service grievance system effective June 10, 2026, requiring providers to establish grievance procedures, disclose grievance rights to individuals annually, and train staff on the grievance process. This applies to Developmental Disability Waiver, Building Independence Waiver, Community Living Waiver, Family and Individual Supports Waiver, and CCC Plus (FFS only) services.
Medium impact
Youth Re-entry Targeted Case Management (RTCM) Implementation
Virginia Medicaid - DMAS·Effective Jul 1, 2026
Virginia Medicaid is launching a new covered service effective July 1, 2026: Re-Entry Targeted Case Management (RTCM) for adjudicated youth and young adults (under 21, or up to 26 if former foster care) transitioning from incarceration. RTCM is a 3-month service (starting 30 days pre-release through 2 months post-release) carved out of managed care and billed as fee-for-service. Community Services Boards (CSBs) must enroll with Provider Class 156 or 456 and Specialty 923 to deliver this service.
High impact
Community Stabilization Coverage Change and Mobile Crisis Response Policy Change
Virginia Medicaid - DMAS·Identified Jul 22, 2026
Virginia Medicaid is eliminating coverage for Community Stabilization services (S9482) effective July 1, 2026, and reducing Mobile Crisis Response (H2011) service limits from 8 hours to 4 hours per encounter. Both changes require CMS approval and will be implemented upon federal authorization. Providers must maintain current enrollment in the PRSS provider portal to avoid claim denials.
High impact
Direct Access to Atrezzo Next Generation (ANG/Atrezzo) Ending Effective 7/31/2026
Virginia Medicaid - DMAS·Effective Aug 1, 2026
Virginia Medicaid is ending direct access to Atrezzo Next Generation (ANG) portal for fee-for-service (FFS) service authorization requests effective July 31, 2026. Starting August 1, 2026, all providers must use DMAS Identity, Credentials and Access Management to log into ANG through the Medicaid Enterprise System (MES). Additionally, providers must ensure their enrollment, contact information, and license information in the Provider Services Solution (PRSS) portal are current to avoid claim payment disruptions for both FFS and MCO claims.
Medium impact
Updates for DD Waiver Autism Advanced Competencies
Virginia Medicaid - DMAS·Effective Jul 20, 2026
Virginia's HB469 clarifies that Positive Behavior Support Facilitators (PBSFs) may conduct training on Autism Advanced Competency Requirements for DD Waiver providers serving individuals with complex health needs and autism at SIS Tier Four. However, PBSFs cannot develop or approve training content. This clarification affects provider qualifications and training delivery within the Developmental Disability Waiver program.
Medium impact
DD Waiver DSP Orientation Test Equivalency
Virginia Medicaid - DMAS·Effective Jul 1, 2026
Virginia Medicaid (DMAS and DBHDS) now recognizes completion of the Virginia Health Workforce Development Authority (VHWDA) eight-module online DSP training program and its associated tests as equivalent to the traditional DSP Orientation Test for DD Waiver providers. Providers must maintain either completed test copies or final test scores along with the completed DSP Assurance Form in their provider records to remain compliant with regulatory requirements.
Low impact
Preeclampsia Biomarker Testing per Public Act 104-0470
Illinois Medicaid - HFS·Effective Jan 1, 2022
The Illinois Department of Healthcare and Family Services confirms Medicaid coverage of preeclampsia biomarker testing (CPT codes 0243U, 0390U, and 0524U) without cost-sharing requirements under Public Act 104-0470. Coverage has been active since January 1, 2022 for both fee-for-service and managed care organizations. This is a clarification notice confirming existing coverage; no new billing code changes are required.
Low impact
Proteomic Blood Test
Illinois Medicaid - HFS·Identified Jul 22, 2026
Illinois HFS confirms ongoing coverage for proteomic blood testing to identify and manage spontaneous preterm birth risk in pregnant persons under Medicaid (both FFS and MCOs). This is a clarification notice stating that coverage already exists; no new policy changes or billing adjustments are required.
Medium impact
Prior authorization at Regence: balancing the needs of all so you get quality care that’s cost-effective
Regence BlueCross BlueShield of Oregon·Effective Jul 21, 2026
Regence has updated its prior authorization policy to emphasize streamlined processes and reduced administrative burden. Key facts: only 5% of claims require prior authorization, 81% are auto-approved in real time, and Regence removed 1,423 prior authorization billing code requirements in 2025. The SmartAuth tool pre-populates authorization forms from EHRs, reducing provider administrative burden by 40%. This is a policy clarification/marketing communication rather than a workflow change, but confirms reduced prior auth requirements across Regence plans.
High impact
26-891 Action Required: Comply with QMED 2.0 Encounter Submission Requirements
Health Net·Effective Oct 1, 2026
Health Net has implemented QMED 2.0 encounter data submission standards for capitated PPGs and hospitals, effective October 1, 2026. Billing teams must ensure 90% of encounters are submitted and accepted within 90 days of service, maintain 97.5% correction rate for denied encounters within 10 days, and meet strict accuracy, completeness, and duplicate thresholds or face performance penalties and corrective action.
High impact
26-892 Action Required: Comply with QMED 2.0 Encounter Submission Requirements
Health Net·Effective Oct 1, 2026
Health Net California has implemented QMED 2.0 encounter data submission requirements for capitated PPGs and hospitals in Fresno, Kings, and Madera counties. Effective October 1, 2026, providers must meet strict performance thresholds for timeliness (90% of encounters submitted within 90 days), accuracy (97.5% of denied encounters corrected within 10 days), completeness (90% with valid Type 1 rendering provider NPIs), uniqueness (duplicate submissions below 0.5%), and reasonability (total denials below 2%). Failure to comply will result in negative performance reporting, plan-level non-compliance risk, and required corrective action.
High impact
26-893 Action Required: Comply with QMED 2.0 Encounter Submission Requirements
Health Net·Effective Oct 1, 2026
Health Net California has implemented QMED 2.0 encounter submission standards for capitated PPGs and hospitals in Imperial County, Medi-Cal. Providers must now meet strict performance thresholds for timeliness (90% of encounters submitted within 90 days), accuracy (97.5% of denied encounters corrected within 10 days), completeness (90% with valid Type 1 rendering provider NPIs), and other quality measures, effective October 1, 2026. Failure to comply will result in negative performance reporting, Plan non-compliance, and corrective action.

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Insurance Policy Changes Tracker: All Payer Updates (Page 79) | PolicyChanges.app

Reminder: Requirements for Research-Based Behavioral Health Treatment Service Delivery

Some Qualified Medicare Beneficiaries Now Have Coverage for Family Planning Services

Attention All Providers: New Personal Care Services (PCS) Initial Prior Authorization (PA) Submission Capability and Updated FA-24 Form

Reminder: first 2026 PIP supplemental data deadline is Nov. 1

Reminder: Your payments will be delivered by ECHO starting Sept. 1

[Indiana] Out of Network Claims Filing Limit

5160:1-6-03.2 - Medicaid: use of qualified income trusts (QIT). (Amend/Original File)

EVV Impacts: Baylor Scott & White and FirstCare MCOs End Participation in Texas Medicaid Managed Care Effective Aug. 31

HHSC LTCR Publishes PL 2026-14 Amendments to the Definitions of Abuse and Neglect

BT2026119: IHCP updates reimbursement percentage for anesthesia medical direction with modifier QK

BT2026120: IHCP reminds providers of specific directions requirement for all prescriptions

DMAS-80 and DMAS 421A Fax Retirement

Updated Private Duty Nursing Regulations and Forms

Home and Community-Based Services (HCBS) Grievance System

Youth Re-entry Targeted Case Management (RTCM) Implementation

Community Stabilization Coverage Change and Mobile Crisis Response Policy Change

Direct Access to Atrezzo Next Generation (ANG/Atrezzo) Ending Effective 7/31/2026

Updates for DD Waiver Autism Advanced Competencies

DD Waiver DSP Orientation Test Equivalency

Preeclampsia Biomarker Testing per Public Act 104-0470

Proteomic Blood Test

Prior authorization at Regence: balancing the needs of all so you get quality care that’s cost-effective

26-891 Action Required: Comply with QMED 2.0 Encounter Submission Requirements

26-892 Action Required: Comply with QMED 2.0 Encounter Submission Requirements

26-893 Action Required: Comply with QMED 2.0 Encounter Submission Requirements