All Insurance Policy Changes (Page 85)

Continuing from page 84. 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
Talk with Members About Access to Contraceptive Care
BCBS New Mexico·Effective Jul 17, 2026
BlueCross BlueShield New Mexico issued guidance for providers serving Turquoise Care (Medicaid) members on contraceptive care access and quality measure tracking. The policy emphasizes HHS-recommended preventive care measures for contraception and postpartum depression screening, with specific requirements for documentation, counseling, and same-day access to contraceptive methods. Providers must implement workflows to close care gaps and track two key HEDIS measures related to contraceptive provision and maternal depression screening.
Medium impact
Annual Provider Directory Outreach
BCBS New Mexico·Effective Jul 20, 2026
Blue Cross and Blue Shield of New Mexico is conducting an annual provider directory audit from July 20 through August 28, 2026, via vendor Press Ganey. All contracted providers must verify their directory information (group/individual name, locations, phone numbers, hours, new patient status) when contacted. Additionally, providers are reminded that directory data must be verified every 90 days using the Demographic Change Form or Provider Data Management tools to ensure member access to accurate practice information.
Low impact
Quality, STARS and Risk Adjustment Updates
CareFirst BlueCross BlueShield·Effective Jul 13, 2026
CareFirst has released new educational resources and training programs focused on risk adjustment coding, quality improvement, and clinical documentation. This includes new AAPC-accredited online courses (30-45 minutes, CEU-eligible), SHORTs videos on Medicare Health Outcomes Survey (HOS) provider awareness, and updated quality toolkits. The policy emphasizes provider support for patient survey completion and documentation best practices to influence CMS Star Ratings.
High impact
26-878 Medicare GLP-1 Bridge Program for Weight Loss Began July 1, 2026
Health Net·Effective Jul 1, 2026
Effective July 1, 2026, a new CMS Medicare GLP-1 Bridge Program provides Medicare Part D coverage for three GLP-1 medications (Wegovy, Foundayo, Zepbound) prescribed exclusively for weight management. Providers must identify eligible patients, include obesity diagnosis code E66 and notation 'SEND TO BRIDGE FOR WEIGHT MANAGEMENT' on prescriptions, and submit prior authorization through a CMS-designated processor if not received within 72 hours.
Medium impact
26-871m Updates to Clinical Policies – June 2026
Health Net·Identified Jul 18, 2026
Failed to analyze policy change
Medium impact
26-872m Updates to Clinical Policies – June 2026
Health Net·Identified Jul 18, 2026
Failed to analyze policy change
Medium impact
26-873m Updates to Clinical Policies – June 2026
Health Net·Effective Jun 1, 2026
Health Net California has released policy update 26-873m for June 2026 that includes clinical policy reviews and retirement of at least one policy. The specific changes, affected codes, and implementation requirements are detailed in a downloadable PDF provider update. This applies to physicians, practitioners, PPGs, hospitals, ancillary providers, and behavioral health providers across 11 California counties.
High impact
Justice-Involved (JI) Reentry Initiative: Billing Requirements for Care Management Bundle 4, Procedure Code T2024
Medi-Cal·Effective Jul 16, 2026
Effective immediately, procedure code T2024 (Reentry Care Plan) for Justice-Involved reentry initiatives must be billed using "from-through" date format, with the "from" date as the day prior to service completion and "through" date as the completion date. Claims not following this format will be denied with RAD code 0394. Additionally, T2024 may only be billed once per member per episode of incarceration.
Medium impact
Psychological Associate Services Billable at All-Inclusive Rate for Tribal FQHCs
Medi-Cal·Effective Jan 1, 2025
Tribal Federally Qualified Health Centers (FQHCs) can now bill for psychological associate services at the All-Inclusive Rate (AIR) when provided under the supervision of a licensed clinical psychologist. The supervising psychologist's NPI must be included on UB-04 claims as a rendering practitioner. This policy is retroactively effective to January 1, 2025, and applies to qualifying Tribal FQHC visits.
High impact
Claim Resubmission and Billing Clarification for Doula Services
Maryland Medicaid·Effective Jun 11, 2026
Maryland Medicaid has established a claim resubmission opportunity for doula services rendered between May 1, 2024 and May 1, 2026, allowing providers to correct previously underbilled claims by requesting void of initial claims and resubmitting with accurate 4-unit billing for 60-minute visits. The policy also clarifies the 8:1 reimbursement model, fee schedule effective July 1, 2023, and eligible place-of-service codes for prenatal (T1032), postpartum (T1032 U9), and labor/delivery (T1033) services.
High impact
Clarification of Administrative Days Reimbursement in Nursing Facilities
Maryland Medicaid·Effective Jun 22, 2026
Maryland Medicaid clarifies that nursing facilities must bill administrative days using Form 2129 starting on the first day of a continued stay review (CSR) period when a patient lacks a valid level of care determination. Facilities may continue full Medicaid billing only if an appeal is filed within 10 days of a denied level of care notification. Any claims already paid at full rate during denied periods must be corrected through the claims adjustment process.
High impact
Implementation of home and Community-Based Services Cost Survey
Maryland Medicaid·Effective Jul 1, 2026
Maryland Medicaid is implementing a mandatory Home and Community-Based Services (HCBS) Cost Survey effective July 1, 2026. All HCBS providers who billed Medicaid from July 1, 2025–June 30, 2026 must complete and submit the survey by September 30, 2026, reporting cost, utilization, workforce data, and the percentage of payments spent on direct care worker compensation. This data will inform future rate-setting methodology and assess payment adequacy.
Medium impact
PACE Payment Rates for Calendar Year 2026
Maryland Medicaid·Effective Jan 1, 2026
Maryland Department of Health has updated PACE (Program of All-Inclusive Care for the Elderly) capitation payment rates for calendar year 2026, effective January 1, 2026. Rates vary by age group (55-64 and 65+), dual eligibility status, and geographic region (Baltimore Metro vs. Washington Metro). Billing teams must verify correct rate application for claims and ensure their systems reflect these new rates.
High impact
Updated Prior Authorization Process for Special Pediatric Hospitals
Maryland Medicaid·Effective Jul 1, 2026
Maryland Medicaid reinstates prior authorization requirements for special pediatric hospital transfers, effective July 1, 2026. This reverses the January 2026 removal of prior auth requirements. Providers must now submit prospective reviews before admission OR concurrent reviews within 5 calendar days of admission, with continued stay reviews required every 3 days. Failure to use correct timing in Qualitrac will result in case closure and claim denials.
Medium impact
Kennedy Krieger Institute Immediate Initial Intervention Service Pilot
Maryland Medicaid·Effective Jul 1, 2026
Maryland Medicaid is launching a new pilot program at Kennedy Krieger Institute for web-based behavioral health services (3i) targeting children aged 3-10 with non-dangerous behavioral problems. Billing teams must implement revenue code 0919 with a flat annual rate of $3,500 per beneficiary and ensure prior authorization through BHASO before claims submission. Services require minimum engagement criteria (two navigator meetings, 30+ minutes of module engagement, and completion of all assigned modules) before reimbursement eligibility.
High impact
Behavioral Technician Credential Upgrade - ePREP Process Prior to the MPRIME Hold
Maryland Medicaid·Effective Jul 6, 2026
Maryland Medicaid requires Behavioral Technicians (BTs) upgrading to Registered Behavior Technicians (RBTs) to submit a NEW enrollment application under provider type RB with RBT certification by July 31, 2026, before the August 1 MPRIME system hold. Current BT provider IDs will be terminated upon approval of the new RBT account. Providers missing the deadline cannot upgrade until October 2026.
Medium impact
Inclusion of Medical Day Care Services in the Brain Injury Waiver Fee Schedule
Maryland Medicaid·Effective Sep 1, 2025
Maryland Medical Assistance Program has added Medical Day Care (MDC) services to the Brain Injury Waiver fee schedule with a per diem reimbursement rate of $116.59 per day. This service was previously offered but lacked a formal fee schedule entry. Billing teams must update their systems to recognize procedure code S5102 for MDC services under this waiver effective September 1, 2025.
High impact
Fiscal Year 2027 Rates for the Developmental Disabilities Administration Targeted Case Management Services
Maryland Medicaid·Effective Jul 1, 2026
Maryland Medicaid Developmental Disabilities Administration is reducing Targeted Case Management (TCM) service rates by 2% effective July 1, 2026. Comprehensive Assessment rate drops to $441.00 per assessment, and TCM coordination services decrease to $27.76 per 15-minute unit statewide, with a higher geographic differential rate of $29.76 per 15-minute unit for five designated Maryland counties (Calvert, Charles, Frederick, Montgomery, Prince George's).
High impact
Fiscal Year 2027 Rates for Nursing Facility Services
Maryland Medicaid·Effective Jul 1, 2026
Maryland Medicaid nursing facility rates are increasing by 1% effective July 1, 2026, based on FY 2027 budget bill SB0282. Rates are adjusted by each facility's case mix index and include 2024 rebasing data. The Medicare coinsurance worksheet has been updated, and the personal needs allowance increases to $109.00 per month per Medicaid participant.
Medium impact
Upcoming MPRIME Training Sessions
Maryland Medicaid·Effective Oct 1, 2026
Maryland Medicaid is launching a new provider enrollment system called MPRIME (Maryland Provider Registration and Information Management Enterprise) in October 2026. All Maryland providers must complete training sessions to learn how to use the new system for provider registration, enrollment applications, updates, and re-validation processes. Training sessions are being offered now with prerecorded versions available closer to launch.
Medium impact
Discuss Preventive Care with Members
BCBS Oklahoma·Effective Jul 16, 2026
This is a new preventive care guidance policy (effective July 16, 2026) from Blue Cross Blue Shield of Oklahoma encouraging providers to discuss and offer preventive services to members, including screenings, vaccines, and physical exams. The policy emphasizes documentation requirements, eligibility verification, and tracking of HEDIS quality measures for preventive care access.
Medium impact
Reminder: Digital Access to Prior Authorization and Referral Decision Letters Through Availity® Essentials
BCBS Oklahoma·Effective Jul 18, 2026
Blue Cross Blue Shield of Oklahoma is transitioning prior authorization and referral approval letters for commercial members from USPS mail to digital access through Availity Essentials Provider Correspondence Viewer, effective July 18, 2026 (approval letters only). Starting September 8, 2026, approval letters will no longer be mailed; denial letters will continue via USPS and remain available electronically. Providers can opt out of digital delivery if preferred.
Medium impact
[California] Change to contracting requirement for CS housing transition navigation
Anthem BCBS·Effective Jan 1, 2027
Effective January 1, 2027, providers contracted with Anthem Blue Cross (Medi-Cal) to deliver community supports (CS) housing transition navigation services must also be contracted to provide CS housing deposits. This requirement consolidates housing services under a single provider to streamline care coordination for homeless Medi-Cal members.
Medium impact
[Virginia] Updated LTSS authorization and care management training material
Anthem BCBS·Effective Jul 16, 2026
Anthem HealthKeepers, Inc. (Virginia Medicaid) has updated training materials for Long-Term Services & Supports (LTSS) authorization and care management, including revised Quick Reference Guide and FAQ documents. These updates clarify provider workflows, authorization alignment, and coordination between providers, care managers, and utilization management teams for consumer-directed and agency-directed personal care services.
Medium impact
Pegzilarginase-nbln (Loargys)
BCBS Tennessee·Effective Jul 31, 2026
BlueCross BlueShield of Tennessee has issued a new medical policy for Pegzilarginase-nbln (Loargys), a treatment for Arginase 1 Deficiency in patients ages 2-31. The policy establishes coverage criteria, prior authorization requirements, and mandatory documentation including genetic testing, enzyme assays, and functional assessments. Coverage is limited to 12-month authorizations with specific plasma arginine level targets and dose restrictions.

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Insurance Policy Changes Tracker: All Payer Updates (Page 85) | PolicyChanges.app

Talk with Members About Access to Contraceptive Care

Annual Provider Directory Outreach

Quality, STARS and Risk Adjustment Updates

26-878 Medicare GLP-1 Bridge Program for Weight Loss Began July 1, 2026

26-871m Updates to Clinical Policies – June 2026

26-872m Updates to Clinical Policies – June 2026

26-873m Updates to Clinical Policies – June 2026

Justice-Involved (JI) Reentry Initiative: Billing Requirements for Care Management Bundle 4, Procedure Code T2024

Psychological Associate Services Billable at All-Inclusive Rate for Tribal FQHCs

Claim Resubmission and Billing Clarification for Doula Services

Clarification of Administrative Days Reimbursement in Nursing Facilities

Implementation of home and Community-Based Services Cost Survey

PACE Payment Rates for Calendar Year 2026

Updated Prior Authorization Process for Special Pediatric Hospitals

Kennedy Krieger Institute Immediate Initial Intervention Service Pilot

Behavioral Technician Credential Upgrade - ePREP Process Prior to the MPRIME Hold

Inclusion of Medical Day Care Services in the Brain Injury Waiver Fee Schedule

Fiscal Year 2027 Rates for the Developmental Disabilities Administration Targeted Case Management Services

Fiscal Year 2027 Rates for Nursing Facility Services

Upcoming MPRIME Training Sessions

Discuss Preventive Care with Members

Reminder: Digital Access to Prior Authorization and Referral Decision Letters Through Availity® Essentials

[California] Change to contracting requirement for CS housing transition navigation

[Virginia] Updated LTSS authorization and care management training material

Pegzilarginase-nbln (Loargys)