Syrtis Solutions distributes a monthly Medicaid news summary to help you stay up-to-date. The monthly roundup focuses on developments, research, and legislation that relate to Medicaid program integrity, cost avoidance, coordination of benefits, improper payments, fraud, waste, and abuse. Below is a summary of last month’s Medicaid news.
WHY COST AVOIDANCE MUST EXTEND BEYOND DRUG PRICING REFORM Syrtis Solutions, May 29
Drug pricing reform has become one of the most discussed strategies for controlling Medicaid costs. As states face rising enrollment, increasing healthcare expenditures, specialty medications, and growing program complexity, policymakers are searching for ways to reduce spending without compromising access to care. One of the latest efforts is the Centers for Medicare & Medicaid Services’ (CMS) GENEROUS Model, which seeks to lower Medicaid drug costs by negotiating supplemental rebates and encouraging states and manufacturers to participate in a framework designed to achieve better pricing.
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Drug pricing reform has become one of the most discussed strategies for controlling Medicaid costs. As states face rising enrollment, increasing healthcare expenditures, specialty medications, and growing program complexity, policymakers are searching for ways to reduce spending without compromising access to care. One of the latest efforts is the Centers for Medicare & Medicaid Services’ (CMS) GENEROUS Model, which seeks to lower Medicaid drug costs by negotiating supplemental rebates and encouraging states and manufacturers to participate in a framework designed to achieve better pricing.
read more
Rep. Mike Dovilla Announces Ohio Medicaid Program Integrity and Fraud Prevention Act The Ohio House of Representatives, May 27
State Representative Mike Dovilla (R-Berea) today unveiled a comprehensive legislative package aimed at fighting fraud, waste and abuse within Ohio’s Medicaid program with the goal of protecting taxpayer dollars. The Ohio Medicaid Program Integrity and Fraud Prevention Act, spearheaded by the Ohio House Republican Caucus, works to strengthen oversight and accountability within the system, target high-risk providers to ensure quality care, boost fraud reporting requirements, implement much-needed guardrails around home-health services, and enhance penalties for Medicaid fraud. read more
State Representative Mike Dovilla (R-Berea) today unveiled a comprehensive legislative package aimed at fighting fraud, waste and abuse within Ohio’s Medicaid program with the goal of protecting taxpayer dollars. The Ohio Medicaid Program Integrity and Fraud Prevention Act, spearheaded by the Ohio House Republican Caucus, works to strengthen oversight and accountability within the system, target high-risk providers to ensure quality care, boost fraud reporting requirements, implement much-needed guardrails around home-health services, and enhance penalties for Medicaid fraud. read more
The Trump Administration Is Ramping Up Medicaid Fraud Enforcement Efforts Mintz, May 26
What Happened: The Trump administration has stepped up its Medicaid fraud enforcement efforts, as demonstrated through a variety of agency actions taken over the past few months. Why It Matters: The focus on Medicaid fraud undoubtedly will result in increased scrutiny of Medicaid providers and Medicaid managed care organizations (MCOs) by state and federal enforcement authorities. The Details: This article provides an overview of recent developments related to the Trump administration’s increased attention to Medicaid fraud control efforts and key takeaways for Medicaid providers and MCOs. read more
What Happened: The Trump administration has stepped up its Medicaid fraud enforcement efforts, as demonstrated through a variety of agency actions taken over the past few months. Why It Matters: The focus on Medicaid fraud undoubtedly will result in increased scrutiny of Medicaid providers and Medicaid managed care organizations (MCOs) by state and federal enforcement authorities. The Details: This article provides an overview of recent developments related to the Trump administration’s increased attention to Medicaid fraud control efforts and key takeaways for Medicaid providers and MCOs. read more
How States Will Implement H.R. 1’s Medicaid Policies, Including Those Taking Coverage Away for Not Meeting Work Requirements Center On Budget and Policy Priorities, May 26
The 2025 Republican megabill (H.R. 1) will take Medicaid coverage away from millions of people for not meeting rigid work requirements. Many will actually be Medicaid-eligible — because they either worked the required hours or were exempt (such as caregivers or people with serious medical conditions) — but will lose coverage due to reporting burdens or red tape. Exacerbating this problem is a rushed rollout, lack of federal guidance, and limited state capacities to handle such a massive change. read more
The 2025 Republican megabill (H.R. 1) will take Medicaid coverage away from millions of people for not meeting rigid work requirements. Many will actually be Medicaid-eligible — because they either worked the required hours or were exempt (such as caregivers or people with serious medical conditions) — but will lose coverage due to reporting burdens or red tape. Exacerbating this problem is a rushed rollout, lack of federal guidance, and limited state capacities to handle such a massive change. read more
CMS proposes rule aimed at limiting Medicaid state-directed payments Fierce Healthcare, May 21
The Trump administration has proposed a “sweeping crackdown” on Medicaid payments that implements, and goes beyond, the reductions directed by last year’s sweeping One Big Beautiful Bill Act. Under a proposed rule, the Centers for Medicare & Medicaid Services takes aim at state-directed payments, aiming to bring Medicaid payments more in line with Medicare. The proposal would cap SDPs at 100% of Medicare rates in states that expanded Medicaid and 110% in non-expansion states for rating periods beginning on or after July 4, 2025. read more
The Trump administration has proposed a “sweeping crackdown” on Medicaid payments that implements, and goes beyond, the reductions directed by last year’s sweeping One Big Beautiful Bill Act. Under a proposed rule, the Centers for Medicare & Medicaid Services takes aim at state-directed payments, aiming to bring Medicaid payments more in line with Medicare. The proposal would cap SDPs at 100% of Medicare rates in states that expanded Medicaid and 110% in non-expansion states for rating periods beginning on or after July 4, 2025. read more
Modern Medicaid Alliance Statement on Proposed Rule Related to Medicaid State Directed Payments
Modern Medicaid Alliance, May 21
In response to yesterday’s proposed rule from the Centers for Medicare & Medicaid Services (CMS) on Medicaid state directed payments, the Modern Medicaid Alliance issued the following statement: “While we are still reviewing the details of yesterday’s proposal, further restrictions on critical Medicaid financing programs could compound the financial shortfalls facing states, hospitals and community-based providers, putting coverage and access to essential care at risk for the more than 75 million Americans who depend on Medicaid. read more
Modern Medicaid Alliance, May 21
In response to yesterday’s proposed rule from the Centers for Medicare & Medicaid Services (CMS) on Medicaid state directed payments, the Modern Medicaid Alliance issued the following statement: “While we are still reviewing the details of yesterday’s proposal, further restrictions on critical Medicaid financing programs could compound the financial shortfalls facing states, hospitals and community-based providers, putting coverage and access to essential care at risk for the more than 75 million Americans who depend on Medicaid. read more
Understanding Medicaid Cost Sharing and Policy Changes from the 2025 Reconciliation Law KFF, May 21
The 2025 reconciliation law makes significant changes to the Medicaid program, including requiring states to impose cost sharing on adults enrolled through the Affordable Care Act (ACA) Medicaid expansion, marking the first time the federal government has required states to impose cost sharing on Medicaid enrollees. Current federal rules allow, but do not require, states to impose cost sharing on certain Medicaid enrollees. read more
The 2025 reconciliation law makes significant changes to the Medicaid program, including requiring states to impose cost sharing on adults enrolled through the Affordable Care Act (ACA) Medicaid expansion, marking the first time the federal government has required states to impose cost sharing on Medicaid enrollees. Current federal rules allow, but do not require, states to impose cost sharing on certain Medicaid enrollees. read more
White House threatens to withhold Medicaid money from states over fraud The Hill, May 13
The Trump administration is threatening to withhold Medicaid money from all 50 states if they do not show that they are complying with federal anti-fraud statutes. Vice President Vance told reporters Wednesday that a letter sent to states by the Department of Health and Human Services inspector general requires them to show that they are “effectively and aggressively prosecuting Medicaid fraud in their states.” States have what’s called Medicaid Fraud Control Units that are funded by the federal government as a way for states to investigate any fraud they find. read more
The Trump administration is threatening to withhold Medicaid money from all 50 states if they do not show that they are complying with federal anti-fraud statutes. Vice President Vance told reporters Wednesday that a letter sent to states by the Department of Health and Human Services inspector general requires them to show that they are “effectively and aggressively prosecuting Medicaid fraud in their states.” States have what’s called Medicaid Fraud Control Units that are funded by the federal government as a way for states to investigate any fraud they find. read more
MACPAC calls for increased transparency in Medicaid AI prior authorization HealthcareDive, May 11
An influential group that advises Congress on Medicaid is recommending increasing transparency into artificial intelligence-backed prior authorization and boosting human oversight over automated pre-approvals for care. The recommendations come as states and the federal government say they have limited insight into payers’ use of the technology in the safety-net insurance program, which can make it challenging for regulators to monitor for data bias or inaccuracies, analysts said during the meeting. read more
An influential group that advises Congress on Medicaid is recommending increasing transparency into artificial intelligence-backed prior authorization and boosting human oversight over automated pre-approvals for care. The recommendations come as states and the federal government say they have limited insight into payers’ use of the technology in the safety-net insurance program, which can make it challenging for regulators to monitor for data bias or inaccuracies, analysts said during the meeting. read more
A Look at the GENEROUS Model and Factors That Could Impact Medicaid Drug Costs KFF, May 8
While spending on prescription drugs accounts for a relatively small share of overall Medicaid spending, Medicaid drug spending has grown in recent years. As a result, both states and the federal government continue to prioritize the management of rising prescription drug costs. There have been several recent Trump administration prescription drug initiatives, including negotiating “most-favored-nation” (MFN) drug pricing deals. These MFN agreements are based on the premise that the U.S. shouldn’t pay higher prices for prescription drugs than other comparable nations. read more
While spending on prescription drugs accounts for a relatively small share of overall Medicaid spending, Medicaid drug spending has grown in recent years. As a result, both states and the federal government continue to prioritize the management of rising prescription drug costs. There have been several recent Trump administration prescription drug initiatives, including negotiating “most-favored-nation” (MFN) drug pricing deals. These MFN agreements are based on the premise that the U.S. shouldn’t pay higher prices for prescription drugs than other comparable nations. read more
West Virginia to increase Medicaid provider reviews to combat fraud WVVA, May 6
Gov. Patrick Morrisey said West Virginia will step up efforts to protect taxpayer dollars by ensuring Medicaid is used for its intended purpose. “West Virginia is building on a strong foundation to ensure Medicaid dollars are protected for our most vulnerable citizens,” Morrisey said. “We fully support the federal government’s efforts to crack down on fraud, waste, and abuse, and we are taking decisive action to strengthen accountability across our system.” read more
Gov. Patrick Morrisey said West Virginia will step up efforts to protect taxpayer dollars by ensuring Medicaid is used for its intended purpose. “West Virginia is building on a strong foundation to ensure Medicaid dollars are protected for our most vulnerable citizens,” Morrisey said. “We fully support the federal government’s efforts to crack down on fraud, waste, and abuse, and we are taking decisive action to strengthen accountability across our system.” read more
Missouri Governor announces partnership with CMS to strengthen medicaid integrity KZRG, May 4
Today, Governor Mike Kehoe announced that the State of Missouri has officially notified the Centers for Medicare & Medicaid Services (CMS) of its intent to launch an accelerated, off-cycle revalidation of high-risk Medicaid providers. This initiative, part of a coordinated “War on Fraud” alongside federal partners, reinforces Missouri’s longstanding commitment to ensuring taxpayer dollars are reserved for the state’s most vulnerable citizens. In a letter sent to CMS Administrator Dr. Mehmet Oz, Governor Kehoe expressed his appreciation for the federal administration’s renewed focus on program integrity and their “detect and deploy” strategy to root out corruption within the Medicaid system. read more
Today, Governor Mike Kehoe announced that the State of Missouri has officially notified the Centers for Medicare & Medicaid Services (CMS) of its intent to launch an accelerated, off-cycle revalidation of high-risk Medicaid providers. This initiative, part of a coordinated “War on Fraud” alongside federal partners, reinforces Missouri’s longstanding commitment to ensuring taxpayer dollars are reserved for the state’s most vulnerable citizens. In a letter sent to CMS Administrator Dr. Mehmet Oz, Governor Kehoe expressed his appreciation for the federal administration’s renewed focus on program integrity and their “detect and deploy” strategy to root out corruption within the Medicaid system. read more
CMS mandates state Medicaid directors to validate providers
Healthcare Finance, May 1
Centers for Medicare & Medicaid Services Administrator Mehmet Oz has sent state Medicaid directors a letter mandating they submit a plan within 30 days on a two-year provider revalidation strategy. CMS wants to ensure that only legitimate, qualified providers are enrolled and participating in Medicaid, Oz said in the April 23 letter. Oz made the announcement public at Politico’s Health Care Summit on April 21. read more
Healthcare Finance, May 1
Centers for Medicare & Medicaid Services Administrator Mehmet Oz has sent state Medicaid directors a letter mandating they submit a plan within 30 days on a two-year provider revalidation strategy. CMS wants to ensure that only legitimate, qualified providers are enrolled and participating in Medicaid, Oz said in the April 23 letter. Oz made the announcement public at Politico’s Health Care Summit on April 21. read more
2026 Report on State Medicaid and CHIP Eligibility, Enrollment, and Renewal Policies Includes Special Edition on Medicaid Work Requirements Georgetown University McCourt School of Public Policy, May 1
Yesterday, the annual KFF survey report was released with a webinar featuring highlights of two reports and a discussion that included Kate McEvoy, executive director of the National Association of Medicaid Directors, and was moderated by KFF’s Larry Levitt. The webinar and reports contain important information that should be of interest to policymakers, stakeholders, members of the media, and anyone interested in health care policy during this pivotal moment for Medicaid. While we report on the survey findings in two reports, the data were collected on one survey conducted by KFF and CCF teams. read more
Yesterday, the annual KFF survey report was released with a webinar featuring highlights of two reports and a discussion that included Kate McEvoy, executive director of the National Association of Medicaid Directors, and was moderated by KFF’s Larry Levitt. The webinar and reports contain important information that should be of interest to policymakers, stakeholders, members of the media, and anyone interested in health care policy during this pivotal moment for Medicaid. While we report on the survey findings in two reports, the data were collected on one survey conducted by KFF and CCF teams. read more
