The Michigan State Medical Society (MSMS) Health Care Delivery Department receives news from several of Michigan’s health plans and insurers related to policies, programs, and education opportunities. Below are some updates which may be of interest to physicians and other health care team members.
CMS News
CMS Issues Interim Final Rule Establishing Nationwide Medicaid Work Requirements
The Centers for Medicare & Medicaid Services (CMS) has issued an Interim Final Rule (CMS-2454-IFC) establishing a nationwide framework for implementing Medicaid work requirements authorized under the Working Families Tax Cut legislation. Under the rule, certain Medicaid applicants and beneficiaries ages 19 through 64 will be required to complete at least 80 hours per month of qualifying activities, such as employment, education, job training, community service, or participation in approved work programs, as a condition of maintaining Medicaid eligibility. States are generally required to implement the new requirements by January 1, 2027.
The rule identifies populations that are exempt from the requirement, including pregnant individuals, caregivers, people with disabilities, veterans with total disability ratings, and American Indians and Alaska Natives. States will also have the option to grant temporary hardship exceptions in specified circumstances.
CMS outlined state responsibilities for verifying compliance, conducting beneficiary outreach, and reporting program data. The rule establishes national standards for eligibility verification, beneficiary communications, and program oversight to promote consistency across state Medicaid programs.
To support implementation efforts, CMS highlighted federal investments that include $200 million in Government Efficiency Grants and more than $600 million in private-sector technology support to help states modernize eligibility systems and improve outreach capabilities. The rule also establishes processes for notifying beneficiaries of noncompliance and providing opportunities for re-enrollment for individuals who lose coverage due to failure to meet program requirements.
According to CMS, the initiative is intended to promote economic self-sufficiency, strengthen program accountability, and support consistent administration of Medicaid work requirements nationwide.
Additional information, including CMS press releases and fact sheets, is available through the CMS Newsroom.
New Webinars
The following webinars are open for registration. Visit the Live Events webpage to learn more and register. Questions can be submitted prior to all events as part of the registration process.
Chronic Care Management (CCM): CCM is likely a service you provide to your patients in some form. Structuring these services under the Medicare guidelines allows you to receive payment. This two-part series focuses on using CCM.
Summer E/M Road Trip: Fueling Your CCM Knowledge (Part 1 of 2)
June 24, 2026, 1:00 – 2:00 pm
This webinar:
- Includes patient and provider eligibility
- Explains the CCM billing elements
- Explains how to bill CCM correctly
Roadside E/M Assistance: Interactive CCM Activity Pit Stop (Part 2 of 2)
June 24, 2026, 1:00 – 2:00 pm
This webinar:
- Briefly recaps the previous day’s webinar
- Covers top denials and rejections
- Includes a Q&A activity
Mental Health Playbook: Answers to Your Questions
June 24, 2026, 11:00 am – 12:00 pm
Allow rookies and seasoned pros master the Medicare Part B mental health game. This webinar:
- Provides a topic overview from previous sessions in this series
- Explains how to access all session recordings
- Offers answers to commonly asked questions posed before, during, and after each session
HAP News
HAP is now Health Alliance Plan by Henry Ford Health
What does this mean? For more than 40 years, Health Alliance Plan (HAP) and Henry Ford Health have been working together to bridge the gap between coverage and care. This new brand is built on the idea of alliance, being all in on a more connected, human-centered healthcare experience for our members. This is a brand evolution, not an organizational restructuring. This does not reflect a change in the provider network or any partnership with providers across the state, including providers from outside the Henry Ford Health network.
For providers who also work with ASR Health Benefits, the third-party administrator that administers employer self-funded plans, that brand is also being updated as part of this evolution. ASR is becoming Health Alliance TPA by Henry Ford Health, reflecting a clearer connection to Health Alliance Plan and Henry Ford Health. This is a phased transition.
They have provided a FAQ to learn more.
What’s staying the same? There are no changes to roles, operations, contracts or provider independence.
These changes do not impact the name of HAP CareSource, HAP’s joint venture with CareSource that offers Medicaid and MI Coordinated Health (MICH) plans in Michigan. No immediate action is required.
BCBSM/BCN News
BCBSM and BCN Remind Providers Not to Resubmit Claims Under Post-Pay Audit Review
Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) are reminding providers not to resubmit, adjust, or rebill claims that are currently under post-pay audit review. Once providers receive an audit notice letter and accompanying patient listing, the affected claims should remain unchanged throughout the audit process.
BCBSM and BCN recommend that provider organizations promptly notify their billing and finance departments about any claims included in an audit and suspend submission of any additional audit-related claims until the review is complete. Attempts to rebill claims to correct coding, diagnosis, quantity, date-of-service, or other billing errors can disrupt the audit process and create unnecessary administrative burdens for both providers and payers.
Post-pay audits may involve a variety of claim types and care settings, including readmissions, diagnosis-related groups (DRGs), catastrophic-cost outliers, emergency department services, high-dollar claims, rehabilitation services, ambulatory surgery facilities, home health care, skilled nursing facilities, and other outpatient services. Audits may also include claims submitted by physicians, specialists, certified registered nurse anesthetists, durable medical equipment suppliers, pharmacies, podiatrists, infusion therapy providers, urgent care centers, and other provider types.
BCBSM also noted that its audit vendors review hospital readmissions occurring within the same hospital network within 30 days of discharge. Under the Medicare Plus Blue™ Readmissions Reimbursement Policy, hospitals remain financially responsible for costs associated with denied readmissions. In addition, hospitals may not rebill denied inpatient admissions under Medicare Part B or combine admissions following a readmission denial.
Providers are encouraged to review internal billing procedures and ensure appropriate communication among audit, billing, and finance teams when audit notices are received.
BCBSM and BCN Clarify Role of Medical Policies in Prior Authorization and Claims Processing
BCBSM and BCN have provided guidance on how medical policies are used in both prior authorization reviews and claims processing activities.
According to the plans, prior authorization requests are evaluated using applicable medical policy coverage criteria based on the clinical information submitted at the time of review. During claims processing, services are reviewed to ensure they are consistent with any approved authorization, meet coverage requirements, and comply with applicable coding and billing guidelines. Claims that do not meet coverage criteria or billing requirements may be denied or adjusted.
For Medicare Advantage plans, Centers for Medicare & Medicaid Services (CMS) coverage determinations, regulations, and billing guidance take precedence over health plan medical policies and provider guidance. When CMS has not established specific coverage criteria, BCBSM and BCN may apply their publicly available medical policies in accordance with Medicare regulations.
Providers can access BCBSM and BCN medical policies through the Medical Policy Router on the BCBSM website. CMS national coverage determinations and local coverage determinations are available through the Medicare Coverage Database.
For further questions or assistance, contact Dara Barrera, Director, Health Quality, Equity and Technology at djbarrera@msms.org.