Critical Medicare/Medicaid Forum

Abstract: This session will share multiple updates for Medicare, Medicaid and Managed Care regulatory and reimbursement issues. Resources will be shared and participants will be invited to ask questions of the ASHA Medicare state advocates of Medicare and Medicaid policy and reimbursement issues.
Description: This course will initially review the latest updates on reimbursement changes, to include those for Medicare, Medicaid and related private insurance and managed care companies. In addition, we will help participants to understand the key differences between Medicare, Managed Medicare and Medicaid.
Medicare Updates: The following Medicare related issues will be shared, in addition to any updates of importance which develop after the point of this submission:
• Managed Medicare- Updates will be shared to include prior authorization, medical necessity and denials with this rapidly growing demographic.
• Resources and guidelines will be shared to include links to applicable regulations (e.g., National Fee schedule, Local Coverage Articles for Novitas Solutions) as well as the most up to date CMS regulations.
• Required documentation for medical necessity and skilled intervention.
• Medicare’s targeted review and trends in denials.

Medicaid Updates: The following Medicaid related issues will be shared, in addition to any updates of importance which develop after the point of this submission:
• Updates on the latest regulations from One Big Beautiful Bill (OBBB) as it pertains to Medicaid in the state of Texas
• Updates on progress toward adding Caregiver Training Codes for billing under Medicaid in Texas
• Best practices for documentation for prior authorization and establishing medical necessity
• Medicaid credentialing updates

Then the importance of advocacy will be shared for addressing current and future rates and protocols for Medicare, Medicaid and other related reimbursement sources. Discussion will include what such advocacy actions look like for Medicare, Medicaid and private insurance, to include strategies each of us can take to make a difference and to be a part of the solution.
Following these most important updates, participants will be encouraged to ask questions for the ASHA Liaisons and experts in these areas, for clarification, resources and key information specific to their settings.

Supporting Research: Reference 1: KFF. (2025, July 9). Tracking the Medicaid provisions in the 2025 reconciliation bill. Health Provisions in the 2025 Federal Budget Reconciliation Bill. https://www.kff.org/tracking-the-medicaid-provisions-in-the-2025-budget-bill/

Supporting Research: Reference 2: Swagel , P. L. (2025, June 24). June 24, 2025 honorable Jodey Arrington chairman ... Information Concerning Medicaid-Related Provisions in Title IV of H.R. 1 . https://www.cbo.gov/system/files/2025-06/Arrington-Guthrie-Letter-Medicaid.pdf

Supporting Research: Reference 3: Centers of Medicare and Medicaid Services. (2025, January 16). CMS. Medicare Benefit Policy Manual. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c15.pdf

Supporting Research: Reference 4: MCOs – example: TCHP - https://www.texaschildrenshealthplan.org/sites/default/files/2022-07/PR-2003-xxx%20Speech%20Therapy%20Documentation%20for%20Referral%20Coordinators.pdf

Supporting Research: Reference 5: Kyle, M. A., & Song, Z. (2023). The Consequences and Future of Prior-Authorization Reform. The New England journal of medicine, 389(4), 291–293. https://doi.org/10.1056/NEJMp2304447