Recent Texas items
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Superior and Ambetter add site-of-care review for shoulder, hip, knee and spine
Published Oct 5, 2026 · Effective Dec 5, 2026
Beginning Dec 5, 2026, Evolent will steer ordering providers to a preferred site of care during prior-auth intake for Superior HealthPlan Medicaid (STAR, STAR+PLUS, STAR Kids, STAR Health), CHIP, Marketplace and ICHRA members. Choosing a hospital for a case that can be done outpatient requires an allowable exception or clinical justification.
Source: Ambetter from Superior HealthPlan, provider news (Oct 5, 2026) ↗
First reported in the Oct 16, 2026 issue.
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BCBSTX: Medicaid post-payment reviews and inactive Record ID cancellations
Published Oct 1, 2026 (reviews) · Oct 8, 2026 (Record IDs)
BCBSTX began post-payment reviews of Medicaid claims Oct 2, with a lookback to claims paid Jan 1, 2026 onward. Separately, if no claim has been filed under a billing or rendering NPI and TIN with a date of service in the past 24 months, BCBSTX may cancel that Record ID, which can terminate the provider from associated networks.
Source: BCBSTX provider news (Oct 1, 2026) ↗
Source: BCBSTX, Record IDs (Oct 8, 2026) ↗
First reported in the Oct 16, 2026 issue.
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BCBSTX expands its commercial Medical Drug Benefit Program Jan 1, 2027
Published Oct 14, 2026
BCBSTX expands its commercial Medical Drug Benefit Program Jan 1, 2027, with limits on some office-administered drugs when a self-administered version exists.
Source: BCBSTX provider news (Oct 14, 2026) ↗
First reported in the Oct 16, 2026 issue.
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Texas Medicaid reviews inpatient claims for the spell-of-illness limit
Published Oct 14, 2026
Texas Medicaid is reviewing inpatient claims with dates of service Sep 26, 2024 to Aug 22, 2026 for the spell-of-illness limit, with recoupment from future payments.
Source: TMHP (Oct 14, 2026) ↗
First reported in the Oct 16, 2026 issue.
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KFF: HCSC (BCBSTX’s parent) exits 498 Medicare Advantage counties for 2027
Published Oct 9, 2026
KFF reports HCSC (BCBSTX’s parent) exits 498 counties in Medicare Advantage for 2027, and Centene exits 359. Open enrollment runs Oct 15–Dec 7.
Source: KFF (Oct 9, 2026) ↗
First reported in the Oct 16, 2026 issue.
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TMA: proposed rule would stop paying for vendor-run remote monitoring
Published Oct 12, 2026
TMA warns the proposed 2027 fee schedule would pay for remote patient monitoring only when clinical staff employed directly by the physician or practice provide it. Services contracted to third-party vendors would no longer qualify.
Source: Texas Medical Association (Oct 12, 2026) ↗
First reported in the Oct 16, 2026 issue.
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TMA asks CMS to delay the mandatory Ambulatory Specialty Model
TMA letter dated Sept 14, 2026 · Becker’s ASC report Oct 1, 2026
The Texas Medical Association asked CMS to delay the mandatory Ambulatory Specialty Model, which is set to start Jan 1, 2027. The Becker’s ASC report cites 614 Texas low-back-pain physicians in connection with the model.
Source: Becker’s ASC (Oct 1, 2026) ↗
First reported in the Oct 9, 2026 issue.
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Medicare upper-limb orthosis prior auth reaches Texas Jan 26, 2027
CMS DMEPOS prior auth page (update dated Jul 29, 2026)
Two upper-limb orthoses phase in to Medicare’s required prior authorization, reaching Texas Jan 26, 2027.
Source: CMS, DMEPOS prior authorization process ↗
First reported in the Oct 16, 2026 issue.
