Hello readers and happy fall!

In the September edition of Health Policy News, we highlight timely developments in related to the implementation of the new Federal Medicaid Community Engagement Requirement (CER), commercial insurance use of Artificial Intelligence, and rural health care. This month’s articles examine new CMS guidance on medical frailty related to CER, emerging state guardrails for the use of artificial intelligence in prior authorization, and the role of Rural Emergency Hospitals in promoting access to care. We hope this issue offers useful context for understanding how federal and state policy developments continue to shape program design, oversight, and implementation across the healthcare landscape. 

CMS Releases Framework for Determining Medical Frailty for a Community Engagement Requirement Exception

CMS released new guidance earlier this month to help states determine when Medicaid beneficiaries qualify for the medical frailty exception to community engagement requirements. The article explains CMS’s proposed tiered framework, key data sources states may use to identify medically frail individuals, and implementation considerations as states develop their methodologies. To read more about CMS’s recommendations and guidance around implementing one of the more challenging aspects of the impending community engagement requirements, click here. 

New Guardrails for AI in Prior Authorization 

As policymakers continue working to strike a balance in the use prior authorization, states are increasingly setting guardrails for how health insurers may use Artificial Intelligence (AI) in coverage and utilization review decisions. This article examines how recent Federal guidance and State legislation are shaping requirements for human clinical review, transparency, documentation, and oversight to ensure AI supports—rather than replaces—individualized decision-making. To read more about how states are setting guardrails around the use of AI in the prior authorization process, click here. 

Preserving Access to Care Through Rural Emergency Hospitals 

As rural communities work to preserve access to healthcare services, Rural Emergency Hospitals (REHs) are emerging as an important part of the solution. Learn how the REH model is helping maintain local access to emergency and outpatient care and what it may mean for rural healthcare providers and EMS agencies by clicking here.