Health Announce: Oct. 21, 2025

10/21/25

Health Announce: October 21, 2025

Topics for this week’s Health Announce:

  1. Window open for applications for Children’s Autism waiver.
  2. Closeout supplemental budget bill through the Massachusetts House and now before the Senate for consideration.
  3. New federal regulations effective on January 1, 2026, require MassHealth to decide Prior Authorization requests (excluding drugs) within 7 calendar days.
  4. Bausch Health withdraws from participation in Medicaid Drug Rebate Program.
  5. Fenway Health limits gender affirming treatment for minors.
  6. Inaugural MassHealth Program Advisory Committee meeting held on October 14, 2025.
  7. HCWG Tomorrow!

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On this day in 1797, the USS Constitution – on her third attempt – successfully launched into Boston Harbor. The warship was a critical part of the new United States’ fight against its former colonial ruler, Great Britain, in the War of 1812. When the larger Royal Navy’s cannonballs failed to penetrate the oak sides of the Constitution, lore is that the American sailors nicknamed the ship “Old Ironsides.” In 1830, after the Navy announced plans to dismantle the Constitution, Oliver Wendell Holmes wrote an ode to the ship, Old Ironsides, and public opposition to the plan led the Navy to reverse course. The USS Constitution is now the oldest commissioned warship still floating, and you can visit the USS Constitution Museum in Charlestown.

Be well,

Health Law Unit
Massachusetts Law Reform Institute

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1. Window open for applications for Children’s Autism Waiver Program (AWP).

The Department of Developmental Services’ (DDS) open enrollment period for the Children’s Autism Waiver Program (AWP) is October 17 - 31, 2025. To remain on the waitlist, families must reapply during this open enrollment period; DDS is discarding previously submitted enrollment forms. Waiver capacity is 300 children at any one time. Eligible children are chosen for Autism Waiver services on a lottery basis. Assistance with filling out AWP applications is available at local Autism Support Centers. Applications are available in multiple languages here.

AWP serves children from birth through age 9 (until the child’s 10th birthday) with a DDS-verified diagnosis of Autism Spectrum Disorder (ASD), and who meet the level of care required for services in an Intermediate Care Facility as assessed by DDS. This Medicaid program provides services and supports to children with ASD to help them remain safely in their homes and communities, services such as expanded habilitation (one-to-one behavioral, social, and communication-based intervention), community integration activities, assistive technology, and respite. The child must be found by the MassHealth agency to be eligible for MassHealth Standard coverage, based on family income.

2. Closeout supplemental budget bill through the Massachusetts House and now before the Senate for consideration.

Last week, the House passed H.4615, an act making appropriations for the fiscal year 2025 to provide for supplementing certain existing appropriations and for certain other activities and projects, to close out FY 2025 state spending. Yesterday, the Senate Committee on Ways and Means reported out its version of the closeout budget, to be placed in the Order of the Day for Thursday, October 23, 2025.

The bill includes a complex amendment raising the annual assessment on hospitals, which will bring in more federal Medicaid matching funds, and changes payment allocations for hospitals. As reported by the Massachusetts Health and Hospital Association, the House plan generates $100 million for the Health Safety Net program, and $112 million in supplemental payments to hospitals. The House Closeout Supp Fact Sheet and Highlights lists:

  • $1.67 billion gross ($303 million net) for MassHealth;
  • $374 million gross ($236 million net) for Steward Hospital Payments;
  • $10 million for Health Care for All to conduct a public awareness campaign to inform vulnerable populations about new Medicaid work requirements put in place by the Federal Government;
  • $5 million for Reproductive Health Care Direct Supports (grants to providers who have lost Federal reimbursement funds); and
  • Provides authority to the DPH Commissioner to determine routine childhood immunizations and determine vaccination schedules rather than relying on the recommendations of the CDC’s Advisory Committee on Immunization Practices.

The Senate Amendments propose $2.04 billion for MassHealth, do not include the funding for Steward Health Care hospitals or for Health Care for All, but do include the reproductive health care funding. Senate amendments are due at 5 pm today.

3. New federal regulations effective on January 1, 2026, require MassHealth to decide Prior Authorization requests (excluding drugs) within 7 calendar days.

The Centers for Medicare and Medicaid (CMS) released on January 17, 2024, the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), focusing on improving health information exchange and prior authorization (PA) processes. The rule requires MassHealth, beginning on January 1, 2026, to send prior authorization decisions within 7 calendar days for standard requests and within 72 hours for expedited requests. This rule does not apply to PA decisions for drugs, which are set under 42 USC § 1396r-8(d)(5). In addition to the changes to the timeframes, as described in a CMS Fact Sheet on the final regulation, the rules require that notices of denials of prior authorization must provide a specific reason for the decision. Also, prior authorization metrics must be reported publicly. MassHealth will post these metrics beginning March 31, 2026, but update them only annually. Once MassHealth has released further information and planned information sessions, Health Announce will share them here.

The final rule also sets application programming interface (API) requirements to improve data sharing and necessary health records access, but impacted payors have until January 1, 2027 -- an additional year -- to meet those requirement.

4. Bausch Health withdraws from participation in Medicaid Drug Rebate Program.

In September, Bausch Health (also known as Bausch & Lomb) withdrew from participating in the Medicaid Drug Rebate Program (MDRP), and now States are no longer required under 42 USC § 1396r-8 to cover in their Medicaid program drugs produced by Bausch. Examples of Bausch Health medications no longer covered by MassHealth include Ativan, Migranal, Pepcid, and Wellbutrin XL. Moreover, Bausch products are no longer subject to the pricing requirements of the 340B Drug Pricing Program. On September 16, 2025, MassHealth issued Pharmacy Facts, a bulletin advising pharmacists that MassHealth will no longer cover non-rebate Bausch Health medications. Important considerations:

  • Bausch Health products should still be covered for MassHealth Standard and CommonHealth members younger than 21 years of age pursuant to Medicaid Early Periodic Screening, Diagnostic and Treatment (EPSDT). MassHealth will review all submitted requests for medical necessity through EPSDT.
  • While non-rebate Bausch Health medications are no longer covered, MassHealth will cover generic formulations or clinically appropriate alternatives from manufacturers that continue participation in MDRP.
  • MassHealth members who require non-rebate Bausch medications for which there is no generic alternative should seek coverage through the Bausch Health patient assistance program.

5. Fenway Health limits gender affirming treatment for minors.

Last week, Fenway Health announced that it would stop offering hormones or puberty blockers to transgender patients under age 19 in response to federal funding requirements. Fenway Health’s announcement stated the change was required in order for it to maintain its designation as a Federally Qualified Health Center and stay in compliance with Health Resources & Services Administration (HRSA) regulations. July 2025 updates to the FY25 general terms and conditions posted by HRSA state that recipients of HRSA awards must be compliant with Presidential Executive Order 14168, titled “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government.” Fenway Health’s chief medical officer pledged to work with each affected patient to identify other resources and maintain continuity of care.

6. Inaugural MassHealth Program Advisory Committee meeting held October 14, 2025.

Last week the new MassHealth Program Advisory Committee (MPAC) – previously known as Medical Care Advisory Committee (MCAC) – held its introductory meeting jointly with the Payment Policy Advisory Board (PPAB). Meeting materials, along with slides, are available here. A list of MPAC members – including MLRI’s own Jeni Kaplan – can be found here. The next meeting is scheduled for January 13, 2026.

7. HCWG Tomorrow!

Please join us tomorrow, Wednesday, October 22, 2025 from 3:00 – 4:30 pm for the Health Care Working Group. This meeting will feature guest speaker Jeanne Funk, a senior immigration attorney at MLRI, who will provide us with an update on developments locally and nationally affecting immigrant healthcare access and coverage. If you have any other issue to add to the agenda, please let us know (jkaplan@mlri.org or ksymmonds@mlri.org).