Maine Expands In-Network Referral Access (Gatekeeping Gets Harder), 340B Rebate Pilot Faces Immediate Legal Challenge From Hospitals, and Medicare Shifts to Tech-First Chronic Care Reimbursement

Hey all,

Happy Monday! We keep rearranging deck chairs on a fundamentally broken system. Hospitals are suing over 340B payment timing, Maine is expanding referral access while insurers maintain veto power, and CMS just launched a decade-long chronic care model—but none of this addresses the core absurdity that we expect employers with no healthcare expertise to negotiate benefits, then dump risk onto Medicare at end-of-life after doing nothing to prevent chronic disease for the preceding decades. The reforms keep coming, the lawsuits keep flying, and the underlying dysfunction remains stubbornly intact.

Enjoy the rundown! 

Jacob Brody (Co-Founder & CEO, ZorroRX)

(BenefitsPro) Maine Health Insurance Referral Policy Update

Maine has expanded its 2019 rule to now require health insurers to accept in-network referrals from any licensed direct health care provider, not just direct primary care providers. This policy shift broadens patient access by allowing more flexible coordination between out-of-network and in-network providers, though insurers may still apply standard cost-sharing and clinical review criteria. Sure, it might make cost containment harder—but honestly, who wouldn’t want their insurance company deciding if and how they can see a specialist? Full Article.

(Fierce Healthcare) Hospital Groups Sue to Block 340B Rebate Pilot

Hospital groups, led by the AHA, are suing to block the federal government's new 340B Rebate Model Pilot, arguing it replaces upfront drug discounts with delayed rebates in a rushed, legally questionable rollout that could cost safety-net providers hundreds of millions. The lawsuit highlights concerns over administrative burdens, lack of transparency, and the potential for drugmakers to delay payments, all while hospitals are left fronting the costs. Sounds like perfect timing for a program that could become a giant cash flow sinkhole—right as Medicaid cuts start digging their own.

(Health API Guy) CMS ACCESS Model Broken Down

CMS has launched the Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) initiative—a 10-year voluntary Medicare model that shifts payment from CPT-coded activities to outcome-based reimbursements for tech-enabled chronic care. By recognizing digital and asynchronous care (like remote monitoring and behavioral coaching) as core components of Medicare and requiring integration with physicians and HIEs, ACCESS aims to modernize care delivery and incentivize real clinical improvements. This move opens billing lanes for digital health players and accelerates demand for interoperable data infrastructure, creating significant opportunities (and risks) across the tech-enabled care ecosystem. Full Article.