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量子资源网 Insights: Your source for healthcare news, ideas and analysis.

量子资源网 Insights鈥攊ncluding briefs, webinars, and our podcast鈥攇ives you easy access to 量子资源网鈥檚 deep expertise, helping you stay current on the latest healthcare trends and topics. Search for a topic of interest or browse the latest insights below.

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Solutions

What Medicaid Policy Changes Should Healthcare Leaders Be Paying聽Attention to聽Right Now?聽

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量子资源网 Solutions

What Medicaid Policy Changes Should Healthcare Leaders Be Paying聽Attention to聽Right Now?聽

Medicaid policy is undergoing a massive regulatory shift driven by the聽One Big Beautiful Bill Act (OBBBA)聽濒别驳颈蝉濒补迟颈辞苍.听

To聽maintain聽financial stability, compliance, and continuity of care during these Medicaid policy changes, healthcare leaders must focus their attention on four聽highly critical, interconnected policy domains.听

Changes to聽Section 1115 Demonstration Waivers

The federal approach to approving, extending, and evaluating Section 1115 waivers is experiencing a significant pivot, holding space for true innovation and pilots.

Shifting Federal Alignments:聽CMS is reshaping the criteria for waiver聽flexibilities. For instance, recent guidance has rolled back certain聽previous聽pathways used to cover health-related social needs (HRSNs) under Section 1115 authority.听

Strategic Scenario Planning:聽As outlined in 量子资源网’s analysis on聽The Medicaid Pivot: New Developments in Section 1115 Demonstration Policy, state changes or extensions will trigger comprehensive CMS reviews. Leaders must transition toward alternative authorities (such as 1915(c) or managed care options) while聽monitoring聽emerging federal priorities around substance use disorders (SUD) and carceral reentry initiatives

Updated聽Eligibility & Community Engagement/Work Requirements

The聽eligibility聽path聽for聽Medicaid聽enrollees is tightening dramatically, introducing聽significant聽risks of coverage disruption聽that聽will create coverage聽churn in聽state insurance markets.听

Mandatory Community Engagement:聽Under federal mandates, able-bodied adults without young children must聽demonstrate聽at least聽80 hours聽per month聽of qualifying activities (employment, education, or community service).听

Accelerated Churn Risks:聽As evaluated in 量子资源网’s report on the聽Medicaid Community Engagement Interim Final Rule, states are shifting to an accelerated six-month redetermination cycle for expansion populations. Managed care organizations (MCOs) and health systems face immediate operational hurdles to track compliance and prevent massive lapses in continuous enrollment.听

Focus on聽Managed Care Oversight & Program Integrity聽to Reduce聽Fraud, Waste,聽& Abuse

Federal regulators are pairing stricter oversight with direct financial consequences to聽reduce聽administrative inefficiencies and improper payments聽and聽crack down on聽fraud and abuse.听

Error Rate Financial Sanctions:聽Beginning in FY 2030, states exceeding聽a聽3% eligibility error rate聽face severe pullbacks聽in federal funding for files lacking insufficient verification data.听

Aggressive Auditing and MCO Risk:聽Enhanced program integrity frameworks require monthly network audits to root out聽terminated聽providers and quarterly data matching for deceased enrollees. Healthcare leaders must聽brace for聽tighter risk adjustments, standardized plan requirements, and intensive fraud, waste, and abuse (FWA) strategies.

Changes to聽State Directed Payments (SDPs) &聽Reimbursement聽

CMS is fundamentally altering provider reimbursement limits and closing localized financing mechanisms to ensure a more regulated environment.听

Medicare-Linked Caps:聽Moving away from average commercial rate benchmarks, CMS is聽establishing聽rigid ceilings. As captured in 量子资源网’s brief on聽Proposed Changes to Medicaid State Directed Payments, new limits cap SDPs at聽100% of Medicare rates聽for expansion states and聽110% of Medicare rates聽for non-expansion states.听

Choking Provider Tax Revenue:聽Effective October 2026, states are restricted from implementing new provider taxes beyond July 2025 thresholds. Furthermore, as detailed in 量子资源网’s commentary on聽Medicaid State Directed Payments: CMS Proposes Major Changes to Financing and Oversight, existing provider taxes in expansion states will steadily choke down from 6% to聽5.5% in 2028, and聽ultimately down聽to聽3.5% by 2032, forcing health systems to rapidly recalibrate their financial baselines.听

How 量子资源网 Helps Leaders Respond聽

量子资源网 (量子资源网) turns high-stakes statutory mandates into functional, compliant operational strategies. We offer end-to-end strategic guidance, actuarial analytics, and technical聽assistance:

  • Strategic Planning & Financing Modeling: Developing innovative strategies to model state-directed payment caps, analyze provider tax restrictions, and structure financial baseline adjustments.
  • Operational & Workflow Overhauls:聽Redesigning eligibility systems to execute 6-month redeterminations and building automated tracking platforms for community engagement.听
  • Program Integrity & Compliance:聽Aligning FWA shielding strategies and conducting pre-audit assessments to mitigate the risk of eligibility error-rate penalties.听
  • Workforce & Stakeholder Alignment:聽Delivering targeted training and managing cross-functional change management to ensure seamless communication between state agencies, MCOs, and providers.听

With a deep bench that includes聽10聽former Medicaid and CHIP directors聽and active project experience across聽more than 35 state programs, 量子资源网 equips healthcare leaders to navigate this shifting regulatory landscape with absolute confidence.听

Brief & Report

Medicaid Community Engagement Interim Final Rule:聽Key Implications for States, Payers, and Providers

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量子资源网鈥檚 issue brief on the Medicaid Community Engagement Interim Final Rule provides a clear, actionable summary of new Medicaid work requirements and community engagement requirements for states, Medicaid health plans, providers, community-based organizations, and technology vendors. The report explains key policy changes issued by CMS on June 1, 2026, including exemptions such as medical frailty, verification and reporting expectations, enrollee notification requirements, and the state systems changes needed to prepare for the January 1, 2027 implementation deadline. If you are searching for a summary of Medicaid work requirements, a summary of Medicaid community engagement requirements, the medical frailty definition, or guidance on Medicaid work requirements state systems changes, this brief helps translate complex federal regulation into practical next steps to support compliance, reduce coverage loss risk, and inform implementation strategy.

Please fill out this form to receive a copy of the issue brief.

Blog

Medicaid State Directed Payments: CMS Proposes Major Changes to Financing and Oversight

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The Centers for Medicare & Medicaid Services (CMS) proposed changes to state directed payments mark a significant inflection point for Medicaid financing. For states, plans, and providers, the coming months will be critical in understanding the rule鈥檚 final shape鈥攁nd how they can position themselves for a more constrained and standardized payment environment.

Federal Medicaid policy is entering a period of rapid change. Policymakers are advancing a series of interconnected proposals鈥攊ncluding Medicaid community engagement (work) requirements, program integrity initiatives, and new scrutiny of financing mechanisms that shape how dollars flow through the program. 

Among the most significant developments: the CMS鈥檚 proposed changes to Medicaid state directed payments (SDPs). As outlined in 量子资源网鈥檚 recent Issue Brief, the proposal signals a meaningful shift in how federal policymakers approach provider reimbursement, managed care financing, and oversight of supplemental payment arrangements. 

量子资源网 (量子资源网) will further examine these developments in future articles, briefs, and its Medicaid summer webinar series, which will focus on SDPs, work requirements, and program integrity鈥攖hree policy areas now moving in parallel and reshaping the Medicaid landscape. This article provides an executive overview of the SDP rule. 

What are Medicaid State Directed Payments? 

State directed payments (SDPs) are a key Medicaid financing tool that allows states to direct how managed care organizations reimburse providers. 

States use SDPs to: 

  • Increase provider payment levels聽
  • Target specific provider types or services聽
  • Support delivery system reforms聽

Over time, SDPs have become a central component of Medicaid managed care financing. As the 量子资源网 issue brief emphasizes, their growing scale and complexity have drawn increased federal scrutiny. 

What Does CMS Propose to Change? 

The CMS proposed rule implements the statutory changes approved in the 2025 budget reconciliation act (P.L. 119-21, which CMS refers to as the Working Families Tax Cut Act, or WFTCA). The rule introduces a new framework for how SDPs are structured, regulated, and reviewed. Based on 量子资源网鈥檚 analysis, the proposal advances several core policy shifts: 

  1. Expanded聽Federal Limits on Payment Levels.听CMS proposes new constraints on how much states can direct plans to pay providers, extending payment limits across a broader range of services and delivery systems. Specifically, CMS proposes to lower the payment ceiling for all SDPs to either 100 percent of Medicare for states administering Affordable Care Act (ACA) expansion programs or 110 percent of Medicare for states without an ACA expansion program. CMS plans to grandfather certain SDPs at levels above Medicare and provide a transition period with an annual 10 percent reduction until the payments are reduced to Medicare levels. In addition, this rule proposes聽limiting SDPs to the total published Medicare payment rate at the service level鈥攁 departure even from Medicaid fee-for-service (FFS) upper payment limits, which are limited to a reasonable estimate of what Medicare would pay but are calculated at the aggregate level by ownership class.听
  2. Extends Limits聽Across Programs聽and Delivery Systems.听The proposal聽seeks聽to align聽the limitations on practitioner payments under聽fee-for-service聽with the new limitations on SDPs. If a state makes payments to a subset of targeted practitioners, the new proposed limit would be actual Medicare payment rates applicable to the practitioner or provider for the same聽time period聽as the Medicaid state plan rate year.听The crosswalk of Medicaid payment rates to Medicare will聽likely be聽administratively burdensome鈥攅specially for states that set Medicaid rates using an entirely different聽methodology聽than Medicare鈥檚. Applying the Medicare payment limit at the service level will limit states鈥� ability to incentivize certain service types that may need enhanced reimbursement amounts to preserve access to care (e.g., primary care, neonatal, etc.).听
  3. Broader Applicability Across Providers.听The changes extend beyond a narrow set of provider types, affecting a wider range of stakeholders聽participating聽in Medicaid financing and delivery.听For example, the WFTCA聽called for the reduced payment ceiling to be applied to the specified four classes of providers. This rule proposes that all providers be limited to the same ceiling and that the revised limits also apply to US territories.听

Why Is CMS Focusing on State Directed Payments Now? 

As highlighted in the 量子资源网 Issue Brief, federal policymakers are increasingly focused on the growth and complexity of SDPs as well as the role of SDPs in broader Medicaid financing strategies. In addition, CMS policy officials are prioritizing program integrity and fraud, waste, and abuse and have couched the current SDP policies as inefficient use of taxpayer dollars. 

These priorities align with a broader shift toward tighter federal oversight of Medicaid funding mechanisms. 

What Are the Implications for States, Plans, and Providers? 

The proposed changes have wide-ranging implications across the Medicaid ecosystem. 

States: SDPs have been a flexible tool for shaping payment policy and directing resources. New federal parameters may limit that flexibility and require states to reassess existing financing strategies. 

Health Plans: Plans may face a more standardized and regulated environment for implementing SDP arrangements, with less variation driven by state policy choices. 

Providers: Many providers rely on SDPs to supplement base Medicaid payment rates. Changes to these payments could affect reimbursement levels and financial stability, particularly for organizations serving large Medicaid populations. 

As the 量子资源网 brief underscores, the impact will vary significantly by state, depending on how SDPs are currently structured. 

How This Fits into Broader Medicaid Policy Changes 

CMS is advancing a broader recalibration of how SDPs fit within Medicaid policy. However, the SDP proposal is also part of a larger set of federal Medicaid policy developments, including: 

  • Medicaid community engagement (work) requirements聽and other changes to eligibility and redetermination rules聽included in聽a June 1, 2026,聽interim final rule聽
  • Program integrity and oversight initiatives聽
  • Changes to financing structures and supplemental payments聽

Taken together, these policies signal a transition toward greater federal standardization and increased oversight of funding flows. 

What Should Stakeholders Watch Next? 

CMS鈥檚 proposed changes to Medicaid state directed payments mark a turning point in Medicaid financing policy. 

Stakeholders should expect continued movement toward greater oversight, tighter payment parameters, and increased consistency across the program. They should begin planning now for a more constrained and standardized payment environment. Key questions center on: 

  • How CMS will implement and phase in payment limits across states聽
  • The extent to which existing arrangements will be grandfathered聽in聽or phased down聽
  • How states respond in redesigning Medicaid payment strategies聽

The proposed SDP rule is open for public comment through July 21, 2026, with final policy decisions expected following federal review. As pending issues are resolved, stakeholders across the Medicaid landscape will need to reassess financial models, policy approaches, and operational strategies. 

Stakeholders should begin evaluating potential impacts now, as the policy direction is clear, even if final details are still evolving. 

Staying Ahead of Medicaid Financing Changes 

Given the pace and breadth of these developments, staying informed is critical. 贬惭础鈥檚&苍产蝉辫;upcoming Medicaid summer webinar series will provide timely analysis of the SDP proposal alongside related policy changes, including community engagement and work requirements and program integrity initiatives. These sessions are designed to help states, plans, and providers understand policy changes and prepare for operational and financial implications, identify compliance gaps, and address sustainability issues. Register for one or multiple webinars here.  

To understand how these Medicaid policy changes affect your organization, contact one of 贬惭础鈥檚&苍产蝉辫;Medicaid experts. 

Webinar

A Summer Webinar Series: How New Program Integrity Expectations Affect Medicaid Payments

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As federal regulators introduce new Medicaid program integrity expectations to reshape the landscape, states, providers, and insurers across the country are facing intense pressure to adapt to changing eligibility and enrollment rules and financing policies while sustaining access to services and improving outcomes.

This webinar series will deliver timely analysis and actionable insights on the evolving policy and operational environment affecting Medicaid funding, enrollment, and access to services. Each session will feature up-to-the-moment information and perspectives from our subject matter experts, with content tailored to reflect the latest federal guidance, waiver activity, litigation, state implementation decisions, and market developments.

Webinar

Webinar Replay – Summer Webinar Series: The Future of Medicaid State Directed Payments聽

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This webinar was held on June 10, 2026.

As CMS advances a proposed rule that would significantly reshape Medicaid State Directed Payments (SDPs), states, health plans, hospitals, and other providers face growing uncertainty around Medicaid financing, reimbursement, and access to care.

In this webinar, 量子资源网 experts examine the proposed SDP changes, including new Medicare-based payment limits, phase-down requirements for existing programs, and restrictions on supplemental payment structures. The discussion explores the potential financial, operational, and policy implications for Medicaid stakeholders and highlights key considerations for planning, advocacy, and implementation.

Learning Objectives

  • Explain the major provisions of CMS鈥檚 proposed Medicaid State Directed Payment rule.
  • Assess how new Medicare-based payment limits could affect provider reimbursement and Medicaid financing strategies.
  • Identify potential impacts on value-based payment arrangements, provider sustainability, and access to care.
  • Evaluate key considerations for states, health plans, and providers as they prepare for implementation and future policy changes.
Webinar

A Summer Webinar Series: Understanding Work and Community Engagement Requirements聽

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As federal regulators seek to reshape the Medicaid landscape, understanding work and community engagement requirements has become crucial. States, providers, and insurers across the country are facing intense pressure to adapt to changing eligibility and enrollment rules and financing policies while sustaining access to services and improving outcomes.

This webinar series will deliver timely analysis and actionable insights on the evolving policy and operational environment affecting Medicaid funding, enrollment, and access to services. Each session will feature up-to-the-moment information and perspectives from our subject matter experts, with content tailored to reflect the latest federal guidance, waiver activity, litigation, state implementation decisions, and market developments.

Blog

Special Alert: CMS Proposes Major Medicaid Payment Reform to Cap State-Directed Payments and Align Rates with Medicare

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On May 20, the Centers for Medicare and Medicaid Services (CMS)聽聽a proposed rule aimed at curbing state Medicaid payment practices that federal regulators have driven excessive federal spending without clear improvements in care. The rule, which implements new statutory requirements approved as part of the 2025 budget reconciliation act (P.L. 119-21, OBBBA) proposes to cap certain state-directed and targeted provider payments and is seeking to better align them with Medicare payment levels. These financial arrangements include healthcare related provider taxes and intergovernmental transfers.

If finalized,聽CMS聽projects the聽rule will聽result聽in聽significant聽federal聽savings over time and聽will聽refocus Medicaid funding on patient care, strengthen oversight, and ensure that supplemental payments are tied to measurable improvements in quality, access, and outcomes rather than financing strategies that increase costs without corresponding value.听量子资源网聽(量子资源网)聽experts are聽continuing to聽review聽the proposed Medicaid payment reform聽and will provide聽additional聽analysis in聽future聽newsletters and communications to聽interest-holders.听聽

Blog

Join us at 量子资源网鈥檚 2026 National Conference: Signals, Signs & Flashing Lights

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Registration is now open for the 量子资源网 (量子资源网) 2026 National Conference, , October 5鈥�7 in New Orleans, LA. 

 is intentionally structured to bring together leaders who are shaping decisions across sectors鈥攖hose setting policy, managing risk, leading clinical operations, and innovating approaches to improve outcomes鈥攖o engage in candid conversations about what is working, what is not, and what is changing in  and adjacent programs. In an environment defined by new challenges and 鈥渇lashing lights,鈥� even the most seasoned healthcare leaders will find value in stepping out of their day鈥憈o鈥慸ay roles to compare strategies, test assumptions, and learn from peers facing similar pressures. 

This year鈥檚 conference is designed to reflect the environment healthcare leaders are navigating today鈥攐ne defined less by policy certainty and more by shifting expectations and competing pressures on cost, access, and performance. Our experts are crafting discussions to address how organizations are approaching policy engagement in this environment, including new strategies for interpreting signals from federal and state policymakers and negotiating policy frameworks that directly shape market dynamics. 

Across plenary sessions, breakout discussions, and 量子资源网鈥檚 signature coffee conversations, the conference will focus on how organizations are interpreting these signals and translating them into practical strategies. 

Programming will center on four cross-cutting themes shaping healthcare decision-making: 

  • Managing聽risk and cost amid continued financial pressure. Discussions will examine聽the drivers of聽utilization聽and affordability trends across Medicare, Medicaid, and commercial markets and which聽strategies are聽demonstrating聽measurable impact.听
  • Sustaining access and system stability. The agenda also will focus on how providers, health systems, and state programs are maintaining access amid workforce challenges, coverage transitions, and ongoing financial strain.
  • Turning innovation into impact.听Sessions will explore where artificial intelligence聽(AI)聽and digital health tools are delivering measurable operational or clinical impact聽and聽what it takes to implement them effectively.听
  • Building partnerships聽that last.听Conversation聽will highlight how stakeholders are聽aligning incentives,聽funding,聽and strategy to move from short-term聽responses to long-term, sustainable聽solutions.听

As in prior years, the 量子资源网 National Conference is structured to support candid dialogue, actionable takeaways, and meaningful connections. Attendees consistently highlight the opportunity to move beyond high-level trends and engage in practical discussions that inform decision-making in their organizations. 

 is now available for a limited time. The  includes new opportunities for your organization. Additional agenda details, featured speakers, and interactive programming announcements will be released in the coming weeks. 

Brief & Report

The New Uninsured: State Policy Options for Californians Losing Medi-Cal Coverage

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量子资源网鈥檚 new report for the California Health Care Foundation explains how recent federal and state policy changes could cause up to two million Californians to lose Medi-Cal coverage. These changes will place new strains on the state budget and safety-net system. The report outlines practical short-term program paths California could use to preserve access to care while full-scope coverage is restored. It summarizes the policy and fiscal context (including work requirements, more frequent eligibility checks, and immigrant eligibility restrictions), describes stakeholder-informed design goals (statewide access, privacy protections, fiscal prudence, scalability, and safety-net stability), and presents two illustrative coverage alternatives with modeled cost ranges and key trade-offs in benefits, provider payment rates, cost sharing, and bridge-period design.

Blog

CMS Proposes Modest Hospital Payment Updates and Signals Expanded Use of Mandatory Value-Based Models

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On April 10, 2026, the Centers for Medicare & Medicaid Services (CMS) released the proposed rule for the . The proposal combines a modest net increase in hospital payments with policy signals around quality reporting and mandatory episode-based payment models鈥攎ost notably a proposed nationwide expansion of the Comprehensive Care for Joint Replacement (CJR) model. 

These proposed updates underscore CMS鈥檚 continued emphasis on value-based purchasing, episode accountability, and alignment across quality programs. In addition, CMS resurfaces ongoing debates with hospital stakeholders about the adequacy of Medicare payment updates amid rising costs and coverage disruptions. 

This article reviews several key provisions in the FY 2027 proposed rule. 

Hospital Payment Updates: Headline Increase Masks Net Impact 

Under the proposed rule, CMS would increase base IPPS and LTCH PPS payment rates by 2.4 percent in FY 2027. However, after accounting for proposed reductions to uncompensated care payments for disproportionate share hospitals (DSH) and changes in outlier payments for extraordinarily high-cost cases, CMS estimates the effective payment increase would be closer to 1.2 percent. 

In aggregate, CMS projects the proposed update would translate to approximately $1.4 billion in additional payments to acute care hospitals next year. Hospital industry groups鈥攊ncluding the American Hospital Association (AHA) and the Federation of American Hospitals (FAH)鈥攈ave pushed back, arguing that the proposed update does not sufficiently reflect medical inflation, workforce pressures, or anticipated growth in the uninsured population. 

These concerns reflect a long-standing dynamic in annual hospital payment rules: CMS seeking to balance statutory updates and budget neutrality constraints against the hospital industry鈥檚 concern that Medicare payments are lagging behind underlying costs. 

Quality Reporting and Program Alignment 

The proposed rule would also make notable updates to the Hospital Inpatient Quality Reporting (IQR) Program. CMS proposes adding three new quality measures to be phased in during 2029 and 2030, while modifying eight existing measures to include Medicare Advantage patients. CMS also proposes shortening the performance period for certain measures from three years to two鈥攁 change designed to accelerate feedback and better align measures across programs. 

These changes continue CMS鈥檚 broader effort to harmonize quality measurement across Medicare payment and value-based programs, reduce reporting lag, and incorporate a more comprehensive view of patient populations. 

Updates to Mandatory TEAM Model 

CMS also proposes several updates to the Transforming Episode Accountability Model (TEAM), the mandatory episode-based payment model finalized last year. Key proposals include: 

  • Expanding the list of聽MS-DRGs聽included in the spinal fusion episode聽
  • Aligning TEAM quality measurement performance periods with the IQR Program聽
  • Making targeted technical refinements to payment聽methodology聽

In addition, CMS is seeking stakeholder feedback on whether ambulatory surgery centers (ASCs) should participate in TEAM and whether participation should be voluntary for physician-owned hospitals, signaling potential future expansion or recalibration of the model. 

Proposed Expansion of Joint Replacement Bundles 

CMS proposes to expand the existing Comprehensive Care for Joint Replacement Expanded (CJR-X) Model nationwide beginning October 1, 2027. The agency also plans to make participation mandatory for most IPPS hospitals. 

CMS tested the original CJR model in 34 metropolitan areas between 2016 and 2024, generating improved patient outcomes and net Medicare savings, according to agency evaluations. CJR-X would become the fifth Center for Medicare and Medicaid Innovation model to meet the statutory criteria for nationwide expansion. 

Under CJR-X, hospitals performing lower extremity joint replacements would be accountable for the cost and quality of care for the initial procedure and most related spending during the subsequent 90 days. Although the overall structure mirrors the original CJR model, CMS proposes several important updates: 

  • Expansion of episodes to include ankle replacements, in addition to hip and knee procedures聽
  • Adoption of a more robust risk adjustment聽methodology聽with significantly more variables, aligning closely with the TEAM model聽
  • Introduction of a 5 percent stop-loss policy for hospitals聽that聽serve聽higher proportions of dually eligible beneficiaries and certain smaller hospitals聽

Participation would be mandatory for most IPPS hospitals, with exceptions for hospitals already participating in TEAM, which includes a lower extremity joint replacement episode; Maryland hospitals operating under global budgets; and hospitals not paid under both IPPS and the Outpatient Prospective Payment System, such as Critical Access Hospitals. 

Why It Matters 

The 2027 IPPS and LTCH PPS proposed rule reinforces several clear policy signals: 

  • Pressure on hospital margins is likely to persist, as payment updates continue to trail hospital-reported cost growth.听
  • Mandatory episode-based models聽remain聽central to CMS鈥檚聽value-based strategy, with CJR-X聽representing聽a significant escalation in scope and scale.听
  • Program alignment and MA inclusion are accelerating, with implications for hospital data systems, care coordination strategies, and reporting infrastructure.听

Hospitals and health systems will need to assess not only the near-term financial impact of the proposed payment updates, but also their readiness to accept expanded episode accountability and meet evolving quality measurement requirements. 

Comments on the proposed rule will shape final decisions regarding payment levels, quality program changes, and the scope of mandatory participation in CJR-X. Stakeholders will be watching closely to see whether CMS moderates its approach to mandatory models or doubles down on episode-based accountability as a cornerstone of Medicare payment reform. 

In parallel, CMS has released several other proposed payment rules this month, including those that would affect skilled nursing facilities, hospice providers, inpatient rehabilitation facilities, and inpatient psychiatric facilities. For these entities, CMS generally proposes payment updates of approximately 2.4 percent and 2.3 percent for inpatient psychiatric facilities. As part of its broader program integrity focus, CMS also has proposed new transparency measures for hospice providers; this follows recent enforcement actions related to fraudulent enrollment. 

Connect with Us 

量子资源网, Inc. (量子资源网), monitors federal regulatory and legislative developments in the inpatient setting and assesses the impact on hospitals, life science companies, and other stakeholders. Our experts interpret and model hospital payment policies and assist clients in developing CMS comment letters and long-term strategic plans. Our team replicates CMS payment methodologies and model alternative policies using the most recent Medicare fee-for-service and Medicare Advantage (100%) claims data. We also support clients with DRG reassignment requests, New Technology Add-on Payment (NTAP) applications, and analyses of Innovation Center alternative payment models. 

For more information about the proposed policies, contact one of our Medicare experts. 

Blog

Medicaid Managed Care Enrollment: Q4 2025 Trends and Early Signals Ahead of New Eligibility Policies

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This week 量子资源网 (量子资源网), draws on its database of monthly Medicaid managed care enrollment to present its latest quarterly analysis, offering a snapshot of enrollment trends across 37 states. 

The analysis comes at a critical time. As states prepare for Medicaid eligibility policy changes that take effect in 2027鈥攊ncluding more frequent eligibility determinations and expanded work and community engagement requirements鈥攃urrent enrollment trends provide an early signal of how policy decisions and administrative practices are already influencing coverage levels. 

The 量子资源网 Information Services (量子资源网IS) analysis shows that Medicaid managed care accounted for 85.6 percent of total Medicaid enrollment in December 2025. This analysis, available to 量子资源网IS subscribers, uses data from nearly 300 health plans in 41 states.鈥疶he report provides by-plan enrollment plus corporate ownership, program inclusion, and for-profit versus not-for-profit status, with breakout tabs for publicly traded plans. 

Key Insights from Q4 2025 Data 

The 37 states included in this review have released monthly Medicaid managed care enrollment data through public websites or in response to a public records request from 量子资源网. The report includes the most recent data obtained and illustrates the effect of state-level choices around eligibility and administration. Key findings include: 

  • As of聽December聽2025,聽Medicaid managed care enrollment across the 37 states declined by聽2.2 million members聽year over year, falling to 62.5 million鈥攁聽3.4 percent decrease.听
  • Of the 37 states,聽eight鈥擟olorado, Delaware, Mississippi, Missouri, New Jersey, North Carolina, North Dakota, and Oregon鈥攄id聽not聽experience year-over-year聽managed care enrollment聽declines,聽and聽instead showed聽flat enrollment or modest gains.听With the exception of Mississippi, these聽are聽all聽Medicaid expansion states.听
  • Arizona聽and Indiana聽experienced聽double-digit聽percentage聽declines. Notably,聽Indiana began requiring聽enrollees聽to actively respond to renewal mailers,聽which aligns with聽enrollment declines that began in March 2025.听
  • Among the聽expansion states in the analysis,聽enrollment聽declined聽by聽1.7聽million (-3.3%) to聽50.8聽million.听The聽seven non-expansion states聽experienced聽a聽similar聽decline (-3.6%),聽bringing聽enrollment to聽11.7聽million enrollees.听

Data Considerations. The data have some important limitations. States report enrollment figures at different points during the month, with some data reflecting beginning of the month totals and others capturing end of the month enrollment. In addition, some state datasets encompass all Medicaid programs offering managed care plans, whereas others reflect only a subset of the managed Medicaid population. As a result, the findings should be viewed as indicative of broader trends rather than a comprehensive state-by-state comparison.鈥�&苍产蝉辫;

Market Share and Plan Dynamics 

Using our data repository for 300 health plans across 41 states, 量子资源网IS analyzes corporate ownership, program participation, and tax status among Medicaid managed care plans. As of December 2025, Centene maintained the largest share of the national Medicaid managed care market at 17.8 percent, followed by Elevance (10.4%), United (8.5%), and Molina (6.0%) (see Figure 1).鈥疶hese figures highlight continued concentration among large national plans, even as overall enrollment declines. 

Figure 1. National Medicaid Managed Care Market Share by Number of Beneficiaries for a Sample of Publicly Traded Plans, December 2025鈥� 

What to Watch鈥� 

Enrollment trends observed in the fourth quarter (Q4) of 2025 and continuing into 2026 indicate increasing state attention to eligibility policy and program integrity. State legislative activity, budget pressures, and federal regulatory developments are prompting many states to assess and strengthen certain aspects of their programs related to eligibility, particularly as they prepare to implement redetermination and work and community engagement requirements. 

Several states are already moving toward implementation. Nebraska is scheduled to launch Medicaid work requirements on May 1,聽2026,聽while Montana plans to begin implementation on July 1, 2026. With聽additional聽federal guidance still聽emerging, most other states are working toward compliance ahead of January 2027 deadlines.听In聽expansion聽states,聽policymakers聽retain聽authority to tighten administrative processes, alter optional benefits, or adjust provider payment levels鈥攁ctions that聽may聽materially affect enrollment.听

These developments underscore why Medicaid managed care enrollment trends deserve close attention. Declines in enrollment are often an early indicator of broader system impacts, including rising uncompensated care for providers, shifts in payer mix, and increased financial pressure on safety鈥憂et systems. For managed care organizations, even modest enrollment changes can mask more significant shifts in risk profiles, geographic concentration, or service needs. 

Connect with Us鈥� 

量子资源网 is home to experts who know the Medicaid managed care landscape聽and how it is evolving. 量子资源网IS鈥檚聽Medicaid聽enrollment data, financials,聽procurement聽tracking, and a robust library of public documents鈥痚quips stakeholders with聽timely, actionable intelligence.听

For more information about the 量子资源网IS subscription, contact鈥�Andrea Maresca鈥痑苍诲鈥�Alona Nenko.鈥�&苍产蝉辫;

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量子资源网 Resource Provides Key Insights about the Evolving Medicare-Medicaid Integration Landscape

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People who are dually eligible for Medicare and Medicaid remain a central focus for policymakers and healthcare organizations, given their complex care needs, disproportionate share of spending, and the long-standing challenge of coordinating coverage across two programs. One of the primary vehicles for advancing integration has been Dual Eligible Special Needs Plans (D-SNPs), which continue to play an increasingly prominent role as federal and state policymakers encourage tighter Medicare-Medicaid alignment.

As states play a more active role in shaping enrollment rules, Medicaid contracting, and procurement strategies, the duals market is becoming more structured and more explicitly guided by state policy decisions. 量子资源网 (量子资源网鈥檚) 2026 Duals Integration Environmental Inventory, examines how this shift shapes the integration landscape in 2026. This comprehensive inventory is based on a review of the 2026 market, insights from states, and other publicly available resources.

This article examines key trends from 贬惭础鈥檚&苍产蝉辫;2026 inventory and addresses federal policy changes scheduled to take effect for 2027, which contribute to this dynamic environment.

What to Expect in 2026

As the landscape for duals integration evolves, the central question has shifted from whether D-SNPs operate in a state to the more consequential question of how states are using Medicaid policy levers (i.e., enrollment rules, procurement, contracting, and managed care structures) to drive tighter alignment between Medicare and Medicaid. 

At the federal level, recent Medicare Advantage and Part D rulemaking is reinforcing that movement. The  finalized the second phase-down of the D-SNP look-alike threshold to 60 percent for 2026 and established 2027 rules that limit enrollment in certain D-SNPs to members of an affiliated Medicaid managed care organization. The rule also limits the number of D-SNP benefit packages that can be offered alongside an affiliated Medicaid managed care organization. More recently, the  requires certain D-SNPs to use integrated member ID cards and integrated health risk assessments beginning in 2027. 

Together these rules signal a continued federal emphasis on linking D-SNP enrollment and operations more closely to Medicaid coverage and delivery systems, with states playing a greater role in determining how alignment is achieved. 

What the 2026 Inventory Shows

量子资源网鈥檚 2026 Duals Integration Environmental Inventory shows how these policy signals are translating into state action. More specifically: 

  • Statewide exclusively aligned enrollment appears in 16 states in the 2026 inventory, up from聽nine聽in 2025.听
  • Applicable Integrated Plans (AIPs) are present in 22 states, up from 14, and default enrollment is in place in 21 states, up from 16.听
  • The inventory also captures 6,084,997 total D-SNP enrollees, including 1,975,250 in聽Highly Integrated聽SNPs聽(HIDE)聽and 743,683 in聽Fully Integrated SNPs (FIDE-SNPs).听

Those changes are already visible in state markets: 

  • Illinois, Massachusetts, Ohio, and Rhode Island entered聽2026 with a greater FIDE-SNP presence tied to legacy Medicare-Medicaid Plan transitions.听
  • Michigan聽launched聽MI Coordinated Health as a HIDE-SNP in selected regions in 2026, with statewide expansion planned for 2027.听
  • Delaware also stands out:聽Although it already had AIPs in the 2025 inventory, it adds statewide exclusively aligned enrollment in 2026 and shows both HIDE-SNPs and coordination-only D-SNPs.听

A Resource to Track State Market Direction

贬惭础鈥檚&苍产蝉辫;, available to 量子资源网 Information Services (量子资源网IS) subscribers, includes a state-by-state view of the Medicaid policy, contracting, and program structures shaping duals integration and D-SNP markets. In addition to enrollment trends, the inventory documents the integration model each state is pursuing, whether long-term services and supports or behavioral health are included in managed care, and how procurement and contract decisions may inform future market activity. 

量子资源网 experts work with clients to apply this information and deepen their understanding of state integration approaches, inform assessments of their market readiness and alignment opportunities, and develop strategies that support more effective Medicare-Medicaid integration. 

Looking Ahead

Notably, 量子资源网鈥檚 inventory reflects a point in time understanding of where an individual state is today and what is known at this time about their next steps and plans. However, we expect changes in many states as they seek guidance from the Centers for Medicare & Medicaid Services and the D-SNP community to implement required changes and adopt new regulatory provisions that support state goals and priorities. 

The 2026 inventory suggests that more states are using formal alignment tools, that more enrollment is concentrated in integrated products, and that more markets are being shaped by the interaction between Medicaid structure, procurement, and D-SNP strategy. 

Connect with Us 

For organizations seeking to understand where the market is headed, the Duals Integration Inventory offers a clear view of how state policy and market structure are evolving and where tighter Medicare-Medicaid alignment is taking hold. 

Contact Holly Michaels Fisher and Julie Faulhaber to discuss your organization鈥檚 questions and needs regarding an integration strategy and market analysis. For information about the 量子资源网IS subscription, access to the Duals Environmental Inventory contact Andrea Maresca and Gabby Palmieri. 

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