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Blog

Cross-Sector Collaboration: Unlocking the Full Potential of Community-Based Services in a Challenging Funding Climate

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Lessons Learned from State-Led Transformation Efforts

As federal and state healthcare policy continues to evolve, the need for cross-sector collaboration has never been more urgent. The 2025 budget reconciliation act (OBBBA, P.L. 119-21) introduces significant changes to Medicaid eligibility and financing, prompting a shift in strategy for policymakers and advocates working to advance whole-person care and address social determinants of health (SDOH). The new policies reflect a reorientation of Medicaid financing, with a greater emphasis on state flexibility, targeted benefits, and value-based care.

In this environment, enhanced partnerships and strategic alignment across sectors will be essential to sustain community-based services and workforce investments. In this article, 量子资源 (HMA), 量子资源s highlight key observations from multiple state transformation programs, including actionable strategies for leveraging these assets and meeting the needs of at-risk populations.

Revisiting SDOH Initiatives in a New Policy Context

Whole-person care models have long called for integrated, multidisciplinary approaches. These models鈥攐nce buoyed by COVID-19 pandemic-era funding and broad federal support鈥攎ust now be recalibrated to align with new federal priorities. Current federal priorities emphasize streamlined benefits, fiscal discipline, and state-led innovation, which presents both challenges and opportunities for advancing integrated care. This shift has heightened the need to clarify roles and responsibilities across clinical and community settings, focusing on how to maintain essential linkages to primary and preventive care, especially for individuals for whom access remains fragile.

In addition, the ongoing healthcare workforce crisis intensifies the need for creative approaches to whole-person care models. Solutions must go beyond traditional payment models, leveraging existing social care networks, shared hub functions, alternative payment strategies above base rates, and braided funding streams.

State and federal initiatives can be used to sustain momentum and test emerging models. For example, the Rural Health Transformation Program (RHTP) offers a critical opportunity to support these efforts. With $50 billion in funding over five years, RHTP is designed to help states implement innovative models that improve rural health outcomes, strengthen workforce capacity, and address SDOH. States will be finalizing their applications to meet the November 5 deadline. HMA is tracking how these applications align with the strategies outlined below, using the program鈥檚 baseline and performance-based funding to invest in infrastructure, workforce development, and cross-sector partnerships.

Key Lessons from State Transformation Programs

Drawing on recent transformation programs, HMA 量子资源s identified several key lessons, including:

  • Prioritize Intensive, Community-Based Outreach: States and health plans should invest in community-based outreach strategies that reach populations facing the greatest SDOH barriers, including funding models that support navigation and engagement beyond traditional clinical settings and leveraging shared infrastructure to extend reach.
  • Update Community Health Worker (CHW) Benefit Structure to Maximize Impact: States, in collaboration with their partners, should revisit CHW benefit design to allow for greater flexibility. Reducing reliance on clinical supervision and referral-only pathways can help CHWs operate more effectively in terms of outreach, education, and engagement.
  • Strengthen Workforce Retention through Flexible Financing: Healthcare stakeholders should explore braided funding, shared hub models, and alternative payment models that go beyond base rates. These approaches can sustain staff and morale amid shifting demands and constrained budgets.

Connect with Us

The strategies in HMA鈥檚 recent report for Illinois, Medicaid Financing for Social Health: A Resource Compendium for Illinois Community-Based Organizations & Networks, can be adapted to other states and communities. By sharing lessons and adopting best practices from transformation programs nationwide, we can reinforce pathways to integrated care and ensure that populations continue to receive the support they need鈥攅ven in the face of unprecedented challenges.

HMA 量子资源s are helping states, healthcare plans, and community partners adapt and thrive as federal and state policy landscapes continue evolving. HMA teams are applying their cross-sector 量子资源ise in SDOH, workforce development, and state-specific knowledge to help organizations better plan, implement, and develop programs to solve healthcare challenges in their community. For questions about the report or opportunities for your organization, reach out to聽our 量子资源s below.

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CY 2026 Physician Fee Schedule Tackles Site Neutrality, Cost-Drivers, and Alternative Payment Models

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On October 31, 2025, the Centers for Medicare & Medicaid Services (CMS)  the  for the calendar year (CY) 2026 Medicare Physician Fee Schedule (PFS), which finalizes payment policies proposed earlier this year. The rule continues the administration鈥檚 focus on developing value-based payment strategies, enhancing care management, and developing innovative payment models. It emphasizes a shift from historical processes and methods of reimbursing clinician services, while also introducing payment policies that include a shift toward site neutrality and cost containment.

The final CY 2026 rule implements immediate policy changes and signals several areas on which CMS might focus its attention in future rulemaking. Through its responses to public comments and the rationale provided for finalized policies, CMS highlights potential shifts in priorities and emerging directions for Medicare payment policy, reflecting the views of the Trump Administration moving forward. Stakeholders should be attentive to these signals, as they provide valuable insights into where CMS could direct further reforms and adjustments in the coming years.

量子资源 (HMA) Medicare 量子资源s are reviewing the finalized policies and have identified the highlights outlined in this article. Stakeholders should consider the effect on payment in 2026 as well as the longer-term practice reforms, investments, and analysis that may be required to deliver high-quality services and remain sustainable.

Enhanced Care and Chronic Disease Management

CMS finalized new billing codes to support behavioral health integration and the Psychiatric Collaborative Care Model (CoCM) services delivered to patients who also receive Advanced Primary Care Management (APCM) benefits, along with an add-on code for in-home primary care to reflect added complexity. CMS also retains and repurposes the social determinants of health (SDOH) risk assessments billing code to align with the administration鈥檚 focus on addressing the root causes of chronic illness.

Takeaway: These changes are designed to support better care coordination, integration of physical and mental health services, and proactive management of patient risk factors. They indicate CMS鈥檚 intent to expand care management strategies beyond traditional settings and into future payment methodologies.

Establishing Specialty Care Models

The rule finalizes the mandatory Ambulatory Specialty Model (ASM) to test value-based payments for specialists who focus on heart failure and lower back pain. ASM adopts a framework similar to the Merit-based Incentive Payment System Value Pathways (MVP) and shares certain quality and cost measures with existing MVPs for heart disease and musculoskeletal care.

The model applies performance-based payment adjustments of up to 12 percent, covering 25 percent of Core-Based Statistical Areas (CBSAs) and metropolitan divisions, and is projected to save $177 million over its test period. ASM will run from 2027-2031, with payment adjustments applied during payment years from 2029-2033.

Takeaway: Stakeholders should plan for CMS鈥檚 continued interest in developing mandatory models and opportunities for specialists to participate in Innovation Center efforts.

Emphasis on Rebalancing the Payment System and Site Neutrality

Efficiency Adjustment

Citing the need to account for efficiencies gained in non-time-based services such as procedures, radiology services, and diagnostic tests, CMS finalized a 2.5 percent efficiency adjustment to work Relative Value Units (RVUs) for certain services and procedures, applied every three years. The agency notes it will monitor the three-year cadence and may refine the frequency in future rulemaking.

In response to public comments, CMS added several services to the exemption list in this final rule, including codes that introduced to the fee schedule in 2026, certain time-based services in physical medicine and rehabilitation, remote therapeutic monitoring (RTM), and drug administration, as well as time-based services on the CMS telehealth list.

Takeaway: The move signals a notable shift from the agency鈥檚 historical reliance on survey data provided by the American Medical Association (AMA)/Specialty Society Relative Value Scale (RVS) Update Committee (RUC) to establish practitioner time in PFS rate setting. Stakeholders should consider how CMS could build on this new approach in future rulemaking.

Site Neutrality

Site neutral policies will now use hospital outpatient data to set payment rates for certain services, including radiation oncology treatment delivery and some remote monitoring. In addition, the rule establishes the same payment rate in both physician office and hospital outpatient settings for certain supplies, including skin substitute products, and by implementing changes in the physician practice expense methodology.

By tackling practice expense reimbursement, CMS intends to recognize higher costs incurred by physicians who operate a freestanding office than by physicians who furnish care in the facility setting (i.e., indirect practice expenses). This methodology lowers practice expense payments to hospital-based physicians, resulting in double-digit cuts for many specialists in facility settings, while independent and group practice physicians generally will see increases.

Takeaway: The site neutrality changes underscore a broader long-term strategy advanced across multiple administrations to reduce payment disparities and discourage shifting care to higher-cost settings. While some providers will see payment increases and others will experience cuts, these adjustments are part of CMS鈥檚 effort to rebalance incentives and move toward value-based models. Stakeholders should recognize that this is not an isolated change, but a signal of continued policy evolution designed to align payment with efficiency and quality.

Strategies to Update PFS Practice Expense Payments

Although CMS implemented major methodology changes to allocate more indirect practice expense (PE) costs to services performed in physician offices and less to those in facility settings, the agency finalized a 鈥渟tatus quo鈥� approach. Specifically, the agency will continue using the existing practice expense per hour (PE/HR) values and cost share weights, despite being almost two decades out of date.

Takeaway: CMS indicates interest in revisiting practice expense data in future cycles, which may effect payment.

Positive PFS Conversion Factor Update

All providers and suppliers paid for services under the PFS will benefit from a positive update to the conversion factor, with Advanced Alternative Payment Model (APM) participants receiving a higher increase and one-time incentive payment. Specifically, under the final rule, two conversion factors will be available in CY 2026.

  • CMS will pay for services furnished by providers who participate in APMs using a conversion factor of $33.5675鈥攁 3.77 percent increase (or $1.221) from the 2025 amount of $32.3465.
  • CMS will compensate providers who do not participate in a qualifying APM using conversion factor of $33.4009鈥攁 3.26 percent ($1.0544) from CY 2025.

Both conversion factors reflect the 2.50 percent overall update required by statute, a 0.49 percent budget neutrality adjustment to account for RVU changes, and an updated factor of 0.75 percent for qualified APMs or 0.25 percent for non-qualifying APMs. CY 2026 is the final year in which eligible clinicians can receive an additional APM incentive. Qualifying clinicians will receive a one-time payment of 1.88 percent of their paid claims for covered professional services based on their performance two years earlier.

Takeaway: These updates provide short-term financial relief. The higher increase and bonus for APM participants signal CMS鈥檚 continued push toward alternative payment models, even as the incentive sunsets. Stakeholders should plan for a future in which APM participation remains a key strategy for maintaining revenue stability.

Telehealth-Related Flexibilities

CMS will implement several policy changes that will collectively extend the footprint of telehealth services in Medicare and expand access for Medicare beneficiaries. These changes directly impact Traditional Medicare beneficiaries, physicians鈥� offices, hospitals, and Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC).

  • All services on CMS鈥檚 Medicare telehealth coverage list are now permanently covered if they are separately payable and can be delivered via two-way audio-video.
  • CMS permanently removed frequency limitations on certain telehealth services, including follow-up inpatient and nursing facility services.
  • FQHCs and RHCs can serve as distant site telehealth providers for all services鈥攏ot just mental health services鈥攖hrough December鈥�31, 2026.
  • Virtual supervision is permanently allowed for nonsurgical services conducted in real time via two-way audio-video. This policy will apply across all settings, including FQHCs and RHCs requiring an on-site supervising physician.
  • Teaching physicians can be virtually present for resident services delivered in all training settings when care is provided via telehealth.
  • New services added to the Medicare telehealth coverage list, including certain psychological rehabilitation services, caregiver training services, and risk assessment services.

Takeaway: These changes solidify that telehealth has become an integral part of Medicare service delivery. By eliminating the distinction between temporary and permanent coverage, removing frequency limits, and allowing virtual supervision and teaching physician presence, CMS advances telehealth as a core component of its long-term strategy to improve access, care coordination, and efficiency. In addition, the change aligns with CMS鈥檚 commitment to modernizing payment policies to support virtual care models. Stakeholders should plan for continued growth and innovation in this space in future rulemaking cycles.

Other Final Policies

  • Addressing Rising Expenditures for Skin Substitutes:听CMS addresses rising expenditures for skin substitute products, which are being adopted and used at a rapid rate. Specifically, the agency reclassifies most of these products as supplies billed incident-to physician services, paid at a uniform rate in both office and hospital outpatient settings rather than as Part B drugs. CMS projects that this change will save Medicare $19.6 billion in 2026 and standardize payment to providers who use these products. The policy takes effect on January 1, 2026. Accompanying these changes is the launch of a new model to test clinical review for certain services, including skin substitutes, in fee-for-service Medicare.
  • Medicare Shared Savings Program: CMS finalizes its proposal to limit the amount of time an accountable care organization (ACO) can participate in an upside-only risk track, provide more flexibility on the number of beneficiaries assigned to an ACO in its early year of operation, and refine quality measures and improve beneficiary attribution to better reflect care standards.
  • Drugs and Biological Products Incident-to Physician Services:听The final rule addresses reimbursement for drugs paid incident-to a physician鈥檚 service, including policies related to the Inflation Reduction Act provisions, continued implementation of discarded units refund requirements, changes and clarifications to average sales price (ASP) reporting, and payment for procedures required to manufacture cell-based gene therapies.
  • Coding and Payment for Technology-Based Services: CMS pays for digital mental health treatment (DMHT) devices that have Food and Drug Administration (FDA) clearance or authorization and are furnished in conjunction with professional services, including initial education and onboarding. CMS expands these payment policies for DMHT used to treat of attention deficit hyperactivity disorder when providers adhere to established billing requirements. The agency recognizes that behavioral health conditions are common chronic diseases and that the field of digital therapeutics is evolving.

Contact an HMA Medicare Expert Today

HMA policy and rate setting 量子资源s are analyzing the details and impacts of the proposed rule and will provide additional updates on key Medicare policies as they become available. Our team can support stakeholder development of policy and data-oriented comments pertaining to this rule and on any other Medicare topic of interest. Contact聽our 量子资源s below to discuss your priorities and approach.

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Preparing for Change: Strategies for States and Issuers Amid 2026 Marketplace Shifts

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The upcoming 2026 open enrollment period for the Affordable Care Act (ACA) marketplaces is likely to be one of the most complex since the program鈥檚 implementation. Recent federal policy changes, ongoing litigation, and uncertainty around the extension of enhanced premium tax credits (ePTCs) are converging to create significant challenges for federal and state regulators, policymakers, and issuers. Rising premiums, expiring subsidies, and shifting federal regulations also have created an environment of significant uncertainty for consumers, navigators, and brokers.

A new report, Complexity for the 2026 Marketplace Open Enrollment: Risks of Consumer Confusion & Coverage Loss, authored by 量子资源 (HMA) and Wakely, an HMA Company, with support from the Robert Wood Johnson Foundation, explains these changes and their collective effect on costs and consumer experiences.

In this article, HMA and Wakely 量子资源s preview the options policymakers, states, regulators, issuers, consumer advocates, enrollment assisters, and other stakeholders can implement to mitigate potential confusion and coverage losses.

Federal Policy Shifts Driving Complexity

Central to the current challenges is the scheduled expiration of ePTCs at the end of 2025. Without congressional action, the 鈥渟ubsidy cliff鈥� returns, eliminating subsidies for consumers with incomes above 400 percent of the federal poverty level and reducing assistance for those living below. Early filings suggest average premium increases of 20 percent, which could be untenable for millions of families and small business owners enrolling in individual market coverage.

Additional federal changes compound the challenge:

  • The 2025 Budget Reconciliation Act (OBBBA)听removes advance premium tax credit (APTC) eligibility for certain lawfully present immigrant populations and eliminates Internal Revenue Service repayment caps on excess APTCs, including financial risk for consumers.
  • 罢丑别听聽changed eligibility and enrollment requirements. Some provisions are paused due to ongoing litigation (听补苍诲听), creating implementation uncertainty.
  • CMS updated issuer renewal and discontinuation notice聽, allowing issuers to omit premium and APTC information from their 2026 renewal notices, reducing clarity for consumers comparing plans.
  • 聽to catastrophic plan policy聽broadens eligibility but may create confusion when comparing options.

These changes are occurring alongside notable issuer exits, affecting millions of enrollees. States and issuers must be prepared to manage plan mapping and consumer transitions, potentially involving different networks and benefits.

Emergent Conditions for Open Enrollment Season

The combined impact of these changes is likely to increase marketplace call center traffic, broker and navigator assistance requests, eligibility appeals, and special enrollment activity, all of which will strain system capacity. Vulnerable populations, including those with limited English proficiency and those living in non-expansion states, face heightened risks of disenrollment. Operational strain is expected across marketplaces, issuers, and enrollment assistance networks.

Enrollment losses and affordability challenges also will be more significant in states that have not expanded Medicaid, particularly for lower income and older enrollees. The ACA Marketplaces experienced an influx of new enrollees as a result of ePTC, leading to historical enrollment growth in these states. On average, non-expansion states have seen their ACA Marketplaces grow by 152 percent from 2020 to 2024 versus 47 percent average growth in expansion states.

Regulators and issuers also must navigate the legal uncertainty surrounding the  and OBBBA provisions. With litigation ongoing, some rules may change mid-enrollment, requiring flexible implementation and communication strategies.

Strategies to Navigate the Current Complexity

To address these challenges, stakeholders can take several steps, including:

  • Clear, Consistent Messaging.聽Consumers will need clear communications advising them to review and update their plan selections. Communications should be direct, succinct, culturally appropriate, multilingual, and delivered repeatedly and through multiple channels.
  • Strengthened Noticing. It will be critical that federal, state, and issuer notifications to consumers be aligned, when possible. Notices should clearly explain premium and eligibility changes for affected populations and the actions they need to take.
  • Expanded Outreach. Enrollment assistance and direct to consumer education are critical, especially for low-income consumers, immigrants, and those previously auto enrolled. Partnerships with brokers, assisters, and community organizations will be key to reaching difficult-to-engage populations.
  • Enhanced Capacity. Investments in call center staffing, assister funding, and broker training can help address increased volume of consumer inquiries. Marketplace and issuer call centers should leverage available data to enhance their ability to serve affected consumers. States may consider adjusting compensation models to reflect the increased complexity.
  • Policy Flexibility. Federal and state marketplaces should prepare to use operational flexibility to mitigate coverage losses. If ePTCs are extended during or after open enrollment, special enrollment periods or extended deadlines may be needed. Retroactive coverage and grace period extensions could also address gaps.

Looking Ahead

The 2026 open enrollment period will test the resilience of the ACA infrastructure. For regulators, states, and issuers, the priority must be clarity, retention, and stability. Monitoring enrollment trends, premium differentials, and consumer confusion will be essential for adapting strategies and maintaining market viability.

Without coordinated communication and outreach, coverage losses and poor plan choices could undermine individual financial protection and destabilize the broader individual market. Lessons from previous enrollment periods and Medicaid鈥檚 COVID-19 public health emergency unwinding can guide efforts to keep consumers informed and enrolled.

Connect with Us

HMA and Wakely 量子资源s are closely tracking federal policy activity and state actions to address these challenges. Our 量子资源s support states, managed care organizations, consumer groups, and other interest holders to achieve success in the operation of and participation in the marketplaces. Our team has broad historical knowledge of the challenges and opportunities in this market and can support every step of the planning and execution processes to optimize markets as they continue to evolve in the coming months and years. If you have questions or want to discuss the recommendations included in the report, contact聽our 量子资源s below.

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The Future of Integrated Care Programs for Dually Eligible Individuals in Massachusetts: Key Takeaways from the Fall 2025 MAHP/HMA Policy Forum

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量子资源 (HMA) recently co-hosted a policy forum with the Massachusetts Association of Health Plans (MAHP), entitled Advancing Better Outcomes: How the One Care and SCO Programs Improve Health for Older Adults and People with Disabilities on Medicare and Medicaid. More than 100 key decision makers from MassHealth (Medicaid), health plans, providers, community-based organizations, and advocacy organizations attended the conference, elevating the value of the MassHealth and (SCO) programs to dually eligible individuals. The policy forum also provided an important opportunity for state legislators and their staff to learn about these complex programs.

MassHealth One Care and SCO Programs

Massachusetts鈥� One Care and the SCO programs currently serve more than individuals covered under MassHealth and Medicare, also known as dually eligible individuals. One Care is a population-specific program for dually eligible adults 21-64 years of age. SCO is a population-specific program for dually eligible older adults 65 and older, tailored to the needs of older adults. The One Care and SCO programs serve individuals with complex chronic conditions and disabilities, including mental health and substance use disorder needs, and high home-and-community-based service (HCBS) needs. The One Care and SCO programs advance independent living, recovery, and community living goals. Approximately 99 percent of One Care enrollees, and 95 percent of SCO enrollees, live in the community.

The One Care program is currently authorized as a Financial Alignment Initiative (FAI) demonstration program. The FAI demonstration ends December 31, 2025. MassHealth will continue the One Care program as a model. This transition from the FAI to a FIDE SNP model introduces changes to the program. A FIDE SNP model is a type of .

HMA鈥檚 Role: Bringing National and State Expertise

In addition to creating the forum in partnership with MAHP, HMA shared its national and state policy 量子资源ise and local market insights with attendees during a series of presentations. HMA outlined ways in which the One Care and SCO programs offer more value to dually eligible individuals than the state鈥檚 fee-for-service (FFS) system.

The event focused on three key topics:

  • The national landscape for Medicare-Medicaid integrated care programs.
  • The value of the One Care and SCO programs and the role that health plans play in improving outcomes for adults who are eligible for both Medicare and Medicaid (“dually eligible”), and
  • The upcoming changes to the One Care and SCO programs, as reflected in the with MassHealth.

Key Takeaways from the MAHP-HMA Conference

Key Takeaway #1. Nationwide trends suggest that Medicare-Medicaid integrated care programs will face competition and financial pressures.

Forum attendees were very interested in the national trends. At the national level, D-SNPs have bipartisan support. At the same time, D-SNPs should expect competition from and innovation models developed by the Centers for Medicare and Medicaid Innovation (CMMI). CMMI models such as the Model and Model will compete with D-SNP models in some markets. Finally, presenters and panelists alike raised concerns about the financial risks that D-SNPs will face due to rising pharmacy costs and changes in Medicare payment methodologies.

Key Takeaway #2. The Massachusetts One Care and SCO programs provide significant value to dually eligible individuals in Massachusetts.

The One Care and SCO programs provide significant value to enrollees. As compared to FFS, Medicaid-Medicaid integrated care programs like One Care and SCO provide care coordination, a personal care plan, bundling prescriptions through a single provider, and other services.

Many forum attendees pointed out that the One Care program is one of the most advanced integrated care programs in the nation. One Care鈥檚 success is tied in part to the active and critical role that the plays in shaping program policy. For more than a decade, the One Care Implementation Council and MassHealth have worked in partnership to improve the program. As shared by the : 鈥淭he Commonwealth intends to preserve the Implementation Council鈥檚 role in the next phase of One Care, and to continue engaging the council as an essential partner in policy and program change, monitoring, and oversight.鈥�

Key Takeaway #3. Over the last two decades, SCO and One Care plans have established many innovations.

The forum highlighted many innovations in these programs, from primary and to . It also provided an opportunity to talk about the important role and commitment that the plans have in emergency situations to ensure that members are safe in the face of a community crisis.

Panelists see many opportunities for plans to continue to evolve and improve outcomes and equity. For example, the One Care program has significant opportunities to address the behavioral health needs of dually eligible adults. Dually eligible adults with mental health and/or substance use disorder diagnoses are at higher risk of an emergency department visit and inpatient stay than other enrollees. Health plan per member per month (PMPM) spending on inpatient services for those with a behavioral health condition is much higher as a share of the total PMPM than other populations. The HMA data pointed to a need for further innovation in the mental health arena to advance better outcomes of quality of life and costs.

Key Takeaway #4. Conference attendees focused on the importance of addressing enrollees鈥� social determinants of health needs.

Throughout the day, the importance of community and addressing the social determinants of health (SDOH) was a common theme. Aging and disability leaders spoke about the importance of community organizations such as , , including peer support since most  One Care and SCO individuals live in the community.

Many One Care and SCO eligible individuals are often just one unmet health related social need away from the risk of hospitalization or institutionalization. Other attendees underscored the risk that enrollee living situations and recovery can become instantly unstable due to the death of an important family member. One aging leader described her role as 鈥渢riaging risk.鈥� Other leaders from the disability community urged plans to use to improve plan and provider attention to identify and address the SDOH needs.

Looking Ahead

As Massachusetts prepares for the 2026 One Care and SCO contract year, the forum underscored the progress made over the past decade and the opportunities ahead to improve care coordination, collect z codes, and invest in outcomes-driven partnerships. Massachusetts is well-positioned to continue leading the nation in designing integrated care programs that improve health and support community living for older adults and people with disabilities.

HMA looks forward to supporting all organizations including state Medicaid programs and health plan and provider associations as they convene stakeholders to improve their integrated care programs. Our 量子资源ise includes program planning, strategy and implementation, technical support and evaluation, and state-specific knowledge to make projects successful. Please contact Ellen Breslin, Rob Buchanan, and Julie Faulhaber for more information on how HMA can help your organization.

Summary Facts About the One Care and SCO Programs
The One Care and SCO programs are population-specific programs, serving more than 125,000 individuals with MassHealth plus Medicare coverage.   MassHealth designed the One Care and SCO programs around the specific needs, preferences and goals of adults and older adults.The One Care program enrolls dually eligible adults with disabilities, ages 21-64 at the time of enrollment, covered under MassHealth Standard or CommonHealth and Medicare (Parts A and B, and eligible for Part D). Enrollees in One Care have multiple chronic conditions and disabilities including significant mental health and substance use disorder needs. The SCO program enrolls dually eligible adults ages 65 and older, covered under MassHealth Standard and Medicare (Parts A and B, and eligible for Part D). SCO enrollees have significant chronic conditions, many of which are associated with aging.
MassHealth launched the SCO program in 2004 and One Care in 2013.   The One Care program currently operates as a Financial Alignment Initiative (FAI) demonstration. The One Care and the SCO programs combine MassHealth & Medicare benefits into a single plan with one card and one care team. One Care covers medical, mental health, and prescription medications, plus support for daily tasks and independent living and recovery. Care coordinators help members stay healthy and get the services they need.
The One Care and SCO Programs Continue to Evolve. The FAI demonstration authority ends in 2025. Massachusetts will shift from the demonstration to a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP) structure. The SCO program currently operates as a FIDE SNP model. The state reprocured the One Care and SCO plan network. The state selected five One Care plans and six SCO plans. New contracts for One Care and SCO plans start January 1, 2026.The new contracts create several changes including changes in eligibility for the program and enrollment processes, benefits, and financial payment provisions.
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Rewriting the Playbook: State Budgeting in the Era of OBBBA

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As of October 22, 2025, all but two states鈥擭orth Carolina and Pennsylvania鈥攈ad enacted budgets covering fiscal year (FY) 2026, even as the federal landscape has shifted dramatically throughout the year. In particular, passage of the 2025 Budget Reconciliation Act (OBBBA) and the ongoing federal budget impasse are creating significant downstream pressures on state budgets and the programs they support.

A new report from  (HMAIS) examines enacted state budgets. Of the 48 enacted budgets, 16 cover the 2025鈥�27 biennium, and three states鈥擪entucky, Virginia, and Wyoming鈥攁pproved budgets in 2024 for the FY 2024鈥�26 biennium.

The HMAIS report highlights state Medicaid funding priorities, initiatives states are pursuing to adapt to new federal Medicaid and other healthcare policy changes, and reforms to strengthen and ensure the sustainability of programs, particularly in states that expect a reduction in the federal share of their Medicaid program.

OBBBA鈥檚 Impact on State Budgets

Congress has yet to reach agreement on the federal fiscal year 2026 spending bills, and there are emerging signals of the challenges this impasse will create for states and federally funded public services. For example, this week the US Department of Agriculture鈥檚 Food and Nutrition Service notified every state that Supplemental Nutrition Assistance Program (SNAP) benefits will be withheld because of the funding lapse. This unprecedented situation puts immediate pressure on states and community organizations, which may need to intervene to fill gaps in essential services and benefits.

In addition to the funding impasse, OBBBA introduces major changes, particularly for the Medicaid program, including:

  • Medicaid Community Engagement/Work Requirements: All states must implement these requirements for certain Medicaid members by December 31, 2026, requiring rapid infrastructure and system changes.
  • Eligibility and Redetermination: States must conduct Medicaid eligibility redeterminations every six months for expansion populations, with new verification requirements and narrowed definitions for 鈥渜ualified鈥� immigrants. States will need to pressure test their systems for increased volume and may need additional capacity to prevent and minimize backlogs.
  • Cost Sharing: By 2028, states must apply a cost sharing requirement for Medicaid expansion adults with incomes above 100 percent of the federal poverty level, with some service exemptions. In 2026, states will need to begin efforts to ensure their systems can track this requirement.
  • Provider Taxes and Payments: Freezes on provider tax programs, phased reductions in allowable tax rates, and caps on state-directed payments will reduce flexibility and funding.

In addition, the Rural Health Transformation Program and new federal drug pricing initiatives present both opportunities, such as new funding streams, and risks, including administrative complexity and compliance expectations.

Given the scope of federal changes, states face urgent decisions. They must quickly assess and act on these opportunities, often without dedicated budget allocations.

These federal changes, combined with the budget impasse, are forcing many states to revisit approved budgets, adapt policies, and plan for new initiatives and revise programs that were already in effect鈥攐ften within short timelines and with limited resources.

State-Level Challenges and Adjustments

Notably, most states enacted their budgets before the passage of OBBBA. As a result, these budgets do not fully account for the new federal requirements, funding changes, and administrative expectations that OBBBA introduces. While many OBBBA provisions will not take effect for at least a year, states must now accelerate planning and make rapid adjustments to comply with new mandates. For example, states are expected to expediently and efficiently implement systems and policies to ensure compliance with OBBBA鈥檚 statutory requirements, particularly for the Medicaid program.

HMAIS has examined state budgets that will guide states through the next fiscal year, while also watching closely how they respond to new demands during the first full state legislative cycle under OBBBA.

The HMAIS report describes a mix of budget conditions and actions. Many states continue to invest in ongoing healthcare priorities as well as new initiatives, including targeted rate increases for behavioral health, dental, and maternal health services. In addition, states are addressing inefficiencies in program administration broadly. In healthcare specifically, they are revisiting approaches to financing healthcare service delivery to drive more value from organizations, such as implementing alternative payment models in Medicaid programs, as well as considering tools to improve patient outcomes and consumer experiences.

States are using a variety of tools in their Medicaid budgets to manage these pressures, as well as implementing more general cost-reduction and efficiency measures, including:

  • Special Legislative Sessions.聽Some state legislatures, including Colorado鈥檚 and New Mexico鈥檚, have reconvened to address emerging gaps.
  • Hiring Freezes.聽Several states, including Alaska, Colorado, Maryland, Massachusetts, New Hampshire, and Washington, have announced hiring freezes, which could complicate OBBBA preparation efforts.
  • Pausing or Ending Planned Programs and Benefit Coverage.聽Oregon announced that it will end its juvenile justice Medicaid reentry program to conserve funding. North Carolina will not cover new weight-loss drugs because of its budget shortfall. The HMAIS report indicates that officials in other states also have signaled that they are planning for similar updates to their programs if required to address budget shortfalls.
  • Medicaid Provider Rate Updates.聽Colorado rolled back a planned Medicaid provider rate increase, while Idaho is decreasing all Medicaid provider rates by 4 percent.
  • Coalitions and Advisory Groups.聽Other states, including Rhode Island, are convening groups charged with analyzing how the federal cuts may affect their state programs and advising the legislature on feasible responses to the changed landscape.

What to Watch

Healthcare organizations are essential partners as states navigate the current federal budget uncertainty and implement OBBBA requirements. Given the challenges cited above, healthcare organizations should be prepared to collaborate and position to anticipate future needs as the exact components of the various policies are in development.

Recommendations for states and healthcare organizations include:

  • Do not delay planning.聽While federal policymakers are developing guidance and regulations, the OBBBA language provides significant information on what states need to do and initial expectations for reporting. States and their partners should be developing options and contingency plans to make expeditious decisions once details are available.
  • Monitor and anticipate state actions and develop responses that are ready to go if needed. For example, states may need to make rate reductions, limit enrollment for optional programs, and communicate with beneficiaries about new requirements. Partners should plan to adapt to these changes and assist providers and beneficiaries as needed.
  • Prepare for changes in workload.聽States will need to design, develop, implement, and report on new Medicaid eligibility and enrollment requirements. They will need a workforce that is trained and can read into the policies, systems, and related needs. States will expect their partners to collaborate on efficient approaches to meet workload demands.
  • Engage with state officials.聽States need thoughtful partners to manage and implement the forthcoming changes that will affect Medicaid partners and beneficiaries. Healthcare organizations should bring experience and data-informed ideas and input to facilitate state approaches and decision-making.

Connect with Us
With federal funding reductions and ongoing uncertainty at the national level, states need to pay heightened attention to the frontline of essential healthcare and human services, implementation of OBBBA, and means of addressing gaps left by federal delays. As we approach the 2026 election year鈥攚ith many governors up for reelection鈥攕tate budgets will serve as a blueprint for leadership and policy priorities in the next cycle.

HMA is on the frontlines, working with states and healthcare partners to navigate these complexities. HMA has 量子资源ise, tools, and insights鈥攆rom budget contingency planning supports to analysis of public coverage program enrollment and market insights.

The full report is available to HMAIS subscribers. For questions contact聽our 量子资源s below.

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On the Horizon: Contract Year 2027 Proposed Rule Will Provide Trump Administration First Opportunity to Reshape Medicare Advantage Program

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The Centers for Medicare & Medicaid Services (CMS) is preparing to release the proposed . Rather than incremental tweaks, this rulemaking cycle offers CMS officials the first full opportunity to advance the Trump Administration鈥檚 policy priorities. With sweeping reforms on the horizon, Medicare Advantage (MA) plans that begin aligning their operations now will be positioned to thrive in the new environment.

These reforms arrive at a pivotal juncture for MA. Enrollment, which has climbed steadily over the past decade, is projected to decline from 34.9 million in 2025 to 34 million in 2026 as financial and regulatory pressures prompt some issuers to narrow or exit select markets. Although CMS  stable average premiums and benefits next year, beneficiaries in areas with reduced competition may face fewer plan choices and marginally higher cost sharing. These market shifts are likely to influence the 2027 contract year rule.

In this article, 量子资源, Inc. (HMA), Medicare 量子资源s delve into the key policy areas CMS is poised to address鈥攑rior authorization reforms, coding and risk adjustment oversight, Star Ratings realignment, and expanded program integrity efforts.

Prior Authorization and Utilization Management Reforms

CMS, across multiple administrations, has viewed prior authorization (PA) as both a cost-control lever and a potential barrier to care. In the contract year 2027 policy and technical rule, CMS officials will have their first unencumbered chance to cement electronic PA standards, enforce strict turnaround timelines, and limit plan鈥檚 use of internal coverage criteria. By mandating consistent rules across the MA landscape, CMS seeks to minimize provider frustration without sacrificing utilization management.

Risk Adjustment and Coding Oversight

MA coding practices leading to elevated MA risk scores have been the subject of bipartisan concern and heightened scrutiny as these have been found to inappropriately increase federal government payments to plans. In response, the 2027 rulemaking cycle provides an opportunity for CMS officials to develop more far-reaching reforms to the MA risk adjustment model and potentially explore more transformative models that move away from reliance on Medicare fee-for-service (FFS) data. Encounter-based risk adjustment or an 鈥渋nferred鈥� CMS-driven scoring approach could narrow payment gaps and deter upcoding.

Next Phase of Star Ratings

Star Ratings will likely see the most pronounced reset under CMS鈥檚 proposed changes. Moving away from purely process measures, CMS intends to elevate health outcomes鈥攕uch as fewer hospital admissions and improved functional status鈥攁nd sharpen its focus on 鈥渆xceptional care for all enrollees鈥� through the  (EHO4all) reward. This framework, announced under the calendar year 2026 rate notice, revised the Health Equity Index reward. In the 2027 proposed rule, CMS could call for retiring outdated measures in favor of streamlined reporting via health IT and patient-reported outcomes. CMS has also indicated it would consider other factors for this reward program.

Oversight and Program Integrity

This rulemaking cycle affords CMS officials an opportunity to expand the agency鈥檚 oversight toolkit. Advanced analytics and AI-driven audit selection will underpin fraud, waste, and abuse detection at greater scale. Potential areas of focus include enhancing efforts to promote accuracy in MA plan payments, addressing concerns with MA coding practices, and harnessing new technology to assist CMS in its oversight and auditing functions.

Charting the Path Forward

The contract year 2027 proposed rule represents the Trump administration鈥檚 first full-cycle effort to align Medicare Advantage with its priorities. By initiating PA automation, rigorous coding compliance, outcome-driven quality enhancements, and next-generation audit preparedness now, MA plans can turn regulatory challenges into competitive advantage. Stakeholders should monitor the Office of Management and Budget鈥檚 review timetable, submit focused comments during the rulemaking window, and leverage specialized modeling support to quantify impacts. The program鈥檚 future is outcome-centered and accountability-driven. Plans that embrace this vision today will lead the market tomorrow.

Preparing for the 2027 Contract Year for Medicare Part C and D

In addition to advancing the Trump Administration鈥檚 healthcare policy priorities, market shifts are likely to influence provisions included in the 2027 contract year proposed rule.

HMA 量子资源s advise that issuers and other interested healthcare organizations consider the following potential proposals as well as the changes to help organizations prepare:

  • CMS might propose to tighten standards around minimum plan offerings per county, bolster network adequacy requirements, and enhance provider directory. transparency to safeguard beneficiary access as the program evolves.
  • Plans that accelerate PA digitization, embed real-time clinical decision support, and train providers on uniform criteria today will smooth their path when CMS announces the contract year 2027 final rule.
  • To stay ahead, plans should launch internal coding audits, fortify provider documentation support, and pilot encounter-level data collection now.
  • MA organizations must recalibrate quality programs toward these high-impact metrics, invest in digital platforms for real-time patient feedback, and forge care-management strategies that demonstrably lower acute events.

Connect with Us

HMA is closely monitoring the federal review timetable for this proposed rule. Our Medicare 量子资源s are working with healthcare organizations to prepare to submit targeted comments during the comment window, including applying specialized modeling support to quantify impacts.

The future of MA is outcome鈥恈entered and accountability鈥恉riven; plans that embrace this vision today will lead the market tomorrow. For details about the MA and Part D regulatory and market landscapes and approaches to position your organization for success, contact our featured 量子资源s聽below.

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ACA Marketplaces at a Crossroads: New Data Reveals Who鈥檚 Covered and What鈥檚 at Stake

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As we approach the end of 2025, the Affordable Care Act (ACA) Marketplaces face a pivotal moment. Enhanced Advance Premium Tax Credits (APTCs), introduced under the American Rescue Plan Act (ARPA) and extended through the Inflation Reduction Act (IRA), have driven record-breaking enrollment, with 24 million individuals now covered through the Marketplaces. Without congressional action, these subsidies will expire on December 31, 2025.

This pending policy shift makes it more urgent than ever to understand who the Marketplace serves, what enrollees receive, and how future changes could affect affordability and access.

HMA and Wakely, an HMA Company, have released a new Issue Brief that provides a comprehensive profile of Affordable Care Act Marketplace enrollees primarily based on claims data from nearly 6 million of the 24 million Marketplace enrollees. The brief answers key questions about Marketplace enrollees, including the types of health conditions they have and the types of services and prescription drugs they use.

The white paper is available on the HMA website.

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Wakely鈥檚 New Star Ratings Analysis: What鈥檚 Changing and What鈥檚 Holding Steady

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As Medicare Advantage and Part D plans prepare for the 2026 contract year, Wakely, an HMA Company, has published two white papers that offer critical insights into the latest developments in the Centers for Medicare & Medicaid Services鈥� (CMS) Star Ratings program. These analyses follow CMS鈥檚 release of the final 2026 Star Ratings, which play a pivotal role in plan performance, member retention, and bonus payments.

Why It Matters

Star Ratings reflect plan quality, member experience, and regulatory compliance. With CMS continuing to refine its methodology and cut points, understanding the nuances of these changes is essential for plans looking to maintain or improve their ratings. Wakely鈥檚 white papers provide a clear, data-driven lens into what鈥檚 new, what鈥檚 stable, and what it means for the industry.

No Major Shifts in 2026 Ratings

In the paper, , Wakely 量子资源s report that the 2026 Star Ratings show no major systemic shifts in overall scores. Wakely鈥檚 analysis finds that:

  • Most plans maintained their previous ratings, with only modest movement across the board.
  • CMS鈥檚 methodology updates had minimal impact on overall scores, suggesting a period of relative stability.
  • The distribution of scores across contracts remains consistent with prior years, offering plans a chance to focus on incremental improvements rather than major overhauls.

A companion white paper, , explains the cut point adjustments that define how performance translates into Star Ratings. The analysis finds that several measures saw tightening of cut points, especially in areas like medication adherence and member experience. In addition, the paper indicates that early signals of quality improvement are emerging in certain domains, suggesting that plans are responding to CMS鈥檚 evolving expectations.

The paper offers guidance on how plans can strategically target measures most likely to influence future ratings.

Read the .

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CMS Clarifies Grandfathering Rules for State Directed Payments

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The Centers for Medicare & Medicaid Services (CMS) last month issued a  to states providing preliminary guidance on  (SDPs), which outlines new federal payment limits, clarifies grandfathering provisions, and signals significant changes ahead for Medicaid financing and policy. The letter is part of CMS鈥檚 implementation of Section 71116 of the Budget Reconciliation Act of 2025 (, P.L. 119-21)鈥攖he portion of the legislation that focuses on curbing SDP spending and reinforcing program integrity.

Though CMS describes the guidance as preliminary, it is the view of 量子资源 (HMA) 量子资源s鈥攊ncluding former state officials, actuaries, and policy strategists鈥攖hat it signals directionally new policy for Medicaid agencies, managed care organizations (MCOs), and providers. CMS is working on two proposed SDP-related regulations, which are in the final stages of federal review. The preliminary guidance and forthcoming rules will likely reflect long-standing concerns for several years, even over shifting congressional control and multiple presidential administrations.

This article addresses key clarifications in the letter; the impact of the preliminary guidance on states, MCOs, and providers; and how the directive may influence Medicaid budgets, financing strategies, and future policy reforms.

Guidance Clarifies Timeframes for SDPs

Grandfathering Limited to Specific Rating Periods

CMS will allow states to maintain SDP spending amounts, up to the average commercial rate ceiling, that were in place for state fiscal year (SFY) 2025, calendar year (CY) 2025, and SFY 2026 rating periods. Nonetheless, new or expanded SDPs above Medicare equivalent levels in expansion states and 110 percent of Medicare in non-expansion states鈥攅ven those based on legislation passed in 2025鈥攁re ineligible for grandfathering if they apply to rating periods starting after July 4, 2025. These grandfathered spending amounts will need to phase down with rating periods beginning on or after January 1, 2028.

Preliminary Grandfathering Determinations

CMS has begun notifying states whether a preprint is 鈥渓ikely eligible鈥� for grandfathering. Because these are preliminary determinations, states should prepare for further review and revisions.

Submission Cutoff Date Clarified

In response to confusion around the May 1, 2025, submission deadline, CMS clarified that July 4, 2025, is the cutoff for grandfathering eligibility, provided the state fully completed the preprint. States may have rushed to meet a July 4 submission deadline and may have left questions on the preprint unanswered. In these instances, it is possible鈥攊f not likely鈥攖hat CMS will consider the application incomplete and thus ineligible for grandfathering. Since this is a developing area with limited precedent, states may still seek clarification or reconsideration, though CMS has not yet issued definitive guidance or a formal process for resolving these situations.

No Increases Allowed Until 2028

States are prohibited from increasing the total dollar amount of grandfathered SDPs鈥攖he 鈥渆xpected spend鈥濃�攗ntil January 1, 2028. This restriction limits flexibility for states to expand their programs and may require that they reassess their SDP strategies. For example, using percentage-based calculations tied to average commercial rates, will no longer capture year-to-year growth because of utilization or acuity changes.

10 Percent Phasedown Unaddressed

CMS has yet to provide official guidance on the 10 percent phasedown of SDPs. Stakeholders remain in a holding pattern, awaiting a forthcoming proposed rule that will clarify how reductions will be calculated.

What It Means for States and Healthcare Organizations

SDPs have become a critical tool for states to stabilize provider networks through increased Medicaid reimbursement. This authority will be significantly limited, and states will need to reduce many existing programs. Medicaid enrollment losses resulting from other Medicaid policy changes, such as work requirements and minimum semiannual redetermination, will likely compound the strain on provider payments.

Providers and states need to start planning for these losses in revenue now. Strategic planning for SDP sustainability and close monitoring of upcoming CMS rulemaking is essential.

While the guidance imposes constraints, it also opens the door for policy innovation. For example, some states may use this moment to reform Medicaid financing, streamline supplemental payments, and reconfigure provider incentives to better reflect quality and access, advancing value-based care goals and achieving total cost of care savings through efficiency and aligned incentives.

Connect with Us

HMA is uniquely positioned to support states, MCOs, and providers as they navigate the evolving landscape of Medicaid SDPs. Our team includes former state Medicaid directors, actuaries, and policy strategists with deep 量子资源ise in designing sustainable financing arrangements and guiding public engagement processes. We bring robust modeling capabilities to clients seeking to assess the financial impact of CMS鈥檚 new restrictions, including the 10 percent phasedown and interactions with provider tax limitations. Our 量子资源s are actively engaged with CMS and understand how to translate federal guidance into actionable strategies that align with state goals and operational realities.

Whether revising preprint submissions, evaluating quality frameworks, or rethinking provider incentives, HMA delivers the technical and policy insight needed to move forward with confidence.

For questions about the federal guidance and considerations for your organization, contact our 量子资源s below.

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Turning HR 1 Medicaid Work Requirements into Workforce Development Opportunities: Lessons from HMA鈥檚 Recent Webinar

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As State Medicaid Agencies prepare for the operational and policy shifts introduced by HR 1鈥檚 Medicaid Work Requirements, the stakes could not be higher. While the intent of these provisions is to encourage workforce participation, their real-world implementation risks leaving behind those who already face systemic barriers鈥攑articularly rural communities, people of color, and individuals with chronic conditions.

In a recent HMA webinar, 鈥�Work That Works: Creating Sustainable Employment Pathways for Medicaid-Enrolled Communities,鈥� Shannon Joseph, Senior Consultant and Workforce Development 量子资源 at 量子资源 (HMA), and Dr. Alicia Johnson, Managing Principal and strategic advisor on Medicaid transformation at HMA, led a dynamic conversation for state leaders and Medicaid stakeholders. Their core message was clear: with thoughtful design, states can transform work requirements from punitive compliance metrics into powerful tools for workforce development and economic mobility.

The Policy Landscape: HR 1 and State Readiness

HR 1 establishes new federal standards that require states to verify that certain Medicaid enrollees are meeting minimum work or community engagement hours as a condition of continued coverage. While exemptions exist for specific populations, the administrative lift, data infrastructure, and interagency coordination needed to operationalize these requirements are significant.

Historically, states that have experimented with work requirements, such as Arkansas, Kentucky, and New Hampshire, have seen coverage losses not because beneficiaries were unwilling to comply, but because systems were unprepared to support them. Barriers such as limited broadband access, low literacy rates, unstable employment markets, and health disparities disproportionately impacted rural residents and people of color.

Key Challenge #1: Avoiding Disproportionate Impact on Vulnerable Communities

One of the most pressing concerns is that work requirements may exacerbate disproportionate access. In rural communities, jobs that meet hour thresholds are often scarce, transportation options are limited, and childcare access is inconsistent. For people of color, historic and systemic barriers to employment persist, from lack of work credentials, to lack of tailored workforce programs. For individuals with chronic conditions or disabilities not formally classified as exempt, participation can be difficult or intermittent.

Dr. Johnson emphasized the importance of a community-based approach that leverages local resources and local social safety nets to increase participation and outcomes but developing targeted strategies that address the varying needs of the Medicaid community.

鈥淲e cannot simply apply a one-size-fits-all model. States must design implementation strategies that close population health gaps and overcome the social structural gaps in their systems, not widen them. Social Determinants of Health are not just passive background factors; they actively shape people’s ability to achieve and maintain good health and life outcomes.鈥�

Best Practice: Conduct community-level impact assessments prior to implementation to identify geographic, demographic, and health-related disparities. Use this data to tailor outreach, exemptions, and workforce partnerships accordingly.

Key Challenge #2: Shifting from Compliance to Workforce Integration

Too often, states have approached work requirements as a compliance exercise鈥攖racking hours, verifying exemptions, and ensuring federal reporting鈥攚ithout connecting to broader workforce development ecosystems. This narrow focus misses the opportunity to align Medicaid with labor, education, and economic development systems.

Shannon Joseph pointed to states like Louisiana, where cross-agency partnerships have begun to link Medicaid beneficiaries to workforce boards, training programs, and supportive services, 鈥淭he most successful models are those where Medicaid is not working alone. When states braid resources and align objectives, work requirements can become a springboard for meaningful employment.鈥�

Best Practice: Develop formal MOUs between Medicaid agencies, state workforce boards, Departments of Labor, and community colleges to share data, coordinate referrals, and leverage federal funding streams like SNAP E&T and WIOA.

Key Challenge #3: Building Administrative Infrastructure and Data Systems

Another central theme of the webinar was the need for robust data infrastructure. Many states lack integrated eligibility systems capable of tracking employment hours, exemptions, and participation across multiple programs. Without this integration, states risk errors, delays, and unnecessary disenrollments.

HMA highlighted the value of interoperable data systems and FHIR-based architecture that allow Medicaid agencies to exchange information with workforce agencies in real time. Digital equity must also be part of the conversation, especially in rural areas where broadband access remains a challenge.

Best Practice: Prioritize system modernization investments and interoperability pilots to build the technical backbone for equitable and efficient implementation such as the one in Georgia launched for the Pathways program.

Key Challenge #4: Partnering with Communities for Culturally Responsive Implementation

Dr. Johnson underscored that states cannot achieve equitable implementation from the statehouse alone. Partnerships with community-based organizations (CBOs), faith institutions, and local employers are critical to reaching populations who may be distrustful of government systems or unaware of new requirements.

Community partners are trusted messengers. They can bridge gaps in communication, help with navigation, and ensure that people understand both their obligations and opportunities,
– Dr. Alicia Johnson

Best Practice: Create local implementation collaboratives that include Medicaid staff, CBOs, workforce entities, and providers to co-design outreach and support strategies tailored to community needs.

Key Challenge #5: Aligning Metrics with Meaningful Outcomes

Finally, both speakers cautioned against relying solely on compliance metrics (e.g., hours reported, exemptions processed) to evaluate success. Instead, states should track workforce and health outcomes, such as employment stability, income growth, retention in coverage, and health status improvements. Shannon Joseph noted, 鈥淚f our only measure of success is whether someone uploads their work hours, we鈥檝e missed the point. The goal should be sustainable pathways to economic mobility and improved health.鈥�

Best Practice: Develop a multi-dimensional performance dashboard that blends compliance data with workforce outcomes, health equity indicators, and beneficiary experience measures.

Solutions & Strategies for States: A Roadmap

Drawing from the discussion, HMA outlined a set of strategic recommendations for state Medicaid agencies:

  1. Conduct Equity Impact Assessments: Identify populations at risk of adverse impacts and tailor exemptions and support services accordingly.
  2. Align with Workforce Systems: Establish data-sharing agreements and coordinated referral pathways with workforce boards and community colleges.
  3. Invest in Data Modernization: Build interoperable systems to reduce administrative burden and ensure real-time verification.
  4. Engage Trusted Community Partners: Leverage CBOs and local institutions for outreach, navigation, and culturally responsive engagement.
  5. Shift Metrics to Outcomes: Measure employment stability, economic mobility, and health outcomes鈥攏ot just compliance.
  6. Pilot, Learn, Scale: Start with targeted pilots in high-need communities, evaluate rigorously, and scale strategies that work.

HMA鈥檚 Role: Strategic Partner to States Developing Public/Private Partnerships to Build Genuine Pipelines of Work

HMA has deep 量子资源ise helping states design, implement, and evaluate Medicaid work requirement policies in ways that are operationally sound, legally defensible, and Medicaid Member-centered. Our team has supported states in:

  • Conducting 1115 waiver design and evaluation,
  • Integrating Medicaid and workforce systems,
  • Designing targeted outreach strategies for rural and underserved populations,
  • Implementing digital modernization projects, and
  • Developing performance dashboards that focus on outcomes.

HMA brings both policy acumen and on-the-ground implementation experience, enabling states to navigate complex regulatory landscapes while advancing population health and real-world outcomes.

Learn More & Partner with HMA

If you missed the live webinar, you can watch the replay here.

You might also be interested in attending the HMA National conference, .in New Orleans October 14-16, for our session on Making Medicaid Work Requirements Work, where we will draw on lessons from states like Georgia.  Panelists will explore what to watch for in program design, including strategies to support workforce readiness, reduce administrative burden, and maintain access to care.  Speakers include:

  • Tonya Moore, Associate Principal, HMA
  •  Chief Health Policy Officer, Georgia Department of Community Health
  •  Medicaid Reforms Project Director, Utah Department of Health and Human Services
  • Moderated by , Managing Principal, HMA

Online registration closes October 10, but if you act now, you can use the code FLASH25 for up to $475 off the standard registration fee for the full conference. 

For more information about how HMA can support your state in strategic planning, operational design, impact analysis, and workforce integration, please contact our 量子资源s below.

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HMA Enrollment Update: Medicaid Managed Care Organizations See Drop in Enrollment in 2Q25

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This week, our second In Focus provides insights into Medicaid managed care enrollment in the second quarter of 2025. 量子资源 Information Services (HMAIS) obtained and analyzed monthly Medicaid enrollment data in 30 states,[1] offering a reliable baseline and timely view of the immediate impact of the current policy landscape as new federal policies take effect.

This analysis presents a snapshot of HMAIS鈥檚 comprehensive detailed quarterly Medicaid managed care enrollment report (available by subscription), which includes plan-level information for nearly 300 health plans in 41 states, corporate ownership, for-profit versus not-for-profit status, and similar information regarding publicly traded plans. Table 1 provides a sample of enrollment trends, representing 57 million Medicaid managed care enrollees of a total of 66 million Medicaid managed care enrollees nationwide. Data reporting periods and program coverage vary by state, so figures may not be fully comparable.

Key Insights from 2Q25 Data

The 30 states included in our review have released monthly Medicaid managed care enrollment data鈥攙ia a public website or in response to a public records request from HMAIS鈥攆or April through June of 2025. This report reflects the most recent data posted or obtained from states. HMA has made the following observations regarding the enrollment data:

  • Year-over-year decline. As of June 2025, in the 30 states reviewed, Medicaid managed care enrollment declined by 1.6 million members year-over-year, a 2.7 percent drop from June 2024.
  • Widespread decreases. Of the 30 states, 27 experienced enrollment declines in June 2025 compared to June 2024. Oregon and the District of Columbia saw modest growth, while California remained flat (Table 1).
  • Sharpest contractions. Arizona and Maryland reported double-digit percentage drops in enrollment in June 2025 (Table 1), underscoring the uneven impact of redeterminations and eligibility policy changes.
  • Difference among expansion and non-expansion states. Among the 24 states included in the analysis that expanded Medicaid, enrollment fell by 1.2 million鈥攁 2.5 percent drop鈥攖o 49.2 million. The six non-expansion states saw a steeper proportional decline of 4.2 percent, to a total of 8 million enrollees.

Table 1. 2Q25 Monthly MCO Enrollment by State, April鈥揓une 2025

Note: 鈥�+/- m/m鈥� refers to the enrollment change from the previous month, and 鈥�% y/y鈥� refers to the percentage change in enrollment from the same month in the previous year.

The data in Table 1 should be viewed as a sampling of enrollment trends across these states rather than as a comprehensive comparison, which cannot be established based solely on publicly available monthly enrollment data. It is also important to note the limitations of the data presented. For example, not all states report data at the same time during the month, resulting in a range of snapshots from the beginning to the end of the month. Second, in some instances, the data cover all Medicaid managed care programs, while in others they reflect only a subset of the broader managed Medicaid population, depending on what data is publicly available.

Market Share and Plan Dynamics

HMAIS鈥檚 report includes plan-level details for nearly 300 plans, covering corporate ownership, program participation, and tax status. As of June 2025, Centene continues to lead the national Medicaid managed care market with 17.8 percent share, followed by Elevance (10.4 percent), United (8.6 percent), and Molina (6.2 percent; see Table 2).

Table 2. National Medicaid Managed Care Market Share by Number of Beneficiaries for a Sample of Publicly Traded Plans, June 2025

What to Watch

The OBBBA (P.L. 119-21) calls for significant changes to Medicaid eligibility and enrollment policies, including work requirements and more frequent eligibility redeterminations.  indicate that Medicaid and Children鈥檚 Health Insurance Program enrollment could decline by up to 7.5 million people by 2034. In addition, the Centers for Medicare & Medicaid Services (CMS) has announced that it will not approve or extend waivers for multi-year continuous eligibility for adults or children.

As these policies are implemented, state governments and healthcare organizations should prepare for increased administrative complexity, potential coverage disruptions, and the resulting effect on MCO revenue and value-based care arrangements.

Connect with Us

HMA is home to 量子资源s who know the Medicaid managed care landscape at the federal and state levels. As the Medicaid landscape continues to evolve, HMAIS equips stakeholders with timely, actionable intelligence, including enrollment data, quarterly by-plan and by-state enrollment reports, financials, Medicaid demonstration and Rural Health Transformation program tracking, and a robust library of publicly available Medicaid-related documents. HMAIS combines publicly available information with HMA 量子资源 insights on the structure of Medicaid in each state, as well as our comprehensive, proprietary State Medicaid Overviews.

For questions about the HMAIS enrollment report and information about the HMAIS subscription, contact our 量子资源s below.

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The Rural Health Transformation Program: Options to Address the Maternity Care Crisis

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This article is part of HMA鈥檚 Weekly Roundup series on the RHT Program, highlighting key opportunities and considerations for states and healthcare organizations.

The Centers for Medicare & Medicaid Services (CMS) recently launched the , which is intended to help states reimagine and rebuild rural healthcare delivery. As outlined in our earlier In Focus article, Rural Health Transformation Program Represents a One-Time Opportunity to Reshape Rural Care, this historic $50 billion federal investment provides states with flexibility to design and implement strategies that improve access, quality, and outcomes in rural communities.

As states develop their RHT applications, they can consider a range of approaches to address persistent gaps in care particularly in maternal health, where rural residents often face limited access to local services. A range of solutions is needed to expand and stabilize access to maternal care, given the shortage of close-to-home birthing care. This article explains one such option: investing in midwifery.

Maternity Care in Rural Communities

Maternity Care Deserts Driving a National Maternal Health Crisis

Families in rural communities鈥攁nd some urban communities鈥攆ace 鈥�,鈥� meaning they do not have access to a birthing facility or obstetric clinician.  are another reality in rural communities, with additional closures projected. Even in larger communities where a hospital is open, obstetric services could be shut down. These deserts are a key driver of the national maternal health crisis. In , the March of Dimes (MOD) reported that 鈥渢wo in three maternity care deserts are rural counties (61.5%)鈥� and that 鈥渃ounties with low access to telehealth were 30% more likely to be maternity care deserts.鈥� 

Midwifery as an Option for Rural Communities

 are trained healthcare professionals who specialize in supporting women through typical, low-risk pregnancies. They provide care during pregnancy, labor, and the postpartum period. There are several types of midwives, each with different training and credentials. States determine which types of midwives may practice and under what conditions.

Expanding the midwifery workforce can be part of a broader strategy to improve access, particularly in rural areas where hospitals and obstetric providers are scarce. In some places, midwives already serve as a critical access point for maternal care in rural communities, with midwives attending to .

The Rural Health Transformation Program Can Help Address the Crisis

The strategic goals of the RHT, as outlined in the CMS application materials and Notice of Funding Opportunity (NOFO), are designed to guide states in transforming rural healthcare delivery. These goals are grounded in the statutorily approved uses of funds and must be explicitly addressed in each state鈥檚 RHT application.

Midwives have long contributed to expanding access to maternal care across diverse settings. For example, midwives can support preventive health by providing prenatal and postpartum care in community settings. Their integration into rural care teams may help sustain  where hospitals and obstetric providers are limited. States may also consider workforce development strategies, such as expanding midwifery training and retention programs, and innovative care models鈥攊ncluding hub-and-spoke systems鈥攖hat incorporate midwives to improve coordination and person-centered experiences (Figure 1).

According to Ginger Breedlove, PhD, CNM, founder of , one of the nation鈥檚 leading , 鈥渕idwifery aligns with all strategic goals of the RHT program.鈥�

States may consider midwifery as one of many options to help build sustainable, community-centered maternity care systems that reflect the RHT Program鈥檚 vision for rural health transformation.

Figure 1. Midwifery Alignment with RHT Strategic Goals

RHT Strategic GoalsMidwifery Alignment
Make Rural America Healthy AgainMidwives support preventive, community-based maternal care and contribute to , such as higher rates of spontaneous vaginal delivery and breastfeeding and lower rates of preterm birth and low birthweight.
Sustainable AccessMidwives can serve as consistent local access points for maternity care, particularly in areas with limited obstetric services.
Workforce DevelopmentMidwifery workforce initiatives  of high-skilled providers practicing at the top of their license, aligning with goals to strengthen recruitment, retention, and licensure flexibility in rural areas.
Innovative CareMidwives can be integrated into flexible care arrangements鈥攈ub-and-spoke or CMS鈥�  model鈥攁longside doulas and community health workers, improving care coordination and patient experience.
Tech InnovationMidwives can leverage telehealth, remote monitoring, and data-sharing and digital care platforms to extend the reach of maternal care in rural communities and connect patients to the broader maternal care system, including remote specialist consultations. Tech innovations ensure that women receive the appropriate level of care for their risk and needs.

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量子资源 (HMA) has deep 量子资源ise in supporting states and healthcare organizations across all phases of rural health transformation. Our team can assist with strategy and writing grants, program design, and implementation plans tailored to specific state goals and approaches. Whether states choose to explore midwifery or other care delivery models, HMA can help define the approach that best fits the needs of rural communities and support organizations in transforming workflows and operations, implementing new initiatives, and enhancing the systems and IT enhancements that sustains them.

HMA brings together 量子资源s in maternal health, finance, rural communities, and delivery systems, contact our 量子资源s below.

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