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Act Now to Implement Community Engagement Requirements

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On June 2, 2026, the Centers for Medicare & Medicaid Services (CMS) issued the highly anticipated Interim Final Rule (IFR) on implementing the Medicaid work and community engagement requirements set forth in the 2025 budget reconciliation act, P.L. 119-21. States are expected to implement the requirements by January 1, 2027, leaving Medicaid authorities, health plans, providers, and community-based partners with a compressed timeline to design, test, and deploy new workflows that will fundamentally change how eligibility and compliance are administered.

This article builds on 量子资源网 (量子资源网) colleagues鈥� ongoing analysis of federal Medicaid policy changes stemming from the Working Families Tax Cut Act and evolving federal priorities (see Connecting the Dots here and here) and explores the implications for enrollees, state agencies, health plans, and providers. 

Community engagement requirements create risk and exposure for all of these interest-holders, opening them to the possibility of increased enrollment churn, particularly during the early stages of implementation as enrollees and administrators adapt to new processes. Even Medicaid enrollees who meet compliance requirements or qualify for exemptions could experience temporary coverage losses or disruptions because of delays in documentation, notice response, or case processing.

Plans and providers, meanwhile, may encounter downstream effects on capitation rate adequacy, financial and membership forecasting, risk adjustment, care management continuity, quality performance, and network stability.

From Policy to Practice: A Systemwide Operational Shift 

Many elements of the IFR align with statutory provisions; however, it introduces new operational expectations that will reshape eligibility processes, including: 

  • Structured verification and documentation requirements听
  • Expanded exemption frameworks tied to functional ability to work听
  • New reporting and oversight obligations听
  • Increased reliance on enrollee notifications and engagement听

Collectively, these changes introduce a new layer of administrative expectations that extend beyond traditional eligibility and enrollment functions and require coordination across state and local agencies, health plans and providers, and community partners. 

Notably, CMS has provided targeted flexibilities鈥攑articularly through income-based compliance pathways鈥攚hich will allow states to leverage existing data sources and potentially reduce administrative burden, if implemented effectively. 

States Need to Build an Operational Foundation 

For state Medicaid agencies, the immediate priority is translating federal requirements into scalable, consistent processes. 

Key actions include: 

  • Redesign eligibility and听compliance听workflows.听States will need to听identify听affected populations, track compliance,听adjudicate听exemptions and hardships, and manage appeals鈥攁ll within tight implementation timelines.听
  • Invest in verification infrastructure.听Although automation opportunities exist,听particularly using income and existing eligibility data,听many determinations (e.g., medical frailty, caregiving, hardship) will require individualized review and new documentation standards.听
  • Strengthen cross-agency coordination and data integration.听Effective implementation will depend on integrating data from workforce, social services, and other programs to support compliance and reduce manual processes.听
  • Develop robust communication strategies. Experience from prior Medicaid initiatives demonstrates that coverage loss often results from administrative barriers, not ineligibility, making clear, proactive communication essential. 
  • Balance automation and administrative complexity.听States that effectively听leverage听automation and streamline enrollee-facing processes will be better positioned to听maintain听coverage continuity while meeting federal requirements.听

Implications for Health Plans: Expanding the Role of Member Engagement 

Health plans will play a pivotal role in implementation, although they cannot determine enrollee compliance with the new requirements. States rely on plans to identify members who may be subject to community engagement requirements, to assist with member communications, and to connect members with resources that support compliance or exemption eligibility. Even though these activities occur outside the traditional managed care financing framework, plans may be called upon to accomplish the following: 

  • Enhance outreach and education capabilities.听Plans are often the primary point of contact for members and will need to support awareness, compliance, and navigation of new requirements.听
  • Identify and support at-risk populations. Plans can help flag members likely to qualify for exemptions and assist with documentation and care coordination to reduce inappropriate disenrollment.
  • Prepare for enrollment volatility.听Increased churn听driven by documentation delays and administrative barriers听may affect financial performance,听care听continuity, and quality outcomes.听
  • Align with state expectations and funding constraints.听Because these activities fall outside traditional听Medicaid听benefits, states and plans must carefully define roles, accountability, and funding mechanisms.听

Implications for Providers: A New Interface with Eligibility Systems 

Providers, particularly safety net organizations, will be directly affected by new documentation and enrollee support responsibilities and should be prepared to address the following: 

  • Expand administrative and clinical workflows.听Providers will increasingly be asked to support medical frailty determinations, document functional limitations, and provide verification related to exemptions.听
  • Prepare for increased administrative burden.听New documentation requirements and coordination with plans and states will听require听operational adjustments, particularly for organizations serving large Medicaid populations.听
  • Mitigate impacts of coverage disruption.听Gaps in coverage鈥攐ften tied to procedural barriers鈥攎ay disrupt care continuity, particularly for high听need populations, and increase uncompensated care.听
  • Serve as a critical partner in engagement efforts.听Providers are uniquely positioned to听identify听at-risk individuals, educate patients, and support compliance,听making them essential to implementation success.听

Many of the most complex determinations鈥攕uch as medical frailty and caregiving鈥攃annot be fully automated, requiring nuanced policy design and consistent operational execution. As a result, successful implementation will depend on the following: 

  • Standardized documentation and review processes听
  • Integrated data systems and verification pathways听
  • Clear division of responsibilities听across听interest-holders听
  • Coordination across policy, operations, and frontline personnel听

Act Now to Influence Community Engagement Rollout 

States and stakeholders face dual, immediate priorities鈥攑reparing for implementation and engaging in the federal rulemaking process. CMS is accepting comments on the IFR through July 31, 2026, creating a critical opportunity to shape final policy while building operational readiness. At the same time, the compressed timeline to 2027 for implementation underscores the need for rapid decision-making on policy design, systems investments, and partner engagement. 

The Medicaid community engagement requirements represent one of the most significant operational transformations in the program鈥檚 60-year history. To succeed, organizations should act early, coordinate with interest-holders, and design implementation strategies that balance compliance, administrative efficiency, and coverage continuity. 

Now is the time to: 

  • Establish cross-functional governance and implementation plans听
  • Evaluate verification strategies and data integration opportunities听
  • Define roles and expectations across plans, providers, and partners听
  • Develop targeted communication and engagement strategies听
  • Conduct readiness assessments and system testing听

量子资源网 can actively support state policymakers, health plans, and providers as they in navigate these challenges. For details, access the full 量子资源网 Issue Brief and explore the Community Engagement State Support Hub.

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New Funding Approaches Prompt Maryland Healthcare Leaders to Reassess Strategies for Affordable Coverage

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Strategies to improve healthcare delivery, sustain coverage, and manage growing cost pressures resulting from federal policy changes and state budget dynamics were key topics of discussion at this year鈥檚 , May 21, 2026, in Baltimore, MD. Hosted by (SOR), an 量子资源网 Company, the program convened state policymakers and leaders of health plans, provider groups, and community-based organizations to examine the most pressing healthcare issues in Maryland.

Across sessions, participants explored key policy priorities, including Maryland鈥檚 implementation of the Rural Health Transformation Program (RHTP), efforts to stabilize and expand health insurance coverage, and early lessons from implementing the AHEAD (Achieving Healthcare Efficiency through Accountable Design) total cost of care (TCOC) model. 

Sustaining Medicaid and Marketplace Accessibility Amid Federal Policy Changes 

Throughout the conference speakers and attendees engaged on myriad issues and concerns resulting from the 2025 budget reconciliation act, now referred to as the Working Families Tax Cuts (WFTC) Act, and its potential impact on state Medicaid programs and coverage stability. Maryland Deputy Secretary for Healthcare Financing and Medicaid Director Perrie Briskin joined Johanna Fabian-Marks, Deputy Executive Director of the Maryland Health Benefit Exchange (MHBE), and Melissa Horn, Director of State Legislative Affairs at the Arthritis Foundation, to examine strategies for mitigating coverage loss and maintaining affordability. 

Speakers emphasized the need for improved coordination between Medicaid and the MHBE, including clear and consistent consumer communications and targeted outreach in counties most affected by federal policy changes. 

For example, Maryland leaders described several innovative approaches the MHBE is using to help people in the state maintain Marketplace coverage, including state-funded subsidies to offset the expiration of enhanced premium tax credits, streamlined auto-renewals, and simplified enrollment pathways for individuals identified as uninsured based on their tax and employment records. The state reported an 8 percent decline in enrollment in April 2026, noting that without these mitigation strategies, enrollment could have dropped by as much as one-third. 

The MHBE is using artificial intelligence (AI) to support document verification and is deploying a chatbot to help consumers navigate common questions. 

On the Medicaid side, the state is consulting multiple data sources鈥攊ncluding CRISP (Chesapeake Regional Information System for our Patients), labor, and education data鈥攖o verify eligibility and, compliance with community engagement requirements to reduce administrative burdens.

Rural Health Transformation Program Implementation and Early Priorities 

Maryland鈥檚 RHTP, supported by nearly $168.2 million in first-year funding from the Centers for Medicare & Medicaid Services (CMS), was a hot topic at the conference. State leaders and implementation partners emphasized the program鈥檚 role in addressing rural health disparities, strengthening care delivery infrastructure, and improving chronic disease outcomes.

Elizabeth Kromm, PhD, Assistant Secretary, Maryland Department of Health, outlined the three pillars of the state鈥檚 RHTP plan: 

  • Expand the rural healthcare workforce听
  • Increase access to integrated primary, specialty, and behavioral health services听
  • Address the underlying drivers of chronic disease through nutrition and food system interventions听

Together, these initiatives highlight Maryland鈥檚 focus on both clinical care delivery and broader population health strategies. 

State officials also discussed the funding opportunities  in April 2026, one of which seeks to support care delivery innovation, improve chronic condition management, and advance value-based care models. Speakers emphasized that connection is central to the program鈥檚 success鈥攂oth the strength of community relationships, the connections enabled through technology, and the integration of clinical and nonclinical services. 

AHEAD Model: Advancing Total Cost of Care and Population Health 

Maryland鈥檚 participation in CMS鈥檚 AHEAD Model represents a significant shift toward healthcare cost containment and system transformation. As one of the first states to implement the framework, Maryland is testing a statewide approach to managing TCOC while improving quality and population health outcomes. 

A panel discussion including leaders from the MedChi, Johns Hopkins, CareFirst Blue Shield, and Kaiser Permanente, addressed implementation considerations, open policy implications, and how providers and payers were approaching these changes in payment for healthcare services. Reimbursement strategies for primary care services were still uncertain and may differ significantly from those used under the Maryland TCOC model. Panelists also discussed what this model means in the broader healthcare environment of reductions in Medicaid payments resulting from the reconciliation legislation and additional funding coming from the Rural Health Transformation Fund. They also described how Maryland could serve as an example for other states working to implement AHEAD in the coming years. 

Speakers noted that successful implementation will require strong coordination among providers, payers, and state agencies, and more details are necessary to fulfill the requirements. The model鈥檚 10-year timeline positions Maryland as a leading test case for future federal and state efforts to scale TCOC approaches. 

AI in Healthcare: From Innovation to Real-World Impact 

AI鈥檚 role in healthcare delivery and policy continues to evolve, with growing attention on its practical applications and regulatory implications. A session led by 量子资源网 (量子资源网) Principal Brandon Greife, JD, and speakers from Microsoft AI, the Pair Team, the Center for Virtual Care, and b.well Connected Health explored how healthcare organizations conceptualize AI use cases to deploy solutions that demonstrate measurable impact. 

AI holds promise for improving care delivery, but realizing that potential requires navigating ethical, regulatory, and operational challenges. Mr. Greife led a panel discussion on how the healthcare industry is transitioning from abstract use cases for AI toward evaluating the real-world impact of deployed solutions. 

Session speakers also explored how healthcare is advancing from AI tools that support clinicians and payers to patient-facing AI that supports care navigation, chronic disease management, and community outreach. They rounded out the session with a focus on fundamentals of healthcare鈥攃oncepts like data quality, clinical trust, patient safety, and demonstrated value at the point of care. 

Looking Ahead 

If you are looking for strategies and solutions to address urgent healthcare policy and operational challenges, 量子资源网 experts are available to help you navigate these complex changes and identify practical paths forward. 

Through the ,  partnership events, and other 量子资源网 convenings across the country, we connect state leaders, providers, health plans, and community stakeholders to share insights, elevate lessons, and advance solutions. Join us at an upcoming event鈥攊ncluding our next 量子资源网 National Conference in New Orleans, LA on October 5-7, 2026鈥攐r explore additional opportunities to engage with 量子资源网 and access the full schedule of conferences and resources. 

State of Reform develops its conference agendas through collaboration with 量子资源网 subject matter experts/market leads and stakeholders across the public and private sectors, including state officials, community-based organizations, providers, payers, and more. 

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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听
  • Target specific provider types or services听
  • Support delivery system reforms听

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听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听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听Across Programs听and Delivery Systems.听The proposal听seeks听to align听the limitations on practitioner payments under听fee-for-service听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听time period听as the Medicaid state plan rate year.听The crosswalk of Medicaid payment rates to Medicare will听likely be听administratively burdensome鈥攅specially for states that set Medicaid rates using an entirely different听methodology听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听participating听in Medicaid financing and delivery.听For example, the WFTCA听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听and other changes to eligibility and redetermination rules听included in听a June 1, 2026,听interim final rule听
  • Program integrity and oversight initiatives听
  • Changes to financing structures and supplemental payments听

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听
  • The extent to which existing arrangements will be grandfathered听in听or phased down听
  • How states respond in redesigning Medicaid payment strategies听

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. 量子资源网鈥檚 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 量子资源网鈥檚 Medicaid experts. 

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Connecting the Dots: Key Trends, Plan Shifts, and 2027 NBPP Changes Affecting ACA Marketplace Enrollment

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Explore how 2026 ACA Marketplace enrollment shifts, plan selection trends, and the 2027 NBPP changes are impacting affordability, market stability, and state strategies. 

Recent 量子资源网 (量子资源网) webinars and reports discussed that Affordable Care Act (ACA) Marketplace enrollment trends are evolving rapidly and the takeaways go beyond total enrollment numbers. In addition in May, the Centers for Medicare and Medicaid Services (CMS) finalized the 2027 Notice of Benefit and Payment Parameters (NBPP), introducing new flexibility for plans and states alongside stronger program integrity requirements. 

To understand how these changes are reshaping the ACA Marketplace,  Andrea Maresca鈥痵poke with鈥�Zach Sherman, Managing Director for Coverage Policy and Program Design at 量子资源网 as well as , PhD, Principal鈥痑t Wakely, and , Principal at Leavitt Partners, both 量子资源网 companies.

Q: The recent Wakely analysis has been central to understanding what鈥檚 happening with ACA enrollment. What should people be paying closest attention to? 

Michael Cohen: The key takeaway is that ACA Marketplace trends are about much more than the enrollment numbers. The plans consumers choose, how long they maintain coverage over the course of 2026, and the evolving picture of the morbidity and demographics of the enrolled population are all critical factors for understanding the ACA Marketplace.

翱耻谤听谤别肠别苍迟听听found that听only about 86 percent of enrollees paid their firstpremium听in听2026.听That鈥檚听a strong indicator that affordability pressures are already affecting coverage听stability.听听

Q: Where are these enrollment changes showing up most clearly?  

Michael Cohen: One data point that stood out is the number of new consumers in 2026, which was down 13 percent compared with prior years.  

The impact also shows up in coverage losses and consumer plan selection. Some consumers are dropping coverage altogether, while others are making tradeoffs to stay covered. These consumers are moving to lower-premium products鈥攑articularly from silver to bronze plans鈥攚hich offer less robust coverage and higher out-of-pocket costs. Both trends matter, especially when thinking about access and financial risk. 

Q: How are enrollment shifts affecting broader ACA Marketplace stability? 

Zach Sherman: It varies by state, but there are notable trends. States that are using the Federally Facilitated Exchange (FFE) and expanded Medicaid saw the largest enrollment declines.  

Notably, non-expansion states on the FFE significantly outperformed expansion states. This was surprising because, with enhanced subsidies ending, the biggest net premium hit consumers would feel is at the lowest income levels, yet that鈥檚 where we saw most enrollment growth. 

Across the individual states, the enrollment shifts have real implications for stability. When healthier individuals leave the market鈥攐r shift to less comprehensive coverage鈥攊t can put pressure on premiums and risk pools. Issuers are taking this information to begin to make estimates for their 2027 pricing and what this means for their 2026 performance.  

At the same time, CMS is introducing new flexibilities in the final 2027 Notice of Benefit and Payment Parameters. 

Q: What are the most important changes in the 2027 final rule? 

Zach Sherman: Broadly, the rule makes a clear push toward increased flexibility for consumers, plans, and state regulators. 

One of the categories of changes is around expanded availability of lower premium plans with higher out-of-pocket costs. For example, catastrophic plans can now be offered for up to 10 years. 

CMS also removed certain requirements for standardized plans and relaxed limits on non-standard plan offerings. That gives issuers more room for plan design innovation, but it also means a more complex landscape and plan selection experience for consumers. 

One of the most notable changes is the introduction of non-network plans as qualified health plans. These plans don鈥檛 rely on traditional provider networks, which could lower costs while introducing new considerations for access and consumer experience.  

We鈥檙e seeing a shift toward allowing more tailored options and potentially less standardized marketplace programs. It will require a different approach from regulators, and it creates a different type of experience for consumers.  

Q: CMS is intensely focused on addressing fraud, waste and abuse. How is that playing out in the Marketplace program? 

Zach Sherman: Program integrity is a central theme in the 2027 final rule, too. It includes stronger eligibility verification, increased oversight of brokers and marketing practices, and new safeguards to reduce improper enrollments. So while there鈥檚 more flexibility in plan design, CMS is pairing it with more scrutiny on how the system operates. 

Q: Where do states fit in all of this? 

Zach Sherman: The final rule gives states more authority in key areas, including oversight of plan network adequacy and essential community provider compliance. We鈥檙e deep into discussions with states and health plan issuers about the changes they鈥檙e interested in exploring for their state. States will have to decide how to use that flexibility to balance affordability, access, and stability. 

Although many of the provisions take effect in the 2027 plan year, regulators and plans are receiving this information fairly late in the cycle which will make it difficult to incorporate some of the flexibilities. We鈥檙e anticipating robust discussions to continue next year and expect to see more variation starting in plan year 2028. 

Differences and Alignment in Federal ACA Marketplace Policy Discussions  

Q: Stepping back from the 2027 NBPP, what should interest-holders know about the evolution of the broader policy landscape? 

Liz Wroe: Members of Congress will need to see the 2027 rates being filed before they consider taking action. Even then, there鈥檚 no consensus on several key issues that prevented a bipartisan deal to bring back enhanced subsidies in 2025. 

Instead everyone has transitioned to a larger affordability conversation, and we鈥檒l spend this year working on the policies with a goal of moving forward in 2027.  

There are different approaches to affordability and coverage that are driven by fundamentally different philosophies on how to structure the market. Some proposals focus on expanding subsidies, reducing cost sharing, and strengthening ACA protections. Others emphasize consumer-directed models like defined contributions, health savings accounts, and expanded use of ICHRAs [Individual Coverage Health Reimbursement Accounts] as well as broader access to lower premium plans. 

There are also several areas of bipartisan alignment. Prior authorization reform is a big one. There鈥檚 broad agreement that the current system creates administrative burden and delays in care. 

We鈥檙e also seeing common interest in policy approaches to strengthen medical loss ratio [MLR] requirements, expand price transparency, and address provider consolidation. 

Even if there is divided government after the November elections, these are areas where policy action may be more likely. States, health plans, providers, and other interest holders will want to monitor these issues now for signals of what may move forward later this year or in the next Congress. 

Stakeholder Opportunities to Inform Marketplace Programs 

Q: What should stakeholders be focused on right now? 

Michael Cohen: For issuers, it鈥檚 about understanding how these changes affect pricing, enrollment, and risk. There鈥檚 more uncertainty in how plans should be priced. 

Zach Sherman: For states, the focus should be on strategy. The choices they make now on plan oversight, market structure, and consumer protections will shape outcomes for several years. Additionally, there were several proposed Marketplace policies that CMS did not finalize in the 2027 rule鈥擲tate-Based Exchange Enhanced Direct Enrollment Model鈥攖hat CMS is likely to revisit in future rules, including the 2028 NBPP.   

Liz Wroe: Broadly, stakeholders should recognize that we鈥檙e in a transition period. The market is evolving, and policy is still catching up. 

Connecting the Dots: Enrollment, Rules, Regulators, and the ACA Marketplace 

For stakeholders across the healthcare landscape, navigating this environment requires both technical expertise and strategic insight. 

量子资源网 works across policy, actuarial, and operational domains to help states, health plans, and other stakeholders translate these developments into actionable strategies鈥攚hether that means evaluating market risk, designing programs, or preparing for future policy scenarios. 

To explore these issues in more detail, access 量子资源网鈥檚 webinar discussions and briefs, including: 

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What听you missed in 2025鈥攁nd why you should join us in 2026听

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Last year鈥檚 量子资源网 conference brought together healthcare leaders to confront a changing landscape across Medicare, Medicaid, and the Marketplace. The agenda reflected the issues shaping the industry in real time: public policy in motion, the future of value-based care, behavioral health innovation, digital transformation, population health, and the partnerships needed to turn strategy into results. From keynote and plenary conversations to focused workshops and collaborative small-group sessions, attendees were immersed in practical discussions about what comes next. 

Want a quick look at what made the 2025 conference so valuable?  

Those conversations matter even more now. Join 量子资源网鈥檚 annual conference, US Healthcare 2026: Signals, Signs & Flashing Lights, October 5鈥�7 in New Orleans. This year鈥檚 event is designed for executives and leaders across providers, payers, government, and the organizations that enable care delivery, with a clear focus on helping attendees navigate financial pressure, performance demands, and AI-driven change. Early registration is already underway, with early-bird pricing available through August 7. 

If you look back at last year鈥檚 agenda, you can see how well it anticipated this moment. In three fast-moving days, this year鈥檚 conference will help attendees read policy and market signals earlier and translate them into decisions, manage risk and costs while protecting outcomes and access, learn what is working to sustain systems of care amid uncertainty, how to apply AI and emerging technology through real operational and clinical use cases, and build relationships through structured networking across sectors. These priorities come to life across four central themes: managing risk and costs, sustaining systems of care, AI and innovation, and partnerships and collaboration. Together, they reflect exactly what healthcare leaders need now: practical strategies for a more complex environment, clearer paths to stability, measurable approaches to innovation, and stronger models for delivery and community impact. 

The 2026 conference is not just another industry event. It is an opportunity to step away from day-to-day demands and engage with peers facing the same questions about cost, risk, performance, access, and technology adoption. Whether you lead strategy, operations, policy, clinical transformation, product development, or partnerships, you will leave with practical insights you can put to work right away. The value is not only in hearing what is next, but in understanding what to do now. 

Attendees this year can expect the same cross-sector depth that stood out last year, paired with even greater urgency. The forces affecting Medicare, Medicaid, Marketplace, and adjacent programs are not moving in isolation. Payment reform connects to access. Digital transformation connects to quality and workforce realities. Behavioral health connects to community capacity, and long-term sustainability, and governmental policy changes drive all of the above. The organizations that succeed will be the ones that can see these connections early and act on them thoughtfully. 

Last year鈥檚 conference showed the value of bringing more than 350 policymakers, providers, payers, advisors, innovators, and community leaders into the same conversation. This year offers the chance to continue that conversation at exactly the right time. If you want insight that is strategic, grounded, and immediately relevant to the decisions in front of you, come join us in New Orleans this October. 

 to take advantage of Early Bird pricing, which ends August 7. 

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Michigan Health Policy Conference 2026: Medicaid, OBBBA, and State Budget Impacts

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Michigan is preparing for significant Medicaid and budget changes under the 2025 federal budget reconciliation law (P.L. 119-21, OBBBA), with more than 200,000 residents at risk of losing healthcare coverage. At the 2026 Michigan State of Reform Conference, state leaders and stakeholders highlighted implementation challenges, fiscal pressures, and strategies to maintain access to care. 

On May 5, 2026,  (SOR), an 量子资源网 Company, hosted its annual , bringing together over 200 interest-holders, including providers, policymakers, and community-based organizations to examine how Michigan is adapting to rapid change and implementing new federal requirements.

The conference fostered candid discussion of the implications of the 2025 federal budget reconciliation act (P.L 119-21, OBBBA), with a particular focus on community engagement requirements, behavioral health, Michigan鈥檚 budget outlook, and the Rural Health Transformation Program (RHTP). 

Michigan DHHS鈥檚 Top Health Policy Priorities in 2026 

The day opened with a presentation from Meghan Groen, Chief Deputy Director of the Michigan Department of Health and Human Services (DHHS). Ms. Groen shared her department鈥檚 priorities and strategies, including implementation of OBBBA requirements and RHTP.  

Medicaid community engagement requirements and six-month eligibility redeterminations are the most immediate operational challenges for DHHS. Michigan also is advancing a set of readiness activities, including internal assessments, coordinated planning, leadership alignment, and regular communication with the Centers for Medicare & Medicaid Services (CMS). 

Another top priority Ms. Groen identified was expanded access to behavioral health. In a discussion focused on programmatic changes in behavioral health, panelists discussed how Michigan is using multiple tools, including Certified Community Behavioral Health Centers (CCBHCs), crisis stabilization units, and psychiatric residential treatment facilities (PRTFs), to address access gaps. Panelists Kristen Morningstar, Director of Michigan鈥檚 Bureau of Specialty Behavioral Health Services and Robert Sheehan, Chief Executive Officer, Community Mental Health Association of Michigan, shared how DHHS continues to collaborate with behavioral health providers to optimize service delivery and better meet member needs. 

How OBBBA Will Affect Michigan Medicaid Coverage and the State Budget 

Across sessions, speakers鈥攊ncluding Danielle Devine, Market President at McLaren Health Plan, and Jen Flood, Budget Director for the State of Michigan鈥攈ighlighted how OBBBA is already reshaping Michigan鈥檚 Medicaid program and broader fiscal outlook. These changes have direct implications for Medicaid financing and long-term planning and are a driver for the state鈥檚 $1 billion budget shortfall. Significantly, Michigan Gov. Gretchen Whitmer has recommended approximately $800 million in new taxes from tobacco and vaping to supplement the budget. The governor has also formed a working group of hospitals, health plans, providers, and other stakeholders to identify options for saving $150 million. 

DHHS projects that more than 200,000 individuals in Michigan are at risk of losing Medicaid coverage. Panelists discussed the downstream effects, including disruptions in care, a rising rate of uninsured residents, and increased financial strain on families and providers. Stakeholders shared concerns about increases in uncompensated care, food insecurity, and household debt. 

Panelists emphasized that navigating this environment will require close collaboration across the delivery system. 

How Michigan Is Using the Rural Health Transformation Program 

Amid the broader changes in the healthcare landscape, RHTP is emerging as a key strategy for sustaining and strengthening access to care in Michigan鈥檚 rural communities. Speakers such as Lauren LaPine-Ray, DrPH, MPH, Vice President, Policy & Rural Health at the Michigan Health & Hospital Association, emphasized the importance of aligning financing strategies, partnerships, and policy levers to optimize the impact of these investments. Michigan has already  RHTP funding to multiple entities to support implementation at the local level. 

Looking Ahead 

The challenges that Michigan is facing are not unique, and the need for shared insight and practical solutions is only growing. 

If you are looking for strategies and solutions to address urgent healthcare policy and operational challenges, 量子资源网 experts are available to help navigate these complex changes and identify practical paths forward. 

量子资源网 (量子资源网),  brings together state leaders, providers, plans, and community organizations to surface real-world strategies for navigating federal change. Join us in  on May 21, 2026, or visit the  to view the full conference schedule and register for an upcoming event. 

State of Reform develops its conference agendas through collaboration with 量子资源网 subject matter experts/market leads and stakeholders across the public and private sectors, including state officials, community-based organizers, providers, payers, and more. 

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National Collaborative Launched to Strengthen US Behavioral Health Crisis System

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National Alliance on Mental Illness (NAMI) and 量子资源网 (量子资源网) launch the National Collaborative for Crisis Systems Innovation 

The United States is facing an escalating behavioral health crisis, with growing demand for mental health and substance use services and persistent gaps in access to timely, appropriate care. In response, the National Alliance on Mental Illness (NAMI) and 量子资源网 (量子资源网) have launched the National Collaborative for Crisis Systems Innovation, a new initiative focused on improving how the United States responds to people in mental health crisis. 

This collaborative effort comes at a critical moment for the national crisis response system, as policymakers, providers, and communities work to build on recent investments and make further progress on sustainable, systemwide changes so that people experiencing a mental health crisis receive the care they need and deserve. 

The Crisis Response System Still Needs Improvement 

The launch of the 988 Suicide & Crisis Lifeline in 2022 marked a major milestone, making it easier for individuals to access immediate behavioral health support. Although the 988 Suicide & Crisis Lifeline has driven recent progress, significant challenges remain in the US mental health crisis system, including: 

  • Rising demand for crisis services听
  • Limited access to community-based behavioral health听services听
  • Fragmentation across crisis responses systems听
  • Overreliance on emergency departments and law enforcement听

Experts increasingly agree that 988 is only one component of a comprehensive crisis system. Effective systems must also include: 

  • Mobile crisis response teams听
  • Crisis stabilization facilities听
  • Ongoing care coordination and follow-up services听

The National Collaborative represents the next phase of work and will focus on connecting these pieces into a more integrated and sustainable system. 

The National Collaborative Is a New Phase of Crisis System Transformation 

Building on four years of foundational work since the 988 Suicide & Crisis Lifeline launched in 2022, the National Collaborative is designed to strengthen the full continuum of behavioral health crisis care, from initial contact to stabilization and follow-up services. 

Its overarching goal is to ensure that individuals experiencing a mental health crisis receive timely, appropriate care rooted in dignity and support. The National Collaborative will: 

  • Serve as a nationwide听hub for coordination, learning, and action听
  • Bring together public and private stakeholders听across sectors听
  • Support听states and communities in building coordinated, person-centered crisis response systems听
  • Advance innovation and shared solutions to improve outcomes听

The launch of this collaborative also reflects a broader shift in national focus鈥攆rom expanding access to improving system performance and long-term sustainability. This approach recognizes that meaningful progress will require coordination across healthcare, social services, and community-based organizations. 

Why This Matters 

For state Medicaid agencies, health plans, and providers, the collaborative provides a platform to: 

  • Learn from peers across states and sectors听
  • Access emerging policy and implementation insights听
  • Align local strategies with national priorities in crisis care听

As crisis system transformation accelerates, coordinated efforts like this one will be essential to sustain momentum and improve outcomes. 

In the coming months, NAMI and 量子资源网 will engage key interest-holders and experts to identify and elevate the urgent needs in crisis response and ensure alignment on shared outcomes to improve crisis systems. Public and private organizations interested in improving behavioral health crisis systems are encouraged to engage with the . 

For more information on 量子资源网鈥檚 work in Crisis services, contact鈥�Monica Johnson, Managing Director, 量子资源网. 

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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)听听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,听CMS听projects the听rule will听result听in听significant听federal听savings over time and听will听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.听量子资源网听(量子资源网)听experts are听continuing to听review听the proposed Medicaid payment reform听and will provide听additional听analysis in听future听newsletters and communications to听interest-holders.听听

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Turning Insight into Action: The New Operating Reality in Behavioral Health

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Thousands of behavioral health leaders, clinicians, advocates, and industry partners convened during NatCon 2026, April 27鈥�29 in Denver, CO鈥攐ne of the sector鈥檚 largest annual gatherings. This year, the event was more focused and pragmatic than in recent years. Although behavioral health providers still face significant pressure, there was also a noticeable shift toward how organizations can move toward sustainable models for growth, technology adoption, and integrated care delivery.

量子资源网 (量子资源网) colleagues attended the event to listen, connect, and contribute to the meaningful conversations. Many of the themes and industry trends we have been tracking emerged consistently throughout the conference. In this article, our behavioral health experts discuss their collective insights and the road ahead for behavioral health interest-holders.

Key Themes from听NatCon听2026听

Financial resilience听remained at the forefront.

Behavioral health organizations continue to respond to constrained funding conditions, evolving reimbursement dynamics, and the need to diversify revenue beyond unstable and uncertain grant support and rate reimbursement volatility.

Operational visibility was closely tied听to听financial resilience.

Leaders discussed the need for a clearer, more real-time understanding of their performance. Performance was considered broadly to include financial indicators, clinical outcomes, and workforce capacity. Data and measurement have moved from a 鈥渘ice to have鈥� to 鈥渆ssential鈥� for effective engagement with payers.

Innovation听conversations are shifting toward听implementation.

Artificial intelligence (AI) and digital tools were still hot topics, but the discussion has moved toward implementation and effective deployment. Conversations centered on practical use cases such as clinical documentation support, measurement-based care linked to improved health outcomes, and better integration with electronic health records (EHR).

This year鈥檚 conference highlighted enduring opportunities and challenges for the field, including:

  • Core service priorities,听such as听crisis response,听suicide prevention, collaborative care听and听increased opportunities around听Certified Community Behavioral Health Clinics听(CCHBCs), and value-based payment strategies听for financial resilience听
  • Workforce sustainability, with organizations looking听to reduce administrative burden, strengthen recruitment and retention, and support staff well-being while demand for services continues to rise

Behavioral Health Industry Trends

The industry trends emerging from NatCon 2026 suggest that behavioral health organizations are entering a more disciplined operating environment to maximize efficiencies and ensure long-term sustainability in what seems sometimes to be a chaotic environment. Organizations are placing greater emphasis on their Medicaid strategy, managed care contracting, and value-based arrangements that reward outcomes and continuity of care. There is also continued momentum behind integrated models that connect behavioral health with primary care, public health, and community-based supports. Rather than treating mental health and substance use services as isolated programs, providers are increasingly building coordinated systems that address whole-person needs across settings.

Another notable trend is that technology is becoming a clearer differentiator. Some organizations are piloting or scaling technology, while others are taking a more cautious approach. Discussions surrounding AI in particular appeared to have matured significantly, with attention moving from abstract concerns toward change management, sequencing of use cases, return on investment, governance, and clinician trust. In that sense, technology is moving from being a side initiative to a strategic differentiator.

Transformation in the Behavioral Health Field

We were struck by the level of alignment across different parts of the field. Many of the themes we heard reinforced what providers experience daily鈥攖he need to manage uncertainty while continuing to meet the growing demand for services and more intentional use of data, infrastructure, and outcomes measurement.

More broadly, the conversations throughout the conference pointed to a field that is moving toward greater pragmatism. There is still a clear need for additional resources, but there is also growing recognition that adaptability will serve an equally important role.

How听We听Can听Help

One of the most valuable aspects of NatCon is the opportunity to compare experiences across organizations and regions. The themes emerging from this year’s conference reflect broader shifts happening across the behavioral health landscape. 

A key role of our team is to connect what we hear in different settings and share it in a way that is useful for others in the field鈥攈ighlighting emerging approaches, surfacing common challenges, and creating opportunities for peer exchange.

For questions about the market dynamics or approaches to strengthen your organization鈥檚 adaptability,  contact one of our 量子资源网 experts.

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Why Children鈥檚 Behavioral Health Demands Action Now

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Practical Strategies for Medicaid, Schools, Hospitals, and Communities

During Children鈥檚 Mental Health Awareness Week, May 3鈥�9, and Mental Health Awareness Month, we are spotlighting actionable solutions across the US children鈥檚 behavioral health system. This post is intended for children鈥檚 behavioral health providers, state Medicaid agencies, school-based health centers, hospitals, local government agencies, local education agencies (LEAs), child welfare agencies, and philanthropic organizations that are working to strengthen prevention, crisis response, care coordination, and community-based continuums of care. 量子资源网 has a robust and growing team of behavioral health experts who support this work and have developed a series of case studies showcasing practical strategies implemented with clients鈥攆rom crisis system design and referral pathway improvements to financing and implementation roadmaps.

Children鈥檚 Mental Health Awareness Week is a reminder that children鈥檚 behavioral health and youth mental health are not niche issues. They are systemic issues that require coordinated action across Medicaid, education, public health, hospitals and health systems, child welfare, and local government鈥攅specially where schools and community partners are on the front line.

The need remains substantial. The Centers for Disease Control and Prevention鈥檚 results, released in 2024, showed that 40% of high school students reported persistent feelings of sadness or hopelessness, even as some measures improved from 2021 levels. CDC also highlighted how bullying, safety concerns at school, racism, unfair discipline, and frequent social media use are tied to youth mental health risks.

The Substance Abuse and Mental Health Services Administration鈥檚 (SAMHSA鈥檚) , released in 2025, adds another important dimension. Among adolescents ages 12鈥�17, the 2024 survey found that:

  • 15.4% experienced a major depressive episode within the past year
  • 10.1% had serious thoughts of suicide
  • 量子资源网 40% who had a major depressive episode in the past year did not receive mental health treatment

The data show that progress is possible when systems respond with real capacity, access, and support. That is why this moment calls for more than awareness. It calls for action that is operational, financeable, and grounded in what works.

At 量子资源网, we work with child-serving systems that are trying to solve real problems, including how to strengthen crisis response, improve referral pathways, build a more coherent continuum of care, and connect strategy with implementation.

Over the coming weeks, we will feature three examples that reflect different parts of the children鈥檚 behavioral health landscape.

1. Children鈥檚 hospital mental health strategy and crisis response

This case study will highlight work to help a children鈥檚 hospital strengthen its mental health approach and support next-stage crisis system design.

In this engagement, 量子资源网 partnered with Rady Children鈥檚 Hospital Orange County to move pediatric behavioral health from strategy to implementation鈥攁ligning emergency department (ED) mental health workflows, clarifying pediatric crisis pathways, building an investment-ready fiscal pro forma, and advancing priority programs to strengthen access and care coordination. This work can inform hospitals and health systems, Medicaid agencies, and community partners seeking to reduce ED boarding and improve pediatric crisis response.

2. County-level ecosystem and referral system improvement

This case study will show how local systems can bring multiple stakeholders together to improve referral pathways and make behavioral health more accessible for children, youth, and families.

量子资源网 supported a county-led effort to strengthen cross-system referral pathways by aligning agencies around shared intake and triage practices, clearer roles and accountability, and more navigable access points for families. This approach is relevant for local government agencies, LEAs, school-based health centers, child welfare agencies, and community providers working to reduce fragmentation and speed connection to the right level of care.

3. Building a stronger children鈥檚 behavioral health continuum in New Orleans

This case study will focus on assessing gaps, identifying opportunities, and supporting a more coherent community-based continuum for children鈥檚 behavioral health.

量子资源网 helped deliver the first integrated view of pediatric behavioral health in New Orleans, LA, aligning schools, healthcare, philanthropy, and government around a shared understanding of unmet needs and critical system gaps, as well as charting a prioritized roadmap to strengthen and better coordinate the continuum of care.

What It Means for Key Child-Serving Audiences

  • Children鈥檚 behavioral health providers: Prepare for stronger care coordination expectations (warm handoffs, follow-up after crisis, shared care plans) and increased demand for community-based alternatives to the ED
  • State Medicaid agencies: Focus on financeable crisis continuums (including pediatric crisis response), payment and contracting approaches that support access and continuity, and data/reporting that demonstrates outcomes
  • School-based health centers and LEAs: Strengthen referral pathways, clarify roles between schools and providers, and build protocols that support early identification while keeping students connected to safe learning environments
  • Hospitals and health systems: Improve pediatric ED mental health workflows, create clearer crisis pathways, and develop investment-ready business cases for behavioral health capacity and partnerships
  • Local government agencies: Convene cross-system partners, establish shared intake/triage and accountability, and use implementation roadmaps to move from planning to operational change
  • Child welfare agencies: Align behavioral health access for children and youth involved with child welfare, reduce handoff failures, and integrate crisis planning into placement stability and permanency strategies
  • Philanthropy: Target catalytic investments that fill continuum gaps, build capacity for implementation (not just planning), and support cross-system governance and measurement

The common thread among these examples is a simple belief: Children鈥檚 behavioral health improvement does not happen through aspiration alone. It happens when organizations and public systems translate urgency into design, partnerships, financing strategies, and implementation steps.

That is also why children鈥檚 behavioral health is so relevant. National data still point to high levels of distress and suicide risk among adolescents, despite recent improvements. CDC鈥檚 findings show how strongly youth mental health is shaped by the environments in which they live, learn, and play鈥攅specially their schools and communities.

For leaders in Medicaid, behavioral health, child welfare, education, county government, hospitals, and provider organizations, the question is not whether children鈥檚 behavioral health deserves attention, but rather is how to build systems that respond earlier, coordinate better, and support children and families more effectively.

We hope this series contributes to that conversation by sharing practical examples of work that can inform future action.

Other Resources on Children鈥檚 Behavioral Health and Youth Mental Health

Contact us to discuss how 量子资源网 can support your children鈥檚 behavioral health strategy鈥攚hether you work for a Medicaid agency, hospital/health system, school-based health partner, LEA, local government agency, child welfare agency, provider organization, or philanthropic funder. We can help with crisis continuum planning, care coordination design, referral pathway improvement, financing and pro forma development, and implementation support.

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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听risk and cost amid continued financial pressure. Discussions will examine听the drivers of听utilization听and affordability trends across Medicare, Medicaid, and commercial markets and which听strategies are听demonstrating听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听(AI)听and digital health tools are delivering measurable operational or clinical impact听and听what it takes to implement them effectively.听
  • Building partnerships听that last.听Conversation听will highlight how stakeholders are听aligning incentives,听funding,听and strategy to move from short-term听responses to long-term, sustainable听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. 

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Outlook 2026: A Conversation on Medicare Draft Payment Rules

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As the Centers for Medicare & Medicaid Services (CMS)听advances through the 2027 Medicare payment rule cycle, stakeholders across Medicare Advantage (MA) and the provider community are assessing how proposed changes could affect payment, utilization, and longer-term revenue. To better understand what to watch as draft rules move toward finalization,听Jen Colamonico, Vice President, Strategy and Communications at 量子资源网 (量子资源网), caught up with Senior Consulting Actuary with Wakley, an 量子资源网 Company. Of particular interest was CMS鈥檚 decision to eliminate the Inpatient Only List (IPO) over a three- year period.

Q: As CMS begins releasing draft payment rules for 2027, what stands out most to you from a budgetary perspective?
Rachel: Timing and uncertainty really stand out. These policies don鈥檛 operate in isolation. Changes to Medicare fee-for-service (FFS) payment ultimately affect Medicare Advantage benchmarks, provider contracting, and long-term revenue expectations. Because bids, budgets, and contracts are set before rules are finalized, modeling different scenarios becomes essential. 

Q: One issue that has garnered significant interest is CMS鈥檚 decision to phase out Medicare鈥檚 Inpatient Only (IPO) policy, which is a list of procedures and services that must be provided on an inpatient basis. In 2026, CMS eliminated nearly 300 services, mostly musculoskeletal services, from the IPO list. How are Medicare Advantage plans thinking about the Inpatient Only list specifically? 

Rachel: Historically, many MA plans have followed the IPO policy even though they weren鈥檛 required to do so, largely because it simplified operations and aligned with Medicare fee-for-service payment systems. Plans do have flexibility in how they contract with providers, and we see a wide range of approaches in the market. Some contracts closely mirror FFS, while others incorporate more customized arrangements or risk sharing. Because of that, the direct impact of IPO changes will vary significantly across plans and provider relationships. 

Q: Where do you see the biggest potential impact for Medicare Advantage?
Rachel: I think the bigger impact may be indirect rather than tied to individual contract changes. Medicare Advantage benchmarks are driven by underlying fee-for-service spending trends. If CMS anticipates lower overall inpatient spending as procedures move to outpatient or ambulatory surgical center settings, that expectation could show up in benchmark growth rates. Even relatively small changes in benchmark growth can affect plan revenue, rebates, and benefit flexibility. 

Q: Are you already seeing signs of that in the data?
Rachel: We do see lower inpatient trends reflected in the 2027 and 2028 US per capita cost projections. It鈥檚 still unclear what鈥檚 driving those trends鈥攚hether its assumptions related to the IPO list removal or other factors. We鈥檝e asked CMS for more clarity. From an actuarial standpoint, understanding what鈥檚 baked into those projections is critical, because so many MA financial decisions flow from them. 

Q: How does this uncertainty affect provider planning, especially for hospitals?
Rachel: Providers are understandably concerned about potential revenue shifts if cases move out of the inpatient setting. But in Medicare Advantage, the picture is more nuanced than in fee-for-service. Many MA arrangements include risk sharing, medical loss ratio targets, and quality incentive payments. If overall costs decline, providers may share in savings through those mechanisms. So, while there may be pressure on inpatient revenue, it鈥檚 not necessarily a one directional loss. 

Q: Does that mean the overall impact may be less dramatic than it appears?
Rachel: Potentially, yes鈥攅specially for organizations already participating in value-based arrangements. A reduction in unit costs doesn’t automatically mean a reduction in total provider revenue in MA. The redistribution of dollars through shared savings and quality bonuses can offset some of that pressure. That鈥檚 why understanding contract structure is just as important as understanding the policy itself. 

Q: What about quality and patient safety as procedures move to lower cost settings?
Rachel: Quality is always central in Medicare Advantage, and plans are already managing a lot of complexity related to Star ratings and quality measurement. We haven鈥檛 yet seen specific quality safeguards tied to the IPO list changes, but I would expect more discussion in the forthcoming proposed rules. From the MA side, contracting remains a key lever. Plans still have flexibility to ensure procedures are performed in appropriate settings and to align incentives with quality outcomes. 

Q: What steps do you recommend to stakeholders to prepare for the final rule and for 2027?
Rachel: Modeling helps organizations understand the range of possible outcomes rather than betting on a single assumption. We鈥檙e looking at different utilization scenarios, site of care shifts, and benchmark growth trajectories. For providers, modeling can inform contract negotiations and capital planning. For plans, it helps assess revenue risk and benefit design flexibility. It doesn鈥檛 eliminate uncertainty, but it helps organizations make informed decisions. 

Q: If you could change one thing about how these policies are rolled out, what would it be?
Rachel: Transparency. The more clarity CMS can provide around cost projections and assumptions鈥攅specially those affecting benchmarks鈥攖he better positioned actuaries, plans, and providers will be to respond. So much of Medicare Advantage pricing relies on understanding how fee-for-service is expected to evolve. Greater transparency helps everyone plan more responsibly. 

量子资源网鈥檚 Medicare Practice Group Can Help 

As CMS moves closer to finalizing the 2027 payment rules, actuarial modeling will continue to be an important tool for translating policy direction into financial strategy. For MA plans and providers alike, early analysis and scenario planning can help mitigate risk and identify opportunity as Medicare鈥檚 payment landscape continues to evolve. 

For additional insights, listen to Rachel Stewart and Zach Gaumer on 量子资源网鈥檚 Vital Viewpoints podcast. Learn more about our Medicare services and solutions. 

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