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Webinar Replay – Navigating Medicaid Managed Care Shifts: Financial Pressures, Federal Policy, and Medicaid MCO Implications
This webinar was held on September 17, 2025.
Medicaid managed care organizations face mounting pressure as enrollment patterns shift, federal policy evolves, and state budgets tighten. In this webinar, experts from 量子资源网IS, Wakely, and 量子资源网 shared exclusive analysis of Medicaid Managed Care Organization (MCO) financial performance, explored the implications of HR 1 and other federal policies, and offered State and MCO perspectives.
Learning Objectives
- Interpret 2024 Medicaid MCO financial trends and historical benchmarks to anticipate future market performance.
- Assess how federal policy changes, including HR 1, are reshaping Medicaid enrollment and creating new fiscal pressures for States and MCOs.
- Evaluate state considerations around risk corridors, medical loss ratios (MLRs), and similar mechanisms in a challenging budget environment.
- Identify strategies and planning initiatives that promote resilience, sustainability, and adaptation for Medicaid managed care organizations in a shifting landscape.
This webinar was for Medicaid managed care leaders, state officials, vendors, budget officers, and investors navigating financial pressures and policy shifts.
Federal Shifts and the Potential Impacts on Healthcare Quality Oversight
This week, our聽In Focus聽section explores how recent federal shifts鈥攑articularly under the Trump Administration鈥攁re reshaping healthcare quality oversight. 量子资源网 (量子资源网) has published several analyses on the 2025 Budget Reconciliation Act (H.R. 1, formerly known as the One Big Beautiful Bill), Title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), and the 2025 Centers for Medicare & Medicaid Services (CMS) Quality Conference. Together, these federal changes and the policy priority shifts described at the Quality Conference, have implications for monitoring and oversight of healthcare quality for publicly insured, commercially insured, and uninsured individuals.
In this article, 量子资源网 experts highlight potential areas for state Medicaid programs, healthcare organizations, and other industry partners to watch for as the rollout of new policies and programs begins to affect programs that monitor quality and creates the imperative to develop new oversight mechanisms.
Overview of Key Federal Policy Shifts
2025 Budget Reconciliation Act/H.R. 1
In July 2025, President Trump signed H.R. 1, the sweeping budget reconciliation legislation that directly affects publicly financed health coverage. Notable policy changes with quality implications include:
- Mandatory six-month redetermination and community engagement for select populations
- Stricter rules on healthcare-related provider taxes and state-directed payment policies
- Elimination of Affordable Care Act (ACA) subsidy eligibility for certain lawfully present immigrants
- An end to conditional eligibility for ACA subsidies, as well as passive re-enrollment
- Required compliance with community engagement and work policies
Personal Responsibility and Work Opportunity Reconciliation Act of 1996
On July 10, 2025, the US Department of Health and Human Services () and other agencies, redefined 鈥渇ederal public benefits鈥� to exclude individuals with 鈥渦nsatisfactory immigration status鈥� from certain healthcare programs. Examples include Certified Community Behavioral Health Clinics (CCBHCs), Community Health Centers/Federally Qualified Health Centers (FQHCs), grant-funded programs administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), and Title X Family Planning.
2025 CMS Quality Conference
During the 2025 , Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz and senior CMS officials, emphasized CMS鈥檚 and HHS鈥檚 evolving priorities under the Trump Administration. Notable priorities include empowering patients with data, reducing waste and tackling fraud, focusing on prevention, and transitioning to digital quality measures.
Quality Oversight Impacts
Key impacts on quality monitoring programs resulting from these federal changes and evolving priorities include:
Budget constraints elevate monitoring and value-based care metrics. Reduced Medicaid funding and tighter payment rules heighten the need for real-time monitoring of value-based care metrics to ensure financial sustainability in the changing market, optimize reimbursement.
Enrollment changes challenge quality tracking. Tighter eligibility and enrollment policies are expected to decrease enrollment in Medicaid (particularly among the adult expansion population) and the Affordable Care Act Marketplace program. Frequent redeterminations may cause coverage gaps and churn, distorting quality measure denominators and complicating performance tracking 鈥� especially for preventive and chronic care metrics.
Specifically, as the population mix in publicly funded programs changes or as gaps in enrollment exceed the 30鈥�45-day continuous enrollment criteria for many quality measures, the eligible population/denominators of quality measures will likewise fluctuate. Populations that lose coverage or churn on and off eligibility rolls can result in differential impacts for various quality measures (e.g., healthier individuals losing coverage affects prevention measures more than measures of chronic disease care).
Although performance on value-based care quality measures will have increased importance, the ability to track and trend performance will be increasingly challenging. Healthcare organizations will benefit from forecasting potential changes to patient mix and volume and real-time monitoring and improvement opportunities.
Rise in uncompensated care requires new quality monitoring. H.R. 1 changes that reduce eligibility, paired with PRWORA changes that limit treatment for certain individuals who receive public benefits, are likely to lead to increases in the uninsured population and inhibit access to preventive care. These populations tend to use emergency departments more often for health issues that could have been treated earlier or more effectively in outpatient settings, yet quality oversight is limited for populations that receive care outside of publicly or commercially funded programs. New mechanisms for quality oversight鈥攁nd funding of those mechanisms鈥攚ill be needed to monitor the health of these populations.
New programs and priorities warrant updated monitoring. H.R. 1鈥檚 Rural Health Transformation Program and CMS鈥檚 dual-track quality measurement approach (鈥渢reating illness鈥� versus 鈥渕aintaining health鈥�) necessitate a reevaluation of current metrics and monitoring systems.
Implementation of digital quality measures will support these efforts when fully implemented. The accelerated movement toward digital quality measurement and interoperability may create an imperative for healthcare organizations to make the shift. For example, the transition to digital quality measures will be necessary to ensure real-time oversight and improvement of quality measures, population health analytics, maximizing value-based care payments and efficiencies needed to effectively respond to federal changes. At the same time, healthcare organizations will need strategies to effectively deploy digital quality and interoperability within and across their organizations to not just comply, but to maximize their capabilities.
Connect with Us
量子资源网 works with state agencies, payers, health systems, and providers to assess and implement quality systems, value-based care programs, performance improvement and digital health. To discuss how federal changes will affect your organization鈥檚 quality programs, contact our featured experts below.
August 27, 2025
Federal Shifts and the Potential Impacts on Healthcare Quality Oversight
What Should Quality in Healthcare Really Mean Today?
Quality is a word we all use in healthcare, but what does it truly mean for patients, clinicians, and systems striving to improve care? In this episode of Vital Viewpoints on Healthcare, Sarah Hudson Scholle, Principal at Leavitt Partners, an 量子资源网 company, and a nationally recognized expert in healthcare quality unpacks how quality has been defined and measured over the years, why measurement sometimes gets in the way of improvement, and how digital interoperability will more accurately capture true drivers of quality. Sarah also shares why engaging patients in defining their goals and outcomes is essential to creating measures that reflect what really matters in people鈥檚 lives.
Applied Behavior Analysis (ABA) Auditing Services聽
THE CLIENT
量子资源网鈥檚 team of expert behavioral health auditors from Crestline Advisors performs audits of behavioral health services, including applied behavior analysis (ABA) services, for a Medicaid health plan in Virginia (鈥渢he client鈥�). The client refers cases to 量子资源网 when there are allegations of possible fraud, waste, or abuse (FWA) concerning documentation and/or billing practices for these services.
BACKGROUND
ABA is an evidence-based behavior therapy for people with autism spectrum disorder (ASD) and other developmental disorders. In recent years, the diagnosis of ASD and subsequent demand for ABA services has increased. State Medicaid administrations and Managed Care Organizations (MCOs) are tracking increased ABA utilization and wait times for these services, and in some situations are investigating quality of care and/or FWA concerns. Types of FWA concerning ABA therapy services may include billing for services not rendered, billing for ABA services without documentation of ABA-specific interventions, billing for services by unqualified individuals, or billing more units than the documentation supports, to name a few. We have a deep bench of licensed behavioral health clinicians and coders with many years of experience in conducting audits for MCOs, state Medicaid administrations, and providers. Given our expertise, we understand the importance of the golden thread of documentation that should underlie billing, including assessments and treatment plans which identify the need for ABA services and documentation of ABA service interventions, supervision, and family training.
APPROACH
The client鈥檚 SIU team identifies providers of ABA services for whom there is an allegation of potential FWA and provides us with sample claims and medical records to review. We have developed customized audit tools to investigate the unique documentation and billing considerations for ABA. Incorporating state-specific provider/billing manual requirements, we conduct pre- and post-pay audits in which we may identify errors in documentation (misalignment with what is billed on the claim). We then provide a detailed report to the client summarizing the identified errors and potential improper payments. Our team also can assist in the pre-audit phase to develop provider communications to request medical records and provides post-audit support to MCOs to help explain findings to providers impacted by the audit, or to support the MCO in an appeal or fair hearing process.
RESULTS
This is an ongoing project that has already provided significant value to our client in a short period of time. The client鈥檚 analysis of our auditing work, which included ABA findings reports as well as findings reports for other behavioral health services, has already identified a 12:1 return on investment, based on associated recoupment of improper payments and estimated prevented loss. Our own internal ROI analysis, focused specifically on ABA audits, also identified a 12:1 benefit. By working with our team, MCOs can expect to see timely and thorough identification of potential improper payments upon which they may act to reduce FWA. Ultimately, reducing FWA leads to increased availability of services for the members who need them most and promotes improved quality of care from qualified professionals. To learn more, email .
Medicaid Coverage of Breastfeeding Support and Supplies
This report presents an independent landscape analysis by 量子资源网 (量子资源网) examining Medicaid coverage of breastfeeding services and supplies in six states: Arkansas, Colorado, Kansas, North Carolina, Oregon, and Vermont. The analysis explores the availability and implementation of lactation consultation services and breast pump benefits within these state Medicaid programs, based on policy reviews and interviews with key stakeholders. Participants included state Medicaid officials, WIC representatives, lactation providers, managed care organizations, community-based organizations, and breastfeeding experts.
Findings reveal persistent barriers to access, inconsistencies in policy execution, and implementation gaps. The report highlights effective practices currently in use and offers targeted policy recommendations to enhance service delivery, promote equitable access, and improve maternal and infant health outcomes. This analysis serves as a strategic resource for stakeholders seeking to strengthen Medicaid鈥檚 role in supporting breastfeeding families.
Building Rural Health Together: Reflections from the Ohio Rural Health Association Conference
Earlier this month colleagues from 量子资源网 (量子资源网) attended the 2025 Ohio Rural Health Association Conference. The gathering brought together providers, policymakers, and advocates from across the state to discuss one of the most pressing issues of our time: the future of rural health care in an uncertain policy and financial environment.
At a moment when federal funding and regulatory debates dominate the headlines, what stood out most was the energy and commitment among local leaders to work together on practical solutions. The challenges facing rural communities are profound鈥攈ospitals and clinics strained by reimbursement shortfalls, workforce shortages threatening access, and shifting payer dynamics creating new administrative burdens. Yet the conversations throughout the conference were grounded in resilience and collaboration, demonstrating that sustainable solutions begin at the community level.
Spotlight on Collaboration
量子资源网 was honored to contribute to this dialogue through three sessions focused on core issues shaping rural care.
- Kenneth Cochran, DSc, RN, FACHE, drew on his deep leadership experience as a former Ohio hospital CEO to highlight the urgency of workforce development. With projections of a 187,000-physician shortfall by 2037, Ken outlined integrated workforce strategies鈥攁pprenticeships, housing partnerships, and a culture of continuous learning鈥攖hat can help stabilize rural hospitals and strengthen community health infrastructure.
- Courtney Smith, RHIT, CCS, shared two critical perspectives. First, she unpacked the growing strain of Medicare Advantage in rural communities, where reimbursement often falls short and administrative requirements delay patient care. Second, she explored the complexities of Medicaid revenue cycle management, offering actionable steps rural providers can take鈥攆rom leveraging technology and analytics to streamlining wrap-around payment reconciliation鈥攖o maintain stability in an unpredictable environment.
- Jennifer Shaw, Senior Consultant, co-presented on best practices for navigating payer relationships with Courtney. She underscored how rural providers can use data to strengthen negotiations and how collaboration across hospitals, clinics, and associations creates the leverage necessary to ensure fair treatment in contracting and payment.
These discussions demonstrated the value of having clinical, operational, and policy perspectives at the table. Each 量子资源网 colleague brought not only technical expertise but also a deep appreciation for the lived realities of rural providers, ensuring our sessions were rooted in practicality.
A Landscape in Flux
The national policy context reinforces the importance of this work. Recent debates in Washington over rural health funding underscore just how fragile the financial footing of many hospitals and clinics can be. While the outcome of federal policy is uncertain, what is clear is that communities cannot afford to wait.
As 量子资源网 has noted in our broader work on rural health, effective solutions hinge on collaboration across sectors and levels of government. Whether it鈥檚 building workforce pipelines, ensuring fair payment, or streamlining operations, progress requires alignment among providers, payers, policymakers, and communities themselves.
Moving Forward
The Ohio Rural Health Association conference was a reminder that even in uncertain times, there is a powerful foundation for innovation and problem-solving when rural providers work together. 量子资源网 is proud to support these efforts, bringing decades of experience in Medicaid policy, health system transformation, and rural health strategy to bear for our partners.
As we look ahead, one lesson stands out: the path forward for rural health will not be written in Washington alone. It will be forged in places like Ohio, where providers, leaders, and communities are building practical, collaborative solutions every day.
Ohio Health Policy Snapshots
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Executive Order Addressing Homelessness: The Federal Shift Toward Institutionalization
President Trump signed an executive order (EO), , on July 24, 2025, signaling a significant shift in federal homelessness policy and the requirements for organizations that use federal dollars to address homelessness in their communities. The order emphasizes public safety and prioritizes institutionalization and mandatory treatment over housing first approaches.
The administration asserts that 鈥渢he overwhelming majority of these individuals are addicted to drugs, have a mental health condition, or both鈥� and calls for transitioning homeless individuals into long-term institutional settings through civil commitment for 鈥渉umane treatment.鈥� Below, 量子资源网 (量子资源网) outlines key elements of the EO, including provisions, key stakeholder considerations, and potential strategies to maintain care continuity amid federal changes.
Key Elements of the Executive Order
End of Housing First: The EO discontinues support for the Housing First model, directing federal agencies to prioritize mandatory treatment. The Department of Housing and Urban Development (HUD) Secretary is directed to take steps requiring treatment participation as a condition of HUD program participation.
Support for Civil Commitment Infrastructure: The federal government will assist state and local governments with technical guidance, grants, and other resources to implement civil commitment, institutional treatment, and step-down treatment standards. The Attorney General and US Department of Health and Human Services (HHS) Secretary are instructed to pursue reversal of legal precedents that restrict civil commitments for individuals with mental illness who pose risks or are unable to care for themselves.
Restructuring Federal Programs: The EO directs HHS, HUD, and the Departments of Justice (DOJ) and Transportation (DOT) to review discretionary grants and restructure programs to ensure compliance with the new guidelines, as outlined below.
- HHS Substance Abuse and Mental Health Services Administration (SAMHSA) grants will no longer support harm reduction or safe consumption efforts and has聽聽a 鈥淒ear Colleague鈥� letter clarifying which services will be funded; for example, naloxone distribution can be funded, but clean syringe distribution cannot.
- HUD will exclusively, where permissible, fund programs for women and children and revise regulations to exclude registered sex offenders.
- Some emergency law enforcement funds may be allocated for encampment removals.
Expanded Roles: The EO directs HHS to leverage the use of federally qualified health centers (FQHCs) and Certified Community Behavioral Health Clinics (CCBHCs) to reduce homelessness and ensure federal funds support crisis intervention and comprehensive behavioral health services. In addition, the Attorney General is directed to prioritize funding for the expansion of drug and mental health courts.
Notably, federal grants will prioritize jurisdictions and states that enforce laws against open drug use, urban camping, urban loitering, and urban squatting. Grant recipients must also share certain health-related data with law enforcement, as permitted by law.
Considerations for Stakeholders
States, local governments, and county jurisdictions must assess housing and homeless programs that use federal funding streams. They must consider the implications of their current program activities and, where possible, realign programs with new requirements. They may gain access to new funding for treatment beds, drug and mental health courts, crisis response, and law enforcement support but risk losing funding for those programs that use harm reduction or housing first models. Local governments could face increased jail overcrowding and legal challenges related to civil commitments and data sharing. Early examination of current programs, particularly HUD and crisis programs, as well as early planning, will be essential.
Providers may need to restructure services to comply with the new mandates, including collaboration with crisis/removal entities and law enforcement and expanded reporting. Emergency department and inpatient facilities may see increased demand, especially from uninsured individuals.
State behavioral health authorities and other stakeholders can benefit from forming advisory councils to develop ethical frameworks for civil commitments, as well as consider providing training for providers and law enforcement and propose revisions to state statutes and regulations
Homeless individuals are likely to experience increased policing, institutionalization, and loss of access to non-mandated services and housing.
What Happens Next
Federal agencies are now responsible for implementing the EO, revising grant programs, issuing guidance, and shifting funding priorities toward enforcement and institutional treatment. These changes will redefine compliance for local governments and service providers.鈥�
Health and housing organizations must quickly assess the implications of this policy shift. Strategic collaboration across sectors, including behavioral health, housing, law enforcement and judicial systems, will be essential to maintain care continuity and protect individual rights.
Connect with Us
量子资源网鈥檚 housing and homelessness and behavioral health experts are closely monitoring the evolving federal policy landscape and legal developments. We are tracking federal funding shifts, priorities, and opportunities across HHS, HUD, DOJ, and DOT, helping stakeholders align their programs with new priorities to enhance eligibility and impact.
For details about federal agency implementation of the EO and downstream effects, contact our featured experts below.
August 20, 2025
Executive Order Addressing Homelessness: The Federal Shift Toward Institutionalization
Addressing the Growing Crisis in Older Adult Behavioral Health
Imagine a 77-year-old man named Don who lives alone in his small apartment after his wife, Marcia, suddenly died a year ago. She had been his constant companion and long-time caregiver, making sure he took his medications for diabetes and bipolar disorder. Now he is socially isolated, lonely, and depressed. When he neglects to eat, his blood sugar levels tend to drop, and he becomes light-headed. He won鈥檛 call his doctors then; he doesn鈥檛 want to bother them. Besides, it was his wife who used to communicate with his doctors and psychiatric team about any concerns. Without her, he doesn鈥檛 have much motivation to do anything.
Don illustrates several U.S. demographic and epidemiologic trends:
He is a 鈥淏aby Boomer鈥� driving the ongoing aging of this country. Within the next 20 years, the number of Americans aged 65 and over will exceed the number of those under 18. The population of working age, including those available to care for older adults, will decline by 5 percent. As a result, the emerging care gap between the numbers of Americans who need care and those who can provide it will greatly increase.
Like greater numbers of older Americans, he has at least two chronic illnesses, adversely affecting his overall functioning and quality of life. According to a 2025 Centers for Disease Control research summary, chronic conditions put him at risk for higher healthcare costs[1]. The combination of chronic physical and mental health conditions will likely mean very high health care costs.
Like increasing numbers of older Americans, he has a behavioral health disorder. 量子资源网 25% of older adults have a diagnosable mental, substance use, and/or cognitive disorder. These conditions are often exacerbated by social isolation and loneliness, which is associated with increased rates of both mental and physical health problems.
Unfortunately, about half of older adults with mental or substance use disorders do not get treatment or are treated by primary health care providers who have limited training in addressing geriatric psychiatric concerns. As a result, only about a third of people who get treatment receive what is “minimally鈥� adequate treatment. Only about half of those who get treatment from mental health professionals receive adequate care.
The low utilization by older Americans of behavioral health services reflects several access challenges including:
- Access to providers who are clinically, culturally, linguistically, and generationally competent are in short supply. The shortages are most acute for rural residents. There is also a shortage of geriatric mental health professionals participating in the Medicare program.
- Service access is also problematic. Many treatment programs are in hard-to-reach locations. There is also a tremendous shortage of services in home and community settings, due to workforce shortages.
- Discrimination including stigma and ageism, plus the lack of awareness about mental illness and the effectiveness of treatment result in reluctance to seek or accept behavioral health services.
Unlike many of his contemporaries suffering from a behavioral health condition, Don does have long-standing behavioral health treatment which has been effective for most of his lifetime for managing his bipolar disorder. But without his wife鈥檚 support, his attendance and adherence have faltered. He now needs other sources of support and guidance, as well as more intensive treatment, or he faces several major risks:
- He may wind up being taken by ambulance to hospital emergency rooms for falls. *
- He may be admitted to the hospital for broken bones, diabetic complications, or even a stroke or heart attack.
- He may deteriorate further and become unable to care for himself, eventually transferring from a hospital to a long-term care facility.
- He may suffer premature death.
Older Americans, like Don, need not suffer injury and decline in addition to grievous loss. With the right systems of behavioral health, supported by care coordination and person-centered care plans, they can recover, adapt, and remain in their homes, as most Americans prefer.
量子资源网 has the expertise to create and strengthen those systems of care. To learn more about How 量子资源网 Can Help.
[1] Watson KB, Wiltz JL, Nhim K, Kaufmann RB, Thomas CW, Greenlund KJ. Trends in Multiple Chronic Conditions Among US Adults, By Life Stage, Behavioral Risk Factor Surveillance System, 2013鈥�2023. Prev Chronic Dis 2025;22:240539. DOI: