量子资源网 Insights | 量子资源网 Weekly Roundup

333 Results found.

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

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

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

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

Key Insights from Q4 2025 Data

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

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

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

Market Share and Plan Dynamics

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

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

What to Watch鈥�

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

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

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

Connect with Us鈥�

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

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

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

Read Blog

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

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

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

What to Expect in 2026

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

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

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

What the 2026 Inventory Shows

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

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

Those changes are already visible in state markets:

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

A Resource to Track State Market Direction

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

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

Looking Ahead

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

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

Connect with Us

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

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

CMS鈥檚 LEAD Model: A New Phase for Accountable Care and Application Considerations

Read Blog

罢丑别听听represents the next major step in the Centers for Medicare & Medicaid Services (CMS)听听strategy and reinforces a federal commitment to value-based participation in Traditional Medicare. Announced as the successor to听, LEAD is a voluntary, nationwide, 10鈥憏ear model that will operate from 2027 to 2036, making it the longest-running accountable care organization (ACO) model the Center for Medicare and Medicaid Innovation has tested.

Momentum around the LEAD ACO model has accelerated since CMS鈥檚 recent release of the (RFA), which formally moves LEAD from policy design to implementation. The RFA requires prospective participants to evaluate program design choices, financial implications, and operational readiness on a compressed timeline. Notably, CMS has indicated that additional opportunities to express interest will follow for organizations that are not prepared to apply for participation in the initial cohort.

This article explains key design elements of the LEAD model and identifies considerations for organizations assessing whether and when to pursue participation in LEAD.

Core Design Evolutions of the LEAD Model

While LEAD builds on many of the elements from ACO REACH, its design reflects how the Innovation Center intends to address challenges with previous ACO models, such as the Medicare Shared Savings Program (MSSP). At its core, LEAD seeks to establish a pathway to long鈥憈erm engagement in value-based care that creates an attractive option for all types of providers, including ACOs with a history of engaging in value-based care and providers that have yet to meaningfully participate.

LEAD introduces a set of targeted design changes intended to improve predictability, alignment accuracy, and long鈥憈erm participation in accountable care鈥攎ost notably through revised benchmarking, updated beneficiary alignment, and expanded flexibility for engaging specialists and high鈥憂eeds populations.

1. Revising Benchmarking Policies to Support Predictability and Success

LEAD provides a major win for ACOs seeking long-term predictability by听setting a long-term benchmark that will not rebase for the entirety of the 10-year model. In MSSP, many ACOs eventually face the 鈥渞atchet effect鈥� in which benchmarks erode after rebasing to reflect the ACO鈥檚 more recent spending patterns. It can create a significant hurdle for ACOs that have already successfully reduced spending, as their own prior success lowers their benchmark. By not rebasing for the entirety of the model period, LEAD provides an attractive alternative to the MSSP, which rebases every five years.
LEAD will also support historically successful ACOs by transitioning to a fully regional rate book by the end of the model period. As a result, benchmarks will be set based on overall spending in the region where an ACO operates rather than an ACO鈥檚 historical spending. While ACO REACH also used a regional rate book to inform some ACO benchmarks, LEAD goes further by seeking to transition all ACOs to a benchmark based听fully听on a regional rate book while also adding protections for higher-spending ACOs by transitioning regions at different timelines to ensure that newer ACOs have the opportunity to implement the kinds of care delivery changes that lead to lower spending before they are subject to penalties.
Other notable changes to benchmarking include a variety of ACO-specific adjustments and the addition of an administrative component to benchmarking.听ACOs will be eligible to receive a boost to their benchmarks with either a regional efficiency adjustment for ACOs with lower spending or a prior savings adjustment for ACOs with a demonstrated history of achieving savings. LEAD also introduces an administratively set component to benchmarking鈥攖he Accountable Care Prospective Trend鈥攚hich already is used in the MSSP, though LEAD adds a new guardrail policy to promote predictability.

2. Improving Accuracy in Beneficiary Alignment

LEAD鈥檚 new 鈥渉ybrid鈥� alignment option increases accuracy and responsiveness.听Monthly additions of voluntarily aligned beneficiaries and mid-year recognition of new participant taxpayer identification numbers (TINs) adopted after the start of the performance year (PY) allow alignment to better reflect real-time care relationships, averting lag and operational friction.

3. Adding Support for High-Needs Beneficiaries

LEAD expands support for beneficiaries with complex needs through a universal High Needs category and recalibrated risk adjustment.听By moving away from ACO REACH鈥檚 population鈥慹xclusive model, LEAD lowers barriers for organizations that serve a disproportionate share of high鈥憂eeds and dually eligible populations. In addition, CMS will test Medicare鈥慚edicaid alignment in two states, and help states develop arrangements supporting the provision of value-based care between ACOs and state Medicaid agencies or managed care organizations.

4. Promoting Deeper Engagement with Specialists

LEAD increases flexibility for engaging specialists in value鈥慴ased arrangements.听New Non鈥慞rimary Care Capitation options and episode-based risk arrangements (CMS鈥慉dministered Risk Arrangements (CARAs)), allow ACOs to share risk with specialists without Total Care Capitation, reducing operational complexity while expanding accountability beyond primary care.

5. Advancing Technology Adoption and Innovation

LEAD introduces structured pathways to promote technology adoption.听Planned Artificial Intelligence (AI)鈥慽nferred risk adjustment will be phased in following successful testing and validation, while the Tech Enabler Initiative and Rapid Cycle Innovation Program seek to reduce administrative burden and accelerate evidence generation鈥攑articularly for smaller or resource鈥慶onstrained ACOs.

Next Steps

The Innovation Center is operating on an accelerated timeline for the initial LEAD cohort. Prospective ACOs have fewer than 50 days to digest a detailed and model potential performance. Applications are due May 17, 2026. ACOs that participated in ACO REACH in PY 2026 will be well-positioned, as many of the provisions in LEAD will be familiar, and the agency is permitting this group of ACOs to submit an abbreviated application for participation.

For organizations not ready to apply for the first cohort, CMS will release a standardized Letter of Interest form by April 17, 2026, to gauge interest in future application rounds. In this context, organizations considering LEAD participation should be assessing not only near鈥憈erm application readiness, but also longer鈥憈erm strategic alignment with the model鈥檚 10鈥憏ear commitment, risk structure, and operational requirements. Key considerations include benchmarking predictability, readiness to manage regional benchmarks, capacity to engage specialists and high鈥憂eeds beneficiaries, technology capabilities, and alignment with broader value鈥慴ased care strategies across Medicare and Medicaid.

Connect with Us

量子资源网 (量子资源网), supports organizations across the LEAD decision continuum, including those pursuing immediate application and those preparing for future cohorts. 量子资源网 can help organizations:

Interpret LEAD鈥檚 policy and financial design relative to existing ACO and MSSP participation
Model performance scenarios under alternative benchmark, alignment, and risk configurations
Assess operational readiness across care management, contracting, analytics, and compliance
Develop application strategies and supporting materials, including responses to the LEAD RFA
Choose to defer application on steps that preserve future optionality

As CMS advances LEAD under an ambitious timeline, early analysis and disciplined decision鈥憁aking will be critical for organizations seeking to align participation with their long鈥憈erm value鈥慴ased care strategies.

For questions contact Amy Bassano and Rebecca Nielsen.

Connecting the Dots: Medicaid Community Engagement Requirements and State Readiness for 2027

Read Blog

Our March 19, 2026, Connecting the Dots analysis described the federal requirements and the operational questions states and partners will need to answer to effectively implement Medicaid work and community engagement requirements. Since then, federal officials have advanced their forthcoming regulation to the final stage of review and intend to meet the statutory requirement to release interim final guidance by June 2026. In addition, many states have taken early steps to communicate upcoming changes and begin planning for system, policy, and partner readiness.

While state sessions are clearly grabbing a lot of energy, timing of pulling together many of the moving parts is becoming a concern as states undergo one of the most fundamental operational challenges to the Medicaid program since its inception. This article synthesizes emerging approaches and identifies practical opportunities to refine strategies and strengthen readiness while minimizing burden for enrollees and state Medicaid agencies.

Early Actions in States Preparing to Implement Work and Community Engagement Requirements

1. States Are Launching Websites that Highlight Coming Changes

As of April 2026, more than half of US states that are subject to the Medicaid work and community engagement requirement had posted web page content describing forthcoming changes associated with the 2025 budget reconciliation act (P.L. 119-12, OBBBA). Some websites provide high-level descriptions of key provisions (e.g., qualifying beneficiary ages, qualifying activities, and exemptions), while others include more detailed information reflecting state-specific policy decisions, educational messages, and suggested steps that beneficiaries, providers, managed care plans (MCPs), and community-based stakeholders can take now (see Figure 1).

Figure 1. States with a Community Engagement Web Page

For example, 鈥檚 website describes the requirements for, and provides examples of, acceptable documentation Medicaid members may use to demonstrate compliance or eligibility for an exemption. Ohio also offers a that contains frequently asked questions (FAQs) and draft outreach materials to support stakeholder communications and increase awareness. The communications tools include a one-page flyer, a rack card, and potential social media posts to raise awareness of the changes, with some use of QR codes to enhance quick access to key websites like the beneficiary self-service portal.

2. States are Beginning to Make and Communicate Preliminary Policy Decisions

States must make a range of policy decisions, including the penalty start date, the number of required months of compliance for both the initial application and subsequent renewals, the potential adoption of short-term hardship exceptions, and how exceptions are defined and operationalized. While most states anticipate compliance beginning January 1, 2027, in alignment with OBBBA, Nebraska and Montana have announced plans to begin implementation in 2026, and their websites reflect additional policy details to support accelerated timelines.

A handful of states, including Arkansas and Ohio, also are communicating ahead of OBBBA鈥檚 timeline to promote awareness and engagement before the work and community engagement requirement becomes effective. Table 1 summarizes examples of the current state planning[1] around the number of required months of compliance for the initial application and renewals.

Table 1. Sample Number of Months in Compliance

States also are taking different approaches to exemptions and short-term exceptions. Although many exemptions and exceptions are defined in statute, the interpretation of 鈥渕edically frail鈥� remains an area in which states have significant flexibility, with implications for how many individuals are exempt. Many states have experiences with establishing definitions of medically frail. For example, states that offer an adult benefit package that differs from the state plan benefit package must allow medically frail adults to opt in to the state plan. At least 12 states already make medically frail determinations, and these existing policies and processes may inform approaches for work and community engagement requirements.

One of those states鈥擭evada鈥攈as posted a with a request for public comment, including a sample list of qualifying medical conditions. Although such lists can provide clarity, they also underscore the importance of a clear and straightforward exemption request process to support appropriate determinations, including for individuals with conditions that are omitted from a specified list.

3. States Are Securing Additional Support to Address Administrative Challenges

The new eligibility criteria, coupled with more frequent eligibility checks, are placing substantial new demands on Medicaid agencies, eligibility systems, and personnel. In response, states are considering or actively pursuing a range of approaches to strengthen administrative capacity. Examples include:

Hiring new state eligibility and enrollment workers:听Indiana and Montana
Funding system enhancements and improvements:听Alaska and New Jersey
Hiring outreach and engagement contractors:听Arizona and Arkansas

States are also proposing to take a more coordinated, cross-agency approach that uses other state agencies and programs as data sources and referral pathways to help beneficiaries meet their work and community engagement requirements. A variety of states are looking to leverage data from their Supplemental Nutrition Assistance Program (SNAP) program to facilitate compliance checks, and Kentucky has receiving data from a variety of sources (e.g., Department of Revenue, Department of Corrections, Unemployment Insurance, Vital Statistics, and others) to more automatically identify eligibility and exemption changes.

States like Hawaii, Montana, and Nebraska have highlighted their labor departments to connect people to job and community service resources. Virginia鈥檚 work and community engagement website directs the public to a series of different programs based on whether they are interested in employment, volunteer, or education resources. Minnesota also has introduced legislation proposing collaboration between the commissioner and county agencies to link beneficiaries to other critical services like job training, childcare, and transportation.

Shrinking federal contributions and constraints on Medicaid revenue strategies鈥攕uch as limits on provider taxes鈥攁re prompting states to rethink how Medicaid agencies operate within existing budgets. Limited federal funding to support administrative needs elevates the importance of efficiency, coordination, and automation.

What States Might Do to Chart a Better Path Forward

A robust pre-implementation plan is critical to successful work and community engagement implementation. A well-documented plan helps states fully document the variety of moving parts across policy, systems, and partners, clarify milestones and decision points, and define what readiness looks like in practice.

Key components of a pre-implementation plan may include:

Signing agreements and contracts to support infrastructure.听Pre-implementation planning should ensure that appropriate support from third-party vendors and sister agencies is secured to optimize flexibilities and manage the requirements. Examples may include maintenance of effort (MOE) agreements, memoranda of understanding (MOU), contract updates, and requests for proposals (RFP) as appropriate. States may need to use expedited contracting vehicles when available and maximize existing vendor arrangements. Agreements should address data governance, privacy, and cost allocation issues to support smooth operational integration and reduce downstream friction.
Quantifying and automating exemptions.听Systems and reporting should be updated to identify, notify, and manage cases for expansion adults who are likely exempt. Leveraging additional resources and data matching may help states identify common exempt populations, such as caretakers with dependents under age 14, disabled veterans, and pregnant women without requiring additional verification. Understanding the demographics of the remaining nonexempt population may also be useful in outreach, education, and links to supports.
Preparing for readiness review, including system readiness, coverage transition, and churn management.听Pre-implementation plans should prioritize robust system testing, staff training, and timely updates to required documentation (e.g., state plan amendments, policy and member manuals, notices, and reviewing and approving MCP communications). Building in clear transition supports for individuals who may lose coverage or transition to other coverage options can improve continuity of coverage, reduce uninsurance and uncompensated care, and limit administrative burden following implementation.
MCP contracts.听Most enrollees subject to work and community engagement requirements are enrolled in Medicaid MCPs. States will need to describe enhanced roles and responsibilities in both the MCP contracts as well as the rates. Clear contract expectations can support transparency and mutual accountability across partners.
Test communications with the target audiences to ensure understanding and appropriate action.听Awareness of the new work and community engagement requirement was one of the biggest challenges Arkansas faced when it launched its program in 2018. Beneficiaries also struggled to understand whether the requirement applied to them and what they needed to do to comply. States must build communications plans and messaging to clearly address these issues to reduce the number of beneficiaries losing coverage simply because they did not understand the new requirements.

Connect with Us

量子资源网 (量子资源网) Medicaid experts assist Medicaid and state policymakers with the following:

Strategic positioning
Policy-to-operations design
Cross-agency governance and partner alignment
Information systems impact assessment, change planning, testing strategies and readiness metrics
Scenario planning and beneficiary impact analysis
Communications and operational playbooks
Program integrity, reporting, and audit support

量子资源网 Medicaid experts can also assist MCPs, providers, and community-based organizations with:

Risk assessments (e.g., enrollment, utilization, and spending impacts)
State-specific policy and operational insights and trends
Communications, outreach, and engagement strategies and content
Member retention strategies
Grassroots workforce development and community engagement strategies

For questions, contact 量子资源网 contributors to this article Lora Saunders, Matt Powers, Andrea Maresca, and Amber Swartzell.

[1] Some of these policies are in pending legislation and, therefore, are subject to change.

HIMSS26: Building the Foundation for Interoperable, AI-Ready Healthcare听

Read Blog

Key Insights from the 2026 HIMSS Global Health Conference and What They Mean for Your Organization

American healthcare is confronting two urgent realities. First, the administrative burden on clinicians and patients remains very high. Prior authorization delays, manual intake forms, fragmented records, and identity challenges continue to drive cost and erode the trust that is the foundation of the provider-patient relationship. At the same time, artificial intelligence (AI) capabilities are advancing rapidly, outpacing governance frameworks, regulatory structures, and data infrastructure. Together, these dynamics are the defining operational challenge of 2026.

Federal policy is responding less through sweeping new regulation than through coordinated execution levers. The Centers for Medicare & Medicaid Services (CMS) initiatives, including the , information blocking enforcement, (HTI-5) Proposed Rule , and the prior authorization (PA) final rule, reflect a shift toward making interoperability operational in production environments. What distinguishes this moment from prior efforts is the explicit linkage between interoperability and AI. Federal leaders are saying openly that reliable, trustworthy, and deflationary AI depends on disciplined data exchange, identify, and governance.

罢丑别鈥� (HIMSS26),鈥疢arch 9鈥�12, in Las Vegas, NV, marked a marked a turning point in which the industry began translating that message into tangible organizational decisions. Two 量子资源网 (量子资源网), companies actively engaged in the program: the moderated sessions in the preconference forums and Interop Experience Pavilion, and , lent their expertise in Medicare Advantage (MA), Medicaid managed care, risk adjustment, and quality measurement鈥攖he areas in which FHIR-based infrastructure will directly reshape performance and risk management.

This article reflects what these teams learned and what it means for the industry.

What We Learned at HIMSS

Several themes surfaced throughout the conference, not as isolated ideas but as shared assumptions of the field shaping near-term strategy:

Successful AI deployments rely on interoperability and quality data. Across sessions and conversations, speakers emphasized that success will require not just access, but data that are standardized, governed, and semantically consistent. The promise of AI is advancing quickly, but many organizations are still working to build the data foundation needed to support it.

CMS-aligned networks are paving the way for federal transformation. Concrete pledge deadlines, and a Centers for Medicare & Medicaid Services (CMS) Administrator willing to say publicly that healthcare is the only sector where technology has failed to be deflationary, sent a signal that the industry took seriously. Voluntary frameworks are being seen as previews of future requirements.

Information blocking enforcement is no longer theoretical. Officials from ASTP/ONC confirmed that notices of potential nonconformity have already gone out to health IT firms under the certification program, and more are on the way. With Department of Health and Human Services Office of the Inspector General penalties of up to $1 million per active violation and more than 1,500 complaints filed since the federal portal launched, the compliance calculus has shifted. Dr. Thomas Keane, National Coordinator for Health Information Technology, was direct: Developers that block information risk losing their certification, and their clients risk losing access to CMS payment incentives. The long implementation runway is over, enforcement is now active, and the consequences are real.

The federal vision for AI is patient-first. CMS Administrator Dr. Mehmet Oz said to slow the inflationary effects of the growth in healthcare technology, he wants to put agentic AI tools in the hands of every Medicare beneficiary before the end of this administration鈥攁n ambitious goal. He cautioned, however, that none of it works without building the necessary data infrastructure now. AI is the destination; interoperability is the road.

CMS is ready to pivot to digital quality measures and put investment behind it. CMS and ASTP/ONC leadership announced that all quality measures will now be modeled on HL7 FHIR. MultiCare Connected Care showed it working in production. Early adopters will shape the pathway and gain strategic advantage as the transition accelerates. Successful transformation will require simplified workflows, established lines of accountability, and a product-oriented mindset geared toward data and interoperability.

Identity is a known gap, but the solution is taking shape. Patient matching, provider directories, and consumer-facing credentialing came up in nearly every policy and technical session. The $6 billion CMS cited for annual provider directory validation waste alone captured attendees鈥� attention. But HIMSS26 brought concrete, live progress on the credential side and a Leavitt Partners-moderated preconference session focused on moving the industry from alignment in principle to alignment in production.

Governance is now an operational discipline. Health system chief information officers and chief medical information officers described governance structures already in place and under active revision. The shift from “we need governance” to “our governance needs to evolve” was palpable.

Consumer technology has entered the clinical conversation. Emory Hillandale Hospital鈥檚 announcement of the first all-Apple facility signaled that the boundary between consumer devices and clinical infrastructure is evolving.

Autonomous AI systems were everywhere. Vendors demonstrated how AI agents are handling administrative workflows, such call centers, revenue cycle, scheduling, and PA. Health system leaders acknowledged real deployments alongside real uncertainty about governance, security, and identity management for non-human actors in clinical environments. The technology is moving faster than the frameworks designed to oversee it.

What It Means: Five Insights

The CMS Health Technology Ecosystem is redefining what “interoperable” means for federal programs; TEFCA will scale what it proves

For years, interoperability has been a certification checkbox rather than a functional description. The CMS ecosystem is changing that by tying the definition to observable behaviors: HL7 FHIRAPIs that respond, encounter notifications that fire, identity verification that works at the front door. More than 700 organizations have pledged; CMS has set hard deadlines (March 31 for initial results, July 4 for advanced capabilities), and the agency is tracking outcomes, not just attestations.

In the fireside chat moderated by , was direct: The regulatory cycle is slow, and what the ecosystem can produce in nine months is what the regulations will eventually codify. Organizations that shape this work now will have less catching up to do when it becomes mandatory.

The Trusted Exchange Framework and Common Agreement (), which now exchanges 600 million health records across 75,000+ organizations (up from 10 million in January 2025), is the rising tide that scales what the speedboat networks prove. And state-level health information exchanges (HIEs) remain strategically important given their governance structures, trust relationships, and operational capabilities.

Provider directory is the sleeper issue

Patient matching and digital identity got considerable attention, but a provider directory may be the highest-yield near-term opportunity. CMS estimates $6 billion is wasted annually simply validating where providers practice, what licenses they hold, and what insurance they accept鈥攁 problem that compounds every time a payer, health system, or patient tries to connect with the right clinician through the right channel.

A real-time, standardized provider directory is foundational to PA, network adequacy, and care navigation. It is also one of the three heavy lifts that the CMS Health Technology Ecosystem is actively working to address. Organizations that invest now in clean, FHIR-based provider data will be ahead of an upcoming requirement.

Semantic Consistency Determines AI Outcomes

The distinction between syntactic interoperability (data move between systems) and semantic interoperability (data means the same thing in every system) was a running thread through the Interoperability and HIE Forum. Dan Liljenquist, chief strategy officer at Intermountain Healthcare, put the operational reality plainly during his keynote address: Intermountain is building a unified semantic data layer in the cloud鈥攊ngesting EHR data daily, normalizing it against common models, making it computable across 34 hospitals鈥攂ecause without that layer, AI produces unreliable outputs at scale.

Graphite Foundry, the mechanism Graphite Health is developing as a nonprofit collaborative, represents a model where health systems build shared semantic infrastructure rather than solving the same problem independently behind proprietary walls. The broader implication: AI strategy and data infrastructure strategy are the same, and organizations that treat them separately will find that their AI investments underperform.

Digital Identity and Privacy Architecture are Converging

Policy and industry discussions reflected growing alignment around higher鈥慳ssurance digital identity, privacy鈥憄reserving design, and consistent credentialing. Progress in this area reduces friction for patient鈥慸irected access while supporting trust and security across ecosystems.

Mr. Howells moderated the preconference session, Bridging Digital Worlds: Identity Federation Strategies Across B2B and B2C Ecosystems, which brought together CMS Chief Health Technology Officer Alberto Colon Viera, David Bardan (CLEAR), Wes Turbeville (ID.me), and Renee Edwards, Applied AI at UnitedHealth Group. The session produced three concrete outcomes:

CMS confirmed Medicare.gov is now live with CLEAR, ID.me, and Login.gov, meaning consumers can choose which credential they use and relying parties can leverage that same credential to authenticate consumers into their own systems.

Participants agreed on a common IAL2 token payload.

UnitedHealth Group announced United Health Group鈥檚 pursuit of Kantara certification and unification of all their portals to a single identity based on IAL2.

Identity has long been a blocker to scalable patient access. Aligning on a common IAL2 model removes another friction point and moves the industry closer to a future in which patients can securely access their medical records through the apps they choose.

Interoperability is Expanding Beyond Traditional Boundaries

For years, FHIR-based infrastructure has been built primarily around clinical and claims data. But two sessions in signaled meaningful progress on two long-neglected fronts: pharmacy and oral health. Pharmacy data 鈥� critical to medication management, managed care, and complete longitudinal records鈥攁re increasingly being drawn into the standards-based exchange ecosystem, including the recognition of pharmacists as clinicians whose data and clinical contributions belong in the longitudinal record.

Patients are also gaining real-time visibility into their own pharmacy benefits: the Consumer Real-Time Pharmacy Benefit Check, an open FHIR-based standard, puts cost and coverage information directly in patients’ hands at the point of prescribing 鈥� a meaningful step toward the same patient empowerment that the “kill the clipboard” and digital identity work is driving elsewhere in the ecosystem.

Oral health data, long absent from the medical record despite its correlation with diabetes, cardiovascular disease, and maternal health, is now the subject of active federal interoperability investment across CMS, the Veterans Health Administration, and the Indian Health Service. Leavitt Partners’ alliances in both domains鈥攖he Oral Health Interoperability Alliance and the Pharmacy Interoperability and Clinical Services Alliance (PICSA)鈥攁re helping shape the technical and policy frameworks that will bring these data streams into the broader ecosystem. Whole-person care requires whole-person data, and the field is finally building the infrastructure to support it.

What Remains Unresolved

Despite momentum, several issues remain unresolved:

The Role of Payers in TEFCA and National Exchange is Still Evolving

There is growing interest in extending TEFCA beyond provider-to-provider exchange to support payer use cases such as quality measurement, care management, and prior authorization. However, questions remain around participation models, data rights, governance, and value alignment. Until these are resolved, payer engagement will likely remain uneven, limiting the full potential of nationwide exchange.

The Business Case for Interoperability is Not Yet Consistently Realized

While the policy direction is clear, the economic incentives are still misaligned. Providers often bear the operational burden of data exchange, while financial benefits may accrue elsewhere. Similarly, investments in interoperability infrastructure do not always translate into immediate or measurable returns. Advancing adoption will require clearer ROI pathways, shared incentives, and models that distribute value more equitably across stakeholders.

Governance and Operating Models are Still Catching Up to the Technology.

There is increasing recognition that interoperability at scale is not just a technical challenge 鈥� it is a governance challenge. Questions around enforcement, delegation of authority, participant accountability, and operational oversight remain active areas of development. As exchange expands, these governance structures will need to mature rapidly to sustain trust and ensure consistent implementation.

Near-term signals, such as CMS responses to pledged-network deadlines, finalization of HTI5 and related rules, continued prior authorization modernization, and digital quality measure implementation, will shape the next phase of execution.

What We’re Watching

Extending Open Standards to Rural and Underserved Providers

The Rural Health Transformation Program offers a unique opportunity to expand the open standards ecosystem being built. Leavitt Partners and Wakely are engaged in both the policy conversations and implementations that will determine how to ensure this opportunity can transform healthcare.

March 31 and July 4 deadlines

CMS set these dates publicly and specifically. How the agency responds to organizations that miss them will signal how serious the voluntary framework really is and how quickly it becomes a program condition.

HTI-5 Finalization and HTI-6 Proposed Rule

ONC’s proposed rule to focus certification on HL7 FHIR APIs, algorithm transparency, and interoperability is still in proposed form. Finalization, as proposed, would transform the vendor landscape and remove the safe harbor that legacy proprietary interfaces have relied on.

Prior Authorization is Moving

The federal regulations and last summer’s voluntary commitment by more than 60 health insurers covering 257 million Americans across commercial, Medicare Advantage, and Medicaid markets has created a moment of regulatory and industry alignment. Payers committed to reducing the volume of services requiring PA, standardizing electronic PA using HL7庐 FHIR庐 APIs, and answering at least 80 percent of electronic requests in real time by 2027. The direction is clear, the commitments are specific, and the infrastructure to support them 鈥� HL7庐 FHIR庐 APIs being built for patient access and the ecosystem is the same infrastructure PA modernization requires. Leavitt Partners and Wakely are watching closely as implementation moves from pledge to production.

The Digital Quality Measure (dQM) Enters the Implantation Phase

CMS has made clear where the market is headed: digital quality measurement built on HL7 FHIR. The challenge now is execution. FHIR infrastructure developed for prior authorization or patient access can be leveraged for quality reporting as well, creating the potential for reusable investment across use cases. But the transition to dQM is not simply a technology upgrade; it is a broader business transformation that will require changes in workflows, governance, and organizational readiness.

Digital Identity Momentum

The IAL2 token payload agreement, Medicare rollout of digital identity, and United Health Group鈥檚 Kantara pursuit signal that the industry is aligning on a shared credential infrastructure. Leavitt Partners will continue to support the development and adoption of the open identity standards that make patient-directed access real across payers, providers, and health technology platforms.

The infrastructure for an interoperable, AI-ready healthcare system is being built under real policy pressure in real-world environments. 量子资源网 companies bring health IT policy and open standards expertise to help organizations shape and navigate that landscape as well as actuarial and implementation depth to translate it into financial and operational decisions. Organizations that invest in the foundation鈥攄ata, identity, standards, governance鈥攚ill be positioned to move faster and more responsibly as AI capabilities continue to advance.

We Can Help

量子资源网 companies are uniquely positioned to help organizations move from interoperability strategy to real-world execution. We provide end-to-end support across digital quality measurement transformation, policy-to-operations execution, pharmacy interoperability, oral health interoperability, digital insurance cards, and the actuarial and financial modeling needed to assess performance impact, revenue implications, and reporting risk. Leavitt Partners and Wakely professionals were active participants in HIMSS26 conversations and bring the policy, operational, measurement, and financial expertise needed to help clients prepare for what comes next.

This blog reflects policy signals and public session content from the 2026 HIMSS Global Health Conference. It represents the perspective of Leavitt Partners and Wakely Consulting Group, both 量子资源网 Companies, and does not constitute legal or regulatory advice

Fiscal 2027 State Budget Proposals: Provider Taxes, Medicaid Financing, and OBBBA Effects

Read Blog

As of March 15, 2026, most governors had released proposed budgets for state fiscal year (FY) 2027. In addition, several governors in states that enacted biennial budgets in 2025 have released supplemental proposals. These FY 2027 state budget proposals signal how governors are responding to Medicaid financing changes, provider tax phase downs, and new implementation costs created in the (P.L. 119-21, OBBBA).

Given the requirement enacted in OBBBA, this year鈥檚 state budgets are more than spending plans. They are critical policy tools governors will use to navigate changes in federal funding, new program requirements, and increasing pressures across Medicaid and broader healthcare markets.

The FY 2027 budgets indicate how governors are attempting to balance competing imperatives: maintaining healthcare coverage and access, stabilizing provider networks, financing Medicaid obligations, and aligning state healthcare and health-related programs with new federal rules. Healthcare provider taxes, revised funding priorities, and targeted funding proposals are key levers in the process of balancing budgets.

量子资源网 Information Services (量子资源网IS) has published its final iteration of the (subscriber access required), which examines proposed FY 2027 state budgets (January 22, 2026, A Look at Proposed State Fiscal Budgets). Our March 2026 issuance covers all proposed FY 2027 budgets for non-biennial budget states and some supplemental budget proposals for states that enacted biennial budgets in 2026. Following is a look at key trends in Medicaid proposals and some of the substantial budget proposals that are discussed within the report.

Provider Taxes and Medicaid Financing Under OBBBA

One notable fiscal federal policy change under OBBBA is the phase down of the Medicaid provider tax programs, a financing mechanism many states rely on to draw down federal matching funds and support provider payments. The federal law freezes existing provider tax programs, prohibits new ones, and requires Medicaid expansion states to phase down the minimum allowable tax rate from 6 to 3.5 percent by 2032.

In addition, OBBBA places new limits on state-directed payments, capping them at 100 percent of Medicare rates for expansion states and 110 percent for non-expansion states. Grandfathered payment arrangements will be phased down by 10 percent annually beginning in 2028.

FY 2027 state budget proposals highlight how these changes will have substantial and long-term fiscal impacts, even if some effects are delayed. Examples include:

Arizona estimates it will receive $5.3 billion less in federal support between FY 2029 and 2033 as a result of policy changes.
California听projects听that听state听expenditures听for Medi-Cal听will听grow $2.4 billion in听FY听2027, largely听because听the Medical Provider Interim Payment听expires听in听FY听2026 and听a decrease in听managed care organization (MCO)听tax revenue available听to support the听Medi-Cal听program.听Gov.听Gavin Newsom鈥檚 proposed听FY听2027 budget assumes a transition period for the decreased MCO tax through December 31, 2026.听
Connecticut Gov. Ned Lamont鈥檚 proposed supplemental budget for the 2025鈥�27 fiscal biennium calls for reducing hospital provider taxes by $275 million. Connecticut increased supplemental payments and provider taxes during the 2025 legislative session, but the governor鈥檚 proposal would reduce the inpatient hospital provider tax rate from 6 percent to 4.1 percent.
Illinois projects that most of the budgetary impacts will begin in FY 2028, with federal Medicaid support reduced by approximately $2.8 billion annually by FY 2031.
New York Gov. Kathy Hochul鈥檚 budget proposal updates the managed care tax spending plan and estimates the state will collect $1.5 billion fewer receipts than anticipated in fiscal 2027.

Implementation Costs: Staffing, Systems, and Administrative Burden

Along with the decreased federal funding, implementing OBBBA carries significant administrative and operational costs, compounding pressure on state budgets.

According to an Associated Press of 25 state budget protections, states will need to spend up to $1 billion in federal and state funds on technology upgrades and additional staff to fully implement the Medicaid work and community engagement requirements. Many FY 2027 budgets reflect this reality, with new investments focused on expanding staffing capacity and modernizing eligibility and data systems. For example:

惭颈肠丑颈驳补苍鈥檚 proposed budget, for example, includes $186.6 million from the state general fund to fully implement OBBBA, including $80.3 million in all funds to hire additional full-time employees who can meet the increased workload.
Missouri proposes $294.6 million and dedicated staff members to comply with OBBBA.
Arizona proposes a $14.4 million one-time investment and dedicated OBBBA implementation staff.

Several governors also propose investments to help beneficiaries remain enrolled amid more frequent eligibility checks and new requirements. For example:

Kentucky proposes $35.6 million in FY 2027 and $11 million in FY 2028 to modify the Medicaid information technology systems and other administrative systems to cover increased costs for the more frequent six-month eligibility redeterminations and to implement the new community engagement and work requirements.
Rhode Island proposes $32.7 million for technology modifications to the RIBridges software to maintain compliance for various health and human services programs to align with OBBBA.

What to Watch: FY 2027 Budget Decisions and Medicaid Financing Risks

Upcoming provider tax phase downs and caps on state-directed payments constrain core funding tools just as implementation costs for staffing and systems are rising, forcing difficult decisions about coverage, provider support, and administrative capacity. Providers face growing uncertainty as tax supported supplemental payments are reduced or restructured, with potential implications for cash flow, service availability, and network participation.

Managed care plans, meanwhile, must navigate shifting rate development assumptions, changes in provider payment arrangements, and increased enrollment churn tied to eligibility and redetermination changes.

While the timing and magnitude of effects vary, these proposals underscore that provider tax and supplemental payment changes are more than abstract future concerns. They already are shaping FY 2027 budget decisions and long-term Medicaid financing strategies.

Most state legislatures are still debating their spending plans, making it critical to track which proposals are included in FY 2027 budgets, which are scaled back, and which are eliminated. These budget decisions will play a central role in determining market stability, access to care, and program sustainability in the years ahead.

量子资源网IS will publish additional reports in the coming months summarizing each state鈥檚 enacted budget. The first iteration is expected in May 2026.

Connect with Us

As the policy and funding landscapes continue to evolve, states and other stakeholders need to remain flexible. 量子资源网 brings the expertise, tools, and insights needed for stakeholders to stay on top of the rapidly changing environment. For questions or to connect with an 量子资源网 expert, contact Andrea Maresca and Kathleen Nolan.

The full report is available to 量子资源网IS subscribers. Questions can be directed to Maddie McCarthy.

Connecting the Dots: Medicaid Community Engagement Requirements and State Readiness for 2027

Read Blog

New federal Medicaid community engagement requirements, along with more frequent redetermination and a reduced retroactive听eligibility timeframe, take effect January 1, 2027. These changes are reshaping state Medicaid policy agendas, budget decisions, and听eligibility system design as states prepare to implement federally mandated听work and听community engagement requirements听for the Affordable Care Act (ACA) expansion population.听This blog addresses the forthcoming policy changes, key issues related to eligibility and information systems, and听timely听actions for state partners preparing to meet the new requirements.

Community engagement requirements听often听are听discussed听in broad terms: whether they encourage听self-sufficiency听or create barriers.听For state Medicaid agencies, managed care plans听(MCPs), and providers, however,听the more听immediate and consequential question is operational:听Is the Medicaid program鈥攁cross eligibility systems, data flows, partner roles, and communications鈥攔eady听to administer these requirements without losing eligible people?听

Based on our work with states, Medicaid programs, and community partners, the answer is dependent on the approach to execution. Specifically, it hinges on how states prepare their systems and partners for compliance with community engagement requirements without placing undue burden or expectations on beneficiaries, government agencies, MCPs, and community partners.

Federal Context: Medicaid Community Engagement Requirements Beginning in 2027

Under , states that extended Medicaid to able鈥慴odied adults in the ACA Medicaid expansion population (up to 138 percent of the federal poverty level) must:

Apply community engagement requirements to expansion adults, unless they qualify for an exemption听
Conduct听eligibility redeterminations at least every听six听months听for these enrollees听
Reduce retroactive coverage eligibility from听90听to听30 days听
Verify听community engagement听or exemptions using available data sources听
Enforce consequences for noncompliance beginning in 2027听

Forthcoming federal guidance and regulations will clarify key implementation details. In the interim, states are using the statutory framework to design the necessary policy changes. For example, many states will move beyond a simple 鈥渞equirement鈥� model toward support-oriented programs that make compliance achievable for enrollees, minimizes administrative churn, and leverages available data and information systems functionality to reduce compliance burden. In so doing, states need to use existing federal guidance to answer the following questions:

Who is in scope and who is听exempt听and听how听are听exemptions听verified听without creating new burdens听on听enrollees听and the people and systems that support them?听
What counts as听a 鈥渜ualifying activity鈥� for compliance听with the community engagement听requirement听(e.g., education/training and caregiving)?听
Which听data sources can听be听deemed听as听鈥渁uthoritative鈥澨齠or听verifying听compliance?听
How听and when听will听beneficiaries be notified, supported, and given opportunities to听supply听missing information?听
How听do they听track compliance with the community engagement听requirement听and听address听its听intended and unintended impacts?听
How听do听the听verify eligibility听for new听applicants and what process听do they听use to听monitor听ongoing compliance for existing enrollees?听

Analyis and planning for听community听engagement听is underway now,听state by state, and will determine whether the mandates听will听increase employment, education, and volunteerism听and yield the expected health听and听economic benefits听or drive avoidable coverage loss.听

From Policy Requirement to Workable Medicaid Community Engagement Implementation

The touch multiple components of a Medicaid enterprise, including:

Eligibility and enrollment systems and renewal workflows听
Data sources (wage databases, SNAP/TANF interfaces, workforce systems, education/training records)听
Managed care member services听and,听potentially,听capitated听payments听
All engagement with contact听centers听(e.g.,听phone, chat, text messaging,听email,听beneficiary portal, etc.)听
Document processing听
Notices, appeals, fair hearing processes, and case management听
Reporting, audit trails, and quality assurance听

In other words, the backend systems that support compliance with the community engagement requirement must be designed and built for real-world administration and meet oversight requirements. Backend system readiness is among the most important operational issues for expansion states, as it will dictate the overall timeline and success in meeting Medicaid leaders鈥� goals.

How Medicaid MCPs and Providers Will Support Enrollees

The Centers for Medicare & Medicaid Services (CMS) collaborated with to meet the compressed community engagement implementation timeline, the scale of system changes required across eligibility and verification workflows, and long-standing cost and capacity constraints. States are being asked to implement these complex new expectation largely within existing eligibility platforms, which were designed for purposes other than continuous activity tracking or cross-agency data exchange.

Although these arrangements may improve affordability and speed, states must still assess whether vendor-offered solutions align with their specific policy choices, data sources, partner roles, and operational risk tolerance.

Medicaid MCPs and provider groups, including hospitals and federally qualified health centers (FQHCs), will be on the front lines of enrollee retention. These organizations should engage with states now to ensure systems and information flows support their work. MCPs should focus on access to:

Timely actionable information听regarding听which听members are subject to the requirement听
Visibility into exemption status and pending听verification听
Clear rules and data feeds that support proactive outreach听
Alignment on plan member communications听

Primary care providers, hospitals, FQHCs, and behavioral health providers play a critical role in identifying and supporting exemptions. If the exemption processes are slow, unclear, or burdensome, patients with legitimate medical or functional limitations may lose coverage and providers may incur increased uncompensated care costs. Providers should be engaging states to solidify:

Streamlined, clinically grounded exemption processes听
Clear guidance on documentation standards听
Fast, predictable exemption determinations听
Feedback loops when exemption requests are denied or incomplete听

Community engagement requirements will require coordination with nontraditional partners, such as:

Departments of Labor/Workforce听Development听
Community colleges, adult education, and training programs听
SNAP/TANF agencies (and their employment and training programs)听
Community-based听and听faith-based organizations,听organizations听that听offer听volunteer and community service opportunities,听and local workforce boards听
Employers, chambers, and sector-based workforce intermediaries听

These partners can become essential to making the policy workable for enrollees, but they often have timelines, data standards, funding streams, and performance incentives that differ from Medicaid鈥檚. Partners should be in conversation with states now about investments in a cross-agency and cross-sector governance structure that answers practical questions about the definitions, systems and workflows, and beneficiary experience.

States Should Act Now

A real and preventable risk is embedded in the 2027 timeline: coverage loss among healthy, working adults who remain eligible but cannot navigate new processes. States must look across every part of their Medicaid system, decide what they need each partner to do, and ensure those partners have the information, tools, and authority to act. Plans and providers must be clear and advocate for what they need to prevent eligible individuals from losing coverage.

Handled well, this is an opportunity to modernize systems, strengthen cross-sector coordination, and may demonstrate whether community engagement can yield a net benefit to members鈥攏ot just add steps to maintaining coverage.

Connect with Us

量子资源网 Medicaid experts assist Medicaid and state policymakers with the following:

Policy-to-operations design听
Cross-agency governance and partner alignment听
Information听systems听impact assessment, change planning,听testing听strategies听and readiness metrics听
Scenario听planning and beneficiary impact analysis听
Communications听and operational playbooks听
Program听integrity, reporting, and audit support听

量子资源网 contributors to this article include Erin Dorrien, Kaitlyn Feiock, Andrea Maresca, and Juan Montanez.

量子资源网 Blog Series

The 量子资源网 (量子资源网) Connecting the Dots blog series brings our experts together to examine the major policy, program, and market forces shaping healthcare coverage, delivery systems, and financing in 2026. The posts look beyond individual changes to connect emerging developments across programs and markets to help leaders understand what鈥檚 changing, why it matters, and how their decisions shape the path ahead. This month our experts weigh in on preparations for Medicaid Work and Community Engagement Requirements.

Outlook 2026: What CMS鈥檚 Proposed 2027 NBPP Signals for ACA Marketplaces, States, and Consumers

Read Blog

The Centers for Medicare & Medicaid Services (CMS) proposed marks a notable shift in Marketplace policy, expanding lower premium plan options, relaxing certain federal standards, and moving more implementation and oversight responsibility to states and Marketplaces. It also introduces eligibility and verification policies that could significantly affect enrollment, operations, and market stability.

To unpack what this could mean for plan year 2027 and beyond, Andrea Maresca spoke with Zach Sherman, Managing Director for Coverage Policy and Program Design at 量子资源网 (量子资源网); Lina Rashid, Principal at 量子资源网; and , PhD, Principal at Wakely, an 量子资源网 company, who, alongside colleagues, published a Policy Brief on state-level and consumer impacts, as well as a Wakely on the proposed rule.

Q: When you zoom out from the technical details, what are the big takeaways from the proposed 2027 NBPP for states, consumers, and issuers?

Lina Rashid: At a high level, the proposal reallocates risk and responsibility across the system. Consumers may see more lower premium options through expanded catastrophic plan eligibility and more flexible bronze plan design, but often with more cost-sharing, higher deductibles, or greater complexity. For consumers, affordability is about more than just premiums; it鈥檚 about how much healthcare costs for individuals and their families overall and the cost of care when they need it.

States are being given options to take on more oversight and operational responsibility but without additional federal funding. And issuers are being given more flexibility, but it comes with uncertainty regarding enrollment and risk mix.

Zach Sherman: The rule鈥檚 cumulative effect matters more than any one policy. Expanded catastrophic eligibility, higher out-of-pocket exposure, relaxed network standards, and tighter verification requirements all interact. Together, they raise questions about access, affordability, and whether Marketplaces are equipped to manage administrative and enrollment disruption.

Q: The paper highlights potentially significant enrollment effects. What鈥檚 driving that dynamic?

Michael: Two things stand out. First, the proposal implements statutory changes that remove advance premium tax credit (APTC) eligibility for certain lawfully present immigrants beginning in 2027. CMS estimates more than a million people could lose eligibility, and it鈥檚 reasonable to expect most of them will exit the individual market.

Second, the proposed income verification changes could generate millions of data matching issues (DMIs) that temporarily or permanently cut off access to advance premium tax credits. While CMS projects a relatively modest disenrollment effect, our analysis suggests losses could be meaningfully higher depending on how quickly issues are resolved. We estimate that approximately 4.7 million enrollees could receive DMIs under the proposal, and upward of 80 percent of them could temporarily or permanently lose access to APTCs, putting coverage at risk.

Zach: If consumers can鈥檛 afford the full premiums while resolving a data issue, many will drop coverage. That creates churn and administrative strain that Marketplaces must manage.

Q: How do these policies affect state Marketplaces and regulators specifically?

Zach: States are being asked to do more across multiple fronts. Network adequacy oversight is shifting toward states that conduct effective rate review. States may also choose or feel pressure to take on Essential Community Provider (ECP) review authority, including for new non-network plans. Accepting that responsibility requires legal authority, staff capacity, and technical infrastructure.

At the same time, states may need to stand up the State Exchange Improper Payment Measurement (SEIPM) program, which CMS acknowledges will increase administrative burden.

The proposed State Exchange Enhanced Direct Enrollment (SBE-EDE) option is also a significant shift. Rather than operating a centralized consumer enrollment platform, Marketplaces would focus on certifying, overseeing, and monitoring multiple third-party entities. As a former director of a state-based Marketplace program, I know this is a fundamentally different operational posture that comes with oversight and compliance costs.

Q: The proposal also introduces non-network plans. What should stakeholders be watching here?

Michael: may offer lower premiums, but they change how access works. Provider participation depends on the willingness to accept the plan鈥檚 payment as payment in full. On paper a plan may meet access standards, but in practice consumers could face difficulty finding care. That places additional oversight responsibility on states to determine whether access is sufficient in practice. If aggressively priced non-network plans disproportionately attract healthier enrollees, it can create financial risk for issuers and for the broader market.

Q: What does this mean for market stability going forward?

Zach: Stability will vary by state. States that invest in oversight, consumer assistance, and operational readiness鈥攐ften a state-based Marketplace鈥攎ay be better positioned to manage these changes. Others may see sharper enrollment declines or access issues. That divergence across states is an important signal from this proposal.

Q: What should states and stakeholders be doing right now?

Zach: States should be doing scenario planning, assessing which flexibilities to adopt, where to maintain higher standards, and whether they have the capacity to take on expanded responsibilities. These decisions will shape how the rule plays out on the ground.

Michael: Issuers should be , risk adjustment exposure, and operational readiness. All stakeholders should remember that comments on the proposed rule are due March 13, 2026.

Lina:听Notably, CMS听is not done with听regulatory reforms.听罢丑别听agency solicited听comment听on听medical听loss听ratio (MLR)听policies听and听paused听Essential Health Benefit听benchmark updates,听as well as issues not covered in this proposed rule, such as revisions to the Section 1332 waiver and听Section听1333 interstate compacts.听States and issuers should be tracking what may come next, not just what鈥檚 in this proposal.

Strategies to Address Fraud, Waste, and Abuse in Non-Emergency Medical Transportation

Read Blog

Fraud, waste, and abuse (FWA) in Medicaid non-emergency transportation (NEMT) remain a persistent challenge for state Medicaid programs and health plans because of the scale and complexity of the benefit. NEMT is a critical, mandatory benefit intended to ensure eligible Medicaid beneficiaries without reliable transportation can get to necessary medical appointments. Numerous investigations and audits, however, have revealed that some transportation providers bill for trips that never occurred, inflate mileage, fabricate tolls, or even recruit patients with kickbacks to generate fraudulent claims, diverting limited program funding away from legitimate care needs.

The NEMT benefit represents a small share of Medicaid costs鈥攅stimated at around 1 percent of total Medicaid spending. With the codification of NEMT as a required benefit in 2020, market analysts forecast NEMT will grow considerably, nearly doubling in market size from 2021 to 2028.

Comprehensive, nationwide estimates specific to NEMT FWA are limited. Federal and state audits like those in , , and , however, have uncovered millions of dollars in claims that did not comply with federal and state requirements, underscoring systemic vulnerabilities in oversight and documentation. For example, a 2022 federal audit of New York Medicaid NEMT found an estimated $84 million in unallowable federal reimbursements and another ~$112 million that may not have complied with requirements over two years.^[1]

Furthermore, individual criminal cases have involved schemes of $1 million to more than $2 million in falsely billed transportation services. Isolated settlements and audits indicate that fraud and abuse can be substantial locally even if we lack a clear, reliable national aggregate estimate.

A 2025 report by 量子资源网 (量子资源网) about NEMT contracting approaches found an opportunity for states and health plans that administer non-emergency transportation to leverage technology and require or incentivize new strategies to improve program integrity and quality in NEMT going forward. Some of the identified strategies to address FWA include:

Adopting or requiring digital solutions鈥攕uch as GPS trip verification, electronic visit logs, and real-time data analytics鈥攖o detect irregular billing patterns before claims are paid, replacing outdated paper logs and manual reconciliations that were prone to error and exploitation.
Focusing trip verification efforts on standing orders (pre-approved authorizations often for repeated treatments), given that they comprise the largest share of trips and are often vulnerable to fraud.
Positioning and educating medical facilities to be critical partners in preventing FWA by confirming appointment attendance, either via phone or signature on the trip log.
Automating mileage reimbursement (for enrollees who drive themselves or are driven by family members or friends) through a mobile app, which enabling riders to schedule and track their trips and submit claims quickly while allowing NEMT brokers to verify the mileage using GPS. This system would also allow brokers to better target their anti-fraud efforts, such as requiring additional documentation only for higher reimbursement amounts.

Since the publication of that report, several state Medicaid programs have issued NEMT procurements that maintain a strong emphasis on preventing FWA. For example, the 2025 Wisconsin NEMT RFP included provisions to promote greater collaboration between the Wisconsin Department of Health Services (DHS) Office of Inspector General (OIG) and NEMT broker, including 鈥渜uarterly and ad hoc meetings to discuss open complaint investigations, red flag patterns, and establish safeguards for ongoing or suspected fraud, waste, and abuse鈥� and imposed penalties for fraud incidents that go undetected by the broker.

FWA in Medicaid NEMT may represent a fraction of overall program spending, but the consequences are outsized: Every improper payment diverts resources away from beneficiaries who depend on transportation to access essential care. As states, health plans, and NEMT brokers modernize contract requirements, strengthen oversight, and embed technology-driven verification into their contracts and operations, the focus is shifting from retrospective recovery to proactive prevention, transparency, and accountability in transportation services.

Continued collaboration among Medicaid agencies, brokers, medical providers, and oversight entities will be critical for sustained progress. By pairing smarter contracting with real-time data tools and clear accountability, states and Medicaid health plans can better safeguard public dollars while ensuring that NEMT remains a reliable lifeline for the people it is designed to serve.

Learn more about how 量子资源网 Helps NEMT Stakeholders Overcome Challenges. If your organization is ready to talk about how 量子资源网 can help advance your NEMT goals, please contact one of our experts below.

Related Resources:

[1] US Department of Health and Human Services, Office of Inspector General. New York Claimed $196 Million, Over 72 Percent of the Audited Amount, in Federal Reimbursement for NEMT Payments to New York City Transportation Providers That Did Not Meet or May Not Have Met Medicaid Requirements. September 12, 2022. Available at: .

2027 NBPP Proposed Rule Signals Further Marketplace Changes

Read Blog

The Centers for Medicare & Medicaid Services听(CMS)听听proposed rule,听published February 11, 2026,听arrived听at a pivotal moment for the听Affordable Care Act (ACA)听Marketplaces. The temporary enhanced premium tax credits (ePTCs), first expanded in 2021 and extended through 2025, expired at the end of last year, returning Marketplace subsidies to their original ACA structure in 2026.听As we discussed in earlier articles听(here听and听here), that shift is already affecting affordability, plan selection, and enrollment dynamics鈥攑articularly for consumers who听are ineligible听for听premium assistance.听

The proposed 2027 NBPP represents a significant reset for the Marketplace, reflecting CMS vision and policy priorities to strengthen program integrity while expanding plan design flexibility and consumer choice as a pathway to affordability, as well as policies to defer to state authority. Healthcare organizations and other interested stakeholders may submit comments on the proposed rule through March 13, 2026.

The remainder of this article addresses the key policy proposals and considerations for issuers, states, and consumer groups.

颁惭厂鈥檚&苍产蝉辫;笔谤辞辫辞蝉补濒蝉&苍产蝉辫;

The proposed NBPP for 2027 sets standards for the Exchanges and ACA-compliant individual and small group markets and updates payment parameters for risk adjustment and risk adjustment data validation (RADV). The rule also implements changes approved under the , (P.L. 119-21, OBBBA) and includes a range of policies spanning plan certification, eligibility and verification, and Exchange oversight.

Expanded Plan Design Flexibility

CMS proposes to discontinue standardized plan options in the Federally-facilitated Marketplace (FFM) and remove limits on the number of non-standardized plans offered by issuers on the FFM and state-based Marketplaces on the federal platform (SBE-FPs). Issuers would be permitted to decide whether to discontinue existing standardized or chronic condition plans or continue them with modified cost sharing.

Considerations: This change is designed to allow greater innovation in plan design. It also raises questions about the potential return of a more complex Marketplace shopping experience for consumers who will have to shift through more plans.

Certification of Non-Network QHPs

One of the most consequential proposals would allow 鈥渘on-network鈥� plans to be certified as qualified health plans beginning in 2027. These plans would not rely on contracted provider networks. Instead, they would set benefit payment amounts and require issuers to demonstrate that sufficient providers鈥攊ncluding Essential Community Providers (ECPs) and mental health and substance use disorder providers鈥攁re willing to accept those amounts as payment in full.

Considerations: CMS positions non-network plans as a way to create lower premium options. For states and issuers, this proposal introduces new oversight and operational considerations related to access standards, consumer protections, the risk of balance billing or access gaps for consumers, and potential market instability.

Changes in Catastrophic and Bronze Cost Sharing

The proposed rule would further expand access to catastrophic plans by codifying hardship exemptions for individuals ineligible for advance premium tax credits (APTCs) or cost-sharing reductions (CSRs) because of projected income. CMS also proposes to allow multiyear catastrophic plans with contract terms of up to 10 consecutive years. In addition, CMS proposes new flexibility for certain bronze plan designs in the individual market. In both cases, CMS proposes to allow catastrophic and bronze plans to exceed the annual maximum out-of-pocket limit.

Consideration: These policies reflect CMS鈥檚 emphasis on affordability through lower premiums and expanded consumer choice, while shifting more financial risk to enrollees through higher cost sharing.

Network Adequacy and Essential Community Providers

CMS proposes to give states greater discretion in provider access for network adequacy and ECP certification reviews, including allowing federally funded exchange (FFE) states to conduct their own reviews if CMS determines they have sufficient authority and technical capacity. CMS also proposes to reduce the minimum percentage of ECPs that issuers must include in their networks from 35 percent to 20 percent.

Considerations: These changes reduce federal prescriptiveness and could lower issuer compliance costs but also place more responsibility on states to monitor access and ensure that vulnerable populations are not adversely affected.

Essential Health Benefits and State Mandates

The proposed rule would prohibit issuers from including routine non-pediatric (adult) dental services as an Essential Health Benefit (EHB). More significantly for states, CMS proposes changes to cost defrayal requirements for state-mandated benefits, requiring states to cover the cost of benefits considered 鈥渋n addition to EHB鈥� under specified criteria, even if those benefits are embedded in the state鈥檚 EHB benchmark plan.

Consideration: These changes could have direct budgetary implications for states, pricing implications for issuers, and could stunt or potentially decrease benefits for consumers.

Program Integrity and Increased Eligibility Verification

CMS includes a robust set of program integrity provisions, including:

Strengthened听standards for agent, broker, and web听broker marketing practices听
Required use of a听US听Department of Health and Human Services (HHS)-approved consumer consent and application review form听
Codification of听听policies听and reintroduction of听听provisions听not听previously听implemented,听including听expanded special enrollment period (SEP) verification听and听increased eligibility standards for enrollees applying for APTCs听(see听Navigating CMS鈥檚 2025 Marketplace Rule: What It Means for ACA Marketplaces, Insurers, and Consumers)听
Implementation of the State Exchange Improper Payment Measurement (SEIPM) program for state-based Marketplaces听

Consideration: These policies continue CMS鈥檚 heightened scrutiny of enrollment activity and subsidy eligibility. CMS鈥檚 policies are likely to increase data matching issues (DMIs), which could increase burden on Marketplaces and enrollees, resulting in reduced enrollment.

Preparing for Policy Driven Changes in ACA Marketplaces

The 2027 NBPP underscores a clear policy shift away from extending federal subsidies toward advancing a Marketplace framework that emphasizes program integrity, state flexibility, and expanded plan design options as mechanisms to promote affordability and consumer choice.

The proposed rule sets the stage for significant strategic and operational decisions for issuers and states ahead of the 2027 plan year. 量子资源网 (量子资源网), including Wakely, an 量子资源网 company, works with issuers modeling enrollment and risk shifts and to assist in pricing decisions. States also should consider the need for new strategies and approaches to adapt to federal policy changes that are expected for ACA Marketplace programs.

For more information about the policies described鈥痠n this article, support with scenario-based modeling of enrollment and data-informed strategy development for 2027 and beyond, please contact鈥痮ur experts , Lina Rashid, or Zach Sherman.

CBO鈥檚 New Baseline Signals Shifting Cost and Risk Dynamics in Medicaid and Medicare

Read Blog

On February 11, 2026, the Congressional Budget Office (CBO) released report. The publication, which represents the first time CBO has released Medicare and Medicaid spending baseline projections since , reflects the impact of the 2025 Budget Reconciliation Act (P.L. 119-21, OBBBA), recent changes to Medicare reimbursement for skin substitute products, and the latest Medicare Part D and Medicare Advantage bids.

CBO鈥檚 baseline serves many functions, including serving as the official 鈥渟corekeeping鈥� benchmark used for cost estimates of proposed legislation under consideration in Congress.

Changes to CBO鈥檚 Medicaid Baseline

CBO decreased its projections of 2026鈥�2035 by approximately $514 million from its January 2025 baseline update. The main driver of that reduction is the impact of the Medicaid provisions in the 2025 Budget Reconciliation Act, which CBO expects will reduce total Medicaid enrollment by 13.1 million people in 2035. The drop in Medicaid spending from the OBBBA-related enrollment reductions was partially offset by technical changes CBO made to the Medicaid baseline.

Medicaid costs per enrollee grew by 16 percent in 2025, which was more than CBO had anticipated. The agency attributes the cost per enrollee growth to a reported decrease in the average health status of Medicaid enrollees following the end of the COVID-era continuous eligibility policy.

CBO anticipates that payment rates for Medicaid managed care plans will begin to rise in 2026 because of this decrease in the average health status of enrollees, and the agency has updated the Medicaid baseline accordingly (see Figure 1).

Source: 量子资源网 analysis of CBO鈥檚 and F reports.

Changes to CBO鈥檚 Medicare Baseline

Compared with its January 2025 baseline, CBO increased its projections of by about $1 trillion (roughly $942 billion, by 量子资源网 (量子资源网) calculations). The main driver of that increase came from CBO鈥檚 updates to its Medicare Part D spending projections, which were increased to reflect higher than expected 2026 bids from private insurance plans that administer the Part D benefit. According to their 2026 bids, Part D plans anticipate a 35 percent increase in their annual per enrollee costs in 2026鈥攁 trend that CBO was not expecting and . Part D spending per beneficiary in 2035 is now projected to exceed $4,000, up from less than $3,000 in the January 2025 baseline (See Figure 2).

The agency鈥檚 Medicare Part A fee-for-service (FFS) spending projection increase was the result of larger than expected increases in 2025 enrollment and per enrollee spending. Those trends were also seen in Medicare Part B FFS but were partially offset by the Centers for Medicare & Medicaid Services鈥檚 (CMS) recent reimbursement changes to skin substitute products. Overall, CBO estimates that the skin substitute reform issued in CMS鈥檚 and final rules will save $245 billion over the 2026鈥�2035 period, including the effects on the Medicare Advantage (MA) program (see Figure 3).

Finally, CBO reduced its spending projections for MA compared to the January 2025 baseline. This change was made to reflect lower-than-expected Medicare Advantage enrollment in 2025, although the spending implications of lower enrollment were partially offset by higher-than-expected bids in 2026 by providers of MA plans (see Figure 4).

Source: 量子资源网 analysis of CBO鈥檚 and reports.

Contact an 量子资源网 Expert Today

Interested in understanding how CBO鈥檚 latest baseline update affects the federal budgetary implications of certain Medicare or Medicaid policy topics or proposals? Contact our experts, Mark Desmaris and Rachel Matthews, to learn more about 量子资源网鈥檚鈥淐BO-style鈥� federal budgetary scoring work, which relies on The Moran Company鈥檚 long-standing methodology. [1]

Beyond federal budget scoring, 量子资源网 is working with states, health plans, and providers to assess how changes in enrollee health status are affecting utilization, costs, and payment rates鈥攁nd what those trends may mean for Medicaid and MA organizations and providers. Our teams support states in evaluating managed care rate setting and program design, help Medicaid and MA plans anticipate risk and bid implications, and assist providers in understanding how changes in patient acuity could affect care delivery, contracting, and financial performance.

[1]Specifically, we apply our understanding of CBO precedents to predict how CBO will likely evaluate the budgetary impact of the legislation in question. We use our best judgment to adopt the assumptions CBO would tend to use, with the understanding that any variance in the assumptions CBO ultimately adopts could cause our estimate to differ from theirs.

Case Study Report: Lessons Learned from HealthySteps Technical Assistance in California

Download

This report synthesizes insights from multiple efforts to support the financial sustainability of HealthySteps sites in California, including federally qualified health centers (FQHCs), community clinics (non-FQHCs), private practices, and other settings. Led by the HealthySteps National Office and 量子资源网 (量子资源网), the technical assistance (TA) elevated challenges, strategies and best practices to achieve sustainability informed by learning collaboratives, individualized TA sessions, and financial modeling exercises. This report complements additional resources that the HS National Office and 量子资源网 developed which are available via the HealthySteps (HS) Sustainability website.

Featured Solutions:

Featured 量子资源网 insights:

More insights from our companies:

333 Results found.

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

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

CMS鈥檚 LEAD Model: A New Phase for Accountable Care and Application Considerations

Core Design Evolutions of the LEAD Model

Next Steps

Connect with Us

Connecting the Dots: Medicaid Community Engagement Requirements and State Readiness for 2027

Early Actions in States Preparing to Implement Work and Community Engagement Requirements

What States Might Do to Chart a Better Path Forward

Connect with Us

HIMSS26: Building the Foundation for Interoperable, AI-Ready Healthcare听

What We Learned at HIMSS

What It Means: Five Insights

What Remains Unresolved

What We’re Watching

We Can Help

Fiscal 2027 State Budget Proposals: Provider Taxes, Medicaid Financing, and OBBBA Effects

Connecting the Dots: Medicaid Community Engagement Requirements and State Readiness for 2027

Outlook 2026: What CMS鈥檚 Proposed 2027 NBPP Signals for ACA Marketplaces, States, and Consumers

Strategies to Address Fraud, Waste, and Abuse in Non-Emergency Medical Transportation

2027 NBPP Proposed Rule Signals Further Marketplace Changes

CBO鈥檚 New Baseline Signals Shifting Cost and Risk Dynamics in Medicaid and Medicare

Case Study Report: Lessons Learned from HealthySteps Technical Assistance in California

Featured Solutions:

Featured 量子资源网 insights:

More insights from our companies:

Insights

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

333 Results found.

Core Design Evolutions of the LEAD Model

Next Steps

Connect with Us

Early Actions in States Preparing to Implement Work and Community Engagement Requirements

What States Might Do to Chart a Better Path Forward

Connect with Us

What We Learned at HIMSS

What It Means: Five Insights

What Remains Unresolved

What We’re Watching

We Can Help