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

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Blog

CMS Clarifies Grandfathering Rules for State Directed Payments

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

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

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

Guidance Clarifies Timeframes for SDPs

Grandfathering Limited to Specific Rating Periods

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

Preliminary Grandfathering Determinations

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

Submission Cutoff Date Clarified

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

No Increases Allowed Until 2028

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

10 Percent Phasedown Unaddressed

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

What It Means for States and Healthcare Organizations

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

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

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

Connect with Us

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

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

For questions about the federal guidance and considerations for your organization, contact our experts below.

Blog

Turning HR 1 Medicaid Work Requirements into Workforce Development Opportunities: Lessons from 量子资源网鈥檚 Recent Webinar

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

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

The Policy Landscape: HR 1 and State Readiness

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

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

Key Challenge #1: Avoiding Disproportionate Impact on Vulnerable Communities

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

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

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

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

Key Challenge #2: Shifting from Compliance to Workforce Integration

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

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

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

Key Challenge #3: Building Administrative Infrastructure and Data Systems

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

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

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

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

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

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

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

Key Challenge #5: Aligning Metrics with Meaningful Outcomes

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

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

Solutions & Strategies for States: A Roadmap

Drawing from the discussion, 量子资源网 outlined a set of strategic recommendations for state Medicaid agencies:

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

量子资源网鈥檚 Role: Strategic Partner to States Developing Public/Private Partnerships to Build Genuine Pipelines of Work

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

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

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

Learn More & Partner with 量子资源网

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

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

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

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

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

Blog

量子资源网 Enrollment Update: Medicaid Managed Care Organizations See Drop in Enrollment in 2Q25

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

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

Key Insights from 2Q25 Data

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

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

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

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

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

Market Share and Plan Dynamics

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

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

What to Watch

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

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

Connect with Us

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

For questions about the 量子资源网IS enrollment report and information about the 量子资源网IS subscription, contact our experts below.

Blog

Navigating the Government Shutdown: Safeguarding the RHT and 鈥淢ake Rural America Healthy Again鈥� Initiatives

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As of October 1, 2025, federal budget negotiations have led to a temporary government shutdown, prompting healthcare leaders to monitor potential impacts on programs administered by the Centers for Medicare & Medicaid Services (CMS). While federal agencies have contingency plans in place, to date CMS has not announced any potential impacts, including to the timelines for the application and award dates for the Rural Health Transformation (RHT) Program.

State governments and healthcare leaders should continue to develop and prepare to submit their applications for the RHT program, which provides a significant opportunity to revitalize rural healthcare infrastructure through strategic investments in access, workforce, innovation, and technology.

Strategies for States to Efficiently Develop Winning Applications

To maintain momentum and optimize their resources during this period of uncertainty in federal government funding and operations:

1. Strengthen Internal Coordination

  • Establish cross-agency working groups to manage RHT program planning and execution
  • Use internal policy experts to interpret the Notice of Funding Opportunity (NOFO) guidance and align initiatives with CMS priorities

2. Leverage Existing Data and Evidence

  • Use state-level health data to identify high-impact areas for investment
  • Prioritize initiatives that align with the RHT program鈥檚 five strategic goals:
    • Prevention and chronic disease management
    • Sustainable access
    • Workforce development
    • Innovative care models
    • Technology innovation

3. Utilize Project Management Tools

To support strategic planning and initiative tracking, 量子资源网 (量子资源网) is offering a free RHT Project Management Tool. This resource helps states:

  • Organize and manage initiative development
  • Cross-reference projects with NOFO categories
  • Track progress and performance metrics
  • Facilitate collaboration across stakeholders

Access the RHT Project Management Tool from 量子资源网:

Complete the form to download
the RHT Project Management Tool

Engage with CMS Resources Proactively

States and their partners can continue to refer to key CMS resources:

States can also submit questions to [email protected].

Final Thoughts

While the government shutdown presents challenges for many federal programs, it remains unclear whether there will be any direct impact on CMS鈥檚 engagement with states regarding the Rural Health Transformation Program. Regardless of federal circumstances, this moment highlights the value of state-level leadership and innovation. By leveraging tools like 量子资源网鈥檚 project management platform and aligning with CMS鈥檚 strategic goals, states can continue advancing rural health transformation and position themselves for success, even in uncertain times.

Brief & Report

Medicaid Financing for Social Health: A Resource Compendium for Illinois Community-Based Organizations & Networks

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量子资源网 (量子资源网) prepared this compendium in September 2025 on behalf of the Chicago Department of Public Health. It was developed at a pivotal moment, as Illinois was poised to take action on multiple program initiatives of critical importance to community providers: reprocure its Medicaid Managed Care system, initiate provider training for 1115 Medicaid Waiver services that address social determinants of health (SDOH), prepare a new Community Health Worker (CHW) benefit, continue implementation of Doula services as a Medicaidcovered benefit, and establish a Third Party Administrator (TPA) support system to promote statewide access to new services, potentially via regional hubs.

A team of subject matter experts with deep experience in Illinois鈥檚 social health and healthcare sectors, as well as national social health integration efforts, created this resource to help organizations evaluate how these program initiatives will affect the services they provide, understand their opportunities to successfully participate in the Medicaid delivery system, and support their ability to effectively serve the needs of their communities. The team brings extensive knowledge of how community-based organizations (CBOs) deliver Medicaid-financed CHW and SDOH services, as well as the alternative payment methodologies managed care organizations (MCOs) use as they engage CBOs to promote population health.

In this context, this compendium is intended to address the following targeted needs identified by stakeholders across the Illinois community-based social health service ecosystem:

  • Guidance to support CBOs鈥� understanding of their value in advancing population health improvement goals, aligning with regional healthcare providers and payers, and identifying opportunities to sustainably fund social health services through Medicaid
  • Insights for CBOs, CBO networks, and emerging CBO hubs and Community Care Hubs (CCHs), with a focus on governance, shared IT infrastructure, financing and integration into the healthcare delivery system
  • Strategic considerations for contracting with Managed Care Organizations to provide social health care services Information to clarify the roles, scopes, and opportunities for collaboration/dual certifications within the community-based workforce that delivers Medicaid services, specifically CHWs, Doulas, and Peer Support Specialists
  • Information from other states on their Doula benefits implementation and Doula hubs to support Medicaid service delivery

Complete the form to receive a copy of the report

Webinar

Webinar Replay- Beyond the Bill: How Pair Team and MCOs Are Meeting Community Needs Under HR 1

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This webinar was held on October 2, 2025.

As Medicaid evolves under HR 1, Managed Care Organizations face increasing pressure to meet new engagement requirements while ensuring vulnerable communities don鈥檛 fall through the cracks. This shifting landscape demands scalable, innovative care models that go beyond compliance 鈥� focusing instead on meaningful connections, coordinated support, and whole-person care.

In this session, Jami Snyder, former HHSC Commissioner of TX and Medicaid Director of AZ, joined Neil Batlivala, CEO and Co-Founder of Pair Team, and Dr. Nate Favini, Chief Medical & Strategy Officer, to explore how Pair Team and its MCO partners are meeting this moment. Learn how their model combines technology, care coordination, and community-based partnerships to engage hard-to-reach members and address social drivers of health.

We heard real-world examples of how payers and partners can come together in smarter, more connected ways. By aligning efforts and building trust, they can drive better outcomes and create stronger community connections for the people who need support the most.

Learning Objectives:

  • Briefly break down HR 1鈥檚 most critical provisions and what they mean for Medicaid and MCO operations.
  • Discover how Pair Team and MCOs are co-designing solutions leveraging technology.
  • Identify best practices for engaging populations facing barriers such as behavioral health needs, housing instability, and transportation challenges.

Featured Speakers:

Carter Kimble, Principal (Moderator) Health Management Associate
Jami Snyder, Former HHSC Commissioner, Texas; Former Medicaid Director, Arizona
Neil Batlivala, Founder and Chief Executive Officer Pair Team
Nate Favini, MD,MS, Chief Medical Officer Pair Team

Blog

Building Bridges: Key Insights from the 2025 HCBS Conference and What They Mean for Your Organization

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This week, our In Focus features insights from the team of 量子资源网 (量子资源网) experts who attended the . Over a handful of days, aging and disability leaders, state officials, health plans, providers, and advocates gathered to explore strategies to transform long-term services and supports. The event celebrated advances in cross-sector collaborations, evidence of program value, seamless access to care for older adults and people with disabilities, member engagement, and integrated care plans for dually eligible individuals.

量子资源网 participants identified seven cross-cutting themes that are reshaping the aging and disability landscape. We examine how these themes connect to ongoing federal policy changes and provide actionable guidance for stakeholders looking to stay ahead of the curve in this evolving field.

Key Cross-Cutting Themes from the Conference                 

Executive Leadership Is Making the Difference

State leaders are developing new partnerships to continue progress toward meeting the needs of people with disabilities and aging adults across the lifespan. The conference showcased the significant progress that states have made by engaging governors and cabinet-level leaders. Pennsylvania’s aging department, for example, though small, leverages lottery funding and executive support to coordinate across departments and various strategic planning initiatives such as their multisector plan for aging.

North Carolina鈥檚 policy leadership in the governor’s office has been instrumental in aligning aging goals across state agencies such as the Department of Commerce on workforce initiatives and Department of Transportation which includes specific older adult needs in its planning.

Tennessee exemplified this approach by merging its Commission on Aging and Disability with the Department of Intellectual and Developmental Disabilities to establish g.

This executive engagement enables what Kathy Greenlee, former ACL Administrator, emphasized: building partnerships beyond traditional aging and disability networks including connections with children and families programs that share common goals around caregiver support and prevention.

Technology Is Extending Human Capacity, Not Replacing It

Technology took centerstage as one of the major solutions to providing personalized caregiver supports and extending the capacity of human services. States are embracing AI (artificial intelligence)-powered tools for routine tasks like call transcription and resource database management, while maintaining human oversight for complex client interactions.

The most successful approaches recognize what highlighted, “High tech won’t replace the need for high touch, but high touch is in short supply.” Technology networks can stretch caregiver capacity, but the human element remains essential. The next generation of service professionals must be tech-savvy integrators who combine digital tools with caring relationships. Key technological advances include digital and virtual coaching platforms, AI precision analytics for risk identification, and “home intelligence” systems that support aging in place. Success, however, depends on ensuring these tools enhance rather than replace human connection.

Direct Care Workforce Crisis Demands Immediate Action

Leading states are not just attempting to manage workforce shortages; they are working on comprehensive workforce infrastructure solutions. Wisconsin’s Certified Direct Care Professional program enrolled over 3,400 workers in its first year, reduced turnover rates, and created a statewide registry where employers actively recruit graduates. Michigan developed four-level stackable credentials that transform direct care into respected career pathways.

States are deploying integrated workforce platforms that combine multiple solutions, including worker registries that promote workforce access and transparency, learning management systems that strengthen development through credentialing, and job matching that enhances access to quality care, and data insights that support evidence-based decisions.

Missouri demonstrates effective stakeholder engagement through its Direct Support Worker Advisory Panel, where 15 workers provide feedback on rates, documentation, scheduling, and professional development while being compensated in developing the solutions, for example, by including them in official advisory entities.

Forward-thinking organizations are breaking down silos through cross-sector partnerships. Area Agencies on Aging and Centers for Independent Living are cross-training workers to serve both populations, effectively expanding the available workforce capacity. Technology integration scales solutions through online, self-paced training that accommodates work schedules and diverse learning needs, while states use federal funding and Medicaid rate increases to boost wages and implement recognition strategies that elevate professional status.

Evidence-Based Investment Strategies

States shared the power of systematic, data-driven approaches to secure aging and disability investments. Ohio’s disciplined four-step process鈥攊dentify priorities, determine evidence-based interventions, quantify return on investment, and operationalize results鈥攔esulted in

Under this reframing, aging can now be seen as an opportunity rather than a burden. States are building ecosystems and partnerships to enhance reach and effectiveness. This positions aging investments as competing priorities capable of delivering measurable returns. with career ladder pathways exemplifies how evidence-based workforce strategies can address critical shortages while improving quality.

The Urban Institute’s research on benefit uptake reveals that nearly 9 million older adults are eligible for programs they don’t receive. Success factors include coordinated state agencies, streamlined applications, community trust-building, and staff training鈥攁ll areas where evidence-based approaches can guide improvement.

Holistic Support for Caregivers and Care Members

The conference emphasized a fundamental shift from viewing caregivers as invisible helpers to recognizing them as partners who require comprehensive support. Key elements for achieving caregiver-driven outcomes include providing support, guidance, and assistance while measuring burden, resilience, satisfaction, and finally, the intent to remain in home settings. , reflecting growing recognition of how caregiver skill-building adds value. This holistic approach extends to addressing the question of who replaces the family caregiver, as older adults increasingly live alone. The answers rest with the development of new partnerships with retailers, pharmaceutical companies, and employers, plus technology that enables remote family support.

Cross-Sector Collaborations: Systems Integration as Survival Strategy

Breaking down silos that have historically separated aging, disability, children and families, and health services resonated throughout the conference. Kentucky observed that states struggle with multiple uncoordinated plans, each with different goals and measures.

Several states have demonstrated successful integration strategies, such as aligning funding streams, creating shared governance structures, and using common metrics across traditionally separate systems. North Carolina’s approach of embedding aging considerations in transportation planning and commerce workforce development shows how integration can extend beyond human services.

From a federal perspective, integration has support. As Greenlee noted, the Administration for Children, Families, and Communities includes “communities” in its title as a signal of broader inclusion. States that build partnerships across these traditionally separate areas will be better positioned for future federal funding and policy changes.

MLTSS as a Critical Vehicle for Whole-Person Care

Managed Long-Term Services and Supports (MLTSS) programs are evolving an infrastructure for providing coordinated and integrated care delivery care. As this transformation occurs, states must have adequate oversight capacity to manage MLTSS programs effectively.

Effective MLTSS programs can help people early enough to prevent nursing facility placement by integrating all services including medical, behavioral, and HCBS and social supports through capitation. Plans should allocate resources to support provider technological investments that facilitate improved care coordination. This technological support becomes essential to maintaining the high-touch, personalized services that MLTSS members require while achieving the scale necessary for program sustainability.

Policy Connections: From Conference Themes to Federal Action

These conference themes reflect broader federal policy shifts, including:

  • New funding must be used more strategically. The $10 billion annually for rural health transformation (2026鈥�2030) can also create opportunities to integrate aging services into the broader health infrastructure.
  • Resource constraints sparks innovation. As the Administration for Community Living faces resource constraints with significant staff reductions, states must be more proactive and resourceful in developing innovative programs.
  • Advocacy must be timed. Upcoming budget cycles require strategic timing for advocacy efforts.

The Road Ahead for Stakeholders

Organizations across the aging and disability ecosystem must prepare for a more integrated, technology-enhanced, and evidence-driven environment. Success will require executive leadership, strategic partnerships, and measurable value.

State Agencies

  • Engage executive orders establishing aging as a priority across all state departments.
  • Developing systematic evidence-based investment strategies that quantify return on investment for aging initiatives, using Ohio’s four-step methodology as a template.
  • Building partnerships beyond traditional aging and disability networks, including with children and family services, workforce development, and transportation agencies.
  • Implementing workforce development strategies that include investing in credentialing and tech-enabled training, and cross-sector partnerships to address to strengthen the direct care workforce.

Health Plans and Payers

  • Implementing holistic caregiver support programs that combine digital tools with human coaching, measuring outcomes like burden reduction and care member satisfaction.
  • Leveraging new Medicare coding opportunities for ADL/IADL supports to pay for evidence-based caregiver training and skill-building programs.
  • Partnering with technology companies to deploy AI-powered risk identification tools while maintaining human oversight for member interactions.
  • Investing in provider technology infrastructure that enables better care coordination and supports MLTSS program effectiveness.

Providers and Community Organizations

  • Developing technology-enhanced service delivery that extends human capacity while preserving personal connection, following the “high tech, high touch” principle.
  • Pursuing evidence-based training and credentialing programs with clear career pathways.
  • Building partnerships with non-traditional allies like retailers, pharmaceutical companies, and employers to expand aging-in-place support networks.
  • Participating in workforce development initiatives that create shared worker pools across aging and disability services.

Technology Vendors

  • Developing AI-powered tools that enhance rather than replace human service delivery, focusing on routine tasks like documentation and risk assessment.
  • Creating integrated platforms that support cross-system coordination between aging, disability, health, and family services.
  • Building home intelligence systems that enable remote family caregiving and professional monitoring while preserving independence and dignity.
  • Designing workforce development platforms that support credentialing, job matching, and career advancement tracking.

Moving Forward Together

The 2025 HCBS Conference revealed a field that is embracing innovation and integration. States leading this transformation share common characteristics: executive leadership, evidence-based investment strategies, technology that enhances human connection, holistic support approaches, and systems that collaborate to break down traditional silos.

The path forward requires strategic planning, rigorous evaluation, cross-sector partnerships, and sustained political will. Organizations that can integrate evidence-based approaches with compassionate care, leverage technology to extend human capacity, build partnerships that transcend traditional boundaries, and develop sustainable workforce solutions, will be best positioned to serve the growing population of older adults and people with disabilities.

Connect with Us

The HCBS Conference highlighted significant momentum toward integrated service delivery, evidence-based investment, and technology-enhanced care. Stakeholders should expect continued federal policy evolution, including new funding opportunities and partnership requirements in the coming years. Organizations that wait will miss critical opportunities. 量子资源网 works with state agencies, health plans, providers, and community organizations to design and implement aging and disability initiatives. We help clients engage executive leadership, develop evidence-based business cases, deploy appropriate technology solutions, build cross-sector partnerships, and create sustainable workforce development strategies. To discuss how these trends affect your organization and explore next steps, contact our featured experts below.

Webinar

Webinar Replay – Medicaid 1115 Justice Involved Reentry Demonstration Opportunities: Engaging Key Stakeholders

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This webinar was held October 22, 2025.

This webinar explored how states, local agencies, and community organizations can maximize Medicaid鈥檚 new 1115 demonstration authority to improve reentry outcomes for justice-involved individuals. Presenters discussed practical strategies for assessing health and social needs, building strong collaborations with community providers, and implementing effective Medicaid enrollment processes. Attendees gained insights into designing and operationalizing reentry programs that promote continuity of care, reduce recidivism, and support successful community reintegration. This session is ideal for State Medicaid agencies, carceral facilities, correctional healthcare companies, health plans, community-based organizations, and federally qualified health centers.

Learning Objectives:

  • Understand the health and resource needs of returning citizens (health, behavioral health and social issues).
  • Identify key partners and formalize collaborations to strengthen the quality of transitions, care and support provided to individuals transitioning to the community.
  • Develop Medicaid enrollment strategies that apply to your state and local framework.
Webinar

Webinar Replay – Navigating Medicaid Managed Care Shifts: Financial Pressures, Federal Policy, and Medicaid MCO Implications

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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.

Brief & Report

Medicaid Coverage of Breastfeeding Support and Supplies

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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.

Blog

Medicaid Managed Care Profitability: Navigating Margin Pressures and Regulatory Shifts in 2024

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This week, our In Focus section highlights findings from 量子资源网 Information Services鈥� (量子资源网IS鈥檚) review of 2024 statutory filings submitted to the National Association of Insurance Commissioners (NAIC). These filings provide a nationwide view of Medicaid managed care plan profitability and medical loss ratios (MLRs) across 221 plans operating in 39 states, the District of Columbia, and Puerto Rico.

These data build upon and offer additional context to a previous  conducted by 量子资源网 and Wakely, an 量子资源网 Company, of increasing post-pandemic financial pressures driven by acuity increases resulting from the continuous eligibility unwinding and increases in behavioral health and home and community-based services access and utilization.

Medicaid Managed Care Underwriting Gains and Losses

As state Medicaid programs have increasingly moved from fee-for-service to managed care, a foundational assumption has been that efficient managed care organizations (MCOs) reduce waste and deliver high quality, cost-effective healthcare services. This transition has made Medicaid plan performance and sustainability a central focus for policymakers and actuaries alike.

Medicaid capitation rates must be actuarially sound, which means they must be projected to cover all 鈥渞easonable, appropriate, and attainable costs,鈥� including medical administrative costs, plus a margin for insurance risk, even for nonprofit plans. According to the Society of Actuaries 2024 , average underwriting margins in Medicaid rates ranged from 0.35 percent to 3.15 percent, with a consistent average between 1.2 percent and 1.3 percent.

However, actual results often deviate from projections for reasons that may be challenging to predict. Rate setting is an inherently forward-looking process, and even with conservative assumptions, unexpected shifts in enrollment, acuity, or service utilization can lead to significant deviations from projected results. Retrospective reviews show variability in margins over time (see Figure 1).

Figure 1. Historical Medicaid MCO Net Gains/Losses, 2012鈥�2024 (39 States, DC)

Based on 量子资源网IS鈥檚 analysis, Medicaid MCOs sustained modest but steady gains from 2012 through 2017. After a decline between 2016 and 2019, margins rebounded to approximately 3 percent until 2022, narrowed in 2023 to 1.9 percent, and turned negative in 2024 at -0.9 percent.

For the first time in over a decade, more plans experienced losses than gains in 2024 (see Figure 2), with only 42 percent reporting positive margins, down from the decade high of 84 percent in 2022. This shift raises critical questions about sustainability and participation in Medicaid managed care.

Figure 2. Medicaid Managed Plans Likelihood of Gain, 2012鈥�2024 (39 States, DC)

The 鈥淟ikelihood of Gain鈥� chart tracks the percentage of Medicaid managed care plans reporting an underwriting gain each year from 2012 to 2024. For most years, the likelihood that a plan posted a gain was relatively high, typically between 60 percent and 80 percent. The probability reached a recent peak in 2022, with 84 percent of plans reporting gains, and remained elevated in 2023 (74 percent). In 2024, however, the likelihood of gain dropped sharply to just 42 percent, the lowest level in the 12-year period.

Risk Corridors, Medical Loss Ratios, and Structural Policy Shifts

MLRs show the portion of plan revenue spent on medical care as compared with the costs to operate the plan and the underwriting gain or loss described previously. When MLRs rise or fall, it can be an indication that medical cost trends experienced by health plans differ from the assumptions used by state rate setting actuaries. High MLRs are the key driver of underwriting gains, and low MLRs are associated with higher profitability. All states report MLRs to the Centers for Medicare & Medicaid Services (CMS), and some enforce minimum MLRs with a remittance provision, requiring plans to return funds if their MLR goes below a certain level.

Risk corridors are another tool that states use to manage financial volatility. These mechanisms share gains or losses between plans and states when results deviate significantly from pricing assumptions, offering protection to MCOs and the state alike, in contrast to minimum MLR provisions with a remittance provision, which only protects the state. During the COVID-19 pandemic, many states implemented or expanded risk corridors to recoup overpayments because of lower utilization. Some risk corridors were set retroactively鈥攁 practice CMS now prohibits.

In 2024, MLRs reached a decade high of 90.8 percent, as indicated by 量子资源网IS鈥檚 analysis. Driving this increase were heightened utilization rates, increased enrollee acuity, and the end of continuous Medicaid coverage protections in 2023. As healthier, lower-cost members left Medicaid, plans were left serving a more complex population with higher per-member costs. Inflation in medical costs鈥攅specially for behavioral health and home and community-based services鈥攁dded more pressure. Delayed or avoided care during the COVID-19 pandemic may also have played a role, as members sought more services in 2022鈥�2024, resulting in a surge in utilization greater than what was priced into rates.

Many states put risk corridors in place to stabilize margins from 2020 to 2022, which may have contributed to the tight band of outcomes around the high underwriting gains in that period. However, many states have been  them for 2024, 2025, and 2026. Without these protections, plans may face greater exposure to underpayment in 2025 and 2026 if cost trends continue to outpace rate assumptions.

What to Watch

Rate setting conversations between states and plans for 2026 are happening now, and in many cases they are quite challenging. In addition to meeting actuarial soundness requirements, states also must balance their budgets, and some may be facing limitations on their traditionally used tools.

Looking ahead, it will be increasingly important that states and plans partner to find cost savings that can ensure the program鈥檚 long-term sustainability.

A subscription to 量子资源网IS provides access to comprehensive financial intelligence on Medicaid managed care. Far beyond surface-level snapshots, 量子资源网IS delivers health plan-level financial performance metrics, enrollment trends, and state policy developments that directly shape rate setting and operational strategy. Whether you鈥檙e a state official, health plan executive, or policy strategist, 量子资源网IS provides the financial clarity and policy context needed to anticipate regulatory shifts, benchmark performance, and make confident, data-driven decisions.

For questions about the analysis discussed in this article, contact our experts below.

Webinar

Webinar Replay – Work That Works: Creating Sustainable Employment Pathways for Medicaid-Enrolled Communities

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This webinar was held on August 14, 2025.

As Medicaid increasingly intersects with the social drivers of health, states have a unique opportunity to strengthen economic mobility for Medicaid-enrolled populations through strategic localized employment initiatives in partnership with municipalities, healthcare systems, and managed care providers. This webinar explored how state Medicaid agencies can lead and support the development of workforce pathways that are sustainable, inclusive, and tailored to the needs of underserved communities.

Learning Objectives:

  • Learn how collaboration and partnerships reduce employment barriers.
  • Explore how data-driven design improves health outcomes.
  • Identify ways to integrate workforce development into Medicaid.
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