As we approach the end of 2025, the Affordable Care Act (ACA) Marketplaces face a pivotal moment. Enhanced Advance Premium Tax Credits (APTCs), introduced under the American Rescue Plan Act (ARPA) and extended through the Inflation Reduction Act (IRA), have driven enrollment to 24 million individuals now covered through the Marketplaces. Without congressional action, these subsidies expire on December 31, 2025.
成人VR视频 and Wakely, an 成人VR视频 Company, have released updated analysis that compares enrollee out-of-pocket spending of ACA marketplace enrollees to other major payers using claims data. The brief answers key questions about Marketplace enrollees and whether they spend more or less out-of-pocket relative to Medicare, ESI and Medicaid enrollees.
On November 28, 2025, the Centers for Medicare & Medicaid Services (CMS) the . Each annual rulemaking cycle offers CMS an opportunity to recalibrate program priorities.
This proposed rule offers a road map for CMS鈥檚 vision for Medicare Advantage (MA) and Part D. Signaling how CMS leadership intends to shape the MA and Part D programs beyond 2027鈥攑rioritizing outcomes, streamlining operations, and inviting dialogue on modernization鈥攖he proposed rule reflects a strategic imprint on the program鈥檚 trajectory. The deadline to submit comments isJanuary 26, 2026.
Given CMS鈥檚 goal of modernizing MA and Part D, plans, providers, and advocates should engage early to inform final policies. 成人VR视频 (成人VR视频) policy and actuarial experts, including Wakely and Leavitt Partners (both 成人VR视频 companies), are analyzing and modeling the effect of the proposed changes. This article highlights some of the major policy updates that require near-term planning by states, Medicare Advantage plans, providers who serve MA beneficiaries, and their partners.
Key Themes in the Proposed Rule
Requests for Information
CMS includes three significant requests for information (RFIs) and highlights additional opportunities to provide input on approaches to reduce administrative burden throughout the program. CMS鈥檚 modernization RFI focuses on financing and other strategies to support beneficiaries with plan selection. In addition, CMS seeks input on emerging trends in MA special needs plans (SNPs), citing concerns about rapid growth and potential program integrity issues. Consistent with the departmentwide priorities, the RFI also delves into potential strategies for plans to address nutrition and wellness benefits for MA enrollees.
Figure 1. RFIs Signaling New Policy Directions
Star Ratings Overhaul: Refocusing on Outcomes and Experience
CMS proposes significant changes to the Star Ratings system, which influences plan bonuses and consumer choice. The changes increase the focus on clinical care, outcomes, and patient experience of care measures where performance is not topped out and align with universal foundation of measures.
Health Equity Index Rollback: Rather than implement the previously planned Excellent Health Outcomes for All reward (formerly Health Equity Index) for 2027, the agency will continue using the historical reward factor that incentivizes consistently high performance across all measures.
Measure Streamlining: Twelve process-heavy or administrative measures will be removed.
Behavioral Health: A new measure for depression screening and follow-up will be introduced for the 2027 measurement year, with integration into Star Ratings by 2029.
Why It Matters: Removing these measures continues the shift away from administrative compliance, easing burden while strengthening quality incentives.
Medicare and Medicaid Dual Eligible SNPs and Integration
CMS is proposing several changes to improve how Medicare Advantage plans serve people who qualify for both Medicare and Medicaid (dual-eligible beneficiaries):
Starting in calendar year (CY) 2027, CMS proposes to allow D-SNPs and I-SNPs two opportunities to change to their model of care (MOC)鈥攖he framework for how they coordinate care. These windows would be January 1 through March 31 and October 1 through December 31.
When beneficiaries are automatically moved (i.e., passively enrolled) from one integrated D-SNP to another, CMS will no longer require the new plan鈥檚 provider network to closely match the old plan鈥檚 network. Instead, the new plan must ensure that all incoming members receive uninterrupted care for at least 120 days (up from 90 days), helping prevent gaps in treatment.
In states where dually eligible individuals are explicitly carved out from or not required to enroll in Medicaid managed care, CMS proposes to let highly integrated dual eligible special needs plan (HIDE SNP) continue to enroll full-benefit, dual-eligible (FBDE) individuals in the same service area, even if those individuals are in Medicaid fee-for-service. This change is intended to maintain coverage and simplify enrollment for these beneficiaries.
Why It Matters: While the proposed changes revise broader policies, the updates could have significant effects on D-SNP and MA integration. These changes also could shape states鈥� decisions regarding their integration policies. Plans should continue to monitor these developments.
Other Notable Changes
CMS proposes a new special enrollment period (SEP) for beneficiaries when their providers leave a plan鈥檚 network, eliminating the requirement that CMS deem the change 鈥渟ignificant.鈥� The intent of this change is to preserve continuity of care and ease the burden of beneficiaries switching plans. In addition, CMS plans to codify SEP policies for greater consistency.
The proposed rule also calls for the following:
Codifying multiyear changes stemming from the Inflation Reduction Act, including elimination of the coverage gap phase
Lowering annual out-of-pocket thresholds and removal of cost sharing in catastrophic coverage
Transitioning to the Manufacturer Discount Program and updating true out-of-pocket (TrOOP) calculations
Clarifying specialty-tier drugs and subsidy structures
As a result, plans will have updated financial responsibilities.
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As CMS sets a new course for Medicare Advantage and Part D, organizations face both opportunities and challenges in adapting to these changes. 成人VR视频 brings deep expertise in Medicare policy, actuarial modeling, and operational strategy. Our team鈥攊ncluding experts from Wakely and Leavitt Partners鈥攃an help plans, providers, and stakeholders interpret the proposed rule, assess its impact, and develop actionable strategies for compliance and competitive positioning.
Whether you need data-driven analysis, scenario modeling, or hands-on support preparing for implementation, 成人VR视频 is ready to partner with you to navigate the evolving Medicare landscape and achieve your goals.听Contact聽our experts below to discuss your questions and how 成人VR视频 can help.
At the National Association of Medicaid Directors (NAMD) 2025 Fall Conference, planned federal health policy changes dominated conversations among attendees, including state Medicaid directors, health plans, and providers. With major changes on the horizon for Medicaid and Affordable Care Act (ACA) Marketplace programs, stakeholders are preparing for transition and transformation in 2026.
A team from 成人VR视频 (成人VR视频) attended the conference and returned with valuable insights on the emerging opportunities, state-specific priorities for 2026 and beyond, and early strategies to address and mitigate the challenges ahead. Among the topics discussed were the Rural Health Transformation Program (RHTP), Medicaid eligibility and community engagement policy changes, drug costs and financing, upstream drivers of health, and data infrastructure.
Five major takeaways about the work state Medicaid agencies, health plans, providers, and industry partners will focus on in the year ahead were as follows.
1. Medicaid leaders are preparing for new eligibility and community engagement policies under tight timelines.
The 2025 budget reconciliation act (P.L. 119-21, OBBBA) requires certain adults ages 19鈥�64 enrolled in Medicaid to complete at least 80 hours per month of community engagement (CE) to maintain coverage. Exemptions to the CE requirement apply to people with disabilities, pregnant individuals, and caregivers. States must now develop processes and information systems that track and verify compliance with CE requirements, manage exemptions, and support members through this policy change.
Medicaid CE and other new eligibility requirements, including more frequent eligibility checks, were a frequent topic of discussion throughout the event. Implementation of these requirements is a major operational lift with significant program integrity implications. State leaders discussed the tight timelines, resource constraints, and the need to coordinate across agencies, health plans, and providers. They are already planning to mitigate the risk of coverage losses for at-risk populations and to minimize administrative burden for all stakeholders. The urgency and complexity of these changes underscore the need for strategic planning and cross-sector collaboration.
2. Coordinated communication and stakeholder engagement remain critical.
States are increasingly relying on multiple forms of communication and feedback channels to engage stakeholders, including Medicaid members. Clear, timely communication is essential to ensure people understand their options and know what they need to do and when to do it. Medicaid leaders described the value of embedding vital eligibility information into workflows at all levels and applying lessons from the COVID-19 public health emergency unwind to new outreach and education initiatives.
Several states emphasized the effectiveness of convening all stakeholders to ensure unified messaging. Other common themes included the importance of plain-language materials, hands-on support through case managers and navigators, and engaging providers to integrate new eligibility and work-related requirements into their workflows, as policies evolve.
3. States are eager to begin implementing initiatives in their rural health transformation plans.
Medicaid leaders are actively discussing their RHTP applications with CMS, preparing to move quickly once awards are announced. Many states are focused on enhancing existing efforts, while others are preparing to invest in systems, technology, and organizations that will better integrate rural providers into the broader healthcare system, including Medicaid.
Federal and state leaders and their partners discussed the opportunity for RHTP funding to strengthen rural health infrastructure, workforce development, education, and outreach鈥攅specially in underserved areas. States are positioning themselves to leverage these funds to address persistent disparities and improve access to care for rural populations.
4. States are seeking to balance cost and access to GLP-1s and other prescription drugs.
Federal and state leaders extolled the benefits of new and innovative prescription drug products and therapies, including GLP-1s. Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz highlighted the administration鈥檚 announcements about drug pricing, including the new GENEROUS (GENErating cost Reductions fOr US Medicaid)鈥痬odel, which is focused on drug costs in the Medicaid program. These discussions reinforced CMS鈥檚 focus on new drug pricing models and the importance of involving Medicaid experts in these nuanced development and implementation conversations.
Attendees gained a deeper appreciation for the administration鈥檚 intent to have GLP-1s and other therapies play a significant role in addressing chronic disease, including obesity. State Medicaid agencies鈥攁nd their Medicaid managed care plans and partners鈥攕hould plan to inform discussions about coverage and financing of these novel products as well as for cell and gene therapies. The intersection of innovation, affordability, and access will remain a central challenge.
5. Medicaid agencies are working on multiple technology interoperability and quality initiatives.
Although Medicaid eligibility policy changes and CE requirements drew significant attention, many discussions also focused on other upcoming deadlines, including:
New federal interoperability and prior authorization rules that go into effect in 2027
State implementation of Medicaid and CHIP Quality Rating System requirements before the end of 2028
The transition to digital quality measurement (dQM) by 2030
Medicaid agencies are collaborating with managed care and provider organizations to understand the operational, clinical, and technical dimensions of these initiatives.
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成人VR视频鈥檚 expert consultants provide聽advanced聽policy,聽technical, and operational聽support, and can聽help聽your organization聽navigate and succeed in the聽evolving regulatory landscape.听Our team brings deep experience and practical solutions to help clients anticipate challenges, leverage opportunities, and achieve their program goals.听For more information or technical assistance on these and other emerging Medicaid priorities, contact the 成人VR视频鈥檚 featured experts聽below.
The Massachusetts Executive Office of Health and Human Services has begun early stakeholder engagement for the next Section 1115 demonstration waiver from 2028 to 2032, which will reflect the priorities of MassHealth, the Commonwealth鈥檚 Medicaid and CHIP (Children鈥檚 Health Insurance Program) system. The program covers roughly two million residents and operates with a budget of more than $20 billion in annual state and federal spending.
In two public meetings November 10 and 17, 2025, senior officials from MassHealth鈥擱yan Schwarz and Caitlin Towey鈥攐utlined MassHealth鈥檚 early thinking for the next 1115 demonstration in the 鈥淩oadmap for MassHealth鈥檚 2028鈥�2032 1115 Demonstration Extension,鈥� released in October 2025. They emphasized the Commonwealth鈥檚 commitment to preserving core programs while acknowledging a more challenging federal landscape than in prior waiver cycles.
The roadmap highlights the 28-year trajectory of progress enabled by Massachusetts鈥� 1115 authority鈥攆rom establishing the Accountable Care Organization (ACO) model and expanding substance use disorder (SUD) treatment, to strengthening safety net providers and driving the uninsured rate to 3 percent, the lowest in the nation. More recent demonstration cycles have deepened primary care investments, expanded the behavioral health continuum, advanced health equity incentives, and integrated housing and nutrition supports into ACO benefits.
Nonetheless, the roadmap also underscores the significant headwinds that are shaping the next waiver. The federal budget reconciliation act (P.L. 119-21, OBBBA) signed in July 2025 is projected to result in coverage losses for up to 300,000 Massachusettsresidents and as much as $3.5 billion in lost annual federal healthcare funding. Meanwhile, new federal policy stances, such as rescinding health-related social needs (HRSN) guidance and discontinuing approval of continuous eligibility authorities, will require Massachusetts to rethink elements of its current demonstration. State budget pressures are also a factor. MassHealth now accounts for nearly one-third of total state spending.
A major source of uncertainty is the lack of federal guidance on several core elements of the existing waiver. During November鈥檚 stakeholder sessions, state leaders said they are still awaiting direction from the Centers for Medicare & Medicaid Services (CMS) on several issues, including budget neutrality, hospital transformation funding, and HRSN services.
HRSN: Current HRSN initiatives were enabled by guidance issued under the Biden Administration, which has since been rescinded. MassHealth officials said they intend to request approval for HRSN-like services in the upcoming waiver, even if the program must be redesigned or authorized through different mechanisms.
Workforce Initiatives: Workforce funding, currently about $40 million over five years, will not be allowed under 1115 authority moving forward. State officials said they must identify alternative pathways to sustain or reconfigure workforce efforts if they are to continue.
ACO & MCO Programs: Stakeholders asked for updates to the ACO and managed care organization (MCO) programs. MassHealth confirmed that the current ACO contracts run through December 31, 2027; however, they did note that Tufts Health Plan will exit the MCO program at the end of 2025, though this will have no effect on MassHealth鈥檚 two ACOs. Future ACO and MCO re-procurements could lead to changes, but those decisions remain several years out.
Behavioral Health: Behavioral health policy also drew substantial interest. The state is assessing its behavioral health diversion system to determine which components require continued 1115 authority and where changes may be needed. Officials also confirmed that they intend to request continued 1115 authority for the Program for Assertive Community Treatment (PACT)鈥攁 multidisciplinary service for individuals with serious mental illness.
Primary Care: Officials described a 鈥渃risis in primary care access鈥�, driven by provider shortages and prolonged underinvestment. Although Massachusetts has historically led the nation in primary care spending, state leaders noted that the 1115 waiver alone cannot resolve these challenges. Gov. Maura Healey鈥檚 administration has convened a new task force to assess primary care access and financing, and MassHealth indicated it intends to align with that panel鈥檚 work.
Cost Containment: Cost containment remains a priority. Officials said managing rising program costs is a theme that will be embedded throughout the renewal process.
As that effort unfolds in 2026, the State appears to be focused on maintaining core programs, adapting to uncertain federal guidance, and preserving flexibility. Officials said they are evaluating whether some current initiatives may need to shift from waiver authority to the State Plan, depending on forthcoming CMS policies. They are also closely monitoring other states鈥� expiring waivers to understand what CMS may approve under the current administration.
成人VR视频 experts have extensive expertise in helping to draft, implement, and evaluate 1115 demonstrations across the country. Our team in Massachusetts will be following the Commonwealth鈥檚 efforts closely and are available to answer your organization鈥檚 questions on how to navigate these new developments.听
KFF and 成人VR视频 (成人VR视频), on November 13, 2025, released the annual Medicaid Budget Survey, . Now in its 25th year, this report offers a window into the evolving landscape of state Medicaid policy, financing, and operations across the United States. The survey was conducted in collaboration with the National Association of Medicaid Directors (NAMD), with 48 states providing survey responses by October 2025.
Released before the NAMD 2025 Fall Conference, Medicaid directors鈥� insights and the challenges, priorities, and innovations shaping Medicaid programs in fiscal years (FYs) 2025 and 2026 will figure prominently at this event. A team of 成人VR视频 experts will be in attendance and available to address new developments and opportunities in state Medicaid policy and financing.
Key Trends and Challenges
Fiscal Pressures and Budget Uncertainty
States are entering FY 2026 with slower revenue growth and rising healthcare costs. In FY 2025, Medicaid enrollment dropped by 7.6 percent as pandemic-era continuous coverage policies ended, but spending continued to climb. In fact, total Medicaid spending grew 8.6 percent in FY 2025 and is projected to rise another 7.9 percent in FY 2026. State Medicaid spending growth is expected to slow from 12.2 percent in FY 2025 to 8.5 percent in FY 2026. Nearly two-thirds of Medicaid directors, however, thought the odds of a Medicaid budget shortfall in FY 2026 was 鈥�50-50,鈥� 鈥渓ikely,鈥� or 鈥渁lmost certain.鈥� Cost drivers include increases in provider rates, higher acuity enrollees, greater long-term care and behavioral health utilization, and rising pharmacy costs, especially for specialty drugs.
Figure 1. Medicaid Spending and Enrollment Trends Since the COVID-19 Pandemic Began
Source: Medicaid Enrollment & Spending Growth: FY 2025 & 2026. FY 2025鈥�2026 spending data and FY 2026 enrollment data are derived from the annual KFF survey of state Medicaid officials that 成人VR视频 conducted in November 2025. Historic data reflects growth across all 50 states and DC and comes from various sources.
Federal Policy Changes and Provider Taxes
States are preparing for major federal policy changes under the 2025 budget reconciliation law (OBBBA), which will reduce federal Medicaid funding and impose new eligibility requirements. On November 14, 2025, the Centers for Medicare & Medicaid Services issued guidance regarding the OBBBA鈥檚 restrictions on states鈥� ability to use healthcare-related provider taxes to finance Medicaid programs (see CMS Provider Tax Guidance Places New Pressures on Medicaid Budgets). States are now generally prohibited from enacting new provider taxes or increasing existing ones after July 4, 2025, and must comply with new rules by the end of FY 2026 or FY 2028, depending on the tax type. In particular, beginning in federal FY 2028, the OBBBA gradually reduces the safe harbor provider tax limit for states that have adopted the ACA Medicaid expansion by 0.5 percent annually until the safe harbor limit reaches 3.5 percent of net patient revenues in federal FY 2032. These changes will reduce states鈥� flexibility to use provider taxes as a source of non-federal Medicaid funding, potentially leading to budget gaps and reductions in provider payments if lost revenue cannot be replaced.
Policy Changes and Priorities
Managing Risk in Managed Care Programs
A total of 46 states operate some form of managed care, and capitated managed care remains the predominant delivery system for Medicaid in most states. Most states that contract with capitated managed care organizations (MCOs) reported imposing a minimum medical loss ratio (MLR) requirement, requiring remittance payments when an MCO falls short of the minimum MLR requirement, and using risk corridors to manage financial risk and ensure value. States are also grappling with the growing use of artificial intelligence, particularly in the context of managed care prior authorization. Early policies focus on transparency, oversight, and ensuring human review to address concerns about bias, inappropriate denials, and privacy risks.
An Uptick in Provider Rate Reductions and Provider Tax Restrictions on the Horizon
Most states implemented fee-for-service rate increases for at least one provider category in FY 2025 and FY 2026. The number of increases is slowing, however, and there was an increase in states reporting provider rate restrictions compared with previous years. States continue to target rate increases for nursing facilities and home and community-based services more than other provider types.
Provider taxes remain a key source of the non-federal share of Medicaid funding, with all states except Alaska having at least one tax. These taxes accounted for a median 18 percent of states鈥� FY 2026 non-federal Medicaid financing, but new federal restrictions enacted in the OBBBA will limit states鈥� ability to use or expand these taxes going forward. As of July 1, 2025, 31 Medicaid expansion states reported having a non-exempt provider tax greater than the 3.5 percent of net patient revenues and therefore subject to the OBBBA鈥檚 phase down requirement.
Strong Benefit Enhancements and Scrutiny of Prescription Drugs
New Medicaid benefits and benefit enhancements continued to outpace benefit cuts and limitations. In all, 37 states reported new or enhanced benefits in FY 2025, and 36 plan to add or enhance benefits in FY 2026. More specifically, states reported expanding services across the behavioral health care continuum and for prenatal, delivery, and postpartum services. Most states reported at least one new or expanded initiative to contain prescription drug costs, including participation in the Centers for Medicare & Medicaid Services (CMS) Cell and Gene Therapy Access Model. State responses also reflected a waning interest in expanding Medicaid coverage for costly obesity drugs (GLP-1s), with some states restricting coverage because of budget pressures.
Challenges and Priorities
Many states are confronting more difficult fiscal conditions while also preparing for future fiscal uncertainty driven, in part, by the OBBBA. Medicaid leaders also expressed concern about the complexity of implementing new federal requirements, including work requirements and more frequent eligibility determinations. At the same time, state Medicaid leaders reported that they continue to pursue a variety of program priorities to expand access, especially to behavioral health and long-term care services, implement initiatives targeting specific populations (e.g., people who are pregnant, justice-involved, and at risk of homelessness), reform and strengthen delivery systems, modernize IT systems and infrastructure, and expand program integrity efforts.
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States face a challenging fiscal environment as they balance cost containment, quality, and access in their Medicaid programs. The combination of rising healthcare costs, new federal restrictions on provider taxes, and anticipated funding reductions will require states to make decisions about coverage, benefits, and provider payments. Nonetheless, states remain committed to maintaining quality and access for Medicaid beneficiaries, using available resources, and pursuing innovative approaches to care delivery.
For more information about the key takeaways from the KFF report and 成人VR视频鈥檚 Medicaid solutions, contact our experts below.
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The Centers for Medicare & Medicaid Services (CMS) issued a on November 14, 2025, which provides preliminary guidance on healthcare-related taxes affected by Sections 71115 and 71117 of the Budget Reconciliation Act of 2025 (, P.L. 119-21)鈥攖he portion of the legislation that focuses on new limitations on provider assessments.
Although this letter does not change federal regulations, it signals an important policy shift that will affect how states fund their Medicaid programs. CMS is working to incorporate these interpretations into rulemaking through the federal notice and comment process.
成人VR视频 (成人VR视频) reviewed the letter specific to these provisions and in the context of other policy and financing changes that are affecting the Medicaid program. This article highlights key clarifications in the letter, the impact of the preliminary guidance on states, and the potential for the guidance to shape Medicaid budgets, financing strategies, and future policy reforms.
Guidance Clarifies the Meaning of 鈥淓nacted鈥� and 鈥淚mposes鈥�
OBBBA prohibits states from establishing new provider taxes after July 4, 2025. Existing provider taxes may be grandfathered if they meet specific criteria, but most taxes in expansion states鈥攅xcept those on nursing and intermediate care facilities鈥攚ill be phased down starting October 1, 2027. To qualify for grandfathering, a tax must be both 鈥渆nacted鈥� and 鈥渋mposed鈥� by July 4, 2025, as defined by CMS.
CMS interprets enacted and imposed in the following way.
Enacted:聽CMS defines enacted based on two components. First, the state or local government must have completed the legislative process to authorize the tax by July 4, 2025. Second, any necessary tax waiver of the broad-based and uniformity requirements must be聽approved聽no later than July 4, 2025. This interpretation will present challenges for some states as any pending tax waiver requests and approvals issued after July 4, 2025, will not qualify for grandfathering.
Imposed:聽In addition to the enacted requirements, a state must have been actively collecting revenue for the new tax as of July 4, 2025. CMS does appear to allow for instances in which a state鈥檚 routine collection and billing practices require the tax be paid on a delayed schedule鈥攁 common practice across states.
CMS may continue to approve pending state proposals for new and revised tax structures; however, with the approvals, CMS is also notifying states that any tax structure that is ineligible for grandfathering must be revised by October 1, 2026, to comply with Section 71115 of the OBBBA.
Guidance Sets Preliminary Timeline for Compliance with New Broad-based and Uniformity Requirements in Section 71117
The OBBBA and a separately published in May 2025 provide CMS with additional flexibility to tighten requirements for waivers that allow states to impose provider taxes that are not broad-based and uniform (i.e., the tax is levied on providers in a class at a common rate). CMS believes states have used a strategy to pass the prescribed statistical test for these waivers while shifting a disproportionate share of tax burden to high Medicaid providers.
The November 14 letter also includes a preliminary timeline for states to restructure their taxes to comply with the new requirements related to waivers of the broad-based and uniformity tests.
MCO taxes: States that levy a higher tax rate on Medicaid managed care organizations (MCOs) than on other MCOs must submit a revised tax structure applicable to the state fiscal year (SFY) starting in calendar year (CY) 2026.
Taxes on all other provider types: States with a similar tax structure on another provider class would need comply by the conclusion of the SFY, ending in CY 2028.
CMS notes that the preliminary timeline for the MCO taxes is the minimum transition period, and the final rule may allow for a transition period of up to three fiscal years.
What It Means for States
All states except Alaska rely on one or more provider tax(es) to fund their Medicaid programs. These additional limitations on the uses of provider taxes鈥攊ncluding those now in place鈥攚ill put a significant strain on state budgets, beginning as early as October 1, 2026. States may need to reduce provider reimbursement and/or enrollee benefits to address these losses.
States and providers should start planning for the changes in revenue now. Strategic planning for provider tax sustainability and close monitoring of upcoming CMS rulemaking are essential.
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The potential impact will vary by state, and each tax structure should be individually assessed to fully understand the implications of this new guidance. 成人VR视频 has designed, developed, and helped implement provider taxes across the country and is uniquely positioned to support states, MCOs, and providers as they navigate the evolving landscape.
For details about the federal guidance and considerations for your organization, contact聽our experts below.
Keep up to date with the 成人VR视频 Weekly Roundup.
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The 25th鈥痑nnual Medicaid Budget Survey conducted by KFF and 成人VR视频 (成人VR视频), in collaboration with the National Association of Medicaid Directors (NAMD), was released on November 13, 2025鈥�in the report鈥�A View of Medicaid Today and a Look Ahead: Balancing Access, Budgets and Upcoming Changes: Results from an Annual Medicaid Budget Survey for State Fiscal Years 2025 and 2026.听
Following years of significant changes in Medicaid spending, enrollment, and policy during the COVID-19 public health emergency and the subsequent Medicaid unwinding period, state Medicaid programs returned to more routine operations in state fiscal year (SFY) 2025 and were focused on an array of other priorities, including improving access to care or addressing social determinants of health.
Heading into SFY 2026, however, states were facing a more tenuous and beginning to prepare for another major set of policy changes to the Medicaid program. The 2025 federal budget reconciliation law (OBBBA) includes Medicaid policy changes and reductions in federal funding, though the impacts vary by state. While many of the provisions do not take effect until FY 2027 or later, states are anticipating the upcoming changes, assessing budgetary and programmatic impacts, and preparing for the implementation of multiple and complex policy changes.
In addition to navigating state budget challenges and implementing new federal policies, the report also addresses other Medicaid program priorities including expanding access, implementing initiatives that target specific populations (e.g., pregnant individuals, justice-involved), continuing delivery system efforts, and improving administrative systems and functions.
Serving over people living in the United States and accounting for nearly of health care spending (and over half of spending), Medicaid represents a large share of state budgets and is a key part of the overall health care system.
The report was prepared by Kathleen Gifford, Aimee Lashbrook, and Carrie Rosenzweig from 成人VR视频; and by鈥�,鈥�,鈥�,鈥�,鈥痜rom KFF. The survey was conducted in collaboration with NAMD.听
成人VR视频 recently released a report analyzing the impacts of the CareSource JobConnect Program, which provides employment assistance to non-elderly adults enrolled in Medicaid. CareSource is a national, nonprofit managed care organization dedicated to transforming healthcare for those served by government-sponsored health care programs. The program helps individuals prepare for a job search, obtain employment, and succeed in the workplace. 成人VR视频 was engaged due to our significant expertise in Medicaid to evaluate the program鈥檚 impacts in 3 of the 6 states where it is currently active: Indiana, Georgia, and Ohio. 成人VR视频 conducted an economic impact analysis to assess outcomes for members participating, a cost鈥揵enefit analysis, and a return-on-investment (ROI) assessment, examining the direct and indirect financial benefits to participants, the broader economic impact on the state and healthcare spending, and the total program operation costs incurred by CareSource.
The recently enacted OBBBA law established 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. Past efforts by states to establish work requirements as a condition of enrollment in Medicaid have resulted in coverage losses because of bureaucratic hurdles that made it difficult for people to comply. A program like CareSource JobConnect can provide support and assistance to those enrolled.
The analysis aimed to help CareSource understand the advantages of this program on those participating, as well as the broader impact on the state鈥檚 economy, and demonstrates potential gains for the state, the job seekers, and CareSource鈥檚 program if more people took advantage of the program鈥檚 benefits.
The report shows significant economic and workforce outcomes, particularly in Ohio and Indiana.
Ohio led with the highest number of participants and employed workers, generating a return-on-investment of 13:1.
Indiana showed impressive efficiency, with a strong return-on-investment of 12:1.
骋别辞谤驳颈补鈥檚 results were still positive with a 5:1 ROI, but there are opportunities for improvement in employment success and economic return that could improve the success for the Georgia program.
成人VR视频 examined direct benefits to those newly employed through the program, including annual earnings and earnings supplements such as tax credits; indirect benefits, such as key elements of social determinants of health like food security and safe and affordable housing; new spending: new worker spending due to employment enhanced by the multiplier (defined as the ripple effect that occurs as new jobholders spend a large portion of their earnings, which creates income for local businesses and nonprofit organizations); the Benefit-to-Cost Ratio: The sum of direct and indirect benefits and the multiplier effect, divided by the cost incurred by the organization making the investment. These things together help determine the full ROI for the program.
As more participants receive job placements over time and their incomes increase, earning supplements will decrease, and other indirect benefits will decrease as participants earn more than the maximum amounts for eligibility. Each of the three states saw a net gain to their state budgets in the form of state sales and income taxes as members earn more and are able to spend their wages on goods and services.
Indiana
Georgia
Ohio
2024 Participants with Employment through the Program
87
28
198
2024 Participants in the Program
220
188
566
Aggregate New Worker Spending
$1,688,001
$537,923
$3,110,462
Multiplier Effect
5
5
5
Aggregate Benefit to Participants and the Local Economy (new worker spending times multiplier)
$8,440,004
$2,689,615
$15,552,308
Estimated Cost Per Participant
$2,938
$2,230
$1,988
Benefit鈥擟ost Ratio
13:1
6:1
14:1
Return-on-Investment
12:1
5:1
13:1
To learn more about the program and to download the whitepaper, click here.
成人VR视频 has more than 40 years of experience in helping to shape and improve Medicaid programs, and supports organizations nationwide to develop, implement, and evaluate programs for state agencies, local governments, health plans, and other community-based partner organizations. Learn more about how 成人VR视频 supports Medicaid and our efforts in Housing and Health.
On November 5, 2025, the Centers for Medicare & Medicaid Services (CMS) that all 50 states had submitted applications to be considered for participation in the (RHTP) created under the Budget Reconciliation Act of 2025. States proposed a range of initiatives to strengthen innovation, modernize rural health infrastructure, and address persistent disparities in healthcare access, workforce, and outcomes in rural communities. Funding decisions are expected by December 31, 2025.
The RHTP represents a major federal investment in rural health transformation. For providers, community partners, and other interest holders, applications offer valuable insight into state priorities, partnership models, and the types of initiatives likely to receive funding.
Many state feedback processes are ongoing for providers, community organizations, and other partners. Even after submission, states are refining their proposals and negotiating with CMS. Organizations should review available materials and take advantage of open comment periods or stakeholder meetings to help states prepare for a strong program launch in early 2025.
成人VR视频 (成人VR视频) reviewed state overviews and applications, where available. In this article we highlight key takeaways from this review and the information available through 成人VR视频鈥檚 Information Services ().
Key Issues and Trends
Breadth of initiatives and focus areas.听State initiatives meet the specific categorical CMS requirements and include a range of innovative models, ideas, and investments in building out pilots and infrastructure. The number of initiatives that states have planned also vary, with most proposing four or five, but at least one state has developed 11 planned programs. Many initiatives involved remote patient monitoring and telehealth, including tele-specialty clinics, tele-psychiatry hubs, tele-intensive care unit support, among others. Several states proposed to establish and enhance models involving emergency medical services (EMS). Proposals also include a range of investments in electronic health records (EHRs), data infrastructure, and interoperability to specific provider types and generally in rural communities.
Subgrant and Partnership Opportunities: Many applications include subgrant programs or call for partnerships with hospitals, clinics, community-based organizations, Tribal entities, and educational institutions. Reviewing state applications can help organizations understand the timelines for upcoming funding and partnership opportunities as well as expectations associated with the state initiatives.
Diverse governance and implementation models: The tracker reveals a range of governance structures, from state-led advisory boards and interagency task forces to regional hubs and cross-sector partnerships. States are leveraging advisory councils, technical assistance partners, and community engagement frameworks to guide implementation and oversight.
Some states have yet to submit their full applications but still have opportunities to engage and shape state efforts through various methods. Many states have kept open public feedback mechanisms even as they negotiate with CMS on budgets and program details. This situation creates an evolving landscape wherein stakeholders must monitor multiple channels for updates and opportunities.
Why This Matters
成人VR视频IS鈥� RHTP Inventory provides states, rural communities, and their partners an actionable road map for state initiatives. This inventory covers focus areas for state initiatives, governance models, funding requests, partnership opportunities, and other key information. This tool helps organizations monitor trends and identify where to engage. 成人VR视频 will continue to follow state activity in this program as states move forward.
Beyond the tracker, 成人VR视频 offers deep regional market expertise鈥攐ur consultants understand state-specific priorities and can provide tailored analysis and strategic planning to position your organization for success. Whether you鈥檙e exploring telehealth investments, building partnerships, or preparing for new initiatives in rural health transformation, our team can help you navigate the details and seize opportunities.
For questions about the聽聽RHTP Inventory and to connect with our state-market leads, contact聽our experts below.
Dually eligible individuals are those who qualify for both Medicare and Medicaid. This population for a disproportionately small share of the total Medicaid or Medicare population, but they account for a disproportionately large share of spending across both programs.
Medicare Advantage Dual Eligible Special Needs Plans Play a Key Role
Over the last several decades, federal and state policymakers have developed and implemented a range of programs, demonstrations, and approaches to improve care for this population and strengthen alignment between Medicare and Medicaid, improve outcomes, and manage costs. Medicare Advantage (MA) Dual Eligible Special Needs Plans (D-SNPs) are a key vehicle to accomplish federal and state goals.
What to Expect in Medicare Advantage Contract Year 2026
In 2026 and beyond, we can expect significant state and local shifts in plan enrollment, due to new federal requirements and state demonstration program transitions. We will see states focused on advancing aligned plan enrollment and setting higher expectations for Medicare-Medicaid integrated programs.
A New Inventory to Stay on Top of State Markets
成人VR视频 (成人VR视频) has published the , a state-by-state view of state Medicaid program structures and regulations shaping integration and D-SNP markets. This resource is designed to help state policymakers, insurers, and healthcare organizations track trends, identify opportunities, and inform strategic planning in an evolving policy landscape.
Looking Ahead at the Changes in 2026 and Beyond
Federal for the Medicare Advantage 2026 contract year鈥攁nd state Medicaid contractual agreements with plans鈥攕trengthen D-SNP integration standards and coordination between states and plans. Examples include:
D-SNP Look-Alike Plans:聽In 2026, the threshold for identifying MA plans as D-SNP look-alikes will decrease from 70 percent to 60 percent. This 10-percentage point drop marks the second of two planned phasedowns in the threshold percentage. Look-alike plans are MA plans that are marketed to dually eligible individuals, but they are not required to comply with D-SNP integration requirements. Stronger federal standards will require MA look-alike plans with high dual enrollment to convert or exit the market, which is expected to lead to shifts in dually eligible enrollment into D-SNPs and other integrated products.
Financial Alignment Initiative Demonstration Transitions: The Centers for Medicare & Medicaid Services (CMS) has worked with several states operating capitated聽聽(FAI) demonstrations to transition Medicare-Medicaid Plans (MMPs) to integrated D-SNPs by January 1, 2026. These states include Illinois, Massachusetts, Michigan, Ohio, Rhode Island, South Carolina, and Texas will end their FAI demonstrations on December 31, 2025.
2027 D-SNP Rules: Beginning in 2027, D-SNPs affiliated with Medicaid managed care organizations (MCOs) must restrict enrollment to Medicaid MCO enrollees. In addition, federal rules will limit the number of D-SNP plan benefit packages, which will require additional coordination with Medicaid affiliates and planning in designing benefit packages and network.
State Medicaid Program Adjustments
States are working to align new federal D-SNP requirements with existing Medicaid managed care contracts, long-term services and supports carve-in strategies, and service-area mappings. Because State Medicaid Agency Contracts () must be updated annually, all SMACs will need to incorporate the new D-SNP provisions as the new requirements take effect. This effort will require close coordination among state agencies, plans, and CMS to manage enrollee transitions, data-sharing, and communications.
Data-Informed Integration Insights
贬惭础鈥檚&苍产蝉辫; is a single hub for insights into requirements, approaches to scope of integration programs, and enrollment data. The inventory will help plans and other types of organizations such as providers and community-based organizations to prepare for future contracting, compliance, and operational transitions.
This inventory is designed to answer the four major questions top of mind:
What is the state鈥檚 integration model and D-SNP type.听The inventory identifies each state鈥檚 approach to integrating care for dually eligible populations, including states with Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs), Highly Integrated D-SNPs (HIDE-SNPs), coordination-only models, and Exclusively Aligned Enrollment (EAE) initiatives or comparable rules
Does the state鈥檚 program integrate LTSS and/or Behavioral Health?聽The inventory details whether long-term services and supports and behavioral health are carved into or out of managed care and how those benefits interact with Medicare coverage within D-SNP structures
What is the state鈥檚 enrollment policy?聽The inventory captures enrollment in HIDE/FIDE products, identifies Applicable Integrated Plan (AIP) states, and gauges overall alignment maturity
What is the state鈥檚 procurement and contract timeline?聽The inventory also tracks state procurement timelines, upcoming RFPs, and effective contract dates
Connect with Us
成人VR视频 experts are tracking state integration strategies, procurement timelines, and future state planning activities. Beyond the tracker, 成人VR视频 colleagues provide tailored analysis and planning for state-specific initiatives. Our team can help health plans prepare for enrollment shifts, compliance requirements, and integration opportunities in 2026 and beyond. For information about subscription access to the 成人VR视频 Information Services (成人VR视频IS) inventory and to connect with 成人VR视频 consultants who can address your integration questions, contact聽our experts below.
As of November 5th, states have submitted their applications for the Rural Health Transformation Program (RHTP) 鈥� a major federal initiative aimed at addressing persistent healthcare challenges in rural communities. Authorized by the 2025 budget reconciliation bill (OBBBA), the RHTP will distribute $50 billion over the next five years to help rural communities improve healthcare access, quality, and outcomes. All 50 states are eligible.
This submission marks a key milestone, but it鈥檚 just the beginning. The Centers for Medicare & Medicaid Services (CMS) is reviewing applications, and ongoing conversations between states and CMS will shape the final design and implementation of each state鈥檚 program. Awards are expected by December 31, 2025, and states 鈥� and their partners 鈥� must be ready to move quickly early in 2026.
States must now prepare for a fast-moving design and implementation phase, building on initiatives already underway and refining plans and budgets based on CMS feedback. States will need to staff up quickly and launch new projects in early 2026. With tight fiscal timelines and the risk of forfeiting funds, agencies and community organizations must act decisively. It will be crucial to demonstrate impact on health outcomes within the first half of 2026 will be critical.
Organizations across the healthcare industry should closely monitor how states plan to operationalize their proposals, as these strategies will shape funding flows and partnership opportunities.
Many state agency leaders will be attending the National Association of Medicaid Directors (NAMD) annual conference November 18-21, 2025. The RHTP applications will be a big topic of conversation, with states sharing ideas and stakeholders discussing challenges and opportunities that could be addressed with RHTP funding. 成人VR视频 will have a strong presence at NAMD and will be gathering important insights on the federal expectations, program content, and operational strategies that states put in their applications.
Organizations interested in learning more about their state鈥檚 direction 鈥� or in becoming part of the implementation conversation 鈥� can reach out to 成人VR视频 experts listed below.
What鈥檚 next with the RHTP?
Any state that is approved for RHTP funding requires:
A strong management structure at the state level, including dashboards and oversight of programs funded through this award
Defined goals and sustainable initiatives in chronic disease management, primary care, behavioral health, maternal health, digital innovation, workforce initiatives, and other topics
Demonstrated outcomes that evidence improvements in rural access and health outcomes, as well as the care experience of rural residents
成人VR视频 is ready to help. Our team brings deep expertise in tackling the complex challenges of delivering quality healthcare and human services to rural communities. We understand the challenges rural providers face鈥攆rom workforce shortages and service gaps to transportation hurdles and socio-economic barriers鈥攁nd can help states and organizations navigate complexities of implementation.
With broad experience, 成人VR视频 is a national leader in healthcare consulting, with a multidisciplinary team of over 700 experts experienced in policy, finance, clinical services, analytics, and community engagement. We help rural organizations act decisively and efficiently, meeting the strict deadlines set by the RHTP and minimizing risks such as funding claw-backs. From actuarial and financial skills to clinical and operational expertise, policy, and analytics, 成人VR视频 can support successful implementation of your State鈥檚 Rural Health Transformation program.
Lessons Learned from State-Led Transformation Efforts
As federal and state healthcare policy continues to evolve, the need for cross-sector collaboration has never been more urgent. The 2025 budget reconciliation act (OBBBA, P.L. 119-21) introduces significant changes to Medicaid eligibility and financing, prompting a shift in strategy for policymakers and advocates working to advance whole-person care and address social determinants of health (SDOH). The new policies reflect a reorientation of Medicaid financing, with a greater emphasis on state flexibility, targeted benefits, and value-based care.
In this environment, enhanced partnerships and strategic alignment across sectors will be essential to sustain community-based services and workforce investments. In this article, 成人VR视频 (成人VR视频), experts highlight key observations from multiple state transformation programs, including actionable strategies for leveraging these assets and meeting the needs of at-risk populations.
Revisiting SDOH Initiatives in a New Policy Context
Whole-person care models have long called for integrated, multidisciplinary approaches. These models鈥攐nce buoyed by COVID-19 pandemic-era funding and broad federal support鈥攎ust now be recalibrated to align with new federal priorities. Current federal priorities emphasize streamlined benefits, fiscal discipline, and state-led innovation, which presents both challenges and opportunities for advancing integrated care. This shift has heightened the need to clarify roles and responsibilities across clinical and community settings, focusing on how to maintain essential linkages to primary and preventive care, especially for individuals for whom access remains fragile.
In addition, the ongoing healthcare workforce crisis intensifies the need for creative approaches to whole-person care models. Solutions must go beyond traditional payment models, leveraging existing social care networks, shared hub functions, alternative payment strategies above base rates, and braided funding streams.
State and federal initiatives can be used to sustain momentum and test emerging models. For example, the Rural Health Transformation Program (RHTP) offers a critical opportunity to support these efforts. With $50 billion in funding over five years, RHTP is designed to help states implement innovative models that improve rural health outcomes, strengthen workforce capacity, and address SDOH. States will be finalizing their applications to meet the November 5 deadline. 成人VR视频 is tracking how these applications align with the strategies outlined below, using the program鈥檚 baseline and performance-based funding to invest in infrastructure, workforce development, and cross-sector partnerships.
Key Lessons from State Transformation Programs
Drawing on recent transformation programs, 成人VR视频 experts identified several key lessons, including:
Prioritize Intensive, Community-Based Outreach: States and health plans should invest in community-based outreach strategies that reach populations facing the greatest SDOH barriers, including funding models that support navigation and engagement beyond traditional clinical settings and leveraging shared infrastructure to extend reach.
Update Community Health Worker (CHW) Benefit Structure to Maximize Impact: States, in collaboration with their partners, should revisit CHW benefit design to allow for greater flexibility. Reducing reliance on clinical supervision and referral-only pathways can help CHWs operate more effectively in terms of outreach, education, and engagement.
Strengthen Workforce Retention through Flexible Financing: Healthcare stakeholders should explore braided funding, shared hub models, and alternative payment models that go beyond base rates. These approaches can sustain staff and morale amid shifting demands and constrained budgets.
Connect with Us
The strategies in 成人VR视频鈥檚 recent report for Illinois, Medicaid Financing for Social Health: A Resource Compendium for Illinois Community-Based Organizations & Networks, can be adapted to other states and communities. By sharing lessons and adopting best practices from transformation programs nationwide, we can reinforce pathways to integrated care and ensure that populations continue to receive the support they need鈥攅ven in the face of unprecedented challenges.
成人VR视频 experts are helping states, healthcare plans, and community partners adapt and thrive as federal and state policy landscapes continue evolving. 成人VR视频 teams are applying their cross-sector expertise in SDOH, workforce development, and state-specific knowledge to help organizations better plan, implement, and develop programs to solve healthcare challenges in their community. For questions about the report or opportunities for your organization, reach out to聽our experts below.
