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ºìÁì½í¹Ï±¨ Insights: Your source for healthcare news, ideas and analysis.

ºìÁì½í¹Ï±¨ Insights—including briefs, webinars, and our podcast—gives you easy access to ºìÁì½í¹Ï±¨â€™s 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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Community Health Assessments & Improvement Plans

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Flexible, actionable support to help communities move from assessment to measurable community health improvement.

Community health leaders need clear, credible, and actionable community health assessment/community health improvement plan (CHA/CHIP) processes that satisfy accreditation expectations while helping partners align around shared priorities. ºìÁì½í¹Ï±¨ (ºìÁì½í¹Ï±¨) supports public health agencies, hospitals, collaboratives, and community partners with right-sized services that move efficiently from assessment to strategy to measurable improvement.

Why Communities Choose ºìÁì½í¹Ï±¨

Practical support designed around local goals, capacity, and community priorities

Right-Sized Scope – Select the level of support that fits your timeline, budget, staffing, and readiness

Meaningful Engagement – Bring community members, partners, and decision-makers into the process in purposeful ways

ºìÁì½í¹Ï±¨â€™s CHA & CHIP Service Offerings

Three flexible pathways—plus add-on support tailored to your community

Every community starts from a different place. ºìÁì½í¹Ï±¨â€™s flexible CHA/CHIP pathways make it easy to select the right level of support and add only the enhancements that advance local priorities.

FOUNDATIONAL

Foundational CHA
MAPP Essentials


Best for: Smaller or rural communities, limited budgets, & routine CHA updates.

Focus: Efficient, PHAB-ready assessment.

COMPREHENSIVE

Comprehensive CHA
MAPP Standard


Best for: Most counties, regions, and accreditation-driven efforts.

Focus: Full MAPP process with comprehensive community engagement.

ADVANCED

Deep Engagement & Equity-Centered CHA
MAPP Advanced

Best for: Large jurisdictions, regional collaborations, and transformation-focused initiatives.

Focus: Community co-creation, equity, systems change, and implementation readiness.

Optional Enhancements

Add targeted support to any pathway based on local priorities, accreditation needs, and implementation goals.

Community Engagement

Focus groups, surveys, listening sessions, and culturally specific outreach

Advanced Analytics & Equity

Neighborhood analysis, equity assessments, and disparities analysis

Data Visualization & Communications

Geographic Information Systems (GIS) mapping, dashboards, and public-facing materials

Accreditation & Planning Support

PHAB documentation, CHIP facilitation, and early implementation planning

Project Examples

Community Health Assessment and Improvement Planning Resources

How can communities move from a compliance-driven assessment to a connected system for improving health?

These four reports demonstrate how ºìÁì½í¹Ï±¨ partners with communities to conduct Community Health Needs Assessments (CHNAs), CHAs, CHIPs that examine local health conditions, identify priority needs, advance health equity, and inform measurable strategies for action.

The reports represent communities in Oregon, Washington, California, and Colorado. They demonstrate the value of combining community voice, quantitative and qualitative data, cross-sector partnership, priority setting, implementation planning, and performance measurement.

A Community-Informed and Equity-Centered Health Assessment of Clackamas, Multnomah, and Washington counties in Oregon and Clark County in Washington State

Prepared for the Healthy Columbia Willamette Collaborative, this regional assessment brings together community input and data to identify health needs across four counties and support coordinated, equity-centered planning for a collaboration across public health, hospitals, and health systems.

Read the 2025 Community Health Needs Assessment →

San Bernardino County: Our Community Vital Signs

Prepared for San Bernardino County Department of Public Health, this community health assessment provides information about the health and well-being of San Bernardino County residents. It is designed to support community understanding, priority setting, cross-sector collaboration, and evidence-informed health improvement efforts.

Read the San Bernardino County Community Health Assessment →

Prepared for the Imperial County Community Health Improvement Partnership, this CHIP translates identified health priorities into strategies and actions designed to improve health outcomes across Imperial County.

The plan illustrates how communities can connect assessment findings to implementation, partnership, accountability, and measurable progress.

Read the Imperial County Community Health Improvement Plan →

Prepared for the Yampa Valley Regional Collaborative, the Yampa Valley Community Health Needs Assessment was developed through a collaborative effort involving The Health Partnership, Memorial Regional Health, Northwest Colorado Health, Routt County Public Health, UCHealth Yampa Valley Medical Center, and United Way.

The report combines community survey findings, community meetings, and public health and socioeconomic data. It identifies two priority areas for Yampa Valley:

  • Behavioral health
  • Access to culturally and linguistically responsive health care

It also identifies four important drivers of health: 1) access to healthy foods; 2) affordable housing; 3) economic opportunity, including jobs and wages; and 4) transportation.

Read the 2022 Yampa Valley Community Health Needs Assessment →

From Assessment to Action

A CHA or CHNA is more than a compliance document. It can serve as the foundation for a connected planning system.

Community engagement → Data and assessment → Priority setting → Implementation → Measurement and accountability

These reports offer practical examples of how ºìÁì½í¹Ï±¨ approaches this important work with communities to gather input, analyze local conditions, identify priorities, plan responses, and create stronger pathways from assessment to measurable action.

Communities represented

  • Clackamas County, OR
  • Multnomah County, OR
  • Washington County, OR
  • Clark County, WA
  • San Bernardino County, CA
  • Imperial County, CA
  • Yampa Valley and Routt County, CO

Topics covered

Community health assessment, community health needs assessment, community health improvement plan, CHA, CHNA, CHIP, health equity, community engagement, community voice, behavioral health, access to health care, culturally and linguistically responsive care, social determinants of health, social drivers of health, cross-sector collaboration, public health planning, hospital community benefit, priority setting, implementation planning, performance measurement, and community health improvement.

Medicaid Managed Care Enrollment Declines in Q2 2026: ºìÁì½í¹Ï±¨ Analysis of State Trends and Market Share

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ºìÁì½í¹Ï±¨ (ºìÁì½í¹Ï±¨) analyzed monthly Medicaid managed care enrollment data reported by 34 states in the second quarter of 2026. Enrollment totaled 59.2 million members in June 2026—a decline of 3.5 million members (5.5%) from June 2025. The broader Medicaid and CHIP population has declined at approximately the same pace as managed care, with the Centers for Medicare & Medicaid Services (CMS) showing a 5.9% decrease from May 2025 to May 2026. 

The findings establish a timely baseline before new eligibility policies take effect. Under the 2025 budget reconciliation act (P.L. 119-21), now known as the Working Families Tax Cut (WFTC) Act, most states must implement Medicaid community engagement requirements for certain adults beginning January 1, 2027, conduct eligibility redeterminations every six months for this population, and implement other policies that will narrow Medicaid eligibility. 

Medicaid Managed Care Enrollment Trends in Q2 2026 

ºìÁì½í¹Ï±¨ Information Services (ºìÁì½í¹Ï±¨IS) tracks monthly Medicaid enrollment for all states, including managed care enrollment in the subset of states with managed care programs. Among the 34 states with managed care programs that reported enrollment data in the second quarter of 2026: 

  • Enrollment changes varied across states, reflecting a combination of state-specific demographic, administrative, operational, and policy factors. 
  • Only three states—Mississippi, Nevada, and South Carolina—reported modest gains in Medicaid managed care enrollment since June 2025. 
  • Arizona, Indiana, and Louisiana each reported double-digit declines, ranging from 10.1% to 21.1%. 
  • The seven non-expansion states in this analysis—Florida, Georgia, Mississippi, South Carolina, Tennessee, Texas, and Wisconsin—experienced a decline of 455,000 (3.8%), bringing enrollment to 11.6 million enrollees. 

Among the expansion states in the analysis, enrollment decreased by 3 million (5.9%) to 47.6 million. The larger decline among expansion states is particularly relevant because adults in expansion states will be most directly affected by the new community engagement and six-month redetermination policies. Details are illustrated in Figure 1. 

Figure 1. States Included in the Medicaid Managed Care Enrollment Analysis, June 2026

Note: States colored as blue shown on the map above are included in the ºìÁì½í¹Ï±¨ Enrollment Analysis. 

National Medicaid Managed Care Market Share 

ºìÁì½í¹Ï±¨IS also tracks Medicaid managed care ownership, program participation, and tax status for nearly 300 plans. In this June 2026 snapshot, Centene covered 17.9% of enrollees, followed by Elevance at 10.7%, UnitedHealth Group at 8%, and Molina at 6% (see Figure 2). These four organizations represented 42.6% of enrollment in the ºìÁì½í¹Ï±¨IS dataset, underscoring continued concentration among large, national Medicaid managed care organizations. (Note: The number and mix of plans changed over the past 12 months, and several state enrollment reports reflect different reporting months. Other limitations are discussed in the Data Considerations section of this article.) 

The enrollment declines as well as pressure from acuity, utilization, and payment rates are compelling Medicaid managed care organizations (MCOs) to reassess where they participate, including whether individual markets can support sustainable performance. For example, one national Medicaid MCO has publicly discussed exiting unprofitable Medicaid markets and left one state market in August 2026 with plans to exit another at the end of the year. These decisions illustrate how enrollment contraction can interact with rate adequacy, acuity, utilization, and state-specific contract performance to influence plan participation. 

Figure 2. National Medicaid Managed Care Enrollment Share by Parent Organization, June 2026 

How Medicaid Work Requirements and Eligibility Policies Could Affect Enrollment in 2027 

In , approximately 20.4 million people were enrolled in Affordable Care Act Medicaid expansion plans—5 million of whom reside in California, and nearly 2 million live in New York. The WFTC Act applies requirements to Affordable Care Act (ACA) expansion adults and certain Medicaid Section 1115 demonstration populations in 44 states beginning January 2027. 

In September 2026, CMS published an that outlines an optional framework that states may use to identify and verify individuals who qualify for the medical frailty exclusion. Although the framework gives states options for consideration, they still must determine which health conditions to cover and data sources to use when additional documentation is requested and how to notify members of their determinations. Many states have already made decisions about these issues, which could materially affect administrative workload, the consistency of determinations, and whether eligible individuals maintain coverage as well as the number of people who retain coverage and the composition of the population that remains enrolled. 

In addition, a few states have already started implementing the new eligibility policies. For example, Nebraska launched Medicaid work/community engagement requirements on May 1, 2026. Montana began implementation on July 1, 2026, while Arkansas began a soft launch in July 2026 before enforcement begins in January 2027. Iowa intends to begin early implementation December 1, 2026. Although Montana and Arkansas are not managed care states, they, along with Nebraska, can offer directional insights on beneficiary response, exclusion determinations, procedural losses, appeals, and administrative workload before nationwide implementation. 

Notably, the second quarter enrollment decline predates full implementation of the new federal eligibility policy changes and community engagement requirement, which means future enrollment changes may not be entirely attributable to the WFTCA requirements. 

Organizations should continue to monitor total enrollment, churn, eligibility category, risk mix, and transitions to Marketplace or uninsured status. 

Data Considerations. ºìÁì½í¹Ï±¨ Information Services (ºìÁì½í¹Ï±¨IS) tracks monthly Medicaid managed care enrollment, ownership, program participation, and tax status for approximately 300 plans. The data in this analysis have some important limitations. States report enrollment figures at different points throughout the month, with some data reflecting beginning of the month totals and others capturing end of month enrollment. In addition, some state datasets encompass all Medicaid programs that offer managed care plans, whereas others reflect only a subset of the managed Medicaid population. As a result, the analysis can be used to identify direction, magnitude, and market signals rather than as a comprehensive state-by-state comparison. 

The ºìÁì½í¹Ï±¨IS enrollment reports and analyses, available through subscription, use data from nearly 300 health plans in 39 states, DC, and Puerto Rico. ºìÁì½í¹Ï±¨IS’s Medicaid enrollment data, financials, procurement tracking, and a robust library of public documents equips stakeholders with timely, actionable intelligence. Subscribe here

Preparing for Enrollment Shifts

WFTC Act implementation will require state-specific policy decisions, eligibility system changes, new data-matching processes, staff training, beneficiary outreach, and workable approaches to identifying people who qualify for exemptions for medical frailty and other conditions. Differences in data availability, verification pathways, documentation requirements, and review processes could produce materially different effects on enrollment, continuity of coverage, beneficiary experience, and the risk profile of the population that remains enrolled. 

Healthcare executives and state Medicaid leaders should establish a baseline, monitor emerging implementation signals, and model the operational and financial implications. Priority measures include enrollment and churn, procedural terminations, exclusion determinations, appeals, transitions to other coverage, changes in acuity and utilization, payer mix, and geographic variation. These insights can inform decisions about eligibility operations, beneficiary support, capitation and rate development, network strategy, provider reimbursement, revenue forecasting, and uncompensated care exposure. 

MCOs are unable to help states with determining eligibility determination or compliance, cannot receive capitation rate bumps for non-medical activities, or use their own work programs to help beneficiaries meet the community engagement requirements but may be able to provide support through outreach and education. CMS has indicated it expects to provide additional guidance on what activities are appropriate. MCOs can potentially use their existing relationships with beneficiaries, care managers, providers, and community organizations to help members understand and navigate the new requirements. 

ºìÁì½í¹Ï±¨IS provides the market intelligence needed to track these shifts, including state-reported enrollment, plan ownership, financial performance, procurement activity, and related public documents. ºìÁì½í¹Ï±¨ consultants extend that intelligence through state- and market-specific scenario modeling, policy and operational analysis, and implementation support—helping clients forecast enrollment and revenue, assess payer mix and utilization effects, strengthen eligibility and beneficiary support workflows, evaluate competitive positioning, and prepare for changes in program financing and oversight. 

Contact ºìÁì½í¹Ï±¨ to translate evolving enrollment and implementation signals into an actionable strategy for your state, market, or organization.

Medicaid Funding Changes, Eligibility Requirements, and the Safety Net: What Community Leaders Need to Know

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ºìÁì½í¹Ï±¨ Solutions

Medicaid Funding Changes, Eligibility Requirements, and the Safety Net: What Community Leaders Need to Know

Federal policy and funding changes are reshaping Medicaid, healthcare delivery, human services, and the local safety net. ºìÁì½í¹Ï±¨ helps healthcare, Medicaid, human services, and community leaders assess the impact of federal funding changes, protect access to care, strengthen local safety-net systems, and develop practical implementation strategies.

Communities Face Converging Fiscal and Service Pressures

Changes to Medicaid financing, eligibility, and community engagement requirements will not remain contained within state Medicaid agencies. The effects can move across health systems, local government, human services programs, community-based organizations, and households. When coverage becomes harder to maintain, people still need care and support. The costs and responsibilities often surface elsewhere in the community.

Hospitals and healthcare providers may face greater uncompensated care and pressure on already vulnerable service lines. Counties and municipalities may encounter increased demand for behavioral health, public health, housing, emergency response, and other locally supported services. Human services agencies may need to implement more complex processes without additional workforce capacity. Community-based organizations may be asked to help people navigate new requirements while also managing reductions or instability in their own funding.

These pressures will not be distributed evenly. Children and families, people with disabilities, older adults, rural residents, people experiencing homelessness, low-income working adults, pregnant and postpartum people, individuals with behavioral health needs, and people involved with child welfare systems may face heightened risk when administrative complexity and service constraints increase.

Supporting the Leaders Closest to Community Impact

ºìÁì½í¹Ï±¨ works with the organizations responsible for financing, administering, delivering, and sustaining healthcare and community supports.

State Medicaid agencies, health and human services departments, and executive and legislative leaders

Counties, municipalities, public health agencies, and local human services systems

Hospitals, rural health organizations, safety-net providers, health plans, and provider associations

Behavioral health organizations, child welfare agencies, housing and homelessness systems, and family-serving organizations

Community-based organizations, coalitions, foundations, associations, and cross-sector partnerships

Our multidisciplinary teams connect Medicaid and healthcare expertise with human services, community systems, organizational strategy, operations, financing, analytics, and implementation support. That breadth allows ºìÁì½í¹Ï±¨ to help clients understand not only what a policy change requires, but also how the change will affect people, providers, partners, workflows, budgets, and outcomes.

ºìÁì½í¹Ï±¨ Can Help Leaders Move from Uncertainty to Action

ºìÁì½í¹Ï±¨ can tailor support to a single organization, local community, statewide system, or cross-sector coalition. Engagements may include rapid analysis, operational planning, stakeholder engagement, implementation support, and performance monitoring.

Assess Policy and Fiscal Impact

Translate federal and state changes into clear implications for coverage, enrollment, provider reimbursement, service utilization, administrative cost, workforce demand, and local government exposure.

How ºìÁì½í¹Ï±¨ helps: Policy analysis, fiscal-impact assessment, coverage and enrollment scenario planning, provider vulnerability analysis, local cost-shift analysis, and executive briefings.

Prepare Medicaid and Eligibility Operations

Help agencies and partners prepare for eligibility, verification, reporting, data-matching, communication, and coverage-retention challenges while reducing avoidable administrative burden.

How ºìÁì½í¹Ï±¨ helps: Operational readiness assessments, workflow mapping, data-gap analysis, implementation roadmaps, community communications, and performance measures.

Evaluate Safety-Net and Provider Vulnerability

Identify where reductions in coverage or reimbursement may threaten access, critical service lines, rural providers, behavioral health capacity, maternity care, specialty services, and community-based care.

How ºìÁì½í¹Ï±¨ helps: Provider and service-line vulnerability assessments, market and network analysis, rural access review, scenario modeling, mitigation planning, and monitoring dashboards.

Strengthen Community Infrastructure

Assess whether community-based organizations and local partners have the capacity, funding, data, referral relationships, and operating infrastructure needed to absorb new responsibilities.

How ºìÁì½í¹Ï±¨ helps: CBO capacity and sustainability assessments, referral-network mapping, partnership strategy, reimbursement opportunity analysis, sustainability planning, and technical assistance.

Build Cross-Sector Response Plans

Bring healthcare, Medicaid, human services, public health, housing, workforce, philanthropy, and community partners together around shared risks, priorities, roles, resources, and accountability.

How ºìÁì½í¹Ï±¨ helps: Stakeholder engagement, facilitated convenings, governance design, shared implementation planning, resource mapping, and accountability frameworks.

Redesign Human Services and Community Systems

Help agencies align policy, funding, operations, workforce, technology, community voice, and performance expectations so systems can function more effectively under constraint.

How ºìÁì½í¹Ï±¨ helps: Current-state assessments, operating-model redesign, workforce strategy, change management, implementation tools, and continuous quality improvement structures.

Develop Sustainable Financing Strategies

Help clients move beyond reliance on a single funding source by identifying opportunities to maximize, blend, braid, and sequence public and private resources.

How ºìÁì½í¹Ï±¨ helps: Funding opportunity scans, Medicaid optimization, financing and reimbursement strategy, financial modeling, grant and partnership strategy, and sustainability roadmaps.

Use Data to Target Resources and Track Results

Combine policy, fiscal, enrollment, utilization, geographic, provider, and community information to identify hotspots, prioritize resources, and monitor whether implementation is protecting access.

How ºìÁì½í¹Ï±¨ helps: Data inventory and gap assessments, community indicator mapping, geographic hotspot analysis, dashboards, performance measures, and evaluation plans.

Questions Leaders Should Be Asking Now

ºìÁì½í¹Ï±¨ Has the Right Team

ºìÁì½í¹Ï±¨ brings deep Medicaid, healthcare, human services, financing, implementation, and community-system expertise to help clients translate policy change into operational readiness, protect access to care, strengthen safety-net infrastructure, and coordinate action across providers, agencies, local governments, and community partners.

Connect with ºìÁì½í¹Ï±¨ to discuss what the changing fiscal landscape means for your state, community, organization, providers, and residents.

ºìÁì½í¹Ï±¨ Conference to Open with State Leaders’ Insights on Healthcare Policy and Program Pressures

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The Health Management Associates (ºìÁì½í¹Ï±¨) Conference, , will open October 6, 2026, with a discussion between two distinguished state officials—Bruce D. Greenstein, Secretary of the Louisiana Department of Health, and Stephen Cha, MD, Commissioner of the New Jersey Department of Human Services. Their conversation will frame the major policy, financial, and operational issues confronting the states and set the tone for deeper discussions throughout the conference about solutions being designed and implemented across the healthcare sector. 

Navigating a New Federal Landscape 

Mr. Greenstein, chief technology officer at the US Department of Health and Human Services (HHS) during the first Trump administration, and Dr. Cha, who has served in a range of roles at HHS and its agencies, bring both state and national perspectives to the discussion. Drawing on their experiences, they will discuss the challenges confronting public healthcare programs and the consequential choices before them. 

Those choices are becoming increasingly significant as federal policy changes reshape public healthcare coverage and financing. State leaders must protect access, sustain systems of care, and accept greater accountability for spending. Mr. Greenstein and Dr. Cha will explore the difficult tradeoffs behind their decisions, the potential consequences for health plans, providers, community organizations, and the people they serve. They will also address how leaders can manage fiscal and operational pressures without losing sight of quality and outcomes. 

In addition, the conversation will answer key questions about the future of state health and human services programs, including:  

  • How can artificial intelligence, data, and other technologies help states reduce administrative burden, improve oversight, and make programs more responsive?  
  • Where can states work more effectively with health plans, providers, technology companies, and other industry partners, and where is closer coordination with sister agencies essential to advancing shared goals? 

Mr. Greenstein and Dr. Cha will offer examples of how their states and their peers in other states have responded to these issues. 

Representing states with different political and policy environments, they also will explore where leaders across party lines are reaching similar conclusions—even when their strategies differ—and which practical challenges receive scant attention. Their exchange will consider how states should define success amid changing federal expectations, which outcomes matter most, and what early evidence can show whether a policy is working or health outcomes are beginning to deteriorate. 

Michael O. Leavitt, former Utah Governor and US Secretary of HHS, and co-founder of Leavitt Partners, an ºìÁì½í¹Ï±¨ Company, will moderate the discussion, adding his state and federal expertise and knowledge to a timely conversation about governance, accountability, and value. 

The opening plenary session will take place Tuesday, October 6, from 8:30 to 9:30 a.m. in New Orleans, LA. 

 to join the conversation.

September 9, 2026

ºìÁì½í¹Ï±¨ Conference to Open with State Leaders’ Insights on Healthcare Policy and Program Pressures

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Why Is Medicaid Program Integrity More Than Fighting Fraud?

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In this episode of Vital Viewpoints on Healthcare, Clint Eisenhower, regional director at ºìÁì½í¹Ï±¨, discusses the critical role of Medicaid program integrity and why it is about much more than preventing fraud. Drawing on his experience leading state and federal Medicaid program integrity organizations, Clint explains how protecting taxpayer dollars, managing enterprise risk, and ensuring the right people and processes are in place all contribute to stronger healthcare programs. He also explores common misconceptions about program integrity and shares why this work is essential to maintaining trust, accountability, and the long-term sustainability of Medicaid.

2027 Maternity Care Coding Changes: How Providers, Health Plans, and States Can Prepare for Service-Level Reimbursement

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What the shift away from global obstetric billing may mean for care delivery, coding and documentation, reimbursement, quality measurement, and more.

AT A GLANCE: Beginning January 1, 2027, maternity care reimbursement will change from bundled global obstetric codes toward more granular, service-level reporting for antepartum care, labor management, delivery, and postpartum care. The new approach is intended to more accurately capture how maternity care is delivered today across multiple clinicians, settings, modalities, and risk profiles. Organizations should begin assessing operational, financial, contracting, and data implications now.

What Is Changing?

Under the new approach, maternity services will be recognized and reported at the service level rather than through a single global obstetric payment. The impacts will unfold over time and will depend on final policy, coding guidance, fee schedules, contracts, and implementation decisions specific to payers, providers, and local markets.

What This Will Mean?

This change is more than a coding update. It will affect payment policy, claims systems, documentation workflows, actuarial assumptions, provider contracts, quality and access monitoring, data reporting, and patient care models. For Medicaid agencies, health plans, federally qualified health centers (FQHCs), hospitals, physician and midwifery practices, and professional associations, the transition creates implementation risks and uncertainties as well as opportunities to modernize maternitycare financing around person-centered perinatal care, social needs screening and management, telemedicine, home monitoring, and postpartum support. Early preparation can reduce disruption and enable increased visibility into access, quality, equity, outcomes, and total cost.

New Questions Stakeholders Will Need to Answer

  • How will payment rates, fee schedules, and contracts change when maternity care is no longer paid as a single global payment?
  • What documentation, coding, and billing workflows will providers need to update before the new codes (and/or potential interim codes, depending on the Centers for Medicare & Medicaid Services (CMS) decision-making) take effect in order to ensure that care is correctly reimbursed?
  • What systems changes and staff training will be needed?
  • What claims edits, utilization management rules, encounter data processes, and reporting systems will need to be revised?
  • How will payers distinguish routine care, higher-risk care, care coordination, social needs services, telehealth, and home monitoring?
  • How can stakeholders use new data to assess access, quality, equity, outcomes, and total cost of maternity care?

Supporting Next Steps

ºìÁì½í¹Ï±¨ can help stakeholders understand the implications of the new coding structure, evaluate policy and operational options, create a practical path forward, and operationalize that plan across programs, systems, contracts, and care delivery models.

StakeholderHow ºìÁì½í¹Ï±¨ Can HelpºìÁì½í¹Ï±¨ Services Include
StatesAssess Medicaid policy impacts, update provider guidance, model budget and rate implications, align managed care contracts, and design monitoring strategies for access, quality, equity, and outcomesRevenue Cycle Management

Actuarial Analysis

Market Analysis and Strategic Planning

Financial Modeling

Operational Planning and Implementation Support

Research and Evaluation

Contract Review and Negotiation Support

Business Analytics

Clinical and Health-Related Social Needs Service Model Development

Quality Measurement and Accreditation Support

Information Technology Advisory Services    
Providers: FQHCs, hospitals, physician practices, and midwifery groupsHelp organizations prepare for coding, documentation, billing, revenue cycle, and clinical workflow changes; identify training needs; and evaluate how new payment rules affect service delivery and financial sustainability
Health plansRevise payment policies, claims logic, provider communications, contract terms, encounter data processes, and network oversight approaches to support a smooth transition
Associations and coalitionsTranslate the changes for members, develop implementation roadmaps, convene stakeholders, identify advocacy priorities, and support coordinated action across the maternity care environment

Frequently Asked Questions

What is changing in maternity care reimbursement in 2027?

Maternity care reimbursement is shifting from bundled global obstetric billing toward more granular, service-level reporting for antepartum care, labor management, delivery, and postpartum care.

Who will be affected by the maternity care coding changes?

OB/GYN practices, hospitals, FQHCs, midwifery groups, health plans, Medicaid agencies, professional associations, and other organizations involved in maternity care financing, delivery, claims, contracting, or oversight will be affected by these significant changes.

What should organizations do first?

Start with an impact assessment: inventory current payment arrangements, map services and documentation, identify systems changes and training needs, model financial effects, review contracts, and develop implementation roadmaps.

MESC 2026 Highlights: Medicaid Modernization, AI, Eligibility, and Program Integrity

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Key Insights from the 2026 MESC Conference and What They Mean for Your Organization 

State Medicaid agencies and partner organizations are facing one of the most consequential periods of operational change in more than a decade. Those challenges were a central focus of the , August 17-20, 2026, in Portland, OR, where state, federal, and industry leaders discussed how technology, data, and operational modernization are becoming essential tools for implementing policy change. 

During the conference, leaders of ºìÁì½í¹Ï±¨ (ºìÁì½í¹Ï±¨) and HealthTech Solutions, an ºìÁì½í¹Ï±¨ company, reinforced a consistent theme: We have moved beyond the era when Medicaid enterprise systems modernization simply meant replacing aging technology. Instead, states are building the infrastructure needed to manage continuous policy evolution, support more sophisticated program integrity efforts, adapt to changing eligibility requirements, and provide the financial and operational visibility necessary to navigate an increasingly complex Medicaid environment. That direction is also reflected in recent  that the Centers for Medicare & Medicaid Services (CMS) issued to gather stakeholder input on how to advance a more standardized, interoperable, and cost-effective MES ecosystem. 

What We Learned at MESC 

Modernization Is Becoming an Ongoing Operating Capability 

Medicaid modernization is moving beyond the replacement of legacy systems. States are building the capabilities needed to manage continuous change. That work includes stronger governance through better data and more disciplined implementation practices; clearer ownership for decisions, risks, dependencies, and outcomes; and the development of cross-functional teams. Policy, operations, technology, finance, communications, and program leadership must work together from the beginning. 

What it means for states and partners
Modernization programs need a clear operating model that defines decision rights, measures of success, implementation responsibilities, and long-term support. Partners should help build state capability instead of focusing only on system delivery. 

Modularity Now Means Managing the Connections Between Systems 

Modularity can give states more flexibility, support specialized solutions, and reduce dependence on one large platform. Modularity, however, also creates more connections and business relationships that must be managed. A modular environment involves multiple vendors, systems, interfaces, data flows, release schedules, and support models. Because difficulties can arise when these elements are disconnected, MESC sessions emphasized the need for enterprise integration and coordination. States must manage testing, release planning, architecture, data contracts, vendor handoffs, and incident resolution. 

What it means for states and partners
Modularity requires more than modular procurement. States need an enterprise layer that manages the relationships between components. Partners should understand how their work affects the broader Medicaid ecosystem. 

Federal Requirements Are Shaping the Modernization Agenda 

CMS and other federal requirements continue to influence state priorities. Certification remains important, along with federal reporting, data quality, security, interoperability, and program integrity. The conference also reflected growing pressure to prevent fraud, waste, and abuse earlier in the Medicaid life cycle. States are strengthening provider enrollment, referral intake, payment controls, analytics, and audit preparation. These efforts move program integrity closer to the front door. The goal is to identify risk before it becomes a payment error or an investigation. 

What it means for states and partners
Compliance and program integrity should be part of solution design from the beginning. States and partners should build evidence, controls, testing, and monitoring into normal operations. These activities should not be postponed until certification or an audit is approaching. 

Eligibility Changes Require New Data and Operational Models 

Changes to Medicaid eligibility are creating new demands for states. Workforce and community engagement requirements are one example. States may also need enhanced verification, new exemption processes, shorter response timelines, and stronger outreach. 

These changes extend beyond eligibility systems. They shape how states communicate with members, support contact centers and caseworkers, manage appeals, connect data sources, and help people understand what they need to do to maintain coverage. MESC sessions underscored the value of listening to stakeholders and explored how health information exchange data and other sources could support exemption decisions and reduce preventable coverage loss. 

What this means for states and partners
Eligibility modernization must connect policy to daily operations. States need reliable data and clear workflows. They also need ways to explain changes and track outreach. Partners can translate policy into decision logic, test cases, notices, training, and operational procedures. 

AI Means Governed Support for Real Medicaid Work 

AI was a major topic of discussion at MESC. The strongest examples involved practical work rather than general experimentation. States are exploring AI for policy questions, quality assurance, document review, contact center support, knowledge management, and program integrity. These use cases can reduce administrative burden and help staff manage complex workloads. Conference speakers clarified that AI is no substitute for reliable governance structures. States need reliable content, security controls, privacy protections, human review, workforce training, and performance monitoring. 

What this means for states and partners
AI adoption should begin with a specific business problem. States should define who is accountable for the outcome and how the tool will be monitored. Partners can support use case selection, governance, procurement, testing, implementation, and workforce adoption. 

How ºìÁì½í¹Ï±¨ Can Help 

MESC 2026 reinforced the argument that Medicaid modernization is no longer a discrete technology project. States and their partners are responding to federal requirements, modular system complexity, eligibility changes, AI adoption, and heightened program integrity expectations at the same time. 

ºìÁì½í¹Ï±¨ and HealthTech Solutions help organizations turn that complexity into an actionable modernization strategy. Our teams bring together Medicaid policy expertise, operational experience, technology strategy, procurement support, compliance knowledge, and implementation discipline so clients can make better decisions and execute with confidence. 

We support organizations in assessing current systems and capability gaps, prioritizing technology investments, translating policy into operational and technical requirements, managing vendor selection and procurement, strengthening compliance and program integrity, and adopting AI in ways that are effectively governed, practical, and aligned with Medicaid business needs. 

Contact ºìÁì½í¹Ï±¨ experts to get your questions answered. 

Federal and State Medicaid Leaders and VA Assistant Secretary to Discuss Public Healthcare Transformation at ºìÁì½í¹Ï±¨ Conference

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ºìÁì½í¹Ï±¨ (ºìÁì½í¹Ï±¨) is pleased to announce that , Principal Deputy for the Center for Medicaid & CHIP Services, will participate in two sessions at , October 5-7, 2026. in New Orleans, LA. As states, plans, providers, and community partners prepare for a new era in Medicaid and other public healthcare programs, these conversations will focus on practical solutions, implementation realities, and the partnerships needed to move from policy change to sustainable results. 

State Medicaid and CHIP Strategies for Applied Behavior Analysis and Autism Services 

As the prevalence of autism has increased, state investments in Applied Behavior Analysis (ABA) and related services have grown substantially. This preconference session will examine federal guidance and state strategies for supporting appropriate, high-quality care for children with autism while helping programs strengthen oversight, access, and service delivery. 

Medicaid Policy Changes and Their Ripple Effects Across Healthcare 

Changes in Medicaid policy and financing will not stay confined to Medicaid. Coverage churn across Medicaid, the Affordable Care Act (ACA) Marketplace, and employer-sponsored insurance can reshape risk pools, influence plan participation, increase provider financial exposure, and leave more people uninsured. This session will bring federal and state leaders together to discuss how Medicaid agencies and their partners are responding, where collaboration is most needed, and what strategies will be needed to navigate the next phase of public healthcare transformation. 

The following current and former Medicaid directors will join Dr. Knapp: 

  • , Administrator, Nevada Medicaid Nevada Health Authority 
  •  Senior Advisor; Former Medicaid Director, Virginia Department of Medical Assistance Services 
  •  Medicaid Director & Assistant Secretary for MassHealth, Massachusetts Executive Office of Health & Human Services 
  • Director, Ohio Department of Medicaid 

VA Community Care and NextGen Healthcare Innovation for Veterans 

As the nation’s largest integrated health system serving military veterans, the VA is working with health plans, providers, health systems, technology firms, and other innovators to bring effective solutions from across the healthcare marketplace to people who have served our nation. Approximately 42 percent of the healthcare services that veterans receive today is delivered through the contracted Community Care program, and that share is expected to grow.  will discuss the VA’s vision for the future of Community Care, the critical role industry partners will play, and how the VA intends to learn from the field, adopt proven practices, leverage emerging technologies, and foster innovation that improves access, quality, and outcomes for veterans.

As Medicaid, VA Community Care, and other public healthcare programs enter a period of significant change, ºìÁì½í¹Ï±¨â€™s conference will focus on the partnerships, operational strategies, and solutions needed to move from policy to implementation.

to join leaders working through the decisions that will shape the next phase of public healthcare. 

September 2, 2026

Federal and State Medicaid Leaders and VA Assistant Secretary to Discuss Public Healthcare Transformation at ºìÁì½í¹Ï±¨ Conference

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Closing the Care Continuity Gap in Substance Use Disorder

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An actuarial view of $569 million in ACA marketplace SUD spending

Today, August 31, 2026, is International Overdose Awareness Day—a time to remember the lives lost to overdose, to support people affected by substance use, and to advance action that saves lives. In recognition of this day, Sober Sidekick and Wakely Consulting Group, an ºìÁì½í¹Ï±¨ Company, are releasing this new report to help strengthen the continuum of substance use disorder (SUD) care.

Health plans spend far more on acute stabilization and short-cycle services than on services that support sustained recovery, according to a joint analysis by Sober Sidekick and Wakely Consulting Group, an ºìÁì½í¹Ï±¨ Company.

The brief examines $569 million in allowed costs for approximately 150,000 Affordable Care Act (ACA) Marketplace members with a primary SUD diagnosis during benefit year 2023.

Key findings

  • For every $1 spent on sustained recovery services, $3.64 was spent on acute stabilization and short-cycle services.
  • Acute stabilization and short-cycle care represented 51.5% of analyzed spending, or approximately $293 million.
  • Sustained recovery services represented 14.1% of analyzed spending, or approximately $80.4 million.
  • Emergency department (ED) utilization accounted for the largest single concentration of spending, totaling $127.9 million across six billing codes.
  • No sustained recovery service appeared among the 11 highest spend billing codes; the first appeared at rank 12.
  • Medically assisted treatment (MAT) accounted for approximately 1.6% of SUD-primary spending in the dataset.
  • Members using acute stabilization services averaged $5,577 in annual allowed costs, compared with $3,506 for members using sustained recovery services.
  • Redirecting a portion of spending toward recovery sustaining services represents an estimated opportunity of approximately $2,071 per member.

The $2,071 figure is a planning estimate, not a guaranteed savings projection. Results are sensitive to local market conditions, member characteristics, benefit design, provider capacity, and claims experience.

Why this matters

EDs, detoxification, ambulance services, and residential care are often clinically necessary and can be lifesaving. The analysis does not recommend reducing access to these services.

Instead, it identifies a care continuity gap—the period before and after an acute event when members may not receive timely follow-up, MAT treatment, case management, psychotherapy, or ongoing peer support.

Closing that gap may help health plans move from episodic crisis response toward a more continuous model of SUD care.

What this brief examines

Wakely actuaries and ºìÁì½í¹Ï±¨ SUD clinical experts classified 200 Healthcare Common Procedure Coding System codes according to their relationship to sustained recovery. The framework considered:

  • Strength of clinical evidence for SUD outcomes
  • Cost-effectiveness reported in the literature
  • Whether a service addresses upstream prevention or downstream consequence
  • Contribution to long-term, stable recovery

The analysis grouped services into highest-value, high-value, mid-value, low-value, and lowest-value tiers. Mid-value services represented 34.4% of analyzed spending and were excluded from the headline 3.64:1 ratio because their relationship to long-term recovery was considered context dependent.

Implications for health plans

The findings point to several opportunities for payer and provider organizations:

  1. Identify members at key inflection points, including ED visits, detoxification, residential discharge, and missed follow-up
  2. Improve initiation and retention of medication-assisted treatment
  3. Connect members with peer support and case management between clinical appointments
  4. Monitor engagement patterns to identify potential disengagement earlier
  5. Explore value-based arrangements tied to treatment initiation, treatment engagement, post-ED follow-up, post-discharge follow-up, and pharmacotherapy for opioid use disorder

Frequently asked questions

What is the care continuity gap in SUD?

The care continuity gap is the period between acute stabilization and ongoing recovery support. It can occur after an ED visit, detoxification episode, residential discharge, or between monthly outpatient appointments.

What is the 3.64:1 finding?

For every $1 of analyzed SUD-primary spending on sustained recovery services, $3.64 was spent on acute stabilization and short-cycle services. The ratio compares low- and lowest-value tiers with high- and highest-value tiers; mid-value services were excluded.

What population was studied?

The analysis examined approximately 150,000 ACA marketplace lives with a primary SUD diagnosis during benefit year 2023, using $569 million in allowed costs from the Wakely ACA Database.

Does the report recommend reducing emergency or detoxification care?

No. Acute services can be clinically necessary and lifesaving. The report focuses on improving the connection between crisis services and sustained recovery.

Is the estimated $2,071 opportunity guaranteed savings?

No. It is a planning estimate based on observed differences in annual allowed costs between members using acute stabilization services and those using sustained recovery services. Actual results will vary by market and population.

Who produced the analysis?

The brief was produced jointly by Sober Sidekick and Wakely Consulting Group, an ºìÁì½í¹Ï±¨ Company. Wakely actuaries and ºìÁì½í¹Ï±¨ SUD clinical experts developed the recovery value classification framework.

Download Closing the Care Continuity Gap in SUD: An Actuarial View of $569M in ACA Marketplace SUD Spending to review the methodology, service classifications, claims distribution, implications for value-based payment, supporting evidence, and modeling disclosures.

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