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From State Discussions to National Policies: Healthcare in Focus

Since January 1, 2025, (SOR), an 红领巾瓜报 Company, has hosted eight conferences across states. SOR conferences give providers, health plans, lawmakers, and other stakeholders from all areas of healthcare the opportunity to have real-time discussions about pressing healthcare issues. These events provide a forum to bring together leaders with different perspectives and areas of expertise to discuss, digest, and synthesize issues and challenges at the state and local levels. These discussions allow states and their partners to improve healthcare delivery and prepare for changes before they happen.

This article explores common themes and issues addressed during the state-specific meetings.

Common Trends and State Priorities

Although each state has unique challenges and priorities, there is clear overlap in the issues being addressed. The exchange of ideas and best practices at these meetings is fostering a collaborative approach to tackling some of the most pressing challenges facing our nation today. Key themes include:

Improving healthcare accessibility and affordability.聽Many states are grappling with similar issues, such as the rising costs of medical services and federal policy changes that will have varying implications for the healthcare sector, especially publicly financed health insurance programs. From new rules coming out of the Centers for Medicare & Medicaid Services (CMS) to the 鈥淥ne, Big Beautiful Bill Act,鈥� which calls for reducing Medicaid funding and federal work requirements, healthcare industry leaders have been considering how these provisions will affect public healthcare programs. It was evident that these issues are at the forefront of state priorities, as leaders from different regions shared their strategies and experiences.
Assessing the evolving landscape for artificial intelligence (AI) and other technologies. Stakeholders discussed the state-specific landscape and opportunities for technologies such as AI, health data information, wearable health tools, and other digital health solutions. They explored opportunities to improve access to services and achieve efficiencies, while seeking to understand the potential limitations of advancements in technology.
Addressing the opioid crisis.聽States are taking various approaches to combat the opioid epidemic, from increasing funding for addiction treatment programs to implementing stricter regulations on prescription medications. The urgency of this issue was palpable, with speakers and participants sharing personal stories and data to underscore the impact of the crisis on their communities. Many panel discussions also focused on approaches to improve behavioral health coverage parity, access to 988 services, and care coordination.
Attracting and retaining all types of clinicians. Each state has designated health professional shortage areas and is thinking creatively about how recruit and keep healthcare practitioners. For example, many sessions at the SOR events explored where states are investing in educational programs to train the next generation of healthcare professionals. Loan repayment programs are also being expanded to incentivize clinicians to work in underserved areas. In addition, states are streamlining licensure processes to make it easier for healthcare providers to practice across state lines.

The conferences also provided a platform to discuss a range of other healthcare and health-related issues. Payment reform was a hot topic, with states exploring ways to make healthcare more affordable and efficient. Attendees were engaged in discussions about the impact of the federal Medicaid policy changes to coverage for health-related social needs (HRSNs), and the importance of community level strategies to address factors like housing, food security, and transportation. Maternal healthcare, the reentry population, the aging population, and rural health were other significant topics, each contextualized by the state-specific challenges and innovative solutions being explored.

What to Watch

The federal health policy landscape will continue to change over the coming months, which will greatly affect how states approach healthcare, especially Medicaid services. The policy changes and the downstream implications for state and local governments and their partners will be at the heart of discussions at the upcoming 红领巾瓜报 (红领巾瓜报) National Conference, Adapting for Success in a Changing Healthcare Landscape, and State of Reform conferences. Key topics include:

The federal budget. On July 1, 2025, the Senate approved a tax and spending package that would cut over $1 trillion from healthcare, including $940 billion from Medicaid over 10 years. The bill introduces work requirements, provider tax limits, and stricter eligibility checks and is projected to increase the number of uninsured people by nearly 12 million, according to the Congressional Budget Office. The bill鈥檚 provisions will likely significantly disrupt the federal share of Medicaid funding so states will need to prepare and decide how to fund optional programs. Stakeholders will also want to prepare for the churn among their clients and expected drop in enrollment in publicly financed programs.
Medicaid work requirements. The federal work requirements in the House-passed and Senate-passed budget bills will require states to make policy and operational changes, including new systems and processes that meet the new federal mandates. State officials will have to tailor their work requirement programs to meet the capabilities and interests of the people who live in their respective states.
The impact of CMS actions. The Trump Administration鈥檚 new regulations and executive actions, particularly those announced by the Centers for Medicare & Medicaid Services (CMS), will affect states in various ways. The聽聽changing portfolio, for example, may provide states with new opportunities to participate in care delivery models. CMS鈥檚 decision to聽聽of new or existing requests for federal matching funds through Section 1115 demonstration waivers for designated state health programs and designated state investment programs may influence how states fund and deliver HRSN services.

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Join a range of healthcare stakeholders, including 红领巾瓜报 experts, at one of the upcoming . These events provide a unique opportunity to delve into state and local-specific discussions, allowing for a deeper understanding of regional healthcare challenges and solutions.

We also invite you to continue these important conversations at the national level at 红领巾瓜报鈥檚 2025 conference, , which will take place October 14鈭�16 in New Orleans, LA. This conference will focus on both state and federal issues, fostering collaboration and learning among state and federal agencies, payers, health systems, providers, and other key stakeholders.

For more information on the 红领巾瓜报 conference, contact Andrea Maresca. For more information on State of Reform, contact SOR program director Katharine Weiss.

What the Senate’s Budget Approval Means for the Future

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On July 1, 2025, the US Senate voted 51鈥�50, to advance its version of , continuing the budget reconciliation process. Like the bill that the House passed in May, the Senate language calls for making significant changes to the Medicare, Medicaid, Affordable Care Act (ACA) Marketplace programs, as well as health savings accounts (HSAs) and publicly funded programs such as the Supplemental Nutrition Assistance Program.

Relative to the House bill, however, the Senate differs substantially in approach and scope. Thus, the bill has been sent back to the House for consideration. Speaker of the House Mike Johnson (R-LA) intends to accelerate voting with the goal of clearing the legislation in the House by July 4, 2025.

Key Differences Between House and Senate Bills

Notable differences between the House and Senate packages pertain to the following:

Medicaid Provider Payments: The Senate version includes more restrictive changes to federal Medicaid provider taxes and state-directed payment policies. These changes are expected to affect hospitals that rely on Medicaid supplemental payments. The Senate bill also would create a $50 billion Rural Health Transformation Program to mitigate financial strain on healthcare providers in rural communities. The provision includes several stipulations regarding distributions, allocations, eligibility standards, and permissible uses of the funds, which will likely prompt considerable ongoing engagement from stakeholders if signed into law, particularly among hospitals and clinics that will face substantial headwinds under other components of the legislation.
ACA Marketplaces: Like the House bill, the Senate version includes provisions to recapture full ACA subsidy amounts, restrict subsidy eligibility for certain immigrant populations, and require verification of ACA subsidy eligibility. The Senate bill neither appropriates funding for cost sharing reduction subsidies nor includes provisions regarding the Marketplace Integrity and Affordability rule, which the Centers for Medicare & Medicaid Services (CMS) finalized on June 20, 2025. In addition, the Senate bill offers several smaller flexibilities intended to increase usage of HSAs but does not include the full suite of HSA changes included in the House bill. The Senate language also does not call for expanding individual coverage health reimbursement arrangements (ICHRAs).
More Limited Medicare Package: Although the Senate language restores the ORPHAN Cures Act and adds a modest one-year payment increase under the Medicare Physician Fee Schedule (PFS), the bill omits a number of significant Medicare policies included in the House version, including a much broader PFS investment tied to the Medicare Economic Index, as well as multiple pharmacy benefit manager (PBM) reforms under Medicare Part D. The Senate legislation also excludes two Medicaid PBM provisions that the House had included.

Estimates from the Congressional Budget Office

The Congressional Budget Office (CBO) has provided several of the cost and coverage impacts of the healthcare and tax provisions in multiple versions of the reconciliation legislation. CBO has provided cost estimates for the , as well as the Senate but has yet to release information on the final Senate version. Of note, CBO estimated the following:

The Medicaid, Medicare, and ACA related provisions in the Senate substitute amendment would reduce healthcare spending by approximately $1.15 trillion over the next 10 years.
The House bill would, by 2034, add 10.9 million people to the number of uninsured individuals in the United States.

What to Watch

Stakeholders should plan for the financial, policy, and operational impacts of the many provisions that could be enacted, including:

New administrative requirements for enrollment that will place additional obligations on individuals seeking coverage and which will require more state resources to implement and manage. Community engagement and work requirements are scheduled to take effect December 31, 2026.
Downward Medicaid financial pressures due to fewer federal funds, which will stress state budgets and states鈥� ability to maintain existing programs. This situation could lead some states to scale back eligibility for Medicaid, limitenrollment for optional programs, or some combination of these. Additionally, states could be expected to address increases in uncompensated care among their providers.
A pause on implementation of previously finalized regulations that streamlined the Medicaid enrollment process for individuals.

The combination of the House and Senate reconciliation bills and the recently finalized Marketplace Program Integrity and Affordability rule indicate an uncertain future for cost sharing subsides and enhanced premium tax credits in Marketplace programs. Healthcare stakeholders should prepare for the impact of the expiration of the enhanced premium tax credits would have on benefit packages, enrollee risk profiles, uncompensated care, and other key issues affecting access, cost, and outcomes.

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To learn more about the these policy changes and the impact on your organization,聽contact our featured experts below.

Forty Years Supporting Medicaid at 红领巾瓜报

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This month鈥檚 Vital Viewpoints podcast features a special conversation with Jay Rosen, founder, president, and chairman of 红领巾瓜报 (红领巾瓜报), as he reflects on the evolution of Medicaid and the 40^th anniversary of 红领巾瓜报鈥檚 founding. From his early days shaping Michigan鈥檚 Medicaid program in Michigan’s Office of Health and Medical Affairs, to building a national firm dedicated to public sector healthcare, Jay鈥檚 story is one of purpose, persistence, and visionary leadership. Over four decades, Jay has guided 红领巾瓜报鈥檚 strategic vision, growth, client service, and innovation in publicly funded healthcare.

Jay began his career at a time when Medicaid was still finding its footing. In the 1970s and early 1980s, states were grappling with how to operationalize a new federal promise鈥攈ealthcare for low-income and aging Americans. Jay saw firsthand the complexity and urgency of that challenge. But he also saw opportunity: to build something better, smarter, and more accountable. That vision led to a fateful meeting at a Big Boy diner in East Lansing, Michigan, where Jay, Paul Allen (Michigan鈥檚 then Medicaid director), Elliot Wicks, and Jay Endsley laid the groundwork for what would become 红领巾瓜报 on June 13, 1985, the date 红领巾瓜报 was founded.

The 1980s saw extreme economic distress in the U.S., with healthcare costs rising by 1,520% annually. Pressure on the federal government to reduce financial support for public sector health programs meant state governments had to lead the way. Managed care emerged as a novel idea, using risk-bearing intermediaries between the state as a payer and providers/consumers. Michigan was an early adopter of managed care.

Over the next four decades, managed care programs evolved to bring more accountability in Medicaid, transforming the state鈥檚 role from administrator to regulator. The state agency could focus on using its levers to improve performance of public programs. Reporting requirements, data-driven decision making, quality measurement and other innovative tools were introduced.

鈥淥ne-third of the country is on Medicaid, covering 90 million people, including the most expensive, vulnerable populations. Medicaid operates well despite financial challenges, addressing significant societal obligations,鈥� says Rosen.

Now, as we celebrate the 60^th anniversary of Medicaid in July, the program faces new operational and financial pressures, but also new tools — like AI and digital health technologies to meet the moment. Innovation in Medicaid isn鈥檛 optional, it鈥檚 essential. 聽红领巾瓜报 experts work with states and other organizations to harness these tools and stay current with these new initiatives.

Hear more from Jay in this month鈥檚 podcast episode, 鈥�Medicaid At (Another) Crossroads: The Future of Public Healthcare Coverage鈥�. And as you look ahead to the future of Medicaid, trust 红领巾瓜报 to be your partner for the next 40 years to come. #红领巾瓜报knowsMedicaid

红领巾瓜报IS Report Examines Medicaid Financial Accountability Policies and Emerging Strategies

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This week, 红领巾瓜报 Information Services (红领巾瓜报IS) released a new report that provides a detailed, state-by-state analysis of how Medicaid managed care programs are implementing and enforcing medical loss ratio (MLR) requirements. The comprehensive report, Medicaid Financial Accountability and Risk Sharing Arrangement Report, looks at 43 states and the District of Columbia, drawing from the most recent publicly available rate certifications and model contracts.

The report鈥攁vailable exclusively to 红领巾瓜报IS subscribers鈥� supports policy analysts, actuaries, and other interested Medicaid stakeholders with comparative analysis and identification of emerging trends, outliers, and best practices in managed care oversight.

Key Highlights in the 2025 Report

The 红领巾瓜报IS team examined rate certifications and model contracts, primarily covering rate periods ending in or extending through 2025. The report also reflects recent federal policy changes, including the requiring the inclusion of state-directed payments in MLR calculations鈥攁n update that is already influencing how states structure their payment, reporting, and oversight processes.

Each state profile outlines key elements of the following:

MLR thresholds and remittance obligations
Risk corridors and reinsurance strategies
Other risk mitigation strategies, including high-cost drug pools and retroactive eligibility adjustments

Key findings include:

Standardization is at 85 percent: Most states with risk-based programs (22) enforce the federal minimum MLR of 85 percent.
Stricter Thresholds: 11 states have adopted thresholds above 85 percent, with some reaching as high as 91.3 percent (Mississippi).
Most states require managed care organizations to remit funds if they fall below the MLR threshold. Enforcement varies, however, with strict enforcement in states like Georgia, Indiana, and Iowa, which require 100 percent of the shortfall to be returned, and more flexible policies in other states.
The analysis finds states are modifying certain traditional policies and tools to strengthen financial accountability mechanisms and evolve policies to address the changing federal policy landscape. For example, in lieu of remittances, Oregon and Tennessee allow plans to reinvest funds in the community.

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As states continue to refine their approaches to financial accountability and program integrity and design innovative approaches to address enrollee healthcare needs, the 红领巾瓜报IS report offers a timely and actionable reference point.

This report is just one component of the broader 红领巾瓜报IS subscription platform, which offers exclusive access to:

Searchable files that enable comparative analysis of key state program information and data
Timely updates聽on Medicaid policy developments
Downloadable state-by-state and industry files

For聽health plans, state agencies, provider organizations, partners, and advocacy groups, subscribing to 红领巾瓜报IS means staying ahead of regulatory changes, identifying emerging trends, and making informed decisions about strategy, compliance, and program design. For more information about the new report, contact featured 红领巾瓜报IS team member聽below.

Disaggregating Managed Care Payments: New Insights into Medicaid Spending

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As states and stakeholders seek greater transparency and accountability in Medicaid, a new analysis from 红领巾瓜报 (红领巾瓜报), offers a fresh perspective on how dollars flow through the system. Drawing on publicly available data from the Transformed Medicaid Statistical Information System (T-MSIS), 红领巾瓜报 disaggregated funding dispersed to Medicaid managed care organizations to discern spending for specific categorically eligible populations. The findings significantly enhance policy discussions and can facilitate development of pragmatic and specific care management interventions that support quality patient care.

For policymakers, regulators, and other stakeholders, this level of disaggregation provides a clearer view of how public dollars are used鈥攁nd where there may be opportunities to improve performance or reinvest savings. It also supports more informed rate development and contract negotiations, particularly as states pursue value-based purchasing and other reforms. As Medicaid continues to evolve, especially in the context of budget pressures and changes in enrollment and risk profiles of enrollees, understanding the financial picture of managed care programs is essential to ensuring sustainability.

红领巾瓜报鈥檚 team of experts鈥攊ncluding actuaries, former Medicaid directors, and data analysts鈥攈as deep experience working with T-MSIS data and advising states, plans, and providers on Medicaid program analysis, evaluation, and strategy. For more information about working with T-MSIS data and the insights it can provide, contact聽our experts below.

Medicaid Expansion: Data-Driven Insights into Healthcare Needs

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As the US Senate debates H.R. 1鈥攁 sweeping legislative package that the House passed on May 22, 2025, which would impose nationwide Medicaid work and community engagement requirements by the end of 2026鈥� 红领巾瓜报鈥� (红领巾瓜报鈥檚) latest analysis offers insights into the potential impact of these changes. Drawing on Transformed Medicaid Statistical Information System (T-MSIS) data, 红领巾瓜报 experts examine the health and demographic profiles of the approximately 16 million individuals who comprise the Medicaid expansion population.

This 10-slide presentation of findings underscores the high prevalence of chronic and behavioral health conditions among these individuals, raising important questions about how new eligibility requirements could affect access to care and health outcomes. Notably, the presentation contextualizes health needs with Medicaid spending patterns, comparing the Medicaid expansion group with other eligibility categories, such as dual eligibles and children. We explore how the proposals of the nine state 1115 demonstration applications could affect the work requirements policy and implementation landscape. It also breaks down pharmacy spending by therapeutic class, spotlighting common conditions like opioid use disorder.

These insights are especially valuable for Medicaid managed care organizations, providers, and other stakeholders that will play a key role in designing work requirement initiatives and operationalizing any new requirements. Our May 22, 2025, article鈥�Building State Capacities for Medicaid Work and Community Engagement Requirements鈥攄elves into the issues that are central to such discussions.

With deep expertise in Medicaid policy, demonstration design, and advanced analytics, 红领巾瓜报 is uniquely positioned to help states, plans, and providers navigate the evolving federal landscape. For more information about 红领巾瓜报鈥檚 T-MSIS capabilities, contact featured experts聽below.

The Medicaid HRSN Pivot: What鈥檚 Next for States, Plans, and Providers?

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On March 4, 2025, the Centers for Medicare & Medicaid Services (CMS) rescinded the 2023 and 2024 guidance on Health-Related Social Needs (HRSN) Section 1115 demonstrations. This policy shift signals a significant pivot in federal Medicaid priorities under the current administration. While states with approved HRSN demonstrations may continue operating under existing terms, the path forward for pending proposals and future renewals is less certain.

This article explores key considerations 红领巾瓜报 (红领巾瓜报), experts identified for states that need to realign HRSN activities with other activities to align with the Trump Administration鈥檚 federal policy objectives and priorities for Section 1115 Medicaid and CHIP demonstrations.

Background on HRSN Initiatives in Section 1115 Demonstrations

In November 2023 and December 2024, CMS published guidance on a new Section 1115 demonstration that gave state Medicaid and CHIP agencies the opportunity to address the broad environmental conditions, or social determinants of health (SDOH), that affect people鈥檚 health. This initiative permitted states to address the individual-level adverse social conditions of enrollees that contribute to negative health outcomes. To assist states in their efforts, CMS approved Section 1115 demonstrations that piloted the provision of housing, food, non-medical transportation, and other environmental supports that meet enrollees鈥� HRSNs.

What does CMS鈥檚 rescission of the HRSN demonstration policy initiative mean for states planning their next steps and priorities for Medicaid and CHIP?

First, CMS鈥檚 March 4 rescission has no impact on states with a current, active Section 1115 demonstration that includes HRSN. States with HRSN demonstrations can maintain their approved programs until the scheduled expiration date; however, requests to amend any aspect of the program before it expires could subject the state to renegotiation of HRSN components that align with the new federal direction.

Second, states with pending HRSN Section 1115 demonstration proposals should proactively consider new coverage approaches to authorize services that address an individual鈥檚 SDOH. Pending proposals developed using the now rescinded guidance may require substantial changes to gain approval. States should also prepare for additional public comment periods if revisions significantly alter the original design.

Looking ahead, CMS is not expected to renew demonstration components that no longer align with current federal objectives. This projection pertains to any demonstration component, not just the rescinded HRSN guidance. States should start planning now for how they will sustain successful HRSN-related outcomes through alternative coverage pathways.

Strategic HRSN Pivot Considerations

While the HRSN guidance has been rescinded, CMS has not withdrawn the 2021 State Health Official Letter (SHO# 21-001), published during the first Trump Administration. This leaves room for states to pivot HRSN initiatives into other federal authorities, such as:

State Plan Amendments and Waivers. These approaches include state plan options, 1915 waiver options, CHIP Health Services Initiatives, as well as certain special program authorities like Program of All-Inclusive Care for the Elderly or Money Follows the Person.聽
Behavioral Health Integration: States may expand SDOH supports for individuals with substance use disorder, serious mental illness, or serious emotional disturbance, leveraging still-active guidance from first Trump Administration, Letter to State Medicaid Directors聽(SMD # 17-003) and聽聽(SMD # 18-011). By expanding activities focused on improving addiction or behavioral health treatment for Medicaid or CHIP beneficiaries, states could explore novel approaches to offering SDOH services.聽
Childhood Chronic Disease Prevention: States could consider aligning SDOH activities with the Make America Healthy Again initiative of the current administration by focusing on environmental factors that adversely affect an enrollee鈥檚 health, such as poor nutrition, chronic stress, overexposure to synthetic chemicals, and mental health challenges.聽
Justice-Involved Populations: States could explore聽聽and SDOH supports for individuals transitioning from carceral settings to the community, including compliance with new Medicaid requirements for incarcerated youth under the Consolidated Appropriations Act of 2023.聽
School-Based Health Services. States could explore SDOH activities as part of new approaches to address gaps in the provision of school-based health services to Medicaid and CHIP eligible children. CMS and the US Department of Education launched a joint effort to expand school-based health services by establishing the聽聽to help states increase healthcare access to children enrolled in Medicaid and CHIP. States could explore SDOH initiatives that expand the capacity of school-based entities that provide assistance under Medicaid or CHIP.聽

Looking Ahead

As states recalibrate their Medicaid and CHIP strategies, understanding how they can align with evolving federal priorities is critical for all stakeholders. Notably, Medicaid stakeholders, including managed care organizations, hospitals and health systems, and providers, also have several opportunities, including:

Inform State Strategy: Plans and providers can share data and outcomes from HRSN interventions to help states assess the value of these services and whether they should continue under alternative authorities.聽
Shape New Demonstration Designs: As states pivot to align with new federal priorities, plans and providers can offer practical insights into how SDOH interventions could be integrated into behavioral health, reentry, school-based services, and chronic disease prevention efforts.聽
Strengthen Community Partnerships: Continued collaboration with community-based organizations will be essential to maintain service delivery and demonstrate impact in new policy contexts.聽

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红领巾瓜报鈥檚 team鈥攊ncluding former CMS Section 1115 leaders and other colleagues steeped in Medicaid and CHIP policies and operations鈥攐ffers unique expertise in designing demonstrations that reflect current federal policy priorities and maximize state outcomes in alignment with program objectives that CMS will support.

For questions about these developments and your organization鈥檚 plan to adapt to new federal Medicaid policy priorities, contact our featured experts聽below. Connect with our experts and other leaders experienced in new pathways for covering effective services at the聽, October 14-16, 2025, in New Orleans, LA.聽

Medicaid Redetermination Ripple Effects in the Individual Market

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As Congress intensifies negotiations over budget reconciliation, including potential changes to Medicaid financing and Affordable Care Act (ACA) subsidies, new data from Wakely Consulting Group, an 红领巾瓜报 (红领巾瓜报) company, sheds light on how the effects of the Medicaid redetermination process continued to unfold well into 2024. Appendix A of the May 2025 white paper , provides a full-year view of enrollment and morbidity trends, showing that the influx of former Medicaid enrollees had some negative effects on risk scores. In fact, relative risk increased across all market types鈥攕tate-based exchanges (SBEs), in federally facilitated exchange (FFE) Medicaid expansion states, and FFEs in non-expansion states鈥攄espite substantial enrollment growth.

Data presented in Wakely鈥檚 and their experts鈥� findings challenge the conventional assumption that higher enrollment dilutes risk and suggest that many new enrollees may have had unmet health needs or delayed care. The data also show that states with the highest enrollment growth did not necessarily experience the greatest morbidity shifts. This decoupling of enrollment and morbidity complicates forecasting for insurers and policymakers alike, especially as Congress debates Medicaid funding and ACA subsidy structures in the ongoing budget reconciliation process.

What to Watch

As federal lawmakers consider reforms that could alter Medicaid eligibility, subsidies, and risk adjustment mechanics, these findings underscore the importance of monitoring not just how many people enroll, but who they are and the type of care they need. The individual market鈥檚 evolving risk profile will have direct implications for premium setting, subsidy design, and the financial stability of plans that serve this population.

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Wakely is experienced in all facets of the healthcare industry鈥攆rom carriers to providers to government agencies. Wakely鈥檚 actuarial experts and policy analysts continually monitor and analyze potential changes to inform clients鈥� strategies and propel their success.

For more questions about the analysis contact聽our experts below.

Medicaid Managed Care Enrollment Update 鈥� Q1 2025

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In this week鈥檚 In Focus section, 红领巾瓜报 Information Services (红领巾瓜报IS) draws on its database of monthly enrollment in Medicaid managed care programs to provide the latest quarterly analysis of Medicaid managed care enrollment, offering a snapshot of developments across 28 states.^[1] The data and insights are particularly timely as stakeholders, including states, Medicaid managed care organizations (MCOs), hospitals and health systems, and providers, continue to plan for multiple possible federal policy changes and the operational realities that will follow.

红领巾瓜报IS also compiles a more detailed quarterly Medicaid managed care enrollment report representing nearly 300 health plans in 41 states. The report provides by plan enrollment plus corporate ownership, program inclusion, and for-profit versus not-for-profit status, with breakout tabs for publicly traded plans. Table 1 shows a sampling of plans and their national market share of Medicaid managed care beneficiaries based on a total of 66 million enrollees. These data should be viewed as a broader representation of enrollment trends rather than as a comprehensive comparison.

Key Insights from Q1 2025 Data

The 28 states included in our review have released monthly Medicaid managed care enrollment data via a public website or in response to a public records request from 红领巾瓜报 (红领巾瓜报). This report reflects the most recent data posted or obtained. 红领巾瓜报 has made the following observations related to the enrollment data:

Year-over-year growth. As of March 2025, across the 28 states reviewed, Medicaid managed care enrollment declined by 2.5 million members year-over-year, a 3.9 percent drop as of March 2025 (see Figure 1). This marks a continuation of the downward trend reported in late 2024, though with notable variation across states.

Figure 1. Year-over-Year Growth in Medicaid Managed Care States, 2020鈭�24, March 2025

Localized growth amid broader declines. While most states experienced enrollment reductions, Indiana and North Carolina bucked the trend with measurable gains, suggesting the influence of state-specific policy shifts or demographic factors. Oregon and Texas also saw modest growth.
Sharpest contractions. Illinois, Maryland, and South Carolina, reported double-digit percentage drops, underscoring the uneven impact of redeterminations and eligibility changes.
Difference among expansion and non-expansion states. Among the 21 states included in our analysis that expanded Medicaid, enrollment fell by 1.8 million (-3.6%) to 48.6 million. In contrast, the seven non-expansion states saw a steeper proportional decline (-5.4%), to a total of 12.2 million enrollees.

Table 1. Monthly MCO Enrollment by State, January 2025 through March 2025

Note: In Table 1 above and the state tables that follow, 鈥�+/- m/m鈥� refers to the enrollment change from the previous month, and 鈥�% y/y鈥� refers to the percentage change in enrollment from the same month in the previous year.

It is important to note the limitations of the data presented. First, states report the data at the varying times during the month. Some of these figures reflect beginning of the month totals, whereas others reflect an end of the month snapshot. Second, in some instances, the data are comprehensive in that they cover all state-sponsored health programs that offer managed care options; in other cases, the data reflect only a subset of the broader managed Medicaid population. This limitation complicates comparison of the data described above with figures reported by publicly traded Medicaid MCOs. Hence, the data in Table 1 should be viewed as a sampling of enrollment trends across these states rather than a comprehensive comparison, which cannot be established solely based on publicly available monthly enrollment data.

Market Share and Plan Dynamics

Using our data repository from 300 health plans across 41 states, 红领巾瓜报IS鈥檚 report addresses corporate ownership, program participation, and tax status. As of March 2025, Centene continues to lead with 17.7 percent of the national Medicaid managed care market, followed by Elevance (10.8%), United (8.8%), and Molina (6.3%), as Table 2 shows.

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

What to Watch

The policy backdrop remains fluid. The US House of Representatives鈥� passage of the One Big Beautiful Bill Act introduces sweeping changes to Medicaid financing, including proposed cuts of up to $715 billion. Additional federal proposals, such as mandatory work requirements, could further reshape enrollment patterns.

Stakeholders should prepare for:

Implementation of work/community engagement mandates for certain adult populations
Potential redesign of Affordable Care Act expansion programs
Retraction of federal regulations focused on streamlining of eligibility and redetermination processes to improve accuracy and efficiency

Connect with Us

红领巾瓜报 is home to experts who know the Medicaid managed care landscape at the federal and state levels. As the Medicaid landscape continues to evolve, 红领巾瓜报IS equips stakeholders with timely, actionable intelligence. Our subscription service includes enrollment data, financials, waiver tracking, and a robust library of public documents.

For more information about the 红领巾瓜报IS subscription, contact our experts below.

[1] Arizona, California, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Mississippi, Missouri, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Washington, West Virginia, Wisconsin.

RADV Just Shifted Again: What CMS鈥檚 Latest Changes Mean for Medicare Advantage Plans聽

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We recently sat down with Medicare experts from 红领巾瓜报 and Wakely to break down the most important and most pressing developments shaping the future of Medicare Advantage, including the latest updates from CMS on Risk Adjustment Data Validation (RADV) audits, specifically the two major announcements released on May 21st and May 30th that are sending waves through the payer and provider communities alike.

On May 21st, CMS issued new guidance related to extrapolation and how sampling methodology and medical record review standards will evolve under the updated RADV Final Rule.

Then, just nine days later, on May 30th, CMS released additional operational instructions that may tighten reporting windows, add new thresholds for error rate evaluation, and expand expectations around provider documentation compliance鈥攑articularly for retrospective reviews and risk adjustment data sourcing.

To help unpack this fast-moving landscape, we鈥檝e spoken with our Medicare experts, , and David Nater, each bringing a unique lens to the RADV conversation.

What was your first thought when you read CMS’s latest RADV update last week?

Tony – My main takeaway was that CMS was really upping the game in terms of what payers need to do to not only do the appropriate measures to optimize their risk scores but then audit claims that are coming in from providers. So this isn’t just a matter of ensuring that risk score optimization strategies are appropriate, not overstepping, but also adding a new administrative task of auditing claims that you鈥檙e getting from providers that may have errors in them.

Can you quickly summarize what CMS actually changed in this latest announcement, and what鈥檚 most significant about it compared to the previous announcement in November last year and previous RADV audits?

Ryan 鈥� The core of these changes, prior to the old way of doing RADV is, of course the extrapolation methodology that CMS will be introducing, as well as the elimination of the fee-for-service adjuster, which is going to be huge. Then we can move on to that with the announcement of enhancements of staffing and technology.

It鈥檚 going to be very interesting how CMS looks to utilize that. As well as every single contract being audited that is eligible are probably the focus points within this, and with CMS they give you a little, and then you have to look into it a lot, so I think there’s still a lot more to come related to these initial announcements that are coming through.

What exactly does this mean from a health plan perspective in the near term – especially for those already in the trenches of risk adjustment audits or pre-audit reviews?

David 鈥� Most financial teams use claims as forecasting and having concurrent risk adjustment processes is really the optimal approach to make sure that there are no surprises on the financial end for month end and quarterly reports. Making sure that plans are getting ahead of this cleanup now is imperative to mitigate those financial impacts, and then on a concurrent level, optimizing the operational processes ensures just better forecasting and overall better financial outcomes.

With the latest announcements regarding RADV, what are the current unknowns at play related to this new look RADV strategy?

Tony 鈥� On a technical level, the key things we don’t know are how CMS is going to sample claims – They’ve indicated that they’re going to move from random sampling to targeted sampling – and we don’t know how they’re going to extrapolate that. So, if you do a targeted sample, do you extrapolate that just to a targeted extrapolation, or do you extrapolate that to the whole plan? And that’s your range of low impact to high impact.

Similarly, we don’t know what confidence interval CMS is going to use. There’s been some indications of 99% in the past. That’s going to be very conservative, but 95 or 90% would be plausible confidence intervals as well, and that gets you to much more aggressive recovery rates. There are a few other small technical issues that I don’t think will have as big of an impact, but those are the three ones that we’re really looking to CMS to figure out.

What鈥檚 the one thing you think plans need to prioritize immediately in light of this update – and what鈥檚 the trap they need to avoid?

Ryan – I think plans need to very quickly understand their exposure. One of the ways to do that鈥攁nd one of the ways we are engaging our clients鈥攊s to run analytics looking at these high-risk codes. There are also certain indicators you can look at to see what needs to be reviewed and what has high error rates, based on previous OIGYG and CMS audits. From there, you need to get a quick plan in place to document and assess whether or not those codes are relevant. If they are not, submit them before the aggressive timeline CMS has put in place.

As I mentioned, there are less than two weeks to submit deletes for 2019 dates of service, and every 7 days after that thereafter for each payment year. So, the time to act is now. You need to quickly understand where your risk is and take action. And if you don鈥檛 have those capabilities, engage with strong consulting groups or partners who can support you through this.聽

What closing thoughts or takeaways would you like to share?

Ryan 鈥� If I put myself on the plan side, I see both a short-term, immediate plan and a long-term sustainability plan.

That short-term immediate plan is action to act NOW. Whether that is engaging with a partner, or engaging in your internal team, you need to be able to highlight where your risk areas are. Take action on this prior to CMS coming in and acting for you. What’s just as important is setting up a long-term roadmap to be able to mitigate this risk going forward.

To look at it concurrently, do you have the right analytics in place? Do you have the correct staffing in place to be able to look at these risk codes coming in? Assess them and send the necessary deletes coupled with closing the loop related to feedback. Are you pushing that information and education back to your physician groups? Because they’re the most important part to this. You need to be able to educate, communicate and meet with your providers to explain how important the act of documentation and coding is and have this at the forefront of every one of your initiatives and incentive programs going forward in value-based care.

David 鈥� 红领巾瓜报 and Wakely are well-positioned to help in both the short-term and the long-term approach, and ideally both. Organizations need to act quickly and align their steady-state processes to ensure that they’re managing both the exposure at the health plan level and with the providers, especially those in risk-based arrangements.

Tony 鈥� Plans need to be thinking of the RADV risk here, apart from the risk that they might see from chart reviews and other add activity. You may be a plan that’s relatively unaggressive in chart reviews and adds that think 鈥渨e’re not risk here鈥�, but CMS has now assigned you risk for all the claims that providers are submitting, and you need to be ensuring that those are correct as well.

There’s a wholly separate administrative task here that plans have now assumed responsibility for, and your revenue is just as at risk for not doing the RADV as it is for being inappropriate in your chart reviews and adds and whatnot. So, you really want to be thinking of this as two separate things and acting from both fronts.

Check out our full conversation.

CSR Funding, Budget Debates, and the Future of Marketplace Affordability

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In May 2025, the US House of Representatives passed a budget bill that includes funding for cost-sharing reduction (CSR) payments, marking a potential end to the 鈥渟ilver loading鈥� practice that has shaped pricing in the Affordable Care Act (ACA) Marketplace pricing since 2017. The US Senate is now considering this legislation as part of a broader budget reconciliation package that includes major Medicaid reforms, such as new work requirements and changes to eligibility and financing rules.

This evolving policy landscape has significant implications for states, payers, providers, and consumers. Wakely, an 红领巾瓜报 Company, recently published , which outlines how reinstating CSR payments could reshape ACA marketplace plan pricing, enrollment patterns, and federal subsidy flows. It also highlights the operational and financial risks stakeholders must prepare for in 2026.

Broad Loading and Silver Loading

Because CSR loading increases premium costs on silver plans that determine subsidies, they also increase federal payments for premium tax credit (PTC) subsidies. Guidance from the US Department of Health and Human Services on silver plan pricing has evolved over time. Three types of CSR loading are occurring in ACA markets, specifically:

Broad loading: Increasing premiums for all metal level qualified health plans (QHPs) in the individual market to collect enough revenue to offset the CSR costs of the silver plan variants enrollees
Two means of silver loading:
- Increasing premiums for only silver QHPs in the individual market to collect enough revenue to offset the CSR costs of the silver plan variant enrollees
- Raising premiums, functionally, for only on-exchange silver QHPs

As discussed in the Wakely paper, the impact of silver loading is that the federal government is likely paying out more in additional PTC subsidies than would be paid if CSR payments were fully funded. On Friday, May 2, 2025, the Centers for Medicare & Medicaid Services (CMS) released guidance related to silver loading and CSR payments for 2026 rate filings. This action was urgently needed, especially for states with May filing deadlines.

What鈥檚 at Stake

If Congress does appropriate funding for CSR payments, some issuers will be reimbursed for the difference in cost sharing between standard and CSR-enhanced silver plans. Issuers that cover nonemergency pregnancy termination services, would be ineligible for CSR payments; however, as the Wakely paper indicates, these payments would not cover the additional utilization driven by richer benefits. For example, it is anticipated that a member in a 94 percent actuarial value CSR plan will use more services (i.e., four primary care visits versus three in a standard plan), but reimbursement would only reflect the cost-sharing difference鈥攏ot the increased volume of care.

States like Georgia and New Mexico, which mandate silver loading, could see significant shifts in premium relativities and enrollment behavior. Wakely鈥檚 modeling suggests that changes in CSR policy鈥攅specially if paired with the expiration of enhanced premium subsidies at the end of 2025鈥攃ould lead to higher net premiums, reduced enrollment, and a deterioration in risk pool morbidity.

What to Watch

The Senate鈥檚 deliberations will determine whether CSR funding is restored and could have significant implications on whether enhanced premium subsidies are extended beyond 2025. These decisions will directly affect the following:

2026 rate filings and benefit designs
Marketplace affordability and enrollment stability
State reinsurance funding and 1332 waiver dynamics
Consumer costs and plan switching behavior

Wakely鈥檚 analysis also cautions that if CSR funding is restored without accounting for induced utilization, issuers may still need to price for higher service use鈥攑otentially leading to premium volatility. In addition, if broad loading is mandated instead of silver loading, it could raise premiums across all metal tiers and reduce the value of premium tax credits for many enrollees.

Key Considerations for Stakeholders

States聽should assess how CSR policy changes affect reinsurance programs, waiver funding, and Medicaid redeterminations.
Payers聽must prepare for multiple pricing scenarios and evaluate how changes in subsidy structures influence enrollment and risk adjustment, 1332 reinsurance programs, and overall market risk.
Providers聽should anticipate shifts in patient mix and utilization (i.e., more uncompensated care with more uninsured patients).
Advocates聽need to monitor how policy changes affect access and affordability for low-income and underserved populations.

These developments also create more opportunities for movement between Medicaid, Marketplace, and uninsured populations, underscoring renewed opportunity for integrated eligibility systems and coordinated outreach.

Connect with Us

红领巾瓜报 (红领巾瓜报), experts are actively advising stakeholders on how to navigate these complex changes. Whether you鈥檙e a state policymaker, health plan executive, provider leader, or advocate, we can help you assess the impact and plan strategically.

These issues will also be explored in depth at the聽红领巾瓜报 Conference in October 2025. To discuss how these developments will affect your organization, contact our featured expert below.

How One Organization Unlocked Exceptional Financial Gains Through Revenue Cycle Optimization

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A recent case study highlighted how 红领巾瓜报 (红领巾瓜报) worked with a medical supply firm to identify gaps in their revenue cycle, and by working with us have seen improvements in denial rates and reimbursement. Advanced Diabetes Supply (ADS)/ US Medical Supply (USMed) came to 红领巾瓜报 for help with its revenue cycle goals. What began as a revenue cycle gap assessment at one ADS office in California was expanded to be repeated for the Florida office. As a result, 红领巾瓜报 helped ADS produce 12% YoY increase in cash collections, resulting in more than $38 million in additional revenue, and a $16 million reduction in outstanding A/R within six months.

A leading provider of diabetes supplies, ADS faced challenges in optimizing their revenue cycle processes. By partnering with 红领巾瓜报, they embarked on a transformative journey that resulted in streamlined operations and improved financial performance. The case study highlights the key strategies implemented by ADS and 红领巾瓜报, including the adoption of advanced technologies, process re-engineering, and staff training. These initiatives not only addressed existing inefficiencies but also paved the way for future growth and innovation.

Organizations need efficient revenue cycle management to ensure sustainability and growth in the constantly changing and competitive healthcare landscape. As healthcare reimbursement can involve many complex processes, it creates opportunities for gaps and process breakdowns. 红领巾瓜报 helps organizations implement the processes, training, and technology necessary to close process gaps, improve cash flow, determine root causes for gaps, and reduce denials.

红领巾瓜报 experts have decades of experience in every facet of the revenue cycle. They come from all sides of the healthcare industry, including providers, payers, managed care organizations, and more.

Delve deeper into this inspiring success story by downloading the full case study and watching the accompanying video featuring a conversation with Melanie Montero, SVP at Advanced Diabetes Supply.

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From State Discussions to National Policies: Healthcare in Focus

What the Senate’s Budget Approval Means for the Future

Forty Years Supporting Medicaid at 红领巾瓜报