October 15, 2025
On the Horizon: Contract Year 2027 Proposed Rule Will Provide Trump Administration First Opportunity to Reshape Medicare Advantage Program
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CMS Clarifies Grandfathering Rules for State Directed Payments
The Centers for Medicare & Medicaid Services (CMS) last month issued a to states providing preliminary guidance on (SDPs), which outlines new federal payment limits, clarifies grandfathering provisions, and signals significant changes ahead for Medicaid financing and policy. The letter is part of CMS鈥檚 implementation of Section 71116 of the Budget Reconciliation Act of 2025 (, P.L. 119-21)鈥攖he portion of the legislation that focuses on curbing SDP spending and reinforcing program integrity.
Though CMS describes the guidance as preliminary, it is the view of 红领巾瓜报 (红领巾瓜报) experts鈥攊ncluding former state officials, actuaries, and policy strategists鈥攖hat it signals directionally new policy for Medicaid agencies, managed care organizations (MCOs), and providers. CMS is working on two proposed SDP-related regulations, which are in the final stages of federal review. The preliminary guidance and forthcoming rules will likely reflect long-standing concerns for several years, even over shifting congressional control and multiple presidential administrations.
This article addresses key clarifications in the letter; the impact of the preliminary guidance on states, MCOs, and providers; and how the directive may influence Medicaid budgets, financing strategies, and future policy reforms.
Guidance Clarifies Timeframes for SDPs
Grandfathering Limited to Specific Rating Periods
CMS will allow states to maintain SDP spending amounts, up to the average commercial rate ceiling, that were in place for state fiscal year (SFY) 2025, calendar year (CY) 2025, and SFY 2026 rating periods. Nonetheless, new or expanded SDPs above Medicare equivalent levels in expansion states and 110 percent of Medicare in non-expansion states鈥攅ven those based on legislation passed in 2025鈥攁re ineligible for grandfathering if they apply to rating periods starting after July 4, 2025. These grandfathered spending amounts will need to phase down with rating periods beginning on or after January 1, 2028.
Preliminary Grandfathering Determinations
CMS has begun notifying states whether a preprint is 鈥渓ikely eligible鈥� for grandfathering. Because these are preliminary determinations, states should prepare for further review and revisions.
Submission Cutoff Date Clarified
In response to confusion around the May 1, 2025, submission deadline, CMS clarified that July 4, 2025, is the cutoff for grandfathering eligibility, provided the state fully completed the preprint. States may have rushed to meet a July 4 submission deadline and may have left questions on the preprint unanswered. In these instances, it is possible鈥攊f not likely鈥攖hat CMS will consider the application incomplete and thus ineligible for grandfathering. Since this is a developing area with limited precedent, states may still seek clarification or reconsideration, though CMS has not yet issued definitive guidance or a formal process for resolving these situations.
No Increases Allowed Until 2028
States are prohibited from increasing the total dollar amount of grandfathered SDPs鈥攖he 鈥渆xpected spend鈥濃�攗ntil January 1, 2028. This restriction limits flexibility for states to expand their programs and may require that they reassess their SDP strategies. For example, using percentage-based calculations tied to average commercial rates, will no longer capture year-to-year growth because of utilization or acuity changes.
10 Percent Phasedown Unaddressed
CMS has yet to provide official guidance on the 10 percent phasedown of SDPs. Stakeholders remain in a holding pattern, awaiting a forthcoming proposed rule that will clarify how reductions will be calculated.
What It Means for States and Healthcare Organizations
SDPs have become a critical tool for states to stabilize provider networks through increased Medicaid reimbursement. This authority will be significantly limited, and states will need to reduce many existing programs. Medicaid enrollment losses resulting from other Medicaid policy changes, such as work requirements and minimum semiannual redetermination, will likely compound the strain on provider payments.
Providers and states need to start planning for these losses in revenue now. Strategic planning for SDP sustainability and close monitoring of upcoming CMS rulemaking is essential.
While the guidance imposes constraints, it also opens the door for policy innovation. For example, some states may use this moment to reform Medicaid financing, streamline supplemental payments, and reconfigure provider incentives to better reflect quality and access, advancing value-based care goals and achieving total cost of care savings through efficiency and aligned incentives.
Connect with Us
红领巾瓜报 is uniquely positioned to support states, MCOs, and providers as they navigate the evolving landscape of Medicaid SDPs. Our team includes former state Medicaid directors, actuaries, and policy strategists with deep expertise in designing sustainable financing arrangements and guiding public engagement processes. We bring robust modeling capabilities to clients seeking to assess the financial impact of CMS鈥檚 new restrictions, including the 10 percent phasedown and interactions with provider tax limitations. Our experts are actively engaged with CMS and understand how to translate federal guidance into actionable strategies that align with state goals and operational realities.
Whether revising preprint submissions, evaluating quality frameworks, or rethinking provider incentives, 红领巾瓜报 delivers the technical and policy insight needed to move forward with confidence.
For questions about the federal guidance and considerations for your organization, contact our experts below.
Helping a Medicare Advantage Plan Identify Gaps in Part D Benefit Quality
THE CLIENT
The client for this project is a health plan that provides both traditional Medicare Advantage (MA) plans and those that address chronic conditions and social determinants of health, to reduce healthcare disparities among historically underserved populations in the central and eastern United States. Their plans integrate Medicare Part A and Part B benefits with Part D prescription drug coverage, along with providing robust extra benefits.
BACKGROUND
MA Plans are assuming bigger risk in their Part D benefit spending than in previous years due to recent changes in MA rules. Audits of the program, a requirement to participate in MA, will mean that there are increased compliance and operational risks in how plans go about serving their members with the Part D benefit. As the regulatory environment changes, guarantees in pharmacy benefit manager (PBM) contracts need solidifying, and will require rigorous oversight by the plans to reduce risk. MA plans need to ensure alignment and collaboration across their organizations and with vendors to optimize initiatives in quality and Stars. It is also important to establish alignment and engagement early within the yearly bid cycle. T he client engaged 红领巾瓜报 due to our diverse expertise in Part D plans including operations, PBM and vendor oversight, health plan leadership, Stars and quality programs, financial and actuarial analysis, and compliance.
APPROACH
红领巾瓜报 performed an assessment to analyze and measure the effectiveness of Part D operations, including a comprehensive review of the plan鈥檚 Part D benefit, and identified gaps in Part D policies, procedures and staffing. The effort also documented operational efficiencies, quality improvement recommendations and opportunities for the client to increase their Part D Star ratings. 红领巾瓜报 identified areas of improvement and provided actionable insights to guide future decisions. The assessment utilized a combination of data, documents and interviews to cover various dimensions such as performance, compliance, effective oversight, and collaboration.
RESULTS
The final report recommended a series of organizational changes and quality improvements to enable the client to optimize their Part D operations. Recommendations were made in the following areas:
- Policies and procedures: Identified gaps in the client鈥檚 internal policies and procedures, and provided recommendations to cure the deficiencies, including the development of desk-level guides.
- Comprehensive oversight: Identified oversight gaps in vendor management and provided recommendations to improve.
- Part D strategic leadership & proposed new staffing model: 红领巾瓜报 drafted a best-in-class organization and staffing plan that permits the client to scale up with a delineated staffing structure designed to ensure optimal oversight of Part D quality.
- Collaboration: Identified gaps in PBM contracts and provided recommendations for negotiating and bolstering account management. The new plan also recommends expanding the Part D team鈥檚 role and involvement with provider engagement teams in order to increase overall CAHPS results to improve Star ratings.
- Financial/actuarial analysis: Identified changing regulatory reporting (Direct and Indirect Remuneration) and capturing required information related to Manufacturer Discount Program (MDP) and Medicare Prescription Payment Plan (M3P).
HOW 红领巾瓜报 CAN HELP YOUR ORGANIZATION
If your organization wants to undertake a similar review of your Part D organization, we encourage you to engage with your teams to review and prioritize findings and recommendations to build out best practices and best in class plan operations. 红领巾瓜报 can help you develop a plan and guide you through the processes, identify issues that might not otherwise be identified internally, and provide recommendations for ways to optimize your efforts. Our team brings together expertise in Medicare Advantage, Part D, pharmacy, quality and accreditation programs, on the ground leadership experience in health plans, financial and actuarial expertise, with in-depth insider knowledge from our work in states across the country. Contact us to learn more about how 红领巾瓜报 can help.
Turning HR 1 Medicaid Work Requirements into Workforce Development Opportunities: Lessons from 红领巾瓜报鈥檚 Recent Webinar
As State Medicaid Agencies prepare for the operational and policy shifts introduced by HR 1鈥檚 Medicaid Work Requirements, the stakes could not be higher. While the intent of these provisions is to encourage workforce participation, their real-world implementation risks leaving behind those who already face systemic barriers鈥攑articularly rural communities, people of color, and individuals with chronic conditions.
In a recent 红领巾瓜报 webinar, 鈥�Work That Works: Creating Sustainable Employment Pathways for Medicaid-Enrolled Communities,鈥� Shannon Joseph, Senior Consultant and Workforce Development expert at 红领巾瓜报 (红领巾瓜报), and Dr. Alicia Johnson, Managing Principal and strategic advisor on Medicaid transformation at 红领巾瓜报, led a dynamic conversation for state leaders and Medicaid stakeholders. Their core message was clear: with thoughtful design, states can transform work requirements from punitive compliance metrics into powerful tools for workforce development and economic mobility.
The Policy Landscape: HR 1 and State Readiness
HR 1 establishes new federal standards that require states to verify that certain Medicaid enrollees are meeting minimum work or community engagement hours as a condition of continued coverage. While exemptions exist for specific populations, the administrative lift, data infrastructure, and interagency coordination needed to operationalize these requirements are significant.
Historically, states that have experimented with work requirements, such as Arkansas, Kentucky, and New Hampshire, have seen coverage losses not because beneficiaries were unwilling to comply, but because systems were unprepared to support them. Barriers such as limited broadband access, low literacy rates, unstable employment markets, and health disparities disproportionately impacted rural residents and people of color.
Key Challenge #1: Avoiding Disproportionate Impact on Vulnerable Communities
One of the most pressing concerns is that work requirements may exacerbate disproportionate access. In rural communities, jobs that meet hour thresholds are often scarce, transportation options are limited, and childcare access is inconsistent. For people of color, historic and systemic barriers to employment persist, from lack of work credentials, to lack of tailored workforce programs. For individuals with chronic conditions or disabilities not formally classified as exempt, participation can be difficult or intermittent.
Dr. Johnson emphasized the importance of a community-based approach that leverages local resources and local social safety nets to increase participation and outcomes but developing targeted strategies that address the varying needs of the Medicaid community.
鈥淲e cannot simply apply a one-size-fits-all model. States must design implementation strategies that close population health gaps and overcome the social structural gaps in their systems, not widen them. Social Determinants of Health are not just passive background factors; they actively shape people’s ability to achieve and maintain good health and life outcomes.鈥�
Best Practice: Conduct community-level impact assessments prior to implementation to identify geographic, demographic, and health-related disparities. Use this data to tailor outreach, exemptions, and workforce partnerships accordingly.
Key Challenge #2: Shifting from Compliance to Workforce Integration
Too often, states have approached work requirements as a compliance exercise鈥攖racking hours, verifying exemptions, and ensuring federal reporting鈥攚ithout connecting to broader workforce development ecosystems. This narrow focus misses the opportunity to align Medicaid with labor, education, and economic development systems.
Shannon Joseph pointed to states like Louisiana, where cross-agency partnerships have begun to link Medicaid beneficiaries to workforce boards, training programs, and supportive services, 鈥淭he most successful models are those where Medicaid is not working alone. When states braid resources and align objectives, work requirements can become a springboard for meaningful employment.鈥�
Best Practice: Develop formal MOUs between Medicaid agencies, state workforce boards, Departments of Labor, and community colleges to share data, coordinate referrals, and leverage federal funding streams like SNAP E&T and WIOA.
Key Challenge #3: Building Administrative Infrastructure and Data Systems
Another central theme of the webinar was the need for robust data infrastructure. Many states lack integrated eligibility systems capable of tracking employment hours, exemptions, and participation across multiple programs. Without this integration, states risk errors, delays, and unnecessary disenrollments.
红领巾瓜报 highlighted the value of interoperable data systems and FHIR-based architecture that allow Medicaid agencies to exchange information with workforce agencies in real time. Digital equity must also be part of the conversation, especially in rural areas where broadband access remains a challenge.
Best Practice: Prioritize system modernization investments and interoperability pilots to build the technical backbone for equitable and efficient implementation such as the one in Georgia launched for the Pathways program.
Key Challenge #4: Partnering with Communities for Culturally Responsive Implementation
Dr. Johnson underscored that states cannot achieve equitable implementation from the statehouse alone. Partnerships with community-based organizations (CBOs), faith institutions, and local employers are critical to reaching populations who may be distrustful of government systems or unaware of new requirements.
Community partners are trusted messengers. They can bridge gaps in communication, help with navigation, and ensure that people understand both their obligations and opportunities,
– Dr. Alicia Johnson
Best Practice: Create local implementation collaboratives that include Medicaid staff, CBOs, workforce entities, and providers to co-design outreach and support strategies tailored to community needs.
Key Challenge #5: Aligning Metrics with Meaningful Outcomes
Finally, both speakers cautioned against relying solely on compliance metrics (e.g., hours reported, exemptions processed) to evaluate success. Instead, states should track workforce and health outcomes, such as employment stability, income growth, retention in coverage, and health status improvements. Shannon Joseph noted, 鈥淚f our only measure of success is whether someone uploads their work hours, we鈥檝e missed the point. The goal should be sustainable pathways to economic mobility and improved health.鈥�
Best Practice: Develop a multi-dimensional performance dashboard that blends compliance data with workforce outcomes, health equity indicators, and beneficiary experience measures.
Solutions & Strategies for States: A Roadmap
Drawing from the discussion, 红领巾瓜报 outlined a set of strategic recommendations for state Medicaid agencies:
- Conduct Equity Impact Assessments: Identify populations at risk of adverse impacts and tailor exemptions and support services accordingly.
- Align with Workforce Systems: Establish data-sharing agreements and coordinated referral pathways with workforce boards and community colleges.
- Invest in Data Modernization: Build interoperable systems to reduce administrative burden and ensure real-time verification.
- Engage Trusted Community Partners: Leverage CBOs and local institutions for outreach, navigation, and culturally responsive engagement.
- Shift Metrics to Outcomes: Measure employment stability, economic mobility, and health outcomes鈥攏ot just compliance.
- Pilot, Learn, Scale: Start with targeted pilots in high-need communities, evaluate rigorously, and scale strategies that work.
红领巾瓜报鈥檚 Role: Strategic Partner to States Developing Public/Private Partnerships to Build Genuine Pipelines of Work
红领巾瓜报 has deep expertise helping states design, implement, and evaluate Medicaid work requirement policies in ways that are operationally sound, legally defensible, and Medicaid Member-centered. Our team has supported states in:
- Conducting 1115 waiver design and evaluation,
- Integrating Medicaid and workforce systems,
- Designing targeted outreach strategies for rural and underserved populations,
- Implementing digital modernization projects, and
- Developing performance dashboards that focus on outcomes.
红领巾瓜报 brings both policy acumen and on-the-ground implementation experience, enabling states to navigate complex regulatory landscapes while advancing population health and real-world outcomes.
Learn More & Partner with 红领巾瓜报
If you missed the live webinar, you can watch the replay here.
You might also be interested in attending the 红领巾瓜报 National conference, .in New Orleans October 14-16, for our session on Making Medicaid Work Requirements Work, where we will draw on lessons from states like Georgia. Panelists will explore what to watch for in program design, including strategies to support workforce readiness, reduce administrative burden, and maintain access to care. Speakers include:
- Tonya Moore, Associate Principal, 红领巾瓜报
- Chief Health Policy Officer, Georgia Department of Community Health
- Medicaid Reforms Project Director, Utah Department of Health and Human Services
- Moderated by , Managing Principal, 红领巾瓜报
Online registration closes October 10, but if you act now, you can use the code FLASH25 for up to $475 off the standard registration fee for the full conference.
For more information about how 红领巾瓜报 can support your state in strategic planning, operational design, impact analysis, and workforce integration, please contact our experts below.
红领巾瓜报 Enrollment Update: Medicaid Managed Care Organizations See Drop in Enrollment in 2Q25
This week, our second In Focus provides insights into Medicaid managed care enrollment in the second quarter of 2025. 红领巾瓜报 Information Services (红领巾瓜报IS) obtained and analyzed monthly Medicaid enrollment data in 30 states,[1] offering a reliable baseline and timely view of the immediate impact of the current policy landscape as new federal policies take effect.
This analysis presents a snapshot of 红领巾瓜报IS鈥檚 comprehensive detailed quarterly Medicaid managed care enrollment report (available by subscription), which includes plan-level information for nearly 300 health plans in 41 states, corporate ownership, for-profit versus not-for-profit status, and similar information regarding publicly traded plans. Table 1 provides a sample of enrollment trends, representing 57 million Medicaid managed care enrollees of a total of 66 million Medicaid managed care enrollees nationwide. Data reporting periods and program coverage vary by state, so figures may not be fully comparable.
Key Insights from 2Q25 Data
The 30 states included in our review have released monthly Medicaid managed care enrollment data鈥攙ia a public website or in response to a public records request from 红领巾瓜报IS鈥攆or April through June of 2025. This report reflects the most recent data posted or obtained from states. 红领巾瓜报 has made the following observations regarding the enrollment data:
- Year-over-year decline. As of June 2025, in the 30 states reviewed, Medicaid managed care enrollment declined by 1.6 million members year-over-year, a 2.7 percent drop from June 2024.
- Widespread decreases. Of the 30 states, 27 experienced enrollment declines in June 2025 compared to June 2024. Oregon and the District of Columbia saw modest growth, while California remained flat (Table 1).
- Sharpest contractions. Arizona and Maryland reported double-digit percentage drops in enrollment in June 2025 (Table 1), underscoring the uneven impact of redeterminations and eligibility policy changes.
- Difference among expansion and non-expansion states. Among the 24 states included in the analysis that expanded Medicaid, enrollment fell by 1.2 million鈥攁 2.5 percent drop鈥攖o 49.2 million. The six non-expansion states saw a steeper proportional decline of 4.2 percent, to a total of 8 million enrollees.
Table 1. 2Q25 Monthly MCO Enrollment by State, April鈥揓une 2025
The data in Table 1 should be viewed as a sampling of enrollment trends across these states rather than as a comprehensive comparison, which cannot be established based solely on publicly available monthly enrollment data. It is also important to note the limitations of the data presented. For example, not all states report data at the same time during the month, resulting in a range of snapshots from the beginning to the end of the month. Second, in some instances, the data cover all Medicaid managed care programs, while in others they reflect only a subset of the broader managed Medicaid population, depending on what data is publicly available.
Market Share and Plan Dynamics
红领巾瓜报IS鈥檚 report includes plan-level details for nearly 300 plans, covering corporate ownership, program participation, and tax status. As of June 2025, Centene continues to lead the national Medicaid managed care market with 17.8 percent share, followed by Elevance (10.4 percent), United (8.6 percent), and Molina (6.2 percent; see Table 2).
Table 2. National Medicaid Managed Care Market Share by Number of Beneficiaries for a Sample of Publicly Traded Plans, June 2025
What to Watch
The OBBBA (P.L. 119-21) calls for significant changes to Medicaid eligibility and enrollment policies, including work requirements and more frequent eligibility redeterminations. indicate that Medicaid and Children鈥檚 Health Insurance Program enrollment could decline by up to 7.5 million people by 2034. In addition, the Centers for Medicare & Medicaid Services (CMS) has announced that it will not approve or extend waivers for multi-year continuous eligibility for adults or children.
As these policies are implemented, state governments and healthcare organizations should prepare for increased administrative complexity, potential coverage disruptions, and the resulting effect on MCO revenue and value-based care arrangements.
Connect with Us
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, including enrollment data, quarterly by-plan and by-state enrollment reports, financials, Medicaid demonstration and Rural Health Transformation program tracking, and a robust library of publicly available Medicaid-related documents. 红领巾瓜报IS combines publicly available information with 红领巾瓜报 expert insights on the structure of Medicaid in each state, as well as our comprehensive, proprietary State Medicaid Overviews.
For questions about the 红领巾瓜报IS enrollment report and information about the 红领巾瓜报IS subscription, contact our experts below.
The Rural Health Transformation Program: Options to Address the Maternity Care Crisis
This article is part of 红领巾瓜报鈥檚 Weekly Roundup series on the RHT Program, highlighting key opportunities and considerations for states and healthcare organizations.
The Centers for Medicare & Medicaid Services (CMS) recently launched the , which is intended to help states reimagine and rebuild rural healthcare delivery. As outlined in our earlier In Focus article, Rural Health Transformation Program Represents a One-Time Opportunity to Reshape Rural Care, this historic $50 billion federal investment provides states with flexibility to design and implement strategies that improve access, quality, and outcomes in rural communities.
As states develop their RHT applications, they can consider a range of approaches to address persistent gaps in care particularly in maternal health, where rural residents often face limited access to local services. A range of solutions is needed to expand and stabilize access to maternal care, given the shortage of close-to-home birthing care. This article explains one such option: investing in midwifery.
Maternity Care in Rural Communities
Maternity Care Deserts Driving a National Maternal Health Crisis
Families in rural communities鈥攁nd some urban communities鈥攆ace 鈥�,鈥� meaning they do not have access to a birthing facility or obstetric clinician. are another reality in rural communities, with additional closures projected. Even in larger communities where a hospital is open, obstetric services could be shut down. These deserts are a key driver of the national maternal health crisis. In , the March of Dimes (MOD) reported that 鈥渢wo in three maternity care deserts are rural counties (61.5%)鈥� and that 鈥渃ounties with low access to telehealth were 30% more likely to be maternity care deserts.鈥�
Midwifery as an Option for Rural Communities
are trained healthcare professionals who specialize in supporting women through typical, low-risk pregnancies. They provide care during pregnancy, labor, and the postpartum period. There are several types of midwives, each with different training and credentials. States determine which types of midwives may practice and under what conditions.
Expanding the midwifery workforce can be part of a broader strategy to improve access, particularly in rural areas where hospitals and obstetric providers are scarce. In some places, midwives already serve as a critical access point for maternal care in rural communities, with midwives attending to .
The Rural Health Transformation Program Can Help Address the Crisis
The strategic goals of the RHT, as outlined in the CMS application materials and Notice of Funding Opportunity (NOFO), are designed to guide states in transforming rural healthcare delivery. These goals are grounded in the statutorily approved uses of funds and must be explicitly addressed in each state鈥檚 RHT application.
Midwives have long contributed to expanding access to maternal care across diverse settings. For example, midwives can support preventive health by providing prenatal and postpartum care in community settings. Their integration into rural care teams may help sustain where hospitals and obstetric providers are limited. States may also consider workforce development strategies, such as expanding midwifery training and retention programs, and innovative care models鈥攊ncluding hub-and-spoke systems鈥攖hat incorporate midwives to improve coordination and person-centered experiences (Figure 1).
According to Ginger Breedlove, PhD, CNM, founder of , one of the nation鈥檚 leading , 鈥渕idwifery aligns with all strategic goals of the RHT program.鈥�
States may consider midwifery as one of many options to help build sustainable, community-centered maternity care systems that reflect the RHT Program鈥檚 vision for rural health transformation.
Figure 1. Midwifery Alignment with RHT Strategic Goals
| RHT Strategic Goals | Midwifery Alignment |
| Make Rural America Healthy Again | Midwives support preventive, community-based maternal care and contribute to , such as higher rates of spontaneous vaginal delivery and breastfeeding and lower rates of preterm birth and low birthweight. |
| Sustainable Access | Midwives can serve as consistent local access points for maternity care, particularly in areas with limited obstetric services. |
| Workforce Development | Midwifery workforce initiatives of high-skilled providers practicing at the top of their license, aligning with goals to strengthen recruitment, retention, and licensure flexibility in rural areas. |
| Innovative Care | Midwives can be integrated into flexible care arrangements鈥攈ub-and-spoke or CMS鈥� model鈥攁longside doulas and community health workers, improving care coordination and patient experience. |
| Tech Innovation | Midwives can leverage telehealth, remote monitoring, and data-sharing and digital care platforms to extend the reach of maternal care in rural communities and connect patients to the broader maternal care system, including remote specialist consultations. Tech innovations ensure that women receive the appropriate level of care for their risk and needs. |
Connect with Us
红领巾瓜报 (红领巾瓜报) has deep expertise in supporting states and healthcare organizations across all phases of rural health transformation. Our team can assist with strategy and writing grants, program design, and implementation plans tailored to specific state goals and approaches. Whether states choose to explore midwifery or other care delivery models, 红领巾瓜报 can help define the approach that best fits the needs of rural communities and support organizations in transforming workflows and operations, implementing new initiatives, and enhancing the systems and IT enhancements that sustains them.
红领巾瓜报 brings together experts in maternal health, finance, rural communities, and delivery systems, contact our experts below.
October 1, 2025
The Rural Health Transformation Program: Options to Address the Maternity Care Crisis
Coding, Coverage, and Reimbursement: Considerations for Women’s Health Access
Persistent gaps in women’s health research, funding, clinical outcomes and access are increasingly well-studied, however less emphasis is placed on the role of coding, coverage, and reimbursement and whether male or female gaps exist in each of these key market access domains. The paper, Coding, Coverage and Reimbursement: Considerations for Women鈥檚 Health Access, examines challenges in these areas and offers recommendations to increase awareness, establish evaluative processes, and collaborative action to achieve incremental policy changes that can have a significant impact over time.
Navigating the Government Shutdown: Safeguarding the RHT and 鈥淢ake Rural America Healthy Again鈥� Initiatives
As of October 1, 2025, federal budget negotiations have led to a temporary government shutdown, prompting healthcare leaders to monitor potential impacts on programs administered by the Centers for Medicare & Medicaid Services (CMS). While federal agencies have contingency plans in place, to date CMS has not announced any potential impacts, including to the timelines for the application and award dates for the Rural Health Transformation (RHT) Program.
State governments and healthcare leaders should continue to develop and prepare to submit their applications for the RHT program, which provides a significant opportunity to revitalize rural healthcare infrastructure through strategic investments in access, workforce, innovation, and technology.
Strategies for States to Efficiently Develop Winning Applications
To maintain momentum and optimize their resources during this period of uncertainty in federal government funding and operations:
1. Strengthen Internal Coordination
- Establish cross-agency working groups to manage RHT program planning and execution
- Use internal policy experts to interpret the Notice of Funding Opportunity (NOFO) guidance and align initiatives with CMS priorities
2. Leverage Existing Data and Evidence
- Use state-level health data to identify high-impact areas for investment
- Prioritize initiatives that align with the RHT program鈥檚 five strategic goals:
- Prevention and chronic disease management
- Sustainable access
- Workforce development
- Innovative care models
- Technology innovation
3. Utilize Project Management Tools
To support strategic planning and initiative tracking, 红领巾瓜报 (红领巾瓜报) is offering a free RHT Project Management Tool. This resource helps states:
- Organize and manage initiative development
- Cross-reference projects with NOFO categories
- Track progress and performance metrics
- Facilitate collaboration across stakeholders
Access the RHT Project Management Tool from 红领巾瓜报:
Complete the form to download
the RHT Project Management Tool
Engage with CMS Resources Proactively
States and their partners can continue to refer to key CMS resources:
States can also submit questions to [email protected].
Final Thoughts
While the government shutdown presents challenges for many federal programs, it remains unclear whether there will be any direct impact on CMS鈥檚 engagement with states regarding the Rural Health Transformation Program. Regardless of federal circumstances, this moment highlights the value of state-level leadership and innovation. By leveraging tools like 红领巾瓜报鈥檚 project management platform and aligning with CMS鈥檚 strategic goals, states can continue advancing rural health transformation and position themselves for success, even in uncertain times.
Big changes ahead for ACA marketplace plan enrollment and premiums
With changes to ACA subsidies included in H.R. 1, the healthcare industry could face the biggest change since the passage of the ACA.
Health insurance coverage is likely to be disrupted by changes in ACA marketplace financing, particularly due to the projected reductions in ACA subsidies, as well as the impacts of eligibility and enrollment changes in Medicaid. At a recent 红领巾瓜报 webinar, our ACA marketplace experts detailed a number of challenges that health plans participating in the ACA will face in the coming months and years due to these new policies, and some of the thinking behind ways that plans can take action now while Congress debates whether to extend any of the subsidies.
The webinar touched on areas including:
- How the recent policy and funding changes will affect strategic planning, longer term goals, and 2027 plan year rate setting;
- Actuarial analysis/rate setting/risk adjustment insights from 红领巾瓜报鈥檚 actuaries;
- Changes likely to occur in plan and marketplace operations in both state exchanges and on the healthcare.gov federal platform;
- The importance of effective communications to avoid creating consumer confusion, and ideas on stakeholder engagement strategies;
- And, how all of this will impact workforce/access to care, and the likelihood of changes to in-network care
The ACA marketplace is bracing for impacts for the 2026 plan year, depending upon potential Congressional actions in the remaining months of 2025. In May 2025, CMS put out a rate filing bulletin for plan year 2026 that gave technical directions for submissions and urging states and issuers to be prepared to react to Congressional action. This was a signal that the administration anticipated potential policy changes between May when they put this out and the rate filing window in the fall.
This is reminiscent of the ACA changes that happened in 2017, when there was litigation around cost-sharing reduction (CSR) subsidies that needed to be appropriated. (This was during the 鈥渞epeal and replace鈥� debate in Congress, in that same July-August timeframe.) When repeal efforts failed in Congress, the Administration decided not to pay CSRs, necessitating a bipartisan agreement to address this new financing issue. Changes to CSRs were dropped from this year鈥檚 law but could be addressed before the end of the year in upcoming appropriations bills in Congress.
鈥淎CA plan strategies need to change to ensure that they are considering different outcomes in the market composition and competitor changes to pricing strategies. Expect more policy changes and potential for market churn, making pricing difficult in 2027 given the limited information on what happens in 2026.鈥� – Michelle Anderson
A recent Wakely report analyzing the early draft of HR 1 before passage () details estimated reductions in the individual market enrollment with potential reduction anywhere from 47 to 57% or 11.2 to 13.6 million enrollment enrollees by 2028. The attrition estimates include the loss of both federally subsidized individuals, as well as the unsubsidized due to premium increases. This paper was quoted in a recent NY Times piece,
鈥淐hanges are coming for Healthcare.gov and state marketplace consumers in 2026. The (likely) expiring enhanced premium tax credits, as well as provisions within HR 1 and the Marketplace Integrity and Affordability rule will all be rolled out to marketplace consumers this coming Open Enrollment. In addition to the marketplaces, state departments of insurance, issuers, enrollment assistance professionals, and other stakeholders will play a critical role in helping consumers navigate the coming eligibility and affordability changes.鈥� – Zach Sherman
Impacted marketplace consumers need to be made aware of these coming changes. States and issuers should undertake a broad, aggressive, and coordinated communication effort around the overall rate changes. Ensuring consumers understand how their net premium is changing due to expiring enhanced premium tax credits as well as the other operational changes will be crucial to their ability to stay covered. We expect to see considerable consumer plan switching this coming open enrollment as a result. Some consumers may need to buy-down to silver or bronze plans to be able to afford to maintain their coverage. Marketplaces will need to ramp up customer service and navigation support. States with reinsurance programs or premium subsidies should consider ramping up funding to mitigate the affordability gaps that are likely to occur.
鈥淚t’s really important for folks in the ACA marketplace community to be active when it comes to policymaking and advocacy.鈥�&苍产蝉辫; 鈥� Liz Wroe
These issues are part of the government funding debates underway right now as a government shutdown looms. Depending upon the outcome with the September funding deadline, or the possibility of a supplemental funding bill this year, these ACA marketplace issues could be addressed in several sets of negotiations. Now is the time to talk to your state officials, insurance commissioners, associations and contacts in the Federal government to ensure they have a good understanding of how these ACA marketplace changes will impact coverage in your state.
To hear the full discussion, you can find the replay and materials for the ACA webinar here, and download the full Wakely paper at .