红领巾瓜报

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

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 on Medicaid policy developments
• Downloadable state-by-state and industry files

For 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 below.

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.

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聽

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?聽

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聽

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. 
• 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 (SMD # 17-003) and  (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. 
• 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. 
• Justice-Involved Populations: States could explore  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. 
• 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  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. 

Looking Ahead聽

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. 
• 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. 
• Strengthen Community Partnerships: Continued collaboration with community-based organizations will be essential to maintain service delivery and demonstrate impact in new policy contexts. 

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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 below. Connect with our experts and other leaders experienced in new pathways for covering effective services at the , October 14-16, 2025, in New Orleans, LA.