This month鈥檚 Vital Viewpoints podcast features a special conversation with Jay Rosen, founder, president, and chairman of 杏吧视频 (HMA), as he reflects on the evolution of Medicaid and the 40th anniversary of HMA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 HMA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 HMA on June 13, 1985, the date HMA 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 60th 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HMA experts work with states and other organizations to harness these tools and stay current with these new initiatives.
This week, 杏吧视频 Information Services (HMAIS) 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 HMAIS 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 HMAIS 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 HMAIS report offers a timely and actionable reference point.
This report is just one component of the broader HMAIS 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 HMAIS 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 HMAIS team member聽below.
As states and stakeholders seek greater transparency and accountability in Medicaid, a new analysis from 杏吧视频 (HMA), 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), HMA 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.
HMA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.
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� 杏吧视频鈥� (HMA鈥檚) latest analysis offers insights into the potential impact of these changes. Drawing on Transformed Medicaid Statistical Information System (T-MSIS) data, HMA 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, HMA is uniquely positioned to help states, plans, and providers navigate the evolving federal landscape. For more information about HMA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 杏吧视频 (HMA), 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 杏吧视频 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 杏吧视频.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 杏吧视频 to Medicaid and CHIP eligible children. CMS and the US Department of Education launched a joint effort to expand school-based health 杏吧视频 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 杏吧视频 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 杏吧视频, 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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HMA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 杏吧视频 at the聽, October 14-16, 2025, in New Orleans, LA.聽
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 HMA (杏吧视频) 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.
In this week鈥檚 In Focus section, 杏吧视频 Information Services (HMAIS) 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.
HMAIS 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 杏吧视频 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 杏吧视频 (HMA). This report reflects the most recent data posted or obtained. HMA 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, HMAIS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
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HMA is home to experts who know the Medicaid managed care landscape at the federal and state levels. As the Medicaid landscape continues to evolve, HMAIS 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 HMAIS 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.
We recently sat down with Medicare experts from HMA 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� HMA 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.
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 HMA 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 杏吧视频, 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 杏吧视频 (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
杏吧视频 (HMA), 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HMA Conference in October 2025. To discuss how these developments will affect your organization, contact our featured expert below.
A recent case study highlighted how 杏吧视频 (HMA) 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 HMA 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, HMA 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 HMA, 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 HMA, 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. HMA helps organizations implement the processes, training, and technology necessary to close process gaps, improve cash flow, determine root causes for gaps, and reduce denials.
HMA 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.
On May 22, 2025, the US House of Representatives advanced a comprehensive legislative package that includes expansive changes to healthcare spending and tax policies. The , will be subject to further revision in the Senate 鈥� and potentially again in the House 鈥� before it can be sent to the president for his signature. If enacted, the legislation would have significant implications for the Medicaid program, including a nationwide work and community engagement requirement. The House-passed bill establishes a deadline of December 31, 2026, for implementation, but individual states could move earlier.
As state legislatures pass work requirement bills, governors consider executive actions, and Congress contemplates revisions to the Medicaid work mandate, vetting key implementation issues may significantly affect the direction of related policies. Even before implementation, states must test operations, enable systems, and establish connections to beneficiaries to reduce potential implementation missteps, inappropriate disenrollments, and litigation risks.
If the goal of Medicaid work requirement policies is to stimulate connections between health benefits and employment/workforce, building state and federal capacities to support these approaches is critical to effectuating that change. In the remainder of this article, 杏吧视频 (HMA), experts focus on the operational dynamics that need to be discussed, tested, and built as states begin introducing work and community engagement initiatives.
Federal Policies and Early State Actions on Work Requirements
The House bill would require all states to implement work and community engagement requirements for adults without dependents for at least 80 hours per month.[1] Employment, work programs, education, or community service (or a combination of those activities) would satisfy the requirement.
The work requirements in the House-passed legislation would apply only to individuals between the ages of 19 and 64 without dependents, and the following groups are exempted:
Women who are pregnant or entitled to postpartum medical assistance
Members of Tribes
Individuals who are medically frail (i.e., people who are blind, disabled, with chronic substance use disorder, has serious or complex medical conditions, or others as approved by the Secretary of the US Department of Health and Human Services)
Parents of dependent children or family caregivers to individuals with disabilities
Veterans
People who are participating in a drug or alcoholic treatment and rehabilitation program
Individuals who are incarcerated or have been released from incarceration in the past 90 days
In addition, individuals who already meet work requirements through other programs, such as Temporary Assistance for Needy Families (TANF) or the Supplemental Nutrition Assistance Program (SNAP), would be exempt. However, the House-passed version would make the eligibility verification and work requirements for SNAP more stringent and shift program costs to these states, which would affect cross-functional eligibility. The legislation also includes temporary hardship waivers for natural disasters and areas with an unemployment rate greater than 8 percent (150 percent of the national average).
Though the federal budget package has received a great deal of attention, at least 14 states already have moved forward (see Table 1) in advance of the current federal debate by passing laws and submitting work requirement demonstration requests to the Centers for Medicare & Medicaid Services (CMS).
Table 1. A Review of 2025 States鈥� Approaches to Work Requirements in Medicaid
Status
State
Population Criteria
Requirements
Exemptions/ Notes
Public Comment
Work Requirement Request Submitted
Arizona
Ages 19鈭�55
80 hours/month
Multiple exemptions; 5-year lifetime limit
Closed
Work Requirement Request Submitted
Arkansas
Ages 19鈭�64; covered by a qualified health plan (QHP)
Data matching to assess whether on track/not on track
No exemptions
Closed
Work Requirement Amendment Request Submitted
Georgia
Ages 19鈭�64; 0-100% FPL
80 hours/month
Already has approval but is requesting reporting be changed from monthly to annually and adding more qualifying activities
Federal comment period open through June 1, 2025
Work Requirement Request Submitted
Ohio
Ages 19鈭�54; expansion adults
Unspecified hours
Limited list of exemptions
Closed
Legislation Passed
Idaho
Ages 19鈭�64
20 hours/week required
Limited list of exemptions
鈥�
Legislation Passed
Indiana
Ages 19鈭�64; expansion adults
20 hours/week required
Limited list of exemptions
鈥�
Legislation Passed
Montana
Ages 19鈭�55
80 hours/month required
Multiple exemptions
鈥�
Ballot Initiative Passed
South Dakota
Expansion adults
鈥�
2024 ballot initiative asking voters for approval for state to impose work requirements for expansion adults passed
鈥�
Legislation Pending
North Carolina
鈥�
鈥�
Pursue requirements that are CMS approvable
鈥�
Work Requirement Request Draft
Iowa
Ages 19鈭�64; expansion adults
100 hours/month required
Limited list of exemptions Separate bill would end expansion if work requirements are withdrawn/ prohibited (80 hr./mo.)
Closed
Work Requirement Request Draft
Kentucky
Ages 19鈭�60; no dependents; enrolled more than 12 months
Connected to employment resources
Multiple exemptions
State comment period open through June 12, 2025
Work Requirement Request Draft
South Carolina
Ages 19鈭�64; 67%鈭�100% FPL
Specified activities (work specific is 80 hours/month)
Limiting participation to 11,400 individuals based upon available state funding
State comment period open through May 31, 2025
Work Requirement Request Draft
Utah
Expansion adults ages 19鈭�59
Register for work, complete an employment training assessment and assigned job training, and apply to jobs with at least 48 employers within 3 months of enrollment
Several exemptions, largely aligned with federal SNAP exemptions
State comment period open through May 22, 2025
Anticipated Waiver Request
Alabama
Non-expansion population
鈥�
Potential to resubmit previous work requirement demonstration request
鈥�
Key Questions to Guide State Policy Decisions
Considerable research and findings from previous Medicaid work requirement initiatives can help prepare policymakers to implement a potential new phase of Medicaid work requirement policies. Some previous findings include the high cost of administration relative to potential savings, the importance of systems that support foundational items like logging an enrollee鈥檚 compliance activities and exemptions, as well as developing an efficient appeals process. The Medicaid and CHIP Payment and Access Commission (MACPAC), General Accounting Office, National Institutes for Health, and multiple researchers have published assessments regarding previous experiences that could prove useful in policy making.
HMA experts have experience identifying key issues and considerations, analyzing options, and implementing critical issues and for state leaders and stakeholders who will be responsible for implementing work requirements. Several of these issues are described below and in more detail in the HMA blog, Building State Capacities for Medicaid Work and Community Engagement Requirements.
Exemptions, particularly medical frailty definitions and assessments. The federal government and states will need to identify individuals classified as 鈥渕edically frail鈥� and make them exempt from the mandates. Medically frail individuals include those with chronic, serious, or complex medical conditions. Various methods can be employed to identify these people.
Developing and streamlining systems and processes to promote continued coverage for eligible individuals. The Medicaid unwinding from the COVID public health emergency taught policymakers lessons about the complexities of Medicaid systems, patient engagement, and reliable methods of member outreach. State Workforce Commissions and Departments of Labor are clear partners, as they manage integrated eligibility systems and data-sharing agreements across programs like SNAP and TANF, which also serve many Medicaid participants. These and other partnerships will need further exploration.
Clinical and utilization data that promote eligibility assessment. Many, but not all, individuals with chronic diseases may be exempt from the requirements. Knowing the health status and chronic conditions of the populations affected and the conditions that qualify people for exemption are variables as implementation questions, like the definition of medically frail, are addressed.
Anticipated need for effective Medicaid managed care engagement in work requirements/community engagement initiatives. Approximately of Medicaid expansion enrollees are members of comprehensive managed care organizations (MCOs). States will need to review the scope of existing vendor contracts as well as determine the need for new 杏吧视频, roles, third-party reporting, oversight, and potential exemptions for emergencies. Work requirements can disrupt MCO risk pool stability and care coordination. MCOs have a financial incentive to drive down inappropriate disenrollments and are uniquely positioned to support state responsibilities, including maintenance of up-to-date contact information.
Measuring impact and adapting policies as needed. Dynamic metrics that provide actionable information to federal and state policy makers will support effective oversight and monitoring.
Connect with Us
HMA helps stakeholders鈥攊ncluding state agencies and their partners鈥攎anage the challenges of implementing new Medicaid or CHIP initiatives, with a focus on ensuring efficient integration and improvements in outcomes. Our teams are adept at developing materials for and supporting stakeholder engagement from design to implementation, which is a critical aspect for work and community engagement initiatives and other potential new eligibility and renewal requirements.
For support tracking federal and state level developments and enhancing your organization鈥檚 strategy and preparations for new Medicaid requirements, contact our featured experts below.
[1] U.S. Congress. House. One Big Beautiful Bill Act. H.R.1. 119th Cong., 1st sess. Introduced May 20, 2025. .
It is hard to keep abreast of the changes being made to the healthcare system at the Federal level, and how these changes will impact behavioral health (BH) 杏吧视频. The current reprioritization of funding by the Department of Health and Human Services (HHS) and the proposed changes in the budget bill pending in Congress will significantly reshape Medicaid and critical behavioral health programs. States and local organizations will need to sharpen their understanding of this new funding landscape, so they are able to focus on addressing critical needs for prevention and treatment of mental health and substance use disorders.
– HMA鈥檚 Behavioral Health Town Hall, Thursday, May 29 at 12 p.m.
With Federal funding levels in question, States and their stakeholders need to consider how they are funding BH initiatives. We鈥檒l address participant questions and topics we know are top of mind, for example:
What steps can states take to ensure sustainable funding for critical programs? Are states strategically utilizing their Medicaid programs to preserve BH specific program dollars for other purposes? What efficiencies and enabling technologies can organizations adopt to support their mission? How should state and local entities be thinking about the opioid settlement dollars to maximize support for 杏吧视频 and initiatives that face uncertain future financial support?
In addition, Congress is debating changes to Medicaid eligibility and funding policies that may result in shifts in key aspects of the program. States can start planning now for changes to their processes and for outreach and education campaigns that will be essential in supporting individuals with mental health and substance use disorder diagnoses. Payers should be planning for changes in enrollment and enrollee risk profiles while providers should expect changes in their payer mix and a need for enhanced collaboration with community organizations. Are there different models that can be pursued to effectively navigate these shifts? How will all of this uncertainty affect the BH workforce? Stakeholders need to be prepared to engage in downside risk arrangements, think about their patient/consumer engagement strategies and integrating digital BH tools that are the focus of the CMS Innovation Center agenda.
You probably have questions that we didn鈥檛 even list here. Here is your chance to ask them: Join HMA on Thursday, May 29 at 12 p.m. at a dynamic and interactive Behavioral Health Town Hall where HMA experts Heidi Arthur, Rachel Bembas, Allie Franklin, Teresa Garate, , and will be available to answer your questions live on a wide range of critical topics, including:
Federal policy, personnel, and funding changes;
Emerging strategies for addressing social determinants of health, substance use disorder and crisis coordination (including 988);
Leveraging cross-sector partnerships to build ecosystems of care across communities promoting coordination and collaboration;
Behavioral health revenue cycle management and alternative payment models; and
Innovations in addressing workforce shortages, integrated service delivery, digital mental health tools, and best practices for community mental health service delivery.
Whether you鈥檙e navigating regulations, searching for new funding, designing service delivery systems, or just trying to understand what happens next, this town hall is your chance to ask questions, share insights, and discuss real-world solutions with industry experts.
