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Solutions

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

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HMA Solutions

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

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

Communities Face Converging Fiscal and Service Pressures

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

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

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

Supporting the Leaders Closest to Community Impact

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

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

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

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

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

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

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

HMA Can Help Leaders Move from Uncertainty to Action

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

Assess Policy and Fiscal Impact

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

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

Prepare Medicaid and Eligibility Operations

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

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

Evaluate Safety-Net and Provider Vulnerability

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

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

Strengthen Community Infrastructure

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

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

Build Cross-Sector Response Plans

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

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

Redesign Human Services and Community Systems

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

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

Develop Sustainable Financing Strategies

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

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

Use Data to Target Resources and Track Results

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

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

Questions Leaders Should Be Asking Now

  • Who is most likely to lose coverage or encounter barriers maintaining eligibility?
  • Where will the effects appear first across emergency care, behavioral health, maternity care, rural access, housing, public health, and human services?
  • Which providers and community organizations have the least capacity to absorb additional uncompensated work?
  • How could federal and state decisions shift costs to counties, municipalities, providers, and families?
  • What data will show where risks are concentrated and whether the response is working?
  • What can be protected, redesigned, financed differently, or delivered through stronger regional and cross-sector partnerships?

HMA Has the Right Team

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

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

Blog

HMA Conference to Open with State Leaders’ Insights on Healthcare Policy and Program Pressures

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

Navigating a New Federal Landscape 

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

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

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

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

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

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

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

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

Register today to join the conversation.

Podcasts

Why Is Medicaid Program Integrity More Than Fighting Fraud?

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

Blog

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

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

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

What Is Changing?

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

What This Will Mean?

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

New Questions Stakeholders Will Need to Answer

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

Supporting Next Steps

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

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

Actuarial Analysis

Market Analysis and Strategic Planning

Financial Modeling

Operational Planning and Implementation Support

Research and Evaluation

Contract Review and Negotiation Support

Business Analytics

Clinical and Health-Related Social Needs Service Model Development

Quality Measurement and Accreditation Support

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

Frequently Asked Questions

What is changing in maternity care reimbursement in 2027?

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

Who will be affected by the maternity care coding changes?

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

What should organizations do first?

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

Blog

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

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

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

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

What We Learned at MESC 

Modernization Is Becoming an Ongoing Operating Capability 

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

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

Modularity Now Means Managing the Connections Between Systems 

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

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

Federal Requirements Are Shaping the Modernization Agenda 

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

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

Eligibility Changes Require New Data and Operational Models 

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

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

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

AI Means Governed Support for Real Medicaid Work 

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

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

How HMA Can Help 

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

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

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

Contact HMA experts to get your questions answered. 

Blog

Federal and State Medicaid Leaders and VA Assistant Secretary to Discuss Public Healthcare Transformation at HMA Conference

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Health Management Associates (HMA) is pleased to announce that Caprice Knapp, PhD, Principal Deputy for the Center for Medicaid & CHIP Services, will participate in two sessions at HMA’s US Healthcare 2026: Signals, Signs & Flashing Lights conference, October 5-7, 2026. in New Orleans, LA. As states, plans, providers, and community partners prepare for a new era in Medicaid and other public healthcare programs, these conversations will focus on practical solutions, implementation realities, and the partnerships needed to move from policy change to sustainable results. 

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

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

Medicaid Policy Changes and Their Ripple Effects Across Healthcare 

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

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

  • Ann Jensen, Administrator, Nevada Medicaid Nevada Health Authority 
  • Cheryl J. Roberts, JD, Senior Advisor; Former Medicaid Director, Virginia Department of Medical Assistance Services 
  • Ryan Schwarz, MD, MBA, Medicaid Director & Assistant Secretary for MassHealth, Massachusetts Executive Office of Health & Human Services 
  • Scott Partika, Director, Ohio Department of Medicaid 

VA Community Care and NextGen Healthcare Innovation for Veterans 

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

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

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

HMA Weekly Roundup

September 2, 2026

Federal and State Medicaid Leaders and VA Assistant Secretary to Discuss Public Healthcare Transformation at HMA Conference

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Brief & Report

Closing the Care Continuity Gap in Substance Use Disorder

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

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

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

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

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Key findings

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

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

Why this matters

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

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

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

What this brief examines

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

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

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

Implications for health plans

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

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

Frequently asked questions

What is the care continuity gap in SUD?

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

What is the 3.64:1 finding?

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

What population was studied?

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

Does the report recommend reducing emergency or detoxification care?

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

Is the estimated $2,071 opportunity guaranteed savings?

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

Who produced the analysis?

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

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

Blog

Rural Health Transformation Program: The Window to Build Sustainable Change Is Now

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The Rural Health Transformation Program (RHTP) is entering a critical implementation phase. As states begin deploying historic federal investments in rural healthcare, attention is shifting from grant awards to execution, performance measurement, and sustainability. Recent Centers for Medicare & Medicaid Services (CMS) approvals of additional state RHTP initiatives, coupled with upcoming reporting requirements and future funding determinations, are heightening the focus on how states, providers, technology companies, and community organizations will demonstrate progress and long-term value. 

This article examines emerging themes in RHTP implementation, including the growing emphasis on chronic disease prevention, technology-enabled care delivery, performance measurement, and sustainability planning. Health Management Associates’s (HMA) multidisciplinary teams also are available to support organizations seeking to maximize the long-term value of RHTP investments beyond the initial federal funding period.

Common Priorities Emerging in State Rural Health Transformation Program Plans 

State RHTP strategies vary considerably; however, state applications share several priorities aligned with CMS’s funding priorities. Technology modernization, telehealth, workforce development, chronic disease management, behavioral health, maternal health, and care coordination appear throughout state proposals. Through its work with states, providers, and rural communities, Health Management Associates (HMA) has identified another common thread across applications: rural health challenges are deeply interconnected.  

Providers struggling with workforce shortages are often serving populations with higher rates of chronic disease. Communities facing limited specialty access frequently experience transportation barriers and gaps in digital connectivity. Behavioral health needs intersect with physical health conditions, maternal health outcomes, and emergency department utilization. States are responding by increasing their focus on and pursuit of broader transformation strategies. 

During a recent HMA webinar, RHTP Beyond the Grant Approval: Building Sustainable Rural Transformation, speakers highlighted one of the most important directional lessons emerging from early RHTP implementation: technology, workforce, access, care delivery, and prevention strategies must be designed as mutually reinforcing investments and not as siloed initiatives. 

Chronic Disease Prevention and Management Is Central to Rural Health Transformation 

Our work with states and their RHTP partners indicates that chronic disease prevention, monitoring, and management have become a central organizing principle for many RHTP investments. Technology modernization, telehealth expansion, workforce initiatives, behavioral health integration, and community-based care models are frequently being positioned as complementary strategies to improve population health and address the conditions that drive preventable morbidity, mortality, and healthcare costs in rural communities. This includes ensuring rural residents receive care earlier, stay connected and engaged in their care longer, and avoid preventable deterioration in health status. 

As HMA experts discussed during the recent webinar, this represents an important shift. Historically, many healthcare systems have been structured around treating disease after complications emerge. RHTP creates an opportunity to invest in more effective models, including those that can identify risk sooner, improve follow-up with patients, and strengthen connections between patients and care teams. 

Telehealth, Data Platforms, and AI Support in Rural Health Transformation 

Technology appears throughout nearly every state strategy and is often viewed as one of the most visible components of RHTP. HMA webinar speakers emphasized that technology is a vital enabling capability in RHTP initiatives.

Technology alone is unlikely to produce meaningful transformation. 

HMA is working with states and their partners on strategic approaches to technology adoption. For example, states, providers, care teams, and patients should consider technology initiatives that can strengthen care models, extend workforce capacity, improve coordination and collaboration in support of population health, and generate actionable insights. 

Sustainability Planning Must Begin Early in the Rural Health Transformation Program  

Every state and RHTP participant understands that this federal funding is temporary. The urgent challenge is to identify, early and explicitly, which initiatives can produce enough value to warrant ongoing support after the funding period concludes. 

While some states awarded the first year of RHTP funding quickly, many of these awards may serve as a bridge while states establish the structures and policies needed to support long-term RHTP initiatives. CMS’s reporting and ongoing evaluation of RHTP programs will require states to embed sustainability into program design, governance, measurement, financing, and partnerships from the outset. 

States will need to provide RHTP participants with clear baselines and direction on meaningful outcomes. It also requires thinking beyond grant budgets to identify long-term operational and financial models capable of supporting ongoing services. 

What States, Providers, and Technology Partners Should Do Next 

The window for shaping long-term RHTP success is open now. State and local government and partner organizations have an opportunity to move beyond individual projects and build integrated strategies.  

HMA’s multidisciplinary teams support program design, implementation planning, data strategy, technology modernization, performance measurement, governance, financing strategy, partnership development, and sustainability planning. As states and RHTP participants make decisions regarding governance, technology, data strategy, care models, and performance measurement, HMA can help ensure decisions and investments are optimized to make the progress needed to secure future funding and sustain transformation beyond the grant period.  

Webinar

Webinar Replay – Modernizing and Streamlining Health Plan Prior Authorization

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This webinar was held on September 9, 2026.

In this webinar, leaders from HMA and NTT DATA explored the common sources of friction and inefficiency in prior authorization (PA) processes and discuss how modern technology, including artificial intelligence (AI), can help streamline PA operations, improve compliance, and enhance the experiences for health plans, providers, and members. Attendees gained insights into the evolving regulatory landscape, the root causes of PA administrative burden, and practical strategies for leveraging IT modernization to create more efficient, transparent, and effective prior authorization workflows.

Explore how AI and other IT modernization strategies can reduce PA administrative burden, improve compliance, and enhance the experiences for health plans, providers, and members.

Learning Objectives:
Identify and discuss the root causes of friction and inefficiency in current prior authorization processes and systems.

Review recent legal and regulatory developments that are shaping the health plan prior authorization function.

Explore how AI and other IT modernization strategies can reduce administrative burden, improve compliance, and enhance the experience for health plans, providers, and members.

Featured Speakers:

Sezin Palmer, Managing Director, AI Industry Solutions Lead, NTT Data

Navesh Kandiyil, MD, MBA, FACHE, Transformative Executive, NTT Data

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