Eric Marshall, principal at Leavitt Partners, an HMA company, shares how collaboration, not competition, is the way to move healthcare policy forward in a polarized environment. In this episode of Vital Viewpoints on Healthcare, he discusses how multi-sector alliances are advancing solutions to common pain points that too often impede progress on issues like drug pricing, supply chain security, and rural health access. Drawing on years of experience bringing stakeholders together, Eric explains why consensus-building is essential to creating durable, effective policy solutions and how trust, persistence, and shared purpose can overcome even the deepest divides in Washington and beyond.
37 Results found.
States Submit Applications for Rural Health Transformation Program: Trends and Opportunities
On November 5, 2025, the Centers for Medicare & Medicaid Services (CMS) announced that all 50 states had submitted applications to be considered for participation in the Rural Health Transformation Program (RHTP) created under the Budget Reconciliation Act of 2025. States proposed a range of initiatives to strengthen innovation, modernize rural health infrastructure, and address persistent disparities in healthcare access, workforce, and outcomes in rural communities. Funding decisions are expected by December 31, 2025.
The RHTP represents a major federal investment in rural health transformation. For providers, community partners, and other interest holders, applications offer valuable insight into state priorities, partnership models, and the types of initiatives likely to receive funding.
Many state feedback processes are ongoing for providers, community organizations, and other partners. Even after submission, states are refining their proposals and negotiating with CMS. Organizations should review available materials and take advantage of open comment periods or stakeholder meetings to help states prepare for a strong program launch in early 2025.
Health Management Associates (HMA) reviewed state overviews and applications, where available. In this article we highlight key takeaways from this review and the information available through HMA’s Information Services (HMAIS).
Key Issues and Trends
- Breadth of initiatives and focus areas. State initiatives meet the specific categorical CMS requirements and include a range of innovative models, ideas, and investments in building out pilots and infrastructure. The number of initiatives that states have planned also vary, with most proposing four or five, but at least one state has developed 11 planned programs. Many initiatives involved remote patient monitoring and telehealth, including tele-specialty clinics, tele-psychiatry hubs, tele-intensive care unit support, among others. Several states proposed to establish and enhance models involving emergency medical services (EMS). Proposals also include a range of investments in electronic health records (EHRs), data infrastructure, and interoperability to specific provider types and generally in rural communities.
- Subgrant and Partnership Opportunities: Many applications include subgrant programs or call for partnerships with hospitals, clinics, community-based organizations, Tribal entities, and educational institutions. Reviewing state applications can help organizations understand the timelines for upcoming funding and partnership opportunities as well as expectations associated with the state initiatives.
- Diverse governance and implementation models: The tracker reveals a range of governance structures, from state-led advisory boards and interagency task forces to regional hubs and cross-sector partnerships. States are leveraging advisory councils, technical assistance partners, and community engagement frameworks to guide implementation and oversight.
Some states have yet to submit their full applications but still have opportunities to engage and shape state efforts through various methods. Many states have kept open public feedback mechanisms even as they negotiate with CMS on budgets and program details. This situation creates an evolving landscape wherein stakeholders must monitor multiple channels for updates and opportunities.
Why This Matters
HMAIS’ RHTP Inventory provides states, rural communities, and their partners an actionable road map for state initiatives. This inventory covers focus areas for state initiatives, governance models, funding requests, partnership opportunities, and other key information. This tool helps organizations monitor trends and identify where to engage. HMA will continue to follow state activity in this program as states move forward.
Beyond the tracker, HMA offers deep regional market expertise—our consultants understand state-specific priorities and can provide tailored analysis and strategic planning to position your organization for success. Whether you’re exploring telehealth investments, building partnerships, or preparing for new initiatives in rural health transformation, our team can help you navigate the details and seize opportunities.
For questions about the HMAIS RHTP Inventory and to connect with our state-market leads, contact our experts below.
States need to move quickly on Rural Health Transformation Program
As of November 5th, states have submitted their applications for the Rural Health Transformation Program (RHTP) – a major federal initiative aimed at addressing persistent healthcare challenges in rural communities. Authorized by the 2025 budget reconciliation bill (OBBBA), the RHTP will distribute $50 billion over the next five years to help rural communities improve healthcare access, quality, and outcomes. All 50 states are eligible.
This submission marks a key milestone, but it’s just the beginning. The Centers for Medicare & Medicaid Services (CMS) is reviewing applications, and ongoing conversations between states and CMS will shape the final design and implementation of each state’s program. Awards are expected by December 31, 2025, and states – and their partners – must be ready to move quickly early in 2026.
States must now prepare for a fast-moving design and implementation phase, building on initiatives already underway and refining plans and budgets based on CMS feedback. States will need to staff up quickly and launch new projects in early 2026. With tight fiscal timelines and the risk of forfeiting funds, agencies and community organizations must act decisively. It will be crucial to demonstrate impact on health outcomes within the first half of 2026 will be critical.
Organizations across the healthcare industry should closely monitor how states plan to operationalize their proposals, as these strategies will shape funding flows and partnership opportunities.
Many state agency leaders will be attending the National Association of Medicaid Directors (NAMD) annual conference November 18-21, 2025. The RHTP applications will be a big topic of conversation, with states sharing ideas and stakeholders discussing challenges and opportunities that could be addressed with RHTP funding. HMA will have a strong presence at NAMD and will be gathering important insights on the federal expectations, program content, and operational strategies that states put in their applications.
Organizations interested in learning more about their state’s direction – or in becoming part of the implementation conversation – can reach out to HMA experts listed below.
What’s next with the RHTP?
Any state that is approved for RHTP funding requires:
- A strong management structure at the state level, including dashboards and oversight of programs funded through this award
- Defined goals and sustainable initiatives in chronic disease management, primary care, behavioral health, maternal health, digital innovation, workforce initiatives, and other topics
- Demonstrated outcomes that evidence improvements in rural access and health outcomes, as well as the care experience of rural residents
HMA is ready to help. Our team brings deep expertise in tackling the complex challenges of delivering quality healthcare and human services to rural communities. We understand the challenges rural providers face—from workforce shortages and service gaps to transportation hurdles and socio-economic barriers—and can help states and organizations navigate complexities of implementation.
With broad experience, HMA is a national leader in healthcare consulting, with a multidisciplinary team of over 700 experts experienced in policy, finance, clinical services, analytics, and community engagement. We help rural organizations act decisively and efficiently, meeting the strict deadlines set by the RHTP and minimizing risks such as funding claw-backs. From actuarial and financial skills to clinical and operational expertise, policy, and analytics, HMA can support successful implementation of your State’s Rural Health Transformation program.
Related resources:
- Rural Health Transformation Program Represents a One-Time Opportunity to Reshape Rural Care
- HMA knows rural.
- The Rural Health Transformation Program: Options to Address the Maternity Care Crisis
- HMA toolkit and webinar to advance health equity & access for rural dually eligible individuals
- HMA’s Experts Support States in Rural Health Initiatives
Rewriting the Playbook: State Budgeting in the Era of OBBBA
As of October 22, 2025, all but two states—North Carolina and Pennsylvania—had enacted budgets covering fiscal year (FY) 2026, even as the federal landscape has shifted dramatically throughout the year. In particular, passage of the 2025 Budget Reconciliation Act (OBBBA) and the ongoing federal budget impasse are creating significant downstream pressures on state budgets and the programs they support.
A new report from Health Management Associates Information Services (HMAIS) examines enacted state budgets. Of the 48 enacted budgets, 16 cover the 2025‒27 biennium, and three states—Kentucky, Virginia, and Wyoming—approved budgets in 2024 for the FY 2024‒26 biennium.
The HMAIS report highlights state Medicaid funding priorities, initiatives states are pursuing to adapt to new federal Medicaid and other healthcare policy changes, and reforms to strengthen and ensure the sustainability of programs, particularly in states that expect a reduction in the federal share of their Medicaid program.
OBBBA’s Impact on State Budgets
Congress has yet to reach agreement on the federal fiscal year 2026 spending bills, and there are emerging signals of the challenges this impasse will create for states and federally funded public services. For example, this week the US Department of Agriculture’s Food and Nutrition Service notified every state that Supplemental Nutrition Assistance Program (SNAP) benefits will be withheld because of the funding lapse. This unprecedented situation puts immediate pressure on states and community organizations, which may need to intervene to fill gaps in essential services and benefits.
In addition to the funding impasse, OBBBA introduces major changes, particularly for the Medicaid program, including:
- Medicaid Community Engagement/Work Requirements: All states must implement these requirements for certain Medicaid members by December 31, 2026, requiring rapid infrastructure and system changes.
- Eligibility and Redetermination: States must conduct Medicaid eligibility redeterminations every six months for expansion populations, with new verification requirements and narrowed definitions for “qualified” immigrants. States will need to pressure test their systems for increased volume and may need additional capacity to prevent and minimize backlogs.
- Cost Sharing: By 2028, states must apply a cost sharing requirement for Medicaid expansion adults with incomes above 100 percent of the federal poverty level, with some service exemptions. In 2026, states will need to begin efforts to ensure their systems can track this requirement.
- Provider Taxes and Payments: Freezes on provider tax programs, phased reductions in allowable tax rates, and caps on state-directed payments will reduce flexibility and funding.
In addition, the Rural Health Transformation Program and new federal drug pricing initiatives present both opportunities, such as new funding streams, and risks, including administrative complexity and compliance expectations.
Given the scope of federal changes, states face urgent decisions. They must quickly assess and act on these opportunities, often without dedicated budget allocations.
These federal changes, combined with the budget impasse, are forcing many states to revisit approved budgets, adapt policies, and plan for new initiatives and revise programs that were already in effect—often within short timelines and with limited resources.
State-Level Challenges and Adjustments
Notably, most states enacted their budgets before the passage of OBBBA. As a result, these budgets do not fully account for the new federal requirements, funding changes, and administrative expectations that OBBBA introduces. While many OBBBA provisions will not take effect for at least a year, states must now accelerate planning and make rapid adjustments to comply with new mandates. For example, states are expected to expediently and efficiently implement systems and policies to ensure compliance with OBBBA’s statutory requirements, particularly for the Medicaid program.
HMAIS has examined state budgets that will guide states through the next fiscal year, while also watching closely how they respond to new demands during the first full state legislative cycle under OBBBA.
The HMAIS report describes a mix of budget conditions and actions. Many states continue to invest in ongoing healthcare priorities as well as new initiatives, including targeted rate increases for behavioral health, dental, and maternal health services. In addition, states are addressing inefficiencies in program administration broadly. In healthcare specifically, they are revisiting approaches to financing healthcare service delivery to drive more value from organizations, such as implementing alternative payment models in Medicaid programs, as well as considering tools to improve patient outcomes and consumer experiences.
States are using a variety of tools in their Medicaid budgets to manage these pressures, as well as implementing more general cost-reduction and efficiency measures, including:
- Special Legislative Sessions. Some state legislatures, including Colorado’s and New Mexico’s, have reconvened to address emerging gaps.
- Hiring Freezes. Several states, including Alaska, Colorado, Maryland, Massachusetts, New Hampshire, and Washington, have announced hiring freezes, which could complicate OBBBA preparation efforts.
- Pausing or Ending Planned Programs and Benefit Coverage. Oregon announced that it will end its juvenile justice Medicaid reentry program to conserve funding. North Carolina will not cover new weight-loss drugs because of its budget shortfall. The HMAIS report indicates that officials in other states also have signaled that they are planning for similar updates to their programs if required to address budget shortfalls.
- Medicaid Provider Rate Updates. Colorado rolled back a planned Medicaid provider rate increase, while Idaho is decreasing all Medicaid provider rates by 4 percent.
- Coalitions and Advisory Groups. Other states, including Rhode Island, are convening groups charged with analyzing how the federal cuts may affect their state programs and advising the legislature on feasible responses to the changed landscape.
What to Watch
Healthcare organizations are essential partners as states navigate the current federal budget uncertainty and implement OBBBA requirements. Given the challenges cited above, healthcare organizations should be prepared to collaborate and position to anticipate future needs as the exact components of the various policies are in development.
Recommendations for states and healthcare organizations include:
- Do not delay planning. While federal policymakers are developing guidance and regulations, the OBBBA language provides significant information on what states need to do and initial expectations for reporting. States and their partners should be developing options and contingency plans to make expeditious decisions once details are available.
- Monitor and anticipate state actions and develop responses that are ready to go if needed. For example, states may need to make rate reductions, limit enrollment for optional programs, and communicate with beneficiaries about new requirements. Partners should plan to adapt to these changes and assist providers and beneficiaries as needed.
- Prepare for changes in workload. States will need to design, develop, implement, and report on new Medicaid eligibility and enrollment requirements. They will need a workforce that is trained and can read into the policies, systems, and related needs. States will expect their partners to collaborate on efficient approaches to meet workload demands.
- Engage with state officials. States need thoughtful partners to manage and implement the forthcoming changes that will affect Medicaid partners and beneficiaries. Healthcare organizations should bring experience and data-informed ideas and input to facilitate state approaches and decision-making.
Connect with Us
With federal funding reductions and ongoing uncertainty at the national level, states need to pay heightened attention to the frontline of essential healthcare and human services, implementation of OBBBA, and means of addressing gaps left by federal delays. As we approach the 2026 election year—with many governors up for reelection—state budgets will serve as a blueprint for leadership and policy priorities in the next cycle.
HMA is on the frontlines, working with states and healthcare partners to navigate these complexities. HMA has expertise, tools, and insights—from budget contingency planning supports to analysis of public coverage program enrollment and market insights.
The full report is available to HMAIS subscribers. For questions contact our experts below.
On the Horizon: Contract Year 2027 Proposed Rule Will Provide Trump Administration First Opportunity to Reshape Medicare Advantage Program
The Centers for Medicare & Medicaid Services (CMS) is preparing to release the proposed Contract Year 2027 Policy and Technical Changes to Medicare Advantage, Medicare Prescription Drug Benefit, Medicare Cost Plan, and Programs of All-Inclusive Care for the Elderly Programs. Rather than incremental tweaks, this rulemaking cycle offers CMS officials the first full opportunity to advance the Trump Administration’s policy priorities. With sweeping reforms on the horizon, Medicare Advantage (MA) plans that begin aligning their operations now will be positioned to thrive in the new environment.
These reforms arrive at a pivotal juncture for MA. Enrollment, which has climbed steadily over the past decade, is projected to decline from 34.9 million in 2025 to 34 million in 2026 as financial and regulatory pressures prompt some issuers to narrow or exit select markets. Although CMS anticipates stable average premiums and benefits next year, beneficiaries in areas with reduced competition may face fewer plan choices and marginally higher cost sharing. These market shifts are likely to influence the 2027 contract year rule.
In this article, Health Management Associates, Inc. (HMA), Medicare experts delve into the key policy areas CMS is poised to address—prior authorization reforms, coding and risk adjustment oversight, Star Ratings realignment, and expanded program integrity efforts.
Prior Authorization and Utilization Management Reforms
CMS, across multiple administrations, has viewed prior authorization (PA) as both a cost-control lever and a potential barrier to care. In the contract year 2027 policy and technical rule, CMS officials will have their first unencumbered chance to cement electronic PA standards, enforce strict turnaround timelines, and limit plan’s use of internal coverage criteria. By mandating consistent rules across the MA landscape, CMS seeks to minimize provider frustration without sacrificing utilization management.
Risk Adjustment and Coding Oversight
MA coding practices leading to elevated MA risk scores have been the subject of bipartisan concern and heightened scrutiny as these have been found to inappropriately increase federal government payments to plans. In response, the 2027 rulemaking cycle provides an opportunity for CMS officials to develop more far-reaching reforms to the MA risk adjustment model and potentially explore more transformative models that move away from reliance on Medicare fee-for-service (FFS) data. Encounter-based risk adjustment or an “inferred” CMS-driven scoring approach could narrow payment gaps and deter upcoding.
Next Phase of Star Ratings
Star Ratings will likely see the most pronounced reset under CMS’s proposed changes. Moving away from purely process measures, CMS intends to elevate health outcomes—such as fewer hospital admissions and improved functional status—and sharpen its focus on “exceptional care for all enrollees” through the Excellent Health Outcomes for All (EHO4all) reward. This framework, announced under the calendar year 2026 rate notice, revised the Health Equity Index reward. In the 2027 proposed rule, CMS could call for retiring outdated measures in favor of streamlined reporting via health IT and patient-reported outcomes. CMS has also indicated it would consider other factors for this reward program.
Oversight and Program Integrity
This rulemaking cycle affords CMS officials an opportunity to expand the agency’s oversight toolkit. Advanced analytics and AI-driven audit selection will underpin fraud, waste, and abuse detection at greater scale. Potential areas of focus include enhancing efforts to promote accuracy in MA plan payments, addressing concerns with MA coding practices, and harnessing new technology to assist CMS in its oversight and auditing functions.
Charting the Path Forward
The contract year 2027 proposed rule represents the Trump administration’s first full-cycle effort to align Medicare Advantage with its priorities. By initiating PA automation, rigorous coding compliance, outcome-driven quality enhancements, and next-generation audit preparedness now, MA plans can turn regulatory challenges into competitive advantage. Stakeholders should monitor the Office of Management and Budget’s review timetable, submit focused comments during the rulemaking window, and leverage specialized modeling support to quantify impacts. The program’s future is outcome-centered and accountability-driven. Plans that embrace this vision today will lead the market tomorrow.
Preparing for the 2027 Contract Year for Medicare Part C and D
In addition to advancing the Trump Administration’s healthcare policy priorities, market shifts are likely to influence provisions included in the 2027 contract year proposed rule.
HMA experts advise that issuers and other interested healthcare organizations consider the following potential proposals as well as the changes to help organizations prepare:
- CMS might propose to tighten standards around minimum plan offerings per county, bolster network adequacy requirements, and enhance provider directory. transparency to safeguard beneficiary access as the program evolves.
- Plans that accelerate PA digitization, embed real-time clinical decision support, and train providers on uniform criteria today will smooth their path when CMS announces the contract year 2027 final rule.
- To stay ahead, plans should launch internal coding audits, fortify provider documentation support, and pilot encounter-level data collection now.
- MA organizations must recalibrate quality programs toward these high-impact metrics, invest in digital platforms for real-time patient feedback, and forge care-management strategies that demonstrably lower acute events.
Connect with Us
HMA is closely monitoring the federal review timetable for this proposed rule. Our Medicare experts are working with healthcare organizations to prepare to submit targeted comments during the comment window, including applying specialized modeling support to quantify impacts.
The future of MA is outcome‐centered and accountability‐driven; plans that embrace this vision today will lead the market tomorrow. For details about the MA and Part D regulatory and market landscapes and approaches to position your organization for success, contact our featured experts below.
CMS Clarifies Grandfathering Rules for State Directed Payments
The Centers for Medicare & Medicaid Services (CMS) last month issued a letter to states providing preliminary guidance on Medicaid State Directed Payments (SDPs), which outlines new federal payment limits, clarifies grandfathering provisions, and signals significant changes ahead for Medicaid financing and policy. The letter is part of CMS’s implementation of Section 71116 of the Budget Reconciliation Act of 2025 (OBBBA, P.L. 119-21)—the portion of the legislation that focuses on curbing SDP spending and reinforcing program integrity.
Though CMS describes the guidance as preliminary, it is the view of Health Management Associates (HMA) experts—including former state officials, actuaries, and policy strategists—that it signals directionally new policy for Medicaid agencies, managed care organizations (MCOs), and providers. CMS is working on two proposed SDP-related regulations, which are in the final stages of federal review. The preliminary guidance and forthcoming rules will likely reflect long-standing concerns for several years, even over shifting congressional control and multiple presidential administrations.
This article addresses key clarifications in the letter; the impact of the preliminary guidance on states, MCOs, and providers; and how the directive may influence Medicaid budgets, financing strategies, and future policy reforms.
Guidance Clarifies Timeframes for SDPs
Grandfathering Limited to Specific Rating Periods
CMS will allow states to maintain SDP spending amounts, up to the average commercial rate ceiling, that were in place for state fiscal year (SFY) 2025, calendar year (CY) 2025, and SFY 2026 rating periods. Nonetheless, new or expanded SDPs above Medicare equivalent levels in expansion states and 110 percent of Medicare in non-expansion states—even those based on legislation passed in 2025—are ineligible for grandfathering if they apply to rating periods starting after July 4, 2025. These grandfathered spending amounts will need to phase down with rating periods beginning on or after January 1, 2028.
Preliminary Grandfathering Determinations
CMS has begun notifying states whether a preprint is “likely eligible” for grandfathering. Because these are preliminary determinations, states should prepare for further review and revisions.
Submission Cutoff Date Clarified
In response to confusion around the May 1, 2025, submission deadline, CMS clarified that July 4, 2025, is the cutoff for grandfathering eligibility, provided the state fully completed the preprint. States may have rushed to meet a July 4 submission deadline and may have left questions on the preprint unanswered. In these instances, it is possible—if not likely—that CMS will consider the application incomplete and thus ineligible for grandfathering. Since this is a developing area with limited precedent, states may still seek clarification or reconsideration, though CMS has not yet issued definitive guidance or a formal process for resolving these situations.
No Increases Allowed Until 2028
States are prohibited from increasing the total dollar amount of grandfathered SDPs—the “expected spend”—until January 1, 2028. This restriction limits flexibility for states to expand their programs and may require that they reassess their SDP strategies. For example, using percentage-based calculations tied to average commercial rates, will no longer capture year-to-year growth because of utilization or acuity changes.
10 Percent Phasedown Unaddressed
CMS has yet to provide official guidance on the 10 percent phasedown of SDPs. Stakeholders remain in a holding pattern, awaiting a forthcoming proposed rule that will clarify how reductions will be calculated.
What It Means for States and Healthcare Organizations
SDPs have become a critical tool for states to stabilize provider networks through increased Medicaid reimbursement. This authority will be significantly limited, and states will need to reduce many existing programs. Medicaid enrollment losses resulting from other Medicaid policy changes, such as work requirements and minimum semiannual redetermination, will likely compound the strain on provider payments.
Providers and states need to start planning for these losses in revenue now. Strategic planning for SDP sustainability and close monitoring of upcoming CMS rulemaking is essential.
While the guidance imposes constraints, it also opens the door for policy innovation. For example, some states may use this moment to reform Medicaid financing, streamline supplemental payments, and reconfigure provider incentives to better reflect quality and access, advancing value-based care goals and achieving total cost of care savings through efficiency and aligned incentives.
Connect with Us
HMA is uniquely positioned to support states, MCOs, and providers as they navigate the evolving landscape of Medicaid SDPs. Our team includes former state Medicaid directors, actuaries, and policy strategists with deep expertise in designing sustainable financing arrangements and guiding public engagement processes. We bring robust modeling capabilities to clients seeking to assess the financial impact of CMS’s new restrictions, including the 10 percent phasedown and interactions with provider tax limitations. Our experts are actively engaged with CMS and understand how to translate federal guidance into actionable strategies that align with state goals and operational realities.
Whether revising preprint submissions, evaluating quality frameworks, or rethinking provider incentives, HMA delivers the technical and policy insight needed to move forward with confidence.
For questions about the federal guidance and considerations for your organization, contact our experts below.
The Rural Health Transformation Program: Options to Address the Maternity Care Crisis
This article is part of HMA’s Weekly Roundup series on the RHT Program, highlighting key opportunities and considerations for states and healthcare organizations.
The Centers for Medicare & Medicaid Services (CMS) recently launched the Rural Health Transformation (RHT) Program, which is intended to help states reimagine and rebuild rural healthcare delivery. As outlined in our earlier In Focus article, Rural Health Transformation Program Represents a One-Time Opportunity to Reshape Rural Care, this historic $50 billion federal investment provides states with flexibility to design and implement strategies that improve access, quality, and outcomes in rural communities.
As states develop their RHT applications, they can consider a range of approaches to address persistent gaps in care particularly in maternal health, where rural residents often face limited access to local services. A range of solutions is needed to expand and stabilize access to maternal care, given the shortage of close-to-home birthing care. This article explains one such option: investing in midwifery.
Maternity Care in Rural Communities
Maternity Care Deserts Driving a National Maternal Health Crisis
Families in rural communities—and some urban communities—face “maternity care deserts,” meaning they do not have access to a birthing facility or obstetric clinician. Hospital closures are another reality in rural communities, with additional closures projected. Even in larger communities where a hospital is open, obstetric services could be shut down. These deserts are a key driver of the national maternal health crisis. In Nowhere to Go: Maternity Care Deserts in the US, the March of Dimes (MOD) reported that “two in three maternity care deserts are rural counties (61.5%)” and that “counties with low access to telehealth were 30% more likely to be maternity care deserts.”
Midwifery as an Option for Rural Communities
Midwives are trained healthcare professionals who specialize in supporting women through typical, low-risk pregnancies. They provide care during pregnancy, labor, and the postpartum period. There are several types of midwives, each with different training and credentials. States determine which types of midwives may practice and under what conditions.
Expanding the midwifery workforce can be part of a broader strategy to improve access, particularly in rural areas where hospitals and obstetric providers are scarce. In some places, midwives already serve as a critical access point for maternal care in rural communities, with midwives attending to 30 percent of deliveries in rural hospitals.
The Rural Health Transformation Program Can Help Address the Crisis
The strategic goals of the RHT, as outlined in the CMS application materials and Notice of Funding Opportunity (NOFO), are designed to guide states in transforming rural healthcare delivery. These goals are grounded in the statutorily approved uses of funds and must be explicitly addressed in each state’s RHT application.
Midwives have long contributed to expanding access to maternal care across diverse settings. For example, midwives can support preventive health by providing prenatal and postpartum care in community settings. Their integration into rural care teams may help sustain access to maternity services where hospitals and obstetric providers are limited. States may also consider workforce development strategies, such as expanding midwifery training and retention programs, and innovative care models—including hub-and-spoke systems—that incorporate midwives to improve coordination and person-centered experiences (Figure 1).
According to Ginger Breedlove, PhD, CNM, founder of Grow Midwives, one of the nation’s leading midwifery organizations, “midwifery aligns with all strategic goals of the RHT program.”
States may consider midwifery as one of many options to help build sustainable, community-centered maternity care systems that reflect the RHT Program’s vision for rural health transformation.
Figure 1. Midwifery Alignment with RHT Strategic Goals
| RHT Strategic Goals | Midwifery Alignment |
| Make Rural America Healthy Again | Midwives support preventive, community-based maternal care and contribute to improved outcomes, such as higher rates of spontaneous vaginal delivery and breastfeeding and lower rates of preterm birth and low birthweight. |
| Sustainable Access | Midwives can serve as consistent local access points for maternity care, particularly in areas with limited obstetric services. States with midwifery care more fully integrated have better maternal and infant health outcomes. |
| Workforce Development | Midwifery workforce initiatives expand the pool of high-skilled providers practicing at the top of their license, aligning with goals to strengthen recruitment, retention, and licensure flexibility in rural areas. |
| Innovative Care | Midwives can be integrated into flexible care arrangements—hub-and-spoke or CMS’ Transforming Maternal Health model—alongside doulas and community health workers, improving care coordination and patient experience. |
| Tech Innovation | Midwives can leverage telehealth, remote monitoring, and data-sharing and digital care platforms to extend the reach of maternal care in rural communities and connect patients to the broader maternal care system, including remote specialist consultations. Tech innovations ensure that women receive the appropriate level of care for their risk and needs. |
Connect with Us
Health Management Associates (HMA) has deep expertise in supporting states and healthcare organizations across all phases of rural health transformation. Our team can assist with strategy and writing grants, program design, and implementation plans tailored to specific state goals and approaches. Whether states choose to explore midwifery or other care delivery models, HMA can help define the approach that best fits the needs of rural communities and support organizations in transforming workflows and operations, implementing new initiatives, and enhancing the systems and IT enhancements that sustains them.
HMA brings together experts in maternal health, finance, rural communities, and delivery systems, contact our experts below.
Coding, Coverage, and Reimbursement: Considerations for Women’s Health Access
Persistent gaps in women’s health research, funding, clinical outcomes and access are increasingly well-studied, however less emphasis is placed on the role of coding, coverage, and reimbursement and whether male or female gaps exist in each of these key market access domains. The paper, Coding, Coverage and Reimbursement: Considerations for Women’s Health Access, examines challenges in these areas and offers recommendations to increase awareness, establish evaluative processes, and collaborative action to achieve incremental policy changes that can have a significant impact over time.
Navigating the Government Shutdown: Safeguarding the RHT and “Make Rural America Healthy Again” Initiatives
As of October 1, 2025, federal budget negotiations have led to a temporary government shutdown, prompting healthcare leaders to monitor potential impacts on programs administered by the Centers for Medicare & Medicaid Services (CMS). While federal agencies have contingency plans in place, to date CMS has not announced any potential impacts, including to the timelines for the application and award dates for the Rural Health Transformation (RHT) Program.
State governments and healthcare leaders should continue to develop and prepare to submit their applications for the RHT program, which provides a significant opportunity to revitalize rural healthcare infrastructure through strategic investments in access, workforce, innovation, and technology.
Strategies for States to Efficiently Develop Winning Applications
To maintain momentum and optimize their resources during this period of uncertainty in federal government funding and operations:
1. Strengthen Internal Coordination
- Establish cross-agency working groups to manage RHT program planning and execution
- Use internal policy experts to interpret the Notice of Funding Opportunity (NOFO) guidance and align initiatives with CMS priorities
2. Leverage Existing Data and Evidence
- Use state-level health data to identify high-impact areas for investment
- Prioritize initiatives that align with the RHT program’s five strategic goals:
- Prevention and chronic disease management
- Sustainable access
- Workforce development
- Innovative care models
- Technology innovation
3. Utilize Project Management Tools
To support strategic planning and initiative tracking, Health Management Associates (HMA) is offering a free RHT Project Management Tool. This resource helps states:
- Organize and manage initiative development
- Cross-reference projects with NOFO categories
- Track progress and performance metrics
- Facilitate collaboration across stakeholders
Access the RHT Project Management Tool from HMA:
Complete the form to download
the RHT Project Management Tool
Engage with CMS Resources Proactively
States and their partners can continue to refer to key CMS resources:
States can also submit questions to [email protected].
Final Thoughts
While the government shutdown presents challenges for many federal programs, it remains unclear whether there will be any direct impact on CMS’s engagement with states regarding the Rural Health Transformation Program. Regardless of federal circumstances, this moment highlights the value of state-level leadership and innovation. By leveraging tools like HMA’s project management platform and aligning with CMS’s strategic goals, states can continue advancing rural health transformation and position themselves for success, even in uncertain times.
MAHA Children’s Health Strategy Report: Driving a New Era for Child Health Policy
The September 2025 release of the “Make Our Children Healthy Again Strategy Report” marks a pivotal moment in the Trump Administration’s effort to address childhood chronic disease. Building on the work of the Make America Healthy Again (MAHA) Commission—established by executive order in February 2025 and led by US Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr.—the Strategy Report provides a proposed road map for federal, state, and local action.
The MAHA child-focused Strategy Report is already driving the Trump Administration’s healthcare agenda. Though the report sets ambitious goals, public health entities, state governments, and other experts have raised concerns that several recommendations run counter to established scientific research or lack sufficient evidence.
In this article, Health Management Associates (HMA) experts highlight the areas of focus in the Make Our Children Healthy Again Strategy Report and offer specific recommendations, initiatives, and considerations for stakeholders. Earlier editions of In Focus have addressed the commission’s formation, initial assessment, and the administration’s growing focus on childhood health (Spotlight on Development of President Trump’s Children’s Health Strategy).
Key Components of the MAHA Strategy
Advancing Critical Research to Drive Innovation
The strategy identifies broad areas of research to inform healthy outcomes and positions HHS to direct initiatives in collaboration with the US Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC), and other agencies. Examples include:
- Support the MAHA Chronic Disease Initiative, advance the Real-World Data Platform linking data from claims, electronic health records (EHRs), and wearables
- Establish a working group on mental health diagnosis and prescription, led by several HHS agencies, to focus on SSRIs (selective serotonin reuptake inhibitors), antipsychotics, mood stabilizers, and stimulants
- Study food for health, with the National Institutes of Health (NIH) Office of Nutrition coordinating research initiatives across HHS and the US Departments of Agriculture and Veterans Affairs (VA)
- Identify opportunities to strengthen the use of repurposed drugs for chronic disease
- Address vaccine injury data collection and analysis, as well as mental health research focused on screen time and prescription practices
Realigning Incentives and Systems to Drive Health Outcomes
The report recommends improvements to transparency and efficiency in regulatory processes to address nutrition, fitness, pharmaceuticals and vaccines, and care delivery and payment to address chronic disease. Specific initiatives include:
- Updating the Dietary Guidelines for Americans and developing an “ultra-processed food” definition
- Promote breastfeeding through the Special Supplemental Nutrition Program for Women, Infants, and Children
- Updating hospital food service nutrition guidance
- Developing options to get “MAHA boxes” of healthy food to Supplemental Nutrition Assistance Program (SNAP) enrollees
- Support states with SNAP waivers to encourage healthy food purchases among SNAP participants
- Enhance oversight of direct-to-consumer pharmaceutical advertising and develop a new vaccine framework
- Establish Medicaid managed care quality metrics for nutrition coaching and fitness, and work with states to develop prescribing safeguards for school-age children
- Promote evidence-based prevention and wellness initiatives and restructure agencies to reduce conflicts of interest
Increasing Public Awareness and Knowledge
Major campaigns will involve:
- Launching the “Make American Schools Healthy Again” initiative to assist states with promoting physical activity and nutrition in schools
- Expanding education on environmental exposures, fluoride, and pesticide safety
- Increasing awareness of opioid dangers, vaping, and screen time impacts
- Training school and library staff to respond to opioid overdoses
Fostering Private Sector Collaboration
The strategy emphasizes the administration’s work to advance private sector partnerships aligned with MAHA priorities, including partnerships to achieve the following:
- Improve nutrition in government-funded programs (schools, VA hospitals, prisons)
- Support community-led initiatives to reduce chronic disease in children
Key Considerations for Partners and Stakeholders
Early engagement is critical as federal agencies begin implementing over 120 recommended actions.
States, providers, health plans, and community organizations should identify how their current approaches to children’s health could align with the MAHA initiative and strategy report, as well as where these new ideas might conflict with present policies. This assessment will identify opportunities to maximize new federal funding opportunities and additional resources.
Progress toward the Strategy Report’s specific goals will require coordinated efforts across agencies, sectors, and communities. Stakeholders should consider how and when to engage in research, policy development, and public awareness campaigns outlined in the report.
Connections to Trump Administration Priorities and Broader Opportunities
The report’s recommendations are already influencing federal agency actions and are driving congressional hearings and new legislation at the federal and state levels.
The US Department of Agriculture’s (USDA), for example, is working with states to approve SNAP waivers to restrict the purchase of junk food with federal benefits. HMA experts are tracking the SNAP waiver actions, and as of September 2025, a total of 12 states have received USDA approval for waivers that restrict the purchase of soda, candy, and other unhealthy foods with SNAP benefits. Other states are considering similar waivers, and the USDA is providing technical assistance to support these efforts.
The FDA has enhanced oversight of direct-to-consumer pharmaceutical advertising, including new enforcement activities and rulemaking on drug safety disclosures in ads. This approach aligns with MAHA recommendations and Trump Administration priorities for transparency and consumer protection.
HHS is also pursuing a new vaccine framework; however, states retain significant authority over school-based immunization requirements, and several are considering alternative approaches or maintaining broader vaccine recommendations than those outlined in the MAHA report. Recent legislative actions in some states seek to shift authority for determining school-based immunization requirements solely to the legislature, reflecting ongoing debate and federal-state dynamics.
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As implementation of the Make Our Children Healthy Again Strategy Report advances, all stakeholders must be ready to engage, partner, innovate, and drive change that will shape the future of child health.
HMA guides state and local government, providers, plans and other partners through the multi-pronged strategies and recommendations in the report as well as the complexities of federal funding opportunities, such as the new Rural Health Transformation Program. We are helping state and local policymakers plan for MAHA and Trump Administration priorities, which includes guidance on how to leverage innovative approaches like SNAP waivers to promote healthy food access for children and families.
With deep expertise in policymaking and operational management, HMA consultants are enabling states and their partners to accelerate their work, build sustainable models for child health improvement, and position themselves to take advantage of new federal, state, and local policy opportunities driven by the MAHA report. To discuss questions about the impact of the report contact our experts below.
Rural Health Transformation Program Represents a One-Time Opportunity to Reshape Rural Care
The Centers for Medicare & Medicaid Services (CMS) has officially opened the application window for the Rural Health Transformation Program (RHTP)—a $50 billion federal initiative designed to stabilize and transform rural health systems across the country. This one-time opportunity allows states to submit a comprehensive plan that could redefine how rural communities access care, manage chronic conditions, and sustain their healthcare infrastructure.
As outlined in our earlier In Focus article, States Begin to Engage with the Rural Health Transformation Program, RHTP represents one of the most significant federal investments in rural health in decades.
Applications must be signed by governors and submitted by November 5, 2025, and awards are expected by December 31, 2025, providing states with a very narrow window to act.
The remainder of this article explains key aspects of the RHTP application, including the evaluation and scoring aspects. Notably, the structure of the scoring system will reward states that are already aligned with these federal priorities, as well as those willing to implement new initiatives or make state policy changes to achieve alignment.
Program Overview and Funding Structure
Created under HR.1, the 2025 Budget Reconciliation Act, the RHTP allocates $10 billion annually from federal fiscal year (FY) 2026 to FY 2030, totaling $50 billion over five years. Funding is split into two tranches:
- Tranche 1 (Baseline funding): $25 billion distributed evenly across all states with approved applications.
- Tranche 2 (Workload funding): $25 billion distributed based on CMS scoring criteria, which include:
- The percentage of the state population in rural census tracts
- The proportion of rural health facilities in the state
- The financial and operational status of hospitals
- Other factors explained in the RHTP application notice
States must submit a single, one-time application that covers the full five-year period. Stand-alone provider applications will be declined. Hence, states must coordinate across agencies, providers, and stakeholders to develop a unified transformation strategy.
Importantly, this award is not a grant; rather, it is a cooperative funding agreement, which means CMS will play an active role in oversight and collaboration. States must be prepared to meet higher standards of accountability, transparency, and performance monitoring. According to the RHTP application, continued funding requires states to demonstrate satisfactory progress toward implementing their plan.
Application Requirements and Strategic Priorities
To be eligible for funding, states must submit a Rural Transformation Plan that addresses eight core priorities as follows:
Within these core priorities, state plans must propose activities that address several specific issues.
Technical Factor Weighting for Workload Funding Reflects Federal Policy Priorities
CMS outlines the eligibility criteria for baseline funding and the scoring components for workload funding. Baseline funds will be distributed equally among states, while workload funding will be based on each state’s rural facility and population score as well as their technical score. Evaluators will score technical factors based on state policy actions and initiative-based plans for each state.
The technical factors, and the weighting of these factors, in the RHTP application are not just neutral scoring mechanisms; rather, they are closely linked to the Trump Administration’s health policy priorities.
- Weighting Structure: The RHTP funding is split evenly between baseline funding (50%) and workload funding (50%). Although baseline funding ensures all states receive support, the workload funding is directly tied to technical scores that reflect how well a state’s plan aligns with federal objectives and demonstrates readiness to implement transformative change that furthers federal objectives.
- Scoring Criteria: Technical factors, such as rural population share, facility density, hospital financial status, scope of proposed activities, administrative capacity, stakeholder engagement, evaluation framework, and especially alignment with federal priorities, all contribute to the overall score. States that have already adopted or are willing to adopt federal policy priorities are positioned to score higher and receive more funding.
- Annual Recalculation: CMS will recalculate each state’s technical score and workload funding annually to incentivize ongoing alignment with federal priorities and measurable progress toward transformation goals.
- Alignment with Federal Priorities: One of the explicit scoring factors is “Alignment with Federal Priorities,” which measures the degree to which a state’s plan supports CMS goals for rural health transformation and sustainability. Under the Trump Administration, these priorities may include promoting value-based payment models, encouraging technology adoption, advancing adoption of Supplemental Nutrition Assistance Program (SNAP) food restriction waivers that prohibit the purchase of non-nutritious items, availability of integrated care plans for the Medicare-Medicare dually eligible population, reporting of full Medicaid T-MSIS data, and align policies with federal guidance on short-term limited duration insurance plans.
Preparing for What Happens Next: Implications for States, Providers, and Health Plans
The RHTP offers a rare opportunity to reshape rural healthcare. But success will require strategic coordination and a commitment to long-term change. States in the short and long term should consider include:
- Identifying stakeholders who will be involved: Hospitals, rural health clinics, federally qualified health centers (FQHCs), behavioral health providers, and community organizations must be part of the planning process.
- Reexamining priorities: States will need to reconcile competing needs across regions and provider types, balancing infrastructure investments with service delivery redesign.
- Understanding infrastructure needs to support their project: Technology, workforce, and models of care must be strengthened to support long-term transformation.
- Designing evaluation frameworks: States must include robust performance monitoring and reporting mechanisms to meet CMS expectations and secure future funding.
Providers and other stakeholders should also prepare to align with state strategies. Examples include:
- Participating in regional partnerships
- Adopting new care models and payment arrangements
- Investing in technology and workforce development
- Contributing data and insights to support evaluation efforts
The scoring structure also incentivizes states that may not yet be fully aligned to implement new initiatives or make policy changes that would improve their technical scores and secure greater funding. States and their partners will need to be united on the goals and initiatives, disciplined about implementing and evaluating the plans based on data informed reports, nimble and willing to make strategic pivots based on feedback and experiences.
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States that are already aligned with Trump Administration priorities—such as those with established value-based payment models, short-term limited duration plan options, preferred technology infrastructure, or strong rural hospital support policies—are positioned to be rewarded in the scoring and funding process.
Health Management Associates (HMA), is actively supporting states in developing compliant and compelling RHTP applications. Our advisory services include:
- Strategic assessments and stakeholder engagement
- Program design and grant writing
- Implementation support and technical assistance
- Actuarial support
- Evaluation and performance monitoring
We help clients navigate the complexities of federal funding, align transformation goals with community needs, and build sustainable models for rural care delivery. For details about the RHTP, including the HMAIS State Action Tracker, contact HMA experts below.
Webinar Replay- Beyond the Bill: How Pair Team and MCOs Are Meeting Community Needs Under HR 1
This webinar was held on October 2, 2025.
As Medicaid evolves under HR 1, Managed Care Organizations face increasing pressure to meet new engagement requirements while ensuring vulnerable communities don’t fall through the cracks. This shifting landscape demands scalable, innovative care models that go beyond compliance – focusing instead on meaningful connections, coordinated support, and whole-person care.
In this session, Jami Snyder, former HHSC Commissioner of TX and Medicaid Director of AZ, joined Neil Batlivala, CEO and Co-Founder of Pair Team, and Dr. Nate Favini, Chief Medical & Strategy Officer, to explore how Pair Team and its MCO partners are meeting this moment. Learn how their model combines technology, care coordination, and community-based partnerships to engage hard-to-reach members and address social drivers of health.
We heard real-world examples of how payers and partners can come together in smarter, more connected ways. By aligning efforts and building trust, they can drive better outcomes and create stronger community connections for the people who need support the most.
Learning Objectives:
- Briefly break down HR 1’s most critical provisions and what they mean for Medicaid and MCO operations.
- Discover how Pair Team and MCOs are co-designing solutions leveraging technology.
- Identify best practices for engaging populations facing barriers such as behavioral health needs, housing instability, and transportation challenges.
Featured Speakers:
Carter Kimble, Principal (Moderator) Health Management Associate
Jami Snyder, Former HHSC Commissioner, Texas; Former Medicaid Director, Arizona
Neil Batlivala, Founder and Chief Executive Officer Pair Team
Nate Favini, MD,MS, Chief Medical Officer Pair Team