HMA Insights: Your source for healthcare news, ideas and analysis.
HMA Insights – including our new podcast – puts the vast depth of HMA’s expertise at your fingertips, helping you stay informed about the latest healthcare trends and topics. Below, you can easily search based on your topic of interest to find useful information from our podcast, blogs, webinars, case studies, reports and more.
As healthcare organizations face sweeping shifts in Medicaid funding, workforce costs, and payer expectations, leaders must think beyond short-term cuts and find sustainable ways to protect access, quality, and mission.
During this webinar, HMA experts Jose Robles, Juan Montanez, and Kristina Ramos-Callan discussed how hospitals, health systems, and providers can reimagine revenue strategy for the next decade.
Learning Objectives:
Understand the financial and operational implications of OBBBA and related regulatory changes on healthcare delivery.
Identify strategies to stabilize payer mix, manage revenue volatility, and mitigate the effects of coverage loss.
Explore technology and operational levers that enhance financial performance, including data analytics, automation, and care delivery redesign.
Examine how innovation and mission-driven decision-making can strengthen organizational resilience and maintain equity in care.
Apply insights to develop forward-looking plans that align fiscal responsibility with community health priorities.
In this episode of Vital Viewpoints on Healthcare, Robert Ross and Warren Brodine from HMA’s Delivery Systems practice explore how hospitals and community health centers can work together to strengthen access, improve health outcomes, and improve financial sustainability across the healthcare system. Drawing from decades of leadership in safety-net hospitals, FQHCs, and integrated care models, they discuss the real-world challenges of fragmented incentives, payer mix, and regulation and share bold ideas for building a truly interdependent and patient-centered delivery system.
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.
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.
Connect With Us
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.
From Crisis to Coordinated Care: Six Behavioral Health Priorities for Hospitals and Health Systems
Hospitals across the country are facing unprecedented levels of behavioral health (BH) challenges that impact every facet of operations, from the emergency department to discharge planning. Extended lengths of stay, ED boarding, workplace violence, and staff burnout present clinical issues and pose operational, financial, and reputational risks.
Individuals with BH needs arrive in emergency departments daily, even if the hospital lacks a dedicated BH inpatient unit. These patients require coordinated care across all clinical sites.
HMA offers an end-to-end partnership helping hospitals identify and implement solutions in ways that build internal capacity and deliver measurable results.
Rapid assessments to identify high-impact opportunities
Financial modeling and reimbursement optimization
Strategic and operational planning for BH integration
Partnership development and M&A advisory for BH service lines
Implementation support with measurable results
Effective Strategies
HMA partners with hospitals to address these challenges with a vision of improving care and operations. Our team offers practical, high-impact solutions that enhance patient care, support your workforce, streamline operations, and promote financial stability. Contact us to discuss how solutions can be tailored to your hospital’s unique needs. Let’s address your most urgent behavioral health challenges now, before they impact care delivery and financial stability.
Six Priority Areas
While every hospital faces unique behavioral health challenges, the pressures they create are consistent. HMA partners with your leadership and frontline teams to focus on six proven priority areas that create lasting impact. Together, we develop solutions that improve care, strengthen operations, and build resilience across your organization.
Rapid stabilization protocols
Integration of psychiatric expertise into acute care workflows
Boarding reduction strategies
Value: Reduce length of stay, improve throughput, and protect staff safety.
Cross-continuum care pathways
Partnerships with community providers
Readmission prevention frameworks
Accreditation readiness (The Joint Commission, DNV (Det Norske Veritas))
Value: Improve continuity, patient satisfaction, and reduce high-cost utilization.
Optimizing reimbursement (e.g., unbundled billing for injectables)
Service line financial assessment
Value: Unlocking new revenue streams.
Joint ventures with behavioral health providers
Sell-side preparation and merger and acquisitions support
Community and payer alignment
Value: Expand service capabilities while sharing risk and resources.
Staffing models to provide effective and efficient care while reducing burnout
Data-driven performance management
Technology-enabled workflows
Value: Increase efficiency and retention through optimized operations.
Medication Assisted Treatment (MAT) and Medication for Opioid Use Disorder (MOUD) implementation in ED and inpatient settings
Peer navigation programs
Integration with primary and specialty care
Value: Reduce mortality, avoidable readmissions to EDs, and improve community health outcomes.
Proven Results
Our work with hospitals across the country delivers measurable, lasting improvements that strengthen care delivery, operational performance, and financial health.
Reduced ED boarding times by up to 40% through targeted intervention models.
Increased reimbursement for behavioral health services by optimizing billing practices for long-acting injectables and other high-value services.
Delivered $1.2M in annual savings for a regional hospital through integrated behavioral health response planning.
HMA Differentiators
Many of our team members are former executives and clinical leaders from the behavioral health sector. They bring decades of experience leading behavioral health care in inpatient, outpatient and emergency department settings. HMA provides the depth, agility, and collaborative approach that hospitals need to address today’s most urgent behavioral health challenges while also building capacity for the future. Our proven track record includes hospitals of all sizes and structures, ensuring that solutions are tailored to your market, patient mix, and resources.
Earlier this month colleagues from Health Management Associates (HMA) attended the 2025 Ohio Rural Health Association Conference. The gathering brought together providers, policymakers, and advocates from across the state to discuss one of the most pressing issues of our time: the future of rural health care in an uncertain policy and financial environment.
At a moment when federal funding and regulatory debates dominate the headlines, what stood out most was the energy and commitment among local leaders to work together on practical solutions. The challenges facing rural communities are profound—hospitals and clinics strained by reimbursement shortfalls, workforce shortages threatening access, and shifting payer dynamics creating new administrative burdens. Yet the conversations throughout the conference were grounded in resilience and collaboration, demonstrating that sustainable solutions begin at the community level.
Spotlight on Collaboration
HMA was honored to contribute to this dialogue through three sessions focused on core issues shaping rural care.
Kenneth Cochran, DSc, RN, FACHE, drew on his deep leadership experience as a former Ohio hospital CEO to highlight the urgency of workforce development. With projections of a 187,000-physician shortfall by 2037, Ken outlined integrated workforce strategies—apprenticeships, housing partnerships, and a culture of continuous learning—that can help stabilize rural hospitals and strengthen community health infrastructure.
Courtney Smith, RHIT, CCS, shared two critical perspectives. First, she unpacked the growing strain of Medicare Advantage in rural communities, where reimbursement often falls short and administrative requirements delay patient care. Second, she explored the complexities of Medicaid revenue cycle management, offering actionable steps rural providers can take—from leveraging technology and analytics to streamlining wrap-around payment reconciliation—to maintain stability in an unpredictable environment.
Jennifer Shaw, Senior Consultant, co-presented on best practices for navigating payer relationships with Courtney. She underscored how rural providers can use data to strengthen negotiations and how collaboration across hospitals, clinics, and associations creates the leverage necessary to ensure fair treatment in contracting and payment.
These discussions demonstrated the value of having clinical, operational, and policy perspectives at the table. Each HMA colleague brought not only technical expertise but also a deep appreciation for the lived realities of rural providers, ensuring our sessions were rooted in practicality.
A Landscape in Flux
The national policy context reinforces the importance of this work. Recent debates in Washington over rural health funding underscore just how fragile the financial footing of many hospitals and clinics can be. While the outcome of federal policy is uncertain, what is clear is that communities cannot afford to wait.
As HMA has noted in our broader work on rural health, effective solutions hinge on collaboration across sectors and levels of government. Whether it’s building workforce pipelines, ensuring fair payment, or streamlining operations, progress requires alignment among providers, payers, policymakers, and communities themselves.
Moving Forward
The Ohio Rural Health Association conference was a reminder that even in uncertain times, there is a powerful foundation for innovation and problem-solving when rural providers work together. HMA is proud to support these efforts, bringing decades of experience in Medicaid policy, health system transformation, and rural health strategy to bear for our partners.
As we look ahead, one lesson stands out: the path forward for rural health will not be written in Washington alone. It will be forged in places like Ohio, where providers, leaders, and communities are building practical, collaborative solutions every day.
Ohio Health Policy Snapshots
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The Rhode Island Attorney General’s Office (the Office) engaged Health Management Associates (HMA) to assess the current capacity of the state’s healthcare delivery system and identify policy considerations to ensure access, quality, and sustainability across hospital, long-term care, and primary care settings.
Amid growing public concern about emergency department crowding, long-term care access, and delays in primary care, the Office commissioned a statewide assessment to understand systemwide strain and inform proactive policymaking. The goal was to quantify key pressure points across care sectors and identify interrelated trends that affect patient access and outcomes.
Today’s healthcare leaders are navigating an era of accelerated disruption. Traditional hospital models are under intense pressure from rising costs, workforce shortages, changing reimbursement landscapes, and shifting community expectations. Hospitals and health systems are increasingly challenged by issues that affect multiple areas of the business from strategy to fiscal management to clinical operations.
Financials & Revenue
Workforce
Improving Health Outcomes
Strategic Partnerships
Technology & Digital Innovation
OUR COMMITMENT
We empower hospitals by guiding transformational decisions — protecting legacy, stabilizing operations, and building the future of healthcare, one courageous step at a time. Our HMA Delivery Systems team works with hospitals, health systems, federally qualified health centers (FQHCs) and associations to support their strategy, clinical services, operations, finance, and value-based care needs. Let us know how we can help your organization.
Five Critical Priorities for Transformation
Financial Reinvention and New Revenue Models
Optimizing operational efficiencies, increasing price transparency, and diversifying revenue through innovations like hospital-at-home.
We offer board- and CEO-level financial, operational, and strategic assessments and tailored scenario planning to evaluate service realignment, restructuring, and sustainable growth.
Workforce Resilience and Sustainability
Investing in staff retention, interdisciplinary team redesign, leadership development, and pipeline programs to stabilize care delivery and safeguard institutional knowledge.
We support clients with strategic workforce planning, interdisciplinary team optimization, and leadership development frameworks to future-proof talent pipelines.
Expanding Access and Improving Health Outcomes
Advancing accessible, high-quality care and strengthening community loyalty.
We guide the development of community health investment strategies, trust-building frameworks, and initiatives to foster patient and stakeholder loyalty.
Strategic Partnerships and Ecosystem Building
Building alliances across systems, payers, technology firms, and community organizations is essential to expanding reach, managing risk, and accelerating innovation.
We bring expertise in strategic partnership development, merger and affiliation exploration, and collaborative ecosystem strategies.
Technology and Digital Innovation
Deploying technology and AI automation to streamline workflows, enhance patient experience, and lower costs is now a competitive imperative.
We partner with hospitals to develop tailored technology enablement roadmaps—integrating digital solutions aligned with operational goals and future-state visions.
Who We Help
We offer a full suite of professional health and human services consulting services to clients serving hospitals and health systems, such as:
Critical access and PPS hospitals
FQHCs, rural health clinics, & provider practice groups
Warren Brodine partners with communities, federally qualified health centers (FQHCs), and payors to deliver optimal patient and community outcomes, supporting … Read more
An experienced healthcare executive, Robert Ross is dedicated to developing solutions to provide quality, accessible, cost-effective care while ensuring the … Read more
Lack of transportation is a common barrier to accessing healthcare, leading to poorer health outcomes and health inequities. Non-emergency medical transportation (NEMT) is a critical Medicaid benefit that helps beneficiaries access the health care they need. However, the NEMT industry has faced numerous challenges. States, NEMT brokers and providers, beneficiaries, and other stakeholders have struggled with member satisfaction, adequate transportation networks and workforce (especially in rural areas), sufficient reimbursement, ride timeliness (e.g. pickup, drop-off, post-discharge), passenger safety, digitization of records, and program integrity.
The NEMT industry is also experiencing significant changes and opportunities related to innovation and new technologies, expansion in modes of NEMT transportation (such as rideshare), standardization of tools and metrics, and the introduction of new NEMT models.
Studies and Analyses
NEMT policy/regulatory reviews, stakeholder engagement, and identification of new broker models, technologies, challenges, and best practices
State Tracking and Trends
NEMT contracts/ procurements, managed care carve-in status, trends in standards and models
value proposition and competitor assessments, goal setting, financial scenario planning and modeling, sales and marketing strategies
Actuarial Analyses
rate reviews and modeling
Quality Improvement
compliance and operational support, development and evaluation of value-based payment and other improvement strategies/initiatives
HMA has a long history of working with the full range of stakeholders directly or indirectly involved in, or affected by, NEMT, including:
State and county Medicaid agencies
Managed care organizations
NEMT brokers
NEMT transportation provider organizations and vendors
Technology companies with NEMT solutions
Contact Center companies
Transportation network companies (TNCs/rideshare)
NEMT associations and commissions
Health systems
Emergency medical services (EMS)
Transportation insurance providers
Medicaid beneficiary and disability advocacy organizations
Investors/private equity firms
Our team includes:
Former health plan executives, state Medicaid and public health officials, and NEMT provider leads with federal and state NEMT policy and operational expertise
Researchers and evaluators with extensive experience examining the implementation and impact of NEMT policy and operational changes
Actuarial analysts with deep experience in quantitative assessments and analyses of the NEMT benefit
Carrie Rosenzweig is an experienced consultant specializing in health policy analysis, qualitative research, grant writing, and project management. Her research … Read more
Sharon Silow-Carroll specializes in health policy research and analysis. She has more than 25 years of experience collaborating with public … Read more
Digital Quality Measurement: A Key Driver to Value
The healthcare industry is on the cusp of a seismic shift in how quality data are collected, analyzed and reported. Beginning in January 2027, new federal interoperability and prior authorization rules will require widespread data exchange, paving the way for full digital quality measurement (dQM) by 2030. This move toward dQM presents enormous opportunity to enhance quality outcomes, strengthen value-based arrangements, and streamline operations. However, it also requires substantial strategic, operational, and technological changes that most organizations simply cannot manage alone.
Regulatory Mandates
Organizations that delay preparing for the 2027 rule risk costly setbacks and non-compliance.
Opportunity for Transformation
dQM drives efficiency and quality improvement, supporting population health initiatives, care coordination, and value-based contracting.
Complexity and Risk
dQM implementation spans multiple departments—IT, quality improvement, analytics, legal, and more—creating a host of challenges requiring specialized expertise.
Competitive Advantage
Early adopters will have a first mover advantage. This advantage could result in revenue associated with auto-assignment, STARS bonus, value-based purchasing, reduced sanctions and fine, etc.
Why Partner with HMA?
HMA’s dQM consulting team understands the operational, clinical, and technical dimensions of transitioning to digital quality measurement. Leveraging deep expertise across health plans, provider organizations, and state and federal agencies, we help you plan, implement, and evaluate your dQM strategies at every stage.
1. Speed to Solution
Front-Seat Knowledge: HMA, together with Leavitt Partners, an HMA Company, is actively influencing and shaping national conversations on interoperability and digital measures. Our front-line insights mean you gain rapid access to the latest best practices, regulatory updates, and strategic guidance.
Streamlined Roadmap & Implementation: We help you develop a clear, achievable plan of action—saving you from the pitfalls of trial-and-error by fast-tracking your implementation and monitoring the results.
2. Cross-Department Coordination
Complexity of Transformation: dQM requires alignment across IT, quality, clinical operations, and finance—often a monumental undertaking for organizations already at capacity. Robust change management & strategic planning and communications is crucial for success.
Meet Mandated Timelines: Waiting to act can result in financial risk, stressed operations, and missed opportunities to optimize reimbursement.
Manage Risk: Because digital quality measurement is in an emerging phase, organizations face higher levels of uncertainty. HMA mitigates risk by leveraging our extensive experience and industry partnerships.
3. Proven Expertise and Ongoing Support
Full Project Lifecycle: From early planning and strategy development through implementation and evaluation, we stand by you every step of the way.
Value Beyond Compliance: Our team identifies how dQM can drive broader business goals—improving population health, care coordination, and value-based contracting performance..
Ready to Transform Your Quality Measurement?
HMA’s expert consultants provide the advanced technical, business, and operational skills you need to succeed in today’s rapidly evolving regulatory landscape. Don’t let the complexity of dQM derail your strategic plans or burden your teams. With HMA as your partner, you can confidently navigate and optimize your transition to digital quality measurement.
Take the first step toward harnessing the power of digital quality measurement. Partner with HMA to position your organization for success today—and well into the future.
Contact our HMA dQM experts to discuss your organization’s goals and challenges:
This week’s In Focus section summarizes states’ Medicaid Section 1115 demonstration priorities over the last four years and highlights predicted changes coming with a new presidential administration. In the waning days of any presidency, regardless of party, reviewing and approving pending Section 1115 applications that reflect the current administration’s key policy initiatives is a priority for officials at the Centers for Medicare & Medicaid Services (CMS).
Each administration has discretion over which Section 1115 demonstrations to encourage and approve. Though specific Medicaid priorities under the upcoming Trump Administration are still nascent, Health Management Associates, Inc. (HMA), federal, and state experts are monitoring these developments. This article describes a subset of the signature initiatives the Biden Administration permitted states to pursue in their Medicaid Section 1115 demonstrations and how the new administration could focus on different priorities, rescind existing guidance, or potentially withdraw already approved waivers.
Overview of Biden-Era Section 1115 Demonstration Initiatives
CMS-approved Section 1115 demonstrations permit alternative methods to improve the accessibility, coverage, financing, and delivery of healthcare services under joint federal-state funded programs, specifically Medicaid and the Children’s Health Insurance Program (CHIP).
Addressing health disparities and promoting integrated care in Medicaid became a primary focus of the Biden Administration. In November 2023, CMS introduced a Medicaid and CHIP Health-Related Social Needs (HRSN) Framework, giving state Medicaid agencies the opportunity to address the broader social determinants of health (SDOH) that affect their enrollees, leading to better health outcomes. The new initiatives were not intended to replace other federal, state, and local social service programs, but rather to coordinate with those efforts. HRSN demonstration approvals to date include coverage of rent/temporary housing and utilities for up to six months and nutrition support (up to three meals per day), departing from longstanding prohibitions on payment of room and board in Medicaid.
During the present administration, CMS also has provided novel opportunities for states to adopt strategies that promote continuity of Medicaid coverage, mainly through bolstering Section 1115 demonstrations to provide multiyear continuous eligibility for children. In addition, CMS released guidance in April 2023 so states could apply for a new Section 1115 demonstration opportunity to test transition-related strategies that support community reentry for incarcerated people who would otherwise be eligible for Medicaid or CHIP.
The table and map below show the types of demonstrations approved and pending to date. We anticipate that incoming administration officials will closely examine the four demonstration initiatives outlined as they determine their own Medicaid policy agenda and priorities. Under President Biden’s Administration, nine states received federal approval for HRSN demonstrations under the new framework. Another 10 states have applications pending.
Rescissions and renewals. Incoming Trump Administration officials technically could attempt to rescind some of the Section 1115 demonstrations approved during the Biden Administration. The Biden Administration unsuccessfully pursued with, a similar strategy for certain 1115 demonstration components approved during President-Elect Trump’s first term. Like the Biden Administration, the incoming Trump officials may choose not to renew demonstrations, even if the courts prevent them from rescinding approvals.
Any signature Section 1115 policy is unlikely to emerge until the new administration’s policy officials are in place. There are, however, important insights to consider based on the first Trump Administration’s priorities and areas of common ground across the Biden and first Trump administrations.
Signature 1115 initiatives. During President Trump’s first term, one signature Medicaid Section 1115 initiative allowed states to apply work requirements to some eligibility groups. CMS officials at that time also approved capped allotments for certain components of a state’s Medicaid program. Some states might consider revisiting these options with incoming administration officials. Two other key policy areas to watch following the transition include:
The first Trump Administration approved a pilot program to test interventions addressing HRSNs in North Carolina’s Medicaid 1115 demonstration program. Though the approved HRSNs were less expansive than the HRSN 1115 interventions later announced by the Biden Administration, this could be an area of common ground where the policy evolves and can be incorporated into discussions on other nascent initiatives.
Multiple administrations, including the first Trump Administration, have prioritized Medicaid policies and demonstration initiatives to address substance use disorders (SUD) and, separately, reentry. The intersection of these issues can provide another area of common ground and opportunity to continue work on state reentry initiatives, though likely with new and modified parameters.
Implementation Considerations
Federal approval of Medicaid Section 1115 demonstration proposals is a critical milestone for states. Demonstration implementation also requires significant and ongoing leadership, resources, and collaboration between states and CMS and states and their partners.
The type of state demonstration activity is expected to shift dramatically over the course of the new administration. For example, proposals may shift from expansions in coverage and benefits to reflect the new administration’s other priorities. States, too, may consider alternative approaches to Section 1115 demonstrations, such as state plan authorities like in lieu of services (ILOS), to pursue certain innovative approaches that they might otherwise have implemented with demonstration authority.
Connect with Us
HMA empowers states, providers, and other stakeholders to thrive in an ever-changing healthcare landscape. With deep expertise at every level, HMA teams support state Medicaid programs and stakeholder partners nationally to address a range of operational challenges, including designing innovative healthcare approaches to address urgent healthcare challenges, expanding coverage opportunities, and optimizing integration to address program efficiencies and improved “whole person” care.
We have expertise in all of the components critical to developing Section 1115 programs—from the policy knowledge, to actuarial/budgeting talent, to communications and project management skills, as well as the necessary IT infrastructure.
Contact our featured experts below to learn more about HMA’s capabilities and expertise.
Laguna Honda Hospital and Rehabilitation Center (LHH) is the largest publicly owned and operated nursing facility in the United States and has cared for those most in need for more than 150 years. Licensed at 780 beds, LHH serves patients with complex medical needs who are low or very low income as part of the San Francisco Health Network. Health Management Associates (HMA) was engaged by the San Francisco Department of Public Health (SFDPH) to conduct a comprehensive, top-to-bottom assessment in support of its effort to attain Centers for Medicare & Medicaid Services (CMS) recertification.
Background
For this engagement, HMA brought together a team of experts with decades of national experience leading public health systems and organizations, including skilled nursing facilities. HMA’s subject matter experts included a long-term care physician specialist, a quality expert, long-term and acute care administrative and nursing.
Expanding access to medical respite care for individuals who are unhoused or have no stable housing and are too ill to be discharged to the streets but not sick enough to stay in the hospital and require some supports to recover from their illness or injury.
Medical respite, or recuperative care, according to the National Institute of Medical Respite Care (NIMRC) is “an intervention that provides post-acute medical care for individuals experiencing homelessness who are not sick enough to warrant hospitalization, but who are too frail or ill to recover safely in a shelter or on the streets.”
Respite care benefits both providers and patients and saves money. According to a study by NIMRC, respite care results in a 24% reduction in Medicaid cost per enrollee, 30% decrease in hospital admissions, 38% reduction in emergency department visits, and a 92% attendance rate at follow up appointments within 30 days of hospital discharge.
Medical respite is not a housing service. Housing support services like housing stability, shelter, and supportive housing are critical components of the housing support system. Medical respite is the bridge and a safe transition from the medical care system back to the community and other needed services and supports. By providing a safe bed, clean restrooms, nursing assistance, and healthy meals, medical respite services can improve health outcomes and begin a process of addressing other critical health-related social needs, such as stable housing.
HMA offers a full suite of professional health and human services consulting services to organizations across the country. In Minnesota, HMA helped write the legislation that helped Minnesota Medicaid give coverage for respite care and has expertise in creating this model that can be used in other states. Many states lack this benefit and even in Minnesota, where it is now covered, there is a shortage of providers.
Project Spotlight: Minnesota Recuperative Care Benefit
THE TASK:
Legislation was passed requiring Minnesota’s Department of Human Services (DHS) to create a recuperative care benefit through Medicaid. Stakeholder engagement to discuss Medicaid options and to define the benefit. Recuperative Care was not well developed in MN and there were few beds operating in the state.
HOW WE HELPED:
HMA engaged interested individuals as guided by DHS. This included interviewing individuals with lived experience. Our Medicaid and recuperative care SMEs walked everyone through understanding the service and defining the service. In addition, we educated interested parties about the pathways in Medicaid including a state plan amendment and the various waiver options. The group came to consensus with DHS on a state plan amendment. HMA wrote the legislative language and report to support this direction.
THE OUTCOME:
The legislative language was approved. The state plan amendment was submitted and approved by CMS. Recuperative care is now a Medicaid benefit in Minnesota.
HMA can help states, providers, and communities create this benefit, implement effective respite services, and adapt the set of national standards for Medical Respite given your state and community needs including:
Safe and quality accommodations
Environmental services
Care transitions into medical respite from other settings
Access to high quality post-acute clinical care
Care coordination and wrap-around services
Safe care transitions out of medical respite to the community
Quality improvement
HMA can also provide technical assistance, help with alternate payment models, workforce and strategic planning to support respite care.
Working to integrate services across systems and communities, Paul Fleissner is a seasoned executive who has developed programs and policies … Read more
