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.
Watch our Medicaid Town Hall hosted by Health Management Associates. Our experts answered your questions live on a wide range of timely and critical topics, including:
Key policies and insights about the ongoing 2025 federal budget reconciliation negotiations, including changes to Medicaid eligibility policies, financing, and cost-sharing rules.
New executive branch priorities to address program integrity and agency regulations and guidance reshaping provider tax rules and state-directed payment arrangements.
The evolving landscape of Medicaid Section 1115 demonstrations, including updated federal monitoring approaches and new state initiatives.
Medicaid managed care trends, payment innovation, and emerging strategies to address whole-person care focused on maternal health and behavioral health needs.
As Congress intensifies negotiations over budget reconciliation, including potential changes to Medicaid financing and Affordable Care Act (ACA) subsidies, new data from Wakely Consulting Group, an HMA (Health Management Associates) company, sheds light on how the effects of the Medicaid redetermination process continued to unfold well into 2024. Appendix A of the May 2025 white paper Medicaid Redetermination Impacts on the Individual Market, provides a full-year view of enrollment and morbidity trends, showing that the influx of former Medicaid enrollees had some negative effects on risk scores. In fact, relative risk increased across all market types—state-based exchanges (SBEs), in federally facilitated exchange (FFE) Medicaid expansion states, and FFEs in non-expansion states—despite substantial enrollment growth.
Data presented in Wakely’s white paper and their experts’ findings challenge the conventional assumption that higher enrollment dilutes risk and suggest that many new enrollees may have had unmet health needs or delayed care. The data also show that states with the highest enrollment growth did not necessarily experience the greatest morbidity shifts. This decoupling of enrollment and morbidity complicates forecasting for insurers and policymakers alike, especially as Congress debates Medicaid funding and ACA subsidy structures in the ongoing budget reconciliation process.
What to Watch
As federal lawmakers consider reforms that could alter Medicaid eligibility, subsidies, and risk adjustment mechanics, these findings underscore the importance of monitoring not just how many people enroll, but who they are and the type of care they need. The individual market’s evolving risk profile will have direct implications for premium setting, subsidy design, and the financial stability of plans that serve this population.
Connect with Us
Wakely is experienced in all facets of the healthcare industry—from carriers to providers to government agencies. Wakely’s actuarial experts and policy analysts continually monitor and analyze potential changes to inform clients’ strategies and propel their success.
For more questions about the analysis contact our experts below.
In this week’s In Focus section, Health Management Associates Information Services (HMAIS) draws on its database of monthly enrollment in Medicaid managed care programs to provide the latest quarterly analysis of Medicaid managed care enrollment, offering a snapshot of developments across 28 states.[1] The data and insights are particularly timely as stakeholders, including states, Medicaid managed care organizations (MCOs), hospitals and health systems, and providers, continue to plan for multiple possible federal policy changes and the operational realities that will follow.
HMAIS also compiles a more detailed quarterly Medicaid managed care enrollment report representing nearly 300 health plans in 41 states. The report provides by plan enrollment plus corporate ownership, program inclusion, and for-profit versus not-for-profit status, with breakout tabs for publicly traded plans. Table 1 shows a sampling of plans and their national market share of Medicaid managed care beneficiaries based on a total of 66 million enrollees. These data should be viewed as a broader representation of enrollment trends rather than as a comprehensive comparison.
Key Insights from Q1 2025 Data
The 28 states included in our review have released monthly Medicaid managed care enrollment data via a public website or in response to a public records request from Health Management Associates (HMA). This report reflects the most recent data posted or obtained. HMA has made the following observations related to the enrollment data:
Year-over-year growth. As of March 2025, across the 28 states reviewed, Medicaid managed care enrollment declined by 2.5 million members year-over-year, a 3.9 percent drop as of March 2025 (see Figure 1). This marks a continuation of the downward trend reported in late 2024, though with notable variation across states.
Figure 1. Year-over-Year Growth in Medicaid Managed Care States, 2020−24, March 2025
Localized growth amid broader declines. While most states experienced enrollment reductions, Indiana and North Carolina bucked the trend with measurable gains, suggesting the influence of state-specific policy shifts or demographic factors. Oregon and Texas also saw modest growth.
Sharpest contractions. Illinois, Maryland, and South Carolina, reported double-digit percentage drops, underscoring the uneven impact of redeterminations and eligibility changes.
Difference among expansion and non-expansion states. Among the 21 states included in our analysis that expanded Medicaid, enrollment fell by 1.8 million (-3.6%) to 48.6 million. In contrast, the seven non-expansion states saw a steeper proportional decline (-5.4%), to a total of 12.2 million enrollees.
Table 1. Monthly MCO Enrollment by State, January 2025 through March 2025
Note: In Table 1 above and the state tables that follow, “+/- m/m” refers to the enrollment change from the previous month, and “% y/y” refers to the percentage change in enrollment from the same month in the previous year.
It is important to note the limitations of the data presented. First, states report the data at the varying times during the month. Some of these figures reflect beginning of the month totals, whereas others reflect an end of the month snapshot. Second, in some instances, the data are comprehensive in that they cover all state-sponsored health programs that offer managed care options; in other cases, the data reflect only a subset of the broader managed Medicaid population. This limitation complicates comparison of the data described above with figures reported by publicly traded Medicaid MCOs. Hence, the data in Table 1 should be viewed as a sampling of enrollment trends across these states rather than a comprehensive comparison, which cannot be established solely based on publicly available monthly enrollment data.
Market Share and Plan Dynamics
Using our data repository from 300 health plans across 41 states, HMAIS’s report addresses corporate ownership, program participation, and tax status. As of March 2025, Centene continues to lead with 17.7 percent of the national Medicaid managed care market, followed by Elevance (10.8%), United (8.8%), and Molina (6.3%), as Table 2 shows.
Table 2. National Medicaid Managed Care Market Share by Number of Beneficiaries for a Sample of Publicly Traded Plans, March 2025
What to Watch
The policy backdrop remains fluid. The US House of Representatives’ passage of the One Big Beautiful Bill Act introduces sweeping changes to Medicaid financing, including proposed cuts of up to $715 billion. Additional federal proposals, such as mandatory work requirements, could further reshape enrollment patterns.
Stakeholders should prepare for:
Implementation of work/community engagement mandates for certain adult populations
Potential redesign of Affordable Care Act expansion programs
Retraction of federal regulations focused on streamlining of eligibility and redetermination processes to improve accuracy and efficiency
Connect with Us
HMA is home to experts who know the Medicaid managed care landscape at the federal and state levels. As the Medicaid landscape continues to evolve, HMAIS equips stakeholders with timely, actionable intelligence. Our subscription service includes enrollment data, financials, waiver tracking, and a robust library of public documents.
For more information about the HMAIS subscription, contact our experts below.
[1] Arizona, California, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Mississippi, Missouri, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Washington, West Virginia, Wisconsin.
As Medicaid faces another set of policy shifts, this episode provides a look-back on the many twists and turns Medicaid has faced throughout the years. Jay Rosen, president and chairman of HMA, reflects on his work with states and health plans over the past four decades in their efforts to deliver services to vulnerable populations amidst shifting federal and state priorities, innovative delivery and payment models, and increased private sector involvement. With a sharp focus on policy, equity, and system transformation, Jay offers strategic insights for leaders across healthcare, government, and investment sectors.
HMA focused this paper on how states disperse Medicaid funds to certain subpopulations within the program’s categorical eligibility infrastructure. A previous companion paper centered on increasing our understanding of Medicaid managed care spending by provider, offering more detail on the relative order of magnitude of the amounts spent on inpatient and outpatient hospital care, professional services, long-term care, pharmacy, and other health services.
As the latest national Medicaid managed care enrollment data show 75% of Medicaid beneficiaries were enrolled in comprehensive managed care organizations (MCOs), these two foundational papers illustrate the importance of developing a sound methodology to reliably estimate costs associated with MCOS. These papers, which are the first to present findings related to the development of the MCO methodologies, help lay the foundation for further work that will enable us to answer relevant questions, including:
How much do we spend on Medicaid patients with chronic conditions like asthma, diabetes, and hypertension?
How much do we spend on Medicaid patients receiving long-term services and supports (LTSS) and what is the unmet need?
How is Medicaid funding spent on childbirth and a child’s first year of life?
What are the opportunities to be more efficient and effective with Medicaid resources?
We recently sat down with Medicare experts from HMA and Wakely to break down the most important and most pressing developments shaping the future of Medicare Advantage, including the latest updates from CMS on Risk Adjustment Data Validation (RADV) audits, specifically the two major announcements released on May 21st and May 30th that are sending waves through the payer and provider communities alike.
On May 21st, CMS issued new guidance related to extrapolation and how sampling methodology and medical record review standards will evolve under the updated RADV Final Rule.
Then, just nine days later, on May 30th, CMS released additional operational instructions that may tighten reporting windows, add new thresholds for error rate evaluation, and expand expectations around provider documentation compliance—particularly for retrospective reviews and risk adjustment data sourcing.
To help unpack this fast-moving landscape, we’ve spoken with our Medicare experts, Tony Pistilli, Ryan McEntee and David Nater, each bringing a unique lens to the RADV conversation.
What was your first thought when you read CMS’s latest RADV update last week?
Tony – My main takeaway was that CMS was really upping the game in terms of what payers need to do to not only do the appropriate measures to optimize their risk scores but then audit claims that are coming in from providers. So this isn’t just a matter of ensuring that risk score optimization strategies are appropriate, not overstepping, but also adding a new administrative task of auditing claims that you’re getting from providers that may have errors in them.
Can you quickly summarize what CMS actually changed in this latest announcement, and what’s most significant about it compared to the previous announcement in November last year and previous RADV audits?
Ryan – The core of these changes, prior to the old way of doing RADV is, of course the extrapolation methodology that CMS will be introducing, as well as the elimination of the fee-for-service adjuster, which is going to be huge. Then we can move on to that with the announcement of enhancements of staffing and technology.
It’s going to be very interesting how CMS looks to utilize that. As well as every single contract being audited that is eligible are probably the focus points within this, and with CMS they give you a little, and then you have to look into it a lot, so I think there’s still a lot more to come related to these initial announcements that are coming through.
What exactly does this mean from a health plan perspective in the near term – especially for those already in the trenches of risk adjustment audits or pre-audit reviews?
David – Most financial teams use claims as forecasting and having concurrent risk adjustment processes is really the optimal approach to make sure that there are no surprises on the financial end for month end and quarterly reports. Making sure that plans are getting ahead of this cleanup now is imperative to mitigate those financial impacts, and then on a concurrent level, optimizing the operational processes ensures just better forecasting and overall better financial outcomes.
With the latest announcements regarding RADV, what are the current unknowns at play related to this new look RADV strategy?
Tony – On a technical level, the key things we don’t know are how CMS is going to sample claims – They’ve indicated that they’re going to move from random sampling to targeted sampling – and we don’t know how they’re going to extrapolate that. So, if you do a targeted sample, do you extrapolate that just to a targeted extrapolation, or do you extrapolate that to the whole plan? And that’s your range of low impact to high impact.
Similarly, we don’t know what confidence interval CMS is going to use. There’s been some indications of 99% in the past. That’s going to be very conservative, but 95 or 90% would be plausible confidence intervals as well, and that gets you to much more aggressive recovery rates. There are a few other small technical issues that I don’t think will have as big of an impact, but those are the three ones that we’re really looking to CMS to figure out.
What’s the one thing you think plans need to prioritize immediately in light of this update – and what’s the trap they need to avoid?
Ryan – I think plans need to very quickly understand their exposure. One of the ways to do that—and one of the ways we are engaging our clients—is to run analytics looking at these high-risk codes. There are also certain indicators you can look at to see what needs to be reviewed and what has high error rates, based on previous OIGYG and CMS audits. From there, you need to get a quick plan in place to document and assess whether or not those codes are relevant. If they are not, submit them before the aggressive timeline CMS has put in place.
As I mentioned, there are less than two weeks to submit deletes for 2019 dates of service, and every 7 days after that thereafter for each payment year. So, the time to act is now. You need to quickly understand where your risk is and take action. And if you don’t have those capabilities, engage with strong consulting groups or partners who can support you through this.
What closing thoughts or takeaways would you like to share?
Ryan – If I put myself on the plan side, I see both a short-term, immediate plan and a long-term sustainability plan.
That short-term immediate plan is action to act NOW. Whether that is engaging with a partner, or engaging in your internal team, you need to be able to highlight where your risk areas are. Take action on this prior to CMS coming in and acting for you. What’s just as important is setting up a long-term roadmap to be able to mitigate this risk going forward.
To look at it concurrently, do you have the right analytics in place? Do you have the correct staffing in place to be able to look at these risk codes coming in? Assess them and send the necessary deletes coupled with closing the loop related to feedback. Are you pushing that information and education back to your physician groups? Because they’re the most important part to this. You need to be able to educate, communicate and meet with your providers to explain how important the act of documentation and coding is and have this at the forefront of every one of your initiatives and incentive programs going forward in value-based care.
David – HMA and Wakely are well-positioned to help in both the short-term and the long-term approach, and ideally both. Organizations need to act quickly and align their steady-state processes to ensure that they’re managing both the exposure at the health plan level and with the providers, especially those in risk-based arrangements.
Tony – Plans need to be thinking of the RADV risk here, apart from the risk that they might see from chart reviews and other add activity. You may be a plan that’s relatively unaggressive in chart reviews and adds that think “we’re not risk here”, but CMS has now assigned you risk for all the claims that providers are submitting, and you need to be ensuring that those are correct as well.
There’s a wholly separate administrative task here that plans have now assumed responsibility for, and your revenue is just as at risk for not doing the RADV as it is for being inappropriate in your chart reviews and adds and whatnot. So, you really want to be thinking of this as two separate things and acting from both fronts.
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
In May 2025, the US House of Representatives passed a budget bill that includes funding for cost-sharing reduction (CSR) payments, marking a potential end to the “silver loading” practice that has shaped pricing in the Affordable Care Act (ACA) Marketplace pricing since 2017. The US Senate is now considering this legislation as part of a broader budget reconciliation package that includes major Medicaid reforms, such as new work requirements and changes to eligibility and financing rules.
This evolving policy landscape has significant implications for states, payers, providers, and consumers. Wakely, an HMA Company, recently published Implications of Ending Silver-Loading on the Individual Market, which outlines how reinstating CSR payments could reshape ACA marketplace plan pricing, enrollment patterns, and federal subsidy flows. It also highlights the operational and financial risks stakeholders must prepare for in 2026.
Broad Loading and Silver Loading
Because CSR loading increases premium costs on silver plans that determine subsidies, they also increase federal payments for premium tax credit (PTC) subsidies. Guidance from the US Department of Health and Human Services on silver plan pricing has evolved over time. Three types of CSR loading are occurring in ACA markets, specifically:
Broad loading: Increasing premiums for all metal level qualified health plans (QHPs) in the individual market to collect enough revenue to offset the CSR costs of the silver plan variants enrollees
Two means of silver loading:
Increasing premiums for only silver QHPs in the individual market to collect enough revenue to offset the CSR costs of the silver plan variant enrollees
Raising premiums, functionally, for only on-exchange silver QHPs
As discussed in the Wakely paper, the impact of silver loading is that the federal government is likely paying out more in additional PTC subsidies than would be paid if CSR payments were fully funded. On Friday, May 2, 2025, the Centers for Medicare & Medicaid Services (CMS) released guidance related to silver loading and CSR payments for 2026 rate filings. This action was urgently needed, especially for states with May filing deadlines.
What’s at Stake
If Congress does appropriate funding for CSR payments, some issuers will be reimbursed for the difference in cost sharing between standard and CSR-enhanced silver plans. Issuers that cover nonemergency pregnancy termination services, would be ineligible for CSR payments; however, as the Wakely paper indicates, these payments would not cover the additional utilization driven by richer benefits. For example, it is anticipated that a member in a 94 percent actuarial value CSR plan will use more services (i.e., four primary care visits versus three in a standard plan), but reimbursement would only reflect the cost-sharing difference—not the increased volume of care.
States like Georgia and New Mexico, which mandate silver loading, could see significant shifts in premium relativities and enrollment behavior. Wakely’s modeling suggests that changes in CSR policy—especially if paired with the expiration of enhanced premium subsidies at the end of 2025—could lead to higher net premiums, reduced enrollment, and a deterioration in risk pool morbidity.
What to Watch
The Senate’s deliberations will determine whether CSR funding is restored and could have significant implications on whether enhanced premium subsidies are extended beyond 2025. These decisions will directly affect the following:
2026 rate filings and benefit designs
Marketplace affordability and enrollment stability
State reinsurance funding and 1332 waiver dynamics
Consumer costs and plan switching behavior
Wakely’s analysis also cautions that if CSR funding is restored without accounting for induced utilization, issuers may still need to price for higher service use—potentially leading to premium volatility. In addition, if broad loading is mandated instead of silver loading, it could raise premiums across all metal tiers and reduce the value of premium tax credits for many enrollees.
Key Considerations for Stakeholders
States should assess how CSR policy changes affect reinsurance programs, waiver funding, and Medicaid redeterminations.
Payers must prepare for multiple pricing scenarios and evaluate how changes in subsidy structures influence enrollment and risk adjustment, 1332 reinsurance programs, and overall market risk.
Providers should anticipate shifts in patient mix and utilization (i.e., more uncompensated care with more uninsured patients).
Advocates need to monitor how policy changes affect access and affordability for low-income and underserved populations.
These developments also create more opportunities for movement between Medicaid, Marketplace, and uninsured populations, underscoring renewed opportunity for integrated eligibility systems and coordinated outreach.
Connect with Us
Health Management Associates (HMA), experts are actively advising stakeholders on how to navigate these complex changes. Whether you’re a state policymaker, health plan executive, provider leader, or advocate, we can help you assess the impact and plan strategically.
These issues will also be explored in depth at the HMA Conference in October 2025. To discuss how these developments will affect your organization, contact our featured expert below.
A recent case study highlighted how Health Management Associates (HMA) worked with a medical supply firm to identify gaps in their revenue cycle, and by working with us have seen improvements in denial rates and reimbursement. Advanced Diabetes Supply (ADS)/ US Medical Supply (USMed) came to HMA for help with its revenue cycle goals. What began as a revenue cycle gap assessment at one ADS office in California was expanded to be repeated for the Florida office. As a result, HMA helped ADS produce 12% YoY increase in cash collections, resulting in more than $38 million in additional revenue, and a $16 million reduction in outstanding A/R within six months.
A leading provider of diabetes supplies, ADS faced challenges in optimizing their revenue cycle processes. By partnering with HMA, they embarked on a transformative journey that resulted in streamlined operations and improved financial performance. The case study highlights the key strategies implemented by ADS and HMA, including the adoption of advanced technologies, process re-engineering, and staff training. These initiatives not only addressed existing inefficiencies but also paved the way for future growth and innovation.
Organizations need efficient revenue cycle management to ensure sustainability and growth in the constantly changing and competitive healthcare landscape. As healthcare reimbursement can involve many complex processes, it creates opportunities for gaps and process breakdowns. HMA helps organizations implement the processes, training, and technology necessary to close process gaps, improve cash flow, determine root causes for gaps, and reduce denials.
HMA experts have decades of experience in every facet of the revenue cycle. They come from all sides of the healthcare industry, including providers, payers, managed care organizations, and more.
