Late 2024, HMA convened a panel of experts, including individuals with lived experience and state leaders, to spotlight the critical need for cross-system transformation. The discussion underscored the importance of centering youth and family voices, aligning placement and community-based services, and leveraging opportunities like the Family First Prevention Services Act, Medicaid waivers, and specialty managed care models. As states grapple with a behavioral health workforce crisis and insufficient foster care placements, the path forward requires bold, coordinated strategies grounded in flexibility, equity, and evidence. This brief includes key takeaways from the 2024 panel and outlines actionable insights to guide the transformation of the children’s behavioral health system.
1325 Results found.
HMA helps support Section 1115 Demonstration initiatives across the country
Section 1115(a) demonstrations, informally known as 1115 waivers, are experimental, pilot, or demonstration projects that give states flexibility to design, test, and evaluate state-specific approaches to improve their healthcare programs and better serve eligible populations.
Approved by the Centers for Medicare & Medicaid Services (CMS), 1115 demonstrations provide alternative options to provide access, coverage, financing, and delivery of services under the joint federal-state funded programs Medicaid and the Children’s Health Insurance Program (CHIP). Across multiple administrations, HMA has helped state Medicaid agencies and cross-agency leaders design programs aligned with federal priorities; develop budget-neutral pathways and sustainable financing strategies; reduce operational, financial, and implementation risk; and position programs for long-term success.
Medicaid and CHIP 1115 demonstrations allow states—and their stakeholders—to test new innovations to improve the health of enrollees and advance program efficiencies. These demonstrations require careful planning, rigorous actuarial analysis, political savvy, policy knowledge, and ongoing support through the application, approval, and implementation phases. In today’s environment, 1115 programs must be responsive to the policy priorities at the federal level and grounded in solutions that work in the state. Stakeholders need aligned engagement strategies and communications plans to achieve shared goals, including monitoring that drives continuous improvements after implementation.
HMA consultants bring extensive real-world and leadership expertise from decades of working with states and federal agencies prior to joining HMA. We offer the range of services and support needed to ensure 1115 programs are financially sustainable, operationally workable, and aligned with federal and state requirements:
Strengthening healthcare safety net sustainability through financial and operational supports
Developing solutions for complex patient populations such as individuals who are justice-involved or have extensive behavioral needs including substance use disorder
Designing coverage strategies for critical social needs, such as community reintegration of vulnerable populations such as the justice involved, including when these require collaboration with agencies and programs beyond Medicaid
Supporting states in meaningful stakeholder engagement efforts, provider training and guidance, and other activities necessary for successful program implementation
Working with managed care organizations, health plans, providers, and other stakeholders to apply our expertise in implementing 1115 demonstrations
HOW HMA CAN HELP
Providing strategic and operational support to design demonstration programs
With several former state Medicaid directors and former CMS officials on staff, HMA helps states design successful new interventions to address the unique needs of their populations and ensures proposals meet CMS’ approval requirements and expectations, including aligning 1115 interventions with evolving federal priorities and objectives for the program. With HMA, states and stakeholders gain valuable insights on strategic engagement and partnerships.
Developing applications for 1115 demonstration proposals
HMA has supported a variety of 1115 initiatives in several states, including developing proposals for new, continuing, and amended 1115 demonstration programs. HMA consultants bring decades of experience in 1115 program design that covers all of the components critical to developing and operating 1115 programs – policy, actuarial and budgeting, operations, communications, project management, and IT.
Supporting federal negotiations for approval of state 1115 demonstration proposals
HMA helps states navigate the federal processes to secure approval for their 1115 initiatives. In many cases, HMA joins in active negotiations with the state agency to support federal negotiations. HMA has unique insight into federal approval parameters with former CMS officials.
Operational Support
We help stakeholders—including state agencies and their partners—manage the challenges of implementing new Medicaid or CHIP initiatives, with a focus on ensuring efficient integration and improvements in outcomes.
Evaluation and Assessment of section 1115 demonstrations
Federal regulations require evaluation of CMS-approved 1115 programs. HMA designs and conducts evaluation reports that meet federal requirements, such as hypotheses, data sources, and comparison strategies. HMA’s work on evaluation designs and evaluation reports has been held out by CMS as best practice models to other states for evaluating new policy interventions as well as for ongoing monitoring activities.
Developing materials for and supporting stakeholder engagement from design to implementation.
HMA works closely with states and their partners to engage stakeholders early in the 1115 process to ensure that communities and local organizations are involved in the planning and implementation of 1115 programs.
Project Spotlights
HMA has supported approved section 1115 demonstration programs testing new strategies for addressing substance use disorder (SUD), serious mental illness (SMI), and/or serious emotional disturbance (SED) through new flexibilities around the federal institution for mental disease (IMD) exclusion in seven states (Alabama, Colorado, Delaware, Indiana, Missouri, Ohio, and Oklahoma). In addition to initial and extension application support, HMA teams also support the evaluation and financial modeling components of 1115 demonstration development. In the last four years, we have delivered six evaluation designs, two midpoint progress assessments, two interim evaluations, and two summative evaluations approved by CMS. In general, HMA’s approved evaluation design plans use multiple evaluation methods, including a mixed-methods approach, drawing from various data sources, measures, and analytics, including quasi-experimental methods, to produce relevant and actionable study findings to conduct analyses. Additional 1115 demonstration program development activities include completing budget neutrality estimates and rate setting for new interventions proposed under demonstrations.
California is the first state in the nation to receive approval from CMS to provide detained and sentenced individuals with 90-day pre-release healthcare services and behavioral health linkages. HMA helps clients build administrative capacity, information technology, pre-release services, care management models, and Medicaid claiming infrastructure to meet their unique needs and leverage this significant state-federal demonstration opportunity. Our planning and implementation support spans the breadth of the CalAIM Justice-Involved Initiative including: the pre-release Medicaid application process, 90-day pre-release services, behavioral health links, Enhanced Care Management (ECM), and Community Supports services. In addition to California, HMA supported other states, such as Illinois and Maryland, with the design, approval, and/or implementation of justice-involved demonstrations approved by CMS. Learn more about CalAIM Justice-Involved Reentry Initiative Planning and Implementation Services.
HMA has supported multiple states in developing alternate approaches to Medicaid eligibility and enrollment tailored to their unique policy goals. For example, our consultants have worked with the Indiana Family and Social Services Administration on the program design, approval, and implementation of the Healthy Indiana Plan (HIP), Indiana’s alternative Medicaid expansion demonstration program. We also supported the Iowa Department of Health and Human services in developing the Iowa Health and Wellness Plan (IHAWP) 1115 demonstration which provides an alternative benefit design to traditional Medicaid expansion. HMA also supported the Kentucky Cabinet for Health & Family Services (CHFS) with a variety of services related to its section 1115 demonstration, Kentucky HEALTH, the first community engagement program in the nation approved by CMS.
Webinars and other resources:
- Five-part webinar series and other resources for Medicaid 1115 Waivers: creating new programs for justice-involved individuals
- Webinar replay – Navigating change: exploring the opportunities of New York’s 1115 Medicaid waiver amendment
- Behavioral health Section 1115 demonstration waivers and extensions
- The Medicaid Section 1115 demonstration landscape: past trends and anticipated shifts
April 23, 2025
New HMA Report Provides Insights on Strengthening State Medicaid NEMT Contracts
Is Medicare Ready for the Next Era of Innovation?
Amy Bassano is a Managing Director at Health Management Associates and a nationally recognized Medicare policy expert. In this episode of Vital Viewpoints on Healthcare, we unpack the complexities of Medicare innovation and examine where the program is headed next. Drawing on decades of experience—including her leadership at the Center for Medicare and Medicaid Innovation—Amy breaks down what makes value-based care so complex, why scaling successful models is harder than it sounds, and how Medicare Advantage continues to reshape the healthcare landscape. She also discusses how financial incentives, regulatory constraints, and the urgent need for system-wide efficiency are shaping the next chapter of Medicare policy. This conversation offers practical insights for policymakers, providers, and advocates navigating the future of one of the nation’s most essential programs.
State Medicaid Non-Emergency Medical Transportation Contracts: Key Provisions, Standards, and Considerations
Federal statute requires states to provide non-emergency medical transportation (NEMT) to Medicaid beneficiaries who have no other means of getting to medically necessary healthcare facilities. Though NEMT programs must meet certain federal requirements, states have considerable flexibility in the design and operation of their NEMT program. As a result, states vary widely in their NEMT procurement and contract standards, metrics, reporting, and enforcement of requirements for NEMT brokers, MCOs, and transportation providers. Health Management Associates, Inc. (HMA), examined NEMT-related requests for proposals (RFPs) and contracts for five states and interviewed state Medicaid officials, transportation brokers and providers, MCOs, advocates, and subject matter experts (SMEs). The goal was to synthesize the information gathered to help inform states and other stakeholders about key NEMT standards, challenges and successes, and considerations for developing RFPs and contracts.
Download the toolkit and the report.
The Medicare Advantage VBID Program Is Ending: Here’s What All Plans Can Do to Prepare for What’s Next
This week, our second In Focus article addresses the transition to end the Medicare Advantage Value-Based Insurance Design (VBID) model, which launched in 2017 and subsequently has been expanded with bipartisan support. This model was designed to promote flexible benefit design, reduce cost barriers, and enhance care for targeted populations, especially dual eligibles and individuals with chronic conditions. In December 2024, however, the Centers for Medicare & Medicaid Services (CMS) announced that the model would be terminated by the end of 2025, citing unmitigable costs to the Medicare Trust Funds, totaling more than $4.5 billion across 2021 and 2022 alone.
Despite its popularity and effectiveness in improving medication adherence and addressing social determinants of health, CMS concluded that the cost trajectory was unsustainable within the parameters of the Innovation Center’s mandate.
The end of the VBID model is not the end of innovation in Medicare Advantage (MA); rather, it is a strategic inflection point. Plans that approach this transition with a proactive, data-driven lens will be best positioned to maintain competitive advantage, compliance, and member trust. This article reviews critical steps VBID plans should be taking and how Medicare Advantage Organizations (MAOs) and their partners can best prepare for future opportunities.
Pain Points and Key Strategic Decisions for MAOs
As plans prepare for a post-VBID world, they face a series of complex trade-offs—especially those with Dual Eligible Special Needs Plans (D-SNPs) that had $0 drug cost sharing under VBID. With the end of CMS’s drug cost offset in the initial coverage phase, MAOs will need to determine whether and how to absorb those costs through alternative mechanisms. In addition, plans will need to make important decisions regarding their other VBID benefits, namely, whether to discontinue or transition them to the special supplemental benefits for the chronically ill (SSBCI) program. MAOs should consider the following key strategic decisions:
- Offer an Enhanced Alternative (EA) or Basic Alternative (BA) Part D Plan: To replicate $0 cost sharing, MAOs would need to use EA or BA plan designs with $0 deductibles and $0 copays across all tiers—an expensive move and potentially untenable investment for many.
- Tier-Specific Buy-Downs (T1/T2): Some plans may consider buying down T1 and T2 copays to $0, a much less costly approach. Others may consider moving key T2 drugs to T1, while keeping T1 copays at $0 to protect access and using non-zero dollar T2 copays to limit costs.
- Competitive Alignment Considerations: MAOs offering broader cost-sharing reductions (e.g., $0 copays on both T1 and T2 drugs) may experience undesirable shifts in enrollment patterns depending on how competitors structure their formularies and benefit designs. MAOs should consider competitive parity and attempt to maintain a balanced benefit structure that aligns with market norms.
- Transferring VBID Benefits to SSBCI: Some benefits—like non-health-related transportation, healthy foods, and general supports for living—could migrate to the SSBCI program. But SSBCI has strict eligibility, documentation, and operational requirements, calling for nuanced workflows and cross-departmental coordination.
Action Plan: What MAOs Should Be Doing Now
To navigate this transition successfully, teams of experts at Wakely, a Health Management Associates, Inc. (HMA) Company, are already working with VBID stakeholders to evaluate multiple transition scenarios. Our experts recommend that MAOs take the following actions:
What to Watch: Future Innovation in Medicare Advantage
Though VBID is ending, the innovation landscape is far from static. With the new Trump Administration and the return of Abe Sutton—a VBID expansion advocate—appointed as Director of the CMS Innovation Center, our experts are closely monitoring the potential for a revised version of VBID or similar models. Stakeholder advocacy could influence how CMS prioritizes the next wave of innovation. Plans should consider engaging in dialogue now to shape what happens next.
Connect with Us
Wakely is embedded in MA strategy and policy. Wakely and HMA teams are working with clients to evaluate multiple transition scenarios, helping them optimize value, protect Star Ratings, and preserve member satisfaction during this pivotal shift, while also supporting targeted policy engagement efforts to ensure their perspectives are reflected in future CMS and Innovation Center decision making.
Our joint capabilities bring together:
- Actuarial modeling expertise to quantify cost and risk impacts of design alternatives
- Regulatory insight to ensure compliance with CMS requirements
- Operational support to help you implement SSBCI programs efficiently
- Market strategy consulting to align your plan offerings with local competition and enrollment goals
- Policy advocacy to help clients engage in the conversation around what comes next after VBID
To connect on additional questions contact our featured experts below.
FY 2026 Medicare Hospital Inpatient Proposed Regulation Signals Several Changes Lie Ahead for the Hospital Industry and Beneficiaries
This week, our In Focus section reviews the policy changes that the Centers for Medicare & Medicaid Services (CMS) proposes to make in the Fiscal Year (FY) 2026 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Acute Care Hospital (LTCH) Proposed Rule (CMS-1833-P). The IPPS proposed rule, released April 11, 2025, includes several important policy changes that will alter hospital margins and change administrative procedures, beginning as soon as October 1, 2025.
Key Provisions of the FY 2026 Hospital IPPS and LTCH Proposed Rule
For FY 2026, CMS proposes to modify several hospital inpatient payment policies. We highlight and interpret six of these proposed policies that may be among the most impactful for Medicare beneficiaries, hospitals and health systems, payers, and manufacturers, as follows:
- Annual inpatient market basket update
- Labor share reduction
- Medicare Advantage (MA) data integration in measuring hospital readmissions
- New Technology Add-on Payment (NTAP) program growth
- Transforming Episode Accountability Model (TEAM) modifications
- Uncompensated care payment increase for disproportionate share hospitals (DSHs)
Annual Inpatient Market Basket Update
Proposed Rule: CMS’s FY 2026 Medicare IPPS Proposed Rule will increase payments to acute care hospitals overall by 2.4 percent from FY 2025, amounting to an estimated $4 billion increase in reimbursement. This update is based on a hospital market basket increase of 3.2 percent and a 0.8 percent reduction for total factor productivity.
HMA Analysis: CMS’s 2.4 percent increase results from the estimated rate of increase in the cost of a standard basket of hospital goods—the hospital market basket. For beneficiaries, this payment increase will lead to a slightly higher standard Medicare inpatient deductible and an increase in out-of-pocket costs. For hospitals and health systems, payers, and manufacturers, the proposed payment increase (2.4 percent) is consistent with economy-wide inflation over the past year (2.4 percent) and below the amount that MA plans will receive for 2026 (5 percent).[1], [2] Although the published payment update for FY 2026 is 2.4 percent, other policy changes result in the average change in inpatient payments totaling slightly more than 3 percent. We anticipate the proposed 2.4 percent increase will increase somewhat by the time CMS finalizes these rates later in the year.
Labor Share Reduction
Proposed Rule: CMS proposes to modify the hospital labor share used to reimburse hospitals for inpatient services. Using 2023 hospital cost report data CMS proposed a national labor‑related share of 66.0 percent, a decrease from the labor share of 67.6 percent.
HMA Analysis: Every five years, CMS recalculates the hospital market basket and the hospital labor share using updated cost data from the hospital cost reports. For FY 2026, CMS conducted its routine rebasing calculation using 2023 cost report data, replacing the 2018 cost data currently used. As a result, CMS calculated that the cost of labor accounts for a slightly smaller share of total hospital costs in 2023 than in 2018. The labor share is used within the IPPS to identify the proportion of payments that are affected by the hospital wage index in an effort to adjust payments for geographic variation in labor costs. The consequence of a lower hospital labor share is that a slightly smaller share of hospital inpatient payments will be adjusted by the hospital wage index. The subtle impact of this change is that hospitals with higher wage index values may experience reductions in payment. Further, this downward revision of the labor share signals that hospital wages, salaries, and employee benefits account for a smaller share of total costs in the post-pandemic environment. This change may come to a surprise to some, as hospital labor costs have been a subject of concern since the COVID-19 public health emergency.
Medicare Advantage Data Integration in Measuring Hospital Readmissions
Proposed Rule: CMS proposed to make several modifications to the Hospital Readmissions Reduction Program (HRRP), including:
- Refining all six readmission measures to add MA patient data
- Removing the COVID-19 patient denominator exclusion from measures
- Reducing the applicable period from three years to two
- Modifying the DRG payment ratios in the payment adjustment formula to include MA beneficiaries
- Clarifying that CMS has the discretion to grant an extension to hospitals under the extraordinary circumstances exception (ECE)
CMS also proposed to include MA data in other measures included in the Hospital Value-Based Purchasing (VBP) program and the Inpatient Quality Reporting (IQR) program.
HMA Analysis: The inclusion of MA data in the HRRP may have significant payment implications for many hospitals because it will alter their readmission rates in unanticipated ways, particularly if hospitals’ MA patients differ substantially from traditional Medicare beneficiaries. Importantly, the inclusion of MA data in the HRRP measures, and also within the VBP program and the IQR program, signals that CMS is moving toward broader integration of MA data into Medicare fee-for-service reimbursement systems.
New Technology Add-on Payment Program Growth
Proposed Rule: CMS proposed to continue NTAP status for 26 products because they continue to meet the newness criteria required under this program. In addition, within the proposed rule CMS discusses new NTAP applications for 43 additional products. Among these applications, 29 were submitted under the alternative pathways for breakthrough devices and qualified infectious disease products (QIDP).
HMA Analysis: The overall number of products with NTAPs is on par with other recent years, but the number of NTAP applications has blossomed in FY 2026 as the result of the alternative breakthrough application pathway. This alternative pathway allows breakthrough devices and certain antibiotic and antimicrobial drugs to apply for NTAP using an abbreviated application process.
Transforming Episode Accountability Model Modifications
Proposed Rule: CMS proposed several modifications to the forthcoming CMS Innovation Center TEAM framework. Among the various methodological modifications proposed to this mandatory payment model beginning January 1, 2026, CMS proposed to take the following actions:
- Limit the deferment period for certain hospitals
- Replace the Area Deprivation Index (ADI) with the Community Deprivation Index (CDI)
- Use a 180-day lookback period and Hierarchical Condition Categories (HCC) for risk adjustment
- Remove health equity and health-related social needs data reporting
- Expand use of the Skilled Nursing Facility (SNF) three-day rule waiver
HMA Analysis: The critical aspect of CMS’s TEAM provision is that the agency proposes to follow through with this Innovation Center model while cancelling other Innovation Center payment models in recent months. It also is noteworthy that the agency has proposed to remove the health equity data reporting requirements for TEAM in line with actions taken with many other CMS programs. Another proposal of note is the plan to expand the use of the waiver to circumvent the SNF three-day inpatient stay rule, which will allow hospitals to discharge patients more quickly to SNFs.
Uncompensated Care Payment Increase for Disproportionate Share Hospitals
Proposed Rule: CMS proposes to increase uncompensated care payments to DSHs by $1.5 billion in FY 2026.
HMA Analysis: CMS’s proposal will increase uncompensated care payments to hospitals by 26 percent. This increase is driven by CMS’s assumption that the rate of uninsured people will increase to 8.7 percent of the population in 2026 from 7.7 percent in 2025.
Stakeholder comments on the IPPS proposed rule are due no later than June 10, 2025.
Connect With Us
The Health Management Associates, Inc. (HMA), Medicare Practice Group monitors federal regulatory and legislative developments in the inpatient setting and assesses the impact on hospitals, life science companies, and other stakeholders. Our experts interpret and model hospital payment policies and assist clients in developing CMS comment letters and long-term strategic plans. Our team replicates CMS payment methodologies and model alternative policies using the most current Medicare fee-for-service and Medicare Advantage (100%) claims data. We also support clients with DRG reassignment requests, NTAP applications, and analyses of Innovation Center alternative payment models.
For more information about the proposed policies, please contact our expert below.
[1] U.S. Bureau of Labor Statistics. Table 1. Consumer Price Index for All Urban Consumers (CPI-U): U.S. City Average, by Expenditure Category. Modified April 10, 2025. Available at.
[2] Centers for Medicare & Medicaid Services. 2026 Medicare Advantage and Part D Rate Announcement. April 7, 2025.
April 16, 2025
FY 2026 Medicare Hospital Inpatient Proposed Regulation Signals Several Changes Lie Ahead for the Hospital Industry and Beneficiaries
Webinar Replay – Medicare Town Hall with HMA Experts
This webinar was held on April 30, 2025.
Whether you’re navigating Medicare Advantage policy changes, seeking actuarial insights, analyzing risk-based payment structures, or working to improve integration for Dual Eligibles and align D-SNPs, our team is here to provide actionable insights and answers. We had HMA professionals from across the country share their perspectives and help navigate the complexities of Medicare during this town hall style webinar.
Webinar Replay: PACE Development Best Practices for Policy Makers and Program Sponsors
This webinar was held on May 15, 2025.
Health Management Associates (HMA) conducted a multi-state study to examine the policy decisions influencing the operation and expansion of Programs of All-Inclusive Care for the Elderly (PACE). It explored different program structures, associated advantages and challenges, and strategies to enhance efficiency while meeting regulatory requirements.
This webinar summarized our research on 10 active PACE states (CA, FL, IL, KY, LA, MA, NJ, NY, OH, and WA) that have either implemented or expanded their PACE programs between 2020 and 2024. Using state survey responses and credible third-party, publicly available data, we showcased the outcomes of PACE program development through open and competitive RFP processes. We also outlined development timelines to demonstrate the effectiveness of each approach and highlight key insights gained during the discovery and research phase of the study.
Learning Objectives:
- Comparing the Open versus Competitive RFP approach
- Understanding state-level practices, challenges, and opportunities for improvement
- Review state profiles highlighting: Program development outcomes; Building PACE program capacity; Program development timelines; Fostering PACE growth
How National Mandates in Digital Health & dQM are Transforming Healthcare
Digital quality measures (dQM) are quickly emerging as a cornerstone of healthcare operations, propelled by federal efforts to enhance efficiency, interoperability, transparency, and real-time data sharing. New bipartisan proposals like the Healthcare Efficiency Through Flexibility Act (H.R. 483) highlight just how quickly the legislative landscape can change.
Healthcare organizations face mounting pressure to do more with less. As legislation continues to evolve at both federal and state levels, digital innovation remains a critical, key strategy for driving efficiency and reducing administrative burden.
National mandates, emerging legislative proposals, and regulations continue to set the “rules of the road” for healthcare, including digital quality transformation. New bills can significantly reshape reporting requirements, data standards, and reimbursement models, often on accelerated timelines. Organizations that proactively adapt to these shifting mandates will be better positioned to improve patient outcomes, streamline operations, and remain leaders in this evolving market.
Foundational Legislation
- 21st Century Cures Act (2016): Enacted by the U.S. Congress, this laid the groundwork for modernizing the healthcare data ecosystem using application programming interfaces (APIs). Healthcare related provisions focused on interoperability & usability of electronic health data by preventing information blocking (unreasonable interference with access/ exchange of electronic health information); required certified electronic health records (EHRs) to utilize Fast Healthcare Interoperability Resources (FHIR)-based APIs to promote patient access to their health data.
- The Centers for Medicare & Medicaid Services (CMS) Interoperability & Patient Access Final Rule(CMS-9115-F) (2020): Required CMS-regulated payers (Medicare Advantage, Medicaid, Children’s Health Insurance Program (CHIP), Qualified Health Plan (QHP), and Federally-facilitated Exchanges (FFEs) beginning on or after January 1, 2022, to offer FHIR-based APIs for Patient Access and Provider Directories.
- Mandated Payer to Payer Data Exchange for patients to take their data with them if they change payers.
- Promoted data exchange by requiring hospital participation in sending patient event notifications through an ADT (Admissions, Discharge and Transfer) feed.
- Publicly reporting providers who do not list their digital contact information in the National Plan and Provider Enumeration System (NPPES).
- Further curtailed information blocking by publicly reporting eligible clinicians and hospitals who may be blocking information.
Subsequent federal communication in December 2021 formalized CMS’s decision not to enforce certain provisions of this rule to give payers additional time to comply.
- Health Data, Technology, and Interoperability (HTI-1): Certification Program Updates, Algorithm Transparency, and Information Sharing-Final Rule (2024): This rule, which was issued by the Office of the National Coordinator (ASTP/ONC)[1] introduces significant changes to software supporting care. It implements the Cures Act’s EHR Reporting Program, requiring transparent reporting on certified health IT metrics. It also updated information blocking regulations to make data easier to share. In addition, it established a new standard data model for all “certified” Health IT products: the United States Core Data for Interoperability (USCDI) version 3, starting January 1, 2026. In addition, the voluntary certification program (which has been adopted by 96% of all EHRs) has updated its standards, criteria, and requirements, including standardized FHIR APIs, electronic case reporting using Health Level Seven International Clinical Document Architecture (HL7 CDA) and FHIR-based specifications, revised decision support intervention criteria, and new functionality for patient Electronic Health Information (EHI) restriction requests.
- CMS Interoperability & Prior Authorization Final Rule (CMS-0057-F) (2024): Builds on previous CMS efforts and the 2020 CMS Interoperability & Patient Access Final Rule to improve access to and exchange of health records among patients, providers, and payers. It also focuses on simplifying and modernizing prior authorization processes while expanding data-sharing requirements to reduce administrative burdens. Impacted payers must begin implementing certain measures by January 1, 2026, while most API-related requirements are extended until January 1, 2027, based on stakeholder feedback provided to CMS.
Beyond federal legislation, other influential entities like CMS, National Committee for Quality Assurance (NCQA), and ASTP/ONC, are adopting new frameworks that accelerate the shift to digital quality measurement.
Rapidly Evolving National Healthcare Frameworks & Healthcare Quality Landscape Changes
- CMS National Quality Strategy/Meaningful Measures 2.0 and CMS Digital Quality Measurement Strategic Roadmap (Published in 2022)
These frameworks map out a future in which interoperability and digital measures play a pivotal role in improving care quality and outcomes.
- NCQA’s Shift to Digital Healthcare Effectiveness Data and Information Set (HEDIS)® Measures:
NCQA has taken a significant step in its quality measurement strategy for health plans. Specifically, HEDIS measures are moving to fully digital by 2030, signaling an industry-wide move toward automated data capture and reporting (published in 2024). In addition, they have also launched their Digital Content Services (DCS) product which allows organizations to submit their quality measures digitally for the 2024 measure year. - Digital Quality Implementers Community:
In 2024, a collaborative consensus-based effort was initiated to develop, advance, and standardize tools and platforms that make digital quality measurement possible using open standards instead of proprietary tools. This group is actively working to advance a quality enablement layer including tools, guidance, and standards changes. Leavitt Partners, an HMA company, facilitates this community.
Signals from the Trump Administration Related to Digital Quality
There is ongoing speculation about how the Trump Administration and Congress will approach digital healthcare transformation—particularly in areas like digital quality measurement. Yet multiple indicators suggest they will stay on this course, and perhaps even accelerate the adoption of digital quality measures.
One key signal is that Ryan Howells, a Principal with Leavitt Partners, an HMA Company, is reportedly one of two finalists under consideration for the position of Assistant Secretary for Technology Policy (ASTP). Known as a champion for digital healthcare data, Howells leads the CARIN Alliance, a national group focused on improving health data access. The ASTP/ONC has significant influence in shaping federal regulations for electronic health records and broader data, technology, and artificial intelligence strategies within the Department of Health and Human Services (HHS).
Additionally, recent bipartisan legislation introduced in January 2025 further underscores a commitment to pursuing digital quality transformation as a linchpin for success in a “digital-first” environment, one that prioritizes efficiency and enhanced patient outcomes.
H.R. 483: Healthcare Efficiency Through Flexibility Act
Proposes delaying electronic clinical quality measures (eCQM) adoption until 2030, citing the need to reduce provider burden and pilot more advanced, interoperable reporting tools, including digital quality measurement.
Meanwhile, the national shift toward dQM continues to gain momentum. With eCQM mandates set to begin in reporting year 2025 for Medicare Shared Savings Program Accountable Care Organizations (MSSP ACOs), many organizations view these requirements as redundant and burdensome, given the industry’s rapid move toward fully digital quality. Unlike eCQMs, dQMs leverage more robust structure and standardization, especially through FHIR-based APIs, to enable broader, more timely, and more efficient data capture. The result is a faster path toward high-impact quality measurement and improvement in our increasingly digital healthcare environment.
Major Implications for Healthcare Organizations
- Compliance Deadlines:
Evolving Administration rules can quickly shift timelines, significantly impacting prior authorizations, data exchange, and quality measurement. - Financial & Legal Risks:
Non-compliance may lead to financial penalties, legal actions, or even program exclusion. - Workforce Readiness & Capacity:
Requires strategic communications, robust change management efforts, and advanced technology infrastructure.
Strategic Recommendations
- Cross-Functional Collaboration:
Engage compliance, IT, clinical, and legal teams to track and adapt to new rules. - Stay Flexible:
Monitor Congress, CMS, ONC, and other federal notices regularly, as new bills and guidance can rapidly change targets. - Technology Assessment:
Evaluate interoperability, API readiness, and EHR workflows to identify gaps.
Need a Tailored dQM Strategy?
Contact HMA for best practices, policy insights, and a customized roadmap for your organization.
Learn more about HMA’s approach to dQM.
[1] ONC was renamed to the “Assistant Secretary for Technology Policy/Office of the National Coordinator (ASTP/ONC) in 2024, but in the current administration, may be folded back into CMS.