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The Pediatric Behavioral Health Service Continuum in New Orleans

The Pediatric Behavioral Health Service Continuum in New Orleans

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Landscape Assessment and Gap Analysis of School-Based Primary Care and Behavioral Health for Medicaid-Eligible Youth Pediatric Healthcare Landscape Analysis and Blueprint

THE CLIENT

The client team is a coalition including a group of local and national funders seeking city-level solutions to address gaps in youth behavioral health services, a non-profit educational “quarterback” organization supporting New Orleans schools as they respond to students’ primary and behavioral health needs, and a children’s hospital with a robust, grant-funded school-based primary and behavioral health program exploring where it could uniquely expand impact.

Together, the partners set out to identify system-level opportunities for aligned funding, reduce the extent to which school-based staff are asked to take on additional care coordination work, and expand access for children and families to school-based primary and behavioral health services as well as community- and facility-based behavioral health services. The work focused on strengthening school-based mental health and integrated care pathways for Medicaid-eligible children and adolescents across the full pediatric behavioral health continuum.

BACKGROUND

In New Orleans, youth behavioral health and pediatric mental health needs were becoming more urgent, but the system designed to respond remained fragmented across schools, community providers, hospitals, and public agencies. School leaders and clinicians described referral pathways that were inconsistent and difficult to navigate, limited visibility into where services existed, and few shared accountability mechanisms across sectors—creating gaps in care coordination, crisis response, and follow-up. This made it difficult for stakeholders to coordinate strategy, align resources, or plan for scale.

In parallel, Manning Family Children’s Hospital and its ThriveKids student wellness initiative saw a significant opportunity to expand school based physical and behavioral health services across New Orleans Public Schools. 

School teams were increasingly operating as de facto care coordinators, triaging crises, managing referrals, and filling behavioral health gaps they were not equipped or designed to address. Stakeholders saw school-based health clinics and school-based health centers as a meaningful opportunity to close gaps in behavioral health screening and response, strengthen connections to primary and behavioral health care, and provide care navigation for students and families—including trauma-informed supports, universal screening, warm handoffs, and alignment with multi-tiered systems of support (MTSS).

This project brought together multiple stakeholders—including philanthropy, education, hospitals, and non-profits—to fund and lay the foundation for a shared view of need and opportunity. Because HMA has credibility across these sectors, we were able to support cross-sector collaboration and create a common fact base to guide investment decisions. Partners also recognized a specific local imperative: Medicaid-eligible youth and public school students needed better access to coordinated primary and behavioral health care, and the community needed a neutral, trusted convening entity to provide backbone coordination and accountability mechanisms.

APPROACH

HMA applied a mixed-methods, system-level approach to understand both the supply of services and the lived experience of accessing care. This behavioral health needs assessment combined service mapping, Medicaid data analytics, and stakeholder input to evaluate the continuum of care—from prevention and early intervention to crisis stabilization, day treatment, and residential treatment. This included: 

Quantitative analysis of Medicaid utilization data to assess service reach, gaps, and demand across the pediatric behavioral health continuum 

Survey of school-based and community-based services, including primary care, behavioral health, and higher-acuity treatment options 

Stakeholder engagement through 20+ interviews, focus groups, and surveys of school staff and providers to capture real-world barriers and system dynamics 

Gap analysis using national benchmarks to estimate unmet need and quantify where the system falls short 

Feasibility and opportunity assessment, evaluating not just need, but financial viability, workforce constraints, and implementation pathways

HMA used a unique approach for this analysis. in the absence of extensive utilization data and services, HMA used the Academy of Child and Adolescent Psychiatry’s framework for the continuum of pediatric behavioral health services as a standard. We cross-referenced this with New Orleans population and Medicaid enrollment data and national utilization data to estimate how many children in New Orleans would be expected to participate in each service on the continuum and assessed the feasibility of launching or expanding each service based on an assessment of the regulatory landscape, viable revenue sources, and projected demand for each service. 

We then translated these findings into a practical, phased roadmap, grounded in local context and designed to align funders, providers, and schools around a shared strategy.

RESULTS

This effort provided the first-ever integrated view of the pediatric behavioral health system in New Orleans, spanning school-based health centers/clinics, community providers, and facility-based care—and translating findings into practical options to improve access, care navigation, and crisis stabilization for Medicaid-eligible youth. 

For behavioral health professionals working in schools, state agencies, and clinical settings, the assessment produced an actionable picture of where the system breaks down—and where investments and operational changes can measurably improve access and outcomes for Medicaid-eligible youth and public school students. Only ~2% of Medicaid-eligible youth are currently receiving school-based behavioral health services. 

Clarified the role schools are being asked to play in a fragmented system—often functioning as care coordinators and first responders to behavioral health need—strengthening the case for school-based health clinics/centers with standardized screening, warm handoffs, and care navigation supports. 

Documented drivers of avoidable acute-care utilization, including gaps in community-based care: an insufficient number of providers willing to accept Medicaid, limited availability of evidence-based treatment, and the absence of respite and crisis residences—factors that can push families toward emergency departments and inpatient settings. 

Balanced a community-first strategy with realistic capacity planning—identifying opportunities to mitigate the need for some facility-based services by strengthening community-based behavioral health, while also underscoring the continued need for day and residential treatment facilities to address behavioral health and substance use needs when higher levels of care are clinically indicated. 

Elevated the need for intermediary coordination to reduce silos and improve accountability across healthcare and education. The work provided a concrete rationale and initial design considerations for a neutral, trusted convening entity to coordinate primary and behavioral healthcare for Medicaid-eligible youth and public school students in New Orleans—an increasingly important model for cross-sector collaboration that has been difficult to implement effectively in practice.

Overall, the work supports a scalable model for integrated school-based behavioral health, Medicaid-aligned financing, and cross-sector care coordination—helping communities strengthen prevention, early intervention, and access to the right level of treatment.

Importantly, HMA’s work does not stop at identifying gaps—we help clients prioritize investments, structure partnerships, and build the infrastructure needed for long-term system transformation. HMA can help organizations implement this kind of organizational change, by bringings a unique combination of: 

Deep expertise in Medicaid, behavioral health systems, and school-based care, enabling rigorous analysis of both financing and service delivery 

Proven ability to integrate quantitative data with stakeholder insight, ensuring recommendations reflect both system realities and lived experience 

Experience designing and implementing system-level solutions, not just conducting assessments 

Cross-sector credibility, allowing HMA to convene and align funders, healthcare providers, educators, and public agencies 

Practical, implementation-focused approach, translating complex findings into actionable strategies that are financially and operationally viable 

Contact us to learn more.

Webinar

Webinar Replay – From Policy to Practice: Exploring CMMI Value Based Care Initiatives and Unlocking Value in Safety-Net Care

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This webinar was held on May 27, 2026.

CMS, through CMMI, has multiple new models focusing on value based care, continuing to push the envelope towards improving care through their programs. In this webinar, experts examined how organizations are able to seize opportunities through operationalizing these models and what it means for safety net providers, health systems, and community-based organizations. The discussion focused on practical insights, emerging challenges, and strategic opportunities to drive impact and sustainability under new models.

Learning Objectives:

  • Understand recent and emerging CMMI models, including its policy intent, structure, and implications for Medicare beneficiaries and safety net providers
  • Examine and gain insights from organizations implementing CMMI aligned models of care, including care model design, infrastructure, and partnerships
  • Identify strategic opportunities for health systems, ACOs, and community-based providers to maximize impact and sustainability

Featured Speakers:

Royal Tuthill, SVP of Networks Pair Team

Lance Donkerbrook, ACO Executive Director P3 Health Partners

Blog

Turning Insight into Action: The New Operating Reality in Behavioral Health

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Thousands of behavioral health leaders, clinicians, advocates, and industry partners convened during NatCon 2026, April 27–29 in Denver, CO—one of the sector’s largest annual gatherings. This year, the event was more focused and pragmatic than in recent years. Although behavioral health providers still face significant pressure, there was also a noticeable shift toward how organizations can move toward sustainable models for growth, technology adoption, and integrated care delivery.

Health Management Associates (HMA) colleagues attended the event to listen, connect, and contribute to the meaningful conversations. Many of the themes and industry trends we have been tracking emerged consistently throughout the conference. In this article, our behavioral health experts discuss their collective insights and the road ahead for behavioral health interest-holders.

Key Themes from NatCon 2026 

Financial resilience remained at the forefront.

Behavioral health organizations continue to respond to constrained funding conditions, evolving reimbursement dynamics, and the need to diversify revenue beyond unstable and uncertain grant support and rate reimbursement volatility.

Operational visibility was closely tied to financial resilience.

Leaders discussed the need for a clearer, more real-time understanding of their performance. Performance was considered broadly to include financial indicators, clinical outcomes, and workforce capacity. Data and measurement have moved from a “nice to have” to “essential” for effective engagement with payers.

Innovation conversations are shifting toward implementation.

Artificial intelligence (AI) and digital tools were still hot topics, but the discussion has moved toward implementation and effective deployment. Conversations centered on practical use cases such as clinical documentation support, measurement-based care linked to improved health outcomes, and better integration with electronic health records (EHR).

This year’s conference highlighted enduring opportunities and challenges for the field, including:

  • Core service priorities, such as crisis response, suicide prevention, collaborative care and increased opportunities around Certified Community Behavioral Health Clinics (CCHBCs), and value-based payment strategies for financial resilience 
  • Workforce sustainability, with organizations looking to reduce administrative burden, strengthen recruitment and retention, and support staff well-being while demand for services continues to rise

Behavioral Health Industry Trends

The industry trends emerging from NatCon 2026 suggest that behavioral health organizations are entering a more disciplined operating environment to maximize efficiencies and ensure long-term sustainability in what seems sometimes to be a chaotic environment. Organizations are placing greater emphasis on their Medicaid strategy, managed care contracting, and value-based arrangements that reward outcomes and continuity of care. There is also continued momentum behind integrated models that connect behavioral health with primary care, public health, and community-based supports. Rather than treating mental health and substance use services as isolated programs, providers are increasingly building coordinated systems that address whole-person needs across settings.

Another notable trend is that technology is becoming a clearer differentiator. Some organizations are piloting or scaling technology, while others are taking a more cautious approach. Discussions surrounding AI in particular appeared to have matured significantly, with attention moving from abstract concerns toward change management, sequencing of use cases, return on investment, governance, and clinician trust. In that sense, technology is moving from being a side initiative to a strategic differentiator.

Transformation in the Behavioral Health Field

We were struck by the level of alignment across different parts of the field. Many of the themes we heard reinforced what providers experience daily—the need to manage uncertainty while continuing to meet the growing demand for services and more intentional use of data, infrastructure, and outcomes measurement.

More broadly, the conversations throughout the conference pointed to a field that is moving toward greater pragmatism. There is still a clear need for additional resources, but there is also growing recognition that adaptability will serve an equally important role.

How We Can Help

One of the most valuable aspects of NatCon is the opportunity to compare experiences across organizations and regions. The themes emerging from this year’s conference reflect broader shifts happening across the behavioral health landscape. 

A key role of our team is to connect what we hear in different settings and share it in a way that is useful for others in the field—highlighting emerging approaches, surfacing common challenges, and creating opportunities for peer exchange.

For questions about the market dynamics or approaches to strengthen your organization’s adaptability,  contact one of our HMA experts.

Blog

Why Children’s Behavioral Health Demands Action Now

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Practical Strategies for Medicaid, Schools, Hospitals, and Communities

During Children’s Mental Health Awareness Week, May 3–9, and Mental Health Awareness Month, we are spotlighting actionable solutions across the US children’s behavioral health system. This post is intended for children’s behavioral health providers, state Medicaid agencies, school-based health centers, hospitals, local government agencies, local education agencies (LEAs), child welfare agencies, and philanthropic organizations that are working to strengthen prevention, crisis response, care coordination, and community-based continuums of care. HMA has a robust and growing team of behavioral health experts who support this work and have developed a series of case studies showcasing practical strategies implemented with clients—from crisis system design and referral pathway improvements to financing and implementation roadmaps.

Children’s Mental Health Awareness Week is a reminder that children’s behavioral health and youth mental health are not niche issues. They are systemic issues that require coordinated action across Medicaid, education, public health, hospitals and health systems, child welfare, and local government—especially where schools and community partners are on the front line.

The need remains substantial. The Centers for Disease Control and Prevention’s (CDC’s) 2023 Youth Risk Behavior Survey results, released in 2024, showed that 40% of high school students reported persistent feelings of sadness or hopelessness, even as some measures improved from 2021 levels. CDC also highlighted how bullying, safety concerns at school, racism, unfair discipline, and frequent social media use are tied to youth mental health risks.

The Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) 2024 National Survey on Drug Use and Health, released in 2025, adds another important dimension. Among adolescents ages 12–17, the 2024 survey found that:

  • 15.4% experienced a major depressive episode within the past year
  • 10.1% had serious thoughts of suicide
  • About 40% who had a major depressive episode in the past year did not receive mental health treatment

The data show that progress is possible when systems respond with real capacity, access, and support. That is why this moment calls for more than awareness. It calls for action that is operational, financeable, and grounded in what works.

At HMA, we work with child-serving systems that are trying to solve real problems, including how to strengthen crisis response, improve referral pathways, build a more coherent continuum of care, and connect strategy with implementation.

Over the coming weeks, we will feature three examples that reflect different parts of the children’s behavioral health landscape.

1. Children’s hospital mental health strategy and crisis response

This case study will highlight work to help a children’s hospital strengthen its mental health approach and support next-stage crisis system design.

In this engagement, HMA partnered with Rady Children’s Hospital Orange County to move pediatric behavioral health from strategy to implementation—aligning emergency department (ED) mental health workflows, clarifying pediatric crisis pathways, building an investment-ready fiscal pro forma, and advancing priority programs to strengthen access and care coordination. This work can inform hospitals and health systems, Medicaid agencies, and community partners seeking to reduce ED boarding and improve pediatric crisis response.

2. County-level ecosystem and referral system improvement

This case study will show how local systems can bring multiple stakeholders together to improve referral pathways and make behavioral health more accessible for children, youth, and families.

HMA supported a county-led effort to strengthen cross-system referral pathways by aligning agencies around shared intake and triage practices, clearer roles and accountability, and more navigable access points for families. This approach is relevant for local government agencies, LEAs, school-based health centers, child welfare agencies, and community providers working to reduce fragmentation and speed connection to the right level of care.

3. Building a stronger children’s behavioral health continuum in New Orleans

This case study will focus on assessing gaps, identifying opportunities, and supporting a more coherent community-based continuum for children’s behavioral health.

HMA helped deliver the first integrated view of pediatric behavioral health in New Orleans, LA, aligning schools, healthcare, philanthropy, and government around a shared understanding of unmet needs and critical system gaps, as well as charting a prioritized roadmap to strengthen and better coordinate the continuum of care.

What It Means for Key Child-Serving Audiences

  • Children’s behavioral health providers: Prepare for stronger care coordination expectations (warm handoffs, follow-up after crisis, shared care plans) and increased demand for community-based alternatives to the ED
  • State Medicaid agencies: Focus on financeable crisis continuums (including pediatric crisis response), payment and contracting approaches that support access and continuity, and data/reporting that demonstrates outcomes
  • School-based health centers and LEAs: Strengthen referral pathways, clarify roles between schools and providers, and build protocols that support early identification while keeping students connected to safe learning environments
  • Hospitals and health systems: Improve pediatric ED mental health workflows, create clearer crisis pathways, and develop investment-ready business cases for behavioral health capacity and partnerships
  • Local government agencies: Convene cross-system partners, establish shared intake/triage and accountability, and use implementation roadmaps to move from planning to operational change
  • Child welfare agencies: Align behavioral health access for children and youth involved with child welfare, reduce handoff failures, and integrate crisis planning into placement stability and permanency strategies
  • Philanthropy: Target catalytic investments that fill continuum gaps, build capacity for implementation (not just planning), and support cross-system governance and measurement

The common thread among these examples is a simple belief: Children’s behavioral health improvement does not happen through aspiration alone. It happens when organizations and public systems translate urgency into design, partnerships, financing strategies, and implementation steps.

That is also why children’s behavioral health is so relevant. National data still point to high levels of distress and suicide risk among adolescents, despite recent improvements. CDC’s findings show how strongly youth mental health is shaped by the environments in which they live, learn, and play—especially their schools and communities.

For leaders in Medicaid, behavioral health, child welfare, education, county government, hospitals, and provider organizations, the question is not whether children’s behavioral health deserves attention, but rather is how to build systems that respond earlier, coordinate better, and support children and families more effectively.

We hope this series contributes to that conversation by sharing practical examples of work that can inform future action.

Other Resources on Children’s Behavioral Health and Youth Mental Health

Contact us to discuss how HMA can support your children’s behavioral health strategy—whether you work for a Medicaid agency, hospital/health system, school-based health partner, LEA, local government agency, child welfare agency, provider organization, or philanthropic funder. We can help with crisis continuum planning, care coordination design, referral pathway improvement, financing and pro forma development, and implementation support.

Solutions

Children’s Behavioral Health Consulting

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HMA Solutions

Children’s Behavioral Health Consulting

Cross‑System Solutions for Schools, Health Systems, and State & Local Agencies

The US children’s behavioral health system is facing significant strains. Workforce shortages, fragmented funding and accountability, and rising demand are converging in the places where children spend time and receive care. Healthcare systems are seeing the impact in emergency departments and inpatient units, schools are expected to respond to student needs without sufficient capacity, and state and local agencies face pressure to align policy, financing, and programs across behavioral health, Medicaid, child welfare, and education.

How HMA Can Help

HMA partners with child-serving systems to translate urgency into practical, financeable, implementable improvements, strengthening the continuum from prevention and early intervention to crisis response and recovery. Examples of services we provide include:

Landscape assessments and needs analyses (qualitative and quantitative)

Stakeholder engagement and facilitated convenings (including family, youth, community, and cross-agency partners)

Gap analysis and service continuum design (school-, community-, and facility-based)

System and model redesign, including governance, referral pathways, and care coordination across settings

Strategic planning and implementation support (operational roadmaps, change management)

Regulatory and policy analysis to support compliant, scalable program models

Workforce strategy and provider training to build sustainable capacity

Financial modeling, including fiscal pro formas and revenue cycle considerations

Site assessments and facility studies to support service expansion and optimization

Who We Serve

We support providers, health systems, children’s hospitals, schools, school-based entities (including local education agencies [LEAs]), state and local government agencies and community-based partners working to improve children’s behavioral health.

Common Challenges

Fragmentation across child-serving systems,

Workforce shortages and training needs,

Misaligned financing and accountability, and

The operational challenge of coordinating care across school, community, and clinical settings.

Where We Help

Hospitals and Health Systems
Strengthen pediatric behavioral health strategy and operations—improving crisis pathways, clarifying roles across ED/inpatient/outpatient settings, and connecting clinical services to community and school-based partners

Schools, LEAs, and School-Based Entities
Build sustainable school mental health approaches—right-sizing service tiers, strengthening referral and care coordination, and aligning school-based services with Medicaid, community providers, and crisis systems

State and Local Government, Child-Serving Agencies, and Community-Based Partners
Advance cross-system solutions—aligning policy, financing, and accountability across behavioral health, Medicaid, child welfare, and education, while building implementable continuums of care that improve access and equity. 

HMA Differentiators

Cross-setting expertise. We work across schools, community-based systems, and healthcare delivery settings, helping partners design handoffs and shared accountability rather than isolated programs.

Implementation and financing. We connect strategy to operations and the realities of financing, reimbursement, and sustainability so plans can move toward successful implementation and delivery.

Multidisciplinary team. Our team includes clinicians, program administrators, researchers, and former state and local leaders with deep knowledge of children’s behavioral health ecosystems. Many of us are parents and grandparents ourselves who are passionate about and personally invested in this work.

Partnership-first approach. We bring a collaborative, community-grounded process that centers children, youth, and families and builds durable cross-sector relationships.

Local context, national perspective. We tailor solutions to market dynamics, resources, and policy environments while bringing lessons learned from diverse geographies and client types.

Other Resources

Blog

Why Children’s Behavioral Health Demands Action Now

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Spotlight

Improving Youth Behavioral Health Through School-Based Initiatives

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Spotlight

From Crisis to Coordinated Care: Six Behavioral Health Priorities for Hospitals and Health Systems

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Let’s strengthen children’s behavioral health—together.

Whether you’re leading in a hospital or healthcare system, a school or LEA, or a state or local agency, we can help you align partners and build an implementable plan across the continuum of care.

Contact us to discuss your priorities and identify next steps.

Blog

Join us at HMA’s 2026 National Conference: Signals, Signs & Flashing Lights

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Registration is now open for the Health Management Associates (HMA) 2026 National Conference, US Healthcare 2026: Signals, Signs & Flashing Lights, October 5–7 in New Orleans, LA. 

HMA’s conference is intentionally structured to bring together leaders who are shaping decisions across sectors—those setting policy, managing risk, leading clinical operations, and innovating approaches to improve outcomes—to engage in candid conversations about what is working, what is not, and what is changing in Medicare, Medicaid, Marketplace and adjacent programs. In an environment defined by new challenges and “flashing lights,” even the most seasoned healthcare leaders will find value in stepping out of their day‑to‑day roles to compare strategies, test assumptions, and learn from peers facing similar pressures. 

This year’s conference is designed to reflect the environment healthcare leaders are navigating today—one defined less by policy certainty and more by shifting expectations and competing pressures on cost, access, and performance. Our experts are crafting discussions to address how organizations are approaching policy engagement in this environment, including new strategies for interpreting signals from federal and state policymakers and negotiating policy frameworks that directly shape market dynamics. 

Across plenary sessions, breakout discussions, and HMA’s signature coffee conversations, the conference will focus on how organizations are interpreting these signals and translating them into practical strategies. 

Programming will center on four cross-cutting themes shaping healthcare decision-making: 

  • Managing risk and cost amid continued financial pressure. Discussions will examine the drivers of utilization and affordability trends across Medicare, Medicaid, and commercial markets and which strategies are demonstrating measurable impact. 
  • Sustaining access and system stability. The agenda also will focus on how providers, health systems, and state programs are maintaining access amid workforce challenges, coverage transitions, and ongoing financial strain.
  • Turning innovation into impact. Sessions will explore where artificial intelligence (AI) and digital health tools are delivering measurable operational or clinical impact and what it takes to implement them effectively. 
  • Building partnerships that last. Conversation will highlight how stakeholders are aligning incentives, funding, and strategy to move from short-term responses to long-term, sustainable solutions. 

As in prior years, the HMA National Conference is structured to support candid dialogue, actionable takeaways, and meaningful connections. Attendees consistently highlight the opportunity to move beyond high-level trends and engage in practical discussions that inform decision-making in their organizations. 

Early-bird registration is now available for a limited time. The 2026 Sponsor Prospectus includes new opportunities for your organization. Additional agenda details, featured speakers, and interactive programming announcements will be released in the coming weeks. 

Brief & Report

The New Uninsured: State Policy Options for Californians Losing Medi-Cal Coverage

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HMA’s new report for the California Health Care Foundation explains how recent federal and state policy changes could cause up to two million Californians to lose Medi-Cal coverage. These changes will place new strains on the state budget and safety-net system. The report outlines practical short-term program paths California could use to preserve access to care while full-scope coverage is restored. It summarizes the policy and fiscal context (including work requirements, more frequent eligibility checks, and immigrant eligibility restrictions), describes stakeholder-informed design goals (statewide access, privacy protections, fiscal prudence, scalability, and safety-net stability), and presents two illustrative coverage alternatives with modeled cost ranges and key trade-offs in benefits, provider payment rates, cost sharing, and bridge-period design.

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Outlook 2026: A Conversation on Medicare Draft Payment Rules

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As the Centers for Medicare & Medicaid Services (CMS) advances through the 2027 Medicare payment rule cycle, stakeholders across Medicare Advantage (MA) and the provider community are assessing how proposed changes could affect payment, utilization, and longer-term revenue. To better understand what to watch as draft rules move toward finalization, Jen Colamonico, Vice President, Strategy and Communications at Health Management Associates (HMA), caught up with Rachel Stewart, Senior Consulting Actuary with Wakley, an HMA Company. Of particular interest was CMS’s decision to eliminate the Inpatient Only List (IPO) over a three- year period.

Q: As CMS begins releasing draft payment rules for 2027, what stands out most to you from a budgetary perspective?
Rachel: Timing and uncertainty really stand out. These policies don’t operate in isolation. Changes to Medicare fee-for-service (FFS) payment ultimately affect Medicare Advantage benchmarks, provider contracting, and long-term revenue expectations. Because bids, budgets, and contracts are set before rules are finalized, modeling different scenarios becomes essential. 

Q: One issue that has garnered significant interest is CMS’s decision to phase out Medicare’s Inpatient Only (IPO) policy, which is a list of procedures and services that must be provided on an inpatient basis. In 2026, CMS eliminated nearly 300 services, mostly musculoskeletal services, from the IPO list. How are Medicare Advantage plans thinking about the Inpatient Only list specifically? 

Rachel: Historically, many MA plans have followed the IPO policy even though they weren’t required to do so, largely because it simplified operations and aligned with Medicare fee-for-service payment systems. Plans do have flexibility in how they contract with providers, and we see a wide range of approaches in the market. Some contracts closely mirror FFS, while others incorporate more customized arrangements or risk sharing. Because of that, the direct impact of IPO changes will vary significantly across plans and provider relationships. 

Q: Where do you see the biggest potential impact for Medicare Advantage?
Rachel: I think the bigger impact may be indirect rather than tied to individual contract changes. Medicare Advantage benchmarks are driven by underlying fee-for-service spending trends. If CMS anticipates lower overall inpatient spending as procedures move to outpatient or ambulatory surgical center settings, that expectation could show up in benchmark growth rates. Even relatively small changes in benchmark growth can affect plan revenue, rebates, and benefit flexibility. 

Q: Are you already seeing signs of that in the data?
Rachel: We do see lower inpatient trends reflected in the 2027 and 2028 US per capita cost projections. It’s still unclear what’s driving those trends—whether its assumptions related to the IPO list removal or other factors. We’ve asked CMS for more clarity. From an actuarial standpoint, understanding what’s baked into those projections is critical, because so many MA financial decisions flow from them. 

Q: How does this uncertainty affect provider planning, especially for hospitals?
Rachel: Providers are understandably concerned about potential revenue shifts if cases move out of the inpatient setting. But in Medicare Advantage, the picture is more nuanced than in fee-for-service. Many MA arrangements include risk sharing, medical loss ratio targets, and quality incentive payments. If overall costs decline, providers may share in savings through those mechanisms. So, while there may be pressure on inpatient revenue, it’s not necessarily a one directional loss. 

Q: Does that mean the overall impact may be less dramatic than it appears?
Rachel: Potentially, yes—especially for organizations already participating in value-based arrangements. A reduction in unit costs doesn’t automatically mean a reduction in total provider revenue in MA. The redistribution of dollars through shared savings and quality bonuses can offset some of that pressure. That’s why understanding contract structure is just as important as understanding the policy itself. 

Q: What about quality and patient safety as procedures move to lower cost settings?
Rachel: Quality is always central in Medicare Advantage, and plans are already managing a lot of complexity related to Star ratings and quality measurement. We haven’t yet seen specific quality safeguards tied to the IPO list changes, but I would expect more discussion in the forthcoming proposed rules. From the MA side, contracting remains a key lever. Plans still have flexibility to ensure procedures are performed in appropriate settings and to align incentives with quality outcomes. 

Q: What steps do you recommend to stakeholders to prepare for the final rule and for 2027?
Rachel: Modeling helps organizations understand the range of possible outcomes rather than betting on a single assumption. We’re looking at different utilization scenarios, site of care shifts, and benchmark growth trajectories. For providers, modeling can inform contract negotiations and capital planning. For plans, it helps assess revenue risk and benefit design flexibility. It doesn’t eliminate uncertainty, but it helps organizations make informed decisions. 

Q: If you could change one thing about how these policies are rolled out, what would it be?
Rachel: Transparency. The more clarity CMS can provide around cost projections and assumptions—especially those affecting benchmarks—the better positioned actuaries, plans, and providers will be to respond. So much of Medicare Advantage pricing relies on understanding how fee-for-service is expected to evolve. Greater transparency helps everyone plan more responsibly. 

HMA’s Medicare Practice Group Can Help 

As CMS moves closer to finalizing the 2027 payment rules, actuarial modeling will continue to be an important tool for translating policy direction into financial strategy. For MA plans and providers alike, early analysis and scenario planning can help mitigate risk and identify opportunity as Medicare’s payment landscape continues to evolve. 

For additional insights, listen to Rachel Stewart and Zach Gaumer on HMA’s Vital Viewpoints podcast. Learn more about our Medicare services and solutions. 

Blog

Early Signals from a Pivotal ACA Enrollment Year

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On April 15, 2026, Wakely Consulting Group, an HMA company, published “Who Paid, and Who Stayed? Early 2026 Enrollment Trends in the Individual Market,” the first comprehensive nationwide look at 2026 enrollment trends in the Affordable Care Act (ACA) market. While the Centers for Medicare & Medicaid Services (CMS) has released 2026 plan selection data, the Wakely report addresses who retained coverage and who did not, what we still don’t know, and what we should be watching for throughout the rest of the 2026 plan year.

This article highlights key findings in the report, related state-level data, impacts and takeaways, and actions states and other interest-holders should consider as they look to mitigate further coverage losses and address market stability in& plan year 2027 and beyond.

Key Findings from the ACA Marketplace Early Enrollment Trends Report 

The Who Paid, and Who Stayed report is based on analysis of data from the Wakely National Risk Adjustment Reporting (WNRAR) project, which includes summary data from participating ACA-compliant individual market plans. WNRAR includes data from over 75 issuers representing nearly 80 percent of enrollment the individual market. Key national findings in the report include:

  • Only 86% of enrollees paid their January 2026 premium. 
  • State variation is significant, ranging from as low as 63% paid in January to as high as 99%. 
  • The overall average enrollment decrease is estimated to be between 17% and 26% lower than 2025, with morbidity projected to worsen by 2.9–6.5%. 

The report highlights shifts in plan choice activity driven by affordability pressures, which resulted in considerable migration away from richer benefit plans to plans with lower premiums and higher out-of-pocket maximums. Examples include:

  • Silver plan enrollment fell approximately 17% from 2025. 
  • Bronze enrollment increased by more than 10%. 
  • More than 13% of 2025 Gold plan enrollees selected a lower priced, Bronze tier plan in 2026. 

The report also demonstrated the importance and value of outreach, operational excellence, and state-level affordability mitigation strategies. Examples include: 

  • Enrollment decreases are lower in states with state-based marketplaces (SBMs) and expected to stay lower than Healthcare.gov states, largely because of proactive outreach and marketing initiatives, lower net premium increases, and state affordability programs. 
  • States with premium alignment and silver-loading as a policy lever for improving gold plan affordability are seeing results. Gold plan enrollment increased by 10 percentage points in states where gold plans cost less than silver plans, whereas gold enrollment did not materially change in states where silver plans cost less. For states, this provides a lever to assist consumers seeking to shift into plans with lower cost-sharing without increasing premiums.

State-Reported Early Enrollment Results 

Many states warned of coverage losses as a result of changing federal policies and the expiration of enhanced premium tax credits (ePTCs). State-specific reporting for 2026 validates the findings in the Wakely report. The recently released state-level data from SBMs affirms that the drop-off in enrollment through cancellations and dis-enrollments is significant. It also illustrates that state efforts to mitigate and address affordability gaps have worked to some extent but have not been enough on their own to head off coverage losses in 2026. Examples are as follows: 

  • In Georgia—the only SBM without Medicaid expansion—enrollment fell 27% from an estimated 1.3 million in April 2025 to approximately 950,000 in April 2026. 
  • In New Jersey—a state with state-funded premium subsidies, a reinsurance program, and a mandate that residents have health insurance—enrollment has decreased by more than 11% since April 2025. 
  • In California—another state with premium subsidies, facilitated enrollment, and an individual mandate—effectuated enrollment decreased by 7% from February 2025 to February 2026. 
  • Overall, SBMs are reporting that coverage drops were 24% higher from January to March 2026 than during the same period in 2025 and that the rate of plan shifting from Silver to Bronze increased significantly, quadrupling in six states. 

Downstream Impact on Healthcare Access and Uncompensated Care 

While not yet apparent in the early enrollment data, the downstream impact of 1) coverage losses, 2) increased enrollment in plans with higher cost-sharing, and 3) a worsening risk pool on the health of consumers, as well as the healthcare system, will be significant. Consumers may decide to postpone or forgo necessary care, which could lead to avoidable and more costly healthcare conditions. Increases in the number of people who uninsured and underinsured will have a direct and negative economic impact on provider finances, which are already strained, and uncompensated care and demands on patient assistance programs will increase accordingly. 

Looking Ahead 

The individual market will continue to evolve and change in the coming years as a result of future regulatory and operational changes. A shortened Open Enrollment Period, increased Medicaid redetermination requirements, and new pre-enrollment verification requirements are notable initiatives that are expected to roll out in the coming years.

Healthcare organizations and government agencies should consider the effect of these changes, including further coverage losses and instability in the individual market driven by the administrative complexity of these changes.

In addition, there are potential federal changes such as expanded availability of catastrophic plans, the introduction of non-network plans, and additional eligibility changes, which could put further strain on ACA Marketplace operations and the individual market.

Getting ahead of these changes will be critical to mitigating coverage losses and ensuring the long-term stability and viability of the individual market. In a federal policy environment that has largely deferred acting on ACA affordability, we expect policymakers, issuers, and other interest-holders to increasingly look to governors and state legislatures for decisive action. State subsidy and reinsurance programs are established affordability mechanisms that can provide consumers with affordability relief quickly, assuming state funding is available.

These investments can pay off for consumers from an economic perspective as well. For every additional dollar spent on state subsidies or reinsurance to maintain or increase coverage, states can expect to see reductions in uncompensated care, less reliance on patient assistance programs, and decreases in the number of consumers who forgo or delay care. In addition, investments in enrollment operations and assistance, outreach, and education will be critical to ensuring consumers are aware of the changes ahead and the actions they need to take to access and stay covered.

Connect with Us 

Health Management Associates, Inc. (HMA), and Wakely colleagues are closely tracking federal policy activity and state actions to address these challenges. Our experts support states, issuers, consumer groups, and other interest-holders to achieve success in the operation of and participation in the marketplaces. Our team has broad historical knowledge of the challenges and opportunities in this market and can support every step of the planning and execution processes to improve affordability and stability as it evolves in the coming months and years. 

Contact our experts below with questions about the report and to discuss opportunities to address the trends and forthcoming changes in the market. 

To read more about the changes ahead, see the following reports: 

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