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From Policy to Practice: HMA Offers New Toolkit for Tackling the Challenges of Implementing the 1115 Justice-Involved Reentry Demonstration in Carceral Settings

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The Section 1115 Justice-Involved (JI) Reentry Demonstration marks a transformative step in closing the healthcare gap for incarcerated individuals. By allowing Medicaid coverage to resume up to 90 days prior to release, the demonstration aims to improve care continuity and reduce recidivism. Yet, translating this vision into action within jails, prisons, and juvenile detention facilities presents a host of operational challenges. For implementation to succeed, jurisdictions must navigate fragmented systems, strained resources, and competing priorities. That’s where structured tools—like implementation checklists—become essential.

The Challenges: Implementation in Complex, High-Stakes Environments

Implementing the 1115 JI Reentry Demonstration is more than a policy shift—it’s a systemic overhaul that requires cross-agency collaboration, infrastructure alignment, and cultural change. Among the most significant challenges:

1. Fragmented Systems and Data Silos

Carceral systems, Medicaid agencies, and community-based providers often operate in silos, using different data platforms and standards. This fragmentation hinders real-time information exchange and care coordination during the transition from incarceration to the community.

2. Operational Readiness Gaps

Many facilities lack established procedures for conducting Medicaid eligibility screenings, care plan development, and referrals to community-based services within the release window. Without predefined workflows, implementation can stall.

3. Workforce Capacity and Training Needs

Reentry planning demands coordination among correctional officers, social workers, nurses, behavioral health clinicians, and Medicaid staff. Many jurisdictions face staffing shortages and limited training on trauma-informed care, care management, or reentry protocols.

4. Policy Misalignment and Legal Constraints

Local policies may restrict access to Medicaid-related functions during incarceration, or limit facility staff’s ability to share data. Misinterpretation of federal and state rules can create implementation delays.

5. Trust and Engagement Barriers

Justice-involved individuals often face stigma or mistrust from systems they’ve interacted with. Culturally responsive engagement strategies are crucial but frequently underdeveloped.

The Solution: Using a Checklist-Based Implementation Framework

To navigate these hurdles, stakeholders need more than vision—they need structure. Implementation checklists tailored to jails, prisons, and juvenile facilities serve as a practical roadmap that transforms policy goals into operational plans. Here’s how they help:

  • Clarify Roles and Responsibilities

Checklists break down complex goals into clear, role-specific tasks—who enrolls individuals in Medicaid, who develops care plans, and who ensures warm handoffs to community providers.

  • Promote Cross-Sector Coordination

Structured checklists prompt regular touchpoints across agencies—corrections, health services, Medicaid, and behavioral health—ensuring alignment and accountability.

  • Standardize Procedures and Tools

By specifying recommended workflows, assessment tools, and communication protocols, checklists minimize variation and streamline implementation across facilities.

  • Track Progress and Gaps

Built-in progress indicators make it easier to monitor what’s completed, what’s pending, and where additional support or training is needed.

  • Support Compliance and Evaluation

A checklist-based approach provides the documentation trail needed for program audits, reporting, and continuous quality improvement.

Conclusion: A Strategic Tool for Lasting Impact

Implementing the Section 1115 JI Reentry Demonstration is a bold, necessary move toward health equity and system transformation. But success depends on more than ambition. With structured checklists in hand, agencies can move from aspiration to execution—building a thoughtful, well-orchestrated reentry infrastructure that improves health outcomes, reduces recidivism, and meets federal expectations.

Download the HMA JI Toolkit here.

Other 1115 demonstration resources that may be of interest:

Blog

President Issues Executive Order Calling for Most Favored Nation Drug Pricing

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On May 12, 2025, the President signed an Executive Order (EO), Delivering Most-Favored-Nation Prescription Drug Pricing to American Patients.” The EO calls for or, in some cases, presumes a range of manufacturer, administrative and regulatory actions to reduce drug prices, but ultimate outcome remains unclear.

HMA experts, including Leavitt Partners, an HMA company, are closely following executive agency and stakeholder responses to the EO. In this article, our experts summarize the EO and identify key considerations for healthcare stakeholders.

Policy Overview

Since his first administration, President Trump has consistently criticized disparities in brand-name prescription drug prices between the United States and other developed countries. In 2018, the previous Trump Administration issued a preliminary proposal to institute an International Pricing Index (IPI) model targeting Medicare payments for a subset of clinician-administered drugs. The IPI model would have set a Medicare payment amount for select Part B drugs at a lower amount to align with international prices and allow for negotiation of prices, while still providing a drug add-on payment to providers consistent with historical drug costs.  In November 2020, the administration issued an interim final rule (IFR) instituting an escalated version of this concept, entitled the Most Favored Nation (MFN) Model. Both the IPI proposal and the MFN final rule, the latter of which was enjoined by the courts on largely procedural grounds and later rescinded by the Biden administration, would have been implemented under the Center for Medicare and Medicaid Innovation’s (CMMI) demonstration authority.

On May 12, 2025, the President signed an EO, Delivering Most-Favored-Nation Prescription Drug Pricing to American Patients, which reaffirms the Administration’s concerns regarding what it perceives to be American funding of pharmaceutical research and development “while foreign health systems get a free ride.” In an effort to address the Administration’s concerns, the EO notes that the Administration “will take immediate steps to end global freeloading” and that “should drug manufacturers fail to offer American consumers the most-favored-nation lowest price, my Administration will take additional aggressive action.”

The EO outlines efforts to implement this policy, including:

  • Trade Efforts. The US Department of Commerce and United States Trade Representative (USTR) are directed to ensure that foreign countries are not engaged in actions with the effect of forcing Americans to “pay for a disproportionate amount” of R&D costs.
  • Direct-to-Consumer (DTC) Sales at MFN Price. The US Department of Health and Human Services (HHS) is directed to facilitate DTC sales programs for manufacturers to offer MFN prices.
  • MFN Targets. The HHS Secretary is directed to provide MFN targets to manufacturers within 30 days with the expectation that manufacturers will “bring prices for American patients in line with comparably developed nations.”
  • If “significant progress” toward MFN pricing is not made, HHS will be directed to propose a rulemaking plan to impose it.
  • The order suggests that the HHS Secretary certify, on a case-by-case basis, that reimportation will pose no additional risk to public health and will result in savings, as well as to create standard mechanisms for importation. It is unclear how this direction aligns with the current statutory framework, which is focused on Canada.
  • Federal Trade Commission/Department of Justice Action. The EO calls for efforts “consistent with law” to undertake enforcement action against anticompetitive practices identified in the prior drug pricing EO, including use of the Sherman Antitrust Act.

Key Considerations

At this stage, the scope and practical effects of the EO remain uncertain, as the administration has not yet provided details regarding the regulatory and subregulatory actions envisioned under the document. With respect to trade policy, for instance, the EO does not outline explicitly what particular tools it expects USTR or the Commerce Department to leverage in combating “foreign freeloading.”

Similarly, the EO does not elaborate on the steps that the administration plans to take in “facilitat[ing]” voluntary MFN target pricing under DTC purchasing arrangements. Such efforts could theoretically bring waivers or other regulatory flexibilities to bear, or else they could take a more hands-off approach, simply encouraging drugmakers to take action on their own.

Without further clarifications around how the administration might define or assess “significant progress” towards MFN pricing targets on the part of manufacturers, nor the form, manner, or timeline that “aggressive action” in the absence of such progress might take, the EO serves principally as an illustration of the President’s posture, perspective, and priorities with respect to prescription drug affordability and access.

Even in the absence of immediate pricing or payment interventions, the EO could provide a preview of future executive actions aligned with the document’s focus. Such actions could include CMMI models building on the IPI or MFN initiatives from the first term, explicit trade negotiation priorities, regulatory measures related to DTC purchasing arrangements, FDA reimportation program flexibilities, or any number of other drug-related policies.

Our experts will continue to monitor these activities as they progress.

Connect With Us

For details regarding the EO and potential impact on the healthcare sector, contact our featured experts below at medicare@healthmanagement.com

Blog

House Committees Consider Policies to Meet Budget Reconciliation Instructions

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This week, key committees in the House of Representatives released recommendations for legislative language that meets their federal savings and spending targets required in the fiscal year (FY) 2025 budget resolution. On May 11, 2025, the House Energy and Commerce Committee released legislation—and subsequently a substitute amendment—that contains several substantive Medicaid proposals designed to address eligibility and enrollment; financing; fraud waste, and abuse; and to institute mandatory work and community engagement requirements and cost sharing. The Committee completed its markup on May 14, 2025, voting to approve the provisions in the substitute amendment.

The release of text and committee markups are key steps in Congress’s budget reconciliation process; however, proposals may change during Senate proceedings.

Health Management Associates (HMA), and Leavitt Partners, an HMA company, are tracking these developments and analyzing the extensive health and health-related legislative text, including the Medicaid, Medicare, and Affordable Care Act (ACA) Marketplace proposals. Below, we review the status of congressional efforts and key policies.

Background

The budget reconciliation process is a powerful tool for enacting significant fiscal policy changes, as it allows for expedited consideration and passage of budget-related legislation. It has been used in the past to enact major tax reforms, healthcare legislation, and other important budgetary measures.

In 2025, Congress has been actively working to develop its budget bills through a series of steps. The House adopted a budget resolution on February 25, 2025, which sets the framework for federal spending, revenue, and the debt limit for fiscal year 2025 and outlines budgetary levels for the following years through 2034. The Senate passed an amended version of the budget resolution on April 5, 2025. The Senate’s amendments included reconciliation instructions that require $4 billion in gross deficit reductions and allow a $5.8 trillion net deficit increase. On April 10, 2025, the House agreed to the Senate’s amendments with a vote of 216−214. This agreement set the stage for the development of a reconciliation bill.

House Energy and Commerce Markup

On May 14, 2025, the House Committee on Energy and Commerce completed its second day of marking up legislative language to comply with the Concurrent Resolution on the Budget for Fiscal Year 2025, voting to advance the proposals out of committee. The committee’s proposal excluded certain significant structural reforms that had generated concern among some members and stakeholders, such as broad reductions in the federal matching rate (enhanced federal matching assistance percentage (FMAP)) for Medicaid expansion populations, per-capita caps on federal Medicaid cost growth, or reductions in the safe harbor threshold for state Medicaid provider taxes. The proposal does, however, contain more than a dozen provisions that would reduce federal health care spending by $715 billion with the funding reductions mostly focused on Medicaid, which the Congressional Budget Office projects will reduce the federal share of Medicaid spending, including:

  • Adding mandatory work and community engagement requirements for individuals ages 19−64 without dependents, subject to exceptions for pregnant women, people who are medically frail, people with disabilities, people in compliance with other government program work requirements, people living in areas experiencing a temporary hardship, and other individuals
  • Adding cost sharing for beneficiaries in the expansion population who earn more than 100 percent of the Federal Poverty Level, not to exceed $35 per item or service
  • Pausing implementation of several final rules published during the Biden Administration, including: the final rule published September 21, 2023, “Streamlining Medicaid; Medicare Savings Program Eligibility Determination and Enrollment”; the April 2, 2024 rule, “Streamlining the Medicaid, Children’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes”; and the May 10, 2024, final rule, “Minimum Staffing Standards for Long Term Care Facilities and Medicaid Institutional Payment Transparency Reporting”
  • Adding provider screening requirements
  • Increasing frequency of eligibility redeterminations for certain individuals and adding enrollee address verification policies
  • Reducing expansion FMAP for certain states that provide Medicaid coverage to undocumented individuals and families, regardless of the source of funding
  • Preventing certain spread pricing arrangements in Medicaid between states and pharmacy benefit managers
  • Restricting funding for certain essential community providers that furnish family planning services, reproductive health, and related healthcare services
  • Ending a temporary increased FMAP to new states adopting Medicaid expansion, revising policies governing the use of Medicaid provider taxes, and payment limits for state directed payments

Committee Markups

Various other House committees have begun holding markups for the reconciliation package. The Committee on Ways and Means conducted its markup on May 13, 2025, to discuss its portion of the reconciliation bill, which involves $4.5 trillion in deficit increases. The initial Ways and Means proposal did not include many significant healthcare proposals, but on May 12, 2025, the committee released a substitute amendment that includes several changes that would affect private insurance coverage and Medicare. Key provisions include:

  • Changes to Medicare and ACA premium tax credit (PTC) eligibility requirements related to immigration status
  • Improvements to ACA PTC eligibility verification checks
  • Changes to Health Savings Account flexibilities
  • Codification and renaming of individual coverage health reimbursement accounts, which serve as a defined contribution that employees can use to purchase insurance in the individual market

Other committees, such as the Education and Workforce, Judiciary, Armed Services, and Homeland Security Committees, also have conducted markups and approved their respective portions of the reconciliation bill.

Connect With Us

These steps are part of the ongoing process to finalize the budget and reconciliation legislation for FY 2025. Our federal policy experts with Leavitt Partners and across HMA are monitoring the legislative policies and ongoing negotiations in Congress and with the administration. They work with healthcare organizations and industry to plan for the range of scenarios and policies Congress is debating.

For more information about the impact of these policies, contact our featured federal policy experts below.

Blog

Health Policy in Maryland Amid Fiscal Uncertainty

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The 2025 Maryland General Assembly session closed on April 7th. While the budget deficit consumed a large portion of legislative bandwidth, there was significant action on health-related programs, including supporting the implementation of the Centers for Medicare & Medicaid Services (CMS) All-Payer Health Equity Approaches and Development (AHEAD) Model, expanding access to care, paving a way for Prescription Drug Affordability Board (PDAB) expansion and increasing access to affordable insurance. The AHEAD Model is an innovation in healthcare finance that drives improvements in population health through increased investments in activities likely to improve health outcomes, and benefits hospitals that participate by providing stable funding through hospital global budgets.

Budget Deficits and Federal Funding Fears Limited New Spending

After intense debate and discussion, House and Senate fiscal leaders reached a budget agreement on the final day of session. From the beginning, significant projected general fund shortfalls existed in the current and future fiscal years. Primarily these shortfalls were due to higher than anticipated Medicaid enrollment and growth in obligations to fund K-12 education under the Blueprint for Maryland’s Future. Through a combination of actions including budget cuts, increasing hospital assessments to cover Medicaid costs, shifting costs to counties, and new taxes and fees, the budget passed along party lines. Due to concerns about the potential harm from federal budget cuts, particularly in the Medicaid program, the final plan includes a trigger provision requiring the Governor to engage lawmakers on solutions should federal funding to the state fall by $1 billion.  

The State Readies for the AHEAD model

Despite fiscal concerns, the General Assembly established two new funds, the Population Health Improvement Fund, and the Maryland Primary Care Program Fund, to support the implementation of the AHEAD model. Revenues to both funds are collected through an increase in hospital assessments.

  • The Population Health Improvement Fund will support efforts to reach statewide population health targets under the AHEAD model.
  • The Maryland Primary Care Program Fund will support the implementation of a Medicaid advanced primary care model and support primary care providers through investments in reimbursements for evaluation and management codes, care management fees to eligible practices, and quality incentives.

Supporting Access to Care

Lawmakers passed several bills aimed at increasing or protecting access to care.

  • The Preserve Telehealth Access Act of 2025 makes permanent provisions of law requiring reimbursement parity between telehealth and in-person services and includes “audio-only” services as telehealth under certain circumstances.
  • Legislation passed to address children and youth boarding in hospital settings beyond medical necessity. The bills define a “pediatric overstay” and requires the Maryland Department of Health and the Maryland Department of Human Services to establish a pediatric overstay coordinator in each department to ensure that each patient is served in the least restrictive environment.

Several pieces of legislation passed to address behavioral health and substance use disorders including:

  • Eliminating the prohibition on using 9-1-1 trust fund dollars to support the 9-8-8 suicide prevention hotline, improving coordination between 9-1-1 and 9-8-8.
  • Establishing a buprenorphine training grant program to support training paramedics to administer the drug.
  • Further delineating uses of opioid restitution fund dollars and creating additional reporting requirements for the Office of Overdose Response.

Since the Dobbs decision, rolling back protections for abortion care in states, Maryland has been on the forefront of protecting reproductive freedom. Legislation passed establishing the Public Health Abortion Grant Program and Fund to support eligible organizations providing equitable access to abortion care services.

Regulating Prescription Drug Prices

Maryland established the Prescription Drug Affordability Board (PDAB) in 2019 joining ten other states in regulating the cost of prescription drugs through affordability boards. The goal of PDABs is to address high prescription costs by setting upper payment limits (UPLs) for drugs that cause or are likely to cause affordability challenges. Currently, Maryland’s PDAB is authorized to set UPLs for prescription drug products purchased by or on behalf of a unit of state or local government.  Legislation passed creating a pathway for the PDAB to set UPLs on prescription drug products paid for by additional state regulated payors if the board determines that the product has led or will lead to an affordability challenge.

Access to Affordable Health Insurance

The General Assembly made permanent the State-Based Young Adult Health Insurance Subsidy program and requires the Maryland Health Benefit Exchange in consultation with the Maryland Insurance Commissioner to establish and implement a state-based health insurance subsidy program for all individuals. The Maryland Health Insurance Protection Commission was reestablished to monitor federal changes that could impact coverage.

Change in Leadership at the Maryland Department of Health

During the busy legislative session, Secretary Laura Herrera Scott, MD, announced she was stepping down from her position as leader of the Maryland Department of Health. Former CMS administrator, Meena Seshamani, MD, was announced as Dr. Scott’s successor and sworn in on April 9th. Secretary Seshamani will be tasked with leading the transition from Maryland’s Total Cost of Care model to the AHEAD model and leading the department through a period of uncertainty and expected budget shortfalls.

Maryland State of Reform Conference to Cover Many of these Issues

These issues and more will be covered at the Maryland State of Reform Health Policy Conference on June 12th at the Baltimore Marriott Waterfront. The day will include a panel of legislative leaders as well as sessions focused on the AHEAD Model, value-based care, behavioral health, public health, and prescription drug costs.

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Governor Asa Hutchinson Announced as Keynote Speaker at HMA 2025 Conference

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We’re excited to welcome former Arkansas Governor Asa Hutchinson as the keynote speaker at the 2025 HMA Conference October 14-16 in New Orleans, LA.  Governor Hutchinson brings over 40 years of leadership in law, national security, and public service. As the 46th Governor of Arkansas (2015–2023), he championed innovation in maternal healthcare, initiating programs and policies focused on improving maternal health outcomes during his time in office. He established the Maternal Life360Home program, expanding access to home visitations and intensive care coordination services for women with high-risk pregnancies and for children after birth, and improving the safety and wellbeing of children in foster care. He launched the Healthy Active Arkansas program, a 10-year plan to encourage schools and businesses to promote healthier eating and more activity.

His prior federal roles include Drug Enforcement Agency (DEA) Administrator, the first Under Secretary for Border and Transportation Security at the Department for Homeland Security (DHS), U.S. Congressman, and the nation’s youngest U.S. Attorney. We’re excited to welcome his perspective on advancing health outcomes across America.

In keeping with changes being made at the federal level affecting all aspects of the healthcare system, Governor Hutchinson will be discussing “The Policy and Politics of Making America Healthy.” In his address, he will share insights from his tenure in Arkansas, his perspective on effective health policy development, and the challenges to implementation at both state and federal levels. Join us for what promises to be an enlightening session as he explores the evolving relationship between federal and state governments and the opportunities for innovative health policy development that gives states more flexibility.

Don’t miss this opportunity to hear from one of our nation’s respected political leaders on issues that directly impact our industry and the health of Americans.

Date: October 14-16, 2025

Time: 8:30 a.m.

Location: Four Seasons New Orleans

Following the Governor’s talk, you will join with industry leaders to discuss new directions in payment and financing of publicly funded healthcare programs, community-level strategies designed to meet the needs of special populations, tailwinds driving the expanding universe of digital health policies, and innovations to strengthen access to behavioral health services. Come for the informative plenary sessions and workshops, explore strategies for navigating changes in funding, access, and coverage to ensure success in a shifting environment, and expand your network with federal and state policymakers, healthcare providers, insurers, philanthropists, and C-suite industry leaders. 

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Empowering Healthcare Leaders: Forging Insights and Collaborations at the National Medicare, Medicaid, and ACA Marketplace Event

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As new federal priorities unfold—particularly for Medicare, Medicaid, and the Affordable Care Act (ACA) Marketplace—healthcare stakeholders must anticipate and adapt to dramatic changes in funding, regulatory requirements, and technological advancements. 

In light of these shifting tides, you won’t want to miss Health Management Associates (HMA), 8th National Conference, Medicare, Medicaid, And Marketplace: Adapting for Success in a Changing Healthcare Landscape, October 14-16, 2025, in New Orleans, LA. The HMA event will feature timely topics with insightful speakers who are at the center of decision making in government, healthcare service delivery, philanthropy, and industry. 

The conference will inspire thought-provoking conversations that will prepare you to navigate the rapidly changing healthcare landscape. The sessions will provide context for big ideas and workshops that will delve deeper into policy, strategy, and operations. Examples include:  

  • The Policy and Politics of Making America Healthy 
  • When the Ground Shifts: Publicly Financed Health Coverage and Policy in Motion  
  • Where Is Disruption Poised to Make Improvements in Healthcare? 
  • Red, Blue, or Purple: Building Resilient Healthcare Systems to Improve Population Health  

The HMA conference welcomes all healthcare stakeholders. Each year we bring together federal and state policymakers, healthcare providers, insurers, philanthropists, and C-suite industry leaders to explore and discuss cross-cutting healthcare policy and operational issues.  

Networking Opportunities 

In addition to insightful sessions, the conference will offer numerous networking opportunities and exhibitor space. Attendees will have the chance to connect with peers, industry leaders, and policymakers during dedicated networking breaks, receptions, and informal gatherings in the vibrant city of New Orleans. These interactions will provide valuable opportunities to share experiences, discuss challenges, and explore potential collaborations. 

Learn more about the agenda, registration, and sponsorship on the conference site, Adapting for Success in a Changing Healthcare Landscape. For sponsorship information contact Andrea Maresca, HMAIS Managing Director.   

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The Evolving Behavioral Health Delivery System

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During the month of May, HMA is featuring thought leadership and insights around Behavioral Health (BH) and changes within the BH delivery system in the U.S. Along with several presentations happening at NatCon25 in Philadelphia, May 5-7, we want to highlight some of the work done by HMA experts.  Starting us off, Josh Rubin, HMA Vice President, Client Solutions, has spent his career working with BH, intellectual and developmental disabilities, and child welfare service providers. In this post, he discusses the changing BH delivery system, and the issues surrounding the treatment of co-occurring mental health conditions.     

Ever since the 19th century when Dorothea Dix crusaded up and down the east coast encouraging state legislatures to fund state psychiatric hospitals, we have had separate systems for medical and mental health care. I mean Ms. Dix no disrespect, far from it; before her work we simply had no system of care for people with mental illnesses. Her contribution was immeasurable. But in 1963 when President Kennedy signed the Community Mental Health Act, it was an acknowledgement that the “out of sight, out of mind” warehousing of people with mental illnesses in large state psychiatric hospitals was inappropriate and had to end.

Those of us who remember the heady days of the 1960s rightly celebrate the advance this represented in acknowledging the rights of people with mental illness to live in the community, and the opportunity it created for people with behavioral health conditions to build lives of dignity, productivity, and inclusion. And while we ought to celebrate that important advancement, we must nonetheless acknowledge that it maintained a separation between the underfunded mental health system, and a significantly better funded medical system. And thus, the community mental health system in America was built. It was designed to provide mental health care to the roughly 5% of the population that has a serious mental illness (SMI). In the nearly 60 years since, much has been done of which community mental health providers should be proud. We have transformed countless millions of people’s lives (and those of their families), built new program models, identified and implemented new practices, and built a service delivery system that offers a comprehensive continuum of care for people with SMI.

Unfortunately, that system was not built to address the needs of people with co-occurring mental health and substance use disorders (SUD), which is problematic because nearly half of people with a substance use disorder have a mental illness and nearly half of people with a serious mental illness have a substance use disorder. This is no surprise; the conditions are related. Some people with mental illnesses use drugs to manage their symptoms. Sometimes drug use can cause or exacerbate mental illnesses. In most cases, it is impossible to figure out where a mental illness ends, and a substance use disorder begins, or vice versa.

Yet in the U.S. we have always had separate service systems for these two conditions. Our systems grew up this way because although the stigma of mental illness is bad, the stigma of substance use is worse. While we have frequently been willing to address mental illnesses as health problems, we have long treated substance use disorders as criminal justice problems. We created community mental health centers. We launched a war on drugs.

The federal government provides two separate funding streams for states, one for mental health, the other for substance use disorder services. In many states there are separate agencies overseeing the two conditions, separate funding streams, and separate regulatory structures. Many providers respond to the funding and offer separate programs for one condition or the other.

This systemic failure leads every day to the death of Americans who have co-occurring mental health and substance use disorders but cannot access treatment for the two conditions together. Treatment works, and recovery is possible, but treatment works best when you are able to get treatment for your entire problem.

And just as the mental health and SUD systems were separated, they were both also segregated from the general healthcare delivery system. The stigma of our clients’ illnesses attached to us and our service system, so we were largely ignored by the healthcare delivery system and the people who funded and oversaw it.

While we have, as I said, much to be proud of, we cannot ignore the impact of our segregation. Our clients continue to die much younger than their peers. BH-related hospitalizations continue to increase. Overdose deaths and completed suicides, the worst possible outcomes, keep climbing, leaving incalculable suffering in their wake. And the financial costs of BH conditions continue to escalate, falling hardest on the historically underserved and marginalized communities that can least afford them. When America establishes a separate system, it isn’t equal; being ignored has consequences.

The good news? BH is not being ignored any longer. The bad news? BH is not being ignored any longer.

Healthcare policymakers have finally awakened to the reality that they will not be able to achieve their goals of better outcomes, lower costs, and improved customer service unless they address the BH needs of their populations. They are figuring out that everyone needs behavioral healthcare, and that a dichotomy that focuses BH care only on those with the most significant BH issues is ill serving. They are coming to understand that the skills, capabilities, and expertise of community BH providers have extraordinary value. It’s nice to be acknowledged and invited to help.

But it’s not all good news, because while being ignored left us underfunded and disrespected, it also protected us. Now that hospitals (which have been buying up outpatient practices at a remarkable pace) have started opening up BH services, we must compete with their deep pockets. And private equity (with even deeper pockets) has increased the pace at which they are acquiring BH providers, forcing additional competition on us. We are not even safe from our own phones. 10,000 mental health apps in the app store offer our clients a totally different paradigm for care, much of it lacking any evidence-based foundation. This makes it more dangerous for our clients, not less competitive for BH providers.

This environment requires fundamental changes in the way BH providers operate. We need new models of care that better meet the needs of the people we serve. Certified Community Behavioral Health Clinics (CCBHCs) are a step in the right direction, but they’re not a significant change in the service delivery model. If you look at the history of the BH system in America, from Dorothea Dix through today, you will see that the movement has been consistently in the same direction – inward. We have moved out of the hospitals in the countryside into clinics in the neighborhood. We have slowly chiseled away at the barriers dividing mental health from substance use disorder services. We have patiently worked to integrate with our health care colleagues. Now things are accelerating, and the pace of change is scary, but we should embrace the opportunity. We have a once in a lifetime chance to build something new, better, more effective.

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NATCON 2025 Updates – Using Applied Improv to Strengthen Behavioral Health Case Management

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HMA consultants are participating on four panel sessions at NatCon25 in Philadelphia, May 5-7. In this blog, HMA Principal Suzanne Daub offers a peek at her session topic and explains how improvisation is being used in behavioral health.

In the fast-paced, high-stakes world of behavioral health, case and care managers are often the steady bridge between crisis and stability, support and recovery. Yet the complexity of their roles—navigating systems, engaging clients with diverse needs, adapting to change in real-time—requires more than clinical knowledge. It calls for presence, empathy, adaptability, and clear communication. These are exactly the skills honed through applied improvisation.

Several years ago, I attended a national healthcare conference and found myself in a session on applied improvisation for medical professionals. I expected a few communication tips. What I experienced instead was a transformative, embodied approach to learning that blended empathy, collaboration, and spontaneity in a way that felt deeply relevant to behavioral health. I knew immediately: this belongs in our field.

That session sparked my own journey. I began formal improv training, developed a personal improv practice that I’ve now sustained for over five years, and eventually became a certified trainer in applied improvisation for healthcare professionals. Since then, I’ve been focused on bridging this work into behavioral health—especially to support case and care managers, who often work at the emotional and logistical front lines of client care.

What Is applied improv? Applied improvisation takes the tools and principles of theatrical improv—like active listening, collaboration, spontaneity, and “yes, and” thinking—and uses them in professional, non-performance contexts to strengthen human interaction. It’s grounded in neuroscience, play theory, and experiential learning.

In medical training, applied improv is used to support communication, teamwork, leadership, and emotional resilience. It helps providers stay grounded in the face of uncertainty, build trust with patients and teams, and respond rather than react. Academic medical centers, residency programs, and interprofessional training teams are increasingly turning to improv to improve quality of care and reduce burnout.

Applied improv is still emerging in behavioral health, but momentum is growing. Innovative programs are using improv to support:

  • Engagement in developmental disability services where play-based, nonverbal, and responsive communication is vital.
  • Reducing isolation among older adults and dementia caregivers through shared storytelling, and connection-building.
  • Substance use disorder recovery by helping individuals rediscover joy, flexibility, and authentic connection in group work.
  • Supervision and team development where role-play and real-time scenarios help staff practice challenging conversations and build peer support.

For case and care managers in behavioral health, applied improv can help:

  • Enhance engagement, improve presence, listening, and rapport-building with clients across cultures and abilities.
  • Build comfort with unpredictability and navigating uncertainty —essential when managing client crises or changing systems.
  • Foster collaboration and trust in interdisciplinary teams.
  • Bring joy, presence, and creative reset—tools we all need to stay grounded, prevent burnout and foster resilience.

If you’re attending NatCon25, I invite you to join our interactive workshop: “Improv in Behavioral Health: Strengthening Empathy, Collaboration and Adaptability,” where you’ll gain hands-on tools, and leave with a new lens on what it means to connect.  There are two sessions available, Monday, May 5, 4:30 PM – 5:30 PM ET or Tuesday, May 6, 11:15 AM – 12:15 PM ET, both located in room 204C.

Don’t miss these other HMA presentations at NatCon25:

Monday, May 5, 10:15 AM – 11:15 AM ET session A3 in room 103B
Harnessing Your Superpowers in Times of Disaster
Breakout Presenter: Monica Johnson, MA, LPC – Health Management Associates

Monday, May 5 10:15 AM – 11:15 AM ET session A13 in room 115BC
Building Sustainable Pathways for Behavioral Health Careers
Breakout Presenter: Allie Franklin, MSSW, LICSW – Health Management Associates

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Preparing for Change: The TEAM Model and what Medicare’s 2026 Inpatient Proposed Rule Means for Hospitals

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This week, in our In Focus section, Health Management Associates’ Medicare experts review the changes to the Center for Medicare and Medicaid Innovation’s (CMMI) Transforming Episode Accountability Model (TEAM) proposed 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, maintains the model with no changes to the timeline, participants, accountable care organization overlap policies, or required episodes.

While most changes are technical in nature, involve minor methodological tweaks, or seek to align with the Trump Administration’s policy priorities, stakeholders should continue to assess their readiness and prepare to implement the TEAM model. This is a critical time for healthcare stakeholders to stay on top of this specific proposed rule, the TEAM model, and other federal and state-level developments that are affecting the healthcare system.

This article reviews key aspects of the IPPS proposed rule policies related to TEAM with strategic steps for stakeholders as they continue to prepare for the model’s implementation.

Background on TEAM

TEAM is a value-based care initiative that requires participating hospitals to manage costs for a range of surgical procedures, including both inpatient and outpatient services. The program involves bundled payments covering all aspects of care from the surgical procedure itself to most post-acute care occurring within a 30-day window following discharge from the hospital. Payments will be calculated based on regional benchmarks, and hospitals will assume financial responsibility for the quality and cost of care provided.

TEAM is scheduled to begin in 2026 with 741 hospitals required to enter into value-based arrangements. The program will affect how hospitals manage five types of surgical episodes in both the inpatient and outpatient hospital setting by shifting more risk to the hospitals themselves. This risk includes not only the cost of the surgery but also post-acute care, including readmissions, complications, and downstream provider services. The goal is to incentivize hospitals to improve care coordination, reduce costs, and enhance patient outcomes.

Proposed Changes to the Model

According to the proposed changes, CMS is moving forward with the five-year mandatory model largely as planned, with minor updates focusing on technical details rather than a significant overhaul. Some of the proposed changes were expected based on the administration’s policy priorities, including removal of:

  • The Decarbonization and Resilience Initiative
  • Health equity plans
  • Health-related social needs data reporting

Other technical changes address flexibility for newly opened hospitals within TEAM’s required geographies, the impact of the possible expiration of the Medicare Dependent Hospital (MDH) program, and modified episode attribution to be based on discharge date, rather than start date. CMS is also still seeking comment on how to finalize the low-volume threshold policy, where hospitals under a certain number of procedures would only have Track 1 (upside only) applied.

Overall, CMS expects that its proposed changes to TEAM “should not result in dramatic shifts to the Medicare savings estimate” of $481 million in savings to CMS across the model’s five performance years.

Stakeholder Considerations for the Future

Keeping this model largely intact and maintaining the mandatory nature signals that the Trump Administration intends to continue with value-based arrangements and is looking for ways to achieve program savings. A mandatory model will generally achieve a higher level of savings than a voluntary one.

As they prepare for implementation, stakeholders will need to take action, including:

  • Thoroughly reviewing the proposed changes to the TEAM model to understand the changes and their implications to model of care policies and operations, financing, and collaborations with clinicians and care teams outside of the facility. Consider submitting comments to CMS on the proposed changes. Review the list of hospitals in TEAM.
  • Contextualizing their work to implement this model alongside other pending federal and state policy changes. Stakeholders will benefit from staying on top of developments in this dynamic policy landscape since many pending proposals have financial and structural implications for healthcare providers.
  • Preparing for the mandatory model by developing strategies to manage the financial risk associated with the bundled payments and improving care coordination. This may include modeling hospital payment policies and assessing the implications of the proposed changes.
  • Assessing the system and technology changes and collaborations that will be required to effectively manage risk in the model.

Connect With Us

Health Management Associates’ (HMA’s) 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 claims data. We also support clients with Diagnosis Related Group (DRG) reassignment requests, new technology add-on payments (NTAP) applications, and analyses of Innovation Center alternative payment models.

For more information about the proposed policies, contact our featured experts below.

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Transforming Medicare: Key Developments and Future Trends 

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April is always a busy month for Medicare. It is the month when Medicare Advantage (MA) policies get finalized and the bid season moves into the final stretch. It is also the starting month for annual rule making for the next cycle of Medicare payment rules. These provide important signals about the Center for Medicare & Medicaid Services (CMS) plans for modernizing Medicare’s quality programs and commitment to value-based care. 

This month, we’ve highlighted the work that HMA’s federal policy experts do to support organizations’ Medicare projects. We’ve discussed our experts’ ability to support organizations with the transition to digital quality measures. Our experts were on top of policies that made it into final MA rate notices and policy rules. We also flagged what wasn’t included and what this may mean for the future of Medicare policy. We examined the notable policy proposals in Medicare payment rules for inpatient hospitals and how these are a “canary in the coal mine” for other upcoming rules, especially related to making quality reporting and measurement more efficient and actionable. And we asked whether Medicare is ready for the next era of innovation?  

We are at the start of a new season of priority setting for CMS. Early signals of what will be important to policy officials include alignment with the Make America Healthy Again (MAHA) initiative, digital health, transparency, and addressing fraud. 

Impact of Recent Policy Changes 

Recent policy changes have impacted the Medicare landscape in various ways. Changes announced in recent Medicare Advantage and Part D rate notices and policy include updates to payment models, quality reporting requirements, and measures to enhance transparency and accountability. The focus on digital health and the integration of digital tools into clinical models are reshaping how care is delivered and measured. Additionally, the emergent emphasis on chronic disease and program integrity is driving organizations to take a fresh look at their data, models of care, and strategies for collaborating with partners to improve patient care. Staying informed and adapting to these policy changes is crucial for organizations to remain competitive and deliver high-quality care to Medicare beneficiaries. 

The Future of Medicare 

Medicare will continue to play a vital role in providing healthcare to the more than 68 million beneficiaries in the program, as it is poised for significant transformation through the integration of digital tools, increased focus on quality care, and the need for cost efficiency in both Medicare Advantage and in Fee-for-Service Medicare. Organizations that stay ahead of these changes and align with policy priorities will be well-positioned to drive meaningful improvements and ensure the sustainability of the program. 

As we look ahead, the commitment to innovation, transparency, and quality will be key to shaping the future of Medicare. HMA is helping clients navigate this dynamic landscape in Medicare Advantage, integrated care programs for dual eligibles, Medicare Advantage Stars and Medicare value-based care programs, PACE, and rural-focused health by providing actuarial support, long term strategic plans for data and quality initiatives, modeling of payment policies, and analyses of alternative payment models.   

If you missed it, watch the replay of our Medicare Town Hall from Wednesday April 30th. And to learn more about our work in Medicare, read our recent blog post Navigating Uncertainty in Medicare and other Federal Health Programs or visit our Medicare page. Our policy team, actuaries, clinicians and digital quality experts are ready to help advance your Medicare projects. Contact us at Medicare@healthmanagement.com. 

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Collaborating for Impact: How Multi-Sector Alliances Are Driving Healthcare Transformation 

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Multi-sector consensus-based alliances, rooted in collaboration, are a critical tool for cutting through the divisive partisanship of our national discourse, providing a pathway to sustainable progress. Through the Leavitt Center for Alliances, an initiative of Health Management Associates, we have helped diverse stakeholders—public and private, government and industry, nonprofit and corporate—solve dozens of the most entrenched challenges in health care. 

Consensus-based alliances can solve complex challenges faster and more creatively than any one organization alone. With the recent publication of several case studies on the Leavitt Center for Alliances website, the tools for collaboration are now more accessible than ever. The site offers a window into the Center’s proven alliance framework and showcases a range of successful collaborations that exemplify how shared purpose, a commitment to consensus, and structured governance can drive real-world impact. 

The case studies bring this to life, illustrating the diversity of issues that alliances can address when built on trust, structure, and shared purpose: 

  • Empowering a Community Against Gang Violence – A multi-sector coalition came together to reduce gang violence, demonstrating how community-based alliances can rebuild safety and trust. 
  • The Long-Term Power of Alliances: Supply Chain Collaboration for Patient Safety – Leaders from across the health care supply chain collaborated to improve patient safety through aligned practices and shared goals. 
  • Creating Value in Business: Alliance Building at the One Intermountain Breast Care Center – A regional alliance centered around a breast care center demonstrated how aligned incentives and coordinated care can improve outcomes and reduce waste. 
  • Unifying the Smart Home: How Matter Brought the Industry Together – Competitors in the tech industry joined forces to create a universal smart home standard, proving that alliances can drive industry-wide innovation. 
  • Bringing Government and the Private Sector Together to Modernize Health Care Data Exchange – Public and private stakeholders worked together to enhance interoperability and improve access to health data. 

In our own ongoing work, ranging from behavioral health integration to payment reform and data interoperability, we see firsthand how alliances are helping translate federal policy shifts into systems change. These examples reveal what’s possible when stakeholders move beyond silos and toward collective action 

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Helping organizations navigate the New Technology Add-on Payment (NTAP) Program

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Hospitals that use specially designated new technologies in the inpatient setting may receive additional reimbursement through a program offered by the Centers for Medicare & Medicaid Services (CMS) known as the new technology add-on payment (NTAP) program. CMS offers a separate NTAP payment in addition to the regular Medicare Severity-Diagnosis Related Group (MS-DRG) payment, for use of specially designated new technologies that qualify. This payment is meant to remove some of the disincentives faced by hospitals under the bundled inpatient payment system, when the costs of new technologies are not incorporated into the payment rates until two to three years after market entry. At a recent webinar, HMA Principal Clare Mamerow discussed the NTAP program, what manufacturers must do to apply for and receive NTAP designation for their new technologies, and some of the changes coming in 2025. This blog shares some of the key issues raised.  

While NTAP designation can offer manufacturers of new technologies a significant advantage, the NTAP application process can be intense, arcane, and difficult to navigate without proper guidance. Most products applying for NTAP need to meet three criteria: newness, cost, and substantial clinical improvement. Certain other products – breakthrough devices and certain antibiotic and antimicrobial drugs – are deemed to have already met the newness and substantial clinical improvement criteria and therefore, only need to show that the cost criterion is met. This alternative application pathway is significantly streamlined and makes gaining NTAP designation much easier for these special products because the majority of products that fail to meet the three criteria miss substantial clinical improvement. 

The newness criterion has two facets. First, the product must be newly on the market (received FDA approval recently, but prior to May 1, 2026) and must not be “substantially similar” to other available products. CMS looks to whether the product has a different mechanism of action or whether the product treats a new or different disease or patient population in making a substantially similar determination. 

The cost criterion involves an analysis of Medicare claims data, where claims from two years ago are identified as cases where the new product could have been used had it been available and then repriced to account for the cost of the new technology. The average charges on those claims are compared to a DRG specific thresholds that CMS calculates. If the claim charges exceed the threshold, the cost criterion is met.

Finally, the substantial clinical improvement criterion requires that applicants show that patient outcomes are better with treatment with the new technology. Outcomes such as reduced mortality, reduced complications, and reduced health care utilization are all examples of clinical improvement. CMS takes a totality of the circumstances view of substantial clinical improvement, so applicants are encouraged to provide as much data as possible to support their application.

While NTAP can provide supplemental payments in some circumstances, it’s important to understand the program’s limits. The NTAP payment that hospitals receive is calculated on a claim-by-claim basis, with the payment at the lesser of 65% of the cost of the product, or 65% of the cost above the regular DRG payment. This means that hospitals are only made aware of the payment amount after the claim has been submitted, and that the hospital can never be made whole for the use of the new technology.  In addition, the payment can be any amount less than 65% of the cost of the product—it’s even possible that the hospital will receive no payment if the cost of the case isn’t high enough to trigger the payment. Certain antibiotics and gene therapies that treat sickle cell disease receive a high payment, up to 75% of the cost of the product. Additionally, the payments are only applicable to Medicare fee-for-service claims in IPPS hospitals. Medicare Advantage, Medicaid, and commercial hospital claims are not eligible for payments. Finally, NTAP eligibility only extends for 2-3 years after market entry.    

Although the NTAP application deadline for FY 2027 has not yet been announced, manufacturers of new technologies with an interest in NTAP should begin preparing their applications soon. 

HMA experts in Medicare and Life Sciences can partner with your organization navigate the challenges in the NTAP program. If you are interested in learning more, contact us.

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