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Blog

CMS Announces New Innovation Agenda: Here’s What You Need to Know

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On May 13, 2025, the Centers for Medicare & Medicaid Services (CMS) published its new strategic direction for the CMS Innovation Center. The strategy builds on the lessons of the first 15 years of the Innovation Center, while presenting a significant pivot in policy direction, which emphasizes evidence-based prevention, consumer engagement, and tech-enabled care, while prioritizing financial performance over broad participation.

The new strategy provides high-level direction on the Trump Administration’s vision for the next phase of value-based payment reform under the leadership of CMS Administrator Dr. Mehmet Oz and Innovation Center Director Abe Sutton. They intend to “double down on our commitment to value-based care and take the learnings from the[se] previous investments to build a health system that empowers people to drive and achieve their health goals and Make America Healthy Again.” Notably, the strategy also aligns with goals central to the Trump Administration’s Make America Healthy Again initiative.

This new direction affirms the administration’s commitment to continue advancing value-based care and opens additional opportunities for organizations seeking to enhance the delivery of services that drive positive outcomes. Health Management Associates (HMA), experts will be tracking the implementation of the Innovation Center’s new strategy, including expected forthcoming models, movement toward greater levels of downside risk, and changes to existing models to align with the administration’s priorities. In this article, our experts review the strategy and provide insights on key takeaways for stakeholders.

New Strategy Overview

CMS leaders view the Innovation Center agenda as a framework for accelerating healthy behaviors, leveraging the agency’s authority to test new approaches designed to incentivize and engage stakeholders. According to CMS officials, the Innovation Center “will work expeditiously toward the future of health—building a system in which people are empowered to achieve their health goals and providers are incentivized to compete to deliver high-quality, efficient care and improve the health outcomes of their patients.”

The strategy has three interrelated, foundational pillars:

  • Promoting evidence-based prevention
  • Empowering people to achieve their health goals
  • Driving choice and competition.

Table 1 provides more detail on each pillar.

In addition to the new agenda, CMS released a request for information (RFI) seeking industry input on strategies that can better leverage data and technology to empower consumers. The focus of the RFI aligns with the Innovation Center’s strategic pillars to use tools, information, and processes that better connect people to their health data and allow them to make informed health decisions alongside their providers.

Table 1. CMMI’s Interrelated Strategic Pillars

Takeaways and Considerations

Critical to CMS’s approach is the belief that empowering individuals to make their health decisions—through incentives, better data access, and more flexible options—can lead to better health outcomes and lower overall costs. This shift reflects an evolution in healthcare policy that places greater emphasis on personal accountability and private sector collaboration—a key theme that is emerging across the administration’s policy initiatives.

Consumer Engagement. One of the most notable aspects of the new Innovation Center strategy is the promotion of consumer engagement; it places more focus on direct consumer engagement through education and incentives compared with earlier initiatives. This is one area in which the Innovation Center plans to collaborate with the private sector to develop consumer-facing tools (e.g., mobile apps, nudges toward healthy behaviors, etc.).

The focus on consumer engagement also presents opportunities for organizations to enhance their customer experience. By understanding the needs and preferences of their patients, organizations can tailor their services and care models to better meet those demands. This personalized approach not only improves patient satisfaction, but also drives continuity of care, ultimately contributing to long-term improvements in health.

Data and Technology. The new strategy also emphasizes the importance of data, indicating intentions to better equip organizations that participate in the model with data that can inform decisions and optimize their processes. CMS officials are examining policies and collaborations that will empower private sector organizations, including model participants, researchers, and technology vendors, to develop innovative data-driven solutions to drive efficiencies and improved health.

To that end, the May 16, 2025, Request for Information (RFI) from CMS and the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health (ASTP/ONC), Health Technology Ecosystem (CMS-0042-NC), focuses on Medicare beneficiaries’ use of technology to improve health outcomes. The RFI, which HMA experts analyze here [insert bookmark or link to the other In Focus article] underscores the administration’s intentions of taking “bold steps to modernize the nation’s digital health ecosystem.”

Medicare Advantage. The Innovation Center’s new strategy indicates that stakeholders should expect more models that address Medicare Advantage (MA). The agency stated that “features of a model could include testing changes to payment for MA plans, such as testing the impact of inferred risk scores, regional benchmarks, or changes to quality measures that better align with promoting health.” Additionally, the strategy references a forthcoming specialty-focused longitudinal care model within MA and Medicaid, signaling intentions to drive multi-payer alignment.

Saving Federal Tax Dollars. Another major aspect of the strategy is “protecting federal taxpayers.” This goal reflects a continued emphasis on total cost of care accountability and indicates a more aggressive shift to downside risk. The Innovation Center says it will “require all models to have downside financial risk and require providers to assume some of the financial risk..” Additional provisions of protecting tax dollars include reducing role of state governments in rate setting, simplifying model benchmark methodology, and ensuring “proper and nondiscriminatory provision of funds for health care services.”

What to Watch

For healthcare organizations, the Innovation Center’s agenda signals a need to prioritize consumer-centric models. Hospitals, providers, and insurers should anticipate the following:

  • Increased focus on preventive care initiatives to align with new model designs
  • More robust data-sharing and technology requirements, meaning investments in patient-focused digital tools will become essential
  • New opportunities in MA, given potential payment model innovations affecting plan structures and risk-adjusted reimbursement

Healthcare stakeholders should monitor possible developments related to the strategy.

  • While details on specific strategies have yet to emerge, the Innovation Center indicated it plans to provide more information on new models, as well as changes to existing models, in the coming months.
  • The Innovation Center has not provided a goal akin to the previous administration’s effort to have 100 percent of Medicare beneficiaries in accountable care relationships by 2030. It is still unknown whether these goals are forthcoming or if this will remain vague.
  • Stakeholders are still awaiting clarity on changes to existing models, including key models set to conclude at the end of 2026 (i.e., ACO REACH and Kidney Care Choices).
  • Strategy language indicates that the agency may develop payment innovation in prescription drugs, medical devices, and technology.

Connect With Us

The Health Management Associates Annual Conference, Adapting for Success in a Changing Healthcare Landscape, October 14-16, 2025, in New Orleans, LA, will feature discussions on how the new strategy is reshaping the healthcare system and care delivery for patients, particularly the opportunities to revisit provider contracts with MA plans and to integrate technology to advance the prevention of chronic conditions and achieve population health goals.

For more information about the opportunities and considerations the Innovation Center agenda presents for your organization, contact HMA’s featured experts below.

Blog

Transforming Crisis Care Intervention: The Role of 988

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This week, our third In Focus section highlights the national 988 Suicide and Crisis Lifeline, the three-digit number for individuals in need of behavioral health crisis support. The 988 Lifeline is composed of 200-plus contact centers across the country, which connect people to trained counselors to deescalate crises, provide behavioral health resources, or connect individuals to an in-person responder. Supported by federal legislation to help create a nationwide, standardized, easy to remember 3-digit number, the program is still in its early stages, having been established three years ago this coming July.

In this article, Health Management Associates (HMA) experts provide important context about the 988 Lifeline and future policy direction and suggests actions state leaders can take to enhance use of this critical resource.

988 Lifeline: A Product of Coordinated Collaboration

The story of how the 988 Lifeline was created is an example of long-term advocacy and innovation that demonstrates how a solution needs to combine the state and local decisionmakers with federal policy and support. People experiencing a mental health crisis, thoughts of suicide, or concerns about substance misuse should receive the appropriate local response to seek support or care.

Prior to the 988 Lifeline, individuals experiencing a behavioral health crisis may have contacted 911 and, therefore, not always received the most appropriate response for their unique needs. In some situations, 911 responders—typically law enforcement, emergency medical services, or hospital emergency departments—are ill-equipped to direct people experiencing a behavioral health crisis. Trained behavioral health professionals responding to an individual experiencing a crisis is the appropriate intervention at most points of access. Increased diversion from 911 calls to 988 when an individual is experiencing a behavioral health crisis is an expected long-term outcome.

The federal government’s role is to continue to support the work to enhance the 988 Lifeline, but there’s so much more that needs to happen to increase education and awareness in states, localities, and Tribal nations. They still need support in building out their systems.

State Initiatives Strengthening the 988 Lifeline

Since the launch of the 988 Lifeline in July 2022, 50 percent of the states have approved some type of appropriation or some type of legislation to further cement 988 in their local communities. Some states have established trust funds or implemented 988 cell phone fees similar to what 911 does to provide financial support. Other states have established committees to study and support 988 implementation, building out the various components of a true coordinated crisis system of care.

HMA experts have identified strategic and operational recommendations to support this ongoing work, including:

  • Be intentional about having the right people at the table where decisions are made, including voices with lived experience and people who are part of the policy-making process. Establishing this formal, standardized 988 system enables local communities to better allocate resources in crisis situations. In most cases, the contact with the 988 Lifeline is the best intervention to ensure people get the support or resources needed to resolve or deescalate the crisis.
  • When designing a crisis system in a community, think about prevention and what happens when the crisis is over. Crisis systems established on a poor behavioral health foundation will fail. Stakeholders and decisionmakers should continue building out their systems by remembering that the entire continuum of care—from crisis to ongoing support—is needed.
  • Identify the data that are needed to tell the story about the value of the 988 Lifeline and crisis care systems. Anecdotes are essential and should be paired with data, especially when ongoing funding is needed.

Where Is the 988 Lifeline Headed?

It is likely to take decades to generate greater awareness about the 988 Lifeline, to have interoperability between 911/988, to ensure every person in the country has access to the service no matter their zip code, and to see a fully transformed behavioral health crisis system will take decades to accomplish. The collaboration between federal, state, territories, Tribal nations, and local communities is pivotal to reaching these goals.

While we are at the beginning phases of this work, much has been done that should be celebrated. The 988 Lifeline has transformed how we as a nation talk about behavioral health and suicide prevention. Still, we as a collective have work ahead to achieve the vision of transforming the behavioral health crisis care system.

Connect with Us

Health Management Associates (HMA) is hosting a live, interactive event on Thursday, May 29, 2025. [The Ask the Experts: Behavioral Health Town Hall https://www.healthmanagement.com/insights/webinars/ask-hma-experts-behavioral-health-town-hall/ ] will explore the latest developments in behavioral health—from policy shifts and funding trends to real-world solutions for service delivery, workforce challenges, and system design. HMA and Leavitt Partners, an HMA Company, experts will be on hand to answer participant questions and share insights about 988 and other topics:

  • Policy and funding updates at the federal level
  • Innovative approaches to crisis response, 988 implementation, and substance use services
  • Revenue cycle improvements and evolving payment models
  • Strategies to strengthen the workforce, integrate care, and leverage digital mental health tools

For more information about 988 systems and effective practices emerging in crisis care, contact Monica Johnson, Managing Director for Behavioral Health. Prior to joining HMA, Ms. Johnson, Managing Director for Behavioral Health, was the director of the 988 & Behavioral Health Crisis Coordinating Office at the Substance Abuse and Mental Health Services Administration—the federal agency that leads public health efforts to advance the behavioral health of the nation.

HMA Weekly Roundup

May 21, 2025

CMS Seeks Input on the Future of Digital Health: What the Health Technology Ecosystem RFI Means for Stakeholders

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Blog

Building State Capacities for Medicaid Work and Community Engagement Requirements

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Medicaid covers nearly 80 million people nationally, with an estimated 20 million covered through the Medicaid expansion. As state legislatures pass work requirement laws, governors consider executive actions, and Congress contemplates a nationwide mandate, vetting key implementation issues can significantly impact the direction of related policies.

It is difficult to generate accurate projections given the lack of specificity in the current legislation and state implementation variables. According to Congressional Budget Office (CBO) estimates, approximately 5 million people with coverage because of the Medicaid expansion would lose their coverage as a result of not meeting community engagement requirements. The legislation passed by the House on May 22nd establishes a deadline of December 31, 2026 for implementation, but individual states could move earlier.  Even before implementation, states must test operations, enable systems, and establish connections to beneficiaries to reduce potential implementation missteps, inappropriate disenrollments, and litigation risks.

If the goal of Medicaid work requirement policies is to stimulate connections between health benefits and employment/workforce, building state and federal capacities to support these approaches is critical to effectuating that change. This blog focuses on introducing operational dynamics that need to be discussed, tested, and built.

Legislative and Other Context

In the language that House advanced, all states would be obliged to implement work and community engagement requirements for adults without dependents for at least 80 hours per month.[1] Employment, work programs, education, or community service (or a combination of those activities) would satisfy the requirement. There were also provisions which enabled states to implement more frequent eligibility checks and compliance requirements as well as co-pays for certain services. Though the federal authorization has received a great deal of attention, at least 14 states have moved forward (see Table 1) in advance of the current federal debate by passing laws and submitting work requirement demonstration requests to the Centers for Medicare & Medicaid Services (CMS).

Table 1. A Review of 2025 States’ Approaches to Work Requirements in Medicaid
StatusStatePopulation CriteriaRequirementsExemptions/ NotesPublic Comment
Work Requirement Request SubmittedArizonaAges 19−5580 hours/monthMultiple exemptions; 5-year lifetime limitClosed
Work Requirement Request SubmittedArkansasAges 19−64; covered by a qualified health plan (QHP)Data matching to assess whether on track/not on trackNo exemptionsClosed
Work Requirement Amendment Request SubmittedGeorgiaAges 19−64; 0-100% FPL80 hours/monthAlready has approval but is requesting reporting be changed from monthly to annually and adding more qualifying activitiesFederal comment period open through June 1, 2025
Work Requirement Request SubmittedOhioAges 19−54; expansion adultsUnspecified hoursLimited list of exemptionsClosed
Legislation PassedIdahoAges 19−6420 hours/week requiredLimited list of exemptions
Legislation PassedIndianaAges 19−64; expansion adults20 hours/week requiredLimited list of exemptions
Legislation PassedMontanaAges 19−5580 hours/month requiredMultiple exemptions
Ballot Initiative PassedSouth DakotaExpansion adults2024 ballot initiative asking voters for approval for state to impose work requirements for expansion adults passed
Legislation PendingNorth CarolinaPursue requirements that are CMS approvable
Work Requirement Request DraftIowaAges 19−64; expansion adults100 hours/month requiredLimited list of exemptions Separate bill would end expansion if work requirements are withdrawn/ prohibited (80 hr./mo.)Closed
Work Requirement Request DraftKentuckyAges 19−60; no dependents; enrolled more than 12 monthsConnected to employment resourcesMultiple exemptionsState comment period open through June 12, 2025
Work Requirement Request DraftSouth CarolinaAges 19−64; 67%−100% FPLSpecified activities (work specific is 80 hours/month)Limiting participation to 11,400 individuals based upon available state fundingState comment period open through May 31, 2025
Work Requirement Request DraftUtahExpansion adults ages 19−59Register for work, complete an employment training assessment and assigned job training, and apply to jobs with at least 48 employers within 3 months of enrollmentSeveral exemptions, largely aligned with federal SNAP exemptionsState comment period open through May 22, 2025
Anticipated Waiver RequestAlabamaNon-expansion populationPotential to resubmit previous work requirement demonstration request

Key Questions Regarding State Policy Options

Considerable research and findings put policymakers in a better position to be prepared to act on a new law since previous attempts and implementing similar policies exposed fundamental problems. Some previous findings include the high cost of administration relative to potential savings, the importance of systems that support foundational items like logging an enrollee’s compliance activities and exemptions, as well as developing an efficient appeals process. The Medicaid and CHIP Payment and Access Commission, General Accounting Office, National Institutes for Health, and multiple researchers have published assessments regarding previous experiences that could improve policymaking.

Below we discuss critical issues and considerations including:

  1. Exemptions, particularly medical frailty definitions and assessments
  2. Developing and streamlining systems and process to promote continued coverage for eligible individuals
  3. Clinical and utilization data that promotes eligibility assessment
  4. Managed Care engagement in Work Requirements/Community Engagement initiatives
  5. Measuring impact and adapting policies where needed

1. Which populations are exempt from work requirements?

The requirements in the current legislation would apply only to individuals between the ages of 19 and 64 without dependents, and the following groups are exempted: women who are pregnant or entitled to postpartum medical assistance, members of Tribes, individuals who are medically frail (i.e., people who are blind, disabled, with chronic substance use disorder, serious or complex medical conditions, or others as approved by the Secretary of the U.S. Department of Health and Human Services), parents or caregivers to a dependent child or individuals with a disability, veterans, people who are participating in a drug or alcoholic treatment and rehabilitation program, or individuals who are incarcerated or have been released from incarceration in the past 90 days. Additionally, individuals who already meet work requirements through other programs, such as Temporary Assistance for Needy Families (TANF) or the Supplemental Nutrition Assistance Program (SNAP), would be exempt. However, according to the House-passed version, the eligibility verification and work requirements for SNAP have been made more stringent and program costs are being shifted to states, which affects cross-functional eligibility. Lastly, the legislation includes temporary hardship waivers for natural disasters and areas with an unemployment rate greater than 8 percent or 150 percent of the national average.

The federal government and/or states will identify individuals classified as “medically frail” and make them exempt them from the mandates. This includes those with chronic, serious, or complex medical conditions. Various methods may be employed to identify these individuals, such as analyzing historical medical and pharmacy data to categorize complex conditions, using proprietary algorithms to stratify individuals with multiple comorbidities, and enabling physicians to evaluate enrollees without relying on a claims history.

2. Which systems best align to build from and support coverage?

The Medicaid unwinding from the COVID Public Health Emergency taught lessons about the complexities of Medicaid systems (e.g., assessing cases to ensure eligible children retain coverage if a parent is removed), patient engagement, and reliable methods of member outreach (e.g., email, text, and member portals rather than paper communication). Call abandonment rates, call center wait times, and application processing times surfaced as practical measures of performance (or lack thereof) during the Medicaid unwinding. Multiple informal sources point to poor mailing address or “return to sender” as being anywhere between 15 and 50 percent, bringing tangibility to an implementation baseline. TANF and SNAP programs have work requirement provisions. While those programs are regulated and administered by multiple federal and state agencies, the platforms that support those provisions and the potential for integration are critical vehicles to explore. 

State Workforce Commissions and Departments of Labor are clear partners, as they manage integrated eligibility systems and data-sharing agreements across programs like SNAP and TANF, which also serve many Medicaid participants. These and other partnerships will need to be explored to address engagement challenges for many populations, including individuals facing housing instability, which disrupts communication, engagement, and compliance tracking.[2] It is essential that states develop targeted outreach and education strategies to support awareness of participation requirements and ways for individuals to meaningfully engage.

3. Do we have a sense of the healthcare needs/chronic conditions among the Medicaid enrollees that will be affected by work requirements?

Many individuals with chronic diseases may be exempt from the requirements, but not all of them. To that end, insights regarding pharmacy claims may be a useful lens through which we can ascertain an understanding of the potential impact on utilization trends. Notably, the Medicaid expansion population still has significant healthcare utilization rates for services related to behavioral health and for chronic health conditions like hypertension and diabetes. In fact, a recent Health Management Associates (HMA), analysis of CMS data indicated that the top pharmaceuticals spending classes for the Medicaid expansion population were hypoglycemics ($7.6 billion), antivirals ($5.5 billion), and anti-inflammatories ($3.3 billion). The drugs are used to treat autoimmune conditions, including rheumatoid arthritis and psoriatic arthritis. Knowing the health status and chronic conditions of the populations affected and which conditions qualify for exemption are variables as implementation issues like the definition of medically frail are addressed.

4. What does this mean for managed care organizations?

Approximately 80 percent of Medicaid expansion beneficiaries are enrolled in comprehensive managed care organizations (MCOs). States will need to review the scope of existing vendor contracts as well as determine the need for new services, roles, third-party reporting, oversight, and potential exemptions for emergencies. Work requirements can disrupt MCO risk pool stability and care coordination because of administrative burdens and disruptive, less predictable enrollment cycles. That said, MCOs not only have a financial incentive to drive down inappropriate disenrollments, but are also uniquely positioned to support state responsibilities, including maintenance of up-to-date contact information. The delineation of roles and clarification of contracts and responsibilities  among states, MCOs, TPAs, and other specialty organizations supporting work requirements will be a critical early-stage framing point for a functional infrastructure.

Many states have sought to support more seamlessness among insurers, with a goal of having the same insurers provide coverage to people as they transition through Medicaid, Marketplace, and employer-sponsored insurance (ESI) as their employment status changes over time. States like Nevada, Rhode Island, and New Mexico require Medicaid MCOs to participate in the Marketplace. Additionally, states like North Carolina, Utah, and West Virginia not only require MCO participation in the Marketplace, but also enable MCOs to co-market Medicaid and Marketplace products for individuals who lose their Medicaid eligibility.

As Figure 1 indicates, Marketplace enrollment in non-expansion states has received considerable traction in recent years and has outpaced expansion states with respect to member growth in the past five years. Marketplaces have undeniably carved out large roles in the health coverage infrastructure in non-expansion states—a point that was less clear just a few years ago. Though, multiple factors affect those Marketplace growth rates, including congressional decisions regarding the continuation and funding of the enhanced premium tax credit program. In the current legislation, these credits expire, which the CBO estimates will lead to an additional coverage loss of nearly 5 million by 2034.

5. Can states measure and be nimble with policies as the impacts are determined?

Federal and state regulations that identify contextualized and dynamic metrics that provide actionable information to federal and state policy makers will support effective oversight and monitoring. States starting with listening sessions in the near term can help identify goals and metrics. The focus of such efforts could include actively monitoring potential changes and cost shifts for the uninsured population to non-public payers and providers.

The Medicaid unwinding also demonstrated that the story was far less of a red/blue story than a series of complex tasks that required many administrative resources, provider and community partnerships, and enrollee outreach to create a path that would limit unnecessary disruptions and expenses. CMS guidance for goals and evaluations as well as state inputs will need to emerge prior to implementation so policymakers can be well-equipped to be nimble and dynamic with policy changes as well as understanding the short-term and longitudinal effects of this fundamental shift.


[1] U.S. Congress. House. One Big Beautiful Bill Act. H.R.1. 119th Cong., 1st sess. Introduced May 20, 2025. https://www.congress.gov/bill/119th-congress/house-bill/1/text.

[2] Soni A, Blackburn J. Health Characteristics of Adults Unable to Complete Medicaid Renewal During the Unwinding Period. JAMA Health Forum. 2025;6(3):e250092. doi:10.1001/jamahealthforum.2025.0092

Solutions

Supporting Medicaid Dental Benefit Administrators: Oral health and dental care are vital for the health of communities 

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HMA Spotlight

Supporting Medicaid Dental Benefit Administrators: Oral health and dental care are vital for the health of communities 

Whether performing under risk-based prepaid ambulatory health plan (PAHP) contracts or non-risk (administrative service organizations), Medicaid dental managed care organizations (MCOs) and dental benefit administrators (DBAs) face the same challenges as Medicaid MCOs, and state Medicaid agencies, including but not limited to:

– Getting into and staying in compliance with state regulatory and contract requirements
 
– Understanding and responding to new federal and state rules and regulations
 
– Growing market share including success in state procurements, in MCO solicitations for DBAs, and attracting and retaining enrollees

– Improving utilization to meet quality measure targets, medical loss ratios, and margin expectations including increased utilization of preventive oral health care, and decreased utilization of unnecessary care such as avoidable emergency room care for dental diagnoses

– Excelling in benefit administration operations including member services and engagement, provider network development and provider services, claim/encounter administration, reporting, and other functional areas
 
– Managing financial risk including developing or validating capitation rates and developing value-based payment arrangements

The importance of oral health and dental care

Oral health is integral to the overall health and quality of an individual’s life, and lack of access to oral health care negatively impacts entire populations.

Tooth decay affects 90% of adults 20 to 64 years of age and costs the U.S. about $45.9B in lost productivity in 2015. This frequently results in visits to hospital emergency rooms where care is often palliative but does not treat the root cause of problems1

Gum disease affects almost 50% of adults 45 to 64 years of age and is a risk factor for nearly 60 other adverse health conditions, including Alzheimer’s disease, diabetes, and heart disease2

More than half of working-age adults living in poverty have untreated caries (52%), whereas only 1 out of 5 adults with incomes of twice the federal poverty guideline or higher have untreated caries (20%)3

Tooth decay is preventable but impacts nearly 46% of U.S. children. Left untreated, tooth decay can cause chronic pain, impaired development, disfiguration, and social isolation. In severe cases, bacteria from a tooth infection can even travel to the brain and cause death. Caries disproportionately affect children who experience poverty, belong to certain racial and ethnic groups, or are affected by other social factors4

OUR EXPERTISE

At HMA, our consultants have led MCOs, state Medicaid agencies, and include senior officials from Medicare, directors of large nonprofit and social services organizations, top-level advisors, C-level executives at hospitals, health systems and health plans, and senior-level physicians. We know that oral health, access to dental care, and oral health literacy play a vital role in the health of communities supported by Medicaid MCOs. HMA can support the work that DBAs do and the challenges they face in the changing Medicaid environment.

How HMA can help

HMA has decades of experience working with Medicaid MCOs, DBAs, state Medicaid agency dental policy makers, and oral health providers. HMA can:

Provide actionable insights into new federal and state regulations and guidance to help clients understand potential impacts and opportunities for their business. We assist clients to determine what must be done, what can be done, and develop recommendations for what should be done, and to implement those activities. DBAs are frequently performing as PAHPs and are subject to many of the federal rules related to interoperability, prior authorization, access, and eligibility that apply to Medicaid MCOs. HMA provides our Medicaid provider and payer clients with analyses about those rules, which could also benefit DBAs.

Perform validation and compliance support to help clients identify and address any compliance gaps and support clients in validating their own compliance with any state or MCO imposed Corrective Action Plans. We also support clients to grow and strengthen their own capabilities and infrastructure to perform these functions.

Support client growth with end-to-end procurement assistance, including market conditioning and strategy, writing, mock scoring, orals preparation, implementation, and operations stabilization assistance; and with market analysis.

Support delivery system, reimbursement, and provider network design by conducting research and analysis on oral health delivery system approaches, provider reimbursement structures, coverage, and access trends.

Identify, assess, and help implement best practices in oral health care programs related to special populations, including children’s access to oral health care and dental access in rural communities.

Support quality improvement and utilization management initiatives that increase appropriate and desired utilization and curb inappropriate utilization. This can include help achieving Healthcare Effectiveness Data and Information Set (HEDIS) measure goals and developing oral health literacy programs, achieving accreditation, developing and implementing Performance Improvement Plans (PIPs), and conducting data analysis to understand utilization and evaluate the impact of program changes on utilization.

Provide actuarial services in support of benefit and program design, capitation rate development, and capitation rate validation.

Design and evaluate value-based payment models that tie provider payments to quality and value.

Project spotlight

Minnesota Medicaid Dental Program Study

The 2021 Minnesota Legislature directed the Department of Human Services (DHS) to conduct a review of Medicaid dental program delivery systems in states that have enacted and implemented a “carve out” dental delivery system. This legislation also directed DHS to conduct an analysis of dental provider hesitancy to participate in the Medical Assistance (MA) program as an enrolled provider. DHS contracted with HMA to conduct the analyses mandated in the legislation. HMA reviewed the Medicaid dental program delivery systems in states that have implemented a carve-out dental delivery system, including comparing state program designs, program costs and rates where available, and quality metrics for children one through 20 years of age with at least one preventive dental service within a year. HMA also surveyed dental providers to better understand hesitancy to participate in Medicaid and opinions on policy approaches to improve provider participation.
The final report, available at https://www.lrl.mn.gov/docs/2022/mandated/220701.pdf, described the analysis of state dental carve-out experiences and the dental provider survey results.

Contact our experts:

Headshot of Sarah Arvey

Sarah Arvey

Associate Principal

Sarah Arvey is a trained medical anthropologist and qualitative researcher with expertise in the impact of social determinants, cultural norms, … Read more
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Rebecca Kellenberg

Principal

Rebecca Kellenberg specializes in assisting public and private health care organizations with Medicaid and CHIP policy analysis and implementation. With … Read more
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Beth Kidder

Managing Principal

Beth Kidder is a transformative and innovative health care leader with more than 20 years of experience working within the … Read more
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Stephen Palmer

Managing Principal

Stephen Palmer, PhD has a broad range of expertise and skills, which enable him to easily join most types of … Read more
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Caroline (Carrie) Rosenzweig

Principal

Carrie Rosenzweig is an experienced consultant specializing in health policy analysis, qualitative research, grant writing, and project management. Her research … Read more

[1] Oral Health in America – April 2022 Bulletin, National Institute of Dental and Craniofacial Research, accessed 4/1/2025, https://www.nidcr.nih.gov/research/oralhealthinamerica/section-3a-summary#:~:text=In%20adulthood%2C%20the%20relationship%20between,to%20achieving%20better%20oral%20health

[2] Oral Health in America – April 2022 Bulletin, National Institute of Dental and Craniofacial Research, accessed 4/1/2025, https://www.nidcr.nih.gov/research/oralhealthinamerica/section-3a-summary#:~:text=In%20adulthood%2C%20the%20relationship%20between,to%20achieving%20better%20oral%20health

[3] National Institutes of Health. Oral Health in America: Advances and Challenges. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2021, https://www.nidcr.nih.gov/sites/default/files/2021-12/Oral-Health-in-America-Advances-and-Challenges.pdf#page=343

[4] Big Hopes for Little Teeth, National Institute of Dental and Craniofacial Research, accessed 4/1/2025, https://www.nidcr.nih.gov/news-events/nidcr-news/2024/big-hopes-little-teeth#:~:text=Left%20untreated%2C%20tooth%20decay%20can,the%20brain%20and%20cause%20death

Blog

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:

Brief & Report

Section 1115 Justice-Involved Reentry Demonstration Implementation Toolkit for Jail, Prison, and Juvenile Settings

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This toolkit provides a set of implementation checklists for Section 1115 Justice-Involved Reentry Demonstrations tailored to three carceral settings: jails, prisons, and juvenile facilities. Each checklist outlines operational tasks across core domains to support effective planning, coordination, and continuity of care pre- and post-release.

This toolkit is intended to provide information for jails, prisons, and youth detention centers in states contemplating submitting a 1115 Justice-Involved Reentry Demonstration, as well as states that have an approved demonstration. All states with approved demonstrations must provide core services, including care management for physical and behavioral health, medication assisted treatment for individuals when clinically indicated before release, and medication in hand at release. It is important to note that states may vary in their populations of focus, care management models, and processes for submitting claims. It is essential to cross-reference your state’s demonstration when planning to operationalize this initiative.

Case Study

A Revenue Cycle Management Success Story: Advanced Diabetes Supply/US Medical Supply

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The Client

Advanced Diabetes Supply (ADS) acquired US Medical Supply (USMed), a Florida-based durable medical equipment provider, in 2021. At the time, ADS and USMed generated $400 million and $250 million in revenue, respectively. Over the next three years, the combined organization experienced rapid growth, reaching over $1 billion in annual revenue.

Background

While the top-line growth was significant—59% over a three-year span—cash collections failed to keep pace. This created a classic case of an organization outgrowing its infrastructure. The foundational tools, technology, and operational structure simply weren’t in place to support the accelerated growth, particularly on the revenue cycle side.

Compounding these challenges were issues stemming from the integration of the two companies, including billing inconsistencies and reimbursement delays. USMed, like many in the industry, was severely impacted by the Change Healthcare ransomware attack, disrupting billing and collections operations nationwide. At the time this project began, USMed was facing a $40 million backlog in accounts receivable and struggling to meet payroll. The revenue cycle team was understaffed and overwhelmed.

HMA had previously performed a successful revenue cycle gap assessment at an ADS office in California. Based on those results, the newly hired CFO of ADS/USMed asked HMA to replicate the process for the Florida office. The goal: support the recently appointed VP of Revenue Cycle in stabilizing operations, implementing recommendations, and aligning practices to industry best standards.

Download and read the approach and results.

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

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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.

Webinar

Webinar Replay – Ask HMA Experts: Behavioral Health Town Hall

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This webinar was held on May 29, 2025.

In this dynamic and interactive Behavioral Health Town Hall hosted by Health Management Associates (HMA), our experts will be available to answer your questions live on a wide range of critical topics, including:

  • Federal policy, personnel, and funding changes;
  • Emerging strategies for addressing social determinants of health, substance use disorder and crisis coordination (including 988);
  • Behavioral health revenue cycle management and alternative payment models; and
  • Innovations in addressing workforce shortages, integrated service delivery, digital mental health tools, and best practices for community mental health service delivery.

Ready to talk?