At the National Association of Medicaid Directors (NAMD) 2025 Fall Conference, planned federal health policy changes dominated conversations among attendees, including state Medicaid directors, health plans, and providers. With major changes on the horizon for Medicaid and Affordable Care Act (ACA) Marketplace programs, stakeholders are preparing for transition and transformation in 2026. 

A team from Health Management Associates (HMA) attended the conference and returned with valuable insights on the emerging opportunities, state-specific priorities for 2026 and beyond, and early strategies to address and mitigate the challenges ahead. Among the topics discussed were the Rural Health Transformation Program (RHTP), Medicaid eligibility and community engagement policy changes, drug costs and financing, upstream drivers of health, and data infrastructure. 

Five major takeaways about the work state Medicaid agencies, health plans, providers, and industry partners will focus on in the year ahead were as follows. 

1. Medicaid leaders are preparing for new eligibility and community engagement policies under tight timelines. 

The 2025 budget reconciliation act (P.L. 119-21, OBBBA) requires certain adults ages 19–64 enrolled in Medicaid to complete at least 80 hours per month of community engagement (CE) to maintain coverage. Exemptions to the CE requirement apply to people with disabilities, pregnant individuals, and caregivers. States must now develop processes and information systems that track and verify compliance with CE requirements, manage exemptions, and support members through this policy change. 

Medicaid CE and other new eligibility requirements, including more frequent eligibility checks, were a frequent topic of discussion throughout the event. Implementation of these requirements is a major operational lift with significant program integrity implications. State leaders discussed the tight timelines, resource constraints, and the need to coordinate across agencies, health plans, and providers. They are already planning to mitigate the risk of coverage losses for at-risk populations and to minimize administrative burden for all stakeholders. The urgency and complexity of these changes underscore the need for strategic planning and cross-sector collaboration. 

2. Coordinated communication and stakeholder engagement remain critical. 

States are increasingly relying on multiple forms of communication and feedback channels to engage stakeholders, including Medicaid members. Clear, timely communication is essential to ensure people understand their options and know what they need to do and when to do it. Medicaid leaders described the value of embedding vital eligibility information into workflows at all levels and applying lessons from the COVID-19 public health emergency unwind to new outreach and education initiatives. 

Several states emphasized the effectiveness of convening all stakeholders to ensure unified messaging. Other common themes included the importance of plain-language materials, hands-on support through case managers and navigators, and engaging providers to integrate new eligibility and work-related requirements into their workflows, as policies evolve. 

3. States are eager to begin implementing initiatives in their rural health transformation plans. 

Medicaid leaders are actively discussing their RHTP applications with CMS, preparing to move quickly once awards are announced. Many states are focused on enhancing existing efforts, while others are preparing to invest in systems, technology, and organizations that will better integrate rural providers into the broader healthcare system, including Medicaid. 

Federal and state leaders and their partners discussed the opportunity for RHTP funding to strengthen rural health infrastructure, workforce development, education, and outreach—especially in underserved areas. States are positioning themselves to leverage these funds to address persistent disparities and improve access to care for rural populations. 

4. States are seeking to balance cost and access to GLP-1s and other prescription drugs. 

Federal and state leaders extolled the benefits of new and innovative prescription drug products and therapies, including GLP-1s. Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz highlighted the administration’s announcements about drug pricing, including the new GENEROUS (GENErating cost Reductions fOr US Medicaid) model, which is focused on drug costs in the Medicaid program. These discussions reinforced CMS’s focus on new drug pricing models and the importance of involving Medicaid experts in these nuanced development and implementation conversations. 

Attendees gained a deeper appreciation for the administration’s intent to have GLP-1s and other therapies play a significant role in addressing chronic disease, including obesity. State Medicaid agencies—and their Medicaid managed care plans and partners—should plan to inform discussions about coverage and financing of these novel products as well as for cell and gene therapies. The intersection of innovation, affordability, and access will remain a central challenge. 

5. Medicaid agencies are working on multiple technology interoperability and quality initiatives.  

Although Medicaid eligibility policy changes and CE requirements drew significant attention, many discussions also focused on other upcoming deadlines, including: 

• New federal interoperability and prior authorization rules that go into effect in 2027 
• State implementation of Medicaid and CHIP Quality Rating System requirements before the end of 2028 
• The transition to digital quality measurement (dQM) by 2030 

Medicaid agencies are collaborating with managed care and provider organizations to understand the operational, clinical, and technical dimensions of these initiatives. 

Connect with Us 

HMA’s expert consultants provide advanced policy, technical, and operational support, and can help your organization navigate and succeed in the evolving regulatory landscape. Our team brings deep experience and practical solutions to help clients anticipate challenges, leverage opportunities, and achieve their program goals. For more information or technical assistance on these and other emerging Medicaid priorities, contact the HMA’s featured experts Beth Kidder and Kathleen Nolan. 

On November 28, 2025, the Centers for Medicare & Medicaid Services (CMS) released the Contract Year 2027 Policy and Technical Changes to the Medicare Advantage Program and Medicare Prescription Drug Benefit Program. Each annual rulemaking cycle offers CMS an opportunity to recalibrate program priorities.  

This proposed rule offers a road map for CMS’s vision for Medicare Advantage (MA) and Part D. Signaling how CMS leadership intends to shape the MA and Part D programs beyond 2027—prioritizing outcomes, streamlining operations, and inviting dialogue on modernization—the proposed rule reflects a strategic imprint on the program’s trajectory. The deadline to submit comments is January 26, 2026. 

Given CMS’s goal of modernizing MA and Part D, plans, providers, and advocates should engage early to inform final policies. Health Management Associates (HMA) policy and actuarial experts, including Wakely and Leavitt Partners (both HMA companies), are analyzing and modeling the effect of the proposed changes. This article highlights some of the major policy updates that require near-term planning by states, Medicare Advantage plans, providers who serve MA beneficiaries, and their partners. 

Key Themes in the Proposed Rule 

Requests for Information 

CMS includes three significant requests for information (RFIs) and highlights additional opportunities to provide input on approaches to reduce administrative burden throughout the program. CMS’s modernization RFI focuses on financing and other strategies to support beneficiaries with plan selection. In addition, CMS seeks input on emerging trends in MA special needs plans (SNPs), citing concerns about rapid growth and potential program integrity issues. Consistent with the departmentwide priorities, the RFI also delves into potential strategies for plans to address nutrition and wellness benefits for MA enrollees. 

Figure 1. RFIs Signaling New Policy Directions 

Star Ratings Overhaul: Refocusing on Outcomes and Experience

CMS proposes significant changes to the Star Ratings system, which influences plan bonuses and consumer choice. The changes increase the focus on clinical care, outcomes, and patient experience of care measures where performance is not topped out and align with universal foundation of measures. 

• Health Equity Index Rollback: Rather than implement the previously planned Excellent Health Outcomes for All reward (formerly Health Equity Index) for 2027, the agency will continue using the historical reward factor that incentivizes consistently high performance across all measures. 
• Measure Streamlining: Twelve process-heavy or administrative measures will be removed. 
• Behavioral Health: A new measure for depression screening and follow-up will be introduced for the 2027 measurement year, with integration into Star Ratings by 2029.  

Why It Matters: Removing these measures continues the shift away from administrative compliance, easing burden while strengthening quality incentives. 

Medicare and Medicaid Dual Eligible SNPs and Integration 

CMS is proposing several changes to improve how Medicare Advantage plans serve people who qualify for both Medicare and Medicaid (dual-eligible beneficiaries): 

• Starting in calendar year (CY) 2027, CMS proposes to allow D-SNPs and I-SNPs two opportunities to change to their model of care (MOC)—the framework for how they coordinate care. These windows would be January 1 through March 31 and October 1 through December 31. 
• When beneficiaries are automatically moved (i.e., passively enrolled) from one integrated D-SNP to another, CMS will no longer require the new plan’s provider network to closely match the old plan’s network. Instead, the new plan must ensure that all incoming members receive uninterrupted care for at least 120 days (up from 90 days), helping prevent gaps in treatment. 
• In states where dually eligible individuals are explicitly carved out from or not required to enroll in Medicaid managed care, CMS proposes to let highly integrated dual eligible special needs plan (HIDE SNP) continue to enroll full-benefit, dual-eligible (FBDE) individuals in the same service area, even if those individuals are in Medicaid fee-for-service. This change is intended to maintain coverage and simplify enrollment for these beneficiaries. 

Why It Matters: While the proposed changes revise broader policies, the updates could have significant effects on D-SNP and MA integration. These changes also could shape states’ decisions regarding their integration policies. Plans should continue to monitor these developments. 

Other Notable Changes  

CMS proposes a new special enrollment period (SEP) for beneficiaries when their providers leave a plan’s network, eliminating the requirement that CMS deem the change “significant.” The intent of this change is to preserve continuity of care and ease the burden of beneficiaries switching plans. In addition, CMS plans to codify SEP policies for greater consistency. 

The proposed rule also calls for the following: 

• Codifying multiyear changes stemming from the Inflation Reduction Act, including elimination of the coverage gap phase 
• Lowering annual out-of-pocket thresholds and removal of cost sharing in catastrophic coverage 
• Transitioning to the Manufacturer Discount Program and updating true out-of-pocket (TrOOP) calculations 
• Clarifying specialty-tier drugs and subsidy structures 

As a result, plans will have updated financial responsibilities. 

Connect With Us 

As CMS sets a new course for Medicare Advantage and Part D, organizations face both opportunities and challenges in adapting to these changes. HMA brings deep expertise in Medicare policy, actuarial modeling, and operational strategy. Our team—including experts from Wakely and Leavitt Partners—can help plans, providers, and stakeholders interpret the proposed rule, assess its impact, and develop actionable strategies for compliance and competitive positioning. 

Whether you need data-driven analysis, scenario modeling, or hands-on support preparing for implementation, HMA is ready to partner with you to navigate the evolving Medicare landscape and achieve your goals. Contact Amy Bassano and Julie Faulhaber to discuss your questions and how HMA can help.