HMA Weekly Roundup

States Submit Applications for Rural Health Transformation Program: Trends and Opportunities

On November 5, 2025, the Centers for Medicare & Medicaid Services (CMS) announced that all 50 states had submitted applications to be considered for participation in the Rural Health Transformation Program (RHTP) created under the Budget Reconciliation Act of 2025. States proposed a range of initiatives to strengthen innovation, modernize rural health infrastructure, and address persistent disparities in healthcare access, workforce, and outcomes in rural communities. Funding decisions are expected by December 31, 2025.

The RHTP represents a major federal investment in rural health transformation. For providers, community partners, and other interest holders, applications offer valuable insight into state priorities, partnership models, and the types of initiatives likely to receive funding.

Many state feedback processes are ongoing for providers, community organizations, and other partners. Even after submission, states are refining their proposals and negotiating with CMS. Organizations should review available materials and take advantage of open comment periods or stakeholder meetings to help states prepare for a strong program launch in early 2025.

Health Management Associates (HMA) reviewed state overviews and applications, where available. In this article we highlight key takeaways from this review and the information available through HMA’s Information Services (HMAIS).

Key Issues and Trends

• Breadth of initiatives and focus areas. State initiatives meet the specific categorical CMS requirements and include a range of innovative models, ideas, and investments in building out pilots and infrastructure. The number of initiatives that states have planned also vary, with most proposing four or five, but at least one state has developed 11 planned programs. Many initiatives involved remote patient monitoring and telehealth, including tele-specialty clinics, tele-psychiatry hubs, tele-intensive care unit support, among others. Several states proposed to establish and enhance models involving emergency medical services (EMS). Proposals also include a range of investments in electronic health records (EHRs), data infrastructure, and interoperability to specific provider types and generally in rural communities.
• Subgrant and Partnership Opportunities: Many applications include subgrant programs or call for partnerships with hospitals, clinics, community-based organizations, Tribal entities, and educational institutions. Reviewing state applications can help organizations understand the timelines for upcoming funding and partnership opportunities as well as expectations associated with the state initiatives.
• Diverse governance and implementation models: The tracker reveals a range of governance structures, from state-led advisory boards and interagency task forces to regional hubs and cross-sector partnerships. States are leveraging advisory councils, technical assistance partners, and community engagement frameworks to guide implementation and oversight.

Some states have yet to submit their full applications but still have opportunities to engage and shape state efforts through various methods. Many states have kept open public feedback mechanisms even as they negotiate with CMS on budgets and program details. This situation creates an evolving landscape wherein stakeholders must monitor multiple channels for updates and opportunities.

Why This Matters

HMAIS’ RHTP Inventory provides states, rural communities, and their partners an actionable road map for state initiatives. This inventory covers focus areas for state initiatives, governance models, funding requests, partnership opportunities, and other key information. This tool helps organizations monitor trends and identify where to engage. HMA will continue to follow state activity in this program as states move forward.

Beyond the tracker, HMA offers deep regional market expertise—our consultants understand state-specific priorities and can provide tailored analysis and strategic planning to position your organization for success. Whether you’re exploring telehealth investments, building partnerships, or preparing for new initiatives in rural health transformation, our team can help you navigate the details and seize opportunities.

For questions about the HMAIS RHTP Inventory and to connect with our state-market leads, contact Andrea Maresca and Gabby Palmieri.

Where Duals Integration Is Headed: State-by-State Intelligence

Dually eligible individuals are those who qualify for both Medicare and Medicaid. This population accounts for a disproportionately small share of the total Medicaid or Medicare population, but they account for a disproportionately large share of spending across both programs.

Medicare Advantage Dual Eligible Special Needs Plans Play a Key Role

Over the last several decades, federal and state policymakers have developed and implemented a range of programs, demonstrations, and approaches to improve care for this population and strengthen alignment between Medicare and Medicaid, improve outcomes, and manage costs. Medicare Advantage (MA) Dual Eligible Special Needs Plans (D-SNPs) are a key vehicle to accomplish federal and state goals.

What to Expect in Medicare Advantage Contract Year 2026

In 2026 and beyond, we can expect significant state and local shifts in plan enrollment, due to new federal requirements and state demonstration program transitions. We will see states focused on advancing aligned plan enrollment and setting higher expectations for Medicare-Medicaid integrated programs.

A New Inventory to Stay on Top of State Markets

Health Management Associates (HMA) has published the Duals Integration Environmental Inventory, a state-by-state view of state Medicaid program structures and regulations shaping integration and D-SNP markets. This resource is designed to help state policymakers, insurers, and healthcare organizations track trends, identify opportunities, and inform strategic planning in an evolving policy landscape.

Looking Ahead at the Changes in 2026 and Beyond

Federal rules for the Medicare Advantage 2026 contract year—and state Medicaid contractual agreements with plans—strengthen D-SNP integration standards and coordination between states and plans. Examples include:

• D-SNP Look-Alike Plans: In 2026, the threshold for identifying MA plans as D-SNP look-alikes will decrease from 70 percent to 60 percent. This 10-percentage point drop marks the second of two planned phasedowns in the threshold percentage. Look-alike plans are MA plans that are marketed to dually eligible individuals, but they are not required to comply with D-SNP integration requirements. Stronger federal standards will require MA look-alike plans with high dual enrollment to convert or exit the market, which is expected to lead to shifts in dually eligible enrollment into D-SNPs and other integrated products.
• Financial Alignment Initiative Demonstration Transitions: The Centers for Medicare & Medicaid Services (CMS) has worked with several states operating capitated Financial Alignment Initiative (FAI) demonstrations to transition Medicare-Medicaid Plans (MMPs) to integrated D-SNPs by January 1, 2026. These states include Illinois, Massachusetts, Michigan, Ohio, Rhode Island, South Carolina, and Texas will end their FAI demonstrations on December 31, 2025.
• 2027 D-SNP Rules: Beginning in 2027, D-SNPs affiliated with Medicaid managed care organizations (MCOs) must restrict enrollment to Medicaid MCO enrollees. In addition, federal rules will limit the number of D-SNP plan benefit packages, which will require additional coordination with Medicaid affiliates and planning in designing benefit packages and network.

State Medicaid Program Adjustments

States are working to align new federal D-SNP requirements with existing Medicaid managed care contracts, long-term services and supports carve-in strategies, and service-area mappings. Because State Medicaid Agency Contracts (SMACs) must be updated annually, all SMACs will need to incorporate the new D-SNP provisions as the new requirements take effect. This effort will require close coordination among state agencies, plans, and CMS to manage enrollee transitions, data-sharing, and communications.

Data-Informed Integration Insights

HMA’s Duals Integration Environmental Inventory is a single hub for insights into requirements, approaches to scope of integration programs, and enrollment data. The inventory will help plans and other types of organizations such as providers and community-based organizations to prepare for future contracting, compliance, and operational transitions.

This inventory is designed to answer the four major questions top of mind:

• What is the state’s integration model and D-SNP type. The inventory identifies each state’s approach to integrating care for dually eligible populations, including states with Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs), Highly Integrated D-SNPs (HIDE-SNPs), coordination-only models, and Exclusively Aligned Enrollment (EAE) initiatives or comparable rules
• Does the state’s program integrate LTSS and/or Behavioral Health? The inventory details whether long-term services and supports and behavioral health are carved into or out of managed care and how those benefits interact with Medicare coverage within D-SNP structures
• What is the state’s enrollment policy? The inventory captures enrollment in HIDE/FIDE products, identifies Applicable Integrated Plan (AIP) states, and gauges overall alignment maturity
• What is the state’s procurement and contract timeline? The inventory also tracks state procurement timelines, upcoming RFPs, and effective contract dates

Connect with Us

HMA experts are tracking state integration strategies, procurement timelines, and future state planning activities. Beyond the tracker, HMA colleagues provide tailored analysis and planning for state-specific initiatives. Our team can help health plans prepare for enrollment shifts, compliance requirements, and integration opportunities in 2026 and beyond. For information about subscription access to the HMA Information Services (HMAIS) inventory and to connect with HMA consultants who can address your integration questions, contact Andrea Maresca or Gabby Palmieri.