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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.听

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

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

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

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

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

2. Coordinated communication and stakeholder engagement remain critical.听

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

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

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

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

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

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

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听GENEROUS听(GENErating听cost Reductions听fOr听US Medicaid)鈥痬odel, which is听focused on drug costs in the听Medicaid program. These discussions reinforced CMS鈥檚 focus on new drug pricing models and the importance of involving Medicaid experts in these nuanced development and implementation conversations.听

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

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

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

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

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

Connect听with Us听

HMA鈥檚 expert consultants provide听advanced听policy,听technical, and operational听support, and can听help听your organization听navigate and succeed in the听evolving regulatory landscape.听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鈥檚 featured experts Beth Kidder听and听Kathleen Nolan.听

On November 28, 2025, the Centers for Medicare听&听Medicaid Services (CMS)听听the听.听Each annual rulemaking听cycle offers CMS an opportunity to recalibrate program priorities.听听

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

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

Key Themes in the Proposed Rule听

Requests听for Information听

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

Figure听1.听RFIs Signaling New Policy Directions听

Star Ratings Overhaul: Refocusing on Outcomes and Experience

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

• Health Equity Index Rollback:听Rather than听implement the previously planned听Excellent Health Outcomes for All听reward (formerly Health Equity Index) for 2027,听the agency will continue using the historical reward factor that incentivizes consistently high performance across all measures.听
• Measure Streamlining: Twelve process-heavy or administrative measures will be removed.听
• 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.听听

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

Medicare and Medicaid Dual Eligible听SNPs and听Integration听

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

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

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

Other Notable听Changes听听

CMS proposes a new听special听enrollment听period (SEP)听for听beneficiaries听when their听providers leave a plan鈥檚 network,听eliminating听the requirement that CMS听deem听the change 鈥渟ignificant.鈥澨齌he intent of this听change听is听to preserve continuity of care and听ease the burden of听beneficiaries听switching plans.听In addition, CMS plans to codify SEP policies for greater consistency.听

The proposed rule听also听calls for the following:听

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

As a result, plans听will听have updated听financial responsibilities.听

Connect With Us听

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

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.听Contact听Amy Bassano听and听Julie Faulhaber to discuss your questions and how HMA can help.