Weekly Roundup -
April 15, 2026
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Unmatched Healthcare Insights from 黑料不打烊,
Leavitt Partners & Wakely.
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Wakely Analysis Signals Significant Enrollment Shifts in ACA Individual Market as 2026 Unfolds
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黑料不打烊鈥檚 Experts Support States in Rural Health Initiatives
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Trending: In Focus
Connecting the Dots: Medicaid Community Engagement Requirements and State Readiness for 2027
Our March 19, 2026, Connecting the Dots analysis described the federal requirements and the operational questions states and partners will need to answer to effectively implement Medicaid work and community engagement requirements. Since then, federal officials have advanced their forthcoming regulation to the final stage of review and intend to meet the statutory requirement to release interim final guidance by June 2026. In addition, many states have taken early steps to communicate upcoming changes and begin planning for system, policy, and partner readiness.
While state sessions are clearly grabbing a lot of energy, timing of pulling together many of the moving parts is becoming a concern as states undergo one of the most fundamental operational challenges to the Medicaid program since its inception. This article synthesizes emerging approaches and identifies practical opportunities to refine strategies and strengthen readiness while minimizing burden for enrollees and state Medicaid agencies.
Early Actions in States Preparing to Implement Work and Community Engagement Requirements
1. States Are Launching Websites that Highlight Coming Changes
As of April 2026, more than half of US states that are subject to the Medicaid work and community engagement requirement had posted web page content describing forthcoming changes associated with the 2025 budget reconciliation act (P.L. 119-12, OBBBA). Some websites provide high-level descriptions of key provisions (e.g., qualifying beneficiary ages, qualifying activities, and exemptions), while others include more detailed information reflecting state-specific policy decisions, educational messages, and suggested steps that beneficiaries, providers, managed care plans (MCPs), and community-based stakeholders can take now (see Figure 1).
Figure 1. States with a Community Engagement Web Page
For example, 鈥檚 website describes the requirements for, and provides examples of, acceptable documentation Medicaid members may use to demonstrate compliance or eligibility for an exemption. Ohio also offers a that contains frequently asked questions (FAQs) and draft outreach materials to support stakeholder communications and increase awareness. The communications tools include a one-page flyer, a rack card, and potential social media posts to raise awareness of the changes, with some use of QR codes to enhance quick access to key websites like the beneficiary self-service portal.
2. States are Beginning to Make and Communicate Preliminary Policy Decisions
States must make a range of policy decisions, including the penalty start date, the number of required months of compliance for both the initial application and subsequent renewals, the potential adoption of short-term hardship exceptions, and how exceptions are defined and operationalized. While most states anticipate compliance beginning January 1, 2027, in alignment with OBBBA, Nebraska and Montana have announced plans to begin implementation in 2026, and their websites reflect additional policy details to support accelerated timelines.
A handful of states, including Arkansas and Ohio, also are communicating ahead of OBBBA鈥檚 timeline to promote awareness and engagement before the work and community engagement requirement becomes effective. Table 1 summarizes examples of the current state planning[1] around the number of required months of compliance for the initial application and renewals.
Table 1. Sample Number of Months in Compliance
States also are taking different approaches to exemptions and short-term exceptions. Although many exemptions and exceptions are defined in statute, the interpretation of 鈥渕edically frail鈥� remains an area in which states have significant flexibility, with implications for how many individuals are exempt. Many states have experiences with establishing definitions of medically frail. For example, states that offer an adult benefit package that differs from the state plan benefit package must allow medically frail adults to opt in to the state plan. At least 12 states already make medically frail determinations, and these existing policies and processes may inform approaches for work and community engagement requirements.
One of those states鈥擭evada鈥攈as posted a with a request for public comment, including a sample list of qualifying medical conditions. Although such lists can provide clarity, they also underscore the importance of a clear and straightforward exemption request process to support appropriate determinations, including for individuals with conditions that are omitted from a specified list.
3. States Are Securing Additional Support to Address Administrative Challenges
The new eligibility criteria, coupled with more frequent eligibility checks, are placing substantial new demands on Medicaid agencies, eligibility systems, and personnel. In response, states are considering or actively pursuing a range of approaches to strengthen administrative capacity. Examples include:
- Hiring new state eligibility and enrollment workers: Indiana and Montana
- Funding system enhancements and improvements: Alaska and New Jersey
- Hiring outreach and engagement contractors: Arizona and Arkansas
States are also proposing to take a more coordinated, cross-agency approach that uses other state agencies and programs as data sources and referral pathways to help beneficiaries meet their work and community engagement requirements. A variety of states are looking to leverage data from their Supplemental Nutrition Assistance Program (SNAP) program to facilitate compliance checks, and Kentucky has receiving data from a variety of sources (e.g., Department of Revenue, Department of Corrections, Unemployment Insurance, Vital Statistics, and others) to more automatically identify eligibility and exemption changes.
States like Hawaii, Montana, and Nebraska have highlighted their labor departments to connect people to job and community service resources. Virginia鈥檚 work and community engagement website directs the public to a series of different programs based on whether they are interested in employment, volunteer, or education resources. Minnesota also has introduced legislation proposing collaboration between the commissioner and county agencies to link beneficiaries to other critical services like job training, childcare, and transportation.
Shrinking federal contributions and constraints on Medicaid revenue strategies鈥攕uch as limits on provider taxes鈥攁re prompting states to rethink how Medicaid agencies operate within existing budgets. Limited federal funding to support administrative needs elevates the importance of efficiency, coordination, and automation.
What States Might Do to Chart a Better Path Forward
A robust pre-implementation plan is critical to successful work and community engagement implementation. A well-documented plan helps states fully document the variety of moving parts across policy, systems, and partners, clarify milestones and decision points, and define what readiness looks like in practice.
Key components of a pre-implementation plan may include:
- Signing agreements and contracts to support infrastructure. Pre-implementation planning should ensure that appropriate support from third-party vendors and sister agencies is secured to optimize flexibilities and manage the requirements. Examples may include maintenance of effort (MOE) agreements, memoranda of understanding (MOU), contract updates, and requests for proposals (RFP) as appropriate. States may need to use expedited contracting vehicles when available and maximize existing vendor arrangements. Agreements should address data governance, privacy, and cost allocation issues to support smooth operational integration and reduce downstream friction.
- Quantifying and automating exemptions. Systems and reporting should be updated to identify, notify, and manage cases for expansion adults who are likely exempt. Leveraging additional resources and data matching may help states identify common exempt populations, such as caretakers with dependents under age 14, disabled veterans, and pregnant women without requiring additional verification. Understanding the demographics of the remaining nonexempt population may also be useful in outreach, education, and links to supports.
- Preparing for readiness review, including system readiness, coverage transition, and churn management. Pre-implementation plans should prioritize robust system testing, staff training, and timely updates to required documentation (e.g., state plan amendments, policy and member manuals, notices, and reviewing and approving MCP communications). Building in clear transition supports for individuals who may lose coverage or transition to other coverage options can improve continuity of coverage, reduce uninsurance and uncompensated care, and limit administrative burden following implementation.
- MCP contracts. Most enrollees subject to work and community engagement requirements are enrolled in Medicaid MCPs. States will need to describe enhanced roles and responsibilities in both the MCP contracts as well as the rates. Clear contract expectations can support transparency and mutual accountability across partners.
- Test communications with the target audiences to ensure understanding and appropriate action. Awareness of the new work and community engagement requirement was one of the biggest challenges Arkansas faced when it launched its program in 2018. Beneficiaries also struggled to understand whether the requirement applied to them and what they needed to do to comply. States must build communications plans and messaging to clearly address these issues to reduce the number of beneficiaries losing coverage simply because they did not understand the new requirements.
Connect with Us
黑料不打烊 (黑料不打烊) Medicaid experts assist Medicaid and state policymakers with the following:
- Strategic positioning
- Policy-to-operations design
- Cross-agency governance and partner alignment
- Information systems impact assessment, change planning, testing strategies and readiness metrics
- Scenario planning and beneficiary impact analysis
- Communications and operational playbooks
- Program integrity, reporting, and audit support
黑料不打烊 Medicaid experts can also assist MCPs, providers, and community-based organizations with:
- Risk assessments (e.g., enrollment, utilization, and spending impacts)
- State-specific policy and operational insights and trends
- Communications, outreach, and engagement strategies and content
- Member retention strategies
- Grassroots workforce development and community engagement strategies
For questions, contact 黑料不打烊 contributors to this article Lora Saunders, Matt Powers, Andrea Maresca, and Amber Swartzell.
[1] Some of these policies are in pending legislation and, therefore, are subject to change.
CMS鈥檚 LEAD Model: A New Phase for Accountable Care and Application Considerations
The represents the next major step in the Centers for Medicare & Medicaid Services (CMS) strategy and reinforces a federal commitment to value-based participation in Traditional Medicare. Announced as the successor to , LEAD is a voluntary, nationwide, 10鈥憏ear model that will operate from 2027 to 2036, making it the longest-running accountable care organization (ACO) model the Center for Medicare and Medicaid Innovation has tested.
Momentum around the LEAD ACO model has accelerated since CMS鈥檚 recent release of the (RFA), which formally moves LEAD from policy design to implementation. The RFA requires prospective participants to evaluate program design choices, financial implications, and operational readiness on a compressed timeline. Notably, CMS has indicated that additional opportunities to express interest will follow for organizations that are not prepared to apply for participation in the initial cohort.
This article explains key design elements of the LEAD model and identifies considerations for organizations assessing whether and when to pursue participation in LEAD.
Core Design Evolutions of the LEAD Model
While LEAD builds on many of the elements from ACO REACH, its design reflects how the Innovation Center intends to address challenges with previous ACO models, such as the Medicare Shared Savings Program (MSSP). At its core, LEAD seeks to establish a pathway to long鈥憈erm engagement in value-based care that creates an attractive option for all types of providers, including ACOs with a history of engaging in value-based care and providers that have yet to meaningfully participate.
LEAD introduces a set of targeted design changes intended to improve predictability, alignment accuracy, and long鈥憈erm participation in accountable care鈥攎ost notably through revised benchmarking, updated beneficiary alignment, and expanded flexibility for engaging specialists and high鈥憂eeds populations.
1. Revising Benchmarking Policies to Support Predictability and Success
- LEAD provides a major win for ACOs seeking long-term predictability by setting a long-term benchmark that will not rebase for the entirety of the 10-year model. In MSSP, many ACOs eventually face the 鈥渞atchet effect鈥� in which benchmarks erode after rebasing to reflect the ACO鈥檚 more recent spending patterns. It can create a significant hurdle for ACOs that have already successfully reduced spending, as their own prior success lowers their benchmark. By not rebasing for the entirety of the model period, LEAD provides an attractive alternative to the MSSP, which rebases every five years.
- LEAD will also support historically successful ACOs by transitioning to a fully regional rate book by the end of the model period. As a result, benchmarks will be set based on overall spending in the region where an ACO operates rather than an ACO鈥檚 historical spending. While ACO REACH also used a regional rate book to inform some ACO benchmarks, LEAD goes further by seeking to transition all ACOs to a benchmark based fully on a regional rate book while also adding protections for higher-spending ACOs by transitioning regions at different timelines to ensure that newer ACOs have the opportunity to implement the kinds of care delivery changes that lead to lower spending before they are subject to penalties.
- Other notable changes to benchmarking include a variety of ACO-specific adjustments and the addition of an administrative component to benchmarking. ACOs will be eligible to receive a boost to their benchmarks with either a regional efficiency adjustment for ACOs with lower spending or a prior savings adjustment for ACOs with a demonstrated history of achieving savings. LEAD also introduces an administratively set component to benchmarking鈥攖he Accountable Care Prospective Trend鈥攚hich already is used in the MSSP, though LEAD adds a new guardrail policy to promote predictability.
2. Improving Accuracy in Beneficiary Alignment
- LEAD鈥檚 new 鈥渉ybrid鈥� alignment option increases accuracy and responsiveness. Monthly additions of voluntarily aligned beneficiaries and mid-year recognition of new participant taxpayer identification numbers (TINs) adopted after the start of the performance year (PY) allow alignment to better reflect real-time care relationships, averting lag and operational friction.
3. Adding Support for High-Needs Beneficiaries
- LEAD expands support for beneficiaries with complex needs through a universal High Needs category and recalibrated risk adjustment. By moving away from ACO REACH鈥檚 population鈥慹xclusive model, LEAD lowers barriers for organizations that serve a disproportionate share of high鈥憂eeds and dually eligible populations. In addition, CMS will test Medicare鈥慚edicaid alignment in two states, and help states develop arrangements supporting the provision of value-based care between ACOs and state Medicaid agencies or managed care organizations.
4. Promoting Deeper Engagement with Specialists
- LEAD increases flexibility for engaging specialists in value鈥慴ased arrangements. New Non鈥慞rimary Care Capitation options and episode-based risk arrangements (CMS鈥慉dministered Risk Arrangements (CARAs)), allow ACOs to share risk with specialists without Total Care Capitation, reducing operational complexity while expanding accountability beyond primary care.
5. Advancing Technology Adoption and Innovation
- LEAD introduces structured pathways to promote technology adoption. Planned Artificial Intelligence (AI)鈥慽nferred risk adjustment will be phased in following successful testing and validation, while the Tech Enabler Initiative and Rapid Cycle Innovation Program seek to reduce administrative burden and accelerate evidence generation鈥攑articularly for smaller or resource鈥慶onstrained ACOs.
Next Steps
The Innovation Center is operating on an accelerated timeline for the initial LEAD cohort. Prospective ACOs have fewer than 50 days to digest a detailed and model potential performance. Applications are due May 17, 2026. ACOs that participated in ACO REACH in PY 2026 will be well-positioned, as many of the provisions in LEAD will be familiar, and the agency is permitting this group of ACOs to submit an abbreviated application for participation.
For organizations not ready to apply for the first cohort, CMS will release a standardized Letter of Interest form by April 17, 2026, to gauge interest in future application rounds. In this context, organizations considering LEAD participation should be assessing not only near鈥憈erm application readiness, but also longer鈥憈erm strategic alignment with the model鈥檚 10鈥憏ear commitment, risk structure, and operational requirements. Key considerations include benchmarking predictability, readiness to manage regional benchmarks, capacity to engage specialists and high鈥憂eeds beneficiaries, technology capabilities, and alignment with broader value鈥慴ased care strategies across Medicare and Medicaid.
Connect with Us
黑料不打烊 (黑料不打烊), supports organizations across the LEAD decision continuum, including those pursuing immediate application and those preparing for future cohorts. 黑料不打烊 can help organizations:
- Interpret LEAD鈥檚 policy and financial design relative to existing ACO and MSSP participation
- Model performance scenarios under alternative benchmark, alignment, and risk configurations
- Assess operational readiness across care management, contracting, analytics, and compliance
- Develop application strategies and supporting materials, including responses to the LEAD RFA
- Choose to defer application on steps that preserve future optionality
As CMS advances LEAD under an ambitious timeline, early analysis and disciplined decision鈥憁aking will be critical for organizations seeking to align participation with their long鈥憈erm value鈥慴ased care strategies.
For questions contact Amy Bassano and Rebecca Nielsen.
Federal Policy News
Fueled By Weekly Health Intelligence
CMS Proposes Expanded Interoperability and Prior Authorization Standards for 2026
On April 10, the Centers for Medicare & Medicaid Services (CMS) the听. The proposed rule builds on the听听and the听, which together require Medicare Advantage (MA) organizations, state Medicaid and Children鈥檚 Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs) to implement Patient Access, Provider Directory, Provider Access, Payer-to-Payer, and Prior Authorization Application Programming Interfaces (APIs).
In this rule, CMS proposes several additional measures to enhance the requirements established in earlier final rules, including:
- Adding small group market QHP issuers offering plans on the Federally-facilitated Small Business Health Options Program (FF-SHOP) as an impacted payer.
- Formally adopting Fast Healthcare Interoperability Resources庐 (FHIR庐) as the HIPAA prior authorization transaction standard, replacing X12 278.
- Require impacted payers implement electronic prior authorization for drugs, using Health Level Seven庐 (HL7庐) FHIR庐鈥慴ased APIs for drugs covered under a medical benefit and NCPDP SCRIPT, Formulary and Benefit and Real-Time Prescription Benefit standards for drugs covered under a pharmacy benefit.
- Require impacted payers to provide notice of drug-related prior authorization decisions within specified timeframes:
- No later than 24 hours after receiving a prior authorization request for Medicaid and CHIP programs, state Medicaid FFS programs, Medicaid managed care plans, and CHIP managed care entities;
- No later than 24 hours after receiving a prior authorization request for any prescription drugs for which Federal Financial Participation (FFP) is available for State CHIP FFS programs; and
- No later than 72 hours after standard prior authorization requests and no later than 24 hours for expedited prior authorization requests for all drugs for QHP issuers on the FFEs.
- Require impacted payers to:
- Report API endpoints to CMS for centralized publication;听and
- Share prior authorization (PA) request status and decisions through the Patient Access, Provider Access, and Payer鈥憈o鈥慞ayer APIs.
- Require state Medicaid and CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and QHP issuers on the FFEs to provide providers with a specific reason for denying prior authorization requests for any drugs. Beginning in 2028, require impacted payers to publicly report detailed PA metrics for all drugs (excluding Part D drugs for MA鈥慞Ds).
- Adopt certain HL7庐 FHIR庐 standards and implementation specifications related to prior authorization attachments.
The proposed rule also includes five Requests for Information (RFI) related to admission, discharge, and transfer (ADT) notifications; cybersecurity as it relates to electronic health information; opportunities to streamline the step therapy process through technology and data sharing; implementation of Payer Application Programming Interface (API) Technology; and prior authorization requirements from health insurers for laboratory tests and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items.
The to submit comments is June 16, 2026. If finalized as proposed, for the majority of this rule鈥檚 provisions, impacted payers would have to be compliant by October 1, 2027.
Coverage at a Crossroads as CMS Narrows Medicaid and CHIP Eligibility
On April 8, CMS a State Health Official (SHO) letter on implementation of section 71109 of the FY 2025 budget reconciliation law (), which limits the definition of 鈥渜ualified immigrants鈥� for the purposes of Medicaid and CHIP eligibility to lawful permanent residents (LPRs), certain Cuban immigrants, and citizens of the Freely Associated States (COFA migrants) lawfully residing in a state or territory. This revision removes Medicaid and CHIP eligibility for several groups defined in the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), including: refugees; noncitizens granted parole for at least one year; noncitizens granted asylum or related relief; certain abused spouses and children; and certain victims of trafficking.
The SHO letter provides states with operational guidance on eligibility systems, applications, verification, and claims processing ahead of the provision鈥檚 effective date on October 1, 2026, after which states will no longer receive federal financial participation (FFP) for non-emergency medical assistance or for child and pregnancy-related health assistance for these beneficiaries. The guidance specifies that in assessing eligibility, states must first attempt to reverify a beneficiary鈥檚 satisfactory immigration status through electronic data sources before attempting to contact the beneficiary and give the beneficiary a reasonable period of time to provide information prior to the state taking adverse action. CMS acknowledges in the letter that states may need to modify their eligibility and enrollment systems and notes that state Medicaid agency IT system costs necessary to support the implementation of these changes may be eligible for enhanced FFP.
In the letter, CMS also notes it 鈥渉as conducted focused financial oversight of eight states with state-only funded programs that provide health coverage for noncitizens regardless of immigration status鈥� and 鈥渉as identified approximately $1.8 [billion] in questionable expenditures reported by states relating to services provided to noncitizens for whom FFP is available only for emergency Medicaid and not for full Medicaid benefits,鈥� and that it intends to conduct continued oversight.
Killing the Clipboard as CMS Pushes Digital First Healthcare Forward
On April 9, CMS held an event, titled, 鈥淗ealth Tech Ecosystem: LIVE! First Wave Launch,鈥� to showcase participants that met the March 31 CMS Health Technology Ecosystem鈥檚 Minimum Viable Product (MVP) deadline by satisfying defined criteria across . First announced on July 30, 2025, the initiative includes providers, payers, electronic health record (EHR) vendors, and tech companies that voluntarily committed to advancing interoperability and supporting a digital-first, patient-centered health system. Since its launch, more than 700 organizations have pledged their participation.
The event highlighted more than 50 organizations that demonstrated interoperable digital tools designed to strengthen the access, use, and exchange of health data to improve the patient experience and support more efficient care delivery. These tools enable consumers to access health data using digital identity solutions (forgoing portal logins), share health records with providers to streamline the check in process, effectively 鈥渒illing the clipboard,鈥� and receive personalized guidance through wellness, chronic condition-focused, and AI-powered applications. During the event, HHS Secretary Robert F. Kennedy, Jr., and CMS Administrator Dr. Mehmet Oz emphasized the elimination of paper-based workflows and the expansion of patient control over their data.
Ecosystem participants are now preparing for the July 4 milestones, including the elimination of PDF-based workflows and a shift toward FHIR庐-based exchange. Companies not yet in production are working toward the July deadline to achieve full MVP status. The initiative aims to make these technologies available-at-scale for Medicare recipients, focusing on reducing administrative burden and improving the human experience of healthcare.
CDC Revises ACIP Charter With Broader Membership and Expanded Scope
On April 8, Centers for Disease Control and Prevention (CDC) a revised charter for the Advisory Committee on Immunization Practices (ACIP), broadening membership criteria and expanding the committee鈥檚 stated responsibilities related to vaccine safety. The ACIP charter is regularly renewed every two years, and the previous ACIP charter was renewed April 2024. Under the updated charter, ACIP membership is drawn from authorities knowledgeable in fields including medicine, vaccines, immunology, toxicology, pediatric neurodevelopment, epidemiology, data science, health economics, and recovery from serious vaccine injuries. The updated charter specifies ACIP鈥檚 duties include:
- 鈥淎dvising CDC on gaps in vaccine safety reports;鈥�
- 鈥淐onsidering analysis of cumulative effects of vaccines and their constituent components;鈥�
- 鈥淓ngaging in re-analysis of vaccine safety and efficacy as gaps are identified and new information becomes available;鈥� and
- 鈥淓valuating the risks and benefits of tailoring immunization practices to maximize benefits and reduce risks and take into account variability in immune response for various populations.鈥�
The charter also adds new liaison organizations to the committee, including the , which lists Children鈥檚 Health Defense as a partner on its website, and . The committee will continue to establish the pediatric vaccine list for the Vaccines for Children Program and issue recommendations that trigger coverage requirements for applicable health plans.
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State Policy News
Idaho Governor Enacts Medicaid Work Requirements Bill
The Idaho Capital Sun听听on April 10, 2026, that Idaho Governor Brad Little signed House Bill 913, directing the state to implement Medicaid expansion work requirements by 2027 in alignment with federal policy. The law requires most expansion enrollees to complete at least 80 hours per month of work or community engagement, prove three-months of employment before applying, the longest allowed by federal law, and have semiannual eligibility redeterminations. Estimates suggest the policy could reduce Medicaid expansion enrollment by 20,000 to 34,000 individuals, driven in part by administrative compliance challenges.
Maryland Prescription Drug Affordability Board Sets Price Cap on Diabetes Medication
Stat News听听on April 13, 2026, that the Maryland Prescription Drug Affordability Board has set an upper payment limit for the type 2 diabetes medication Jardiance. The cap is the second time a state board has set an upper payment limit for a drug, Colorado being the first to set an upper payment limit for an autoimmune disease treatment in 2025. It will go into effect January 2027 and is expected to save $320,000 a year.
Massachusetts Medicaid Director Mike Levine to Step Down June 2026
WWLP听听on April 9, 2026, that Massachusetts MassHealth Director Mike Levine is stepping down in June. Levine was appointed to lead San Francisco鈥檚 Department of Homelessness and Supportive Housing. The exit comes as the state braces for federal changes and prepares to negotiate an extension of its Section 1115 demonstration waiver, which expires at the end of 2027.
Nebraska Legislature Passes Bill Preserving Retroactive Medicaid Coverage
Nebraska Public Radio听听on April 10, 2026, that the Nebraska Legislature passed LB958, requiring the state to maintain the maximum federally allowable retroactive Medicaid coverage, ensuring eligible beneficiaries can receive reimbursement for care received prior to application. The bill would prevent the state from pursuing a previously proposed waiver to eliminate retroactive coverage, instead aligning with new federal limits of two months for traditional Medicaid enrollees and one month for Medicaid expansion enrollees beginning 2027. The legislation also introduces additional Medicaid provisions, including increased transparency in disability assessments and restrictions on changes to home and community-based services without legislative approval, alongside the state鈥檚 planned implementation of Medicaid work requirements.
Federal Government Acknowledges Data Error in New York Medicaid Fraud Probe
The Associated Press听听on April 10, 2026, that the Trump administration acknowledged a significant error in data used to justify its Medicaid fraud investigation into New York, overstating personal care service utilization by a wide margin. Federal officials initially claimed roughly 5 million enrollees used personal care service, but later corrected the figure to about 450,000, citing a misinterpretation of state billing practices. While the investigation remains ongoing amid broader federal anti-fraud efforts across multiple states, the error has raised concerns among analysts and state officials about the accuracy and credibility of the administration鈥檚 methodology and approach. New York officials maintain that the state鈥檚 higher Medicaid spending reflects policy choices and cost factors rather than fraud.
Oregon Awards Funding for 12 RHTP Projects; Opens Competitive Funding Grants
The Oregon Health Authority听 on April 10, 2026, 12 initial Rural Health Transformation Program projects expected to receive up to $6.5 million in 2026 to support community-driven healthcare initiatives, including training for healthcare professionals, mental health and substance use prevention at schools, and support for people managing chronic diseases. The state is also opening a competitive funding round (Catalyst Awards) with proposals due May 26, aiming to distribute approximately $80 million annually for projects focused on maternal health, behavioral health, aging, and chronic disease. Additional funding streams will provide direct support to rural hospitals, clinics, public health authorities, and Tribal communities, with total 2026 investments exceeding $197 million. This includes $21.7 million to the nine federally recognized Tribes of Oregon this year for the Tribal initiative.
Private Market News
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ICHRAs, A Growth Opportunity for Insurers, Face Uphill Battle
are emerging as a growing opportunity for insurers and employers by shifting from traditional group insurance plans to defined contributions, helping control costs as group enrollment declines. Adoption is rising quickly, especially among large employers; growth is challenged by instability in the ACA individual market, rising premiums and regulatory uncertainty. Overall, ICHRAs represent a broader shift toward consumer-driven coverage, requiring insurers to adapt to strategies, tools, and engagement models.
Our Insights
Fueled By Experts Across Our 黑料不打烊 Companies
黑料不打烊
Wakely Analysis Signals Significant Enrollment Shifts in ACA Individual Market as 2026 Unfolds
A new report from Wakely Consulting Group, an 黑料不打烊 Company, models changes to the 2026 ACA market enrollment due to the loss of federal subsidies. Findings suggest a larger drop in ACA marketplace enrollment 鈥� lower than some feared, but higher than the CBO analysis.听
Saving Lives with Compassion: Overdose Response Training with RiVive庐
This webinar will present findings from the 2025 RiVive Community Engagement Report and best practices in compassionate overdose response鈩�, with a focus on the community use of RiVive naloxone nasal spray 3 mg. A panel of expert speakers will present their protocols for effective overdose intervention, guidance on the training of others, and strategies for integrating trauma-informed approaches into post-overdose care. Designed for program teams, medical professionals, and harm reduction leaders, anyone who attends will leave with research and experience-backed methods for improving outcomes in opioid overdose emergencies. A recording of this webinar will be available after this session, with a link to the 2025 report.
2026 Michigan State of Reform Health Policy Conference | May 5, 2026
The 2026 Michigan State of Reform Health Policy Conference will be taking place in-person on May 5th,听2026听at the Kellogg Hotel and Conference Center!听Managing constant change in healthcare takes more than听just hard听work. It takes a solid understanding of the legislative process and knowledge about听intricacies听of the healthcare system.听That鈥檚听where听State听of Reform comes in.
2026 Maryland State of Reform Health Policy Conference | May 21, 2026
The 2026 Maryland State of Reform Health Policy Conference will be taking place in-person on May 21st, 2026 at the Baltimore Marriott Waterfront! Managing constant change in healthcare takes more than just hard work. It takes a solid understanding of the legislative process and knowledge about intricacies of the healthcare system. That鈥檚 where State of Reform comes in.
Wakely
Who Paid, and Who Stayed? Early 2026 Enrollment Trends in the Individual Market
A new report from Wakely Consulting Group, an 黑料不打烊 Company, models changes to the 2026 ACA market enrollment due to the loss of federal subsidies. Findings suggest a larger drop in ACA marketplace enrollment 鈥� lower than some feared, but higher than the CBO analysis.听
Summary of CY2027 Final Rate Announcement
The Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2027 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies, which finalizes important changes in plan payments, risk adjustment and other financial and regulatory requirements for 2027. Wakely summarizes key changes that will affect Medicare Advantage pricing for CY2027 and discusses how this Final Rate Announcement is more consequential than others in recent history.
The LEAD Model: A New Chapter in Medicare Accountable Care
This Wakely white paper presents the LEAD (Long-term Enhanced ACO Design) Model as CMS鈥檚 next-generation approach to accountable care, distinguished from ACO REACH and MSSP by several key structural and financial changes. Running from 2027鈥�2036, LEAD introduces significant new design elements and evolves benchmarking through blended trends and a future shift to administratively set regional rate books, while strengthening quality incentives and prevention-focused benefits.
Performance, Risk Reduction, and Strategic Implications for ACA Insurers in States with Reinsurance Programs
In this white paper, Wakely examines state reinsurance programs through a financial and actuarial lens. It focuses on how reinsurance improves insurer profitability, reduces earnings volatility, and changes the marginal financial impact of members with chronic and catastrophic conditions.
Save the Date: October 5-7 | New Orleans
黑料不打烊 Conference: U.S. Healthcare 2026 鈥� Signals, Signs & Flashing Lights
RFP Calendar
RFP Calendar
| Date | State/Program | Event | Beneficiaries |
|---|---|---|---|
| Date: February 2026 - DELAYED | State/Program: Illinois | Event: Awards | Beneficiaries: 2,400,000 |
| Date: May 1, 2026 | State/Program: Nevada Children's Specialty | Event: Proposals Due | Beneficiaries: NA |
| Date: May 12, 2026 | State/Program: Nevada CO D-SNP | Event: Awards | Beneficiaries: 88,000 |
| Date: June 24, 2026 | State/Program: Wisconsin LTC GSR 3 | Event: Awards | Beneficiaries: 56,000 (all GSR) |
| Date: Summer 2026 | State/Program: Illinois Foster Care | Event: RFP Release | Beneficiaries: 33,000 |
| Date: July 1, 2026 | State/Program: Hawaii Community Care Services | Event: Implementation | Beneficiaries: 5,500 |
| Date: July 28, 2026 | State/Program: Nevada Children's Specialty | Event: Awards | Beneficiaries: NA |
| Date: August 2026 | State/Program: Indiana | Event: RFP Release | Beneficiaries: 1,400,000 |
| Date: January 1, 2027 | State/Program: Illinois | Event: Implementation | Beneficiaries: 2,400,000 |
| Date: January 1, 2027 | State/Program: Nevada CO D-SNP | Event: Implementation | Beneficiaries: 88,000 |
| Date: January 1, 2027 | State/Program: Wisconsin LTC GSR 3 | Event: Implementation | Beneficiaries: 56,000 (all GSR) |
| Date: January 1, 2027 | State/Program: Illinois Tailored Care Management Program | Event: Implementation | Beneficiaries: 22,400 |
| Date: July 1, 2027 | State/Program: Nevada Children's Specialty | Event: Implementation | Beneficiaries: NA |
| Date: January 1, 2028 | State/Program: Wisconsin LTC GSR 4,6 | Event: Implementation | Beneficiaries: 56,000 (all GSR) |
| Date: Fall 2027 | State/Program: Oregon | Event: RFP Release | Beneficiaries: 1,200,000 |
| Date: 2028 | State/Program: North Carolina | Event: RFP Release | Beneficiaries: 2,200,000 |
| Date: 2029 | State/Program: California | Event: RFP Release | Beneficiaries: NA |