CMS Expands ACCESS Model to Include More Chronic Conditions

Beginning in spring 2027, more people with Original Medicare will be able to use CMS’s ACCESS Model for ongoing support with conditions including heart failure, chronic obstructive pulmonary disease, substance use disorders, and tobacco cessation. Through the ACCESS Model, participating organizations are paid based on measurable improvements in patient health rather than the volume of services delivered, while offering support such as virtual care, remote monitoring, connected devices, and health coaching. Under the expansion, the substance use disorder track will cover opioid, alcohol, and other substance use disorders, including support for people with co-occurring depression and anxiety. Certain patients with chronic musculoskeletal conditions will also be able to receive support beyond the initial 12-month care period.

Together, these changes expand the model’s reach, with CMS estimating that three out of four Medicare beneficiaries now qualify for at least one ACCESS track. The model currently includes 160 participating organizations. While ACCESS itself is limited to people with Original Medicare, CMS is also working to extend a similar payment approach across Medicare Advantage, Medicaid, and commercial insurance. So far, 17 health payers representing 165 million people have pledged to adopt ACCESS-aligned payment arrangements. As part of that broader effort, CMS is also developing guidance for a maternal cardio-kidney-metabolic track that Medicaid and other payers could voluntarily incorporate into their operations (CMS, September 15; Fierce Healthcare, September 16).

RHTP Leaves Financial Gaps for Hospitals to Manage as Medicaid Reductions Begin

Hospital leaders remain wary of the Rural Health Transformation Fund Program (RHTP) as Medicaid cuts loom in the coming years, with the program only covering 5% of the $1T in reductions expected over the next 10 years. Originally, the $50B was discussed among hospital leaders and lawmakers as a way for hospitals to sustain operations with cash infusions. However, the RHTP is different than those initial plans, with payment contingent upon state proposals that prioritize sustainable, transformative policies, such as rural health workforce initiatives and the implementation of new technologies to make care more accessible and efficient. As a result, some hospitals have signaled to their state leaders that they are no longer interested in participating in the RHTP due to concerns about a lack of capital funding.

Some hospital leaders are concerned about prioritizing innovation over day-to-day operational realities. However, other providers feel the traditional payment model is no longer sustainable, and the RHTP creates a new opportunity to improve the healthcare system. Hospitals and health systems must make critical financial decisions about their operations while navigating the RHTP and the substantial Medicaid changes on the horizon (STAT News, September 14).

Trump Administration to Send $500 Rebates to Exchange Enrollees

On September 10, President Trump announced that the federal government would issue $500 rebates to nearly one million unsubsidized healthcare.gov enrollees across 30 states. According to the White House, the refunds will be funded through excess “user fees” that were paid by qualified health plans participating in the ACA marketplaces, the cost of which was passed to enrollees through higher premiums. The Trump Administration alleges that these fees contributed to higher premiums under the Biden Administration, although fees were higher this year compared to plan year 2025, an increase from 1.8% to 2.5%. The announcement has drawn attention among healthcare advocates who question whether the refund amount is adequate to provide financial relief to recipients, given the cost-of-living and high healthcare costs. The refunds are expected to be issued to eligible individuals beginning this October (Inside Health Policy, September 10).

Two Lawsuits Filed Against DHS and Immigration Agencies Over Public Benefit Restrictions

Two coalitions, one made up of 22 states and the other of six counties and cities across the US, have filed two separate lawsuits against the U.S. Department of Homeland Security and the U.S. Citizenship and Immigration Services ahead of a new policy that would penalize immigrants who utilize public benefits. Under the rule, set to take effect on September 18, immigration officers will be allowed to consider enrollment in programs like Medicaid and SNAP as grounds for a “public charge” determination when reviewing applications for green cards, visas, and admission into the US. The states cite DHS’ own estimates, where they stand to lose roughly $4.05B in federal payments for Medicaid and CHIP alone. The coalition of cities and counties estimates that roughly 1.3 million people, including 600 thousand children, would be at risk of losing health coverage. Separately, the coalition notes that they may be forced to withdraw from ongoing free or low-cost educational programs (Stateline, September 14).

CMS Outlines Three-Tier Approach for Medicaid Medical Frailty Exemptions

CMS outlined an optional three-tier framework states can use to identify Medicaid beneficiaries who qualify for the medically frail exemption from community engagement requirements, with Tier 1 based on existing claims and clinical data, Tier 2 requiring additional information on severity or functional status, and Tier 3 requiring manual review. Some conditions, including recent acute congestive heart failure, could qualify based on available data alone, while other cases may require additional information on a beneficiary’s health care use or functional limitations or a manual review. As part of that process, CMS generally requires states to use claims and encounter data from the prior 12 months, although it anticipates allowing a five-year lookback for substance use disorder because individuals in stable recovery for five or more years do not qualify under the SUD medically frail category. CMS also clarified that before January 1, 2028, states may accept self-declaration when reliable data are unavailable, but beginning on that date, self-declaration may generally be used only once during a beneficiary’s enrollment period. The AMA said the approach could reduce some documentation requirements but warned that claims data often do not show how a condition affects a person’s ability to meet the requirements, meaning many beneficiaries could still need manual review (Inside Health Policy, September 11; Medicaid, September 3).

State Outreach Varies Ahead of Medicaid Work Reporting Requirements

Georgetown University McCourt School of Public Policy’s Center for Children and Families reviewed outreach materials from the 43 states, including DC, implementing Medicaid work reporting requirements and found variation in how states explain who is affected and what beneficiaries need to do. That finding aligns with April 2026 CMS research, which found that many Medicaid enrollees were unaware of the upcoming changes or unsure whether the requirements applied to them. In 27 states and D.C., nearly all parents or caretaker relatives living with a child are either exempt or can satisfy the requirements through income, yet few states clearly explain that in their outreach materials. State materials also vary in how prominently they highlight the $580 monthly income threshold, while many provide limited guidance on how beneficiaries should document an exclusion or show compliance. Montana’s early implementation offers an example of that complexity, with a verification matrix outlining multiple documents, self-declaration forms, and other paperwork beneficiaries may need to submit to prove compliance or qualify for one of 10 exclusions or short-term exceptions (The Center for Children & Families, September 11).