Reflections from the National Association of Medicaid Directors 2025 Conference: Challenges, Changes, and Opportunities

Acentra Health returned from NAMD 2025 energized by the dedication of our nation’s Medicaid Directors and their teams. The conference, held November 18-21 at the Gaylord National Resort & Convention Center in Oxon Hill, Maryland, was the largest to date, giving us the opportunity to speak with many Directors. In a nutshell, here’s what we heard: the challenges brought on by market constraints will force them to change how they operate, giving them opportunities to do new things.

Challenges

At the highest levels, most states are dealing with significant challenges, and all agencies are feeling the pressure. Specifically, Medicaid agencies are struggling with:

  1. Funding Gaps: States are grappling with decreasing funding across many programs, at a time when inflation, tariffs, and medical costs are increasing. Medicaid agencies are looking at rate reductions, service limits, or elimination of optional benefits.
  2. Staff Shortages: Decreased funding has led to Medicaid agency staff reductions, leaving fewer people to do the same, if not more, work.
  3. New Requirements: Implementing H.R. 1 requirements and new rules from the Centers for Medicare and Medicaid Services (CMS) will tax already resource-strapped Medicaid agencies.
  4. Outdated Technology: Many Medicaid eligibility, claims, and other programs run on old hardware with software that is expensive and time-consuming to modify to meet new requirements. Systems are fragmented, making inter- and intra-agency data sharing difficult at a time when it’s needed the most.
  5. Heightened Expectations: States are expected to boost Medicaid program integrity with improved eligibility and auditing processes. Payment Error Rate Measurement (PERM) program scores were discussed at length. CMS also stressed the need for better health outcomes and long-term stability for beneficiaries.
Changes

Many states are still addressing the impacts of the unwinding of the Medicaid Continuous Enrollment Provision with ongoing member outreach and redetermination work, and the addition of new laws, requirements, and rules is adding more to their plates. Medicaid agencies are looking to CMS to help them prioritize the myriad requirements and rules.

  1. Community Engagement (CE) Requirement: A transformative component of H.R. 1, the CE requirement is the top priority of CMS and one of the biggest, most complex changes states must implement. Communicating the requirement to beneficiaries; identifying information sources needed to verify employment, education, and volunteer hours; and modifying or building systems to process the data are but a few tasks that must be completed by January 1, 2027.
  2. Managed Care Rule of 2024: The latest final rule from CMS sets new, more granular requirements for access, quality, state-directed payments, in-lieu-of services, medical loss ratios, and the Children’s Health Insurance Program (CHIP).
  3. Medicaid Access Rule of 2024: Supporting improved access to care for beneficiaries, the Medicaid Access Rule sets forth new requirements for advisory boards/councils, home- and community-based services, and fee-for-service payments.
  4. Rural Health Transformation (RHT) Fund: The deadline for states to submit grant applications for their piece of the $50 billion fund passed a few weeks ago, and awardees will be notified by the end of the year. Monitoring of programs will begin in January. While the increased funding is welcome, states are unsure how they will prioritize RHT programs against pressing requirements.
  5. Increased Oversight of Vendors: Written into the new laws and rules as well as stressed by CMS as a priority, oversight of vendors is another area on which states must increase attention. Medicaid Managed Care Organizations (MCOs) will be looked at for better care coordination and outcomes in maternal health, behavioral health, long-term care, and care transitions. Technology vendors are expected to bring forth complete, proven solutions; modernize platforms and programs; and collaborate transparently with states, CMS, and each other.
Opportunities

With change comes the chance to do things differently, and states are doing just that. From focusing on improving the basics to creating innovative programs, states are finding ways to take their Medicaid programs to new levels despite the challenges.

  1. Rural Health: States are exploring shared savings waivers, support for provider workforce needs, new telehealth models, and modern, automated tools.
  2. Maternal Health: Postpartum access and reducing Caesarean sections are among priority maternal health initiatives. Medicaid agencies are innovating with enhanced outreach, incentives, and community support. Data integration, care coordination, and accountability for outcomes are key to successful programs; the same holds true for Behavioral Health.
  3. Technology Modernization: States are looking for modular, interoperable technology that can grow and change quickly to adapt to changing requirements and policies. Artificial Intelligence (AI) is everywhere, but Medicaid agencies are taking a measured approach to ensure safe and responsible use.
  4. Data and Analytics: Medicaid agencies are looking to maximize their data, with predictive risk models, real-time dashboards for crisis response, and whole-person data integration.
  5. Food as Medicine: States are realizing the importance of proper nutrition for all citizens and the challenges that vulnerable populations have with accessing healthy food. Food-as-medicine pilots are being considered for maternal health and long-term care recipients.
  6. New Programs: Creativity abounds among agencies using the 1115 waiver for programs addressing re-entry and identifying health-related social needs. Other states are excited about structured programs to cover and distribute diapers, help beneficiaries transition off Medicaid, and provide General Educational Development support.

Looking Ahead
Nearly everyone we heard from said the next 12-36 months will be overwhelming. Now, more than ever, is the time for those of us who support state Medicaid agencies to come together and deliver valuable solutions that save them time and money.
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