The Center for Medicare & Medicaid (CMS) has released a Notice of Funding Opportunity (NOFO) for the Rural Health Transformation (RHT) Program. The RHT Program, authorized through the recent enactment of H.R.1 (the One Big Beautiful Bill Act), aims to transform healthcare delivery in rural America by helping state governments improve access, quality, and outcomes for their communities.  

NACHC worked closely with Congress and CMS during the H.R.1 negotiations to ensure that Community Health Centers (CHCs) and Primary Care Associations (PCAs) are recognized as key stakeholders and providers in the Rural Health Transformation Program. One CHC, Scenic Bluffs Community Health Centers in Western Wisconsin, is even highlighted  for their innovative Help Team model that connects patients to essential  services, such as healthcare benefits, insurance, transportation needs and prescription drug programs. Scenic Bluffs Help Team also provides patients with information about area food pantries, thrift stores, and community care applications. 

Scenic Bluff’s approach exemplifies how the RHT Program’s strategic framework can be effectively implemented at the community level. The RHT Program is built around five strategic goals focused on promoting innovation, strategic partnerships, infrastructure development, and workforce investment – areas that align with the CHC mission.  

Make rural America healthy again: Support rural health innovations and new access points to promote preventative health and address root causes of chronic diseases, behavioral health, and prenatal care. 

Sustainable access: Help rural providers become long-term access points for care by improving efficiency and sustainability through coordinated operations, technology, primary and specialty care, and emergency services. 

Workforce development: Attract and retain skilled healthcare professionals in rural areas, including community health workers, pharmacists, and patient navigation staff, while ensuring providers can practice at the top of their license. 

Innovative care: Develop and implement value-based care and flexible care arrangements that improve outcomes, coordinate services, and reduce costs, including ACO participation. 

Tech innovation: Support digital tools that enhance care delivery, remote access, data sharing, cybersecurity, and patient engagement. 

The RHT Program offers CHCs and PCAs a unique opportunity to work directly with state officials in shaping funding applications as the provider, employer, and partner of choice for rural health initiatives.  

Application Process

States must submit a detailed application that includes project narratives and supporting documents. Application are due by 11:59pm ET November 5, and awards will be decided by December 31, 2025. One requirement is the Governor’s endorsement letter, which confirms support for the state’s RHT Plan, describes stakeholder engagement during development and implementation, and commits to any necessary state-level actions such as cross-agency collaboration, legislation, or regulatory changes. Beyond the endorsement, each state’s application must include a detailed plan for how they propose to use funding for their identified project initiatives. 

Importantly, CMS emphasizes that CHCs and PCAs should be engaged as key stakeholders in the application development and project implementation process, more information on that is described below. CHCs bring deep, trusted connections to rural communities and can serve as local implementation hubs for chronic disease management, behavioral health integration, and value-based care initiatives. PCAs, meanwhile, provide statewide coordination, technical assistance, and workforce development expertise—making them essential partners for ensuring initiatives are both sustainable and scalable. 

Strategic Funding Approach 

The RHT Program provides states with the flexibility and targeted resources necessary to transform rural healthcare systems. To maximize impact, states are required to direct their funding toward at least three approved project initiatives that directly address the most critical healthcare challenges facing their rural communities. 

Improve prevention and chronic disease: Promote  evidence-based, measurable interventions to improve prevention and chronic disease management. 

Provider payments: Providing payments to providers for the provision of health care items or services. 

Consumer tech solutions: Promote consumer-facing, technology-driven solutions for the prevention and management of chronic diseases. 

Training and technical assistance: Provide training and technical assistance for the development and adoption of technology-enabled solutions that improve care delivery in rural hospitals, including remote monitoring, robotics, artificial intelligence, and other advanced technologies. 

Workforce: Recruit and retain clinical workforce talent to rural areas, with commitments to serve rural communities for a minimum of 5 years. 

IT advances: Advance technical assistance, software, and hardware for significant information technology advances designed to improve efficiency, enhance cybersecurity capability development, and improve patient health outcomes. 

Appropriate care availability: Assist rural communities to right size their health care delivery systems by identifying needed preventative, ambulatory, pre-hospital, emergency, acute inpatient care, outpatient care, and post-acute care service lines. 

Behavioral health: Support access to opioid and SUD treatment services and mental health services. 

Innovative care: Develop projects that support innovative models of care that include value-based care arrangements and alternative payment models, as appropriate. 

Additional uses include:  

Capital expenditures and infrastructure for rural health care facility buildings and infrastructure, including minor building alterations or renovations and equipment upgrades.   

Fostering collaboration and local and regional strategic partnerships between rural facilities and other health care providers to promote quality improvement, improve the financial stability of rural facilities, and expand access to care.

The funds are not allowed to be used for the following purposes (though some exemptions may be allowed):  

• New construction projects 
• Payments for already reimbursable services 
• Cosmetic/experimental procedures (per CMS definitions) 
• EMR replacement beyond 5% of the award (if system already certified) 
• Rural Tech Catalyst-like initiatives beyond 10% or $20M cap
• Clinician salaries with non-competes 
• Intergovernmental transfers or federal share financing 
• SSA Sec. 2105 restrictions (abortions, documentation, general limits) 

Funding 

The RHT Program allocates $50 billion over five years (FY 2026–2030) to eligible states. All 50 states may apply; D.C. and territories are excluded. Funding flows through two channels: 

Baseline Funding ($25B): Equally distributed among approved states. 

Workload Funding ($25B): Allocated based on data-driven health outcomes, initiative quality, and state policy commitments (policy scoring begins FY 2027). 

While states are the official recipients of the funds, CMS allows funding to be sub-awarded or contracted to partners—including CHCs and PCAs.  

Per the NOFO, funding is available only to providers and facilities operating in designated rural areas; however, the CHC definition applies to all health centers regardless of location, ensuring that CHCs serving mixed geographic areas can use funds to deliver care across their full service area. 

States have flexibility in deciding which factors to focus on in scoring, allowing them to tailor their applications to their unique strengths and priorities. This means states can strategically select areas where they have strong data, innovative program ideas, or opportunities for improvement to maximize their potential funding. 

To see the complete breakdown of scoring factors and methodology, check out the NOFO.

Some of the notable scoring provisions outlined in the NOFO include: 

• Uncompensated Care: Scores are based on the percentage of hospital charity care and bad debt from Medicare cost reports. CHCs s are not included in the calculation.  
• Population Health Infrastructure: States earn higher scores for detailed plans to strengthen rural health ecosystems, including:  
• Technological innovation  
• Primary care  
• Behavioral health  
• Expanded scope of practice for mid-level providers and pharmacists  
• Health and Wellness: States must require schools to reestablish the Presidential Fitness Test as a state policy action to receive full points under this metric.
• Workforce Support: Higher scores for proposals that include, but not limited to, relocation grants and pathway programs for non-physician, non-hospital-based, and allied health providers in rural areas.  
• Licensure Compacts: Strong preference for states to enact interstate licensure compacts for nurses, physicians, psychiatrists, physician assistants, and EMS.  
• Data Infrastructure: States earn higher scores for plans that improve HIEs, interoperability, and exchange program. There is a preference to transition to cloud-based, multi-tenant systems.

The NOFO also provides examples of how to structure project proposals so they align with RHT Program strategic goals and allowable uses of funds. Several examples specifically highlight CHCs and PCAs as key stakeholders, including: 

Interoperability infrastructure initiative: The NOFO recommends that PCAs serve as a key stakeholder to help rural providers invest in technology infrastructure to improve data liquidity and availability between patients, digital health products, and providers. This initiative focuses on goals for enhancing interoperability in the community by creating a long-term sustainable health IT system and workforce. Provide technical assistance to providers and patients to maximize value of their EHRs.        

Value-based care initiative: The NOFO recommends that CHCs and PCAs serve as a key stakeholder to help rural providers, especially those inexperienced with value-based care, participate in value-based care models and position them to deliver proactive, preventive care that is coordinated across the spectrum of health care providers that treat patients. A State-based or private entity could lead efforts to engage a variety of stakeholders, with the expectation that the value-based arrangement would become self-sustaining over time. 

Conclusion 

CHCs and PCAs are uniquely positioned to strengthen their state’s RHT Program applications by providing essential data on rural health needs, target patient populations, workforce challenges, and financial sustainability. Our recommendation is that PCAs should survey member CHCs to identify priorities and advocate for funding that addresses real community gaps. By combining direct data from health centers with PCA-led surveys, CHCs and PCAs help demonstrate need, measurable impact, and explain sustainability—key factors for securing funding. With CHCs serving up to one in seven Americans—and up to one in three in rural areas—these organizations are ready to partner with state officials to successfully implement the RHT Program and ensure rural communities receive the care they deserve.

On January 8, 2025, the State of Hawaii received approval from the Centers for Medicare and Medicaid Services (CMS) to extend its QUEST Integration § 1115 Medicaid demonstration. This waiver extension expanded Medicaid coverage for health-related social needs (HRSN) services, select Medicaid services for justice-involved populations within 90 days of their scheduled release, and various home and community-based services (HCBS) flexibilities, and more.  

Additionally, this demonstration created opportunities for Hawaii health centers to provide tailored nutritional support to their patients. The The Hawai‘i Primary Care Association (PCA) participated in conversations that informed the State’s 1115 waiver submission on nutritional provisions and continues to support Medicaid as it determines how to implement the benefit.

Under the current Administration, advancing “Food is Medicine” is a prominent priority on the Make America Healthy Again (MAHA) agenda. This approach promotes efforts to address the growing health crisis in America. This includes introducing fresh thinking on nutrition, healthy lifestyles, and food and drug quality and safety.   

NACHC recently interviewed the Hawaii PCA to learn more about how they are working with the State of Hawaii to maximize the QUEST Integration demonstration. I spoke with Jermy Domingo, DrPH, Community Wellness Initiatives Director with the Hawaii PCA, to better understand their role in planning this waiver and maximizing its impact for the State of Hawaii.  

Dr. Domingo began her public health career at Kalihi-Palama Health Center (KPHC), where she designed nutrition and physical activity programs for its diverse patient population, and went on to coordinate cancer patient navigation trainings, pilot screening navigation, and worksite wellness initiatives at ‘Imi Hale Native Hawaiian Cancer Network.

Dr. Domingo oversees the development and implementation of community health and research initiatives and provides training and technical assistance to Hawaii’s 14 Federally Qualified Health Centers. 

How is the Hawaii PCA addressing nutritional insecurity among Medicaid patients?

A key policy recommendation for Primary Care Associations aiming to address food insecurity at a state level is to start by understanding their own food ecosystem. That means asking the important questions: What are your health centers already doing? What do they want to do? Because health centers are always at the cutting edge of innovation for their communities, understanding where they’ve been and where they want to go is vital to moving any initiative forward. Along with understanding your ecosystem, collecting strong data and evaluating that data will help you make the best case for these programs.

For example, Dr. Domingo discussed the work the Hawaii PCA has been doing to address nutritional insecurity through Medicaid. With Hawaii being located approximately 2,500 miles from the continental United States. About 85-90% of Hawaii’s food is imported, which makes it particularly vulnerable to natural disasters and global events that might disrupt shipping and the food supply. At any given time, Hawaii has a 5–7 day food supply. Health centers have long worked to address the lack of access to nutritious food, from local food pantries, and nutritional guidance to structured screenings and pilot programs. Efforts that have been held together by short term grants and temporary funding, leaving a level of uncertainty for the State of Hawaii.

During the COVID-19 pandemic, food insecurity became more apparent. Being able to understand your ecosystem and having data that supports those needs provides a stronger case for health centers which can lead to obtaining and maintaining funding. With the lack of funding, it can lead to work stopping due to the inability to keep staff and resources. “When the grants end, it leads to a shortage of staff which results in the work stopping,” Dr. Domingo stated. “It made the need glaringly clear. The community needed consistent support, not just emergency response.” Now, with QUEST Integration waiver, there’s an opportunity to change that.

The Four Pillars of Nutritional Support

Hawaii’s waiver outlines four pillars for nutritional support: nutrition instruction, food and pantry restocking, medically tailored meals, and produce prescription/protein boxes. The Hawaii PCA recently conducted an assessment and found that the majority of Hawaii health centers are already engaged in nutritional guidance programs, many of which focus on chronic disease prevention and management and healthy eating. About a third of the health centers offer produce prescription programs.

Some have even developed formalized structures for prescribing fruits and vegetables to patients with specific conditions like obesity or diabetes. And through support from the National Association of Chronic Disease Directors, the Hawaii PCA was able to launch an “umbrella hub” that helps support and build capacity across its member health centers to implement evidence-based prevention initiatives at scale. 

What is Medicaid’s role in addressing Food Insecurity? 

Another policy recommendation for PCAs looking for guidance with addressing their food insecurity is by engaging with stakeholders. One of the big stakeholder engagements that helped cultivate this program for Hawaii was their involvement with their state Medicaid office. Hawaii PCAs involvement began about two years ago, when they were invited to early community-engagement discussions around the Nutrition Supports with the state’s Medicaid office. This engagement involved regular meetings with the planning team to review aspects of their application and offer insights from our health centers.

In anticipation of this waiver and guidance from our Payment Reform Advisory Committee, HPCA brought together dietitians, community health workers (CHWs), providers, and other community leaders and experts to help inform implementation strategies and conversations with the state’s Medicaid office. Understanding the importance behind stakeholder engagement also means knowing that the process is not easy due to external factors that may be out of your control.

“There’s some uncertainty with how quickly things will move under the current administration,” Domingo noted. “We’ve been told nutritional support will likely roll out in 2026. In the meantime, we’re helping health centers get ready.”

From a policy standpoint it is highly recommended to expand collaborations because collaborations should not only be restricted to the usual suspects. Create those fundamental relationships with people and organizations who are specializing in the field that includes food banks, local farms, and community groups. They are powerful allies and provide a testament that the government agencies may not be able to provide. Within Hawaii’s QUEST Integration demonstration extension waiver, Hawaii introduced new initiatives and investments to improve health coverage, access, and consistent provision of high-quality services for Medicaid beneficiaries. For the Hawaii PCA and its network of community health centers, they understood that this could be transformational.

“Many centers had to pause food programs in the past due to funding issues. With this waiver, they can now restart with more stability and intention,” Dr. Domingo shared. “It’s about more than just handing out food, it’s about giving providers the tools and confidence to ask the right questions and provide the right support, including medically tailored meals and groceries based on health needs.”

Even though the state is still in the planning stages, some health centers have already started pilot programs. One example includes a diabetes management program offering medically tailored meals, combined with education and cultural context to reinforce long-term behavior change. “These programs are showing strong outcomes,” Domingo said. “But we’re also learning in real time, asking whether it’s sustainable, and whether Medicaid will provide ongoing support.” 

 When asked what success will look like if the waiver reaches its full potential, the answer is both practical and hopeful: “We’d see better health outcomes and stronger engagement from patients. Communities would feel trust in their healthcare system, and we’d see less food insecurity and food waste. Farmers and community-based organizations would be fairly compensated. Food would be local, fresh, and part of the solution.” And most importantly, she added, “The solution is already in the community. We just need to listen, include their voices, and make sure we make space for them at the table.” 

With one in eight U.S. households (12.8%) experiencing food insecurity, or lack of access to an affordable, nutritious diet. Integrating nutritious food into clinical care can help address chronic conditions such as obesity, diabetes, and/or heart disease. With Community Health Centers being the largest primary care network in the United States, serving more than 34 million people, or one in 10, NACHC is determined to continue place health centers at the forefront of this mission.  Many health center patients are experiencing food insecurity and food as medicine can be both preventive and restorative, and at NACHC, we believe that food access should be as integral to healthcare as any clinical service.

Community Health Centers (CHCs) remain a critical lifeline for underserved communities. However, the capacity to meet growing demand is increasingly strained. In 2024, CHCs served over 1 million more patients than in 2023, even as operating margins decreased to an average of -2%. (Figure) Although their growth demonstrates CHCs’ resilience, underlying pressures threaten patients’ ability to access care, maintain continuity, and receive high quality care.

Access at Risk Despite Growth

In 2024, CHCs expanded visits for primary care, behavioral health, and oral health services. Philanthropic and private grants, targeted federal support, and operational efficiencies enabled them to reach more patients even while running at a financial loss. Increased visits from patients with private insurance and Medicare provided crucial financial stability, helping CHCs continue delivering comprehensive primary care to all patients.    

But vulnerabilities are accumulating. According to 2024 CHC audit data, half of CHCs have fewer than 90 days cash on hand, and one quarter operate with margins below -4%. These fragile conditions limit their ability to sustain service hours, expand capacity, or invest in innovative care delivery models. The freeze in federal funding that took place in February 2025 has forced some CHCs, particularly in rural areas, to close sites and reduce hours, leaving patients temporarily without care. Such disruptions highlight how quickly access can be affected when reserves are low.  With federal CHC funding set to expire this year, such disruptions can happen again.

CHCs in the Path of a Rising Uninsured Wave

Even as CHCs expand, new policy changes threaten to stretch capacity further. The One Big Beautiful Bill Act (HR.1) is projected to increase the number of uninsured patients seeking care. CHCs are a cost-saving alternative to emergency departments, and they are likely to see an increasing number of uninsured patients seeking accessible primary care, preventive services, and chronic disease management. If CHCs cannot absorb this surge, uninsured patients will turn to emergency departments or delay care, leading to higher costs for the health system and greater risk of complications.

CHCs also continue to be leaders in quality of care, delivering outcomes that outperform many other primary care settings, including high patient satisfaction. A surge in demand without support threatens not only access but also the quality and effectiveness of care that millions rely on.

The Stakes Could Not Be Higher

CHCs serve at least 34 million patients nationwide, including at least one in five rural Americans and one in five Medicaid enrollees. If CHCs are forced to scale back services, rural communities, low-income families, and urban underserved populations will be the hardest hit. Research shows that when CHCs close, mortality rises. The cost of inaction is measured in lives.

Resilience Requires Resources

CHCs demonstrated remarkable resilience in 2024 but growth without structural support cannot guarantee continued patient access or maintain the high quality of care they provide. Thin margins, declining reserves, and the anticipated wave of uninsured all jeopardize the ability of CHCs to meet demand. 

To secure the future of CHCs, core funding and reimbursement must reflect the true cost of providing comprehensive primary care and enabling services that support patient health. Dedicated resources are essential to offset the surge of uninsured patients. Policymakers face a clear choice: stabilize CHCs now or risk unraveling access to primary care for millions of Americans. To preserve timely, comprehensive, and high-quality care for millions of Americans, policymakers must act to support CHCs before patient access and outcomes erode.

A monthly series from NACHC’s state policy team sharing updates on state policies that can supporting health centers.

The first half of 2025 has been marked by a surge of legislative activity across the United States, with state lawmakers addressing a wide array of pressing issues impacting Community Health Centers and the broader healthcare landscape. From bold reforms in drug pricing to forward-looking investments in workforce training and new models of maternal health care, state legislatures have acted with urgency and purpose amidst a rapidly changing federal landscape.  

This blog will highlight three notable pieces of state legislation that health centers can take advantage of: allowing pharmacists to be reimbursed for their full scope of practice, expanding the pool of eligible providers to practice at health centers, and advancing maternal health initiatives. These efforts showcase state policies that support accessible, community-based care models that support resilient health center infrastructure.

Hawai’i: Expanding Pharmacist Reimbursement to Strengthen Healthcare Access

Hawai‘i Governor Josh Green recently signed Senate Bill (SB) 1245 into law. Effective July 1, 2026, this legislation requires public and private health plans in the state to reimburse licensed pharmacists for providing healthcare services within their scope of practice at rates equivalent to other medical providers. These services include patient education on blood sugar monitoring, hypoglycemia prevention, safe medication use, and medication adherence strategies—core components of chronic disease management that go well beyond dispensing prescriptions. 

Pharmacists undergo extensive training, often completing six to eight years of education through pre-pharmacy coursework, a Doctor of Pharmacy (PharmD) program, and sometimes a residency program. Yet, despite their clinical expertise, pharmacists in many states are not recognized as reimbursable healthcare providers for non-dispensing services. By acknowledging their qualifications and enabling proper reimbursement, SB 1245 aligns payment structures with modern team-based care models and helps fully integrate pharmacists into the healthcare delivery system. 

This reform is particularly timely for Hawai‘i, which faces significant healthcare workforce shortages, especially in rural communities. The state struggles to recruit and retain primary care providers, leaving gaps that pharmacists are well-positioned to help fill. Reimbursing pharmacists for services they are already trained and authorized to provide helps address these shortages, improves patient access to care, and supports the long-term sustainability of Hawai‘i’s health centers. 

The Hawai‘i Primary Care Association (HPCA) strongly supported SB 1245, with the issue first raised by pharmacists at Wahiawa Health who saw firsthand how limited reimbursement was constraining patient care. Without the ability to bill for clinical pharmacy services, health centers had to rely on their 330 funds or alternative funding sources to cover these costs, limiting their reach and scalability. SB 1245 changes that dynamic by allowing health centers to expand access to pharmacist-led care, which improves patient outcomes and builds a more resilient healthcare workforce across the state. 

“The Hawaii Primary Care Association strongly supports this new law because it mandates reimbursement for services provided by pharmacists within their scope of practice by private and public health plans in the State.  This measure greatly improves the accessibility of essential health care services to patients, especially those in geographically isolated communities, by recognizing the vital role pharmacists play in team-based care models, particularly in managing chronic diseases amidst healthcare workforce shortages.”

Robert Hirokawa, DrPH, CEO, Hawai‘i Primary Care Association. 

North Carolina: Internationally Trained Physician Licensure 

In July 2025, Governor Josh Stein signed into law House Bill (HB) 67 , known as the “Healthcare Workforce Reforms” bill. Part of the legislation authorizes internationally trained physicians to obtain a provisional state license if they have secured full-time employment at a qualifying North Carolina hospital or medical practice, particularly in rural areas where there is a shortage of licensed physicians. After meeting certain criteria, including passing required examinations and demonstrating clinical competence, these physicians can transition to full licensure. This legislative change is expected to alleviate physician shortages in health professional shortage areas (HPSAs) and enhance the capacity of health centers to serve their communities. 

Many regions of the state, particularly rural communities, are experiencing a shortage of doctors, nurses, and allied health professionals. This gap threatens timely access to care, worsens health disparities, and strains already overburdened health systems. A key challenge is the existing limited number of available providers, made worse when medical students leave the state for residency and do not return. Research shows that approximately 60% of physicians practice in the state where they completed their residency. One untapped solution lies in authorizing internationally trained medical professionals to practice within health centers.  

Internationally trained medical professionals represent a highly skilled and often underutilized segment of the healthcare workforce. Many have years of clinical experience, advanced training, and specialized skills gained abroad. However, licensure barriers and complex credentialing requirements frequently prevent them from practicing in the U.S., leaving their expertise largely untapped. They bring value extending well beyond providing care. Many internationally trained providers help share cultural backgrounds or languages with immigrant and refugee patients, which improves communication, trust, and health outcomes. Providers who understand patients’ cultural contexts are better equipped to address non-clinical factors of health, a key factor in chronic disease management. 

North Carolina serves as a model for other states grappling with healthcare workforce shortages. By creating structured pathways for internationally trained medical professionals, states can increase the number of available healthcare providers, improve health outcomes, and strengthen the state’s healthcare system. As the healthcare workforce shortage deepens, states must think innovatively about new approaches to get trained professionals out of the waiting rooms and into the clinics. It’s time to bridge this critical gap and ensure that every qualified provider can contribute to building healthier communities. 

Oregon: Strengthening Access to Community-Based Perinatal Services 

On July 25, 2025, Oregon Governor Tina Kotek signed into law Senate Bill 692. This law expands access to maternal health services, establishing a community-based perinatal services access program to increase access to culturally specific and culturally competent community-based services during the perinatal period. In addition, it expands coverage under the state’s medical assistance program and health insurance policies to include services provided by doulas, lactation counselors, and lactation educators. The law also directs the Health Licensing Office to promulgate state regulations overseeing the practice of lactation counselors and lactation educators.   

Maternal and Child Health (MCH) is a critical public health priority under the Make America Healthy Again (MAHA) plan. The health of a women during pregnancy, childbirth and postpartum, lays the foundation for the overall health and wellbeing of their families and communities. Investing in MCH is not just about reducing the maternal mortality and morbidity rates but also creating proper conditions for healthy pregnancies. By investing in community-based maternal and childcare models, and recognizing the value of responsive providers, Oregon is setting a precedent for how states can integrate innovation into their maternal and child health system.   

Community health centers are the most innovative, and most resilient part of our nation’s health system. In 2023, health centers served over 32.5 million patients, including one in nine children and adolescents. With strong community ties, health centers are often the first point of contact for pregnant individuals who may face barriers accessing maternal and childcare. Health centers stand ready implementing the bill by scaling up access to doula care, lactation counseling, and other essential perinatal services in communities that need them most. 

The newly signed bill creates opportunities to further leverage health centers as hubs for delivering doula services, lactation support and other responsive care during the perinatal period. With over 470,000 Oregonians— including one in six Oregon Health Plan members—receiving care at community health centers, many of which already partner with midwives and doula programs, this new legislation presents a valuable opportunity to formalize and expand those partnerships. 

As we round the end of 2025 AND look ahead to the 2026 legislative session, NACHC is carefully monitoring the introduction of new state bills that could impact health centers and the patients they serve. NACHCs state policy team is actively engaging with PCAs and health centers to stay alert to legislative developments as they unfold. This groundwork ensures that we are ready to respond quickly and effectively when key issues arise. Stay tuned for our next blog, where we will take a closer look at newly introduced legislation and what it could mean for health centers across the country. 

A new federal rule that shortens enrollment time on Federal Marketplaces by 32 days starts next year, November 1 through December 15 in 2026. The Marketplace Integrity and Affordability Rule, effective August 25, 2025, finalized this change. According to the Centers for Medicare and Medicaid Services (CMS) the new rule will protect consumers from improper enrollment and changes to their health coverage while strengthening the integrity of the Affordable Care Act exchanges.  

NACHC, alongside Community Health Centers (CHCs) and Primary Care Associations (PCAs), commented on the proposed rule underscoring the potential impact on millions of CHC patients with Marketplace coverage. The rule emphasizes balancing program integrity with consumer administrative burdens, but advocates like the National Health Law program believe changes may cause confusion and result in coverage losses among many patients. CMS projects that between 725,000 and 1.8 million individuals to lose coverage due to this rule.  

CHCs and PCAs connect patients to coverage through their Outreach and Enrollment (O&E) staff who educate and enroll individuals in insurance plans and subsidies. CHCs, however, face a $360 million cut in funding for the Federal Navigator program, which provided funding for O&E staff. The smaller and less funded O&E workforce will also have to navigate changes from the recently enacted  “One Big Beautiful Bill (OBBB)” which has an estimated loss of coverage for nearly 12 million people, including individuals on Marketplace plans. CHCs have been essential in improving access to coverage, e especially during the recent Medicaid unwinding.   

A federal judge recently placed a temporary stay on several of the rule’s provisions until further legal action, meaning they would not be implemented on the original August 25 date. The provisions that are currently delayed have been noted throughout the blog and in NACHC’s comparison chart. 

Shorter Enrollment Periods Will Likely Cause Coverage Loss  

CMS acknowledged that a longer enrollment period provides “consumers additional time to make informed choices and increase access to health coverage, while mitigating risks of adverse selection, consumer confusion, and issuer and Exchange operational burden.” A shortened open enrollment period (OEP), coupled with reductions in times someone can enroll outside the OEP (a Special Enrollment Period), will create fewer opportunities to get coverage and could lead to more uninsured patients at CHCs.  

In recent years, O&E staff had until January 15 to educate and enroll patients in Marketplace coverage, which is usually done through 1:1 appointments booked in advance. Now that’s not the case.  A shorter deadline means O&E staff will have less time to educate and enroll individuals.  

As trusted sources of information, CHCs need to start educating patients about the new enrollment period in their own state, beginning in just a few months. Although the Federal Marketplace OEP will be shortened in 2026 to December 15, the 20 state-based exchanges may choose their own OEP parameters.

Changes for Consumers 

To balance improper enrollment with ‘overall disruptions’, CMS finalized parts of the rule to only be effective in the 2026 plan year. These temporary, finalized changes are a win for consumers. A 2023 KFF survey shows that 32 percent of respondents said it was somewhat or very difficult to determine if their income qualified them for financial help. However, the temporary nature of some of these changes may cause confusion and impact consumer enrollment in health insurance.  The OBBB changes may add to this confusion, as the bill includes certain Marketplace changes effective in 2026, 2027, or 2028. To help CHC patients experience fewer disruptions in their insurance coverage—which improves affordability and access to care—CHCs should educate their patients about the temporary 2026 changes that might lead to different coverage options in the future. Depending on the timing of the further legal action in the lawsuit, provisions may not begin in 2026 as planned, creating more confusion. 

Verification Changes 

Patients juggle multiple responsibilities, and during the insurance selection process, they may be inundated with forms that take hours to complete. This rule’s additional data and income verification requirements could pose a challenge. For example, previously, people could self-certify if the IRS did not have a tax return, but now individuals must provide evidence from ‘trusted sources’. CMS estimates that data verification would take an hour, but individuals with unstable housing or living situations may need more time to gather sufficient documentation from multiple places of work. As a result, enrollment staff will need to spend extra time to ensure individuals understand the requirements and are able to gather enough evidence to show their potential income. Due to the pending lawsuit, many of the income verification provisions have been put on pause. 

Coverage Rescinded for DACA Recipients

More than 500,000 people are enrolled in the Deferred Action for Childhood Arrivals (DACA) program, which provides work authorization and deportation protection for individuals who came to the U.S. as children. In 2024, CMS expanded eligibility on the Marketplace to DACA recipients to access Marketplace coverage and tax credits. However, because of a pending lawsuit, DACA recipients in 19 states were unable to enroll in the Marketplace.  

Starting August 25, 2025, DACA recipients cannot enroll in a qualified health plan (QHP) through an Exchange, Premium Tax Credit (PTC), APTC, cost-sharing reduction, or a Basic Health Plan (BHP).  Additionally, the OBBB prohibits all lawfully present low-income immigrants who are ineligible for Medicaid from receiving PTCs starting January 1, 2026. In 2027, all PTC eligibility for most lawfully present immigrants (except for legal permanent residents, certain Cuban and Haitian immigrants, and people from COFA nations) will be eliminated.  

CHCs should educate their staff and patients about these imminent changes, particularly if their state was not part of the lawsuit and had previously permitted DACA recipient health insurance enrollment. 

CHCs are operating with thin financial margins and an increased projection of uncompensated care costs. In 2023, federal 330 grant funding accounted for only 11% of health center revenue. Insurance reimbursements help CHCs provide essential services to all patients. The O&E staff will continue their efforts to support patients in securing the right coverage. 

For more details about the provisions in this rule, see NACHC’s comparison chart. Please contact Elizabeth Linderbaum, Deputy Director of Regulatory Affairs, at [email protected] with any questions. 

It is with deep sorrow that we announce the passing of Sue Veer, a visionary national leader for community health and a longstanding member of the Executive Committee of the NACHC Board of Directors. Sue also helped lead the NACHC 340B Work Group and served on the Board of Directors for the South Carolina Primary Health Care Association.  

Her career in health care spanned 40 years, including nearly 20 years as the President and CEO of Carolina Health Centers, Inc. (CHC), a medical home for more than 26,000 patients in rural Greenwood, South Carolina. CHC’s 19 medical practices include 10 family medicine practices, three pediatric centers, two pharmacies, and four primary care clinics located within community mental health clinics. Under Sue’s leadership, CHC became a pioneer in developing an integrated pediatric medical home model that includes an array of early childhood services, including evidence-based home visitation programs.  

As she wrote in one of her regular “Monday Messages” emailed to friends and colleagues, her work with Community Health Centers brought purpose to her life: 

“Nothing in the professional realm has brought greater purpose to my life than participating in the process of ensuring everyone has access to comprehensive health care, along with the knowledge and motivation for them to seek better health and well-being for themselves and those they love and care about.” 

Sue’s grace, eloquence, and deft policy skills won over skeptics in Congress. Widely respected for her expertise in the minutiae of 340B, health policy, finance, and governance, she possessed an uncanny ability to distill complex regulatory language into clear messages – a skill that made her an invaluable ambassador for NACHC and health centers.  

Sue helped shape national policies and strengthen the voice of health centers at the highest levels of government. Whether speaking to county, state, or federal lawmakers, Sue was a persuasive champion for the health center mission. 

As recently as last year, Sue appeared before the House Energy and Commerce Committee to describe the impact of changes to the 340B program on CHC and other health centers. 

Sue recognized early on the value a pharmacy would bring to her patients and how it would help achieve CHC’s goals of access, quality, and cost effectiveness. She became an expert in understanding the benefits of the federal 340B drug pricing program for patients. Sue explained these benefits in one of the many testimonies she gave to elected officials on the topic:

“[T]he 340B Drug Pricing Program has not only made it possible for health centers to provide access to affordable prescription medication for those vulnerable populations; it also enabled increased access to primary and preventive care that would otherwise be unfunded and therefore unavailable in the communities served.” 

Sue said she found her ‘forever career home’ when she toured CHC more than 20 years ago. Throughout her tenure, she touched all who had the pleasure of working with her through her deep compassion, integrity, love of books, and exceptional gift for writing and communication. As both mentor and leader, Sue cultivated the next generation of health care advocates while never losing sight of the patients and communities at the heart of her work. Her legacy lives on in the thousands of lives she touched and the enduring strength of the Community Health Center movement that she helped nurture.