Medicaid · August 2026 · 6 min

Medicaid policy only works if operations can run it

Waivers, capitation, and supplemental payments fail when the budget office, CMS, and the provider are looking at three different pictures of the same dollar.

A state plan amendment or 1115 waiver can be well written and still miss in year one. The usual cause is not CMS. It is a rate, an IGT, or a PACE/MLTSS design that was never walked through a provider's general ledger.

We start with the payment: capitation, fee schedule, wrap, or supplemental. Then we ask what has to be true in enrollment, utilization, and cost for that payment to cover the service. If those facts are not in one file, the waiver narrative and the appropriations request will drift.

Providers living under the program need the same file. A safety-net hospital or PACE organization cannot budget to a slide. They need the rate, the encounter definition, and the settlement rules in language their controller can post.

The output is a short decision memo: what the program pays, what it costs to operate, and which assumptions will break first.

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Use the engagement form and we will tell you whether the work is a fit before anyone sends a binder.