Maryland faces unprecedented dual transformation unlike any other state: implementing Medicaid work requirements while simultaneously transitioning its entire hospital payment system from the Total Cost of Care model that ended December 31, 2025, to the AHEAD model beginning 2026. Approximately 300,000 to 330,000 expansion adults face 80-hour monthly requirements beginning December 2026, with potential coverage losses of up to 100,000 Marylanders. Deputy Health Secretary Perrie Briskin has warned that with all H.R.1 provisions fully implemented, Maryland could lose $2.7 billion in federal Medicaid funding, representing approximately 20 percent of current program funding. The state must build work requirement verification systems, exemption processing capacity, and member navigation infrastructure while managing a healthcare payment system transformation that affects every hospital in the state.
For over 40 years, Maryland held unique authority to set hospital payment rates for all payers including Medicare and Medicaid, creating cost consistency across health plans. The Total Cost of Care model provided this rate-setting framework until its expiration December 31, 2025. The AHEAD model represents new hospital payment system negotiated first under Biden administration then revamped under Trump administration. The two-year initial period provides stability, but substantial policy complexities remain unresolved. Maryland’s AHEAD Primary Care Programs launched August 1, 2025, with Medicaid Path beginning to enroll practice organizations in advanced primary care model. This creates opportunity for care coordination infrastructure that could support work requirement navigation but also adds complexity as practices adapt to new payment models while potentially absorbing compliance verification support responsibilities.
Secretary of Health Meena Seshamani brings unique federal perspective to state implementation. Seshamani served as deputy administrator at Centers for Medicare and Medicaid Services from 2021 to 2025 before joining Governor Wes Moore’s administration. Her federal experience during Biden administration’s opposition to work requirements may inform Maryland’s coverage-protective approach, though her CMS tenure preceded current federal mandate. Briskin emphasized that “this administration is investing to implement HR 1 in a way that will keep people covered,” reflecting commitment to coverage-protective implementation within federal constraints.
Geographic disparities create stark contrasts in employment opportunities, healthcare access, and verification capacity. The Baltimore-Washington corridor concentrates population, employment, and healthcare infrastructure. Baltimore City and surrounding counties have dense provider networks, strong public transportation, and diverse employment sectors. However, Baltimore also has concentrated poverty and communities facing multiple barriers to employment including limited transportation, childcare access, and systematic discrimination. The Eastern Shore presents opposite challenges. Eight rural counties have 76 percent of residents living in federally designated medically underserved areas. Caroline, Kent, Somerset, and Worcester counties each have 100 percent of their population in medically underserved areas. The five Maryland counties with the fewest primary care physicians per capita are all on the Eastern Shore, with Caroline County having only one provider per 2,500 residents compared to Baltimore County’s one per 1,000.
Agricultural work dominates Eastern Shore employment, creating seasonal patterns complicating monthly work hour verification. Poultry processing, crab picking, and produce harvesting follow seasonal cycles where workers may exceed 80 hours monthly during harvest seasons and fall below that threshold during dormant periods. Whether Maryland’s verification systems will accommodate seasonal averaging or require month-by-month compliance determines whether agricultural workers maintain coverage or experience seasonal churn. Western Maryland faces different challenges with former manufacturing communities experiencing persistent unemployment and limited economic diversification. Allegany and Garrett counties have unemployment rates consistently above state averages with limited employment opportunities requiring multiple part-time positions to reach 80 hours monthly.
Maryland operates HealthChoice, its Medicaid managed care program, through nine MCOs serving approximately 1.5 million total enrollees: Aetna Better Health, Amerigroup Maryland, CareFirst BlueCross BlueShield Community Health Plan, Jai Medical Systems, Kaiser Permanente, Maryland Physicians Care, MedStar Family Choice, Priority Partners, and UnitedHealthcare Community Plan. This fragmented MCO landscape creates coordination challenges compared to states with two or three plans. The state must negotiate uniform verification protocols, standardized member communication, and coordinated exemption processing across nine partners with different operational capacities, technology platforms, and member service philosophies. However, the mature MCO infrastructure provides member communication channels and care coordination capacity that could theoretically support work requirement compliance assistance if the state structures contracts to eliminate conflict of interest concerns.
The political environment ensures Maryland will design implementation to minimize coverage losses within federal constraints rather than aggressively enforce compliance. Governor Moore, elected in 2022, leads unified Democratic government with strong opposition to work requirements as policy. Lieutenant Governor Aruna Miller has been particularly vocal about protecting Medicaid access. State legislators introduced LD782 in February 2025 proposing MaineCare financial eligibility changes including raising asset limits and expanding coverage for certain populations, suggesting legislative interest in expanding rather than restricting access. However, federal work requirements override state-level eligibility expansions for affected populations. Maryland’s advocacy ecosystem including healthcare organizations, consumer groups, and community organizations will closely monitor implementation and document procedural terminations.
Coverage loss projections of up to 100,000 Marylanders represent approximately 30 to 33 percent of the affected expansion population, aligning with other states’ projections based on Arkansas experience showing substantial procedural terminations among working or exempt populations unable to navigate verification systems. Opponents of work requirements argue that most recipients are already working and will be tripped up by increased paperwork needed to prove 80-hour monthly requirement. Maryland Health Connection and Maryland Department of Health have begun member outreach about upcoming changes, emphasizing that work requirements apply to expansion adults but attempting to reassure members that the state is building systems to support compliance.
The state’s investment in administrative infrastructure, commitment to coverage protection, and strong MCO network provide advantages for minimizing procedural terminations. However, the dual challenge of work requirement implementation and AHEAD model transition creates unprecedented complexity. Secretary Seshamani’s federal experience may inform Maryland’s navigation of CMS guidance and waiver processes. Whether Maryland’s managed care infrastructure, geographic disparities, and fiscal constraints allow coverage-protective implementation preventing projected 100,000 coverage losses while simultaneously managing healthcare payment system transformation remains the central question. Maryland did not choose work requirements but must implement federal mandates affecting 300,000 expansion adults while managing the most significant healthcare system transformation the state has undertaken in over four decades.