Maryland’s Medicaid program ranked 43rd out of 50 states in a new national scorecard, scoring 32 of 100 possible points, according to a report from the Heartland Institute, a free-market policy organization. The ranking lands just months before new federal rules change how some Maryland Medicaid members keep their coverage.
Starting Jan. 1, 2027, some adults on Medicaid will need to complete at least 80 hours a month of work, school, job training or volunteering, or show income of at least $580 a month, the Maryland Department of Health says. The department estimates the changes could affect up to 320,000 members statewide, including in Charles, Calvert and St. Mary’s counties. Some members will also have to renew their coverage every six months instead of annually.
How the scorecard works
Heartland’s report, authored by policy analyst Jack McPherrin and released in September, grades all 50 states across 16 measures grouped into four categories: program design and enrollment, fiscal sustainability, program integrity and oversight, and the provider environment. Kansas ranked first with 74 points; California ranked last with 22. Maryland tied New Jersey for 43rd.
Maryland earned 10 of 36 points for program design, 6 of 26 for fiscal sustainability, 9 of 24 for program integrity, and 7 of 14 for its provider environment.
Two of the report’s biggest point categories cost Maryland the most. Heartland awards 12 points to states that have not expanded Medicaid and zero to states that have; Maryland expanded coverage in 2014 under the Affordable Care Act. The report also awards 8 points to states that showed early activity on federal work requirements — Maryland got none. Every state in Heartland’s bottom 10 has expanded Medicaid.
The state lost points for 7.21% average annual Medicaid spending growth from 2019 through 2023, a certificate-of-need law that requires state approval for certain hospital and facility projects, and a low rate of Medicaid fraud convictions relative to enrollment. Maryland’s improper-payment rate — which can reflect paperwork or coding errors rather than fraud — also scored below average. State auditors reported in May that the agency overseeing Medicaid payments lacked effective processes to catch questionable payments made for people who were incarcerated or deceased.
Maryland did earn full credit for its managed-care system, its all-payer claims database, independent practice authority for nurse practitioners, and membership in a compact that eases cross-state physician licensing.
Heartland says its scorecard measures fiscal discipline and program targeting, not health outcomes or patient experience, and that a state’s ranking doesn’t reflect the overall quality of its health care system.
Budget pressure already building
Maryland’s nonpartisan Department of Legislative Services has been tracking Medicaid cost growth separately from the scorecard. The fiscal 2027 state budget included a $294.6 million deficiency appropriation to cover fiscal 2025 Medicaid claims billed late, since providers can submit bills up to a year after service. Legislative analysts found the bills trickling in more slowly than expected and cut that amount by $70 million, to roughly $224.6 million, based on claims paid through January 2026.
Medicaid and the related children’s health program have consumed more than 17% of Maryland’s general fund revenue every year since fiscal 2024, analysts noted, though general fund spending on the programs is projected to level off in fiscal 2026 and 2027. State budget officials have already asked agencies to prepare for possible cuts as Maryland works through a projected multibillion-dollar structural budget gap.
Legislative analysts estimate roughly 115,000 of the 326,510 expansion adults enrolled as of January could lose coverage once the new work requirement takes hold, though the effects aren’t expected to show up in the state budget until late in fiscal 2027. A separate provision drops coverage for about 15,000 people, including certain refugees and asylees, starting Oct. 1, 2026. Health advocates warned last year that the federal law behind these changes could strain Maryland’s broader health care system.
Children under 19, adults 65 and older, pregnant people, people with disabilities, caregivers of young children and people managing serious health conditions are exempt from the new work rules. The health department says it plans to use every available exemption and pull data from tax, wage and food-assistance records to verify compliance automatically rather than requiring separate paperwork from members.
What’s changing locally
Maryland is also expanding how it pays primary care practices to reach Medicaid members. The Medicaid Advanced Primary Care Program, part of the state’s broader AHEAD care model, started its first full year Jan. 1 and now covers roughly 800,000 members. Participating practices must offer same- or next-day appointments, telehealth, a patient portal or after-hours visits, and reach out to members who haven’t been getting regular primary care. An insurance industry official warned in August that the broader AHEAD transition carries real financial risk if not managed carefully.
The same federal law creating the work requirements also funds a new rural health program. Seven Southern Maryland health organizations shared more than $11.6 million in the program’s first Maryland funding round.
Medicaid members can check whether the new rules apply to them through their Maryland Health Connection account, and the state’s Medicaid check-in tool walks through the requirements. The health department is urging members to keep their contact information current so renewal notices reach them on time.
