Cramer Seeks Phased Medicaid Payment Changes and Rural Health Coordination in North Dakota

U.S. Senator Kevin Cramer asked the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) to work with North Dakota on a “reasonable glidepath” for changes under review to the state’s Medicaid expansion reimbursement program. CMS is reviewing the program in connection with a proposed rule concerning state-directed payments. Cramer’s request, announced November 2, 2026, calls for agency-state collaboration and a phased implementation schedule if changes are identified. It does not announce a procurement, grant award, or vendor selection.

Cramer framed the request around North Dakota’s healthcare delivery conditions, including its large rural population and long travel distances. His letter said Medicaid reimbursement is important to sustaining a reliable delivery system and warned that abrupt changes to existing payment arrangements could disrupt providers, patients, and communities. A phased approach, he argued, would give the state and affected providers time to adapt to new requirements and mitigate risks to service continuity. He also raised the possibility of a “fiscal cliff” for providers if reimbursement changes are implemented without an adequate transition period.

The request connects the Medicaid payment review with the Rural Health Transformation Program (RHTP), a $50 billion investment created through the Working Families Tax Cut Act. CMS is partnering with North Dakota to administer the program, which is intended to support rural hospitals and transform healthcare delivery. Cramer urged HHS and CMS to pair a glidepath for payment changes with RHTP investments that could expand innovation and improve access, particularly in more rural parts of the state. The source does not specify North Dakota’s allocation, individual project awards, application requirements, or a procurement mechanism.

For government contractors and rural-health suppliers, the development is best read as program and policy context rather than an active business opportunity. Providers and organizations supporting rural healthcare can monitor agency guidance, state planning, and the schedule for any identified payment changes. Companies serving rural hospitals may track how RHTP implementation translates into programs or projects, but should not assume that the $50 billion investment will be distributed through federal contracts. The statutory schedule described in the signal provides for beginning reductions to certain approved state-directed payment rates on January 1, 2028; the senator’s letter seeks a phased approach, not confirmation that a particular schedule or agency decision has been adopted.

• Kevin Cramer sent a letter to HHS Secretary Robert Kennedy, Jr. and CMS Administrator Dr. Mehmet Oz requesting a collaborative, phased approach.
• CMS is reviewing North Dakota’s Medicaid expansion reimbursement program in connection with a proposed rule on state-directed payments.
• The statutory schedule cited in the signal calls for reductions to certain approved state-directed payment rates to begin January 1, 2028.
• Cramer cited North Dakota’s large rural population and long travel distances as factors shaping healthcare access and delivery challenges.
• The senator warned that abrupt reimbursement changes could disrupt providers, patients, and communities and potentially create a provider “fiscal cliff.”
• The RHTP represents a $50 billion investment created through the Working Families Tax Cut Act; CMS is partnering with North Dakota on its administration.
• Cramer wants RHTP implementation to support rural hospitals, innovation, and access while providers adjust to any payment changes.
• Rural healthcare providers and supporting organizations can use the request as planning context and monitor state and agency implementation details.
• Contractors should treat this as funding and policy context: the source identifies no solicitation, contract award, vendor, eligibility criteria, or specific project funding.