Every state submitted its RHTP application by November 5, 2025. CMS announced awards on December 29. For many state agencies, the natural instinct is to shift focus from the application to implementation. But the application itself isn't going anywhere.
There's a nuance in the program's design that's worth internalizing early: the application isn't a historical document. It's the baseline CMS will measure against.
CMS recalculates workload allocations annually. A state's follow-through on its initiative milestones and policy commitments directly influences whether its workload funding holds steady, increases, or decreases the following year. CMS also retains the authority to reduce, withhold, or recover funds from states that aren't using award dollars consistent with their approved applications.
The new Office of Rural Health Transformation, housed within the Center for Medicaid and CHIP Services, has assigned dedicated project officers to every state. These officers are responsible for onboarding, technical guidance, and ongoing performance tracking throughout the five-year engagement.
Applications required states to propose initiatives spanning at least three of the program's ten approved use categories. But the commitments went beyond initiative selection. States also had to identify a lead agency and governance structure, describe their stakeholder engagement approach, and commit to specific state-level policy actions that factored into their workload funding score.
Those policy commitments were scored. They contributed to how much workload funding each state received. And CMS has been clear that it will evaluate whether states follow through on them.
The timeline is tighter than it might appear. States had a short window after their award announcement to submit revised budgets reflecting actual award amounts. The first budget period runs through September 2027. FY2027 workload allocations will reflect what states have demonstrated during the first budget period.
For states still standing up governance structures and onboarding implementation partners, the runway is real but finite. The states that translate their application commitments into operational workplans with defined milestones, outcome metrics, and accountability structures will be in the strongest position when CMS conducts its first annual reassessment.
States that build robust evaluation frameworks—tracking both process metrics like deployment timelines and enrollment numbers, and outcome metrics like health improvements and cost savings—will have the evidence base to justify continued or increased funding.
The states that succeed will be those that treat the application not as a grant proposal that's been filed away, but as a working document that defines what they owe. To CMS. To their rural communities.
To the sustainability of the program itself.