Maryland ranks 43rd in a new 50-state Medicaid scorecard as the state manages continued Medicaid costs and prepares thousands of residents for new federal work and eligibility requirements.

The Heartland Institute gave Maryland 32 out of 100 points in its Medicaid Report Card, which compares states using 16 measures covering enrollment, spending, oversight and access to healthcare providers.

Maryland received 10 of 36 points for program design and enrollment and 6 of 26 for fiscal sustainability.

The state received 9 of 24 points for program integrity and administrative oversight and 7 of 14 for its provider environment.

The report credited Maryland for its managed care system, all-payer claims database, independent practice for nurse practitioners and participation in the Interstate Medical Licensure Compact.

It gave the state lower marks for Medicaid expansion, five-year spending growth of 7.21%, Medicaid fraud-control enforcement and certificate-of-need laws.

Heartland is a free-market policy organization whose scorecard favors a more targeted Medicaid program. Under its methodology, states that have not expanded Medicaid can receive 12 points for that measure, while expansion states receive none.

Maryland expanded Medicaid under the Affordable Care Act in 2014, extending eligibility to more low-income adults. The report also awards up to eight points for early state activity on work requirements.

Heartland says the scorecard focuses on fiscal sustainability, oversight, administration and the health care market rather than every measure of Medicaid performance.

The Department of Legislative Services has separately documented continued Medicaid budget pressure in Maryland.

The fiscal 2027 budget included a $294.6 million fiscal 2026 deficiency appropriation for Medicaid services provided in fiscal 2025 but billed later.

Lawmakers reduced that amount by $70 million, to about $224.6 million, based on lower estimated prior-year spending using claims paid through January 2026.

Maryland is preparing for federal eligibility changes beginning in January 2027 under a new federal law.

The Maryland Department of Health says the changes could affect up to 320,000 Medicaid members.

Some recipients will have to complete at least 80 hours a month of work, school, job training or volunteering, or earn at least $580 a month. Some members will also have to renew their Medicaid eligibility every six months instead of once a year.

Maryland is separately expanding its primary care system.

The state’s Medicaid Advanced Primary Care Program requires participating practices to offer access through options such as same- or next-day appointments, telehealth, patient portals or expanded hours.

Practices must also reach out to Medicaid members who have not been receiving regular primary care. The program’s first full year began Jan. 1, 2026.