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Von Halliday Consulting · North Dakota Rural Health Intelligence
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The Halliday Brief
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Rural Health Policy · North Dakota & Federal
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Vol. 1 · No. 8 May 11, 2026 RHTP & Medicare Part D
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This Week
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◆ ND HHS has compressed eight RHTP application deadlines across May 15, 22, and 29 — Workforce Retention closed April 30 with state-reported low application volume; Rightsizing TA for CAHs and FQHCs is due May 22
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◆ CMS indefinitely delays the Medicare Part D portion of the BALANCE Model — extends GLP-1 Bridge demonstration through Dec. 31, 2027 at a $50 monthly copay, starting July 1, 2026
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◆ FDA publishes proposed rule removing the term “gender” throughout Title 21 CFR — Docket FDA-2026-N-2886, comment period closes July 6
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From the Desk
Two weeks after the Bismarck 340B ruling, the operational news cycle has shifted from litigation to implementation. ND HHS has compressed eight RHTP application deadlines into the next four weeks — across May 15, May 22, and May 29 — covering workforce, behavioral health, safety-net delivery, and operational restructuring. The Workforce Retention application window for CAHs closed April 30, but as of the most recent state reporting, application volume was strikingly low. The Rightsizing technical assistance grant for rural CAHs and FQHCs, due May 22, is the centerpiece for boards that have not yet engaged the program.
At the federal level, CMS indefinitely delayed the Medicare Part D portion of the BALANCE Model on April 21, after the 80% Part D plan sponsor participation threshold went unmet. The short-term Medicare GLP-1 Bridge demonstration has been extended through 2027 in its place. This issue covers the state grant pipeline in depth, the Bridge mechanics for rural primary care, and four regulatory developments worth tracking.
Doson
Principal, Von Halliday Consulting · Bismarck
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RHTP Implementation · North Dakota · Rural FQHCs & CAHs
The Application Gap: North Dakota's RHTP Pipeline Tightens to Three Deadlines in May
ND HHS has compressed eight RHTP application deadlines across May 15, 22, and 29 — covering workforce, behavioral health, safety-net delivery, and operational restructuring. The October 30 federal obligation deadline is tight. As of the most recent state reporting on the Workforce Retention grant that closed April 30, application volume was strikingly low. The Rightsizing technical assistance grant due May 22 is the next test of whether CAH and FQHC boards are engaging the program at the scale the funding contemplates.
The Workforce Retention for Critical Access Hospitals funding opportunity (Solicitation 210-22102) closed April 30 at 5:00 p.m. CT. The official funding announcement projected approximately $10 million in federal funding available in year one and an estimated 37 awards of approximately $270,000 each, with applicants permitted to submit prioritized funding proposals requesting more.1 Eligible uses include retention bonuses, tuition reimbursement, child care partnerships, professional development, and mentorship programs.1 Some strategies require a minimum five-year service commitment per federal grant guidance; ND HHS determines for each applicant which proposed strategies are subject to the commitment, with reimbursement back to ND HHS required if the threshold is not met.1
As of April 21, however — the most recent state reporting available — only one application had been completed, with another 63 opened but unfinished, according to Interim ND HHS Commissioner Pat Traynor.2 Whether the final volume of applications received by the April 30 deadline approached the 37 projected awards has not been publicly disclosed. Award decisions have not yet been announced.
The Next Four Weeks of Deadlines
What's now open is the second phase. On April 30, ND HHS posted two workforce pipeline opportunities both due May 15: Expand Rural Health Care Rotations (each grant anticipated at approximately $200,000, for supervised training opportunities for students in healthcare facilities, including new rotation positions and student housing subsidies), and Train In Place (each award approximately $135,000, supporting current healthcare workers in earning new credentials through local evening, weekend, or virtual training).3
Three opportunities are due May 22. The state's $3.6 million in fitness, walking, and community gardens grants posted April 22 remain open — a Zero-Hour Physical Education initiative ($700,000, awards $10,000–$70,000), Community Gardens ($300,000, awards $5,000–$30,000), and Community-Based Walking Programs ($2.6 million, awards $25,000–$125,000).4 The fourth opportunity due May 22 is the centerpiece for this audience: Rightsizing Health Care Delivery Systems for the Future.
Two opportunities are due May 29: a $1.6 million Behavioral Health Promotion Community Grants opportunity with 10 anticipated awards of $160,000 each, and a $15 million Ensuring Safety Net Service Delivery opportunity with approximately 50 anticipated awards of $300,000 each — with allowable uses spanning mobile clinics, telehealth equipment, and behavioral health crisis response services.3
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42
Rightsizing TA
awards of $40,0005
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$2.31M
Total Rightsizing TA
year-one budget5
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May 22
Application
deadline, 5pm CT5
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What the Rightsizing Grant Funds
The Rightsizing Health Care Delivery Systems for the Future grant totals approximately $2.31 million, with the state anticipating 42 awards of approximately $40,000 each to rural CAHs and FQHCs.5 Award recipients will work with consulting firm Eide Bailly, designated by ND HHS as the technical assistance vendor; the engagement produces an assessment report with recommendations for improvement.5 Critical Access Hospitals may apply for an additional $42,000 award for the Eide Bailly CAH Analytics tool, a benchmarking platform for staffing, KPIs, productivity, and clinic workflows.56 Applications close May 22, 2026 at 5:00 p.m. CT.5
The grant funds analysis and planning only. No clinical operations, no construction, no implementation funding flows under this opportunity.5
The State Is Building Internal Advisory Capacity
On May 8, ND HHS announced two additions to the RHTP team that signal how the state intends to support facilities working through these assessments. Douglas A. McMillan joined as RHTP Advisor; per the agency, McMillan “will lead efforts serving North Dakota rural health care facilities assessing their current operations and building effective pathways from ‘survivability to thrive-ability.’”7 McMillan brings more than 40 years in healthcare administration, including 28 years as CEO of Cody Regional Health in Wyoming — a 145-bed rural system. Vincent Roehr, an enrolled citizen of the Mandan, Hidatsa and Arikara Nation, joined as Tribal Liaison to integrate tribal perspectives into the program.7
The hires complement the external Eide Bailly Rightsizing engagement and matter for boards thinking about which conversations to be in. McMillan's portfolio sounds operational — facility-by-facility advisory — and “survivability to thrive-ability” is closer to a restructuring frame than a stabilization one. Boards engaging the Rightsizing TA should expect the state-side counterpart to be active in shaping how the resulting assessments translate into year-two implementation funding.
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Von Halliday Analysis
The low application volume on Workforce Retention as of April 21 is the operational story that frames everything else in the May pipeline. The funding announcement projected 37 awards of $270,000; if the final application count approximated 64 (the 1 completed plus 63 opened), the state may need to re-open or extend windows to obligate the full year-one workforce allocation by the October 30 federal deadline. CAH boards that did not apply should expect a second window; boards that did apply will want to track whether the state moves toward fewer larger awards or maintains the projected per-award distribution.
The Rightsizing TA is the more strategically consequential opportunity for this audience. The Eide Bailly assessment is fundamentally a financial and operational diagnostic. For CAH and FQHC boards weighing scenario plans for 340B revenue under Eighth Circuit affirmance, reversal, or tightened CMS audit posture, that diagnostic is one of the few state-funded vehicles available right now to produce the kind of analysis those decisions will require. The Eide Bailly CAH Analytics tool is a benchmarking platform — staffing ratios, KPIs, productivity — not a 340B exposure model, but it is the right kind of data infrastructure for boards that need to be making operational decisions with more granular insight than they currently have.
The May 22 deadline is tight. The hire of McMillan suggests the state is positioning to be a sustained operational partner; boards intending to participate in future RHTP implementation rounds should treat the May 22 Rightsizing application as a strategic priority, not an administrative one.
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Medicare Part D · GLP-1 Coverage
Medicare's GLP-1 Bridge Survives, BALANCE Model Delayed Indefinitely for Part D
CMS reversed course on Medicare Part D coverage for GLP-1 weight-loss drugs on April 21. The Part D portion of the BALANCE Model, originally planned for January 2027, will be delayed indefinitely after the 80% Part D plan sponsor participation threshold went unmet. The short-term Medicare GLP-1 Bridge demonstration — originally scheduled to run July through December 2026 — has been extended through the end of 2027 in its place.8
The mechanics of the Bridge are unusual. Beginning July 1, 2026, eligible Medicare Part D beneficiaries will pay a flat $50 monthly copay for covered GLP-1 medications used for weight management, regardless of Part D benefit phase.8 The program operates outside the standard Part D coverage and payment flow — CMS contracts Humana, the administrator of the Limited Income Newly Eligible Transition (LI NET) program, as the central processor.9 Pharmacies submit prior authorization requests and claims directly to Humana; Part D plan sponsors carry no financial risk for Bridge-furnished GLP-1s.89 Pharmacies are reimbursed at the wholesale acquisition cost minus the $50 copay, plus a dispensing fee; manufacturers then rebate CMS for the difference between WAC and the negotiated $245 net price per monthly supply.9
Eligibility under the Bridge runs through three clinical pathways established by CMS.9 A beneficiary must be 18 or older, prescribed an eligible GLP-1 for weight reduction in combination with structured lifestyle modification, and meet one of the following at the time GLP-1 therapy was initiated: a BMI of 35 or higher; or a BMI of 30 or higher with heart failure with preserved ejection fraction, uncontrolled hypertension (systolic above 140 or diastolic above 90 on two antihypertensives), or chronic kidney disease stage 3a or higher; or a BMI of 27 or higher with prediabetes (per ADA guidelines), prior myocardial infarction, prior stroke, or symptomatic peripheral artery disease.9 Eligibility is assessed at the time of therapy initiation, not at the time of prior authorization — meaning a beneficiary whose BMI has come down on therapy still qualifies if they met criteria when they started.9 Eligible drugs as of April 2026 are Wegovy (injection and tablets), the KwikPen formulation of Zepbound, and Foundayo.9 Bridge spending does not count toward Part D true out-of-pocket totals, and Extra Help low-income subsidies do not reduce the $50 copay.8
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$50
Monthly copay,
flat across phases8
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Jul 1
Bridge start
date, 20268
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Dec 2027
Extended end
(was Dec 2026)8
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Why the Reversal
BALANCE had been designed as a voluntary Center for Medicare and Medicaid Innovation (CMMI) model running January 2027 through December 2031 for state Medicaid agencies and Part D plan sponsors, with CMS negotiating directly with GLP-1 manufacturers.10 Both Novo Nordisk and Eli Lilly agreed to a $245 net price per monthly supply for the model drugs — a substantial discount from prevailing list prices.10 CMS had established a minimum 80% Part D plan sponsor participation threshold for the model to proceed; on April 21, CMS confirmed the threshold was not met.8 Per CMMI Director Abe Sutton, Part D plan sponsors expressed concern about Part D instability and indicated they did not have sufficient visibility into projected GLP-1 utilization to underwrite the financial risk under the model design.11 CMS said the extension of the Bridge will allow the agency to collect additional utilization data and share it with Part D plan sponsors ahead of potential implementation of BALANCE in Part D in 2028.10 The Medicaid arm of the BALANCE Model is still scheduled to launch in May 2026, separately from the Medicare decision.10
What This Means for Rural Primary Care
Per ND HHS, 71% of North Dakotans are overweight or obese and nearly 10% have been diagnosed with diabetes12 — so Bridge eligibility criteria will capture a meaningful share of rural Medicare patients. The operational implication for rural primary care is the prior authorization workflow: provider attestation that the beneficiary met BMI and clinical criteria at therapy initiation, and a routing decision between the Bridge program and standard Part D coverage. Beneficiaries already receiving Part D coverage for a GLP-1 for a Medicare-covered use — type 2 diabetes, cardiovascular disease risk reduction, sleep apnea — continue accessing the drug through their Part D plan, not the Bridge.9 Clinics should also be prepared to explain to patients why the $50 copay does not advance them toward Part D catastrophic coverage and why Extra Help does not reduce it.8 CMS has indicated additional implementation guidance will be issued before July 1.8
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CMS Medicaid work requirements IFR — due June 1.
CMS's interim final rule implementing the OBBBA community engagement mandate is at OMB review, with the statutory June 1 deadline three weeks out.13 Nebraska's work requirements became operational May 1, the first state to launch enforcement; Montana targets July 1, Iowa December 1, and Arkansas a July 1 soft launch with penalties beginning January 1, 2027.13 North Dakota Medicaid has not announced an implementation date, and the state's posture pending the IFR remains the central administrative question for CAH and FQHC revenue cycle planning through the back half of 2026.
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CMS-0062-P comment period closes June 15.
The 2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule was released April 10, 2026, and published in the Federal Register April 14, 2026 (RIN 0938-AV31). It would impose 24-hour expedited and 72-hour standard response time requirements for prior authorization decisions on drugs covered under Medicare Advantage, Part D, Medicaid managed care, CHIP managed care, and Qualified Health Plan issuers on the Federally-facilitated Exchanges.14 The provider-side burden falls on documentation workflows regardless of payer API build-out. The comment window closes June 15.14
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Eighth Circuit Hanaway decision pending.
No new federal appellate ruling this week on 340B contract pharmacy preemption, but the standing posture from Issue 7 holds. The pending Eighth Circuit decision in Novartis Pharms. Corp. v. Hanaway (No. 25-1619, argued January 15, 2026) will materially shape the practical implications of the Bismarck Traynor ruling for North Dakota's 37 CAHs.15 Boards that have not yet run the three-scenario 340B revenue analysis recommended last week should consider doing so before the Eighth Circuit ruling lands.
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FDA proposed rule on Title 21 terminology.
On May 6, 2026, FDA published a proposed rule (Docket FDA-2026-N-2886) that would remove the term “gender” throughout Title 21 of the Code of Federal Regulations, either replacing it with “sex” or deleting the reference, along with editorial changes for readability.16 The proposed rule is issued pursuant to Executive Order 14168 (January 20, 2025).16 The comment period closes July 6, 2026.16
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Dakota Conference on Rural Health — June 3–4, Grand Forks.
The region's longest-running gathering of rural health practitioners, hospital leaders, public health officials, tribal health representatives, and state policymakers. Hosted by the UND Center for Rural Health at the Alerus Center.17 Two days of plenaries, breakouts, and unstructured time that — for many ND CAH boards — is the year's best opportunity to compare notes with peer organizations, hear directly from state agency leadership, and surface emerging concerns before they become policy. Worth attending whether or not you have a specific issue to raise.
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Sources & Citations — This Issue
State Feature: RHTP Pipeline
1 North Dakota Department of Health and Human Services, “Workforce Retention Funding for Critical Access Hospitals and Their Owned and Operated Clinics,” Solicitation Number 210-22102, https://www.hhs.nd.gov/rural-health-transformation/funding/workforce (“Approximately $10,000,000 in federal funding is available in year one... An estimated 37 awards of approximately $270,000 each are expected to be made in year one. Applicants may submit a prioritized funding proposal and requested amounts may exceed $270,000.”). Federal grant guidance requires a minimum five-year service commitment tied to financial incentives, with reimbursement back to ND HHS if the threshold is not met (per ND HHS Workforce Retention FAQ, accessed May 11, 2026).
2 Application volume figures as reported by Interim ND HHS Commissioner Pat Traynor and reported in Mary Steurer, “Next round of federal rural health grants to promote fitness, community gardens,” North Dakota Monitor, April 24, 2026, https://northdakotamonitor.com/2026/04/24/next-round-of-federal-rural-health-grants-to-promote-fitness-community-gardens/ (“As of Tuesday, one facility had applied for the first grant, Traynor said. Another 63 applications had been opened.” — “Tuesday” referring to April 21, 2026, in advance of the April 30 deadline). ND HHS has not publicly released the final application count received by the April 30 deadline or announced award decisions as of May 11.
3 Mary Steurer, “Additional $20 million in federal rural health grants announced for North Dakota,” North Dakota Monitor, May 5, 2026, https://northdakotamonitor.com/2026/05/05/additional-20-million-in-federal-rural-health-grants-announced-for-north-dakota/ (Expand Rural Health Care Rotations at approximately $200,000 per grant; Train In Place at approximately $135,000 per award, both due May 15; Behavioral Health Promotion at $1.6 million, 10 anticipated awards of $160,000, due May 29; Ensuring Safety Net Service Delivery at $15 million, approximately 50 anticipated awards of $300,000, due May 29). Solicitation numbers and detailed scope per ND HHS RHTP Funding Opportunities page, https://www.hhs.nd.gov/rural-health-transformation/funding.
4 ND HHS News Release, “North Dakota announces $3.6 million in school & community-based grant opportunities for Rural Health Transformation,” April 22, 2026, https://www.hhs.nd.gov/news/north-dakota-announces-36-million-school-community-based-grant-opportunities-rural-health (Zero-Hour PE: $700,000, awards $10,000–$70,000; Community Gardens: $300,000, awards $5,000–$30,000; Community-Based Walking: $2.6 million, awards $25,000–$125,000; all due May 22, 2026).
5 Rightsizing Health Care Delivery Systems for the Future grant parameters per ND Monitor (May 5, 2026) and KVRR Local News (May 5, 2026), citing ND HHS funding opportunity description ($2.31 million total funding; 42 anticipated awards of approximately $40,000 each; CAHs may apply for an additional $42,000 award for the Eide Bailly CAH Analytics data tool; due May 22, 2026; Eide Bailly designated as technical assistance vendor for assessment with recommendations for improvement). Red River Regional Council, “Rural Health Transformation Grants to Support North Dakota Communities,” https://redriverrc.com/rural-health-transformation-grants-to-support-north-dakota-communities/ (confirming May 22 deadline and program description). Note: as of this reporting, ND HHS had not published a dedicated news release announcing the Rightsizing opportunity; full funding announcement details are on the ND HHS RHTP funding portal.
6 Eide Bailly CAH Analytics Solution description per Michigan Center for Rural Health, MI CAH Financial Network, https://mcrh.msu.edu/programs/hospital-programs/critical-access-hospital/financial-network (benchmarking platform for CAH staffing ratios, KPIs, productivity, and clinic workflows).
7 ND HHS News Release, “Tribal Liaison and Rural Health Care Advisor, Join HHS Rural Health Transformation Program,” May 8, 2026, https://www.hhs.nd.gov/news/tribal-liaison-and-rural-health-care-advisor-join-hhs-rural-health-transformation-program (announcing Vincent Roehr as Tribal Liaison and Douglas A. McMillan as RHTP Advisor; McMillan formerly CEO of Cody Regional Health, Wyoming, more than 28 years; quoted directive on “survivability to thrive-ability”).
Federal Short: GLP-1 Bridge
8 CMS announcement on Medicare GLP-1 Bridge demonstration extension and BALANCE Model determinations, April 21, 2026; AHA News, “CMS delays Part D portion of BALANCE Model on expansion of GLP-1 access,” April 22, 2026, https://www.aha.org/news/headline/2026-04-22-cms-delays-part-d-portion-balance-model-expansion-glp-1-access; KFF Quick Take, “CMS Extends Medicare's Short-Term Bridge Program for GLP-1 Obesity Drug Coverage,” April 21, 2026.
9 CMS, “Medicare GLP-1 Bridge — Frequently Asked Questions,” https://www.cms.gov/medicare/coverage/prescription-drug-coverage/medicare-glp-1-bridge (Humana as central processor leveraging LI NET infrastructure; three-pathway clinical eligibility — BMI ≥35 alone, BMI ≥30 with HFpEF/uncontrolled hypertension/CKD stage 3a+, or BMI ≥27 with prediabetes/MI/stroke/symptomatic PAD; eligibility assessed at therapy initiation; eligible drugs Wegovy (injection and tablets), Zepbound (KwikPen only), Foundayo, updated April 6, 2026; pharmacy reimbursement at WAC minus copay plus dispensing fee; manufacturers rebate CMS for difference between WAC and $245 net price per monthly supply).
10 KFF, “What to Know About the BALANCE Model for GLP-1s in Medicare and Medicaid” (issue brief, March 24, 2026, updated to note April 21 BALANCE delay), https://www.kff.org/medicare/what-to-know-about-the-balance-model-for-glp-1s-in-medicare-and-medicaid/; Juliette Cubanski and KFF Health News, “CMS Extends Medicare's Short-Term Bridge Program for GLP-1 Obesity Drug Coverage,” U.S. News & World Report, April 27, 2026 (Novo Nordisk and Eli Lilly $245 net price agreement; Medicaid arm proceeding May 2026).
11 Fierce Healthcare, “CMS delays Part D GLP-1 model amid skepticism from insurers,” April 2026, https://www.fiercehealthcare.com/payers/cms-delays-part-d-glp-1-model-amid-skepticism-insurers (quoting CMMI Director Abe Sutton on plan sponsor concerns about Part D instability and insufficient utilization data).
12 Per ND HHS News Release, April 22, 2026 (citing Trust for America's 2023 State of Obesity Report and American Diabetes Association data).
What to Watch
13 H.R. 1, One Big Beautiful Bill Act §71119 (community engagement requirements for Medicaid expansion population); CMS interim final rule pending at OMB review as of early May 2026, statutory publication deadline June 1, 2026. State implementation status per KFF, “An Early Look at Policy Decisions as States Get Ready to Implement Work Requirements,” April 2026, https://www.kff.org/medicaid/an-early-look-at-policy-decisions-as-states-get-ready-to-implement-work-requirements/ (Nebraska May 1, 2026; Montana July 1, 2026; Iowa December 1, 2026); Arkansas DHS News Release, “DHS to launch soft implementation of work and community engagement requirement starting July 1,” February 23, 2026, https://humanservices.arkansas.gov/news/dhs-to-launch-soft-implementation-of-work-and-community-engagement-requirement-starting-july-1/ (July 1, 2026 soft launch; penalties effective January 1, 2027).
14 CMS, Notice of Proposed Rulemaking, “Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Interoperability Standards and Prior Authorization for Drugs,” CMS-0062-P (RIN 0938-AV31), released April 10, 2026, published Federal Register April 14, 2026, https://www.federalregister.gov/documents/2026/04/14/2026-07205/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-interoperability-standards (proposed 24-hour expedited and 72-hour standard response timeframes; applies to Medicare Advantage, Part D, state Medicaid and CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan issuers on the Federally-facilitated Exchanges including FF-SHOP small group issuers). Comment period closes June 15, 2026.
15 Novartis Pharms. Corp. v. Hanaway, No. 25-1619 (8th Cir.), interlocutory appeal from denial of preliminary injunction (W.D. Mo., Judge M. Douglas Harpool). Oral argument heard January 15, 2026 (per Eighth Circuit calendar and Bloomberg Law coverage). The case challenges Missouri Senate Bill 751 (the state's 340B contract pharmacy protection law) on Dormant Commerce Clause and Supremacy Clause grounds. Decision pending as of May 11, 2026.
16 Food and Drug Administration, Proposed Rule, “Modification of Certain Terminology in Title 21,” Docket No. FDA-2026-N-2886, 91 Fed. Reg. (May 6, 2026), https://www.federalregister.gov/documents/2026/05/06/2026-08826/modification-of-certain-terminology-in-title-21. Issued pursuant to Executive Order 14168, “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” (Jan. 20, 2025). Comments due July 6, 2026.
17 UND Center for Rural Health, Dakota Conference on Rural Health, June 3–4, 2026, Alerus Center, Grand Forks, ND, https://ruralhealth.und.edu/dakota-conference.
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A Note on This Brief
The Halliday Brief is published weekly by Von Halliday Consulting. It synthesizes federal and North Dakota state rural health policy developments for administrators, clinicians, tribal health leaders, foundation officers, and state-level decision-makers who need accurate, actionable intelligence — without wading through agency websites and legislative reports themselves.
If a colleague should be reading this, forward it. If you have a policy question, a funding opportunity your organization is navigating, or a challenge that deserves a closer look — reach out.
Von Halliday Consulting
North Dakota Rural Health Policy & Strategy
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