ASPIRE (Accelerating State Pediatric Innovation Readiness and Effectiveness) Model

Analysis updated November 9, 2026

Strategic questions for your team

Does our state Medicaid agency have the political will and administrative capacity to compete for one of only five ASPIRE cooperative agreement slots, and can we credibly demonstrate to CMS that we have sufficient accountable entities — either existing managed care plans or ACOs — already capable of meeting total cost of care accountability requirements for high- and rising-risk Medicaid/CHIP enrollees under age 21, or that we can build that capacity during the pre-implementation phase?
Can our organization qualify and operate as an ASPIRE 'accountable entity' responsible for managing total health care costs for complex pediatric Medicaid/CHIP populations, and do we currently have — or can we rapidly recruit — providers with specialized experience delivering care for children with behavioral health conditions, substance use disorders, chronic conditions, and physical, intellectual, and developmental disabilities across the full continuum from rising-risk to high-risk?
What is our realistic financial exposure under a total cost of care payment model for pediatric Medicaid/CHIP populations, and have we modeled the actuarial risk of assuming accountability for a population defined by co-occurring medical and behavioral health complexity, where crisis intervention, emergency department utilization, and inpatient psychiatric admissions — precisely the cost drivers the ASPIRE model targets for reduction — currently represent significant uncontrolled expenditures in our market?
Do we have the care coordination infrastructure — including same-day telehealth assessment capability, multi-provider shared care plans with real-time communication, joint specialist review processes (e.g., psychiatry and developmental pediatrics collaborating on medication management), and school-and-home environment tracking — required to replicate the 'With ASPIRE' care model described in the Journey Map and avoid the high-cost utilization patterns illustrated in the 'Without ASPIRE' scenarios?
Are we operationally prepared to deliver the full suite of ASPIRE wrap-around services — including family caregiver training in behavioral management, long-term transition-to-adulthood planning for youth approaching age 21, and empowerment resources that enable families to partner actively in care — and what would it cost to build or contract for these capabilities if we currently lack them?
Given that ASPIRE runs for 10 years and is structured through state cooperative agreements with federal funding allocations that CMS may direct toward infrastructure and access expansion, have we assessed our 10-year strategic commitment tolerance, and do we understand how cooperative agreement terms will govern our operational flexibility, performance requirements, and exposure to federal recoupment or compliance risk over that horizon?
What quality measures framework will CMS apply to assess our performance under ASPIRE's outcomes-focused accountability structure, and can we currently capture and report the pediatric-specific metrics — including care experience, appropriate setting of care, avoidance of inpatient psychiatric hospitalization, and school and community functioning — that will likely determine whether we generate savings or face penalties under the model's value-based accountability design?
How does ASPIRE participation interact with our existing Medicaid managed care contracts, ACO agreements, or InCK (Integrated Care for Kids) model relationships in our state, and have we mapped potential overlap, duplication, or conflict in population attribution, care coordination responsibilities, and financial accountability between ASPIRE accountable entity obligations and our current contractual arrangements?
What is our competitive positioning risk if a rival health system, managed care plan, or ACO in our state becomes the designated ASPIRE accountable entity — capturing cooperative agreement funding, deepening Medicaid/CHIP relationships with complex pediatric populations, and building care coordination infrastructure that could lock in long-term market advantages over a 10-year model period — and how does that scenario affect our strategic calculus around applying versus remaining on the sidelines?

Traps and concerns

Total Cost of Care Accountability Without Pediatric Benchmarking Infrastructure
ASPIRE's payment model places accountable entities — managed care plans or ACOs — at risk for total cost of care for high- and rising-risk children and youth up to age 21. However, pediatric Medicaid/CHIP populations have historically thin actuarial data, high expenditure volatility driven by rare diseases and catastrophic events, and no established CMMI benchmarking methodology equivalent to adult primary care models. Accountable entities that accept capitated or shared savings arrangements before CMS releases its benchmark-setting methodology risk signing cooperative agreement terms that embed unfavorable baseline costs — particularly for children with complex behavioral health, intellectual disabilities, and developmental conditions, who can generate six-figure annual expenditures. States that fail to negotiate benchmark reconciliation corridors, risk corridors, or stop-loss provisions during the pre-implementation phase could face retrospective payment clawbacks or shared risk losses that make participation financially untenable, especially in smaller states where a handful of high-cost children can distort population-level cost trends.
Five-State Cap Creates Exclusionary Selection Dynamics
CMMI will award cooperative agreements to up to five state Medicaid agencies (SMAs), meaning the vast majority of states — including those with the highest unmet need — will be excluded regardless of population burden. The NOFO has not yet been released as of the model's announced stage, and selection criteria remain vague beyond requiring 'sufficient potential accountable entities with capacity to meet model requirements.' States that invest staff time and resources building ASPIRE applications, engaging potential accountable entities, and developing care coordination infrastructure only to be rejected face sunk costs with no federal reimbursement pathway. Additionally, states with robust managed care penetration may crowd out states where Medicaid operates on a fee-for-service basis, even though FFS states may have larger underserved pediatric populations — creating a structural bias in model participation that undermines the equity rationale of the model.
Behavioral Health and Physical Health Data Integration Failure Risk
ASPIRE's care model explicitly requires a single comprehensive care plan shared across all providers — including psychiatrists, developmental pediatricians, primary care providers, school-based services, and emergency departments — as illustrated in the Journey Map. Achieving real-time, bidirectional data sharing across these fragmented systems requires interoperability infrastructure that most Medicaid-participating pediatric providers, particularly rural and community-based organizations, currently lack. Federal 42 CFR Part 2 substance use disorder confidentiality regulations add an additional compliance layer for children with co-occurring SUDs, requiring specific consent protocols before behavioral health data can be shared with physical health providers. States that underestimate the technology build timeline — which for Medicaid IT systems typically spans 24-36 months and requires CMS MMIS certification — risk launching ASPIRE with providers operating on disconnected records, directly undermining the care coordination model and exposing states to CMS performance-related cooperative agreement penalties.
Accountable Entity Readiness Gap in Pediatric Specialty Markets
CMS requires that accountable entities partner with providers who have 'specialized experience delivering care for high- and rising-risk children and youth.' In most states, this specialized provider ecosystem — pediatric behavioral health, developmental pediatrics, early intervention specialists, pediatric palliative care — is sparse, often nonprofit or academic-affiliated, and not structured for value-based contracting. Managed care plans and ACOs that qualify as accountable entities may lack existing network relationships with these specialists, and building those networks during the pre-implementation phase introduces substantial contracting risk. If accountable entities cannot demonstrate adequate specialist network adequacy for medically complex pediatric populations, states risk failing CMS model participation requirements, losing cooperative agreement funding, or launching ASPIRE with a care delivery infrastructure that cannot actually serve the target population — high- and rising-risk children whose needs are precisely those requiring the rarest specialties.
Transition-to-Adulthood Coverage Cliff at Age 21
ASPIRE covers children and youth up to age 21, but the model's explicit goal includes 'long-term planning to support health, productivity, and economic stability during the transition to adulthood.' Youth with complex medical, behavioral, and developmental conditions who age out of ASPIRE at 21 face Medicaid coverage cliffs — moving from a CHIP-eligible or pediatric Medicaid category to adult Medicaid eligibility categories with different covered services, different provider networks, and potentially different managed care contracts. If ASPIRE's accountable entities have not established transition care planning protocols and formal handoff agreements with adult Medicaid managed care organizations at least 12-24 months before a youth's 21st birthday, the investments made in coordinated pediatric care are likely to be lost. This represents both a quality risk — poor health outcomes at the transition point — and a payment risk, as deterioration in health status post-transition may generate retrospective quality metric failures that affect state cooperative agreement performance evaluations.
Cooperative Agreement Compliance Burden on State Medicaid Agencies
ASPIRE is structured as a cooperative agreement rather than a grant or contract, meaning CMS maintains substantial involvement in model design, implementation decisions, and allowable use of funds — including potentially requiring states to dedicate portions of federal awards to specific infrastructure investments like wrap-around services. For state Medicaid agencies already managing waiver renewals, managed care contract oversight, and federal ILOS reporting requirements, ASPIRE's cooperative agreement compliance layer — including model-specific quality measure reporting, accountable entity oversight, and CMS evaluation cooperation requirements — represents a significant administrative burden. States with lean SMA staffing, particularly smaller states with smaller Medicaid populations, may find that cooperative agreement management consumes a disproportionate share of federal award dollars. Failure to comply with cooperative agreement terms risks CMS suspension of funding mid-model, which would strand children mid-care-coordination and expose states to political and legal liability for program disruption.
Rising-Risk Population Definition and Attribution Instability
ASPIRE targets two distinct populations: 'high-risk' children with existing complex conditions and 'rising-risk' children with one or more risk factors for developing a complex condition. The rising-risk category is operationally ambiguous — no source document specifies the clinical criteria, risk stratification algorithms, or claims-based triggers that would define eligibility. Accountable entities that develop care coordination infrastructure and accept financial accountability for a rising-risk cohort will face attribution instability if children cycle in and out of eligibility as risk factors appear or resolve, or if CMS modifies the rising-risk definition mid-model. This creates serious payment reconciliation problems: an accountable entity that builds care coordination capacity for a rising-risk population of 5,000 children could face mid-year attribution reductions if the definitional criteria are tightened, while still bearing the fixed costs of the care infrastructure it built. CMMI's failure to release the NOFO with explicit rising-risk criteria before states commit to participation represents a material information gap that amplifies this risk.