The Government Accountability Office reports that the Centers for Medicare & Medicaid Services (CMS) has already awarded the first $10 billion of a five-year program that may fund up to $50 billion, while much of the monitoring GAO reviewed is, by GAO's own account, still planned rather than carried out.
What CMS has done
Under the Rural Health Transformation (RHT) program, created by the One Big Beautiful Bill Act in July 2025 and run as cooperative agreements with states, CMS "awarded a total of $10 billion in RHT program funding to 50 states" by the end of 2025, covering budget period 1, which runs through October 30, 2026, GAO writes. State awards ranged from $147 million for New Jersey to $281 million for Texas. Each state received a flat $100 million in baseline funding, plus workload funding tied to its rural characteristics and a "technical score" built from its proposed initiatives, dual-eligibility and Medicaid-data measures, and whether it had or committed to specific policy actions CMS listed, such as restricting SNAP purchases of "non-nutritious foods" or reestablishing the Presidential Fitness Test in schools.
What CMS has started, and what it has not
GAO writes that CMS "plans to monitor states' RHT program activities through communicating with states to discuss progress and challenges, reviewing information submitted by states, and conducting audits and site visits," and found those planned activities "generally consistent with selected requirements for monitoring federal awards." As of July 2026 — the date GAO's monitoring information reflects — CMS "has not yet reviewed state information such as quarterly and annual reports," since the first of those reports was not due until August 31, 2026. CMS officials told GAO they had begun bimonthly meetings with states in January 2026 and had completed 21 site visits as of July 2026; audits of states' use of program funds are planned to begin in 2027. GAO states: "It is too early to know whether CMS's implementation of these monitoring activities will fully address the post-award monitoring requirements."
How states may spend it, and the next four years
States must spend the money on CMS-approved initiatives, such as recruiting clinicians to rural areas or adopting telehealth and remote-monitoring technology. GAO writes that, under the program's notice of funding opportunity, funds may not pay for "new construction and payments for clinical services that could be reimbursed by insurance." CMS plans to allot up to $40 billion more over the next four years, through budget periods running to October 30, 2030, based on its assessment of each state's "demonstration of satisfactory progress" toward approved initiatives and policy actions. States generally cannot appeal CMS's funding decisions in court or through administrative review — a limit GAO says the authorizing law imposes.
No recommendations
GAO made no recommendations in this report. It sent HHS a draft; HHS "provided technical comments, which we incorporated as appropriate," and nothing further. GAO says it has "future planned work to continue evaluating CMS's implementation of the RHT program."