Maryland is considered one of the more progressive states when it comes to testing and implementing innovative models of care and healthcare reform. The state has passed many payer and provider legislations, keeping the healthcare ecosystem dynamic. The state has one of the top healthcare systems in the nation and has average premiums on the reasonable side of the scale. Maryland's exchange premiums dropped three years in a row and has seen positive changes following a disappointing start. Lack of growth in commercial enrollment remains a challenge for most managed care organizations in Maryland, although some carriers have seen growth of consumer-directed health plans and self-insured products. As the state continues to accept new residents under its expanded Medicaid program, HealthChoice, to 138 percent of the federal poverty level, competition between participating MCOs will increase as they seek to gain a bigger share of this growing segment. The largest health systems have entered the managed Medicare and Medicaid markets with product offerings.