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Introduction

The Children’s Health Insurance Program (CHIP) was enacted 25 years ago. ^[1]  Today it provides coverage for children whose family incomes are too high to allow them to qualify for Medicaid but too low to enable them to afford private health insurance coverage.  Together, CHIP and Medicaid insure over half ^[2] of the nation’s 77.8 million children under 19.  (Medicaid insures 34.2 million children and 47.2 million adults). These two programs are the main reason that the rate of uninsured children has fallen to 5.4 percent. ^[3]

CHIP is a block grant. The federal government makes a fixed allotment of funds available on a matching basis to each participating state each year to provide health care services to children (and/or some pregnant women) in low-income families who are not eligible for Medicaid or enrolled in private health insurance coverage. The federal matching rate ^[4] for state spending (up to each state’s allotment ^[5]) is significantly higher (ranging from 65 percent to 84.5 percent in 2023) than the matching rate a state receives under Medicaid (ranging from 50 percent to 78 percent in 2023).  Federal spending on CHIP in FY 2023 is estimated ^[6] at $18 billion. States are not required to participate, but all have chosen to do so. They have broad flexibility in designing and administering their programs.

One of many CHIP design choices states have ^[7] is whether to operate a separate CHIP program or enroll CHIP children in their Medicaid program (or do a combination of both). According to the Medicaid and CHIP Payment and Access Commission (MACPAC), ^[8] only 10 states (Alaska, Hawaii, Maryland, New Hampshire, New Mexico, North Dakota, Ohio, South Carolina, Vermont, and Wyoming) and the District of Columbia currently do not have a separate CHIP program. (These categories are not static; North Carolina, currently a combination state, has announced ^[9] it will merge its separate CHIP program into Medicaid on April 1, 2023). Six states operate separate CHIP programs for pregnancy coverage only (Illinois, Michigan, Minnesota, Nebraska, Oklahoma, and Rhode Island). In these six states, as well as in the ten states (and the District of Columbia) that do not have a separate CHIP program, all of the CHIP-eligible children are enrolled in Medicaid.

That leaves 34 states with separate CHIP programs for children from birth up to age 19. (California’s separate CHIP program is limited to three counties (San Francisco, Santa Clara, and San Mateo)). Two of the 34 states (Connecticut and Washington) enroll all of their CHIP-eligible children in separate CHIP programs.  The remaining 32 states enroll some of their CHIP children in a separate CHIP program and others in Medicaid. MACPAC reports ^[10] that of the 8.6 million children ever enrolled in CHIP during 2021 (even for only one month), 3.4 million were served by separate CHIP programs.

Another program design choice that states have in both Medicaid and CHIP is what health care delivery system to use:  fee-for-service, risk-based managed care, or a combination of both.  Of the 34 states with separate CHIP programs for children from birth up to age 19, all but seven—Alabama, Arkansas, Connecticut, Idaho, Maine, Montana, and South Dakota—use managed care organizations (MCOs) to deliver covered services. States that use MCOs, whether in Medicaid or CHIP, contract with insurers on a risk basis.  These risk contracts can be specific to CHIP; for example, Utah’s Department of Health has a CHIP risk contract ^[11]  and a separate Medicaid risk contract ^[12] with the same contractor (Molina Healthcare of Utah).  Or they can combine Medicaid and CHIP in the same contract, which is what the Virginia Medicaid agency’s Medallion 4.0 risk contract does (an Addendum to the contract specifies CHIP program requirements). ^[13]  Whatever the contracting arrangements, how well the MCOs perform largely determines whether the CHIP children they enroll receive the services they need, whether the quality of those services is high or low, and whether any racial disparities affecting CHIP children are reduced or exacerbated.

The Kaiser Family Foundation’s Medicaid managed care tracker ^[14] lists the state Medicaid agencies that contract with MCOs, the MCOs with which they contract, and the parent organizations of those MCOs.  In managed care states that cover some or all CHIP children through their Medicaid programs, those children enroll in the same MCOs as Medicaid children and are entitled to the same protections and EPSDT services ^[15] as children covered by Medicaid.

In contrast, there is no national, public database of MCOs with which separate CHIP programs contract. As a result, it is difficult for policymakers, stakeholders and the public to know which MCOs are enrolling CHIP children in separate CHIP programs or how those MCOs are performing for those children.

This brief aims to fill that gap.  It begins with a short overview of the federal rules governing managed care in CHIP, focusing on beneficiary protections, MCO performance standards, quality monitoring, and transparency.  It then presents the MCOs that separate CHIP programs use and whether these MCOs (or their parent companies) also contract with the state Medicaid agency.  It concludes with a brief discussion of challenges relating to transparency and accountability about the performance of these MCOs for the children they enroll. For information about the type of CHIP program in each state, their chosen method of service delivery, and links to each MCO in managed care states, interact with the map below.

Federal Rules for Managed Care in CHIP

Separate CHIP programs that contract with MCOs are subject to many of the same federal requirements ^[16] that apply to state Medicaid programs that contract with MCOs.  In particular, the requirements for enrollee rights, such as the right to information about how to access benefits, and enrollee protection from liability for the cost of covered services, are completely aligned.  The same applies to the standards for accessibility and availability of services and network adequacy, as well as coordination and continuity of care.  In addition, the program integrity standards that organizations must meet in order for states to contract with them are common to both Medicaid and separate CHIP programs.  A comparison of selected federal requirements is at Table 1; a more comprehensive comparison is available here. ^[17]

Table 1

Selected Federal Managed Care Requirements

(Sections in 42 C.F.R. Part 438 and Part 457)

Federal Requirement	Medicaid	CHIP	Notable Differences
Beneficiary Protections
Enrollee Rights and Protection from Liability	Yes (§438.100, §438.106)	Yes (§457.1220, §457.1226)	None
Coverage and Prior Authorization of Services	Yes (§438.210)	Yes (§457.1230(d))	Medicaid protections relating to medical necessity standard at §438.210(a)(5) do not apply to CHIP
Grievances and Appeals	Yes (§§438.400 – 438.420) (Fair hearings §§431.220-431.246)	Yes (§457.1260)	The CHIP state external review is not a Medicaid fair hearing; unlike Medicaid, CHIP does not provide for continuation of benefits pending a decision
MCO Performance Standards
Availability of services	Yes  (§438.206)	Yes  (§457.1230(a))	None
Adequate capacity and services	Yes  (§438.207)	Yes  (§457.1230(b))	None
Network adequacy standards	Yes  (§438.68)	Yes  (§457.1218)	None
Coordination and Continuity of Care	Yes (§438.208)	Yes (§457.1230(c))	None
Quality Monitoring
Annual EQRO review and posting Annual Technical Report (ATR)	Yes  (§§438.350 – 438.364)	Yes  (§457.1250(a))	None
Program Integrity
Program integrity safeguards (other than annual EQRO review)	Yes  (§§438.600- 438.610)	Yes  (§457.1285)	Requirements in Medicaid relating to “actuarially sound” capitation rates do not apply to CHIP.
CMS prior approval of risk contracts	Yes  (§438.3)	No  (§457.1201(c))	CHIP MCO contracts are subject to CMS review, §457.1201(a), but not CMS prior approval
CMS approval of capitation rates as “actuarially sound”	Yes (§438.4(b))	No  (§457.1201(c))	Separate CHIP programs must submit rates to CMS on request
Minimum Medical Loss Ratio with remittance	No  (§438.8(c))	No  (§457.1203(j))	None
Annual MLR report to State	Yes  (§438.8 (k))	Yes  (§457.1203(e))	None
Transparency (other than posting EQRO ATR)	Yes  (§438.602(g))	No	Separate CHIP programs are not required to post risk contracts, documentation of network adequacy, or results of financial audits.

The MCOs Used by Separate CHIP Programs

As noted above, 27 of the 34 separate CHIP states contract with MCOs to deliver services to eligible children. (Some of these states also cover some pregnant women; this discussion focuses on coverage of children). In all 27 of these states, the Medicaid agency contracts with MCOs to deliver services to its program beneficiaries. Those Medicaid MCOs, many of which also enroll CHIP children, are listed on a national, publicly available database. ^[18] There is no corresponding national, publicly available database identifying the individual MCOs that separate CHIP programs use.

To obtain this information, we searched the websites of each separate CHIP agency that uses MCOs to deliver services to eligible children. If the information was not available there, we searched the state Medicaid agency website and other state websites where the information could potentially be found.  The results are shown in Appendix 1, which lists the MCOs with which each separate CHIP program is contracting at the beginning of 2023, including the parent company and (where available) enrollment.  Appendix 2 contains links to the state agency website from which the information in Appendix 1 was obtained.

In total, the 27 states with separate CHIP programs are contracting, either separately or through their Medicaid programs, with 154 different MCOs.  As noted above, many of these MCOs also enroll Medicaid children; determining from public sources how many of an individual MCO’s enrollees are Medicaid children and how many are CHIP children is often not possible. Our January 2023 scan found only eight separate CHIP states that posted CHIP enrollment data for each MCO: Florida, Georgia, Indiana, Iowa, Missouri, Nevada, North Carolina, and Utah. New York posted CHIP enrollment for some MCOs but not others, and Pennsylvania combined its total CHIP enrollment for three plans owned by the same parent company. The remaining 17 states did not post CHIP enrollment data for each MCO.

In Medicaid, five national publicly-held companies—Aetna/CVS Health, Centene, Elevance Health (formerly Anthem), Molina, and UnitedHealth Group—enroll half ^[19] of all Medicaid beneficiaries (children and adults) who are enrolled in MCOs.  Because the majority of separate CHIP states do not post MCO-specific CHIP enrollment data, we are unable to measure the CHIP market shares of these companies.  What we were able to determine is that, as of January 2023, these five firms owned 66 of the 154 MCOs contracting with separate CHIP states.  Three nonprofit companies owned another 10 of these MCOs:  AmeriHealth Caritas (4), CareSource (2), and Highmark (4).

Table 2 lists the parent companies with MCO subsidiaries participating in both the separate CHIP program and the Medicaid program in the same state.  In many cases, the same MCO enrolls both Medicaid and CHIP beneficiaries under the same risk contract.  In those cases, children who lose Medicaid eligibility due to increases in family income but still qualify for CHIP coverage (and vice versa) could potentially keep their providers by remaining enrolled in the same MCO. And in cases where a parent company has separate contracts for Medicaid and CHIP, children who lose Medicaid eligibility but qualify for CHIP could, if notified of the option, choose to enroll in the same parent company’s CHIP MCO, potentially avoiding disruption in their relationships with their providers (if the networks align). These overlaps will take on heightened importance after April 1, 2023, when states will begin redetermining Medicaid eligibility for all beneficiaries. ^[20]

Table 2

CHIP MCO Parent Company Participation in Medicaid*

(As of January 2023)

State	Parent Company
AZ (Kids Care)	Centene, United
CA (Healthy Families)	Elevance, San Francisco Health Plan, Health Plan of San Mateo, Santa Clara Family Health Plan
CO (CHP+)	Colorado Access, Denver Health, United
DE (HealthyChildren)	Highmark, AmeriHealth
FL (Florida Kid Care)	CVS Health, Community Care Plan, Elevance
GA (PeachCare for Kids)	Elevance, CareSource, Centene
IN (Hoosier Healthwise)	Elevance, CareSource, Centene, McLaren
IA (Hawk-I)	Elevance, Centene
KS (Healthwave)	CVS Health, Centene, United
KY (KCHIP)	CVS Health, Elevance, Humana, Molina, Centene
LA (LaCHIP)	CVS Health, AmeriHealth, BCBS of LA, Centene, United
MA (MassHealth)	BMC HealthNet Plan, Point32, Baystate Healthcare Alliance, Berkshire Fallon Health Collective, Fallon Health, My Care Family, Tufts & Fallon Health
MS (CHIP)	Molina, United
MO (MO HealthNet for Kids)	Centene, Elevance, United
NV (Nevada Check Up)	Elevance, United, Molina, Centene
NJ (New Jersey Family Care)	CVS Health, AmeriHealth, BCBS of NJ, United, Centene
NY (Child Health Plus)	CDPHP, Centene, MVP Health Plan, United, BCBS of NY, Molina, Emblem, Elevance, Healthfirst PHSP, MetroPlus, Excellus BCBS, Independent Health Association, Excellus Health
NC (NC Health Choice for Children)	AmeriHealth, Centene, BCBS of NC, United
OR (Healthy Kids)	Advanced Health, AllCare, Cascade Health Alliance, Columbia Pacific, Eastern Oregon, Health Share of Oregon, InterCommunity Health Network, Jackson Care Connect, PacificSource Community Solutions, Centene, Umpqua Health Alliance, Yamhill
PA (CHIP)	CVS Health, BCBS of PA, Highmark, Geisinger, Independent Blue Cross, United, UPMC
TN (CoverKids)	Elevance, BCBS of TN, United
TX (CHIP)	CVS Health, Elevance, BCBS of Texas, Community First Health Plans, Community Health Choice, Cook Children's Health Plan, Driscoll Health Plan, El Paso Health, FirstCare, Molina, Seton Health Plan, Centene, Texas Children's Health Plan, United, Health Care Services Corporation
UT (CHIP)	Molina, SelectHealth
VA (FAMIS)	CVS Health, Elevance, Molina, Sentara, United, Sentara/VCU
WA (AppleHealth for Kids)	Elevance, Community Health Plan of Washington, Centene, Molina, United
WV (CHIP)	CVS Health, The Health Plan, Elevance
WI (BadgerCare Plus)	Elevance, Children's Community Health Plan, Dean Health Plan, Group Health Cooperative of South Central Wisconsin, MercyCare, Molina, Network Health, Quartz, Security Health Plan
Total: 27	136

*Company enrolls CHIP beneficiaries and Medicaid beneficiaries under one or more risk contracts with the state.  There may be separate risk contracts for CHIP and for Medicaid, or there may be one risk contract that combines CHIP and Medicaid.

CHIP MCO Performance

How are the 154 MCOs used by separate CHIP programs performing for the CHIP children they enroll?  Are these children receiving the services they need?  What is the quality of those services?  Are there racial disparities in the accessibility or quality of the services CHIP MCOs have contracted to provide?  The MCOs know the answers to these questions, as do the state agencies with which they contract and to which they report.  Unfortunately, in many separate CHIP states, other stakeholders, as well as the public at large, face significant challenges in accessing performance information specific to individual MCOs.  This makes it unnecessarily difficult to hold individual MCOs—and the state agency that has selected them as contractors—accountable in cases where performance is substandard.

The obvious starting point in assessing an MCO’s performance would be to know how many CHIP children are enrolled in the MCO and what their demographic profile is. For over half of the MCOs, we were unable to determine from the state program website the number of CHIP children enrolled, much less break those enrollments down by age (e.g., 0 to 6), or by race and ethnicity.  Both the state CHIP agency and the MCOs have information on the number of CHIP enrollees stratified by age because it determines the amount of the state’s per member per month (capitation) payments to an MCO that are subject to the enhanced CHIP federal matching rate.  The public does not.

As shown in Table 1, federal transparency requirements for Medicaid managed care, while limited, are stronger than those that apply to CHIP managed care. Only one federal transparency requirement applies to both Medicaid and CHIP: the conduct of a performance review by an External Quality Review Organization (EQRO) with which the state  agency contracts, and the posting of the results of that review in an Annual Technical Report (ATR).  The ATR must include, for each MCO, information on the performance measures (e.g., well-child visits in the first 30 months of life) selected by the CHIP agency and validated by the EQRO. ^[21]

CMS collects ATRs from each state for both Medicaid and CHIP MCOs, analyzes the contents of these reports relating to performance measures, and abstracts the data into summary tables that it posts on Medicaid.gov. ^[22]  These tables do not break out results for the individual MCOs in which CHIP children are enrolled. The tables do, however, indicate that the performance measures reported in the ATRs vary from state to state, as do the points of comparison (e.g., the statewide median rate, the national median rate, etc.)

Appendix 3 provides links to the most recent ATRs available for the 27 separate CHIP program states that use MCOs to deliver services.  One state—Colorado—posts an ATR for its Medicaid MCOs and separate one for its CHIP MCOs.  The CHIP-specific ATR presents, among other data, measures of the performance of each of the CHIP MCOs for their CHIP enrollees. Five states—Mississippi, Nevada, Pennsylvania, Texas, and Utah—post ATRs that combine the results of external quality reviews for MCOs serving both Medicaid and CHIP enrollees but break out the performance measures specific to CHIP children, enabling comparison with the measures for Medicaid children within the same MCO and among all participating MCOs. The remaining 21 states post ATRs that present performance measures for both Medicaid and CHIP enrollees in combination, so it is not possible for the public to determine an MCO’s performance for CHIP children.

Another potential source of information about CHIP MCO performance is the Annual CHIP Report ^[23] that each state submits to CMS. The CMS template for the report asks whether states use a managed care delivery system, how much the state spent on managed care benefits for the reporting year, how many children were eligible for managed care that year, and whether the MCOs have safeguards in place to prevent fraud and abuse.  However, there is no requirement that states with separate CHIP programs using MCOs identify those MCOs or provide enrollment or performance information about them. Only one of the 27 states with separate CHIP programs that uses MCOs—New Jersey ^[24]—voluntarily provided some MCO-specific performance information in its report for FY 2021 (the most recent year for which these reports are posted).  Pennsylvania’s report ^[25] indicates that data comparing MCO performance for Medicaid and CHIP is available on its website, but does not provide a link.

This is in sharp contrast to the Managed Care Program Annual Report (MCPAR) that all state Medicaid programs are required to file with CMS.  The MCPAR reporting template ^[26] developed by CMS calls for performance information on each MCO, including enrollment, medical loss ratio, quality measures, sanctions and corrective action plans, and appeals of denials of authorizations of service.  CMS has begun collecting these reports and will be posting them on its website. ^[27] CMS does not require states with separate CHIP programs that use MCOs to submit this information, either in the CHIP Annual Report or otherwise. In this regard, CHIP managed care is even more opaque than Medicaid managed care, which is hardly a model of transparency. ^[28]

Conclusion

The CHIP program finances health care coverage for about 7 million of our nation’s low-income children.  About 3 million of those receive coverage through separate CHIP programs; the remaining 4 million or so receive coverage through their state’s Medicaid delivery system.  In 27 states, the separate CHIP program uses MCOs to deliver services to CHIP-eligible children.  The contracting arrangements vary; in some cases, states contract separately for their CHIP children, in others the CHIP and Medicaid contracts are combined into one. In either case, the contracted MCOs assemble networks of providers, determine when and how much those providers will be paid for services furnished to enrollees, and collect and report data on the accessibility and quality of those services.  In short, while MCOs are obligated to operate within the guidelines of their contracts with the state CHIP or Medicaid agency, they largely determine how well coverage works for their CHIP enrollees on a day-to-day basis.

How well are these MCOs performing for CHIP children in the 27 separate CHIP states?  The MCOs know, of course, as do the separate state CHIP programs. But in most of these 27 separate CHIP states, there is not enough transparency for other stakeholders or the public to know.  As a result, many basic questions about managed care in CHIP go unanswered.  How well do individual MCOs perform for their CHIP enrollees on national metrics for access and quality? How do CHIP kids enrolled in an MCO do in comparison with CHIP kids enrolled in a different MCO in the same state?  How do CHIP kids enrolled in MCOs do in comparison with Medicaid kids enrolled in those same MCOs?

The answers to these and other basic questions would inform other inquiries that could lead to improvements.  If, for example, accessibility and quality of care is measurably better for CHIP kids enrolled in an MCO than for Medicaid kids enrolled in the same MCO, what explains this disparity?  Is it the income differential between Medicaid and CHIP eligibility?  A more adequate provider network?  Lower prior authorization denial rates?  Higher per member per month payment amounts?  These questions just scratch the surface, but even they are out of reach without much greater transparency on the part of separate CHIP programs and CMS.

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Appendices

[1] “CHIP:  Serving America’s Children for 25 Years” (Georgetown University Center for Children and Families: July 15, 2022), available at https://ccf.georgetown.edu/2022/07/15/chip-serving-americas-children-for-25-years/

[2] J. Alker and A. Osorio, “Child Uninsured Rate Could Rise Sharply if States Don’t Proceed with Caution” (Georgetown University Center for Children and Families: February 1, 2023), available at: https://ccf.georgetown.edu/2023/02/01/child-uninsured-rate-could-rise-sharply-if-states-dont-take-care/#_ftn1

[3] J. Alker, “Child Uninsured Rate Declined During the Pandemic Thanks to Medicaid” (Georgetown University Center for Children and Families:  September 15, 2022), available at:  https://ccf.georgetown.edu/2022/09/15/child-uninsured-rate-declined-during-the-pandemic-thanks-to-medicaid/

[4] MACPAC, “MACStats: Medicaid and CHIP Data Book, Exhibit 6. Federal Medical Assistance Percentages and Enhanced FMAPs by State, FYs 2020-2023” (Medicaid and CHIP Payment and Access Commission: December 2022), available at: https://www.macpac.gov/wp-content/uploads/2022/08/EXHIBIT-6.-Federal-Medical-Assistance-Percentages-and-Enhanced-FMAPs-by-State-FYs-2020-2023-1.pdf

[5] MACPAC, ibid., “Exhibit 34. Federal CHIP Allotments, FYs 2020-2022 (millions),” available at:  https://www.macpac.gov/wp-content/uploads/2022/10/EXHIBIT-34.-Federal-CHIP-Allotments-FYs-2020–2022-millions.pdf

[6] CBO, “Baseline Projections: Children’s Health Insurance Program” (Congressional Budget Office: May 2022), available at: https://www.cbo.gov/system/files?file=2022-05/51296-2022-05-chip_0.pdf

[7] MACPAC, “Key CHIP design features” (Medicaid and CHIP Payment and Access Commission: 2023), available at: https://www.macpac.gov/subtopic/key-design-features/

[8] MACPAC, op. cit., “Exhibit 35: Medicaid and CHIP Income Eligibility Levels as a Percent of the FPL for Children and Pregnant Women by State, July 2022,” available at:  https://www.macpac.gov/wp-content/uploads/2022/12/EXHIBIT-35.-Medicaid-and-CHIP-Income-Eligibility-Levels-Children-and-Pregnant-Women.pdf

[9] North Carolina Department of Health and Human Services, “NC Health Choice is moving to Medicaid,” available at: https://medicaid.ncdhhs.gov/nc-health-choice-move-medicaid

[10] MACPAC, op. cit., “Exhibit 32:  Child Enrollment in CHIP and Medicaid by State, FY 2021 (thousands),” available at:  https://www.macpac.gov/wp-content/uploads/2022/12/EXHIBIT-32.-Child-Enrollment-in-CHIP-and-Medicaid-by-State-FY-2021-thousands.pdf

[11] Utah Department of Health, “Utah CHIP Molina Healthcare of Utah CHIP Contract Managed Care Entity (MCE) Effective:  July 1, 2022 (SFY 2023)” available at: https://medicaid.utah.gov/Documents/pdfs/managedcare/SFY23-Molina%20CHIP%20Contract.pdf

[12] Utah Department of Health, “Utah Medicaid Molina Healthcare of Utah Contract Accountable Care Organization (ACO) Effective July 1, 2022 (SFY 2023)” available at: https://medicaid.utah.gov/Documents/pdfs/managedcare/SFY23-Molina%20ACO%20Contract.pdf

[13] Virginia Department of Medical Assistance Services, “Medallion 4.0 Managed Care Services Agreement:  Contract to Provide Managed Care Services for the Medicaid and Family Access to Medical Insurance Security (FAMIS) Programs July 1, 2021-June 30, 2022)” available at: https://www.dmas.virginia.gov/media/3583/medallion-4-contract-sfy22-v1.pdf

[14] Kaiser Family Foundation (KFF), “Medicaid Managed Care Tracker,” available at: https://www.kff.org/statedata/collection/medicaid-managed-care-tracker/

[15] T. Brooks and K. Whitener, “At Risk:  Medicaid’s Child-Focused Benefit Structure Known as EPSDT” (Georgetown University Center for Children and Families: June 2017) available at: https://ccf.georgetown.edu/wp-content/uploads/2017/06/EPSDT-At-Risk-Final.pdf

[16] Centers for Medicare & Medicaid Services (CMS), “Medicaid and CHIP Managed Care Notice of Final Rulemaking (CMS-2390-F) Overview of CHIP Provisions,” available at:  https://www.medicaid.gov/sites/default/files/2019-12/overview-chip-provision.pdf

[17] K. Whitener and S. Somers, “Looking at the New Medicaid/CHIP Managed Care Regulations Through a Children’s Lens,” (Georgetown University Center for Children and Families and the National Health Law Program: June 2016), available at: https://ccf.georgetown.edu/wp-content/uploads/2016/06/Childrens-Lens-Final-1.pdf

[18] KFF, op. cit., “Medicaid MCO Enrollment by Plan and Parent firm, March 2022,” available at: https://www.kff.org/medicaid/state-indicator/medicaid-mco-enrollment-by-plan-and-parent-firm-march-2021/?currentTimeframe=0&sortModel=%7B%22colId%22:%22State%22,%22sort%22:%22asc%22%7D

[19] E. Hinton and J. Raphael, “10 Things to Know About Medicaid Managed Care” (Kaiser Family Foundation:  March 1, 2023), available at: https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-managed-care/

[20] “Unwinding Medicaid Continuous Coverage: Resources to help keep eligible children and adults enrolled in Medicaid when pandemic-era continuous coverage provision expires,” (Georgetown University Center for Children and Families), available at: https://ccf.georgetown.edu/subtopic/unwinding-phe/

[21] 42 CFR 438.364(c), available at:  https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-E/section-438.364

[22] CMS, “Quality of Care External Quality Review:  EQR Annual Reporting,” available at:  https://www.medicaid.gov/medicaid/quality-of-care/medicaid-managed-care/quality-of-care-external-quality-review/index.html

[23] CMS, “Reports & Evaluations:  CHIP Annual Reports” available at: https://www.medicaid.gov/chip/reports-evaluations/index.html

[24] New Jersey FamilyCare, “New Jersey CARTS FY2021 Report” available at: https://www.medicaid.gov/CHIP/downloads/nj-2021chipannualreport.pdf

[25] Pennsylvania Department of Human Services, “Pennsylvania CARTS FY2021 Report,” available at:  https://www.medicaid.gov/CHIP/downloads/pa-2021chipannualreport.pdf

[26] CMS, “Medicaid and CHIP Managed Care Reporting: Annual Managed Care Program Report,” available at: https://www.medicaid.gov/medicaid/managed-care/guidance/medicaid-and-chip-managed-care-reporting/index.html#AMCPR

[27] D. Tsai, “Medicaid and CHIP Managed Care Monitoring and Oversight Tools,” CMCS Informational Bulletin (July 6, 2022), available at: https://www.medicaid.gov/federal-policy-guidance/downloads/cib07062022.pdf

[28] A. Corcoran et al., “Transparency in Medicaid Managed Care:  Findings from a 13-State Scan” (Georgetown University Center for Children and Families:  September 2021), available at:  https://ccf.georgetown.edu/wp-content/uploads/2021/09/MCO-13-state-scan-v3.pdf