Managed Care
In 41 states and DC, most children covered by Medicaid are enrolled in managed care organizations (MCOs). MCOs are responsible for organizing and maintaining networks of providers that are adequate to furnish needed services to enrollees.
For-Profit MCOs in Minnesota Medicaid: No More Welcome Mat
Like 41 other states, Minnesota requires most of those enrolled in its Medicaid program to receive services through managed care organizations (MCOs). Unlike most other states, however, Minnesota is in the midst of a policy conversation about whether to move away from managed care toward fee-for-service. In May 2023, the state legislature directed the Medicaid […]
Strengthened Tool to Address Health-Related Social Needs: The New Medicaid Managed Care Regulation’s “In Lieu of Services” Explained
Medicaid managed care plans have long covered “In Lieu of Services” (ILOS), which are services that are provided in substitution of traditional Medicaid state plan services. For example, a managed care plan might provide a community-based depression screening in lieu of an office visit screening. In 2016, CMS first defined the contours of ILOS in […]
Medicaid Managed Care: Results of the PHE Unwinding for the Big Five in Q1 2024
It’s now been four corporate reporting quarters since the start of the PHE unwinding on April 1, 2023. During that time, net national Medicaid enrollment—the combination of disenrollments from redeterminations, re-enrollment by some of those terminated, and new enrollments—has fallen by 13.1 million, including 5.0 million children. Of the disenrollments, 70 percent have been for […]
A Closer Look at Transparency in the Medicaid Managed Care Rule
The Medicaid Managed Care Rule published on May 10 has lots of moving parts. As my colleague Leo Cuello explains, the rule includes provisions to increase the transparency of state directed payments (SDPs). The rule also contains a number of other transparency requirements that are the focus of this blog, most of which are identical to those […]
Medicaid Managed Care Excess Profits and Maternal and Early Childhood Health in Nebraska
Like most states, Nebraska contracts with managed care organizations (MCOs) to deliver covered services to people enrolled in Medicaid. Unlike most states, Nebraska operates a Medicaid Managed Care Excess Profit Fund. Established in 2020, the Excess Profit Fund holds profits that MCOs are required to return to the state, remittances from MCOs in the event […]
Final Medicaid Managed Care Rule Explained
CMS recently finalized two key regulations: “Ensuring Access to Medicaid Services” (Access Rule) and “Medicaid, CHIP Managed Care Access, Finance, and Quality” (Managed Care Rule), aimed at improving access to care in Medicaid across delivery systems (fee-for-service and managed care) and authorities (state plan and waiver services). The Managed Care Rule addresses five primary areas: […]