Managed Care
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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…
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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…
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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…
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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…
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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:…
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Medicaid Managed Care Appeals and Grievances: GAO Takes a Look
Last week, GAO issued a performance audit of data on Medicaid MCO appeals and grievances. The database GAO examined was the first year of Managed Care Program Annual Reports (MCPARs) submitted by state Medicaid agencies to CMS. MCPARs are one of three reports on which CMS relies to conduct oversight of state managed care programs…
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Medicaid Managed Care: Congress Falls Short on Medical Loss Ratios
On March 9, the President signed into law the Consolidated Appropriations Act, 2024 (P.L. 118-122). Buried in the 428-page text is a 3-line provision delightfully, if somewhat obscurely, titled “Promoting Value in Medicaid Managed Care.” This is a classic in the genre of offsets, flying well under the radar to carry out its mission of…
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Medicaid Managed Care Financial Transparency: Which States Are High Performers?
As Say Ahhh! readers know, CCF researchers have scanned state Medicaid agency websites for information about the performance of individual managed care organizations (MCOs) for children, for children and youth in foster care, and, most recently, for pregnant and post-partum women. In most of the states we looked, it wasn’t possible to identify which MCOs…
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Medicaid Managed Care: Results of the PHE Unwinding for the Big Five in Q4 2023
Q4 2023 was also the third quarter of the PHE “unwinding”—the redetermination of eligibility for all 86.7 million Medicaid enrollees following the expiration of the Public Health Emergency continuous coverage provision in March 2023. These redeterminations have resulted in the disenrollment of over 16 million Medicaid enrollees as of January 2024, which translates into a…
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Minnesota Medicaid Revisits the Question: Managed Care or Fee-for-Service?
In the beginning, there was fee-for-service (FFS). In this case, the beginning was 1965, when Medicaid (and Medicare) were enacted. FFS was the way that these public programs, as well as almost all private insurers, purchased health care. Fast forward to today. Propelled by an interest in budget predictability and federal policy changes giving them…
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It’s Unanimous: CMS Needs to Bring More Transparency to Medicaid Managed Care
Last week, MACPAC Commissioners voted to recommend that the Centers for Medicare & Medicaid Services post all state Managed Care Program Annual Reports (MCPARs) to the CMS website. The vote was unanimous: 17-0. The recommendation will be included in MACPAC’s March 2024 Report to Congress. At first glance, this may seem unremarkable, but on further…
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Transparency in Medicaid Managed Care: The Wait Goes On
Last month, the Centers for Medicaid & CHIP Services (CMCS) issued a Center Informational Bulletin, “Medicaid and CHIP Managed Care Monitoring and Oversight Tools.” Among other items, this CIB discusses the Managed Care Program Annual Reports that state Medicaid agencies are required to submit to CMS. MCPARs are each state’s accounting of how each of…
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Medicaid Managed Care in 2023: The Year that Was
2023 marked an inflection point in the growth of Medicaid managed care. Enrollment in MCOs, which had climbed continuously in both 2021 and 2022 due largely to the continuous coverage policy in place during the Public Health Emergency, plateaued and then headed downward, due largely to the PHE unwinding. Much uncertainty remains as to how…
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Medicaid Managed Care: Results of the PHE Unwinding for the Big Five in Q3 2023
The “Big Five” Medicaid managed care companies—Centene, CVS Health (Aetna), Elevance Health (formerly Anthem), Molina Healthcare, and UnitedHealth Group—have reported their Medicaid enrollment for the quarter ending September 30. The downward trend that began in Q2 continued for all of the companies except Molina, which experienced a small net increase (+16,000). Centene reported the largest…
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Webinar: Medicaid Managed Care Organizations and Maternal Health
View Webinar Transcript Download the Presentation Slides
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Medicaid Managed Care: Transparency of Performance on Maternal Health
Our nation is in the midst of an ongoing maternal health crisis, one that particularly affects Black women. The causes are complex, the need to address them is urgent, and there is no single solution. One of many potential solutions that has not received enough attention is Medicaid managed care. Medicaid, the nation’s largest health…
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Medicaid Managed Care, Maternal Mortality Review Committees, and Maternal Health: A 12-State Scan
Download the Full Report Introduction The United States is in the midst of an ongoing maternal mortality crisis and Medicaid, the health insurer for low-income Americans, has an important role to play in addressing it. Medicaid is the nation’s single largest maternity care insurer, paying for more than 40% of all births on average across all states,…
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How Did We Get Here? A Recent Legislative History of Medicaid Managed Care
Just over 25 years ago, Congress enacted a major change in federal policy on Medicaid managed care. It eliminated the 75/25 rule—the requirement that no more than 75 percent of the enrollees in a Medicaid managed care organization (MCO) could be Medicaid or Medicare beneficiaries. The logic of the rule was that if an MCO…
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Medicaid Managed Care: Early Results of the PHE Unwinding for the Big Five in Q2 2023
The Medicaid enrollment results for the “Big Five” during the quarter ending June 30 are now in. The Big Five have the largest share of the Medicaid managed care market: Centene, CVSHealth (Aetna), Elevance Health (formerly Anthem), Molina Healthcare, and UnitedHealth Group. They, along with two large nonprofit companies, were the focus of a recent…
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Medicaid Managed Care: Denials of Prior Authorization for Services
Kudos to the OIG! That would be the Office of the Inspector General of the Department of Health and Human Services. Although OIG is better known for its fraud-fighting persona, it also has a broader mission of making government programs work better. And with last month’s report, “High Rates of Prior Authorization Denials by Some…
