Managed Care
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A Closer Look at the Network Adequacy Provisions of CMS’s Proposed Medicaid Managed Care Rule
Editor’s Note: Since this post was published, CCF submitted formal comments on the Managed Care proposed rule. Last week my colleague Kelly Whitener promised readers of the Say Ahhh! Blog a series of blogs on the proposed rules that CMS has published to improve access to care in Medicaid and CHIP. Promises made, promises kept. …
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New Brief: An Introduction to Managed Care in CHIP
Some three million kids in states with separate CHIP programs are enrolled in Managed Care Organizations (MCOs). Who are those MCOs, and how are they performing for those children? Unlike Medicaid, there’s no publicly available national database that answers those questions. Our new brief attempts to fill that gap. We utilized a variety of methods,…
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An Introduction to Managed Care in CHIP
DOWNLOAD THIS REPORT 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]…
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How Did We Get Here? An Early Legislative History of Medicaid Managed Care
Here is where we are today. Managed care—more precisely, comprehensive risk-based managed care—is the dominant delivery system in Medicaid. States can require beneficiaries to enroll in Medicaid managed care organizations (MCOs) in order to receive the health care services to which they are entitled, and 40 states now do so. MCOs can limit the network…
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Medicaid Managed Care: The President’s FY 2024 Budget
President Biden’s FY 2024 Budget includes a number of provisions relating to Medicaid and the Children’s Health Insurance Program (CHIP). Two of these would improve Medicaid managed care. One involves recovery of overpayments to managed care organizations (MCOs); the other, a new tool for enforcing MCO compliance with federal rules. Judging from the lack of…
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Medicaid Managed Care Financial Results for 2022: Another Big Year for the Big Five
The 2022 earnings reports for the “Big Five”—CVS Health (Aetna), Centene, Elevance Health (formerly Anthem), Molina, and United Health Group—are now in. As expected, combined Medicaid enrollment for the “Big Five” increased during 2022 by 3.3 million to 43.2 million, an increase of 8.2 percent (Table 1). (If children are enrolled in “Big Five” MCOs…
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Medicaid Managed Care in 2022: The Year that Was
2022 was another year of growth in Medicaid managed care. Growth in enrollment. Growth in spending. There was even a modest—but most welcome—growth in transparency about the performance of Medicaid managed care organizations (MCOs) from 2021. Here are some of the top-line developments at the national and state level. The MCO Industry As of March…
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Medicaid Managed Care: Quality Performance, Sanctions, and Transparency in California
Three years ago, the California Health Care Foundation published a ground-breaking report on Medicaid managed care in the state. Researchers from the University of California at San Francisco presented and analyzed data on the quality of care furnished by each Medicaid managed care organization (MCO) over the 10-year period 2009 – 2018. The researchers found that, over…
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Transparency in Medicaid Managed Care: The Power of the California Procurement Database
The Illinois Answers Project has just published a must-read piece of investigative reporting: “Insurance Giant Failed Foster Kids with Inadequate Care.” It raises a number of disturbing questions about the way children in foster care are being treated in the state’s Medicaid managed care program. About the performance of a Centene subsidiary that has contracted…
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Medicaid Managed Care: The Big Five in PHE Q11 (Q3 2022)
September 30 marked the end of the 3rd quarter of this calendar year. It also marked the end of the 11th quarter of the Public Health Emergency (PHE). The two are not unrelated. During the PHE, states receive an additional 6.2 percentage points on their regular federal matching rate if they agree not to terminate…
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California’s Medicaid Managed Care Procurement: A Transparency Event
On August 25, California’s Medicaid agency announced its selections of managed care organizations (MCOs) to serve some 6.4 million beneficiaries in 21 counties beginning in 2024. The selections, which resulted from the procurement that the agency launched with a Request for Proposal (RFP) in February—a potential game-changer—did not meet with universal applause. Losing bidders have…
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Medicaid Managed Care: OIG, MLRs, and the Future of Oversight
Last month, the Office of Inspector General (OIG) issued a report that speaks volumes about the oversight of Medicaid managed care organizations (MCOs). As the OIG delicately puts it, CMS has “opportunities” to “strengthen States’ oversight.” An alternative framing would be that CMS and many states have not met minimum standards of stewardship for Medicaid…
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Medicaid Managed Care Research: 2022 in Review
As frequent (or even infrequent) readers of Say Ahhh! have heard us say, the world of Medicaid managed care is complex. But because over 70 percent of all Medicaid beneficiaries (and over 80 percent of child beneficiaries) are enrolled in a Managed Care Organization (MCO), those of us who are invested in keeping track of…
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Medicaid Managed Care Meets the False Claims Act (Again)
Last week the Department of Justice announced that a California managed care organization (MCO) and three providers had agreed to pay a total of $70.7 million to settle allegations that they submitted false claims to the state’s Medicaid program. Most of the payments ($68.25 million) will go to the federal government, the remaining $2.45 million…
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Medicaid Managed Care: The Big Five in PHE Q10 (Q2 2022)
June 30 marked the end of calendar quarter 10 of the COVID-19 Public Health Emergency (PHE), or PHE Q10. For the five national companies with the largest Medicaid managed care businesses, the past two- and one-half years have been a period of particularly robust growth. Since PHE Q1, which ended on March 31, 2020, enrollment…
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Bipartisan Safer Communities Act Provision Directs CMS to Review State EPSDT Implementation, including in Managed Care
Last month my colleague Anne Dwyer summarized the now-enacted Bipartisan Safer Communities Act and its provisions with potential to boost access to mental health services for children and families. One we will be watching closely: a review of state Medicaid EPSDT requirements, services, and practices. Long time Say Ahhh! Readers know that Medicaid’s Early Periodic…
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Transparency in Medicaid Managed Care: Are the Times A-Changin’?
If the phrase “transparency in Medicaid managed care” sounds like an oxymoron, that’s because in many states it is. Finding information on the performance of individual Medicaid managed care organizations (MCOs) for children and families and other Medicaid beneficiaries on state Medicaid agency websites can be challenging. This is more than unfortunate because in the…
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Vermont’s Section 1115 Demonstration: Medicaid Managed Care Meets Single Payer
Vermont is one of ten states that don’t use risk-based Medicaid managed care. It’s not that Vermont isn’t interested in risk-based managed care. The state is very interested—so long as it is the managed care organization (MCO). The state made its case to CMS in its application to extend its section 1115 demonstration beyond June…
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An Advocate’s Guide to Medicaid Managed Care Procurement
2022 is a big year for Medicaid managed care procurements. Procurements are already underway in California, Iowa, and Nebraska with awards scheduled to be announced in August. New Mexico is scheduled to launch its procurement in September, and three more states — Florida, Georgia, and Texas — are expected to issue Requests for Proposals (RFPs)…
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A Guide for Health Care Advocates: Medicaid Managed Care Procurement
Overview Most Medicaid beneficiaries in most states are enrolled in managed care organizations (MCOs). (See text box, “What’s a Medicaid MCO?”) State Medicaid agencies contract with MCOs to assemble networks of health care providers to furnish services to program beneficiaries and protect them from medical debt. Simply put, if an MCO does not do its job,…
