Managed Care
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Take the Child Health Dashboard Tour
Since we debuted the Dashboard Library, we’ve been keeping our eyes on state Medicaid agency websites and are pleased to announce that we’ve discovered quite a few more. The dashboards we’ve added to the list vary widely in content and presentation style, ranging from slides to interactive workbooks. Unfortunately, none of the dashboards that we…
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Show Me the Data: A Medicaid Dashboard for Missouri
We are pleased to announce the most recent addition to our library of Medicaid dashboards: Missouri. One of the most important functions of easily accessible and digestible data (like a dashboard) is the increased transparency that it offers both Medicaid beneficiaries and advocates. This is especially significant when it comes to holding Managed Care Organizations…
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Standards for Provider Network Adequacy in Medicaid and the Marketplaces
The Centers for Medicare & Medicaid Services (CMS) has issued final rules for provider network adequacy in Qualified Health Plans (QHPs) offering coverage in the Marketplaces that the federal government operates through HealthCare.gov. Under these rules, which come with the snappy title, “Notice of Benefit and Payment Parameters” and the even snappier initialism (NBPP), CMS…
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Medicaid Managed Care: The Big Five in PHE Q9 (Q1 2022)
March 31 marked the end of the ninth quarter of the COVID-19 Public Health Emergency (PHE). First declared by the Secretary of HHS on January 31, 2020, the PHE has subsequently been extended nine times, through July 15. As long as the PHE is in place, states qualify for an additional 6.2 percentage points on…
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New Florida Law Requires Stratified Performance Measure Data for Medicaid Managed Care
By Anne Swerlick, Senior Policy Analyst, Florida Policy Institute Experts agree that to reduce health disparities, you first need to know where they exist. The collection of health plan performance measure data, such as timely prenatal care and well-child check-ups, broken down by demographic factors like race and ethnicity is essential for developing targeted health…
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Medicaid Managed Care Compliance Tools: Another ‘Pay-For’
Discussions have begun on the possibility of enacting a scaled-down version of the Build Back Better legislation. Any agreement that includes new federal spending will also require pay-fors (a/k/a offsets) either in the form of spending reductions or tax increases, or both. In Medicaid, responsible pay-fors—i.e., policy changes that the Congressional Budget Office will score…
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Medicaid Managed Care: SDOH, MCO, and MLR
There is no shortage of acronyms or initialisms in government agencies and programs and Medicaid is no exception. The Medicaid and CHIP Payment and Access Commission or MACPAC (one of our favorite acronyms) devotes an entire glossary to them. The most prominent initialism in Medicaid policy discussions these days is SDOH: social determinants of health,…
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Medicaid Managed Care: What Can the Annual MLR Report Tell Us?
Over 32.8 million children are covered by Medicaid, and the large majority are enrolled by their state Medicaid agencies in managed care organizations (MCOs). In exchange for monthly capitation payments, the MCOs contract with the state Medicaid agency to furnish covered services through networks of providers. These arrangements, in 40 states and the District of…
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California’s Medicaid Managed Care Procurement: A Leap Forward
Last week, California’s Medicaid agency issued a Request for Proposals (RFP) to provide managed health care services to program beneficiaries. This is not just another Medicaid RFP. California is far and away the nation’s largest Medicaid managed care market. As of September 2021 the state Medicaid agency contracted with 24 managed care organizations (MCOs) to…
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Medicaid Managed Care Financial Results for 2021: A Big Year for the Big Five
The Q4 2021 earnings reports are in, and the five largest companies in the Medicaid managed care market—CVS Health, Anthem, Centene, Molina, and UnitedHealth Group—did very well, thank you very much. CVS Health made $17.3 billion last year; Anthem, $7.5 billion; Centene, $1.8 billion; Molina, $1.0 billion; and UnitedHealth Group $24.0 billion. Not all of…
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California’s Medicaid Managed Care Waiver: New Potential for Access and Transparency
One of the most significant Medicaid managed care developments in 2021 happened on December 29, when CMS approved federal funding and waivers for California’s reform initiative, Advancing Innovation in Medi-Cal (CalAIM). The approval involved two sets of waivers, one operating under section 1115 of the Social Security Act, the other under section 1915(b)(4). For good…
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Medicaid Managed Care in 2021: The Year that Was
The Medicaid managed care ecosystem is huge and complex. (If you need a primer, the health policy podcast Tradeoffs has a short and entertaining one). As of March of this year, forty states and the District of Columbia were contracting with over 280 different managed care organizations (MCOs). The federal government and states combined spend…
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CMS Tools Suggest Key Roles for Managed Care Plans in Helping Enrollees Retain Coverage
While we were all unwinding from our Thanksgiving celebrations, CMS was busy putting out two new tools to assist state Medicaid eligibility and enrollment operations. The first is focused on preparing for the return to normal operations after the COVID-related continuous enrollment requirement is lifted while the second is a refresher on best practices and…
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Medicaid Managed Care: Results for the “Big Five” in Q3
The Q3 results for the “Big Five” are in. Loyal readers of the Say Ahhh! Blog will recognize them as the publicly-traded companies with the largest shares of the Medicaid managed care market: Aetna/CVS, Anthem, Centene, Molina, and UnitedHealth Group. Their Medicaid footprints for the quarter ending September 30, summarized below, reflect a continuation of…
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Medicaid Managed Care for Foster Care Children and Youth: A Natural Experiment with Little Transparency
There’s a natural experiment underway involving a highly vulnerable population: children and youth in foster care. The experiment is a test of whether MCO/FCs outperform other ways of furnishing needed health care to this population. No, MCO/FCs are not a soccer team in the English Premier League. The initialism stands for Medicaid managed care organizations…
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Transparency in Medicaid Managed Care for Children and Youth in Foster Care
Executive Summary Children and youth in foster care are among the most vulnerable populations covered by Medicaid. When children and youth enter the child welfare system, they are often not up to date on routine care, and many have unrecognized and untreated medical needs. In addition, the experience of removal from a child’s biological family,…
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Transparency in Medicaid Managed Care: Findings from a 13- State Scan
Report Download the report. Appendix Online appendix tables. Blog Read the blog.
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Scan of 13 States’ Medicaid Managed Care Organizations Uncovers Need for More Transparency
At the beginning of July, North Carolina became the fortieth state to make the switch from fee-for-service (FFS) to Medicaid managed care. With the new system barely off the ground, a recent news report highlighted the stories of providers facing denied prior authorizations, delayed payments, and excessive paperwork. One provider stressed that she hadn’t received…
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Hidden in Plain Sight: A Medicaid Managed Care Pay-For
The Medicaid managed care market continues to grow. A review of the Q2 financial reports of the “Big Five” national managed care companies by my colleague Allie Corcoran finds that, over the first six months of 2021, Medicaid enrollment increased, on average, by 14.9 percent year-to-year. This increase is being driven in part by the…
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Medicaid Managed Care: 2021 Results for the “Big Five” at Q2
You’ve heard it here before: for children and families in forty states and the District of Columbia, managed care organization (MCO) performance determines if they get the care to which they are entitled. And, for many MCOs, this performance is influenced by the rules, regulations, and corporate culture of their national parent firm. As of…
