Medicaid Managed Care: Resources for Providers

Medicaid plays a significant role in the US health care system, currently providing coverage to more than one in five Americans.   The Medicaid program continues to transform, responding to changes in the economy, the broader health system, state budgets and policy priorities, as well as to requirements and opportunities in the Affordable Care Act (ACA).

In particular, the shift to Medicaid managed care has become increasingly prevalent in recent years, an evolution with enormous impacts for community-based providers like LSA members, as well as those you serve.  According to the Kaiser Family Foundation, more than half of all Medicaid beneficiaries nationally receive most or all of their care from risk-based managed care organizations (MCOs) that contract with state Medicaid programs to deliver comprehensive Medicaid services to enrollees. Although not all state Medicaid programs contract with MCOs, a large and growing majority do, and states are also rapidly expanding their use of MCOs to reach larger geographic areas, serve more medically complex beneficiaries, deliver long-term services and supports, and, in states that have expanded Medicaid under the ACA, to serve millions of newly eligible low-income adults. 

This page is designed to help LSA members navigate this complex and rapidly changing landscape, by housing the latest resources in three key categories: (1) Technical Assistance,  (2) State-Specific Information, and (3) State Trends & Changes.  We will be updating this information frequently, and invite you to share your feedback, questions, and resources with LSA's Director of Public Policy and Advocacy, Lindsey Copeland.

Technical Assistance 

ACL’s Business Acumen for Community-Based Organizations

Over the past few years, the Administration for Community Living (ACL) has been working to position the aging and disability network as logical partners for managed care companies looking to provide home and community-based long-term services and supports.  From May 2013 to December 2014, ACL provided technical assistance (TA) to a pilot learning collaborative with nine networks of community-based organizations (CBOs) to assist them in marketing, contracting, and pricing the services they provide to older adults and individuals with disabilities.  Scroll down on this page for the resources that have resulted from the collaborative, including  profiles of the selected pilot networks, learnings, and webinars.

Building on the success of the seven-network pilot, ACL recently announced an expansion of the project to 11 additional groups.  As in the pilot, the participating CBOs will receive TA in areas such as marketing, contracting, and pricing services, but no funding from ACL.  In addition to training, the 11 networks will share experiences, lessons learned, innovative ideas, and best practices for providing integrated care in a variety of community settings. At the conclusion of the initiative, the collaborative will share its models and other tools with communities and local agencies facing similar challenges.  More information is at the top of this page.

n4a’s Aging and Disability Partnership for Managed Long-Term Services and Supports

One of the National Association of Area Agencies on Aging’s (n4a) key initiatives is around Medicaid Managed Long-Term Services and Supports (MLTSS) and integrated care.  A main vehicle for this is the Aging and Disability Partnership, which was established by n4a as part of the aforementioned ACL business acumen project. It is a partnership between n4a and the National Disability Rights Network (NDRN), the Disability Rights and Education Defense Fund (DREDF), Justice in Aging, and Health Management Associates (HMA). The Resources page has a variety of TA materials, including a toolkit, webinars, and a link to AGEcomm, n4’as e-learning website for providers.   

The SCAN Foundation’s Linkage Lab

The ACA and other policy actions have changed the landscape for delivering services to older adults and persons with disabilities. CBOs can play a central role in integrating long-term services and supports with the health care sector for these populations. The SCAN Foundation’s Linkage Lab is an organizational development program for leadership and management teams from selected California CBOs. Its goal is to prepare CBOs seeking to deliver care coordination services for effective partnership with health care entities (e.g., health plans, hospitals) through structured management education and on-site technical assistance.  Also check out their Pricing Guide for CBOs and Tools for CBOs to Value and Price Services.

State-Specific Information

2015 Medicaid Data Book

In December 2015, the Medicaid and CHIP Payment and Access Commission (MACPAC) released the first edition of MACStats, a comprehensive source for Medicaid and CHIP data. The information contained in the data book was previously included by MACPAC in its semiannual reports to Congress. This year's MACStats draws on 2014 data to provide a picture of Medicaid and CHIP trends in enrollment and spending, along with snapshots of coverage provisions, program administration, and beneficiary experiences with these programs.

Medicaid Reforms to Expand Coverage, Control Costs, and Improve Care - Results from a 50-state Medicaid budget survey for SFY 2015 and 2016

This report provides an in-depth examination of the changes taking place in Medicaid programs across the country. The findings are drawn from the 15th annual budget survey of Medicaid officials in all 50 states and the District of Columbia conducted by the Kaiser Commission on Medicaid and the Uninsured and Health Management Associates, in collaboration with the National Association of Medicaid Directors. This report highlights policy changes implemented in state Medicaid programs in FY 2015 and those planned for implementation in FY 2016, based on information provided by the nation’s state Medicaid directors. Policy changes and initiatives described in the report include those in eligibility and enrollment, managed care, delivery and payment system reforms, provider payment rates, and covered benefits (including prescription drug policies). The report also looks at the key issues and challenges now facing Medicaid programs.

CMS 2013 State Profiles

There are a variety of Medicaid managed care initiatives, and CMS’ most recent state profiles provide a detailed breakdown of Medicaid managed care program features for all states. The Managed Care State Profiles include basic information about a state’s Medicaid managed care program (major program type and name, whether it operated statewide or in certain regions, federal operating authority, start and end dates) in addition to which populations are enrolled (e.g., children and/or low-income adults), services covered, participating plans or organizations, and quality/performance incentives.

Medicaid Managed Care Enrollment and Program Characteristics, 2013

CMS contracted with Mathematica to produce this report.  It compiles the CMS 2013 state profiles mentioned above into one searchable document, and contains national tables summarizing data on Medicaid managed care, including: (1) enrollment at the state- and plan-level, as of July 1, 2013; and (2) program features, including type of enrollment (mandatory or voluntary) by population group enrolled, quality assurance requirements, and use of performance incentives by managed care program type.

Kaiser Family Foundation’s Medicaid Managed Care Market Tracker  

Currently, 39 states contract with a grand total of about 265 MCOs to provide comprehensive Medicaid services; over 90 percent of Medicaid beneficiaries live in these 39 states. The Kaiser Family Foundation has developed the Medicaid Managed Care Market Tracker, an interactive tool that analyzes data for 39 states that contract with MCOs, including state- and plan-specific information on enrollment and spending; MCO quality; MCO ownership by parent firms; and parent firm participation across insurance markets nationally. 

NASUAD Medicaid Integration Tracker

NASUAD’s State Medicaid Integration Tracker© is intended to provide a compilation of states’ efforts to implement integrated care delivery system models.  To do so, the Tracker focuses on the status of the following state actions: (1) Managed Long-Term Services and Supports (MLTSS); (2) State Demonstrations to Integrate Care for Dual Eligible Individuals and Other Medicare-Medicaid Coordination Initiatives; and (3) Other LTSS Reform Activities, including: the Balancing Incentive Program, Medicaid State Plan Amendments under §1915(i), Community First Choice Option under §1915(k), and Medicaid Health Homes. Released monthly, each edition includes new updates that occurred during the preceding month.  Prior versions are archived, and state-specific information is available as well.  The Tracker is available here.  

Care Coordination in MLTSS

The AARP Public Policy Institute contracted with Truven Health Analytics to conduct this major study on care coordination.  Though it has been a focal point of managed LTSS, little was previously known about care coordinators - who they are, what they do, who they help, and if they involve family caregivers. This research provides an inventory of state managed LTSS programs and answers these questions. In developing the report, Care Coordination in Managed Long-Term Services and Supports, the authors reviewed state contracts with health plans in the 18 states with Medicaid managed LTSS for older people and adults with physical disabilities. For added insight, they conducted two site visits, in Illinois and Ohio. At the time, both states were in the early stages of implementation, and the report offers a glimpse into the disruption that managed LTSS can have on traditional case management organizations, such as area agencies on aging.

State Trends & Changes

The Expanded State of Medicaid in the United States

Coupled with an historic increase in Medicaid enrollment through expansion, the continuing arc towards private managed care health plans has broad implications for the American population, providers, health plans, and government finances. This January 2016 PricewaterhouseCoopers paper, a follow-up to 2013’s The State of Medicaid in the United States, seeks to update the comprehensive view of Medicaid composition, assess the impacts of Medicaid expansion – and the opportunity should states choose to expand Medicaid eligibility, and proffer some key takeaways for health plans, policy makers, and others, leveraging a comprehensive, proprietary collection of state Medicaid data. 

Key Themes in Capitated MLTSS Waivers

This issue brief examines key themes in the 19 capitated Medicaid MLTSS waivers approved by CMS to date, including: (1) § 1115 demonstrations in 12 states (Arizona, California, Delaware, Hawaii, Kansas, New Jersey, Minnesota, New York, Rhode Island, Tennessee, Texas, and Vermont), and (2) § 1915(b)/(c) waivers in six states (Florida, Illinois, Michigan (two waivers), Minnesota, Ohio, and Wisconsin).  The brief notes that state interest in MLTSS is increasing, with over half (11 of 19) of these waivers approved in 2012, 2013, or 2014. By contrast, one state (Arizona) has a long-standing MLTSS waiver, first approved in 1989.  California, Delaware, Florida, Illinois, Kansas, Michigan, New Jersey, New Mexico, New York, Ohio, and Rhode Island have all transitioned since 2012.  The brief can be downloaded here. 

Comprehensive Capitation Rates 

This CMS-backed analysis includes information about programs that deliver LTSS to older persons, persons with physical disabilities, and/or persons with intellectual/developmental disabilities. Several of these programs include persons with mental health and substance abuse conditions.  According to the report, seven states with MLTSS programs have comprehensive capitation rates that include all major Medicaid service categories (Arizona, California, Florida, Massachusetts, Minnesota, New York, and Wisconsin). One (Minnesota) limits contractors’ risk on nursing facility stays to 180 days. The other nine states (Delaware, Hawaii, Michigan, New Mexico, North Carolina, Pennsylvania, Tennessee, Texas, and Washington) exclude one or more of the major Medicaid service categories from their capitation rates. For the purposes of this analysis, “major” service categories include: primary, acute, behavioral, prescription drugs, and LTSS.

Medicaid Reforms in 2015 and 2016 to Expand Coverage, Control Costs, and Improve Care

Also referenced under the previous section, this report summarizes the changes states made to their Medicaid programs in 2015, and what they are planning in 2016.  Below are some specific breakdowns that  may be of interest to LSA members:

States Expanding to Specific Populations (p. 21) - In both FY 2015 and in FY 2016, states continued to take actions to increase enrollment in managed care, although fewer states reported doing so than in last year’s survey – likely reflecting full or nearly full MCO saturation in a growing number of states. Of the 39 states (including DC) with MCOs, a total of 20 states indicated that they made specific policy changes in either FY 2015 (13 states) or FY 2016 (13 states) to increase the number of enrollees in MCOs, compared to 34 in last year’s survey; no states with MCOs took any action to restrict MCO enrollment.

  • The eligibility group most commonly added to MCOs was persons eligible for LTSS (New Jersey, New Mexico, New York, Texas, Virginia and Washington), followed by the newly eligible adult group in states adopting the ACA Medicaid expansion (Illinois, Indiana, Pennsylvania and West Virginia).
  • In addition, five states (Florida, Indiana, Iowa, Louisiana and Rhode Island) are terminating their Primary Care Case Management (PCCM) programs in either FY 2015 or FY 2016 and shifting those populations into risk-based managed care.
  • Four states (Florida, Illinois, Louisiana and New York) made enrollment mandatory for specific eligibility groups in FY 2015, and nine states (Louisiana, New Hampshire, New York, Rhode Island, Utah, Virginia and Washington) are doing so in FY 2016. 
  • Expansions of MCO geographic service areas were reported in five states in FY 2015 (Colorado, Illinois, New York, Texas, Wisconsin) and in four states for FY 2016 (Illinois, Iowa, Utah, Wisconsin)
  • In addition, California reported plans to enroll undocumented children into MCOs in FY 2015. This is predominantly a state-funded program and is therefore not counted as a Medicaid policy change in the report.

States Covering Behavioral Health (p.24) - States cover behavioral health services (mental health and substance abuse services) through a wide array of delivery arrangements. Sixteen (16) MCO states generally cover outpatient mental health services through their MCO contracts; a similar number cover inpatient mental health services (15 states) and substance abuse services (16 states) through their MCO contracts. Of the remaining states, a number contract with Prepaid Health Plans (PHPs) to provide carved-out specialty behavioral health services. 

Eight states reported planned changes for FY 2016.  Six states (Arizona, Iowa, Louisiana, New York, Washington and West Virginia) plan to carve inpatient and outpatient mental health services as well as substance abuse services into at least some of their MCO contracts. 

  • Arizona plans to carve-in these services for their dual-eligible beneficiaries under their acute care contracts; New York continues to phase in coverage of these services under managed care plans. 
  • Iowa and Louisiana plan to transition coverage from PHPs to their managed care contracts. 
  • Washington also reported plans to carve these services into managed care contracts regions that elect to be “Early Adopters” as part of their effort to establish common purchasing regions for managed behavioral health and physical health. (Those that do not will contract separately for physical and behavioral health.) 
  • In addition, Mississippi plans to carve inpatient mental health services into its managed care contracts as part of its larger effort to carve-in inpatient services generally. 
  • Maryland reported carving substance abuse services out of managed care contracts in FY 2015.

States Covering Institutional LTSS and HCBS (p. 25) - Only a small number of states reported that most LTSS is provided by MCOs – five states for institutional LTSS (Arizona, Hawaii, Kansas, New Mexico and Tennessee) and four states for HCBS (Arizona, Kansas, New Jersey and Tennessee). In some of these states, however, persons with intellectual and developmental disabilities (IDD) are excluded from enrollment or IDD waiver services are carved-out. In addition, 17 other MCO states reported providing some HCBS and institutional LTSS through MCOs, often based on specific population characteristics and/or geographic region (for example, under a Financial Alignment Demonstration for dual eligible beneficiaries). Ten states reported changes for FY 2015 or planned for FY 2016. 

In FY 2015, six states (California, Michigan, New Jersey, New York, South Carolina and Texas) implemented MCO arrangements for institutional LTSS and HCBS for at least some populations; many of these states noted this change was in reference to the launch of dual eligible demonstrations (Michigan, New York, South Carolina and Texas).

  • California implemented MCO contracts including both HCBS and institutional care services in some counties in FY 2015. 
  • New Jersey carved HCBS (services and beneficiaries) into managed care contracts as well as institutional services for new nursing facility entrants (those already in nursing facilities will remain in Fee-For-Service (FFS)). 
  • Texas also carved institutional LTSS into its non-dual managed LTSS program. 
  • Additionally, Idaho added institutional as well as HCBS to its Medicare-Medicaid Coordinated Plan (MMCP) in FY 2015.

In FY 2016, five states will implement new LTSS MCO arrangements. 

  • Rhode Island will implement its dual eligible demonstration
  • Iowa will include both HCBS and institutional LTSS into new MCO contracts
  • New Hampshire will add HCBS to its MCO contracts
  • New York and New Mexico will add additional LTSS (services and beneficiaries) to their MCO contracts (assisted living services in New York, waiver services for the medically frail in New Mexico)