This week’s In Focus is the second in a two-part look at the Centers for Medicare & Medicaid Services’ (CMS’s) recently proposed changes to the Medicaid program. Last week we covered CMS’s proposed changes to the federal Medicaid managed care regulations (CMS-2439-P). This week we review the Medicaid Access to Care proposed rule (CMS-2442-P).

As we discussed last week, the managed care and access to care rules include significant changes to core structural and financing aspects of the Medicaid program. Though state agencies, providers, health plans, consumer groups, and other stakeholders will want to understand the distinct requirements and expectations in each rule that apply to them, the proposed changes cannot be viewed in isolation.

The Access to Care rule addresses a range of challenges that shape the experience of Medicaid enrollees, regardless of whether they are in managed care programs or traditional fee-for-service (FFS). The proposed policy changes also are designed to create an updated federal framework for Medicaid’s home and community-based services (HCBS) programs. These proposals come at a pivotal time, as states are facing workforce shortages, particularly among HCBS direct care workers (DCWs).

The remainder of this In Focus delves into notable components of the proposed changes and includes analysis of the implications of these policies for stakeholders. CMS will benefit from stakeholder input; the deadline for submitting comments is July 3, 2023.

Table 1. Access to Care Regulations: Overview of Proposed Changes

Key Themes and Considerations

Ensuring Payment Adequacy for Key HCBS Services Experiencing Workforce Shortages. One of the most notable proposed changes that would directly impact DCWs is a requirement that at least 80 percent of Medicaid payments be spent on compensation. The proposed rule would apply to homemaker, home health aide, and personal care services, as they represent a large portion of HCBS services that DCWs provide. The proposal is based on feedback from states that have implemented similar provisions, which have ranged from 75 to 90 percent compensation requirements.

CMS specifically seeks stakeholder feedback on the percentage that should be adopted. This policy provision also is important from an equity perspective, given that 90 percent of DCWs are women and 60 percent are members of racial or ethnic minority populations. However, increased or mandated DCW rates may make it difficult for HCBS providers to sustain their businesses as they manage the increased administrative pressures of electronic visit verification, the complexity of filing claims for managed long-term services and supports (MLTSS), and the additional work that HCBS quality measurement may create. Smaller HCBS providers, some of which may have deep cultural expertise, may struggle to sustain themselves and meet these requirements.

Table 2. Access to Care Regulations: Snapshot of Proposed Rate, Access, and Payment Changes

Payment Alignment. CMS is seeking to align access to care strategies and payment rate transparency more closely across the FFS and managed care delivery systems. The proposed rule includes several changes that CMS has developed achieve this goal. For example:

• CMS plans to require that states publish more detailed rate information in a consistent format. States, health plans, providers, and other interested stakeholders will want to consider the implications by delivery system. Additional transparency requirements could create a new opportunity to understand rates across payers and states and use this information in addressing access challenges for services.
• The proposed rule also would require extensive comparative analysis of Medicaid FFS rates and Medicare rates. CMS proposes to use Medicare non-facility payment rates as a benchmark to determine if states are meeting federal Medicaid access State analyses will be vital to CMS oversight as well as advocacy efforts within states to monitor and update FFS rates as needed.

Strengthening the Focus on Quality in State HCBS Programs. Over the last several decades, states and Medicaid stakeholders have made significant progress toward increasing participation in HCBS programs and community integration initiatives to counter Medicaid’s institutional bias. CMS is proposing more consistency in the expectations and reporting for HCBS quality measures to further the impact and create a consistent foundation for the recently mandated HCBS quality initiatives starting to take root.

In the short-term, the proposed changes will require states, and likely downstream providers and Medicaid agencies, to immediately change their quality reporting policies and systems. States and their stakeholders will want to map out processes for cyclical updates to HCBS quality measures, including cross-walking the future measures with existing ones, making systems changes, and updating dashboards. Targeted attention and focus will be needed to identify realistic HCBS performance targets that yield successful improvement strategies in the midst of a workforce crisis. Longer term, it will be necessary to map out when updates and reporting will be required to strengthen the rigor and accountability for state performance in the HCBS quality measure set, as well as reinforce the information available to make policy, clinical, and operational improvements to Medicaid programs.

HCBS Access Measurement. CMS is proposing new FFS HCBS payment and access transparency requirements to ensure compliance with Medicaid provider payment rules that require payments to be adequate to enlist at least the same number of providers that the overall geographic population can access. Because the targeted HCBS services do not have a comparable Medicare rate, CMS proposes implementation of a payment rate disclosure approach that would standardize data and monitoring across service delivery systems, with the goal of improving access. In addition to proposed payment transparency changes, CMS proposed new reporting on HCBS waiver waiting lists and timelines for the start of related services once authorized.

These new reporting requirements will provide stakeholders with more information to benchmark their state’s experience with other providers across the nation. This information could be influential to policymakers and legislators and help uncover some of the core contributors to our nation’s HCBS workforce shortage.

Improving Health Equity with Medicaid Beneficiary Input. CMS proposes overhauling the scope and membership of the state Medical Care Advisory Committee. The new Medicaid Advisory Committee (MAC) would continue to advise the state on health and medical matters and play an expanded advisory role on matters of policy development and effective administration of the program. CMS also plans to require that states establish a Beneficiary Advisory Group (BAG) composed of current or past Medicaid beneficiaries. A subset of BAG members would serve on the MAC to ensure their perspectives are integrated into the committee’s recommendations to states.

Under the new federal requirements, MAC representatives could have greater relative input and influence on policies and actions each state Medicaid agency advances. Medicaid stakeholders will want to ensure the MAC’s minimum federal requirements support effective structures and processes in states.

What’s Next

CMS plans to reframe Medicaid access as one of three parts of the continuum of care, along with enrollment and maintenance of coverage. The proposals in the Access to Care rule would have a meaningful impact on the volume and type of data available to evaluate the relationship between Medicaid payment rates and access across all delivery systems.

States, managed care organizations, providers, Medicaid enrollee advocacy organizations, and other interested stakeholders should analyze the proposals and consider submitting comments to CMS on the feasibility, potential impact, and, where applicable, alternatives to the proposed changes. They also can use this time to begin planning and determine which resources and tools they may need to prepare for implementation of changes across delivery systems in the Medicaid program.

HMA’s experts are taking a wholistic approach to reviewing the Access to Care and Managed Care proposed rules in tandem and identifying key points of intersection.

For more information on the access to care proposed rule, contact HMA’s team of experts, Susan McGeehan and Andrea Maresca.

This week, our In Focus section reviews CMS’s proposed changes to the federal Medicaid managed care access, finance, and quality regulation (CMS-2439-P). A future In Focus will take a closer look at the proposed changes to the federal Medicaid access to care regulation (CMS-2442-P), which also has significant implications for state Medicaid programs.

On April 28, 2023, the Centers for Medicare & Medicaid Services (CMS) unveiled two significant and related proposed rules addressing Medicaid managed care access, finance, and quality requirements. Together these proposed rules signal a new era of accountability and transparency in the Medicaid program. They also strengthen beneficiaries’ role in influencing the policies and administration of state Medicaid programs.

Table 1 identifies a few of the key themes and issues addressed in the Medicaid managed care proposed rule. The deadline for submitting comments to CMS is July 3, 2023.

Table 1. Medicaid Managed Care Proposed Rule: Snapshot of Proposed Changes

Key Themes and Considerations

Payment Ceilings May Accelerate Value-Based Payment Arrangements. Current federal regulations allow states to direct managed care organizations (MCOs) to pay providers according to specific rates or methods. States have used these directed payment arrangements to set minimum payment rates for certain types of providers or to require participation in value-based payment (VBP) initiatives.

In the proposed rule, CMS calls for establishing an upper limit for these payments. Specifically, the agency plans to limit the projected total payment rates to the average commercial rate (ACR) for inpatient and outpatient hospital services, nursing facility services, and qualified practitioner services at academic medical centers that states include in state-directed payment (SDP) arrangements. The ACR limit, in concert with the proposed SDP documentation and reporting, is among the most significant and complex proposed changes in the rule.

Considerations: The proposed changes represent a strong federal regulatory push to accelerate movement to VBP in Medicaid, which provides states with new levers to drive value in their Medicaid delivery systems. It also means that MCOs, providers, and other stakeholders will need to navigate and help inform the policies and contractual arrangements that will flow from the pending changes. For example, states may need to reflect on the following considerations:

• Whether the proposals will require them to reduce reimbursement
• Whether they will need to develop new value-based arrangements through SDPs and how these policies will be structured
• What outcomes they might need to prioritize
• How transparency in reporting provider-level payments could affect non-federal funding and SDP initiatives

Updated Approach to in Lieu of Services (ILOS) Facilitates Whole-Person Care. In January 2023, CMS issued a State Medicaid Director Letter (SMDL#23-001) advising states of the option to use the ILOS authority in Medicaid managed care programs to reduce healthcare inequities and address unmet health-related social needs (HRSNs), such as housing, food insecurity, and intimate partner violence. The proposed Medicaid managed care rule would expand upon and codify in regulation that guidance.

Considerations: Although the ILOS proposal adds reporting requirements and guardrails to address fiscal accountability, overall, the updated policy signals CMS’s willingness to support innovative state approaches to meet a continuum of beneficiary needs, including HRSNs that affect the social drivers of health. Notably, CMS advises that the substitution of an ILOS for a state plan service or setting should be cost-effective but does not need to be budget-neutral. States also can specify that an ILOS can be an immediate or longer-term substitute for a state plan service or setting.

States could pursue a variety of options under CMS’s revised ILOS framework. State Medicaid agencies and their partners can collaborate on ILOS strategies that will allow them to make further progress toward reducing healthcare inequities, as well as fulfill their quality strategy goals and objectives.

New Standards for Medical Loss Ratio Strengthen Link to Performance Improvement. Existing federal regulations require Medicaid managed care plans to report their medical loss ratio (MLR) to states annually, and, in turn, states must submit a summary of those reports to CMS. Many state MCO contracts require plans to comply with provider incentive and bonus policies; however, MCOs infrequently make incentive payments contingent on the provider meeting quantitative clinical or quality improvement standards.

Consistent with the healthcare sector’s transition toward value-based care, CMS proposes to strengthen the link between an MCOs incentive payment to a provider and the provider meeting defined quality improvement or performance metrics. Additionally, contractual language between MCOs and providers will need to more explicitly identify the dollar amounts tied to successful completion of these metrics. Only incentive payments based on quality improvement will be considered incurred claims when plans calculate their MLR; administrative costs cannot be included in quality improvement activity reporting.

Considerations. The proposed requirements are expected to add more transparency to negotiations between Medicaid MCOs and providers. MCOs will retain flexibility to determine the quality improvement or quantitative performance metrics, which carry more weight and accountability in CMS’s revised regulatory framework.

Network Adequacy Requirements Strengthen Link to Access and Rates. CMS also proposes policies that the agency believes will help strengthen Medicaid enrollees’ access to services. For example, the rule would require states to develop wait-time standards for adult and pediatric primary care and outpatient mental health, substance use disorder (SUD), and OB/GYN services, with CMS establishing federal minimum appointment wait times. States also will need to develop a quantitative network adequacy standard, beyond wait times, for certain providers.

Notably, CMS also plans to require states to submit an MCO-level analysis of MCO-to-provider payments. This analysis may provide more insights about the relationship between rates and access to certain types of providers and services. It may also improve alignment in access policies across delivery systems.

Considerations: States and MCOs should expect to need more sophisticated analysis of provider capacity at state and local market levels. This information will be critical in developing network adequacy standards and determining where additional provider support may be necessary. Expanded and new strategies may be needed to ensure compliance with the federal rules and resulting changes to state policies.

What’s Next

Many of CMS’s proposals track closely with many recent recommendations from federal commissions and oversight entities, including the Medicaid and CHIP Payment and Access Commission (MACPAC) and Government Accountability Office (GAO), which may indicate a greater likelihood that CMS will finalize those policies. If they are finalized largely as proposed, the rule will further the Biden Administration’s directional imprint on the Medicaid program.

Within the proposed rules described above, CMS identifies numerous areas where stakeholder input would be beneficial. States, MCOs, providers, and other interested stakeholders should analyze the proposals and consider submitting comments to CMS on the feasibility, potential impact, and, where applicable, alternatives to the proposed changes. Stakeholders also may use this time to begin planning for 2024 and determining what resources and tools they may need to prepare for implementation of the final regulations, as well as how their approach may vary based on state-specific factors.

For questions about the rule and how HMA’s team of experts can support your organization’s response, please contact Andrea Maresca, Joe Moser, and Patrick Tigue.

This week our In Focus section reviews the Florida Statewide Medicaid Managed Care Program (SMMC) Invitation to Negotiate (ITN), released on April 11, 2023, by the Florida Agency for Health Care Administration (AHCA). SMMC consists of three programs: Managed Medical Assistance (MMA), Long-term Care (LTC), and dental, covering 4.4 million individuals. This ITN is for contracts to provide MMA and LTC.

Under the SMMC program, all enrollees receive their services from a single plan providing managed medical assistance, long-term care, and specialty benefits. (Dental benefits are provided separately.)

AHCA will select plans that will achieve the agency’s goals, including providing healthy birth outcomes for mothers and their infants, improving childhood and adolescent mental health, maximizing home and community-based placement and services, and supporting the HOPE Florida program. HOPE Florida utilizes ‘Hope Navigators’ to help individuals achieve economic self-sufficiency, develop long term-goals, and map out a strategic plan by focusing on community collaboration between the private sector, faith-based community, nonprofits and government entities.

Additionally, with the new contracts, AHCA will implement the following changes:

• Specialty plans will no longer be awarded separately but must be awarded to a comprehensive or MMA plan.
• Enrolling voluntary recipients (such as individuals with intellectual or developmental disabilities) into the SMMC program and providing the opportunity for them to opt out
• AHCA may mandatorily enroll into the MMA program full benefit dual-eligibles who are also in a Medicare Dual Eligible Special Needs Plan (DSNP).

AHCA will invite 10 plans to negotiate for awards as shown below:

Timeline

Proposals are due August 15, 2023, with an anticipated award date of December 11. Contract will run from October 1, 2024, through December 31, 2030. Contracts may not be renewed, but AHCA may extend the term to cover any delays during the transition to a new plan.

Evaluation

Plans can receive a total maximum number of points of 5,950. AHCA will invite top-ranking plans to negotiations to ensure that AHCA can enter into contracts with the minimum required number of plans per region.

Current Market

As of December 2022, Florida served 4.3 million MMA and LTC enrollees, excluding an additional 97,000 Children’s Medical Services enrollees in the Children’s Medical Services Network plan. Centene had the highest market share based on enrollment, at over 40 percent.

Link to ITN

This week, our In Focus section reviews recent Medicaid enrollment trends in capitated, risk-based managed care in 32 states.^[1] Many state Medicaid agencies post monthly enrollment figures by health plan for their Medicaid managed care population to their websites. This data allows for the timeliest analysis of enrollment trends across states and managed care organizations. All 32 states highlighted in this review have released monthly Medicaid managed care enrollment data into the fourth quarter (Q4) of 2022. This report reflects the most recent data posted. HMA will continue tracking enrollment throughout the eligibility redetermination period. HMA has made the following observations related to the enrollment data shown on Table 1 (below):

• The 32 states in this report account for an estimated 71 million Medicaid managed care enrollees as of December 2022. Based on HMA estimates of MCO enrollment in states not covered in this report, we believe that nationwide Medicaid MCO enrollment was likely about 75 million in December 2022. As such, the enrollment data across these 32 states represents approximately 95 percent of all Medicaid MCO enrollment.
• Across the 32 states tracked in this report, Medicaid managed care enrollment is up 7.5 percent year-over-year as of December 2022.
• All states, besides Mississippi, saw increases in enrollment in December 2022, compared to the previous year, due to the gains from the COVID-19 pandemic. Mississippi Medicaid managed care enrollment fell because the state shifted members to FFS during the public health emergency.
• Twenty-three of the 32 states – Arizona, California, District of Columbia, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, Ohio, Oregon, Pennsylvania, Virginia, Washington, and West Virginia – expanded Medicaid under the Affordable Care Act and have seen increased Medicaid managed care enrollment since expansion.
• The 23 expansion states listed above have seen net Medicaid managed care enrollment increase by 3.5 million members, or 7.2 percent, in the past year, to 52.2 million members at the end of 2022.
• The nine states that have not yet expanded Medicaid as of December 2022 – Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, Tennessee, Texas, and Wisconsin – have seen Medicaid managed care enrollment increase 8.3 percent to 19 million members at the end of 2022.

Table 1 – Monthly MCO Enrollment by State – July 2022 through December 2022

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Arizona	2,069,048	2,079,360	2,095,101	2,106,800	2,116,444	2,127,666
+/- m/m	8,527	10,312	15,741	11,699	9,644	11,222
% y/y	7.6%	0.0%	7.5%	7.4%	7.2%	7.1%
California	12,929,500	13,013,324	13,073,427	13,132,616	13,231,993	13,204,398
+/- m/m	215,506	83,824	60,103	59,189	99,377	(27,595)
% y/y	9.8%	9.9%	9.9%	9.9%	10.2%	9.5%
D.C.	246,957	247,704	248,577	249,617	250,676
+/- m/m	3,223	747	873	1,040	1,059	N/A
% y/y	6.7%	6.7%	6.5%	6.5%	6.4%
Florida	4,385,965	4,432,233	4,465,670	4,502,297	4,537,121	4,581,266
+/- m/m	41,441	46,268	33,437	36,627	34,824	44,145
% y/y	10.9%	10.9%	10.7%	10.7%	10.7%	11.0%
Georgia	1,975,277	1,988,727		2,016,462	2,027,275	2,035,673
+/- m/m	13,117	13,450	N/A	N/A	10,813	8,398
% y/y	9.8%	9.5%		9.0%	8.7%	8.3%
Illinois	2,890,332	2,884,029	2,900,232	2,929,584	2,965,007	3,000,717
+/- m/m	(8,672)	(6,303)	16,203	29,352	35,423	35,710
% y/y	5.1%	4.5%	4.1%	4.4%	5.1%	5.5%
Indiana	1,742,762	1,761,692	1,769,400	1,781,464	1,797,451	1,813,044
+/- m/m	6,906	18,930	7,708	12,064	15,987	15,593
% y/y	11.6%	11.3%	11.0%	10.5%	10.2%	10.3%
Iowa	795,534	799,748	807,296		812,481	814,490
+/- m/m	2,642	4,214	7,548	N/A	N/A	2,009
% y/y	5.9%	5.8%	6.4%		6.0%	6.1%
Kansas	489,309	490,911	492,640	497,257	499,143	500,814
+/- m/m	2,691	1,602	1,729	4,617	1,886	1,671
% y/y	N/A	N/A	N/A	N/A	8.3%	6.3%
Kentucky	1,494,068	1,487,387	1,509,274	1,518,906	1,528,484	1,534,657
+/- m/m	6,069	(6,681)	21,887	9,632	9,578	6,173
% y/y	5.5%	5.3%	5.6%	5.8%	6.7%	6.1%
Louisiana	1,821,644	1,828,015	1,833,457	1,841,693	1,858,092	1,860,170
+/- m/m	7,213	6,371	5,442	8,236	16,399	2,078
% y/y	4.6%	4.5%	4.4%	4.7%	5.2%	5.8%
Maryland	1,496,677	1,502,271	1,508,469	1,514,381	1,521,171	1,529,308
+/- m/m	8,205	5,594	6,198	5,912	6,790	8,137
% y/y	6.5%	6.2%	6.1%	5.8%	5.8%	5.7%
Michigan	2,280,243	2,294,432	2,299,913	2,309,913	2,319,951	2,324,046
+/- m/m	2,923	14,189	5,481	10,000	10,038	4,095
% y/y	3.8%	3.6%	3.5%	3.7%	4.5%	4.3%
Minnesota	1,261,112	1,262,073	1,278,954	1,286,890	1,293,858	1,299,194
+/- m/m	1,893	961	16,881	7,936	6,968	5,336
% y/y	7.3%	6.7%	7.4%	7.5%	7.5%	7.5%
Mississippi	367,137	363,387	364,612	355,694	367,902	396,880
+/- m/m	(452)	(3,750)	1,225	(8,918)	12,208	28,978
% y/y	-22.7%	-19.9%	-17.4%	-17.3%	-12.5%	-3.9%
Missouri	1,038,239	1,065,217	1,099,707	1,118,373	1,136,589	1,157,005
+/- m/m	26,520	26,978	34,490	18,666	18,216	20,416
% y/y	27.0%	29.1%	32.6%	31.7%	31.8%	29.0%
Nebraska	363,328	366,202	369,770	372,613	374,857	378,237
+/- m/m	2,740	2,874	3,568	2,843	2,244	3,380
% y/y	12.4%	11.9%	11.7%	11.2%	10.8%	10.6%
Nevada	687,362	689,139	697,752	675,465	685,736	692,890
+/- m/m	9,464	1,777	8,613	(22,287)	10,271	7,154
% y/y	9.3%	9.0%	9.3%	4.2%	5.2%	5.7%
New Jersey	2,100,947	2,113,930	2,125,181	2,130,868	2,144,514	2,158,966
+/- m/m	10,897	12,983	11,251	5,687	13,646	14,452
% y/y	7.4%	7.4%	7.2%	7.0%	7.1%	7.0%
New Mexico	809,991	811,732	812,995	813,630	814,466	815,798
+/- m/m	2,491	1,741	1,263	635	836	1,332
% y/y	4.2%	3.7%	3.4%	3.0%	2.6%	2.3%
New York	5,855,615	5,853,108	5,878,519	5,906,264	5,929,288	5,961,782
+/- m/m	39,970	(2,507)	25,411	27,745	23,024	32,494
% y/y	4.5%	4.3%	4.2%	4.3%	4.5%	4.6%
North Carolina	1,738,545	1,746,948	1,757,503	1,768,974	1,778,199	1,837,423
+/- m/m	9,047	8,403	10,555	11,471	9,225	59,224
% y/y	8.0%	6.8%	6.7%	6.6%	6.6%	9.5%
Ohio	2,964,731	2,963,616	2,960,922	2,958,666	2,961,983	2,973,763
+/- m/m	(1,340)	(1,115)	(2,694)	(2,256)	3,317	11,780
% y/y	3.4%	2.6%	1.9%	1.4%	1.0%	0.9%
Oregon	1,193,358	1,202,198	1,206,520	1,211,099	1,221,435	1,228,054
+/- m/m	3,920	8,840	4,322	4,579	10,336	6,619
% y/y	8.3%	8.4%	7.7%	7.6%	7.4%	7.2%
Pennsylvania	2,895,837	2,909,985	2,920,584	2,937,049	2,950,613	2,966,207
+/- m/m	13,973	14,148	10,599	16,465	13,564	15,594
% y/y	7.4%	7.3%	6.9%	6.8%	6.6%	6.5%
South Carolina	1,055,785	1,063,445	1,069,569	1,078,094	1,084,529	1,089,577
+/- m/m	5,226	7,660	6,124	8,525	6,435	5,048
% y/y	7.6%	7.5%	7.4%	7.9%	7.6%	7.5%
Tennessee	1,692,395	1,704,398	1,710,125	1,718,539	1,726,603	1,734,108
+/- m/m	6,737	12,003	5,727	8,414	8,064	7,505
% y/y	6.0%	6.1%	6.1%	6.0%	5.9%	5.8%
Texas		5,466,045			5,653,169
+/- m/m	N/A	N/A	N/A	N/A	N/A	N/A
% y/y		8.6%			10.6%
Virginia	1,572,923	1,582,973	1,589,722	1,598,875	1,608,840	1,619,311
+/- m/m	11,829	10,050	6,749	9,153	9,965	10,471
% y/y	11.3%	11.0%	10.0%	9.6%	10.1%	9.8%
Washington	1,884,734	1,898,983	1,904,127	1,913,230	1,927,690	1,959,278
+/- m/m	8,867	14,249	5,144	9,103	14,460	31,588
% y/y	#DIV/0!	#DIV/0!	5.8%	5.9%	6.0%	7.2%
West Virginia	519,992	524,042	524,922	527,226	530,494	533,194
+/- m/m	2,871	4,050	880	2,304	3,268	2,700
% y/y	6.5%	6.8%	6.4%	5.9%	5.9%	5.7%
Wisconsin	1,161,202	1,166,208	1,172,719	1,179,204	1,184,899	1,190,673
+/- m/m	5,263	5,006	6,511	6,485	5,695	5,774
% y/y	7.5%	7.2%	7.1%	7.1%	6.9%	6.6%

Note: In Table 1 above and the state tables below, “+/- m/m” refers to the enrollment change from the previous month. “% y/y” refers to the percentage change in enrollment from the same month in the previous year.

Below, we provide a state-specific analysis of recent enrollment trends in the states where HMA tracks data.

It is important to note the limitations of the data presented. First, not all states report the data at the same time during the month. Some of these figures reflect beginning-of-the-month totals, while others reflect an end-of-the-month snapshot. Second, in some cases the data is comprehensive in that it covers all state-sponsored health programs for which the state offers managed care; in other cases, the data reflects only a subset of the broader Medicaid managed care population. This is the key limiting factor in comparing the data described below and figures reported by publicly traded Medicaid MCOs. Consequently, the data we review in Table 1 and throughout the In Focus section should be viewed as a sampling of enrollment trends across these states rather than a comprehensive comparison, which cannot be developed based on publicly available monthly enrollment data.

State-Specific Analysis

Arizona

Medicaid Expansion Status: Expanded January 1, 2014

Enrollment in Arizona’s two Medicaid managed care programs grew to 2.1 million in December 2022, up 7.1 percent from December 2021.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Acute Care	2,002,584	2,012,802	2,028,335	2,039,880	2,049,311	2,060,376
ALTCS	66,464	66,558	66,766	66,920	67,133	67,290
Total Arizona	2,069,048	2,079,360	2,095,101	2,106,800	2,116,444	2,127,666
+/- m/m	8,527	10,312	15,741	11,699	9,644	11,222
% y/y	7.6%		7.5%	7.4%	7.2%	7.1%

California

Medicaid Expansion Status: Expanded January 1, 2014

Medi-Cal managed care enrollment was up 9.5 percent year-over-year to 13.2 million, as of December 2022.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Two-Plan Counties	8,356,137	8,409,817	8,446,514	8,481,885	8,548,096	8,588,418
Imperial/San Benito	100,384	101,117	101,633	102,064	102,881	103,437
Regional Model	364,066	366,437	368,624	370,361	373,402	375,473
GMC Counties	1,435,250	1,445,532	1,452,127	1,458,149	1,470,122	1,391,421
COHS Counties	2,561,831	2,578,747	2,593,003	2,608,731	2,625,795	2,634,112
Duals Demonstration	111,832	111,674	111,526	111,426	111,697	111,537
Total California	12,929,500	13,013,324	13,073,427	13,132,616	13,231,993	13,204,398
+/- m/m	215,506	83,824	60,103	59,189	99,377	(27,595)
% y/y	9.8%	9.9%	9.9%	9.9%	10.2%	9.5%

District of Columbia

Medicaid Expansion Status: Expanded January 1, 2014

Medicaid managed care enrollment in the District of Columbia was up 6.4 percent to almost 251,000 in November 2022.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22
Total District of Columbia	246,957	247,704	248,577	249,617	250,676
+/- m/m	3,223	747	873	1,040	1,059
% y/y	6.7%	6.7%	6.5%	6.5%	6.4%

Florida

Medicaid Expansion Status: Not Expanded

Florida’s statewide Medicaid managed care program had seen an 11 percent rise in total covered lives over the last year to nearly 4.6 million beneficiaries as of December 2022. (Note that the managed LTC enrollment figures listed below are a subset of the Managed Medical Assistance (MMA) enrollments and are included in the MMA number; they are not separately added to the total to avoid double counting).

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
MMA	3,908,539	3,948,929	3,978,098	4,010,534	4,041,816	4,080,381
LTC (Subset of MMA)	124,107	124,691	125,397	126,144	126,720	126,621
SMMC Specialty Plan	332,179	338,057	342,325	346,516	350,058	355,638
FL Healthy Kids	145,247	145,247	145,247	145,247	145,247	145,247
Total Florida	4,385,965	4,432,233	4,465,670	4,502,297	4,537,121	4,581,266
+/- m/m	41,441	46,268	33,437	36,627	34,824	44,145
% y/y	10.9%	10.9%	10.7%	10.7%	10.7%	11.0%

Georgia

Medicaid Expansion Status: Not Expanded

As of December 2022, Georgia’s Medicaid managed care program covered more than 2 million members, up 8.3 percent from the previous year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total Georgia	1,975,277	1,988,727		2,016,462	2,027,275	2,035,673
+/- m/m	13,117	13,450			10,813	8,398
% y/y	9.8%	9.5%		9.0%	8.7%	8.3%

Illinois

Medicaid Expansion Status: Expanded January 1, 2014

Illinois enrollment across the state’s managed care programs was up 5.5 percent to 3 million as of December 2022.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
HealthChoice	2,800,420	2,793,124	2,809,689	2,839,342	2,874,700	2,909,303
Duals Demonstration	89,912	90,905	90,543	90,242	90,307	91,414
Total Illinois	2,890,332	2,884,029	2,900,232	2,929,584	2,965,007	3,000,717
+/- m/m	(8,672)	(6,303)	16,203	29,352	35,423	35,710
% y/y	5.1%	4.5%	4.1%	4.4%	5.1%	5.5%

Indiana

Medicaid Expansion Status: Expanded in 2015 through HIP 2.0

As of December 2022, enrollment in Indiana’s managed care programs—Hoosier Healthwise, Hoosier Care Connect, and Healthy Indiana Program (HIP)—was more than 1.8 million, up 10.3 percent from the previous year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Hoosier Healthwise	845,910	852,904	857,952	863,973	869,613	876,606
Hoosier Care Connect	102,805	102,819	102,537	102,253	102,200	102,150
HIP	794,047	805,969	808,911	815,238	825,638	834,288
Indiana Total	1,742,762	1,761,692	1,769,400	1,781,464	1,797,451	1,813,044
+/- m/m	6,906	18,930	7,708	12,064	15,987	15,593
% y/y	11.6%	11.3%	11.0%	10.5%	10.2%	10.3%

Iowa

Medicaid Expansion Status: Expanded January 1, 2014

Iowa launched its statewide Medicaid managed care program in April of 2016. Enrollment across all populations was nearly 814,500, as of December 2022. Enrollment was up 6.1 percent from the previous year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Traditional Medicaid	507,266	510,618	516,556		520,234	521,118
Iowa Wellness Plan	237,910	239,261	242,555		244,724	246,385
hawk-i	50,358	49,869	48,185		47,523	46,987
Total Iowa	795,534	799,748	807,296		812,481	814,490
+/- m/m	2,642	4,214	7,548			2,009
% y/y	5.9%	5.8%	6.4%		6.0%	6.1%

Kansas

Medicaid Expansion Status: Not Expanded

Kansas Medicaid managed care enrollment was nearly 501,000 as of December 2022, up 6.3 percent from the previous year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total Kansas	489,309	490,911	492,640	497,257	499,143	500,814
+/- m/m	2,691	1,602	1,729	4,617	1,886	1,671
% y/y					8.3%	6.3%

Kentucky

Medicaid Expansion Status: Expanded January 1, 2014

As of December 2022, Kentucky covered more than 1.5 million beneficiaries in risk-based managed care. Total enrollment was up 6.1 percent from the prior year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total Kentucky	1,494,068	1,487,387	1,509,274	1,518,906	1,528,484	1,534,657
+/- m/m	6,069	(6,681)	21,887	9,632	9,578	6,173
% y/y	5.5%	5.3%	5.6%	5.8%	6.7%	6.1%

Louisiana

Medicaid Expansion Status: Expanded July 1, 2016

Medicaid managed care enrollment in Louisiana was more than 1.86 million as of December 2022, up 5.8 percent from the previous year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total Louisiana	1,821,644	1,828,015	1,833,457	1,841,693	1,858,092	1,860,170
+/- m/m	7,213	6,371	5,442	8,236	16,399	2,078
% y/y	4.6%	4.5%	4.4%	4.7%	5.2%	5.8%

Maryland

Medicaid Expansion Status: Expanded January 1, 2014

Maryland’s Medicaid managed care program covered more than 1.5 million lives as of December 2022.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total Maryland	1,496,677	1,502,271	1,508,469	1,514,381	1,521,171	1,529,308
+/- m/m	8,205	5,594	6,198	5,912	6,790	8,137
% y/y	6.5%	6.2%	6.1%	5.8%	5.8%	5.7%

Michigan

Medicaid Expansion Status: Expanded April 1, 2014

As of December 2022, Michigan’s Medicaid managed care was up 4.3 percent to 2.3 million.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Medicaid	2,239,937	2,251,810	2,256,800	2,265,219	2,274,763	2,279,473
MI Health Link (Duals)	40,306	42,622	43,113	44,694	45,188	44,573
Total Michigan	2,280,243	2,294,432	2,299,913	2,309,913	2,319,951	2,324,046
+/- m/m	2,923	14,189	5,481	10,000	10,038	4,095
% y/y	3.8%	3.6%	3.5%	3.7%	4.5%	4.3%

Minnesota

Medicaid Expansion Status: Expanded January 1, 2014

As of December 2022, enrollment across Minnesota’s multiple managed Medicaid programs was nearly 1.3 million, up 7.5 percent from the prior year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Parents/Kids	748,197	748,513	758,100	763,044	767,798	770,918
Expansion Adults	272,666	273,387	278,421	281,284	284,073	288,680
Senior Care Plus	24,190	24,252	25,344	25,914	26,415	26,740
Senior Health Options	43,429	43,686	43,920	44,162	44,248	44,324
Special Needs BasicCare	64,656	64,484	65,562	65,763	65,987	66,171
Moving Home Minnesota	11	11	10	10	9	11
Minnesota Care	107,963	107,740	107,597	106,713	105,328	102,350
Total Minnesota	1,261,112	1,262,073	1,278,954	1,286,890	1,293,858	1,299,194
+/- m/m	1,893	961	16,881	7,936	6,968	5,336
% y/y	7.3%	6.7%	7.4%	7.5%	7.5%	7.5%

Mississippi

Medicaid Expansion Status: Not Expanded

MississippiCAN, the state’s Medicaid managed care program, had membership down 3.9 percent to nearly 397,000 as of December 2022.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total Mississippi	367,137	363,387	364,612	355,694	367,902	396,880
+/- m/m	(452)	(3,750)	1,225	(8,918)	12,208	28,978
% y/y	-22.7%	-19.9%	-17.4%	-17.3%	-12.5%	-3.9%

Missouri

Medicaid Expansion Status: Expansion Enrollment began in October 2021

Missouri managed care enrollment in the Medicaid and CHIP programs was nearly 1.2 million in December 2022.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total Medicaid	758,928	757,312	769,419	775,076	782,863	787,611
Total CHIP	28,949	28,937	29,026	29,121	29,231	29,402
Total AEG	199,963	228,361	250,131	262,612	272,574	287,692
Total SHK	50,399	50,607	51,131	51,564	51,921	52,300
Total Missouri	1,038,239	1,065,217	1,099,707	1,118,373	1,136,589	1,157,005
+/- m/m	26,520	26,978	34,490	18,666	18,216	20,416
% y/y	27.0%	29.1%	32.6%	31.7%	31.8%	29.0%

Nebraska

Medicaid Expansion Status: Expanded October 1, 2020

As of December 2022, Nebraska’s Medicaid managed care program enrolled 378,000 members, up 10.6 percent from the previous year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total Nebraska	363,328	366,202	369,770	372,613	374,857	378,237
+/- m/m	2,740	2,874	3,568	2,843	2,244	3,380
% y/y	12.4%	11.9%	11.7%	11.2%	10.8%	10.6%

Nevada

Medicaid Expansion Status: Expanded January 1, 2014

Nevada’s Medicaid managed care enrollment was up 5.7 percent to nearly 693,000 as of December 2022.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total Nevada	687,362	689,139	697,752	675,465	685,736	692,890
+/- m/m	9,464	1,777	8,613	(22,287)	10,271	7,154
% y/y	9.3%	9.0%	9.3%	4.2%	5.2%	5.7%

New Jersey

Medicaid Expansion Status: Expanded January 1, 2014

As of December 2022, New Jersey Medicaid managed care enrollment was up 7 percent to nearly 2.2 million.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total New Jersey	2,100,947	2,113,930	2,125,181	2,130,868	2,144,514	2,158,966
+/- m/m	10,897	12,983	11,251	5,687	13,646	14,452
% y/y	7.4%	7.4%	7.2%	7.0%	7.1%	7.0%

New Mexico

Medicaid Expansion Status: Expanded January 1, 2014

As of December 2022, New Mexico’s Centennial Care program covered nearly 816,000 members, up 2.3 percent from the previous year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total New Mexico	809,991	811,732	812,995	813,630	814,466	815,798
+/- m/m	2,491	1,741	1,263	635	836	1,332
% y/y	4.2%	3.7%	3.4%	3.0%	2.6%	2.3%

New York

Medicaid Expansion Status: Expanded January 1, 2014

New York’s Medicaid managed care programs collectively covered nearly 6 million beneficiaries as of December 2022, a 4.6 percent increase from the previous year. The Medicaid Advantage program ended in December 2021.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Mainstream MCOs	5,399,089	5,395,489	5,418,915	5,446,409	5,467,467	5,494,358
Managed LTC	255,999	256,538	258,236	257,360	260,087	264,965
Medicaid Advantage	0	0	0	0	0	0
Medicaid Advantage Plus	34,357	34,355	34,689	34,764	34,717	35,061
HARP	164,514	165,067	165,024	166,063	165,340	165,713
FIDA-IDD (Duals)	1,656	1,659	1,655	1,668	1,677	1,685
Total New York	5,855,615	5,853,108	5,878,519	5,906,264	5,929,288	5,961,782
+/- m/m	39,970	(2,507)	25,411	27,745	23,024	32,494
% y/y	4.5%	4.3%	4.2%	4.3%	4.5%	4.6%

North Carolina

Medicaid Expansion Status: Not Expanded

As of December 2022, enrollment in North Carolina’s Medicaid managed care program was 1.8 million, up 9.5 percent from the prior year. North Carolina implemented Medicaid managed care on July 1, 2021.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total North Carolina	1,738,545	1,746,948	1,757,503	1,768,974	1,778,199	1,837,423
+/- m/m	9,047	8,403	10,555	11,471	9,225	59,224
% y/y	8.0%	6.8%	6.7%	6.6%	6.6%	9.5%

Ohio

Medicaid Expansion Status: Expanded January 1, 2014

As of December 2022, enrollment across all four Ohio Medicaid managed care programs was nearly 3 million, up 0.9 percent from the prior year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
CFC Program	1,800,781	1,800,038	1,798,135	1,796,327	1,798,873	1,804,860
ABD/Duals	348,071	348,176	347,461	347,371	347,473	347,839
Group 8 (Expansion)	815,879	815,402	815,326	814,968	815,637	821,064
Total Ohio	2,964,731	2,963,616	2,960,922	2,958,666	2,961,983	2,973,763
+/- m/m	(1,340)	(1,115)	(2,694)	(2,256)	3,317	11,780
% y/y	3.4%	2.6%	1.9%	1.4%	1.0%	0.9%

Oregon

Medicaid Expansion Status: Expanded January 1, 2014

As of December 2022, enrollment in the Oregon Coordinated Care Organization (CCO) Medicaid managed care program was more than 1.2 million, up 7.2 percent from the previous year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total Oregon	1,193,358	1,202,198	1,206,520	1,211,099	1,221,435	1,228,054
+/- m/m	3,920	8,840	4,322	4,579	10,336	6,619
% y/y	8.3%	8.4%	7.7%	7.6%	7.4%	7.2%

Pennsylvania

Medicaid Expansion Status: Expanded January 1, 2015

As of December 2022, Pennsylvania’s Medicaid managed care enrollment was nearly 3 million, up 6.5 percent in the past year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total Pennsylvania	2,895,837	2,909,985	2,920,584	2,937,049	2,950,613	2,966,207
+/- m/m	13,973	14,148	10,599	16,465	13,564	15,594
% y/y	7.4%	7.3%	6.9%	6.8%	6.6%	6.5%

South Carolina

Medicaid Expansion Status: Not Expanded

South Carolina’s Medicaid managed care programs collectively enrolled nearly 1.1 million members as of December 2022, which represents an increase of 7.5 percent in the past year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total Medicaid	1,041,909	1,049,706	1,056,026	1,064,548	1,071,016	1,076,146
Total Duals Demo	13,876	13,739	13,543	13,546	13,513	13,431
Total South Carolina	1,055,785	1,063,445	1,069,569	1,078,094	1,084,529	1,089,577
+/- m/m	5,226	7,660	6,124	8,525	6,435	5,048
% y/y	7.6%	7.5%	7.4%	7.9%	7.6%	7.5%

Tennessee

Medicaid Expansion Status: Not Expanded

As of December 2022, TennCare managed care enrollment totaled 1.7 million, up 5.8 percent from the prior year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total Tennessee	1,692,395	1,704,398	1,710,125	1,718,539	1,726,603	1,734,108
+/- m/m	6,737	12,003	5,727	8,414	8,064	7,505
% y/y	6.0%	6.1%	6.1%	6.0%	5.9%	5.8%

Texas

Medicaid Expansion Status: Not Expanded

Texas’ state fiscal year begins in September and program-specific enrollment is only reported at the end of each state fiscal quarter. As of November 2022, Texas Medicaid managed care enrollment was nearly 5.7 million across the state’s six managed care programs, up 10.6 percent from the previous year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
STAR		4,559,293			4,748,820
STAR+PLUS		559,746			568,456
STAR HEALTH		45,760			46,228
Duals Demo		34,336			33,673
CHIP		97,153			85,773
STAR KIDS		169,757			170,219
Total Texas		5,466,045			5,653,169
+/- m/m
% y/y		8.6%			10.6%

Virginia

Medicaid Expansion Status: January 1, 2019

Virginia Medicaid managed care enrollment was up 9.8 percent in December 2022 to 1.6 million members.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total Virginia	1,572,923	1,582,973	1,589,722	1,598,875	1,608,840	1,619,311
+/- m/m	11,829	10,050	6,749	9,153	9,965	10,471
% y/y	11.3%	11.0%	10.0%	9.6%	10.1%	9.8%

Washington

Medicaid Expansion Status: Expanded January 1, 2014

Washington’s Medicaid managed care enrollment increased 7.2 percent to nearly 2 million as of December 2022, compared to the previous year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total Washington	1,884,734	1,898,983	1,904,127	1,913,230	1,927,690	1,959,278
+/- m/m	8,867	14,249	5,144	9,103	14,460	31,588
% y/y	#DIV/0!	#DIV/0!	5.8%	5.9%	6.0%	7.2%

West Virginia

Medicaid Expansion Status: Expanded January 1, 2014

As of December 2022, West Virginia’s Medicaid managed care program covered 533,000 members, up 5.7 percent year-over-year.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
Total West Virginia	519,992	524,042	524,922	527,226	530,494	533,194
+/- m/m	2,871	4,050	880	2,304	3,268	2,700
% y/y	6.5%	6.8%	6.4%	5.9%	5.9%	5.7%

Wisconsin

Medicaid Expansion Status: Not Expanded

Across Wisconsin’s three Medicaid managed care programs, December 2022 enrollment totaled nearly 1.2 million, up 6.6 percent from the year before.

	Jul-22	Aug-22	Sep-22	Oct-22	Nov-22	Dec-22
BadgerCare+	1,042,456	1,047,217	1,053,361	1,059,587	1,065,182	1,070,788
SSI	61,841	61,916	62,065	62,129	62,165	62,293
LTC	56,905	57,075	57,293	57,488	57,552	57,592
Total Wisconsin	1,161,202	1,166,208	1,172,719	1,179,204	1,184,899	1,190,673
+/- m/m	5,263	5,006	6,511	6,485	5,695	5,774
% y/y	7.5%	7.2%	7.1%	7.1%	6.9%	6.6%

More Information Available from HMA Information Services

More detailed information on the Medicaid managed care landscape is available from HMA Information Services (HMAIS), which collects Medicaid enrollment data, health plan financials, and the latest on expansions, waivers, duals, ABD populations, long-term care, accountable care organizations, and patient-centered medical homes. HMAIS also includes a public documents library with copies of Medicaid RFPs, responses, model contracts, and scoring sheets.

HMAIS enhances this publicly available information with an overview of the structure of Medicaid in each state, as well as proprietary Medicaid Managed Care RFP calendars.

For additional information on how to subscribe to HMA Information Services, contact Carl Mercurio at 212-575-5929 or cmercurio@healthmanagaement.com.

[1] Arizona, California, District of Columbia, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Washington, West Virginia, Wisconsin.