Innovations in Publicly Sponsored Healthcare: How Medicaid, Medicare, and Marketplaces Are Driving Value, Equity, and Growth
Pre-Conference Workshop: October 29, 2023 Conference: October 30−31, 2023 Location: Fairmont Chicago, Millennium Park
Health Management Associates has announced the preliminary lineup of speakers for its sixth annual conference, Innovations in Publicly Sponsored Healthcare: How Medicaid, Medicare, and Marketplaces Are Driving Value, Equity, and Growth.
Hundreds of executives from health plans, providers, state and federal government, investment firms, and community-based organizations will convene to enjoy top-notch content, make new connections, and garner fresh ideas and best practices.
A pre-conference workshop, Behavioral Health at the Intersection of General Health and Human Services, will take place Sunday, October 29.
Confirmed speakers to date include (in alphabetical order):
Jacey Cooper, State Medicaid Director, Chief Deputy Director, California Department of Health Care Services
Kelly Cunningham, Administrator, Division of Medical Programs, Illinois Department of Healthcare and Family Services
Karen Dale, Chief Diversity, Equity, and Inclusion Officer, AmeriHealth Caritas
Peter Lee, Health Care Policy Catalyst and former Executive Director, Covered California
John Lovelace, President, Government Programs, Individual Advantage, UPMC Health Plan
Julie Morita, MD, Executive Vice President, Robert Wood Johnson Foundation
Anne Rote, President, Medicaid, Health Care Service Corp.
Drew Snyder, Executive Director, Mississippi Division of Medicaid
Tim Spilker, CEO, UnitedHealthcare Community & State
Stacie Weeks, Administrator/Medicaid Director, Division of Health Care Financing and Policy, Nevada Department of Health and Human Services
Lisa Wright, President and CEO, Community Health Choice
Publicly sponsored programs like Medicare, Medicaid, and the Marketplaces are leading the charge in driving value, equity, and growth in the U.S. healthcare system. This year’s event will highlight the innovations, initiatives, emerging models, and growth strategies designed to drive improved patient outcomes, increased affordability, and expanded access.
Early bird registration ends July 31. Questions may be directed to Carl Mercurio at cmercurio@healthmanagement.com. Group rates, government discounts, and sponsorships are available.
This week our In Focus section reviews the Illinois Healthcare Transformation 1115 Waiver Extension request, posted for review on May 12, 2023.
In pursuing this waiver extension, Illinois joins a growing list of states taking advantage of new Centers for Medicare & Medicaid Services (CMS) policy flexibilities to address health-related social needs (HRSNs) through Medicaid and test community-driven initiatives that are focused on improving health equity, improving access to care, and promoting whole-person care.
The Illinois waiver incorporates two of the most significant new opportunities in the CMS demonstration waiver flexibilities by proposing to incorporate housing supports for people who are experiencing or at risk of homelessness. The waiver also would extend community reintegration services for justice-involved adults and youths for up to 90 days before their release from incarceration. For a full list of proposed benefits and demonstrations, see Table 1.
Table 1. Summary of Illinois Medicaid 1115 Waiver Extension
The Illinois waiver represents an unprecedented opportunity to demonstrate the long-term, positive impact of providing HRSN services to achieve health equity and create a sustainable, community-driven system for delivering those services. The demonstration proposes to offer a range of HRSN services that are focused on the unmet needs of people who are homeless and housing insecure, are justice-involved, have behavioral health conditions, are pregnant, are unemployed, are food insecure, and/or have been exposed to violence or are at risk of violence with the goal of eliminating health disparities.
The waiver projects a five-year total of $4.4 billion in HRSN services expenditures and another $800 million in HRSN-related infrastructure, indicating Illinois’ long-term commitment to healthcare transformation and to building an equitable, accessible, and high-quality delivery system.
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.
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.
Join us on Monday, March 6, 2023, at the Fairmont Chicago, Millennium Park, for “Healthcare Quality Conference: A Deep Dive on What’s Next for Providers, Payers, and Policymakers,” where Lee Fleisher, MD, chief medical officer and director of CMS’ Center for Clinical Standards and Quality, will deliver the keynote titled A Vision for Healthcare Quality: How Policy Can Drive Improved Outcomes.
HMA’s first annual quality conference will provide organizations the opportunity to “Focus on Quality to Improve Patients’ Lives.” Attendees will hear from industry leaders and policy makers about evolving health care quality initiatives and participate in substantive workshops where they will learn about and discuss solutions that are using quality frameworks to create a more equitable health system.
In addition to Fleisher, featured speakers will executives from ANCOR, CareOregon, Commonwealth Care Alliance, Council on Quality and Leadership, Intermountain Healthcare, NCQA, Reema Health, Kaiser Permanente, United Hospital Fund, and others.
Working sessions will provide expert-led discussions about how quality is driving federal and state policy, behavioral health integration, approaches to improving equity and measuring the social determinants of health, integration of disability support services, stronger Medicaid core measures, strategies for Medicare Star Ratings, value-based payments, and digital measures and measurement tools. Speakers will provide case studies and innovative approaches to ensuring quality efforts result in lasting improvements in health outcomes.
“What’s different about this conference is that participants will engage in working sessions that provide healthcare executives tools and models for directly impacting quality at their organizations,” said Carl Mercurio, Principal and Publisher, HMA Information Services.
Early Bird registration ends January 30. Visit the conference website for complete details or contact Carl Mercurio at 212-575-5929/cmercurio@healthmanagement.com. Group rates and sponsorships are available.
This week, our In Focus section reviews the State of Texas Access Reform (STAR), Children’s Health Insurance Program (CHIP), and Healthy Texas Women (HTW) Medicaid managed care request for proposals (RFP) released by the Texas Health and Human Services Commission (HHSC) on December 7, 2022. Medicaid managed care organizations (MCOs) will serve over 4.6 million members. Prior STAR & CHIP program contracts were valued at roughly $9.7 billion annually, with new contracts to be worth more.
Background
Texas is currently in the process of rebidding all of its Medicaid managed care programs. A former STAR & CHIP RFP was cancelled in March 2020.
STAR is Texas’ traditional Medicaid program. Under the STAR program, MCOs will provide preventive, primary, acute care, behavioral health (including mental health and substance-use disorder counseling and treatment), Non-Emergency Medical Transportation (NEMT), and pharmacy services to eligible pregnant women, newborns, children, and parents with limited income.
CHIP is the state-federal jointly funded program covering children whose families who earn too much to qualify for Medicaid but cannot afford private insurance. In Texas, CHIP contracts also include the CHIP Perinatal Program covering pregnant women who are ineligible for Medicaid due to income or immigration status to receive prenatal care for their unborn children. Once born, newborns receive 12 months of continuous coverage.
The HTW program provides family planning services, family planning-related services, and other preconception women’s health services. The HTW program was originally a fee-for-service program until the Centers for Medicare & Medicaid Services (CMS) approved a Section 1115 waiver demonstration in January 2020. Texas is currently waiting on CMS approval for a waiver amendment to also add HTW Plus, an enhanced postpartum benefits package, into Medicaid managed care.
RFP
HHSC intends to award at least three contracts for each service area (SA). The maximum number of MCOs that will be awarded in the new procurement for each SA is shown below.
As of August 2022, STAR enrollment was 4.56 million and CHIP enrollment was over 97,000.
Timeline
A preproposal conference will be held on December 21, 2022. While optional, the conference is recommended and will include training on the completion of the Historically Underutilized Business (HUB) Subcontracting Plan. Proposals will be due February 17, 2023, with awards anticipated in February 2024. Implementation is expected February 2025. Contracts will run for six years, with three two-year renewal options, not to exceed a total contract term of 12 years.
Evaluation
MCOs will be scored out of 2,000 points as shown below. HHSC will recommend contract awards in SAs based on MCOs’ final weighted scores and will take consideration of MCOs’ ranking of SAs by preference.
Each MCO can be awarded contracts in up to seven SAs. However, HHSC may choose to award more per MCO if the SA has not reached a maximum number of MCOs.
The holiday season is grounded in gratitude. At HMA, we are grateful for successful partnerships that have fueled change to improve lives.
We are proud to be trusted advisors to our clients and partners. Their success is our success. In 2022 our clients and partners made significant strides tackling the biggest healthcare challenges, seizing opportunities for growth and innovation, and shaping the healthcare landscape in a way that improves the health and wellness of individuals and communities.
HMA partnered with the Colorado Department of Human Services to support the planning and implementation of a new Behavioral Health Administration (BHA). HMA provided technical research and extensive stakeholder engagement, drafted models for forming and implementing the BHA, employed an extensive change management approach, and created a detailed implementation plan with ongoing support. Today the BHA is a cabinet member-led agency that collaborates across agencies and sectors to drive a comprehensive and coordinated strategic approach to behavioral health.
Wakely Consulting Group, an HMA Company, was engaged to support the launch of a Medicare Advantage (MA) joint venture partnership between a health plan and a provider system. Wakely was responsible for preparing and certifying MA and Medicare Part D (PD) bids, a highly complex, exacting, and iterative effort. The Wakely team quickly became a trusted advisor and go-to resource for the joint venture decision makers. The joint venture has driven significant market growth over its initial years, fueled by a competitive benefit package determined by the client product team.
In 2021 Indiana Governor Eric Holcomb appointed a 15-member commission to assess Indiana’s public health system and make recommendations for improvements. The Indiana Department of Health (IDOH) engaged HMA to provide extensive project management and support for six workstreams. HMA prepared a draft report summarizing public input as well as research findings and recommendations. The commission’s final report will form the basis of proposed 2023 legislation, including proposals to substantially increase public health service and funding across the state.
In early 2022 HMA and Wakely Consulting Group, an HMA Company, assisted multiple clients with their applications to participate in the new CMS ACO REACH model. The purpose of this model is to improve quality of care for Medicare beneficiaries through better care coordination and increased engagement between providers and patients including those who are underserved. The team tailored their support depending on each client’s needs. The application selection process was highly competitive. Of the 271 applications received, CMS accepted just under 50 percent. Notably, nine out of the 10 organizations HMA and Wakely supported were accepted into the model.
HMA, and subsidiaries The Moran Company and Leavitt Partners, were selected by a large pharmaceutical manufacturer to analyze the current pipeline of innovative therapies, examine reimbursement policies to assess long-term compatibility with the adoption of innovative therapies and novel delivery mechanisms, and make policy recommendations to address any challenges identified through the process. The project equipped the client with a holistic understanding of future potential impacts and actions to address challenges in a detailed pipeline analysis of innovative therapies.
This week, our In Focus reviews the Oklahoma Medicaid managed care SoonerSelect Program request for proposals (RFP) and the SoonerSelect Children’s Specialty Program RFP released by the Oklahoma Health Care Authority (OHCA) on November 10, 2022.
Background
Oklahoma currently does not have a fully capitated, risk-based Medicaid managed care program. The majority of the state’s 1.3 million Medicaid members are in SoonerCare Choice, a Primary Care Case Management (PCCM) program in which each member has a medical home. Other programs include SoonerCare Traditional (Medicaid fee-for-service), SoonerPlan (a limited benefit family planning program), and Insure Oklahoma (a premium assistance program for low-income people whose employers offer health insurance).
Prior efforts to transition to Medicaid managed care have encountered roadblocks, starting in 2017 with a failed attempt to move aged, blind, and disabled members to managed care.
More recently, in June 2021, the Oklahoma Supreme Court struck down a planned transition of the state’s traditional Medicaid program to managed care, ruling that the Oklahoma Health Care Authority does not have the authority to implement the program without legislative approval.
Contracts had been awarded to Blue Cross Blue Shield of Oklahoma, Humana, Centene/Oklahoma Complete Health, and UnitedHealthcare. Centene/Oklahoma Complete Health also won an award for the SoonerSelect Children’s Specialty Program.
In May 2022, Governor Kevin Stitt signed a new Oklahoma law to implement Medicaid managed care by October 1, 2023.
SoonerSelect RFP
Oklahoma will award contracts to at least three entities to provide medical, behavioral, and pharmacy coverage to nearly one million eligible children, pregnant women, newborns, parents and caretake relatives, and the expansion population. However, enrollment in these populations is expected to drop following the end of the public health emergency (PHE).
At least one of the contracts may be awarded to a provider-led entity (PLE). PLEs would need to provide proof that a majority of their ownership is held by Oklahoma Medicaid providers or the majority of the governing body is composed of individuals who have experience serving Medicaid members and are licensed providers. PLEs would also be able to bid on urban regions if the PLE agrees to develop statewide readiness within a timeframe set by the OHCA. If no PLEs meet OHCA standards, Oklahoma can choose not to award a PLE.
Goals of the program will include:
Improve health outcomes for Medicaid members and the state as a whole
Ensure budget predictability through shared risk and accountability
Ensure access to care, quality measures, and member satisfaction
Ensure efficient and cost-effective administrative systems and structures
Ensure a sustainable delivery system that is a provider-led effort and that is operated and managed by providers to the maximum extent possible.
Timeline
Proposals will be due on February 8, 2023, and contract implementation is scheduled for October 1, 2023. The contract is expected to run through June 30, 2024, with five, one-year options.
Evaluation
Bidder’s technical proposals will be scored out of a total 1550 points. OHCA will award PLEs an additional 50 points for qualifying, bringing the total up to 1600 points. OHCA may also choose to conduct oral presentations for an extra total of 50 points.
SoonerSelect Children’s Specialty Program RFP
Oklahoma will select one of the awarded SoonerSelect plans for a separate statewide contract to provide comprehensive integrated health coverage to foster children, former foster children up to 25 years of age, juvenile justice-involved children, and children receiving adoption assistance. Contract terms will be the same as the main SoonSelect procurement, running from October 1, 2023, through June 30, 2024, with five one-year renewal options.