This week, Health Management Associates Information Services (HMAIS) released a new report that provides a detailed, state-by-state analysis of how Medicaid managed care programs are implementing and enforcing medical loss ratio (MLR) requirements. The comprehensive report, Medicaid Financial Accountability and Risk Sharing Arrangement Report, looks at 43 states and the District of Columbia, drawing from the most recent publicly available rate certifications and model contracts.
The report—available exclusively to HMAIS subscribers— supports policy analysts, actuaries, and other interested Medicaid stakeholders with comparative analysis and identification of emerging trends, outliers, and best practices in managed care oversight.
Key Highlights in the 2025 Report
The HMAIS team examined rate certifications and model contracts, primarily covering rate periods ending in or extending through 2025. The report also reflects recent federal policy changes, including the Centers for Medicare & Medicaid Services (CMS) 2024 final rule requiring the inclusion of state-directed payments in MLR calculations—an update that is already influencing how states structure their payment, reporting, and oversight processes.
Each state profile outlines key elements of the following:
- MLR thresholds and remittance obligations
- Risk corridors and reinsurance strategies
- Other risk mitigation strategies, including high-cost drug pools and retroactive eligibility adjustments
Key findings include:
- Standardization is at 85 percent: Most states with risk-based programs (22) enforce the federal minimum MLR of 85 percent.
- Stricter Thresholds: 11 states have adopted thresholds above 85 percent, with some reaching as high as 91.3 percent (Mississippi).
- Most states require managed care organizations to remit funds if they fall below the MLR threshold. Enforcement varies, however, with strict enforcement in states like Georgia, Indiana, and Iowa, which require 100 percent of the shortfall to be returned, and more flexible policies in other states.
- The analysis finds states are modifying certain traditional policies and tools to strengthen financial accountability mechanisms and evolve policies to address the changing federal policy landscape. For example, in lieu of remittances, Oregon and Tennessee allow plans to reinvest funds in the community.
Connect With Us
As states continue to refine their approaches to financial accountability and program integrity and design innovative approaches to address enrollee healthcare needs, the HMAIS report offers a timely and actionable reference point.
This report is just one component of the broader HMAIS subscription platform, which offers exclusive access to:
- Searchable files that enable comparative analysis of key state program information and data
- Timely updates on Medicaid policy developments
- Downloadable state-by-state and industry files
For health plans, state agencies, provider organizations, partners, and advocacy groups, subscribing to HMAIS means staying ahead of regulatory changes, identifying emerging trends, and making informed decisions about strategy, compliance, and program design. For more information about the new report, contact featured HMAIS team member below.
