Insights

This week, our In Focus section highlights findings from the Centers for Medicare & Medicaid Services (CMS) preliminary CMS-64 Medicaid expenditure report for federal fiscal year (FFY) 2024. According to the preliminary estimates, Medicaid expenditures on medical services across all 50 states and six territories in FFY 2024 totaled $908.8 billion.

This figure provides important context and an initial baseline for tracking Medicaid spending trends following the enactment of H.R. 1, the One Big Beautiful Bill Act. According to the Congressional Budget Office’s preliminary analysis, H.R. 1 will reduce federal Medicaid and Children’s Health Insurance Program (CHIP) spending by approximately $1.02 trillion over the next decade (2025−2034)—a significant share of total Medicaid expenditures.

Total Medicaid Managed Care Spending

The following analysis is based on a Health Management Associates Information Services (HMAIS) analysis of the draft CMS-64 report. This report contains preliminary estimates of Medicaid spending by state for FFY 2024. CMS tracks state expenditures through the automated Medicaid Budget and Expenditure System/State Children’s Health Insurance Budget and Expenditure System (MBES/CBES). The CMS-64 form identifies annual expenditures through these systems.

Key findings from HMAIS’ analysis, as also shown in Table 1, include:

• Total Medicaid managed care spending (federal and state share combined) reached $517.5 billion in FFY 2024, up from $508.1 billion in FFY 2023.
• This amount represents a 1.9 percent year-over-year increase from FFY 2023 to FFY 2024, a notable slowdown compared to the 8.5 percent growth observed in our analysis of year-over-year spending from FFY 2022 to FFY 2023.
• Managed care accounted for 56.9 percent of total Medicaid spending in FFY 2024, down 2.6 percentage points from the previous year.
• In terms of dollars, the increase in Medicaid managed care spending from FFY 2023 to FFY 2024 was $9.4 billion, compared with $39.8 billion from FFY 2022 to FFY 2023.

These figures include spending on comprehensive risk-based managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), and prepaid ambulatory health plans (PAHPs). PIHPs and PAHPs refer to prepaid health plans that provide only certain services, such as dental or behavioral health care. Fee-based programs, such as primary care case management models, are not included in this total.

Table 1. Medicaid MCO Expenditures as a Percentage of Total Medicaid Expenditures, FFY 2020−2024 ($M)

Medicaid Managed Care Spending Insights

Medicaid managed care expenditures have grown consistently each year with total Medicaid expenditures. In FFY 2024, however, the growth in the share of managed care expenditures was notably lower than in the previous four years. The slower growth in managed care spending aligns with the post-COVID-19 policy unwinding period, during which many states completed eligibility redeterminations that had been paused during the public health emergency, driving historic enrollment increases (see Figure 1).

Figure 1. Total and MCO Medicaid Expenditures, FFY 2020−2024 ($M)

In addition, Health Management Associates (HMA) has access to data in the Transformed Medicaid Statistical Information System (T-MSIS) and has analyzed MCO spending in major categories of healthcare, including inpatient and outpatient hospital care, physician and other professional services, skilled nursing facilities (SNFs) and home and community-based services (HCBS), clinics, pharmaceuticals, and other services. Similarly, based on the CMS-64 data, in FFY 2024, the largest non-managed care spending categories included:

• HCBS: $108.8 billion
• Inpatient hospital services: $71.9 billion
• Nursing facilities: $46.3 billion

HMA’s analysis of the T-MSIS database shows that while managed care remains the dominant delivery system model for Medicaid, spending in certain categories, such as SNFs and professional services, is growing faster. This shift may explain the declining share of managed care in overall Medicaid expenditures, even as absolute spending remains high. Further details can be found on this webpage and this webpage as well.

Federal Versus State Spending

This year’s data reflect the phase-out of the temporary 6.2 percentage-point federal medical assistance percent increase under the Families First Coronavirus Response Act, which ended December 31, 2023. In FFY 2024, 64.7 percent of FFY 2024 spending came from federal sources (see Table 2).

Table 2. Federal versus State Share of Medicaid Expenditures, FFY 2020−2024 ($M)

What to Watch

Looking ahead, state Medicaid agencies will need to reassess financing strategies as total Medicaid federal funding declines because of H.R. 1 and other federal regulatory oversight and policy changes take effect. H.R. 1 includes provisions to gradually reduce allowable state provider tax rates from 6 percent to 3.5 percent by 2032, potentially requiring states to restructure financing or identify cost-saving measures.

CBO projections estimate that the Medicaid provisions in the bill will increase the number of uninsured individuals by an estimated 7.8 million by 2034.

Connect with Us

HMAIS, a subscription-based tool offered by HMA, provides detailed state by state analysis of the CMS-64 data and Medicaid managed care enrollment trends. For more information about the HMAIS subscription and access to the CMS-64 data, contact our experts below.

This month’s Vital Viewpoints podcast features a special conversation with Jay Rosen, founder, president, and chairman of Health Management Associates (HMA), as he reflects on the evolution of Medicaid and the 40^th anniversary of HMA’s founding. From his early days shaping Michigan’s Medicaid program in Michigan’s Office of Health and Medical Affairs, to building a national firm dedicated to public sector healthcare, Jay’s story is one of purpose, persistence, and visionary leadership. Over four decades, Jay has guided HMA’s strategic vision, growth, client service, and innovation in publicly funded healthcare.

Jay began his career at a time when Medicaid was still finding its footing. In the 1970s and early 1980s, states were grappling with how to operationalize a new federal promise—healthcare for low-income and aging Americans. Jay saw firsthand the complexity and urgency of that challenge. But he also saw opportunity: to build something better, smarter, and more accountable. That vision led to a fateful meeting at a Big Boy diner in East Lansing, Michigan, where Jay, Paul Allen (Michigan’s then Medicaid director), Elliot Wicks, and Jay Endsley laid the groundwork for what would become HMA on June 13, 1985, the date HMA was founded.

The 1980s saw extreme economic distress in the U.S., with healthcare costs rising by 1,520% annually. Pressure on the federal government to reduce financial support for public sector health programs meant state governments had to lead the way. Managed care emerged as a novel idea, using risk-bearing intermediaries between the state as a payer and providers/consumers. Michigan was an early adopter of managed care.

Over the next four decades, managed care programs evolved to bring more accountability in Medicaid, transforming the state’s role from administrator to regulator. The state agency could focus on using its levers to improve performance of public programs. Reporting requirements, data-driven decision making, quality measurement and other innovative tools were introduced.

“One-third of the country is on Medicaid, covering 90 million people, including the most expensive, vulnerable populations. Medicaid operates well despite financial challenges, addressing significant societal obligations,” says Rosen.

Now, as we celebrate the 60^th anniversary of Medicaid in July, the program faces new operational and financial pressures, but also new tools — like AI and digital health technologies to meet the moment. Innovation in Medicaid isn’t optional, it’s essential.  HMA experts work with states and other organizations to harness these tools and stay current with these new initiatives.

Hear more from Jay in this month’s podcast episode, “Medicaid At (Another) Crossroads: The Future of Public Healthcare Coverage”.  And as you look ahead to the future of Medicaid, trust HMA to be your partner for the next 40 years to come. #HMAknowsMedicaid

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.