Understanding the growth, complexities, and variations in Medicaid managed care across states is crucial for skilled nursing facilities as they navigate contracting, reimbursement, and care coordination for this resident population. The analysis underscores the need for facilities to actively engage with both state Medicaid agencies and managed care organizations to understand program design, utilization review processes, and quality metrics shaping care delivery and financial sustainability.
Managed care is the dominant delivery system for Medicaid enrollees. The latest national Medicaid managed care enrollment data (from 2021) show 74% of Medicaid beneficiaries were enrolled in comprehensive managed care organizations (MCOs). The Centers for Medicare and Medicaid Services (CMS) continues to highlight the role MCOs can play in helping people eligible for Medicaid use and keep their coverage during the unwinding of the continuous enrollment requirement. While managed care is the dominant Medicaid delivery system, states decide which populations and services to include in managed care arrangements, which leads to considerable variation across states. Additionally, while state requirements for Medicaid managed care plans can be tracked, plans have flexibility in certain areas, including in setting provider payment rates, and plans may choose to offer additional benefits beyond those required by the state. The Biden Administration released final regulations involving Medicaid Managed Care Access, Finance, and Quality in April 2024. While these rules are extensive and complex, a primary aim of the new rules is to strengthen standards for timely access to care and states’ monitoring and enforcement efforts. This brief describes 10 themes related to the use of comprehensive, risk-based managed care in the Medicaid program.
1. Today, capitated managed care is the dominant way in which states deliver services to Medicaid enrollees.
2. Nearly three-quarters (74%) of all Medicaid beneficiaries received their care through comprehensive risk-based MCOs.
Hinton, E., & Raphael, J. (2024, June 26). 10 things to know about Medicaid Managed Care | KFF. KFF. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-managed-care/
Improve Medicare Advantage reimbursements with payer contract management that puts payer rules in the hands of clinicians & billers.
