There are three key elements to understanding the impact of Medicaid managed care enrollment and financing arrangements in any state:
- The financing mechanism – fee-for-service (FFS), primary care case management (PCCM), or managed care
- The services provided under the financing arrangement – behavioral health, physical health, and long-term services and supports
- The populations included in the arrangement – the Medicaid-eligible population, the Medicaid-eligible population also eligible for LTSS, and the Medicare-Medicaid dual eligible population
Over time, Medicaid managed care programs have grown to be the dominant contracting model with 70% of the Medicaid population enrolled in managed care in 2017—a 43% increase since 2010. See OPEN MINDS 2017 Medicaid Managed Care Market Share Report for more information. Managed care delivery models typically are structured to provide a capitated payment to health plans to provide services to Medicaid enrollees. Due to the risk associated with capitation, managed care entities rely heavily on utilization and rate control measures such as limited provider networks, prior authorization, and value-based provider reimbursement.
Although new states are slow to adopt managed care financing arrangements, at least three states that already have Medicaid managed care programs—Illinois, Pennsylvania, and Virginia—are continuing to add new populations and services to their current managed care arrangements.
This OPEN MINDS Market Intelligence Report explains the populations enrolled in Medicaid managed care, explores the trends in Medicaid financing arrangements and gives a state-by-state analysis of Medicaid managed care enrollment.