Medicaid Managed Care and Integrated Delivery Systems: Technical Assistance to States and Strengthening Federal Oversight

Prepared for
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services

Managed care has become the dominant delivery system in the Medicaid program; about three-quarters of the 60 million people enrolled in Medicaid in 2014 received some or all covered benefits through comprehensive managed care organizations, a 24 percent increase from 2013. More than half of state Medicaid agencies also operate other types of integrated delivery systems, such as health homes and accountable care organizations, to provide more coordinated and cost-effective services to people with complex care needs, such as chronic health conditions, serious mental illness, and substance use disorders.

This project works in partnership with the Center for Medicaid and CHIP Services (CMCS) within the Centers for Medicare & Medicaid Services (CMS), and state Medicaid agencies to strengthen and improve the design, operation, and oversight of Medicaid managed care (MMC) programs and integrated delivery systems. The project has a special focus on ensuring managed care organizations provide high quality, timely access to care for vulnerable groups of enrollees, including older adults, people with disabilities, and people with complex care needs.

Mathematica and its partners provide technical assistance to CMS and to states to support the four building blocks of effective managed care and health home programs:

  1. Enforceable contracts that comply with all federal rules
  2. Actuarially sound capitation rates and value-based payment methods
  3. Strong data collection and information management
  4. Quality and performance measurement

The project has developed several tools to strengthen federal monitoring and oversight of state MMC programs, including:

  1. Annual data collection and reports on enrollment and program features
  2. Checklists and workflow systems to support CMS’s review of managed care contracts and capitation rates
  3. Development of new quality and performance measures for Medicaid Managed Long-Term Services and Supports (MLTSS) programs and health homes programs
  4. Issue briefs and analyses of emerging trends, such as the use of medical loss ratios in MMC, new models for covering and delivering substance abuse services, and MLTSS quality strategies

In technical assistance (TA) and training to states, Mathematica prepared a comprehensive Encounter Data Toolkit, a practical guide to collecting, validating, and reporting data on services delivered by managed care plans; produced nine webinars on a variety of MMC topics; and provides individual TA to states on health home program development, care coordination models, quality measures for groups with special health care needs, and the development of MLTSS programs.

The project is working closely with CMCS and states to support implementation of the final MMC rule issued in May 2016