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

2012-Present
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; nearly 70 percent of the 80 million people enrolled in Medicaid in 2016 received some or all covered benefits through comprehensive managed care organizations. 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, report templates, and workflow systems to support CMS’s review of managed care contracts and capitation rates

  3. Toolkits and forums on ensuring adequate provider networks, and collecting and validating encounter data

  4. A national survey to examine coverage of services provided through Medicaid managed care to adults ages 21 to 64 who are receiving treatment of a psychiatric or substance use disorders in institutions for mental diseases (IMDs)

  5. Issue briefs and analyses of emerging trends, such as provider payment in MMC, the use of medical loss ratios in MMC, new models for covering and delivering substance abuse services, and MLTSS quality strategies

Mathematica and its partners at CHCS also provide 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.