Projects
State and Federal Tools for Ensuring Accountability of Medicaid Managed Care Organizations (MCOs)
2024-2025
Project Overview
Objective
Mathematica is conducting an environmental scan and stakeholder interviews to deepen our understanding of the tools used to assess MCO performance, the consequences for not complying with contract requirements or not achieving performance standards set by the state, and the use and effectiveness of enforcement tools to hold MCOs accountable and improve performance.
Project Motivation
Risk-based contracts with managed care have been the predominant delivery system for providing health coverage to Medicaid beneficiaries over the past decade. As enrollment in Medicaid managed care has increased, so too has the share of total Medicaid expenditures made through capitation payments to managed care plans. The growth in managed care enrollment and spending creates enormous potential to improve access, quality, and health outcomes for enrollees. However, achieving these goals depends on strong federal and state oversight of managed care plans’ performance. While CMS has made concerted efforts to strengthen federal and state managed care oversight, little is known about the enforcement and accountability tools that states use to assess MCO compliance with contract requirements and compare MCO performance to access and quality standards.
Prepared For
Medicaid and CHIP Payment and Access Commission
Investigating the use and effectiveness of enforcement tools in Medicaid managed care to hold MCOs accountable and improve performance.
As a nonpartisan legislative agency, MACPAC plays a key role in advising Congress, the Secretary of HHS, and states on policies and practices to advance the goals of Medicaid and CHIP programs. MACPAC and other federal oversight agencies such as GAO and OIG have raised concerns about the need for more transparency in CMS oversight activities. This lack of transparency raises questions about whether existing accountability and enforcement tools are sufficient to ensure compliance with MCO contract requirements and the effectiveness of states and CMS use of these tools to improve access, quality, and outcomes for Medicaid managed care enrollees.
Mathematica is working with MACPAC to deepen its understanding of the tools used to assess MCO performance, the consequences for not complying with contract requirements or not achieving performance standards set by the state, and the use and effectiveness of enforcement tools to hold MCOs accountable and improve performance. Key research questions include: (1) what tools (such as penalties or incentives) are available to states to ensure MCO compliance and to improve MCO performance, and what tools do states actually use? (2) Is there evidence to suggest that certain tools are more or less effective? Should use of certain tools be required? (3) What tools are available to CMS to ensure state and MCO compliance and to improve MCO performance (for example, oversight of state monitoring and direct authority for sanctions)? (4) To what extent does CMS use existing tools, and does CMS need additional tools?
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