Projects
Supporting CMS and State Use of Medicaid Managed Care Payment Strategies
2021-2026
Project Overview
Objective
To strengthen CMS oversight of Medicaid managed care payment strategies, support CMS policy development, and encourage state use of these strategies in innovative ways. Mathematica also supports CMS efforts to implement recent access, eligibility and enrollment, and managed care regulations.
Project Motivation
Managed care is the dominant delivery system that states use to deliver Medicaid services, and CMS and states share a goal to ensure that Medicaid managed care plans spend public funds wisely. CMS contracted with Mathematica as a trusted partner with the payment policy and operations, technical assistance, compliance, and analytics capabilities needed to help CMS and states meet this goal.
Partners in Progress
Myers and Stauffer
Prepared For
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services
Mathematica is helping CMS and states use, oversee, and improve Medicaid payment tools and financial mechanisms such as medical loss ratios, state directed payments, and risk mitigation strategies to help ensure that public funds are spent wisely.
Managed care has replaced fee-for-service as the dominant delivery system that states use to deliver Medicaid services to beneficiaries. Under this system, states contract with managed care plans, which are paid predetermined rates to cover and coordinate Medicaid services. CMS and states share responsibility to ensure that managed care plans spend public funds wisely, provide high quality care, and deliver adequate access to services. To help meet these responsibilities, states use payment tools and financial mechanisms such as minimum medical loss ratio standards, state directed payments, and risk mitigation mechanisms, including risk corridors, risk pools, reinsurance, and gainsharing arrangements.
The Medicaid Payment Strategies (MPS) project provides advisory services to help CMS and states use, oversee, and improve these payment tools and financial mechanisms. Mathematica evaluates state compliance with medical loss ratio requirements, provides data-driven insights on state directed payments, and provides technical assistance to states.
Project Impact
Mathematica’s contributions to CMS and states on this project include:
An MLR toolkit for states on collecting and validating MLR data received from managed care plans.
Publicly available Medicaid managed care MLR data.
Risk mitigation and MLR reporting templates states can use to gather standardized information from managed care plans.
SDP analyses, such as state use of SDPs for value based payment.
The SDP preprint technical guide, which walks states though CMS’s SDP application and approval process.
Reports on state use of risk mitigation strategies to mitigate financial impacts from the COVID-19 public health emergency.
Evidence & Insights From This Project
Publication
Incorporating Value-Based Payment into State-Directed Payment Arrangements can Improve Outcomes for Dually Eligible Individuals
State-directed payments are a powerful yet underused tool to implement value based payment and reward plans and providers for producing better outcomes. In this Health Affairs Forefront article, we explain how states can use them to improve health outcomes for dually eligible individuals.
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