Medicaid | National MCO Analyzer | 2014

Author: Paula Wade

Report Summary:
Medicaid is the fastest-growing segment of the healthcare industry and is set to expand by 6–8 million members in 2014 as 25 states expand their Medicaid programs under the ACA or in expansion waivers sanctioned by CMS. That growth changes Medicaid's patient mix significantly in the expansion states, where Medicaid will effectively become an income-based healthcare safety net. As of July 2013, 58 percent of Medicaid members had their benefits administered by at-risk managed care organizations—and MCO penetration continues to grow as states expand their MCO territories and add new populations to their MCO contracts. This report explores MCO growth, plan penetration, pharmacy control by MCOs, and the impact of the ACA expansion to stakeholders.
Questions Answered In This Report: 
Medicaid previously has been chiefly for needy children, their low-income parents, and the disabled. Medicaid expansion will broaden the patient mix to take in non-parents and those with incomes below 133 percent of the federal poverty level (in the expansion states). How will this change effect patient mix in the expansion states? Which states are expanding through the ACA and which are expanding through special waivers? How many people are expected to be added, given the difficulties with the exchanges?
States are expanding their use of MCOs, hiring them to manage long-term care and the medical care of acute populations including the disabled. What is the pharmacy utilization of these acute groups? How is that likely to be handled by MCOs?

The expansion population includes young, healthy individuals as well as the longtime uninsured.  How will the Medicaid population's health risk status change? What conditions are likely to be prevalent in this group? How are the state expansion alternatives creating a different paradigm for Medicaid coverage, and how may that impact pharma?
Primary Research: Data from HealthLeaders-InterStudy, documents and research from and the Centers for Medicare & Medicaid Services, Kaiser Family Foundation, National Association of State Medicaid Directors, MEDPAC.

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