As of fiscal 2023, nearly three-quarters of Medicaid beneficiaries were enrolled in a full-risk managed care organization, up from less than half in fiscal 2010.
On June 15, the Medicaid and CHIP Payment and Access Commission, an agency that advises on Medicaid and the Children’s Health Insurance Program, released its June 2026 report for Congress.
Here five things to know from the report:
1. Managed care capitation payments made up 57.3% of Medicaid benefit spending in fiscal 2023, versus 23.5% in fiscal 2010.
2. Data from state-submitted Managed Care Program Annual Reports does not always accurately reflect sanctions, such as one state only reporting a $2,500 sanction but not $33.8 million in liquidated damages.
3. All states and managed care organizations interviewed use automation tools. Rules-based algorithms for determining medical necessity are popular. Only a subset of respondents use automation for prior authorization decisions.
4. States said automation in prior authorization is more common with managed care than fee-for-service Medicaid.
5. There is limited federal guidance with automated Medicaid prior authorization, something MACPAC specifically calls for. Oversight standards should not differ between FFS and managed care, MACPAC said.
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