Medicaid managed care means working with Managed Care Entities (MCEs) that get fixed payments to provide health care to Medicaid members. In Indiana, there are four main managed care programs that serve more than a million Medicaid recipients: Healthy Indiana Plan (HIP), Hoosier Healthwise, Hoosier Care Connect, and Indiana PathWays for Aging. These programs try to improve access and quality of care. The MCE must manage and coordinate health services for its members using a risk-based capitation model.<\/p>\n
The Indiana Family and Social Services Administration\u2019s (FSSA) Office of Medicaid Policy and Planning (OMPP) oversees these programs. It manages contracts with six health insurance companies, making sure they meet service agreements and have financial stability. These contracts usually last four years but can be extended. The Centers for Medicare and Medicaid Services (CMS) must approve them to meet federal rules.<\/p>\n
Indiana checks that Medicaid managed care programs work well by having MCEs send monthly and quarterly reports to OMPP. OMPP reviews these reports against many service agreements. These cover things like access to primary care, how fast specialist visits happen, hospital readmission rates, and preventive services. OMPP also does detailed reviews and site visits with outside partners like Burns & Associates, which do annual External Quality Reviews (EQR). This is required by federal rules to make sure services meet set standards.<\/p>\n
Indiana also looks at the quality of care with accreditation from the National Committee for Quality Assurance (NCQA). NCQA checks managed care groups on clinical results, patient happiness, and care coordination. Meeting NCQA standards is like a quality benchmark. NCQA runs the Healthcare Effectiveness Data and Information Set (HEDIS\u00ae), which uses over 90 measures to look at healthcare access, results, and patient experience. By checking these, OMPP finds areas that need fixing and enforces contract rules.<\/p>\n
Indiana\u2019s Medicaid managed care fits into a bigger national picture where managed care is common for Medicaid. In 2022, 75% of Medicaid recipients across the country were enrolled in risk-based Managed Care Organizations (MCOs). By mid-2024, 42 states, including Indiana, had contracts with Medicaid MCOs using capitation payments. These payments make up about 52% of all Medicaid spending, which was over $880 billion in 2023.<\/p>\n
Nationally, Medicaid managed care covers many people with complex needs. This includes older adults over 65 and people with disabilities. These groups need many coordinated services like mental health care, long-term disease management, and care before and after birth. Indiana\u2019s managed care contracts address these needs too. They also look at social factors like housing problems and food shortages, so MCEs work beyond just medical care.<\/p>\n
Big companies play a big role in Medicaid managed care. Five major firms\u2014Centene, UnitedHealth Group, Elevance (formerly Anthem), Molina, and Aetna\/CVS\u2014serve about half of Medicaid MCO members nationwide. These companies bring experience and money, but also raise concerns about how clear and consistent care is. CMS rules in 2024 added stronger standards on wait times and prior authorizations, but states vary in how well they enforce the rules.<\/p>\n
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