Skilled nursing facilities that lack a clear strategy for engaging Medicaid MCOs on contracting, prior authorization, and quality metrics risk being squeezed on rates and referrals as states expand managed care to higher-acuity populations.
10 Things to Know About Medicaid Managed Care
As of July 2024, 42 states (including DC) contract with comprehensive, risk-based managed care plans to provide care to at least some of their Medicaid beneficiaries. Payments made to MCOs accounted for about 52% of total Medicaid spending in FY 2023. As of July 2022, nearly 72 million Medicaid enrollees received their care through risk-based MCOs. Five firms – Centene, UnitedHealth Group, Elevance (formerly Anthem), Molina, and Aetna/CVS – account for 50% of all Medicaid MCO enrollment. A July 2023 OIG report found that Medicaid MCOs had an overall prior authorization denial rate of 12.5%–more than 2 times higher than the Medicare Advantage rate.
— KFF, February 27, 2025
Hinton, Elizabeth and Jada Raphael. “10 Things to Know About Medicaid Managed Care.” KFF, 27 Feb. 2025. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-managed-care/.
✔ Comply with every payer's rules
✔ Equip your team with the Playbook
✔ Monitor rates and payer trends
