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Management and Delivery of the Medicaid Pharmacy Benefit

States are limited in their leverage when it comes to controlling drug spending and use a variety of strategies to manage utilization, including an increased reliance on managed care and pharmacy benefit managers (PBMs). As policymakers debate proposals that include provisions related to Medicaid pharmacy benefits, it is important to understand the challenges state Medicaid programs face and how policy proposals may impact Medicaid beneficiaries and costs.

Mapping Medicaid Delivery System and Payment Reform

This interactive provides state-by-state data on Medicaid delivery system and payment reform initiatives. Users can track state Medicaid managed care, patient-centered medical home (PCMH), Health Home, Accountable Care Organization (ACO), and Delivery System Reform Incentive Payment (DSRIP) waiver activity.

A View from the States: Key Medicaid Policy Changes: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2019 and 2020

This report provides an in-depth examination of the changes taking place in Medicaid programs across the country. The findings are drawn from the 19th annual budget survey of Medicaid officials in all 50 states and the District of Columbia conducted by the Kaiser Family Foundation (KFF) and Health Management Associates (HMA), in collaboration with the National Association of Medicaid Directors (NAMD). This report highlights certain policies in place in state Medicaid programs in FY 2019 and policy changes implemented or planned for FY 2020.

10 Things to Know about Medicaid Managed Care

This brief describes key themes related to the use of comprehensive, risk-based managed care in the Medicaid program and highlights data and trends related to MCO enrollment, service carve-ins, spending, MCO parent firms, and state and plan activity related to quality, value-based payments, and the social determinants of health.

A First Look at North Carolina’s Section 1115 Medicaid Waiver’s Healthy Opportunities Pilots

Medicaid funds typically cannot be used to pay for non-medical interventions that target the social determinants of health. However, in October 2018, CMS approved North Carolina’s Section 1115 waiver which provides financing for a new pilot program, called “Healthy Opportunities Pilots,” to cover evidence-based non-medical services that address specific social needs linked to health/health outcomes. The pilots will address housing instability, transportation insecurity, food insecurity, and interpersonal violence and toxic stress for a limited number of high-need Medicaid enrollees. This brief summarizes key features of the pilots.

CMS’s 2018 Proposed Medicaid Managed Care Rule: A Summary of Major Provisions

On November 14, 2018, the Centers for Medicare and Medicaid Services (CMS) proposed revisions to the Medicaid managed care regulations with public comments due by January 14, 2019. CMS previously finalized a major revision to these regulations in 2016. The November 2018 proposed rule is not a wholesale revision of the 2016 final rule but proposes changes in the following key areas: network adequacy, beneficiary protections, quality oversight, and rate setting and payment.

States Focus on Quality and Outcomes Amid Waiver Changes: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2018 and 2019

This report provides an in-depth examination of the changes taking place in Medicaid programs across the country. Report findings are drawn from the annual budget survey of Medicaid officials in all 50 states and the District of Columbia. This report examines the reforms, policy changes, and initiatives that occurred in FY 2018 and those adopted for implementation for FY 2019 (which began for most states on July 1, 2018). Key areas covered include changes in eligibility, managed care and delivery system reforms, long-term services and supports, provider payment rates and taxes, covered benefits, and pharmacy and opioid strategies.

Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity

Research demonstrates that improving population health and achieving health equity will require broad approaches that address social, economic, and environmental factors that influence health. This brief provides an overview of the broad factors that influence health and describes efforts to address them, including initiatives within Medicaid.