Transparency in Medicaid Managed Care: Findings from a 13- State Scan by Allie Corcoran, Emma Hurler, Andy Schneider, and Julia Buschmann Key Findings Contents zz State Medicaid agency and Managed Care Executive Summary Organization (MCO) websites varied in the amount Why MCO Performance Matters to Child and type of information that they made publicly and Maternal Health available, but most fell far short of including basic information about MCO enrollment and performance Why Transparency Matters to MCO for children and pregnant individuals. Out of the 13 Performance states included in the scan: zz Onlythree posted child enrollment on an MCO- The States and MCOs We Scanned specific basis. The Performance Information We zz Noneposted MCO-specific Early and Periodic Searched For Screening, Diagnostic and Treatment (EPSDT) screening metrics. The Performance Information We Found zz Noneposted MCO-specific quality metrics Racial and Ethnic Disparities disaggregated by race or ethnicity. Discussion and Recommendations zz None of the state Medicaid agency websites posted all of the minimum data elements required by federal Methodology regulations. zz The little information available hinted that quality and access to services varied widely between MCOs within states, between states, and across managed care parent firms in calendar year 2018. This variation highlights the need for further transparency as advocates and stakeholders work with state agencies to ensure that children and pregnant individuals enrolled in managed care receive the services to which they are entitled. September 2021 CCF.GEORGETOWN.EDU Transparency in medicaid managed care 1 Executive Summary Medicaid is the nation’s largest health insurer for children; posted enrollment, EPSDT, or child and maternal health more than one in three children in the United States are quality data disaggregated by race and ethnicity. covered by Medicaid or CHIP.1 The programs promise The state Medicaid agency websites we searched varied children a comprehensive pediatric benefit package at widely in the availability of MCO-specific information and little to no cost and have been shown to improve health user-friendly organization, but tended towards opacity. and educational outcomes well into adulthood.2 In 40 Illinois, Iowa, Kentucky, and Pennsylvania’s websites were states, Medicaid coverage means enrollment in a Medicaid the most transparent; those of Kansas, Missouri, and Utah managed care organization (MCO). If the MCO fulfills its the least. Even among the more transparent states, however, obligations to its beneficiaries, Medicaid coverage works; if there was still a considerable lack of data. None of the state the MCO does not, Medicaid continues to spend but its full Medicaid agency websites posted all of the minimum data promise is not realized. In this paper we ask the question: elements required by federal regulations. Does the public have the information needed to tell whether or not MCOs are fulfilling their responsibilities to children We have three recommendations for improving Medicaid and pregnant individuals* enrolled in Medicaid? We find that, coverage for children and pregnant women by increasing in the states we examined, the answer is “no.” transparency of information about the performance of individual MCOs: Over a 12-month period, June 2020 through May 2021, we searched the websites of state Medicaid agencies, state 1. State Medicaid agencies should maintain a child health insurance departments, and individual MCOs for information dashboard that contains MCO-specific performance data on the performance of 56 MCOs in 13 states: Arizona, and is easily accessible. At a minimum, this performance Georgia, Illinois, Iowa, Kansas, Kentucky, Mississippi, data should include EPSDT screenings and treatment, Missouri, Nevada, Pennsylvania, Tennessee, Utah, and West Child Core Set metrics, and all information required to Virginia. We searched for a set of basic, non-proprietary data be posted by federal regulations. The dashboard should elements that could help us gauge how individual MCOs include a data hub with links to relevant structural are performing. These included the number of children information about each MCO. enrolled in an individual MCO, disaggregated by age, race, 2. The Centers for Medicare & Medicaid Services and ethnicity; whether those children received the Medicaid (CMS) should monitor and enforce state Medicaid pediatric benefit, Early and Periodic Screening, Diagnostic, agency compliance with the minimum transparency and Treatment (EPSDT) services, to which they were requirements in its managed care regulations. entitled; measures of the quality and accessibility of covered 3. CMS should add a child health dashboard as a measure pediatric and maternity services; and the amount of money to the State Administrative Accountability pillar of its the state paid each MCO to furnish services to children Medicaid & CHIP Scorecard. The child health dashboard and pregnant individuals. We also searched for information should include MCO-specific performance information relating to the structure and organization of MCOs required on EPSDT screenings and treatment and Child Core Set by federal transparency regulations.3 metrics. Of the 13 state Medicaid agency websites we scanned, only three posted the number of children enrolled in each MCO, and only two posted the number of pregnant women* * Editor’s Note: To maintain accuracy, CCF uses the term ‘pregnant enrolled. Only one posted the amount the state paid each women’ when referencing statute, regulations, research, or other data sources that use the term pregnant women to define or count MCO to furnish services. No state posted information people who are pregnant. Where possible, we use more inclusive on receipt of EPSDT services (other than dental care) by terms in recognition that not all individuals who become pregnant and give birth identify as women. children enrolled in each MCO. And none of the 13 states September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 2 Why Medicaid MCO Performance Matters to Child and Maternal Health A Medicaid managed care organization (MCO) is an health insurance branch is Aetna), Molina, and UnitedHealth entity that contracts with the state Medicaid agency on Group—own 119 of the 287 MCOs operating in the 40 a risk basis to manage the provision of comprehensive states and D.C., and each of these parent companies owns acute care services to Medicaid beneficiaries. Under the subsidiaries in at least 15 states.8 contract between the MCO and the state Medicaid agency, Because Medicaid covers over 35 million children and the agency pays the MCO a fixed amount each month pays for over 40 percent of the nation’s births, how well on behalf of each beneficiary enrolled with the MCO, Medicaid works matters enormously to the health and life regardless of whether the enrollee uses services in that outcomes of eligible children and pregnant individuals. month. In exchange for this monthly capitation payment, And because so many state Medicaid agencies contract the MCO agrees to make services covered under the with MCOs to manage the care of eligible children and contract accessible to its enrollees through a network of pregnant individuals, how well those MCOs perform largely hospitals, physicians, and other providers with which it has determines how well Medicaid works for these beneficiaries. subcontracted. Finally, because the children and pregnant individuals who State Medicaid programs are not required to purchase are eligible for Medicaid are disproportionately people of covered services through MCOs, but most do. As of March color, how well MCOs perform will largely determine how 2021, 40 states and the District of Columbia contracted with effectively Medicaid addresses racial and ethnic health a total of 287 MCOs on a risk basis.4 As a result, most of the disparities. children and pregnant individuals covered by Medicaid are enrolled in an MCO.5 Each MCO determines the hospitals, physicians, and other providers with which it will contract; if enrollees want Medicaid to pay for their care, they will generally be limited to using those network providers. MCOs also manage beneficiary utilization of medical services through administrative requirements like prior authorization and review of provider claims for “medical necessity.” If an MCO’s provider networks are too limited, or if the MCO’s utilization controls are too tight, children and pregnant individuals enrolled in the MCO will not receive the services they need and to which they are entitled.6 MCOs may be for-profit, nonprofit, or public. Some MCOs are wholly-owned subsidiaries of national, publicly-traded firms for which Medicaid managed care is a profitable line of business.7 MCOs that belong to these companies have multiple, sometimes competing, incentives: to furnish services to their enrollees per the contract with their state agency client and to maximize profits for their shareholders. Nationally, five companies—Anthem, Centene, CVS (whose September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 3 Why Transparency Matters to Medicaid MCO Performance Medicaid MCOs are complex organizations. In any given good providers, and bonus payments. When performance is state, individual MCOs can be responsible for the coverage low, questions can be asked of both the MCO management of hundreds of thousands of beneficiaries and receive and the state Medicaid agency. State auditors, legislators, hundreds of millions, if not billions, of state and federal beneficiary advocates, and members of the media all have funds to do so. The control over the health care for that ways of calling either the MCOs or the agencies, or both, to many people, and such large sums of federal and state account. resources, combined with the ability to select providers for Transparency is not the only tool for holding MCOs and state their networks, gives them considerable leverage over local Medicaid agencies accountable, but it has the advantage of health care delivery systems. The hundreds or thousands not imposing additional costs or significant administrative of jobs they support can make them one of the most burden on either the MCOs or the state Medicaid agency. economically and politically significant employers in a state. MCOs are already being paid to manage care and report They are typically well-provisioned with actuaries, lawyers, their performance to the state Medicaid agencies; state and lobbyists.9 In contrast, the state Medicaid agencies agencies are already reviewing this information to assess that are responsible for contracting with and monitoring the the accessibility and quality of care Medicaid beneficiaries performance of the MCOs are often under-resourced relative receive from the contracted MCOs. Transparency simply to the task at hand. With such limited resources, state requires that this information be publicly available so that all agencies’ focus on the possible savings from managing the stakeholders—beneficiaries, providers, state policymakers, care of high-cost populations means that children’s primary investors, researchers, advocates, and the public at large— and preventive care often takes the back seat in both MCO can know which MCOs are performing at a high level and contracting and oversight.10 which are not. In addition, we believe there is a potential “transparency Transparency allows Medicaid stakeholders, effect” that comes from the norm of transparency itself. If including beneficiaries, providers, and MCO management knows that performance information competitor MCOs, to understand how will be made available to public, and if they are interested in protecting their organization’s reputation, they are more individual MCOs are performing. likely to take action to improve their performance than if they are confident that information about poor performance will remain out of view. The same logic applies to state Transparency—i.e., making performance data that is Medicaid agencies, who do not want to be seen as being reported by individual MCOs to the state Medicaid agency poor stewards of public dollars that tolerate substandard public—is one solution to this asymmetry. It allows Medicaid performance by individual MCOs under their oversight. stakeholders, including beneficiaries, providers, and competitor MCOs, to understand how individual MCOs are performing in relation to both what their contract with the state requires of them and how their peer MCOs in the state are doing. When performance is high, an MCO can be recognized for that and potentially be rewarded with increased enrollment, improved ability to recruit and retain September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 4 The States and MCOs We Scanned To obtain information on the performance of individual The 56 MCOs represent a mix of for-profit and nonprofit MCOs for children and pregnant individuals, we firms and include subsidiaries of all five of the largest searched the websites of state Medicaid agencies, state national health insurance companies in the Medicaid Insurance Departments, and individual MCOs. We did managed care market (Aetna/CVS, Anthem, Centene, not submit Public Records Act requests for information Molina, and UnitedHealth Group). Appendix A lists the to state agencies or make direct requests for data to MCOs and parent companies by state. They are not individual MCOs. (See the Methodology section below). necessarily representative of all 287 MCOs with which We were unable to find any child or maternal health state Medicaid agencies contracted as of March 2021. We performance information specific to individual MCOs on focused our search on results for performance year 2018, the federal Medicaid agency’s website, Medicaid.gov. the most recent year available at the beginning of our search We did not submit a Freedom of Information Act request (see Methodology section for more detail). Because the for this data to CMS. Medicaid managed care market is not static, some of the MCOs we reviewed have subsequently exited the Medicaid We focused on 13 states: Arizona, Georgia, Illinois, market, changed ownership due to an acquisition, or ceased Iowa, Kansas, Kentucky, Mississippi, Missouri, Nevada, operations altogether. Pennsylvania, Tennessee, Utah, and West Virginia. These states are in different regions of the United States, have both large and small Medicaid populations, and vary in demographic and political makeup (see Table 1). Some— Focus on MCOs 13instates Arizona and Tennessee—have been contracting with MCOs for decades; others—Iowa and Kansas—for just a few years. Despite their diversity, these 13 states are not different necessarily representative of all 40 states (and the District regions of the of Columbia) that contract with Medicaid MCOs on a risk country that vary basis. They were selected because CCF partners with in the size of their child health advocates in each and because each state Medicaid populations, contracts with less than ten MCOs.11 and in their During the period of our search, these 13 states demographic and contracted with a total of 62 MCOs. Six of those political makeup. MCOs were contracted to furnish services only to Arizona, Georgia, Illinois, youth in foster care and similar highly vulnerable child Iowa, Kansas, Kentucky, populations (e.g., justice-involved youth). Our findings Mississippi, Missouri, on these MCOs are not included in the results presented Nevada, Pennsylvania, in this paper; they will be the subject of a separate Tennessee, Utah, analysis. The remaining 56 MCOs enrolled both children West Virginia and adults. September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 5 Table 1. Characteristics of States Selected Total Medicaid Total Medicaid Number of Share of Low-Income Children State Rank State and CHIP and CHIP Child Contracting for Child Enrollment Enrollment MCOs in who are POC who are Latino Health (December 2020) (December 2020) Scan Arizona 2,090,266a 828,083a 7c 32.9% 58.8% 28 Georgia 2,093,853 1,463,575 4c 63.8% 21.7% 40 Illinois 3,238,003 1,440,817 7 c 50.8% 34.1% 20 Iowa 750,018 361,097 2 23.6% 18.3% 13 Kansas 429,274 295,769 3 33.8% 30.0% 25 Kentucky 1,529,906 600,553 5c 24.5% 8.7% 35 Mississippi 680,078 459,572 3 69.4% 6.4% 50 Missouri 1,022,258 639,211 3 30.3% 10.1% 38 Nevada 749,040 332,540 3 52.9% 54.3% 34 Pennsylvania 3,261,323 1,482,422 9 45.9% 23.2% 17 Tennessee 1,571,521b 882,033 b 3c 40.1% 18.1% 39 Utah 390,385 216,642 4 14.9% 36.9% 18 West Virginia 560,146 225,596 3c 14.0% -- 43 a Arizona does not provide enrollment information to CMS. Georgetown CCF sources enrollment from the state’s quarterly report on beneficiary demographics available at https://www.azahcccs.gov/Resources/Reports/population.html; figure represents enrollment as of January 2021. b Historically, Tennessee’s enrollment reports to CMS have varied in data quality. As a consequence, Georgetown CCF sources enrollment from the state’s administrative records posted on the Agency website, available at https://www.tn.gov/tenncare/information-statistics/enrollment-data.html and at https://www. tn.gov/content/dam/tn/coverkids/documents/Enrollment1220.pdf. Figure represents enrollment as of December 2020. Tennessee child enrollment includes CHIP youth 0-19, unborn children of women over the age of 19, and Medicaid ages 0-18. c Arizona, Georgia, Illinois, Kentucky, Tennessee, and West Virginia all contract with an additional MCO to manage care for specialty populations, such as foster care children. These MCOs are not included in this count. Note: Estimate suppressed due to high margin of error and low reliability. Sources: Enrollment data: Georgetown CCF analysis of “State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data,” (Center for Medicaid Services, June 2021), available at https://data.medicaid.gov/Enrollment/State-Medicaid-and-CHIP-Applications-Eligibility-D/n5ce-jxme. Demographics: Georgetown CCF analysis of U.S. Census Bureau American Community Survey 2019 Public Use Microdata Sample (PUMS). Low-Income defined as living in a household with income below 138 percent of the Census Poverty Threshold. The American Community Survey defines race and ethnicity as two separate facets of a person’s identity. “POC” includes children who are Black, Asian/ Native Hawaiian/Pacific Islander, American Indian/Alaska Native, and some other race/two or more races. White and POC individuals may be of any ethnicity. Latino individuals may be of any race. Child health rank: “2021 Kids Count Data Book,” Annie E. Casey Foundation (June 2021), available at https://www.aecf.org/interactive/databook?d=h&l=54. September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 6 The Performance Information We Searched For There is no generally accepted set of measures for individuals? How much is the state Medicaid agency answering the question: How well is a Medicaid MCO paying the MCO to provide covered services to these performing for children and pregnant individuals? Our search populations? focused on data elements that we believe are the minimum necessary to answer that question. Some of these data Second, we wanted to find out whether children enrolled elements are required to be posted by federal regulation; in the MCO received the Early and Periodic Screening, others are not. None of the data elements are trade secrets Diagnostic, and Treatment (EPSDT) services to which they or commercially privileged information.12 They are listed in were entitled and for which the state Medicaid agencies Appendix B: Data Elements Sought and fall into four broad contracted. We looked for the same data elements that categories. the state Medicaid agencies report annually to CMS on Form-416 (see text box) on an MCO-specific basis. We First, we examined a simple question. How many children also wanted to know whether there were any differences in and pregnant individuals are enrolled in the MCO? What access to these services based on race or ethnicity. is the age distribution of the children (e.g., <1, 1-5, etc.)? What is the demographic profile of the children and pregnant Collected and Cleaned: EPSDT Services and CMS Form-416 Children enrolled in Medicaid are entitled to the comprehensive Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit package (§1905(r) of the Social Security Act). In order to monitor access to these preventative services, §1902(a)(43)(D) of the Social Security Act requires that, at a minimum, states report the following on a yearly basis: zz The number of children provided child health screening services zz The number of children referred for corrective treatment as a result of the screenings zz The number of children who received dental services CMS collects this information from states on CMS-416, the Annual EPSDT Participation Report. In order to complete the form for their states, Medicaid agencies in managed care states have to work with the MCOs to get claims data on the number of children receiving these screenings and services. In other words, MCOs are already required to collect this data in their claims logs. And, state agencies are already cleaning the data by removing duplicative entries, incomplete information, and correcting formatting errors before it is aggregated in the statewide rate. We searched to see if any of the states in our scan made the MCO-specific screening numbers and rates publicly available.13 September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 7 Third, we wanted to know what results each MCO produced Finally, we tried to gather information about the structure for children and pregnant women as measured by the child of each MCO, including its management, its accreditation and maternal health metrics selected by the Centers for status, and its subcontractors (if any) for functions such as Medicare & Medicaid Services (CMS) in its Child Core Set utilization management. We also looked for the contract (see text box).14 Most of these are nationally standardized between the state Medicaid agency and each MCO. These HEDIS metrics developed by the National Committee for data elements are among those that federal Medicaid Quality Assurance (NCQA). Again, we looked for whether managed care regulations require to be posted on either the measure results varied by race and ethnicity. state Medicaid agency or the individual MCO’s website. Collected and Cleaned: Collected, Cleaned, and Validated: Child and Maternity Core Set External Quality Review Organization The Child and Adult Core Set are metrics chosen Reports by a national committee of experts to evaluate In managed care states, Medicaid agencies are required access to and quality of care for Medicaid and CHIP to contract with an External Quality Review Organization beneficiaries. The measures cover a variety of domains (EQRO) to conduct an annual quality review of each including preventative care, oral health, and behavioral MCO and to report its assessment of the quality, health. Measures included in the Child and Adult Core timeliness, and accessibility of care for each MCO Set that assess maternal and perinatal health compose in an Annual Technical Report (ATR).20 The ATR must the sub-group Maternity Core Set. The standard be posted on the state Medicaid agency’s website.21 metrics in the Sets allow for comparisons both over States determine which metrics their EQRO contractor time and between states, though there are limitations. should review, which in turn determines which metrics the ATR contains. The EQRO validates the measures Currently, it is optional for state agencies to report the by assessing the MCOs’ information system and metrics on an aggregate, statewide basis to CMS, medical record data collection protocol and reviewing but reporting on all measures will become mandatory its practices for measure calculation with an onsite starting in fiscal year 2024.15 As of the 2020 reporting visit.22 When states maximize the potential of the EQRO cycle, all states reported on at least two Child Core process, ATRs are an excellent and cost-efficient way of Set measures and one Maternity Core Set measure.16 collecting, validating, and sharing information on MCO Sixteen states reported 22 or more Child Core Set performance. metrics.17 As with the EPSDT metrics, this means that managed care states are already collecting the records from their MCOs and are cleaning the data to There are data elements relevant to MCO performance ensure accuracy and consistency across MCO and for children and pregnant individuals for which we did not FFS records before they combine the datasets to find search. These include information on: the adequacy of the the statewide rate. Starting in measure year 2022, the MCO’s provider network for pediatric and maternity services; National Committee on Quality Assurance will require denials of services for children and pregnant individuals; the that the HEDIS metrics for Prenatal and Postpartum disposition of grievances, appeals, and state fair hearings Care as well as Child and Adolescent Well Care Visits involving children and pregnant individuals; and sanctions or are disaggregated by race and ethnicity.18 Some states administrative penalties or corrective action plans imposed already disaggregate measures by race and ethnicity on MCOs for violations of contract requirements affecting on a statewide basis for health equity reports.19 children and pregnant individuals. We also did not search for information relating to the MCO’s financial performance, such as the annual medical loss ratio report to the state Medicaid agency and the annual financial filing with the state insurance department. September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 8 The Performance Information We Found Our search of state Medicaid agency and individual MCO Early and Periodic Screening, Diagnostic, websites did not yield enough data to allow us to answer and Treatment (EPSDT) Services for the basic question: how well is an MCO performing for children and pregnant individuals? Here is what we found Children (and what we did not). None of the 13 states we scanned posted information about the provision of EPSDT services by individual MCOs, except with Enrollment respect to dental care. Six states (Arizona, Georgia, Kentucky, Of the 13 states we scanned, 11 posted MCO-specific Illinois, Pennsylvania, and West Virginia) posted a dental care enrollment information; Kansas and Utah did not. Only metric, and two of them (Kentucky and West Virginia) explicitly three states—Illinois, Iowa, and Pennsylvania—posted identified the metric as a form of EPSDT reporting. After the data child enrollment in each contracted MCO. After the data collection for this scan was completed, Iowa added a children’s collection for this scan was completed, Iowa began to health dashboard to its quarterly report on Medicaid MCO break out child enrollment by age group on its children’s performance. The dashboard includes EPSDT metrics for lead, health dashboard, becoming the only one of the 13 hearing, and vision screenings.24 All 13 states report information states to do so. on the use of EPSDT services annually to CMS on Form-416; the sources of their data are the MCOs with which they contract to Only two of the 13 states we scanned—Illinois and West furnish these services.25 Virginia—posted the number of pregnant women enrolled in each MCO. In West Virginia’s case, the data appear in one line in a table in an annual agency report to the legislature. No state posted the number of postpartum people enrolled in each MCO. None of the states posted race and ethnicity or other demographic information on either children or pregnant individuals enrolled in individual MCOs. None of the states posted the total amount they were paying each MCO for furnishing services to children or pregnant individuals. (We were searching not for capitation rates but for total amounts paid over a contract year). Arizona’s state Medicaid agency posted the amount it paid each MCO on its website but did not break out the amount paid for children or pregnant individuals.23 September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 9 Child and Maternal Health Quality Metrics Child Health We searched for MCO-specific performance on ten measures drawn from the Child Core Set. As shown in Table 2, no single measure was available for all 56 MCOs in our scan. The most frequently reported metric was well-child visits in the 3rd, 4th, 5th, and 6th years; the least frequently reported metric was depression screenings and follow-up among children aged 12 to 17. There was wide variation in the number of measures posted by the 13 states. Pennsylvania reported almost all of the Child Core Set metrics for which we searched; Kansas and Missouri reported the fewest (see Appendix C). For the measures for which we found results, there was wide variation from MCO to MCO across all states, within a state, and among subsidiaries of national companies. Table 2. Child Core Set Metrics: Children’s Health Child Core Set Measure Number of MCOs Reporting the Measure Well-child visits in 3rd, 4th, 5th, and 6th years 51 Well-child visits in first 15 months 47 Weight assessment for children and adolescents 41 Childhood Immunization Status, Combination 3 40 Adolescent Immunization Status, Combination 1 40 Adolescent well care visits 37 Children and adolescent access to primary care 36 Chlamydia screening in women ages 16-20 22 Developmental screening in first 3 years 19 Depression screening and follow-up ages 12-17 9 Note: Table excludes MCO/FCs in Arizona, Georgia, Illinois, Kentucky, Tennessee, and West Virginia. Comparing measures across all states, performance on Childhood Immunization Status (Combination 3) showed the greatest variation, with a 77.0 percentage point difference between the highest and lowest reported rates (see Appendix C). Children and Adolescent Access to Primary Care: 12-24 Months had the smallest variation with a range of only 10.4 percentage points. Comparing the performance of MCOs within states reveals that not all beneficiaries have equal access to care. For example, in Illinois, the statewide rate reported to CMS for the share of children up-to-date on their Combination 3 vaccines by age two was 58.6 percent, approximately ten percentage points below the national median. However, three MCOs achieved rates higher than the national median and two MCOs were substantially lower. One MCO even reported that only 2.3 percent of enrolled two-year olds were up-to-date on their Combination 3 vaccines (see Figure 1).26 September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 10 Figure 1. Childhood Immunization Status: Combination 3 Performance for Illinois MCOs National Median 68.8% State Rate Reported to CMS 58.6% Blue Cross Blue Shield of Illinois 73.7% CountyCare Health Plan 73.2% Molina Healthcare of Illinois (Molina) 69.6% Meridian Health Plan (Centene) 64.4% IlliniCare Health Plan (Centene) 47.2% NextLevel Health Partners 2.3% Note: Reflects performance in calendar year 2018. Source: Georgetown Center for Children and Families analysis of 2019 Child Core Set Report and Illinois 2020 External Quality Review Annual Technical Report. Similarly, in Georgia, three out of the four MCOs’ performance on the measure for ensuring enrolled infants receive six or more well-child visits were near the national median level, while the fourth MCO was more than twenty percentage points lower (see Figure 2). Figure 2. Well-Child Visits in the First 15 Months of Life Performance for Georgia MCOs National Median 64.0% State Rate Reported to CMS 62.0% Amerigroup Community Care (Anthem) 66.4% WellCare of Georgia (WellCare/Centene) 66.4% Peach State Health Plan (Centene) 64.4% CareSource 39.4% Note: Reflects performance in calendar year 2018. Source: Georgetown Center for Children and Families analysis of 2019 Child Core Set Report and Georgia 2020 External Quality Review Annual Technical Report. Finally, performance also varied among subsidiaries of the same parent company that operate in different states (see Appendix E). For example, only 29.1 percent of young children enrolled in one of Centene’s Arizona subsidiaries received appropriate developmental screenings while almost double this share (59.4 percent) of children enrolled in its Georgia subsidiary were screened. September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 11 Maternal Health We searched for individual MCO results on seven maternal health measures drawn from the Maternity Core Set. Overall, state posting of maternal health measures can best be described as sparse (see Appendix D). As shown in Table 3, of those measures, only two—postpartum visit on or between 21 and 56 days after delivery, and timeliness of prenatal care—were reported frequently (42 and 41 MCOs, respectively). One state—Arizona—did not post any maternal health metrics for any of its seven MCOs. Kansas reported only one (timeliness of prenatal care). Pennsylvania, on the other hand, posted six of the seven measures for all of its MCOs. Table 3. Child Core Set Metrics: Maternal Health Child Core Set Measure Number of MCOs Reporting the Measure Postpartum care 42 Timeliness of prenatal care 41 Live births weighing less than 2,500 grams 13 Cesarean birth 9 Contraceptive care for postpartum women ages 15 to 20 9 Contraceptive care for all women ages 15 to 20 9 Audiological diagnosis no later than 3 months 0 Note: Table excludes MCO/FCs in Arizona, Georgia, Illinois, Kentucky, Tennessee, and West Virginia. As with performance on the child health metrics, performance on the maternal health metrics varied widely among MCOs across all states, within a state, and among subsidiaries of national companies. Across the selected states, MCOs showed the most variation on the timeliness of prenatal care measure, ranging from 61.8 percent for NextLevel in Illinois to 99.03 percent for Molina in Mississippi (see Appendix D).27 Within a state, among the three MCOs in Nevada, one lagged far behind the other two on measures for timeliness of prenatal care and postpartum care (see Figure 3). Figure 3. Maternal Health Metrics Performance for Nevada MCOs Timeline of Prenatal Care Postpartum Care National Median 80.7% 61.2% State Rate Reported to CMS 79.1% 61.1% Anthem Blue Cross Blue Shield 80.8% 59.4% Health Plan of Nevada (United) 80.5% 65.0% Silver Summit Health (Centene) 66.4% 48.4% Note: Reflects performance in calendar year 2018. Source: Georgetown Center for Children and Families analysis of 2019 Child Core Set Report and Nevada 2020 External Quality Review Annual Technical Report. September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 12 Similarly, as shown in Figure 4, several MCOs in Pennsylvania performed close to the national median for low-birthweight births while at least one was much higher (lower rates are better for this measure). Figure 4. Live Births Weighing Less than 2,500 Grams Performance for Pennsylvania MCOs National Median 9.5% State Rate Reported to CMS 9.1% Geisinger Health Plan 7.7% AmeriHealth Caritas Pennsylvania 7.9% UPMC for You, Inc. 8.2% Health Partners Plans 9.1% Aetna Better Health of Pennsylvania 9.3% (CVS/Aetna) AmeriHealth Northeast 9.3% Gateway Health 9.3% United Healthcare Community Plan 9.9% (UnitedHealth) Keystone First 10.5% Notes: Low rates are better for the measure. Reflects performance in calendar year 2018. Source: Georgetown Center for Children and Families analysis of 2019 Child Core Set Report and Pennsylvania 2020 External Quality Review Annual Technical Report. MCO performance on maternal health metrics also varies within parent companies (see Appendix F). The widest range in performance—37 percentage points—occurred among Molina subsidiaries on the “timeliness of prenatal care” measure. The lowest performer was the subsidiary in Utah, where only 62.3 percent of beneficiaries had a prenatal care visit in their first trimester or within 42 days of their enrollment in the MCO. In comparison, according to their own report (as opposed to an EQRO-validated score), 99 percent of beneficiaries in Molina’s subsidiary in Mississippi had a visit in that same time period. September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 13 Racial and Ethnic Disparities For each category of performance data above—enrollment, Core Set, no state posted these measures stratified by race EPSDT services, and child and maternal health—we or ethnicity (see Table 4). A CMS assessment of 2018 state searched for data disaggregated by race and ethnicity. administrative records ranked those of Mississippi and Of the 13 states we scanned, only Pennsylvania reported Tennessee as “unusable” and those of Arizona, Kansas, MCO-specific enrollment by race and ethnicity; even then, Iowa, Missouri, Utah, and West Virginia as “high concern” the state did not post MCO-specific child enrollment by race for the purposes of analyzing beneficiary race and ethnicity. and ethnicity. No state posted EPSDT by race and ethnicity. However, several states were only deemed “medium” or And while all states posted at least some MCO-specific child “low” concern, yet still failed to make their data available for and maternal health metrics from the Child and/or Maternity public inspection. Table 4. State Transparency in MCO Race and Ethnicity Reporting CMS Rating of State Presents Managed Care Presents Managed Care Presents Quality Metrics State Race and Ethnicity Plan Enrollment by Plan Child Enrollment by Disaggregated by Data Quality Race and Ethnicity Race and Ethnicity Race and Ethnicity Arizona High Concern No No No Georgia Medium Concern No No No Illinois Low Concern No No No Iowa High Concern No No No Kansas High Concern No No No Kentucky Medium Concern No No No Mississippi Unusable No No No Missouri High Concern No No No Nevada Low Concern No No No Pennsylvania Low Concern Yes No No Tennessee Unusable No No No Utah High Concern No No No West Virginia High Concern No No No Source: Georgetown Center for Children and Families analysis of state administrative websites. CMS rating from CMS DQ Atlas, an analysis of calendar year 2018 state administrative data submitted to the T-MSIS system. More information can be found at https://medicaid.gov/dq-atlas/landing/topics/single/ map?topic=3m16&tafVersionId=16. September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 14 Federal Transparency Requirements Federal regulations require state Medicaid agencies that contract with Medicaid MCOs to post certain information on their websites (or ensure that the information is posted on the websites of the MCOs).28 In theory, this publicly accessible information gives advocates and stakeholders an understanding of an MCO’s contractual obligations to beneficiaries and the MCO’s standing in the eyes of third- party reviewers, auditors, and accreditation bodies. We searched for a subset of that information that was most relevant to the performance of MCOs for children and pregnant individuals: the risk contract between the state and each MCO; the management and other individuals with ownership or control interests in each MCO; subcontractors State Medicaid agencies (if any) used by each MCO to carry out utilization management and other critical functions; the accreditation and MCOs should make status of each MCO; and EQRO Annual Technical Reports. the following information Our findings are summarized in Table 5. Of the 13 states easily available on an we scanned, eight did not post the risk contracts between MCO-specific basis: each MCO and the state Medicaid agency. Some of these eight states posted template contracts, rather than the final, Executed Contracts executed contracts. In Kansas, the contracts available had Management to be cross-referenced with the initial request for proposal (RFP) issued by the state and were consequently difficult Enrollment and time-consuming to interpret. Mississippi made an Revenues executed contract available, but it expired in June 2020. Accreditation Most states did not make information about MCO (or subcontractor) management easily accessible on the state Quality Metrics Medicaid agency’s website. The exception is Pennsylvania, which posted a directory listing both the MCO management and the state official in charge of overseeing the contract. Nine of the state Medicaid agencies posted the accreditation status of each MCO on their website as required. Kansas, Nevada, and Tennessee provided a link to the website of the National Committee on Quality Assurance (NCQA). All 13 states posted the EQRO Annual Technical Report. September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 15 Table 5. Performance Data Elements: MCO-Specific Information Available on State Agency Websites Data Element AZ GA IA IL KS KY MO MS NV PA TN UT WV Total Service Area P P P P P P P P P P P P 12 Risk Contract P P P* P P 5 Management P P 2 MCO-Specific Medicaid Enrollment P P P P P P P P P P P 11 MCO-Specific Medicaid Enrollment (Child) Pa P P 3 MCO-Specific Medicaid Revenues (Total) P 1 MCO-Specific Medicaid Revenues (Child) 0 NCQA Accreditation P** P P Pb P Pb P Pb P 9 HEDIS Child Metrics P Pc P P Pd P Pe Pf P P P Pg P 13 HEDIS Maternal Health Metrics P P P Ph P Pg P P P Ph Pi 11 EPSDT Metrics Pi Pi Pa Pi P Pi P 7 Total 6 6 7 7 3 7 4 5 5 8 6 4 6 Table Notes: Elements in blue are required by federal regulation. * No current risk contracts were available; the most current were for July 2017-June 2020. ** As of July 2021, only one MCO in AZ has achieved accreditation. a Began reporting after scan. b KS, NV, and TN only provide a link to NCQA’s website on their state website. In our initial sweep, NV and TN did not include any reference to NCQA Accreditation on their Medicaid agency websites; they have since added these links. c Thirteen HEDIS metrics were available in GA’s EQRO report; almost all HEDIS metrics were available in separate reports entitled Validation of Performance Measures for each MCO. One of the Validation for Performance Measure reports was not posted until months after the other plans’ respective reports upon inquiry from the press. d All three MCOs reported only three HEDIS Child Health metrics. MCO-specific results were found in an annual report to CMS on the state website, as opposed to the state EQRO report. e All three plans in Missouri reported only two HEDIS Child Health Metrics for Calendar Year 2018. f Only two MCOs out of the three in Mississippi reported HEDIS metrics for Calendar Year 2018; Molina was not included in the state’s EQRO report. g Some measures for Molina were found only on Molina’s website in Mississippi and Utah; these few measures were not included in the EQRO report for the other MCOs in Utah. h Only one maternal health metric reported. In Kansas, this metric was included in a report to CMS buried on the website, not in the annual EQRO report. i Reported the HEDIS Annual Dental Visit (ADV) measure as a proxy for EPSDT in state EQRO report for Calendar Year 2018. Georgia presented the HEDIS Annual Dental Visit (ADV) measure and the Percentage of Eligibles Who Received Preventative Dental Services (PDENT-CH) measure in a report entitled Validation of Performance Measures, rather than in the state’s EQRO report. September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 16 Discussion and Recommendations Risk-based managed care is the dominant delivery system each MCO to provide services to all of its enrollees on its for children and pregnant individuals enrolled in Medicaid. website, but even that agency did not post payments made Currently, forty states and the District of Columbia contract on behalf of children and pregnant individuals. As in the with a total of 287 MCOs on a risk basis to manage services case of enrollment data, the size of the state and federal for Medicaid beneficiaries. How those MCOs perform investment in an MCO is foundational to an evaluation of its determines the quality and accessibility of the care that performance. beneficiaries receive. What can publicly available information The one area of relative transparency relates to the Child tell us about the performance of Medicaid MCOs for children Core Set. We were able to find many—but not all—of the and pregnant individuals? Based on our analysis of the child health measures and some of the maternal health websites of 13 states and the 56 MCOs with which they measures for each MCO. This information was in the Annual contracted, the public has very little information available to Technical Review prepared by each state’s EQRO and answer this important question. posted on each state Medicaid agency website. In a few In fact, our analysis found that opacity is often the norm. cases, results were posted on individual MCO websites. We frequently confronted a maze of different websites, Although the measures available were far from complete, hidden webpages, outdated documents, and large gaps a quick comparison between the MCO-specific metrics in information. We infrequently found the MCO-specific and statewide rates makes clear that aggregation masks performance information we were seeking. significant variation in performance: children and pregnant individuals enrolled in different MCOs do not have equal We were able to find the number of children enrolled in each access to care. If advocates and other stakeholders are MCO on only three of the state websites we scanned. Only going to address which children are underserved and in two states posted the number of pregnant women enrolled what ways, they need access to these MCO-specific rates in each MCO on their websites. None of the MCOs posted on a timely and consistent basis. this information on their websites. Without this enrollment data, demographic data like age, gender, and race and Finally, none of the 13 state Medicaid agency websites we ethnicity are, by definition, also unavailable. This information scanned posted enrollment, EPSDT, or child and maternal is foundational to any assessment of the performance of health quality data disaggregated by race and ethnicity. This individual MCOs. is particularly concerning. Collecting and reporting MCO- level enrollment and performance disaggregated by race EPSDT services are the core of Medicaid coverage for and ethnicity data is vital to ensuring that Medicaid equitably children. Children enrolled in an MCO depend on the MCO delivers care to all of its enrollees. An MCO may report to manage the delivery of EPSDT services for them. None high overall scores on quality metrics, but without data that of the 13 state Medicaid agencies posted information is disaggregated by race and ethnicity, these scores can on receipt of EPSDT services (other than dental care) by hide disparities in the receipt of services and inequitable children enrolled in each MCO. MCO performance for patterns of care. To be sure, there are gaps in Medicaid children simply cannot be assessed without information on administrative data on race and ethnicity that can make the delivery of EPSDT services. disaggregation difficult. Nonetheless, some states have We were unable to find how much any of the 13 state developed techniques for reducing these gaps, leading to Medicaid agencies were paying each MCO to furnish more complete and accurate data.29 The next step is to post children’s services (including EPSDT) or pregnancy-related this data on an MCO-specific basis. services. Only one agency posted the amount it paid September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 17 The state Medicaid agency websites we searched varied These recommendations are designed to promote widely in the availability of MCO-specific information and accountability for the performance of individual MCOs for user-friendly organization. By our reckoning, Illinois, Iowa, children and pregnant individuals—accountability not just Kentucky, and Pennsylvania’s websites were the most on the part of the MCOs, but also on the part of the state transparent; those of Kansas, Missouri, and Utah the least. Medicaid agencies that contract with them and the federal Even among the more transparent states, however, there is agency that finances two thirds of the public investment. still a considerable lack of publicly available performance Without transparency, there is no accountability. And without data, especially with respect to maternal health metrics. accountability, children and pregnant individuals enrolled None of the state Medicaid agency websites posted all of in MCOs are at risk of poor access and quality. Having the minimum data elements required to be posted by federal Medicaid coverage is essential for many families to ensure regulations. they do not go uninsured, but this is not enough. Medicaid managed care is the predominant delivery system for low- With these findings in mind, we make three income children and pregnant women and disproportionately recommendations to improve transparency about the serves families of color. Federal and state policymakers alike performance of individual MCOs for children and pregnant must do a better job of ensuring that Medicaid provides high individuals. quality care to all children and promotes health equity. 1 State Medicaid agencies should maintain a child health dashboard that contains MCO- specific performance data and is easily accessible. At a minimum, this performance data should include EPSDT screenings and treatment, Child Core Set metrics, and all information already required to be posted by federal regulations. The dashboard should include a data hub with links to relevant structural information about each MCO with which the state contracts. 2 CMS should monitor and enforce state Medicaid agency compliance with the minimum transparency requirements in its regulations. This would help reset state and MCO expectations about transparency. 3 CMS should add a child health dashboard as a measure to the State Administrative Accountability pillar of its Medicaid & CHIP Appendix tables referred to in this report can be Scorecard. The child health dashboard should found at https://ccf.georgetown.edu/2021/09/09/ include performance information on EPSDT transparency-in-medicaid-managed-care-findings- screenings and treatment and Child Core Set from-a-13-state-scan-appendix/. metrics specific to each MCO in each state. September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 18 Methodology Data Sources We searched state Medicaid agency websites, state insurance sanctions and administrative penalties imposed; and financial department websites, and individual MCO websites for data performance (e.g., Medical Loss Ratios). Federal regulations about the performance of MCOs for children and pregnant require states to report this information annually to CMS; the individuals. In some cases, state agency websites referred us first reports are not due until December 2022. to external websites, such as that of the National Committee We limited our search to publicly accessible websites. We for Quality Assurance (NCQA). did not file Public Records Act requests with state Medicaid We cross-checked our findings relating to MCO contractors, agencies or insurance departments for the performance data parent companies, and overall MCO quality rankings with we were seeking. We also did not file Freedom of Information the information presented on the Kaiser Family Foundation’s Act requests for this information with CMS. Medicaid Managed Care Market Tracker. We organized the data that we were able to find into MCO- The quality measures presented in this paper reflect MCO specific profiles using Google Sheets. This facilitated performance during calendar year (CY) 2018 (Healthcare collaboration with other researchers and comparison of Effectiveness Data and Information Set 2019). These rates results across MCOs. were the most recent data available at the beginning of our scan in June 2020. In order to permit comparison of MCO Limitations performance, we present (CY) 2018 performance data for all This scan was limited to 56 MCOs operating in 13 states. 56 MCOs, even though (CY) 2019 (HEDIS) may have become It focused on a minimum set of performance data and, available for some MCOs in some states during the course of with respect to Child Core Set measures, captured only our scan. information for CY 2018. The findings therefore do not necessarily apply with respect to the remaining 231 MCOs Data Collection that operate in the other 27 Medicaid managed care states or The 13 states included in this scan are states where CCF the District of Columbia. provides ongoing technical assistance to child health The 13 states we scanned do not represent a random advocates as part of our Finish Line project. Each of the 13 sample; we selected them from a narrow pool (24 states states had fewer than ten MCOs in operation as of June 2020. included in the Finish Line project) and excluded from that As noted below, neither the states nor the MCOs we scanned pool those with more than ten MCOs in operation as of June are necessarily representative of all states that contract with 2020. It is possible that a scan of the MCOs operating in the MCOs or all MCOs contracting with those states. We limited remaining 27 Medicaid managed care states and the District our scan in order to be able to provide information on MCO of Columbia would have found greater or less transparency performance and state agency transparency to state child around performance for children and pregnant individuals. health advocates in a reasonable period of time. The same applies to the performance data for which The list of data elements for which we searched can be we searched. We limited the data elements to those we found in Appendix B. In our view, these elements are the considered most relevant to the performance of individual minimum necessary for advocates and the public to make MCOs for children and pregnant women. It is possible an informed assessment of the performance of an individual that, had we searched for all potential performance data, MCO for children and pregnant individuals. There are other we would have uncovered more information to assess the data elements that could also inform an assessment of MCO performance of individual MCOs, thereby affecting our performance for which we did not search. These include judgments regarding transparency in the 13 states that we MCO-specific information on: the resolution of grievances, did scan. appeals, and state fair hearings relating to denials of care; September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 19 In addition to disaggregation by race and ethnicity, states from year to year. In addition, even for the one year for may sometimes disaggregate enrollment by sex (male or which we found measure data, caution should be exercised female). Only one state broke out MCO enrollment by sex in comparing MCO performance across states. The (Pennsylvania); no other states made MCO enrollment demographic profile and health status of the children and by sex publicly available. We did not address the issue pregnant women enrolled in MCOs, as well as the provider of disaggregating data by sex, gender identity, or sexual networks that MCOs are able to assemble to furnish services orientation in our scan. to those populations, may vary significantly from state to state, affecting measure results. Finally, we looked for Child Core Set data only for one year (CY 2018). We are therefore not able to present trends in MCO performance on child and maternal health measures This brief was written by Allie Corcoran, Emma Hurler, Andy Schneider, and Julia Buschmann. The authors would like to thank Kyrstin Racine, Joan Alker, and Catherine Hope of the Center for Children and Families for their contributions. Design and layout provided by Nancy Magill. The Georgetown University Center for Children and Families (CCF) is an independent, nonpartisan policy and research center founded in 2005 with a mission to expand and improve high-quality, affordable health coverage for America’s children and families. CCF is based in the McCourt School of Public Policy’s Health Policy Institute. September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 20 Endnotes 1 “Health Insurance Coverage of Children 0-18,” Kaiser Family 11 The child health partners with whom Georgetown CCF partners in Foundation, available at https://www.kff.org/other/state-indicator/ each state are as follows: Children’s Action Alliance (Arizona); Voices children-0-18/?currentTimeframe=0&sortModel=%7B%22colId%22:%2 for Georgia’s Children (Georgia); EverThrive Illinois and Sargent Shriver 2Location%22,%22sort%22:%22asc%22%7D. National Center on Poverty Law (Illinois); Child and Family Policy 2 Park, E., Alker, J., and Corcoran, A., “Jeopardizing a Sound Center (Iowa); Kansas Action for Children (Kansas); Kentucky Voices Investment: Why Short-Term Cuts to Medicaid Coverage During for Health (Kentucky); Mississippi Center for Justice (Mississippi); Pregnancy and Childhood Could Result in Long-Term Harm” Kids Win Missouri, Missouri Budget Project, and Missouri Coalition of (Washington DC: The Commonwealth Fund, December 2020), available Children’s Agencies (Missouri); Children’s Advocacy Alliance (Nevada); at https://www.commonwealthfund.org/publications/issue-briefs/2020/ Pennsylvania Partnerships for Children (Pennsylvania); Tennessee dec/short-term-cuts-medicaid-long-term-harm. Justice Center (Tennessee); Voices for Utah’s Children (Utah); and West Virginians for Affordable Health Care (West Virginia). 3 See “Appendix 1: MCO-Specific Federal Requirements for Transparency, 42 C.F.R. Part 438,” in Schneider, A. “A Guide for Child 12 Most managed care contracts provide for the protection of trade Health Advocates: Medicaid Managed Care Accountability Through secrets, as aligned with exemption four of the Freedom of Information Transparency” (Washington DC: Georgetown University Center for Act Statute (P.L. 114-185) and there is a growing body of case law Children and Families, July 2021), available at https://ccf.georgetown. about what information can be considered proprietary. MCOs may edu/2021/07/16/a-guide-for-child-health-advocates-medicaid- claim that public access to information on rate setting, formularies, managed-care-accountability-through-transparency/. and fee structures would put them at a competitive disadvantage. However, it is not plausible to claim that basic enrollment numbers, 4 Georgetown CCF analysis of “Medicaid MCO Enrollment by Plan and enrollee demographics, EPSDT performance data and HEDIS Parent Firm, March 2021,” Kaiser Family Foundation (March 2021), metrics should be exempt from public oversight. See, Turner, W., available at https://www.kff.org/medicaid/state-indicator/medicaid- Machledt, D., and Somers, S., “A Guide to Oversight, Transparency, mco-enrollment-by-plan-and-parent-firm-march-2021. Total count and Accountability in Medicaid Managed Care” (Washington DC: includes some MCOs that cover children in foster care on a statewide National Health Law Program, March 2015), available at https:// basis, which we refer to as MCO/FCs. Georgetown CCF will explore healthlaw.org/wp-content/uploads/2015/03/2015_03_17_NHeLP_ MCO/FCs in more detail in a future brief. Georgetown CCF’s total count ManagedCareAccountabilityGuide-1.pdf. differs slightly from the Kaiser Family Foundation’s (KFF) table as MCOs that have enrollment for special populations may be aggregated under 13 “MCO External Quality Review Annual Technical Reports,” District of one name in the KFF table. Georgetown’s count also includes MCOs Columbia Department of Health Care Finance, available at https://dhcf. in North Carolina, which began enrollment in March 2021 and are fully dc.gov/page/mco-external-quality-review-annual-technical-reports. operational as of July 2021. 14 In this instance, we use the term women because the original data 5 The most recent national data, from fiscal year 2018, shows that 81.3 source—the state websites—do so. percent of children enrolled in Medicaid are enrolled in comprehensive 15 “State Readiness to Report Mandatory Core Set Measures,” Medicaid managed care plans. This share has likely grown as North Carolina and CHIP Payment and Access Commission, March 2020, available completed its transition to risk-based managed care in July 2021. at https://www.macpac.gov/publication/state-readiness-to-report- MACStats, “Exhibit 30: Percentage of Medicaid Enrollees in Managed mandatory-core-set-measures/; and, §1139A of the Social Security Act. Care by State and Eligibility Group, FY 2018,” Medicaid and CHIP 16 Center for Medicaid and CHIP Services, “Quality of Care for Children Payment and Access Commission (December 2020), available at in Medicaid and CHIP: Findings from the 2019 Child Core Set” https://www.macpac.gov/wp-content/uploads/2015/01/EXHIBIT-30.- (Baltimore, MD: Centers for Medicaid and Medicare Services, October Percentage-of-Medicaid-Enrollees-in-Managed-Care-by-State-and- 2020), available at https://www.medicaid.gov/medicaid/quality-of-care/ Eligibility-Group-FY-2018.pdf. See also, Hinton, E., et al., “10 Things to downloads/performance-measurement/2020-child-chart-pack.pdf; Know About Medicaid Managed Care” (Washington DC: Kaiser Family and Center for Medicaid and CHIP Services, “Quality of Maternal and Foundation, October 2020), available at https://www.kff.org/medicaid/ Perinatal Health Care in Medicaid and CHIP: Findings from the 2019 issue-brief/10-things-to-know-about-medicaid-managed-care/. Maternity Core Set” (Baltimore, MD: Centers for Medicaid and Medicare 6 “Managed Care’s Effect on Outcomes,” Medicaid and CHIP Payment Services, December 2020), available at https://www.medicaid.gov/ and Access Commission, available at https://www.macpac.gov/ medicaid/quality-of-care/downloads/2020-maternity-chart-pack.pdf. subtopic/managed-cares-effect-on-outcomes/. 17 Center for Medicaid and CHIP Services, “Quality of Care for Children 7 Schneider, A. and Corcoran, A., “Medicaid Managed Care: 2020 in Medicaid and CHIP,” op cit. Results for the ‘Big Five’” Georgetown University Center for Children 18 O’Kane, M. et al., “The Future of HEDIS: Health Equity,” National and Families, SayAhh! Health Policy Blog, February 23, 2021, available Committee on Quality Assurance (webinar, June 22, 2021), available at at https://ccf.georgetown.edu/2021/02/23/medicaid-managed-care- https://www.ncqa.org/wp-content/uploads/2021/06/2021-0622-Future- 2020-results-for-the-big-five/. of-HEDIS.pdf. 8 “Medicaid MCO Enrollment by Plan and Parent Firm, March 2021,” op cit. 19 “Health Equity Reports,” Michigan Department of Health & Human 9 To wit, one MCO in Pennsylvania has a form on its website inviting Services, available at https://www.michigan.gov/mdhhs/0,5885,7-339- candidates running for public office to request a donation from its 71547_4860-489167--,00.html. affiliated political action committee. 20 Machledt, D., “Medicaid External Quality Review: An Updated 10 Guyer, J., Boozang, P., and Toups, M., “Moving to the Vanguard on Overview” (Washington, DC: National Health Law Program, November Pediatric Care: Recommendations for the MassHealth 1115 Waiver 2020), available at https://healthlaw.org/resource/medicaid-external- Renewal” (Washington DC: Manatt Health, November 2020), available quality-review-an-updated-overview/. at https://www.manatt.com/insights/white-papers/2020/moving-to-the- 21 42 C.F.R. §438.364 (2020). vanguard-on-pediatric-care-recommend. September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 21 22 Center for Medicaid and CHIP Services, “CMS External Quality Review (EQRO) Protocols” (Baltimore, MD: Centers for Medicaid and Medicare Services, October 2019), available at https://www.medicaid. gov/medicaid/quality-of-care/downloads/2019-eqr-protocols.pdf. 23 Iowa, Pennsylvania, and Tennessee posted the amount paid to each MCO on their states’ Department of Insurance website, as opposed to their state Medicaid Agency website. 24 Trefz, M. “Iowa’s New Child Health Dashboard Provides Insight into How Medicaid Managed Care is Working for Kids,” Georgetown University Center for Children and Families, SayAhh! Health Policy Blog, February 23, 2021, available at https://ccf.georgetown.edu/2021/06/07/ iowas-new-child-health-dashboard-provides-insight-into-how- medicaid-managed-care-is-working-for-kids/. 25 See Washington DC’s EQRO report for an example of EPSDT reporting on an MCO-specific basis. “MCO External Quality Review Annual Technical Reports,” District of Columbia Department of Health Care Finance, available at https://dhcf.dc.gov/page/mco-external- quality-review-annual-technical-reports. 26 Combination 3 includes DTAP, IPV, MMR, HIB, Hepatitis B, VZV and PCV vaccinations. “Childhood Immunization Status (CIS),” National Committee on Quality Assurance, available at https://www.ncqa.org/ hedis/measures/childhood-immunization-status/. 27 Note that this measure was posted on the Mississippi Molina subsidiary website, not included in an externally-validated EQRO ATR. 28 See “Appendix 1: MCO-Specific Federal Requirements for Transparency, 42 C.F.R. Part 438,” in Schneider, A. “A Guide for Child Health Advocates: Medicaid Managed Care Accountability Through Transparency,” op cit. 29 “Collection of Race, Ethnicity, Language (REL) Data in Medicaid Applications: A 50-state Review of the Current Landscape,” State Health Values and Strategies, February 2021, available at https://www. shvs.org/resource/collection-of-race-ethnicity-language-rel-data-in- medicaid-applications-a-50-state-review-of-the-current-landscape/. September 2021 CCF.GEORGETOWN.EDU transparency in medicaid managed care 22