Medicaid and CHIP Risk-Based Managed Care in 20 States. Experiences Over the Past Decade and Lessons for the Future.. Purpose of This Study


This study is designed to provide new information on the evolution of comprehensive risk-based Medicaid and CHIP managed care programs for acute care over the first decade of the 21st century, in order to develop lessons learned for states and the federal government as they jointly prepare to serve the new populations eligible for Medicaid via the Affordable Care Act expansion. This study is important because there has been less study of Medicaid risk-based managed care in the recent decade than in the 1990s, and because there has been almost no description of the risk-based managed care used by separate CHIP programs.

The study builds on results from two other recent papers describing Medicaid managed care, one by Gifford, Smith, Snipes, & Paradise (2011) and one by the Medicaid and CHIP Payment and Access Commission—MACPAC (2011). The results from this study complement those efforts. Both of those papers provide point-in-time descriptions of Medicaid managed care in 2010, while this study explores how managed care programs have evolved over the past decade and why states have chosen to design their managed care programs in the ways that they have. This study also includes CHIP, examines the perceptions of a wider range of informants (including providers and health plan representatives), and produces new data on quality of care measures in both programs. In addition, a companion report will provide information on trends in capitation rates for risk-based Medicaid and CHIP managed care programs.

The principal research questions addressed in this report are:

  • How do Medicaid and CHIP risk-based managed care approaches vary across states, and how have these Medicaid and CHIP managed care approaches varied over time?
  • How do Medicaid and CHIP programs monitor access to and quality of care, and what have been the results?
  • Synthesizing across all study state experiences, what are the best practices in state Medicaid and CHIP managed care? What implications do these state experiences have for the 2014 Medicaid expansion included in the Affordable Care Act?

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