Medicaid Risk Adjustment

Medicaid Risk Adjustment Simplified

These are tumultuous times for Medicaid Risk Adjustment and Medicaid managed care plans. Medicaid is now the largest health plan sponsor.  It also remains in the cross-hairs of Washington politicians.

With over 70 million beneficiaries (including the Americans living in Puerto Rico), Medicaid is the single largest healthcare payer in the United States. States are aggressively transitioning Medicaid recipients into private managed care organizations.  As of March 2017, there were 275 Medicaid managed care plans receiving capitation in operation.

Provisions of the 2016 Medicaid Managed Care Regulation (the “Mega-Reg”) are starting to take effect, particularly the encounter data submission requirements (states will start incurring financial penalties in July 2018), MLR thresholds, and how mandated quality improvement programs are incorporated.

Medicaid Risk Adjustment Pie

How Medicaid risk adjustment scores slice the budget pie

Risk adjustment in Medicaid MCOs operates completely different from Medicare-Advantage and most other risk-adjusted lines of business.  In over 30 Medicaid states, the risk scores are “baked into” the capitation rates.  These baked in risk scores determine how big the MCO’s “slice of the pie” is- with the pie being the actuarially sound aggregate spend for all Medicaid MCOs.






Technology Solutions for Medicaid Risk Adjustment

Hence, this doesn’t mean that Medicaid risk scores shouldn’t be managed.  Quite the contrary, ensuring that MCO’s risk score are consistent with the members’ underlying illness burden is essential to the MCO being paid an accurate capitation rate.  Mile High can deploy a real-time visualization solution (Cortex-Scope) to track your risk scores, ensure that all data describing the member’s morbidities are submitted and accepted.


Mile High Healthcare Analytics helps health plans, providers and vendors assess and adapt their risk adjustment programs to the complex requirements of Medicaid managed care.  We can calculate risk scores in real-time using the CDPS, CDPS+Rx, and Johns Hopkins ACG models.  These three models are in use by all but three states with risk adjustment integrated into Medicaid managed care.

Mile High can design and even help implement your Medicaid revenue management program.  We can offer either an, "out-of-the-box" design or a more customized approach that builds upon program elements that are already successfully in place in your Medicaid MCO.

There are numerous operational components of a Medicaid managed care program that need to be addressed.  Mile High can assist your MCO with these and many other requirements:

  • Are you ready for the oversight of your provider network?
  • Are you obtaining the maximum allowable on in those states that employ risk adjustment for Medicare managed care?
  • Are you delivering care efficiently to high-need subpopulations in your Medicaid products?



Medicaid Management

Here are some of the areas in which Mile High Healthcare Analytics can support your Medicaid managed care program:


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Mile High Healthcare Analytics is the proud host of the MHHA Webinar Series. In these sessions, Richard Lieberman and occasional guest speakers from various parts of the industry discuss topics relevant in Medicare Advantage, Medicaid, and the Health Insurance Exchanges.

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