How do States Deliver Care in Medicaid?

VISIT THE PILLAR: National Context

National Context

State Health System Performance

State Administrative Accountability

Federal Administrative Accountability

States administer their Medicaid programs and determine how to deliver care. Federal law requires states to provide certain “mandatory” benefits and allows states the choice of covering other “optional” benefits. Comparisons across states should consider differences in their benefits and care delivery approaches. For example, some states choose to deliver Medicaid health benefits and additional services through managed care organizations. States may also use waiver authorities, such as 1915(b), 1915(c) waivers, or section 1115 demonstrations to offer coverage or extend benefits to a target population. The following data show examples of the ways states can vary in benefit coverage and how they deliver care.

Managed Care Delivery Systems

How do States Deliver Care in Medicaid?

Examples of the ways states can vary in benefit coverage and how they deliver care.

National Context

Total National Medicaid Managed Care Enrollment

Total National Medicaid Managed Care Enrollment Tile with the categories and values

Enrollment in Any Type of Managed Care Plan by State

Enrollment in Any Type of Managed Care Plan by State US Map with the categories and values

State or Territory	Category
Alabama	800,000 to 1,499,999
Alaska	No Managed Care
Arizona	1.5 Million and over
Arkansas	800,000 to 1,499,999
California	1.5 Million and over
Colorado	800,000 to 1,499,999
Connecticut	No Managed Care
Delaware	Less than 300,000
District of Columbia	Less than 300,000
Florida	1.5 Million and over
Georgia	800,000 to 1,499,999
Hawaii	300,000 to 799,999
Idaho	Less than 300,000
Illinois	1.5 Million and over
Indiana	800,000 to 1,499,999
Iowa	300,000 to 799,999
Kansas	300,000 to 799,999
Kentucky	800,000 to 1,499,999
Louisiana	1.5 Million and over
Maine	Less than 300,000
Maryland	800,000 to 1,499,999
Massachusetts	800,000 to 1,499,999
Michigan	1.5 Million and over
Minnesota	800,000 to 1,499,999
Mississippi	300,000 to 799,999
Missouri	800,000 to 1,499,999
Montana	Less than 300,000
Nebraska	Less than 300,000
Nevada	300,000 to 799,999
New Hampshire	Less than 300,000
New Jersey	800,000 to 1,499,999
New Mexico	300,000 to 799,999
New York	1.5 Million and over
North Carolina	1.5 Million and over
North Dakota	Less than 300,000
Ohio	1.5 Million and over
Oklahoma	300,000 to 799,999
Oregon	800,000 to 1,499,999
Pennsylvania	1.5 Million and over
Puerto Rico	800,000 to 1,499,999
Rhode Island	Less than 300,000
South Carolina	800,000 to 1,499,999
South Dakota	Less than 300,000
Tennessee	800,000 to 1,499,999
Texas	1.5 Million and over
Utah	Less than 300,000
Vermont	Less than 300,000
Virginia	800,000 to 1,499,999
Washington	1.5 Million and over
West Virginia	300,000 to 799,999
Wisconsin	800,000 to 1,499,999
Wyoming	Less than 300,000

National Percentage of Medicaid Enrollees by Care Delivery Approach

National Percentage of Medicaid Enrollees by Care Delivery Approach Pie chart breaking down by percentage of comprehensive managed care vs non-comprehensive managed care vs fee-for-service

National Percentage of Medicaid Enrollees by Care Delivery Approach

Pie chart breaking down by percentage of comprehensive managed care vs non-comprehensive managed care vs fee-for-service

Category	Percentage
Comprehensive managed care	70%
Non-comprehensive managed care	13%
Fee-for-service	17%

Percentage of Medicaid Enrollees in Comprehensive Managed Care Plans by State

Comprehensive-Managed-Care-Plans-State

Percentage of Medicaid Enrollees in Comprehensive Managed Care

US Map with the categories and values:

State or Territory	Category
Alabama	Less than 1%
Alaska	No Managed Care
Arizona	80% to 89.9%
Arkansas	1% to 39.9%
California	80% to 89.9%
Colorado	1% to 39.9%
Connecticut	No Managed Care
Delaware	80% to 89.9%
District of Columbia	70% to 79.9%
Florida	70% to 79.9%
Georgia	70% to 79.9%
Hawaii	90% and over
Idaho	1% to 39.9%
Illinois	70% to 79.9%
Indiana	70% to 79.9%
Iowa	90% and over
Kansas	80% to 89.9%
Kentucky	90% and over
Louisiana	80% to 89.9%
Maine	Less than 1%
Maryland	80% to 89.9%
Massachusetts	40% to 69.9%
Michigan	40% to 69.9%
Minnesota	70% to 79.9%
Mississippi	40% to 69.9%
Missouri	40% to 69.9%
Montana	Less than 1%
Nebraska	90% and over
Nevada	70% to 79.9%
New Hampshire	80% to 89.9%
New Jersey	90% and over
New Mexico	80% to 89.9%
New York	70% to 79.9%
North Carolina	Less than 1%
North Dakota	1% to 39.9%
Ohio	80% to 89.9%
Oklahoma	Less than 1%
Oregon	80% to 89.9%
Pennsylvania	80% to 89.9%
Puerto Rico	90% and over
Rhode Island	80% to 89.9%
South Carolina	40% to 69.9%
South Dakota	Less than 1%
Tennessee	90% and over
Texas	90% and over
Utah	70% to 79.9%
Vermont	40% to 69.9%
Virginia	80% to 89.9%
Washington	80% to 89.9%
West Virginia	70% to 79.9%
Wisconsin	40% to 69.9%
Wyoming	Less than 1%

Managed Long-Term Services and Supports (MLTSS) Plans by State

Managed Long-Term Services and Supports (MLTSS) Plans by State US Map breaking down states by MLTSS or Comprehensive Managed Care Includes LTSS or Both of these or None

Managed Long-Term Services and Supports (MLTSS) Plans by State

US Map breaking down states by MLTSS or Comprehsive Managed Care Includes LTSS or Both of these or None

State or Territory	Category
Alabama	None
Alaska	None
Arizona	Comprehensive managed care includes LTSS
Arkansas	Comprehensive managed care includes LTSS
California	Comprehensive managed care includes LTSS
Colorado	None
Connecticut	None
Delaware	Comprehensive managed care includes LTSS
District of Columbia	None
Florida	MLTSS
Georgia	None
Hawaii	Comprehensive managed care includes LTSS
Idaho	Comprehensive managed care includes LTSS
Illinois	Both
Indiana	None
Iowa	Comprehensive managed care includes LTSS
Kansas	Comprehensive managed care includes LTSS
Kentucky	None
Louisiana	None
Maine	None
Maryland	None
Massachusetts	Comprehensive managed care includes LTSS
Michigan	Both
Minnesota	Comprehensive managed care includes LTSS
Mississippi	None
Missouri	None
Montana	None
Nebraska	None
Nevada	None
New Hampshire	None
New Jersey	Comprehensive managed care includes LTSS
New Mexico	Comprehensive managed care includes LTSS
New York	Both
North Carolina	None
North Dakota	None
Ohio	Comprehensive managed care includes LTSS
Oklahoma	None
Oregon	None
Pennsylvania	Comprehensive managed care includes LTSS
Puerto Rico	None
Rhode Island	None
South Carolina	None
South Dakota	None
Tennessee	Comprehensive managed care includes LTSS
Texas	Comprehensive managed care includes LTSS
Utah	None
Vermont	Comprehensive managed care includes LTSS
Virginia	Comprehensive managed care includes LTSS
Washington	None
West Virginia	None
Wisconsin	Both
Wyoming	None

Source: 2019 Managed Care Enrollment Report

Note: Comprehensive managed care plans provide all acute and primary medical services.

1915(c) Waivers and Section 1115 Demonstrations for Home & Community-Based Services

How do States Deliver Care in Medicaid?

Examples of the ways states can vary in benefit coverage and how they deliver care.

National Context

1915 (c) Waivers and Section 1115 Demonstrations for Home & Community-Based Services US Map showing states broken down into 1915c Waiver vs Section 1115 Demonstration vs 1915c Waiver and Section 115 Demonstration

1915 (c) Waivers and Section 1115 Demonstrations for Home & Community-Based Services US Map showing states broken down into 1915c Waiver vs Section 1115 Demonstration vs 1915c Waiver and Section 115 Demonstration

1915(c) Waivers and Section 1115 Demonstrations for Home & Community-Based Services

US Map showing states broken down into 1915c Waiver vs Section 1115 Demonstration vs 1915c Waiver and Section 115 Demonstration

State	Category
Alabama	1915c Waiver
Alaska	1915c Waiver
Arizona	Section 1115 demonstration
Arkansas	1915c Waiver
California	1915c Waiver and Section 1115 demonstrations
Colorado	1915c Waiver
Connecticut	1915c Waiver
Delaware	1915c Waiver and Section 1115 demonstrations
District of Columbia	1915c Waiver and Section 1115 demonstrations
Florida	1915c Waiver and Section 1115 demonstrations
Georgia	1915c Waiver
Hawaii	1915c Waiver and Section 1115 demonstrations
Idaho	1915c Waiver
Illinois	1915c Waiver and Section 1115 demonstrations
Indiana	1915c Waiver
Iowa	1915c Waiver
Kansas	1915c Waiver and Section 1115 demonstrations
Kentucky	1915c Waiver
Louisiana	1915c Waiver
Maine	1915c Waiver
Maryland	1915c Waiver and Section 1115 demonstrations
Massachusetts	1915c Waiver and Section 1115 demonstrations
Michigan	1915c Waiver and Section 1115 demonstrations
Minnesota	1915c Waiver and Section 1115 demonstrations
Mississippi	1915c Waiver
Missouri	1915c Waiver
Montana	1915c Waiver
Nebraska	1915c Waiver
Nevada	1915c Waiver
New Hampshire	1915c Waiver
New Jersey	Section 1115 demonstration
New Mexico	1915c Waiver and Section 1115 demonstrations
New York	1915c Waiver and Section 1115 demonstrations
North Carolina	1915c Waiver and Section 1115 demonstrations
North Dakota	1915c Waiver
Ohio	1915c Waiver
Oklahoma	1915c Waiver
Oregon	1915c Waiver
Pennsylvania	1915c Waiver
Rhode Island	Section 1115 demonstration
South Carolina	1915c Waiver
South Dakota	1915c Waiver
Tennessee	1915c Waiver and Section 1115 demonstrations
Texas	1915c Waiver and Section 1115 demonstrations
Utah	1915c Waiver
Vermont	Section 1115 demonstration
Virginia	1915c Waiver and Section 1115 demonstrations
Washington	1915c Waiver and Section 1115 demonstrations
West Virginia	1915c Waiver
Wisconsin	1915c Waiver
Wyoming	1915c Waiver

Source: CMS’s analysis of administrative data.

Notes: This map reflects whether states have one or more 1915(c) waivers or a section 1115 demonstrations as of June 2021. States may deliver HCBS through State Plan Amendments and/or other waiver authorities.

Home & Community-Based Services Statewide Transition Plan Approval Status

How do States Deliver Care in Medicaid?

Examples of the ways states can vary in benefit coverage and how they deliver care.

National Context

Home & Community-Based Services Statewide Transition Plan Approval Status US Map with the categories and values

Home & Community-Based Services Statewide Transition Plan Approval Status

US Map shows which states have which status: Initial Approval, Final Approval, Clarifications and/or Modifications Required for Initial Approval

State	Status
Alabama	Initial Approval
Alaska	Final Approval
Arizona	Initial Approval
Arkansas	Final Approval
California	Initial Approval
Colorado	Initial Approval
Connecticut	Final Approval
Delaware	Final Approval
District of Columbia	Final Approval
Florida	Initial Approval
Georgia	Initial Approval
Hawaii	Final Approval
Idaho	Final Approval
Illinois	Clarifications and/or Modifications Required for Initial Approval
Indiana	Initial Approval
Iowa	Initial Approval
Kansas	Initial Approval
Kentucky	Final Approval
Louisiana	Initial Approval
Maine	Clarifications and/or Modifications Required for Initial Approval
Maryland	Initial Approval
Massachusetts	Clarifications and/or Modifications Required for Initial Approval
Michigan	Initial Approval
Minnesota	Final Approval
Mississippi	Initial Approval
Missouri	Final Approval
Montana	Initial Approval
Nebraska	Initial Approval
Nevada	Clarifications and/or Modifications Required for Initial Approval
New Hampshire	Initial Approval
New Jersey	Clarifications and/or Modifications Required for Initial Approval
New Mexico	Initial Approval
New York	Initial Approval
North Carolina	Initial Approval
North Dakota	Final Approval
Ohio	Final Approval
Oklahoma	Final Approval
Oregon	Final Approval
Pennsylvania	Initial Approval
Rhode Island	Initial Approval
South Carolina	Final Approval
South Dakota	Final Approval
Tennessee	Final Approval
Texas	Clarifications and/or Modifications Required for Initial Approval
Utah	Final Approval
Vermont	Initial Approval
Virginia	Final Approval
Washington	Final Approval
West Virginia	Initial Approval
Wisconsin	Initial Approval
Wyoming	Final Approval

Source: Statewide Transition Plans

Notes: This map reflects the approval status of states’ statewide transition plans (STPs) for home and community-based services (HCBS) as of July 31, 2021. The STP is the vehicle through which states describe how they will comply with the new requirements for home and community-based settings in the HCBS final regulation effective March 17, 2014. States have until March 17, 2023 to come into compliance.

All states have submitted at least one STP. Initial approval requires: (1) identification in the STP of all settings subject to the rule; (2) a systemic assessment of state statutes, regulations, and policies, necessary remediation strategies for those resources; (3) a public comment period and a summary of responses to comments received on the STP. Final approval requires: (1) a summary of completed and validated site-specific assessments, with remediation strategies and timelines for resolution; (2) a plan for identifying and evaluating those settings; (3) a process for communicating with beneficiaries who are currently in settings that cannot or will not come into compliance with the settings criteria by the end of the transition period; (4) a description of ongoing monitoring and quality assurance to ensure all settings remain in full compliance with the settings criteria. States must post the updated version of the STP for a minimum 30-day public comment period prior to final approval.

For more information about STPs and updates to approval status that occurred after July 2021, please visit the Statewide Transition Plans webpage. CMS guidance for states concerning statewide transition plans may be found here: https://www.medicaid.gov/medicaid/home-community-based-services/guidance/home-community-based-settings-requirements-compliance-toolkit/index.html.

Percentage of Dual Eligible Beneficiaries in Integrated Care Programs by State

How do States Deliver Care in Medicaid?

Examples of the ways states can vary in benefit coverage and how they deliver care.

National Context

Percentage of Dual Eligible Beneficiaries in Integrated Care Programs by State showing which states fall into which range of percentages and which states have no integrated care

Percentage of Dual Eligible Beneficiaries in Integrated Care Programs by State showing which states fall into which range of percentages and which states have no integrated care:

State	Category
AK	No integrated care
AL	0 to <1%
AR	0 to <1%
AZ	26% to 52%
CA	10% to <26%
CO	1% to <10%
CT	No integrated care
DC	No integrated care
DE	1% to <10%
FL	26% to 52%
GA	No integrated care
HI	26% to 52%
IA	1% to <10%
ID	26% to 52%
IL	10% to <26%
IN	0 to <1%
KS	1% to <10%
KY	No integrated care
LA	0 to <1%
MA	26% to 52%
MD	0 to <1%
ME	No integrated care
MI	10% to <26%
MN	26% to 52%
MO	No integrated care
MS	No integrated care
MT	No integrated care
NC	1% to <10%
ND	1% to <10%
NE	1% to <10%
NH	No integrated care
NJ	26% to 52%
NM	1% to <10%
NV	No integrated care
NY	1% to <10%
OH	26% to 52%
OK	1% to <10%
OR	26% to 52%
PA	10% to <26%
RI	26% to 52%
SC	10% to <26%
SD	No integrated care
TN	26% to 52%
TX	10% to <26%
UT	No integrated care
VA	10% to <26%
VT	No integrated care
WA	10% to <26%
WI	1% to <10%
WV	No integrated care
WY	1% to <10%

Source: Medicare-Medicaid Coordination Office

This measure reports the percentage of dual eligible beneficiaries in integrated care programs by state as of July 2020. Integrated care programs include: Programs of All-Inclusive Care for the Elderly, Medicare-Medicaid plans, Medicare-Medicaid demonstration programs, certain integrated dual eligible special needs plans, and total cost of care fee-for-service.

Section 1115 Substance Use Disorder and Serious Mental Illness Demonstrations

How do States Deliver Care in Medicaid?

Examples of the ways states can vary in benefit coverage and how they deliver care.

National Context

Section 1115 Substance Use Disorder (SUD) and Serious Mental Illness (SMI) Demonstrations US Map showing which states have Demonstrations of SUD, SUD and SMI, and Neither SUD nor SMI

Section 1115 Substance Use Disorder (SUD) and Serious Mental Illness (SMI) Demonstrations US Map showing which states have Demonstrations of SUD, SUD and SMI, and Neither SUD nor SMI:

State	Status
Alabama	No SUD or SMI Demonstration
Alaska	SUD Demonstration
Arizona	No SUD or SMI Demonstration
Arkansas	No SUD or SMI Demonstration
California	SUD Demonstration
Colorado	SUD Demonstration
Connecticut	No SUD or SMI Demonstration
Delaware	SUD Demonstration
District Of Columbia	SUD and SMI Demonstration
Florida	No SUD or SMI Demonstration
Georgia	No SUD or SMI Demonstration
Hawaii	No SUD or SMI Demonstration
Idaho	SUD and SMI Demonstration
Illinois	SUD Demonstration
Indiana	SUD and SMI Demonstration
Iowa	No SUD or SMI Demonstration
Kansas	SUD Demonstration
Kentucky	SUD Demonstration
Louisiana	SUD Demonstration
Maine	SUD Demonstration
Maryland	SUD Demonstration
Massachusetts	SUD Demonstration
Michigan	SUD Demonstration
Minnesota	SUD Demonstration
Mississippi	No SUD or SMI Demonstration
Missouri	No SUD or SMI Demonstration
Montana	No SUD or SMI Demonstration
Nebraska	SUD Demonstration
Nevada	No SUD or SMI Demonstration
New Hampshire	SUD Demonstration
New Jersey	SUD Demonstration
New Mexico	SUD Demonstration
New York	No SUD or SMI Demonstration
North Carolina	SUD Demonstration
North Dakota	No SUD or SMI Demonstration
Ohio	SUD Demonstration
Oklahoma	SUD and SMI Demonstration
Oregon	SUD Demonstration
Pennsylvania	SUD Demonstration
Rhode Island	SUD Demonstration
South Carolina	No SUD or SMI Demonstration
South Dakota	No SUD or SMI Demonstration
Tennessee	No SUD or SMI Demonstration
Texas	No SUD or SMI Demonstration
Utah	SUD and SMI Demonstration
Vermont	SUD and SMI Demonstration
Virginia	SUD Demonstration
Washington	SUD and SMI Demonstration
West Virginia	SUD Demonstration
Wisconsin	SUD Demonstration
Wyoming	No SUD or SMI Demonstration

Source: Section 1115 Demonstrations: Substance Use Disorders, Serious Mental Illness, and Serious Emotional Disturbance

Note: This map reflects whether states have approved section 1115 substance use disorder and/or serious mental illness and serious emotional disturbance (SMI-SED) demonstrations as of May 2021.