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Waiver priorities have been identified by the Trump Administration and present countless opportunities for states and carriers, alike. As states move to expand Medicaid through Section 1115 waivers, Medicaid Managed Care Organizations (MCOs) must look toward MITA-aligned, HIPAA-compliant financial management solutions.  

More than 270 MCOs across 39 states, including D.C., are on the front lines of efforts to facilitate access to care for Medicaid Enrollees. According to Deloitte, “in states that expanded Medicaid eligibility, Medicaid managed care plans had higher margins each year except 2016.”

Attributing to premium decreases and expanded access to affordable health coverage options, Section 1115 Waiver activity is expected to continue. To date 45 Section 1115 Waivers have been approved across 37 states. An additional 29 states have expressed interest and are awaiting a decision from the CMS on their pending waiver statuses.

Most rules that govern each state’s Medicaid program are set by state policymakers to meet the state’s unique mission and needs. Similarly, states that have received approval have utilized the waiver in different manners to test new approaches in Medicaid that differ from traditional, federal program rules. Seven states have expanded Medicaid, 3 enforced Medicaid Work Requirements, 7 introduced eligibility and enrollment restrictions, and 6 imposed processes and requirements around benefit restrictions, copays, and healthy behaviors.  

Supporting these priorities, Medicaid MCOs in Arkansas, Arizona, Iowa, Indiana, Michigan, Montana, and New Hampshire have turned their attention toward establishing new processes associated with their state’s decision to pursue non-traditional Medicaid expansion. And for the first time ever, these states except for New Hampshire have permitted Medicaid MCOs to charge Medicaid beneficiaries a health insurance premium. As result, these organizations must now develop processes to handle member invoicing, premium billing, and member outreach and engagement initiatives.   

Softheon works with carriers to reduce administrative burdens and overcome regulatory challenges associated with Medicaid managed care. If you would like to discuss how Softheon can help you with these challenges, please email



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