CMS published updated guidance in December 2024 on how states should develop and document Medicaid capitation rates for PACE organizations, which provide comprehensive care to elderly enrollees. The white paper explains changes to rate-setting methodology, including how to calculate the "Amount That Would Have Otherwise Been Paid" (AWOP) benchmark and broader implications for Medicaid capitation rate development. This matters for state Medicaid directors and actuaries responsible for setting compliant rates for PACE plans, as well as MCOs and health plans considering or operating PACE programs.

This white paper provides Medicaid managed care plans with a framework for optimizing care coordination for enrollees with sickle cell disease, addressing specialized service access, continuity of care, and patient education. It examines how technology can reduce avoidable costs and improve care coordination, and explores integrating federal disease action plans and health equity frameworks to reduce acute care utilization. The analysis is particularly timely given new gene therapy approvals that may reshape treatment approaches for this Medicaid population.

This white paper examines how health plans and provider organizations can structure bundled payment arrangements for musculoskeletal conditions like knee osteoarthritis, moving away from fee-for-service models. While the analysis applies broadly to value-based payment design across payers, the concepts are directly relevant to Medicaid managed care organizations exploring episode-based payment with orthopedic providers. The framework covers which organizations should enter bundled arrangements, model types, and why orthopedic episodes offer predictable cost and outcome patterns suitable for bundling.