Scanning sources…acquiring signal · establishing uplink
90M+
Medicaid + CHIP combined (2025)
50–83%
federal match varies by state income
72%
of enrollees in managed care plans
56
50 states + DC + territories
Federal-State Financing Structure
FMAP determines federal match rate per stateBase FMAP Range
50% – 83%
Higher for lower-income states; Mississippi receives maximum 83%
ACA Expansion FMAP
90%
Federal share for ACA adult expansion population; states pay 10%
CHIP FMAP
65% – 91%
Enhanced CHIP match: base FMAP + 15 percentage points floor
Medicaid is an entitlement: states must cover all eligible individuals. CMS matches state expenditures at the FMAP rate through quarterly advance payments. States submit Form CMS-64 for financial reporting. The CMS-2500 state plan amendment process governs benefit and eligibility changes.
Managed Care Penetration (% of enrollees)
Spending by Eligibility Group
Eligibility Groups
Mandatory and optional coverage categoriesChildren
Mandatory: below 100% FPL. CHIP extends to 200%+ FPL in most states.
Pregnant Women
Mandatory coverage at 133% FPL minimum; many states at 200%+ FPL.
Adults (ACA Expansion)
138% FPL for states accepting ACA Medicaid expansion (41 states + DC as of 2025).
Aged / Blind / Disabled
Linked to SSI eligibility; dual-eligibles (Medicare + Medicaid) receive full wrap.
Foster Care Youth
Mandatory through age 26 regardless of state of residence under ACA.
Medically Needy
Optional: spend-down pathway for those who exceed income but have high medical costs.
Drug Pricing & Rebate Programs
MDRP · NADAC · FUL · SDUDMDRP (Drug Rebate)
Manufacturers pay rebates: AMP-based Basic + Additional rebate. Inflation penalty if price growth exceeds CPI.
NADAC (Drug Acquisition)
National Average Drug Acquisition Cost — weekly CMS survey of pharmacy invoice prices. Benchmark for reimbursement.
FUL (Federal Upper Limit)
CMS-set maximum reimbursement for multi-source drugs. 175% of weighted average NADAC.
SDUD (Utilization Data)
State Drug Utilization Data — quarterly public files on drug utilization, payments, and units by state.
Waiver & Flexibility Mechanisms
Federal authorities allowing state innovation§1115 Research & Demo
Broad authority to test new approaches. Requires budget neutrality. Allows expansion populations and novel delivery models.
§1915(b) Managed Care
Requires beneficiaries to enroll in managed care organizations or use restricted provider networks.
§1915(c) HCBS
Home and Community-Based Services waivers — alternative to institutional care for elderly/disabled populations.
§1915(i) HCBS State Plan
HCBS via state plan amendment rather than waiver; no enrollment cap or budget neutrality requirement.
PACE
Programs of All-inclusive Care for the Elderly — integrated Medicare/Medicaid for dual-eligibles age 55+.
Quality Measurement & Reporting
CMS Core Sets, HEDIS, and digital transitionChild Core Set
24 measures covering well-child visits, immunizations, ADHD follow-up, dental care, behavioral health screening.
Adult Core Set
26 measures covering chronic disease management, preventive care, behavioral health, maternity care.
HEDIS / ECDS
NCQA HEDIS measures + Electronic Clinical Data System (ECDS) transition — moving from claims to real-time clinical data.
MQD Initiative
Medicaid Quality Display — CMS national dashboard for state-level quality performance comparison.
Regulatory Timeline
Key legislative and program milestonesTitle XIX of the Social Security Act — joint federal-state program for low-income individuals
State Children's Health Insurance Program — covers children in families above Medicaid thresholds
Optional expansion to 138% FPL for non-elderly adults; enhanced federal match (90% FMAP for expansion group)
42 CFR Part 438 updated: network adequacy, encounter data, quality, MLR requirements for MCOs
Continuous enrollment protections (PHE); 6.2 pp enhanced FMAP during COVID-19 public health emergency
Post-PHE redetermination: ~23M disenrollments through 2024; significant churn in coverage continuity
Transformed MSIS Analytic Files (TAF) — standardized national claims database for Medicaid research
Medicaid Knowledge Base
Environment 13 — ingested Medicaid research, entities, and relationships