红领巾瓜报

This week, our second In Focus provides insights into Medicaid managed care enrollment in the second quarter of 2025. 红领巾瓜报 Information Services (红领巾瓜报IS) obtained and analyzed monthly Medicaid enrollment data in 30 states,[1] offering a reliable baseline and timely view of the immediate impact of the current policy landscape as new federal policies take effect.

This analysis presents a snapshot of 红领巾瓜报IS鈥檚 comprehensive detailed quarterly Medicaid managed care enrollment report (available by subscription), which includes plan-level information for nearly 300 health plans in 41 states, corporate ownership, for-profit versus not-for-profit status, and similar information regarding publicly traded plans. Table 1 provides a sample of enrollment trends, representing 57 million Medicaid managed care enrollees of a total of 66 million Medicaid managed care enrollees nationwide. Data reporting periods and program coverage vary by state, so figures may not be fully comparable.

Key Insights from 2Q25 Data

The 30 states included in our review have released monthly Medicaid managed care enrollment data鈥攙ia a public website or in response to a public records request from 红领巾瓜报IS鈥攆or April through June of 2025. This report reflects the most recent data posted or obtained from states. 红领巾瓜报 has made the following observations regarding the enrollment data:

• Year-over-year decline. As of June 2025, in the 30 states reviewed, Medicaid managed care enrollment declined by 1.6 million members year-over-year, a 2.7 percent drop from June 2024.
• Widespread decreases. Of the 30 states, 27 experienced enrollment declines in June 2025 compared to June 2024. Oregon and the District of Columbia saw modest growth, while California remained flat (Table 1).
• Sharpest contractions. Arizona and Maryland reported double-digit percentage drops in enrollment in June 2025 (Table 1), underscoring the uneven impact of redeterminations and eligibility policy changes.
• Difference among expansion and non-expansion states. Among the 24 states included in the analysis that expanded Medicaid, enrollment fell by 1.2 million鈥攁 2.5 percent drop鈥攖o 49.2 million. The six non-expansion states saw a steeper proportional decline of 4.2 percent, to a total of 8 million enrollees.

Table 1. 2Q25 Monthly MCO Enrollment by State, April鈥揓une 2025

The data in Table 1 should be viewed as a sampling of enrollment trends across these states rather than as a comprehensive comparison, which cannot be established based solely on publicly available monthly enrollment data. It is also important to note the limitations of the data presented. For example, not all states report data at the same time during the month, resulting in a range of snapshots from the beginning to the end of the month. Second, in some instances, the data cover all Medicaid managed care programs, while in others they reflect only a subset of the broader managed Medicaid population, depending on what data is publicly available.

Market Share and Plan Dynamics

红领巾瓜报IS鈥檚 report includes plan-level details for nearly 300 plans, covering corporate ownership, program participation, and tax status. As of June 2025, Centene continues to lead the national Medicaid managed care market with 17.8 percent share, followed by Elevance (10.4 percent), United (8.6 percent), and Molina (6.2 percent; see Table 2).

Table 2. National Medicaid Managed Care Market Share by Number of Beneficiaries for a Sample of Publicly Traded Plans, June 2025

What to Watch

The OBBBA (P.L. 119-21) calls for significant changes to Medicaid eligibility and enrollment policies, including work requirements and more frequent eligibility redeterminations.  indicate that Medicaid and Children鈥檚 Health Insurance Program enrollment could decline by up to 7.5 million people by 2034. In addition, the Centers for Medicare & Medicaid Services (CMS) has announced that it will not approve or extend waivers for multi-year continuous eligibility for adults or children.

As these policies are implemented, state governments and healthcare organizations should prepare for increased administrative complexity, potential coverage disruptions, and the resulting effect on MCO revenue and value-based care arrangements.

Connect with Us

红领巾瓜报 is home to experts who know the Medicaid managed care landscape at the federal and state levels. As the Medicaid landscape continues to evolve, 红领巾瓜报IS equips stakeholders with timely, actionable intelligence, including enrollment data, quarterly by-plan and by-state enrollment reports, financials, Medicaid demonstration and Rural Health Transformation program tracking, and a robust library of publicly available Medicaid-related documents. 红领巾瓜报IS combines publicly available information with 红领巾瓜报 expert insights on the structure of Medicaid in each state, as well as our comprehensive, proprietary State Medicaid Overviews.

For questions about the 红领巾瓜报IS enrollment report and information about the 红领巾瓜报IS subscription, contact our experts below.

This week, our In Focus section highlights findings from 红领巾瓜报 Information Services鈥� (红领巾瓜报IS鈥檚) review of 2024 statutory filings submitted to the National Association of Insurance Commissioners (NAIC). These filings provide a nationwide view of Medicaid managed care plan profitability and medical loss ratios (MLRs) across 221 plans operating in 39 states, the District of Columbia, and Puerto Rico.

These data build upon and offer additional context to a previous  conducted by 红领巾瓜报 and Wakely, an 红领巾瓜报 Company, of increasing post-pandemic financial pressures driven by acuity increases resulting from the continuous eligibility unwinding and increases in behavioral health and home and community-based services access and utilization.

Medicaid Managed Care Underwriting Gains and Losses

As state Medicaid programs have increasingly moved from fee-for-service to managed care, a foundational assumption has been that efficient managed care organizations (MCOs) reduce waste and deliver high quality, cost-effective healthcare services. This transition has made Medicaid plan performance and sustainability a central focus for policymakers and actuaries alike.

Medicaid capitation rates must be actuarially sound, which means they must be projected to cover all 鈥渞easonable, appropriate, and attainable costs,鈥� including medical administrative costs, plus a margin for insurance risk, even for nonprofit plans. According to the Society of Actuaries 2024 , average underwriting margins in Medicaid rates ranged from 0.35 percent to 3.15 percent, with a consistent average between 1.2 percent and 1.3 percent.

However, actual results often deviate from projections for reasons that may be challenging to predict. Rate setting is an inherently forward-looking process, and even with conservative assumptions, unexpected shifts in enrollment, acuity, or service utilization can lead to significant deviations from projected results. Retrospective reviews show variability in margins over time (see Figure 1).

Figure 1. Historical Medicaid MCO Net Gains/Losses, 2012鈥�2024 (39 States, DC)

Based on 红领巾瓜报IS鈥檚 analysis, Medicaid MCOs sustained modest but steady gains from 2012 through 2017. After a decline between 2016 and 2019, margins rebounded to approximately 3 percent until 2022, narrowed in 2023 to 1.9 percent, and turned negative in 2024 at -0.9 percent.

For the first time in over a decade, more plans experienced losses than gains in 2024 (see Figure 2), with only 42 percent reporting positive margins, down from the decade high of 84 percent in 2022. This shift raises critical questions about sustainability and participation in Medicaid managed care.

Figure 2. Medicaid Managed Plans Likelihood of Gain, 2012鈥�2024 (39 States, DC)

The 鈥淟ikelihood of Gain鈥� chart tracks the percentage of Medicaid managed care plans reporting an underwriting gain each year from 2012 to 2024. For most years, the likelihood that a plan posted a gain was relatively high, typically between 60 percent and 80 percent. The probability reached a recent peak in 2022, with 84 percent of plans reporting gains, and remained elevated in 2023 (74 percent). In 2024, however, the likelihood of gain dropped sharply to just 42 percent, the lowest level in the 12-year period.

Risk Corridors, Medical Loss Ratios, and Structural Policy Shifts

MLRs show the portion of plan revenue spent on medical care as compared with the costs to operate the plan and the underwriting gain or loss described previously. When MLRs rise or fall, it can be an indication that medical cost trends experienced by health plans differ from the assumptions used by state rate setting actuaries. High MLRs are the key driver of underwriting gains, and low MLRs are associated with higher profitability. All states report MLRs to the Centers for Medicare & Medicaid Services (CMS), and some enforce minimum MLRs with a remittance provision, requiring plans to return funds if their MLR goes below a certain level.

Risk corridors are another tool that states use to manage financial volatility. These mechanisms share gains or losses between plans and states when results deviate significantly from pricing assumptions, offering protection to MCOs and the state alike, in contrast to minimum MLR provisions with a remittance provision, which only protects the state. During the COVID-19 pandemic, many states implemented or expanded risk corridors to recoup overpayments because of lower utilization. Some risk corridors were set retroactively鈥攁 practice CMS now prohibits.

In 2024, MLRs reached a decade high of 90.8 percent, as indicated by 红领巾瓜报IS鈥檚 analysis. Driving this increase were heightened utilization rates, increased enrollee acuity, and the end of continuous Medicaid coverage protections in 2023. As healthier, lower-cost members left Medicaid, plans were left serving a more complex population with higher per-member costs. Inflation in medical costs鈥攅specially for behavioral health and home and community-based services鈥攁dded more pressure. Delayed or avoided care during the COVID-19 pandemic may also have played a role, as members sought more services in 2022鈥�2024, resulting in a surge in utilization greater than what was priced into rates.

Many states put risk corridors in place to stabilize margins from 2020 to 2022, which may have contributed to the tight band of outcomes around the high underwriting gains in that period. However, many states have been  them for 2024, 2025, and 2026. Without these protections, plans may face greater exposure to underpayment in 2025 and 2026 if cost trends continue to outpace rate assumptions.

What to Watch

Rate setting conversations between states and plans for 2026 are happening now, and in many cases they are quite challenging. In addition to meeting actuarial soundness requirements, states also must balance their budgets, and some may be facing limitations on their traditionally used tools.

Looking ahead, it will be increasingly important that states and plans partner to find cost savings that can ensure the program鈥檚 long-term sustainability.

A subscription to 红领巾瓜报IS provides access to comprehensive financial intelligence on Medicaid managed care. Far beyond surface-level snapshots, 红领巾瓜报IS delivers health plan-level financial performance metrics, enrollment trends, and state policy developments that directly shape rate setting and operational strategy. Whether you鈥檙e a state official, health plan executive, or policy strategist, 红领巾瓜报IS provides the financial clarity and policy context needed to anticipate regulatory shifts, benchmark performance, and make confident, data-driven decisions.

For questions about the analysis discussed in this article, contact our experts below.

As states and stakeholders seek greater transparency and accountability in Medicaid, a new analysis from 红领巾瓜报 (红领巾瓜报), offers a fresh perspective on how dollars flow through the system. Drawing on publicly available data from the Transformed Medicaid Statistical Information System (T-MSIS), 红领巾瓜报 disaggregated funding dispersed to Medicaid managed care organizations to discern spending for specific categorically eligible populations. The findings significantly enhance policy discussions and can facilitate development of pragmatic and specific care management interventions that support quality patient care.

For policymakers, regulators, and other stakeholders, this level of disaggregation provides a clearer view of how public dollars are used鈥攁nd where there may be opportunities to improve performance or reinvest savings. It also supports more informed rate development and contract negotiations, particularly as states pursue value-based purchasing and other reforms. As Medicaid continues to evolve, especially in the context of budget pressures and changes in enrollment and risk profiles of enrollees, understanding the financial picture of managed care programs is essential to ensuring sustainability.

红领巾瓜报鈥檚 team of experts鈥攊ncluding actuaries, former Medicaid directors, and data analysts鈥攈as deep experience working with T-MSIS data and advising states, plans, and providers on Medicaid program analysis, evaluation, and strategy. For more information about working with T-MSIS data and the insights it can provide, contact聽our experts below.