Actuarial Consulting for Medicaid Managed Care Programs

This case study outlines the role of Mercer in providing actuarial consulting services to state-managed care programs, particularly in the context of Medicaid. It discusses the challenges faced by state, county, and local governments in delivering quality health care amid budget constraints and evolving federal policies. The study highlights the implementation of the One Big Beautiful Bill Act (OBBBA) of 2025, which introduces new requirements affecting Medicaid and health insurance marketplaces. Mercer’s actuarial consultants assist in various areas, including capitation rate setting, risk adjustment, and financial analysis related to dual integration projects. The case study emphasizes the importance of medical efficiency analyses in developing capitation rates that reflect value-based purchasing, ensuring that Medicaid programs can demand optimal performance from managed care organizations. Additionally, it details specific analyses conducted by Mercer, such as low acuity non-emergent emergency room visits and potentially preventable admissions, aimed at improving health care delivery and reducing costs.