State Medicaid agencies and Managed Care Organizations (MCOs) are facing growing pressure to better coordinate care across providers, vendors, and different state and federal agencies while reducing administrative complexity for members. Federal and state priorities—including greater focus on behavioral health integration, mental health parity, continuity of coverage, and proactive oversight—are also increasing expectations around coordination, accountability, and operational performance.
These shifts were reflected in recent industry discussions, including conversations at the 2026 Medicaid Managed Care Conference in San Diego, which reinforced broader trends emerging across Medicaid managed care: stronger coordination across complex care systems, reducing barriers that make it harder for members to access and navigate care, and earlier identification of member needs, service gaps, and challenges.
While Medicaid managed care programs vary across states, several common operational challenges continue to surface across programs.
Reducing fragmentation across care delivery systems
One recurring challenge involves fragmentation across the organizations, vendors, providers, and systems involved in managing member care.
As Medicaid programs adapt to new federal requirements and continue expanding focus on behavioral health integration, Long-Term services and Supports (LTSS), social determinants of health, and complex care management, states are strengthening coordination across overlapping care delivery systems. Care transitions often require coordination across multiple entities, including state agencies, MCOs, providers, and case workers—each responsible for different aspects of the member experience.
Without clear expectations around information sharing, accountability, and follow-through across multiple handoffs, coordination breakdowns may occur. As a result, organizations are focused on building more standardized and coordinated operational models through:
- Clear accountability structures and standardized escalation pathways
- Shared visibility into care transitions and barriers
- More integrated care planning approaches
Together, these approaches reflect growing recognition that fragmentation is as much an operational challenge as a clinical one. For states, this trend is likely to drive greater emphasis on coordination requirements within procurements, contracts, and oversight of health plan activities.
Addressing administrative complexity, member navigation challenges, and continuity of care
Members often must navigate multiple administrative care coordination challenges simultaneously in order to maintain coverage and receive care, including:
- Managing eligibility and coverage renewal requirements
- Delays and requirements related to service and medication approvals
- Resolving coverage denials and grievance issues
- Managing prescription coverage and pharmacy requirements
- Language and communication barriers
- Navigating multiple organizations involved in coverage and care
Recent Medicaid public health emergency unwinding activities and prior state experiences implementing community engagement requirements highlighted how procedural barriers and communication challenges impact continuity of coverage and access to care, particularly for vulnerable populations and individuals with complex needs. Recent KFF analyses of Medicaid unwinding data found that a significant share of Medicaid disenrollments nationally were tied to procedural reasons rather than confirmed ineligibility.
As states implement new federal Medicaid eligibility and redetermination requirements, many managed care programs may face renewed pressure to strengthen member outreach, communication, and navigation support in order to reduce avoidable coverage disruptions.
Moving from reactive intervention to proactive, data-driven oversight
Historically, managed care oversight has focused heavily on retrospective reporting and compliance monitoring. Today, organizations are seeking to identify risks earlier—before they result in avoidable utilization, member dissatisfaction, or coverage disruptions.
This shift is driving greater focus on:
- Real-time operational dashboards and integrated reporting across vendors and functions
- Utilization management and care transition monitoring
- Predictive analytics and risk stratification
- Proactive member outreach models
- Greater visibility into operational “friction points” across the member experience
This growing emphasis underscores that challenges for members, such as delayed authorizations, communication breakdowns, fragmented transitions, or barriers navigating eligibility, authorization, or care coordination processes, can directly impact program quality, equity, and continuity of care. In response, State Medicaid managed care programs are looking for ways to better connect areas such as member services, utilization management, pharmacy, grievances, and care management to identify barriers and risks earlier in the member journey.
Creating seamless member experiences
Medicaid managed care programs continue evolving alongside changing regulatory requirements, member needs, and growing expectations around coordination and accountability. More focus on coordination, greater insight into how systems perform in practice, and earlier identification of risk (not solely whether minimum compliance requirements are being met) can create a better member experience. Streamlining managed care operations requires stronger coordination across systems, vendors, and care coordination activities to support more seamless and member-centered experiences.
How BerryDunn can help
We provide key insights to Medicaid agencies seeking opportunities to improve their delivery of services, expand and manage provider networks, and mature provider payment models. We can help you oversee benefits and services through contracted arrangements with MCOs. Learn more about our services and team.
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