{ "slug": "medicaid", "title": "Who runs the Medicaid portal in your state", "shortTitle": "Medicaid portals", "intro": "Medicaid is 51 programs, each with its own fiscal agent, portal and prior auth process. This map has four layers: who runs claims, who reviews prior auth, how much of the program is managed care, and CMS-0057 readiness. Tap a state for its portal, vendor, sources and the contract end where one is dated, or download the whole dataset as CSV or JSON.", "updated": "2026-10", "vendors": [ { "id": "gainwell", "name": "Gainwell Technologies", "domain": "gainwell.com" }, { "id": "conduent", "name": "Conduent", "domain": "conduent.com" }, { "id": "state", "name": "State-run", "neutral": true }, { "id": "acentra", "name": "Acentra Health", "domain": "acentra.com" }, { "id": "gdit", "name": "GDIT", "domain": "gdit.com" }, { "id": "noridian", "name": "Noridian Healthcare Solutions", "domain": "noridian.com" }, { "id": "wipro", "name": "Wipro Infocrossing", "domain": "wipro.com" }, { "id": "accenture", "name": "Accenture", "domain": "accenture.com" } ], "states": [ { "code": "AK", "name": "Alaska", "vendor": "conduent", "portal": "Alaska Medicaid Health Enterprise", "portalUrl": "https://www.medicaidalaska.com/", "note": "Conduent operates the MMIS under a $92M 2025 contract; HMS (a Gainwell company) runs fiscal-agent operations since Apr 2023.", "confidence": "high", "source": "https://www.news.conduent.com/news/alaska-awards-92-million-contract-to-conduent-to-enhance-medicaid-program-delivery-systems", "pa": { "vendor": "Comagine Health", "detail": null, "portal": "Comagine Health Provider Portal", "portalUrl": null, "channels": "Comagine Health Provider Portal; registration packet required; paper/fax submission processes", "confidence": "high", "source": "https://comagine.org/program/alaska-medicaid-health-care-services/providers" }, "pbm": "Prime Therapeutics", "managedCare": { "share": 0, "year": "2024", "plans": [], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "in_progress", "note": "State-issued RFI seeks an electronic service-authorization solution integrated with the FFS-only MMIS and expressly requires conformance with CMS-0057-F; this is procurement/vendor planning, not production API evidence. Public planning/procurement evidence reviewed as of 2026-10-13; API deadline January 1, 2027, with no production launch confirmed.", "source": "https://aws.state.ak.us/OnlinePublicNotices/Notices/Attachment.aspx?id=151444" }, "transition": null, "events": [ { "date": "2024-11-01", "summary": "Alaska completed the final phase of transitioning behavioral-health Medicaid claims processing from Optum to the state MMIS; the first phase was completed by 2024-10-01.", "source": "https://health.alaska.gov/media/ya5hhm30/long-term-forecast-of-medicaid-enrollment-and-spending-in-alaska-fy2025fy2045.pdf" } ], "verified": "2026-10-13" }, { "code": "AL", "name": "Alabama", "vendor": "gainwell", "portal": "Alabama Medicaid Provider Web Portal", "portalUrl": "https://www.medicaid.alabamaservices.org/ALPortal/", "note": "CPMS/AMMP procurement language was observed, but no awarded core-MMIS replacement was verified. Current MMIS operations remain attributed to Gainwell Technologies.", "confidence": "low", "source": "https://medicaid.alabama.gov/alert_detail.aspx?ID=16627", "pa": { "vendor": "State agency", "detail": "Alabama Medicaid Agency / Gainwell Technologies fiscal agent", "portal": "Alabama Medicaid Interactive Web Portal", "portalUrl": "https://www.medicaid.alabamaservices.org/ALPortal/", "channels": "Web portal; PES electronic FFS PA; fax 334-215-7416 for supporting documentation", "confidence": "high", "source": "https://medicaid.alabama.gov/news_detail.aspx?ID=15388" }, "pbm": "Acentra Health", "managedCare": { "share": 0, "year": "2024", "plans": [], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "AR", "name": "Arkansas", "vendor": "gainwell", "portal": "Arkansas Medicaid Provider Portal", "portalUrl": "https://portal.mmis.arkansas.gov/ARMedicaid/Provider", "note": "No current replacement award verified in the sources reviewed; PBM scope is separate from medical-claims/MMIS operations.", "confidence": "medium", "source": "https://portal.mmis.arkansas.gov/ARMedicaid/Provider", "pa": { "vendor": "State agency", "detail": "Arkansas Medicaid/State and Clinical Services Medicaid contractors (service-dependent)", "portal": "Arkansas Medicaid Health Care Provider Portal", "portalUrl": "https://portal.mmis.arkansas.gov/ARMedicaid/Provider", "channels": null, "confidence": "high", "source": "https://humanservices.arkansas.gov/divisions-shared-services/medical-services/helpful-information-for-providers/provider-faqs/" }, "pbm": "Prime Therapeutics State Government Solutions", "managedCare": { "share": 5, "year": "2024", "plans": [ "Arkansas Total Care (Centene)", "CareSource PASSE (CareSource)", "Empower Healthcare Solutions", "Summit Community Care (Elevance Health)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "AZ", "name": "Arizona", "vendor": "state", "portal": "AHCCCS Online", "portalUrl": "https://ao.azahcccs.gov/", "note": "AHCCCS operates PMMIS in-house on its own mainframe and also hosts Hawaii's copy (HPMMIS). NTT Data hired for modular replacement roadmap.", "confidence": "high", "source": "https://www.azahcccs.gov/shared/News/GeneralNews/MainframeModernizationContractAward.html", "pa": { "vendor": "State agency", "detail": null, "portal": "AHCCCS Online Provider Portal", "portalUrl": "https://ao.azahcccs.gov/", "channels": "AHCCCS Online; limited FFS fax; FFS PA phone 602-417-7670", "confidence": "high", "source": "https://www.azahcccs.gov/PlansProviders/FeeForServiceHealthPlans/PriorAuthorization/index.html" }, "pbm": "Optum Rx", "managedCare": { "share": 79, "year": "2024", "plans": [ "Arizona Complete Health - Complete Care Plan (Centene)", "Banner-University Family Care (Banner Health)", "Molina Healthcare", "Mercy Care (Aetna/CVS Health)", "Blue Cross Blue Shield of Arizona Health Choice (Blue Cross Blue Shield of Arizona)", "UnitedHealthcare Community Plan (UnitedHealth Group)", "DCS/CHP", "DES/Division of Developmental Disabilities" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": { "vendor": "Modular replacement roadmap with NTT Data", "date": null, "status": "procuring" }, "events": [], "verified": "2026-10-13" }, { "code": "CA", "name": "California", "vendor": "gainwell", "portal": "Medi-Cal Provider Portal / Medi-Cal Connect", "portalUrl": "https://medi-calconnect.dhcs.ca.gov/", "note": "California's FI scope is split. Gainwell Technologies is the verified current FI Business Operations and dental business-operations vendor, with its BusOps contract reported through June 30, 2028. DHCS separately pursued an FI Maintenance and Operations procurement; the retrieved primary evidence does not establish the selected replacement or confirm that the new FI-M&O contract is live.", "confidence": "medium", "source": "https://www.dhcs.ca.gov/providers-partners/procurement-and-contracting-division/request-for-information-23-072/", "pa": { "vendor": "State agency", "detail": null, "portal": "eTAR (electronic Treatment Authorization Request) via Medi-Cal Provider Portal", "portalUrl": "https://mcweb.apps.prd.cammis.medi-cal.ca.gov/provider-portal", "channels": "eTAR/provider portal; paper TAR; limited fax/mail exceptions", "confidence": "high", "source": "https://mcweb.apps.prd.cammis.medi-cal.ca.gov/file/manual?fn=tar.pdf" }, "pbm": "Prime Therapeutics State Government Solutions (Medi-Cal Rx)", "managedCare": { "share": 96, "year": "2024", "plans": [ "Alameda Alliance for Health", "Anthem Blue Cross Partnership Plan (Elevance Health)", "Blue Shield of California Promise", "CalOptima", "CalViva Health", "CenCal Health", "Central California Alliance for Health", "Community Health Group", "Community Health Plan of Imperial Valley", "Contra Costa Health Plan", "Gold Coast Health Plan", "Health Net Community Solutions, Inc. (Centene)", "Health Plan of San Joaquin/Mountain Valley Health Plan", "Health Plan of San Mateo", "Inland Empire Health Plan", "Kaiser Permanente (Kaiser Foundation Health Plan)", "Kern Family Health Care", "L.A. Care Health Plan", "Molina Healthcare of California Partner Plan (Molina Healthcare)", "Partnership HealthPlan of California", "San Francisco Health Plan", "Santa Clara Family Health Plan", "SCAN Health Plan" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": null, "events": [], "contractEnd": "2028-06-30", "contractEndNote": "business operations contract", "verified": "2026-10-13" }, { "code": "CO", "name": "Colorado", "vendor": "gainwell", "portal": "Colorado Provider Portal", "portalUrl": "https://colorado-hcp-portal.coxix.gainwelltechnologies.com/hcp/provider/Home/tabid/135/Default.aspx", "note": "Gainwell remains the current Core MMIS and fiscal-agent vendor. Colorado has awarded separate module scopes to other vendors, including Optum for the Provider Call Center, Cotiviti (formerly Edifecs) for EDI, AssureCare for Care and Case Management, and Sandata for EVV; these do not replace the Core MMIS. The EDI transition is scheduled for phased implementation beginning in 2025 and late-summer 2026.", "confidence": "high", "source": "https://hcpf.colorado.gov/mmis-procurement", "pa": { "vendor": "Acentra Health", "detail": "Acentra Health (ColoradoPAR; formerly Kepro)", "portal": "Acentra PAR Portal / Atrezzo", "portalUrl": "https://portal.kepro.com/", "channels": "Atrezzo portal; fax exemption/paper only where approved; phone 720-689-6340; fax 800-922-3508", "confidence": "medium", "source": "https://hcpf.colorado.gov/provider-forms" }, "pbm": "MedImpact Healthcare Systems, Inc. (effective April 1, 2026; transitioned from Prime Therapeutics)", "managedCare": { "share": 0, "year": "2024", "plans": [ "Rocky Mountain Health Plans PRIME (UnitedHealth Group/Optum)", "Elevate Medicaid Choice (Denver Health)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "in_progress", "note": "HCPF FY27 compliance materials explicitly budget staff/system changes for the required FFS Patient Access, Provider Access, Payer-to-Payer and Prior Authorization APIs, with implementation described as required in 2027; not production yet. Public planning/procurement evidence reviewed as of 2026-10-13; API deadline January 1, 2027, with no production launch confirmed. CMS 2024 reports 0.4% comprehensive enrollment, rounded to 0; Colorado nevertheless has comprehensive MCO contracts.", "source": "https://hcpf.colorado.gov/sites/hcpf/files/HCPF%2C%20FY27%2C%20S-09%2C%20BA-09%20Additional%20Resources%20for%20Federal%20Compliance%20_combined.pdf" }, "transition": null, "events": [ { "date": "2025-05-01", "summary": "Optum became Colorado's Provider Services Call Center vendor, replacing Gainwell for that module; Gainwell remained the core MMIS and Provider Web Portal vendor.", "source": "https://hcpf.colorado.gov/mmis-procurement" } ], "verified": "2026-10-13" }, { "code": "CT", "name": "Connecticut", "vendor": "gainwell", "portal": "CT Medical Assistance Program Provider Portal", "portalUrl": "https://www.ctdssmap.com/CTPortal/", "note": "No replacement award verified in the sources reviewed; PBM scope is separate from medical claims.", "confidence": "low", "source": "https://www.ctdssmap.com/CTPortal/Provider/Provider-Services", "pa": { "vendor": "CHNCT", "detail": "Community Health Network of Connecticut (CHNCT) for medical goods/services; eviCore for radiology; CT BHP/Carelon for behavioral health", "portal": "HUSKY Health Medical Authorization Portal (GuidingCare)", "portalUrl": "https://cnt.guidingcare.com/AuthorizationPortal/Account/PPSelfRegistrationSearch", "channels": "GuidingCare portal; phone 800-440-5071; fax 203-265-3994; radiology via eviCore", "confidence": "high", "source": "https://www.ctdssmap.com/CTPortal/Information/Get-Download-File?Filename=pb2025_28.pdf&URI=Bulletins%2Fpb2025_28.pdf" }, "pbm": "Gainwell Technologies Pharmacy Prior Authorization Center", "managedCare": { "share": 0, "year": "2024", "plans": [], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "DC", "name": "District of Columbia", "vendor": "gainwell", "portal": "Gainwell DC Medicaid Provider Portal", "portalUrl": "https://www.dc-medicaid.com/", "note": "Gainwell Technologies became the District's fiscal agent and Medicaid claims-payment vendor on March 2, 2026, replacing Conduent for fee-for-service claims. The evidence supports the live fiscal-agent transition; it does not establish a separate PBM vendor.", "confidence": "high", "source": "https://dhcf.dc.gov/publication/medicaid-director-letter-mdl-26-01-dhcf-fiscal-agent-transition-gainwell-technologies", "pa": { "vendor": "Comagine Health", "detail": "Comagine Health (FFS QIO/UM reviewer; service-specific exceptions may apply)", "portal": "Comagine Health DC Medicaid Provider Portal", "portalUrl": "https://comagine.org/program/dc-medicaid-um/providers", "channels": "Comagine portal; fax 800-731-2314; phone 800-251-8890", "confidence": "high", "source": "https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/Transmittal%2025-08%20-%20Prior%20Authorization%20Updates%20for%20General%20Hospitals%20and%20Nursing%20Home%20Placements.pdf" }, "pbm": "Prime Therapeutics State Government Solutions (FirstRx; 2025 FFS manual)", "managedCare": { "share": 87, "year": "2024", "plans": [ "AmeriGroup District of Columbia (Elevance Health)", "AmeriHealth Caritas District of Columbia (AmeriHealth Caritas)", "Health Services for Children with Special Needs", "MedStar Family Choice DC (MedStar Health)", "UnitedHealthcare Community Plan of District of Columbia (UnitedHealth Group)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "in_progress", "note": "DC capital-plan documentation says the EDIS project will implement CMS-0057-F compliance, including payer-to-payer and prior-authorization interoperability; ongoing project, not demonstrated production FFS API. Public planning/procurement evidence reviewed as of 2026-10-13; API deadline January 1, 2027, with no production launch confirmed.", "source": "https://cfo.dc.gov/sites/default/files/dc/sites/ocfo/publication/attachments/ht0_dhcf_capital_2027a.pdf" }, "transition": { "date": "2026-03-02", "status": "live", "vendor": "Gainwell Technologies" }, "events": [ { "date": "2026-01-20", "summary": "Gainwell provider portal went live.", "source": "https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/Medicaid%20Director%20Letter%20-%20MDL%2026-01%20-%20DHCF%20Fiscal%20Agent%20Transition%20to%20Gainwell%20Technologies.pdf" }, { "date": "2026-03-02", "summary": "DHCF transitioned fiscal-agent and claims-payment responsibilities from Conduent to Gainwell Technologies; Gainwell system go-live occurred.", "source": "https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/Medicaid%20Director%20Letter%20-%20MDL%2026-01%20-%20DHCF%20Fiscal%20Agent%20Transition%20to%20Gainwell%20Technologies.pdf" } ], "verified": "2026-10-13" }, { "code": "DE", "name": "Delaware", "vendor": "gainwell", "portal": "Delaware Medical Assistance Portal for Providers (DMAP Provider Portal)", "portalUrl": "https://medicaid.dhss.delaware.gov/provider", "note": "No replacement award verified in the reviewed sources; current Gainwell scope is supported by Delaware provider communications, including Gainwell contact and EDI addresses. No separate replacement or split scope was verified.", "confidence": "high", "source": "https://medicaidpublications.dhss.delaware.gov/docs/search?Command=Core_Download&EntryId=1352", "managedCare": { "share": 85, "year": "2024", "plans": [ "AmeriHealth Caritas Delaware (AmeriHealth Caritas)", "Delaware First Health (Centene)", "Highmark Health Options (Highmark/Blue Cross Blue Shield)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "FL", "name": "Florida", "vendor": "gainwell", "portal": "Florida Medicaid Web Portal", "portalUrl": "https://portal.flmmis.com/FLPublic/Provider_PublicHome/tabId/36/Default.aspx", "note": "Gainwell fiscal-agent contract extended through December 31, 2027. FX modernization roadmap paused in March 2026 after cancellation of the HHS Technology Group provider-services release. No replacement medical-claims operator verified.", "confidence": "high", "source": "https://facts.fldfs.com/Search/ContractDetail.aspx?AgencyId=680000&ContractId=MED37", "pa": { "vendor": "eQHealth Solutions", "detail": "eQHealth Solutions (FFS medical PA/QIO); service-specific QIOs may also apply", "portal": "eQHealth web-based authorization system (exact public login URL not observed)", "portalUrl": null, "channels": "Web QIO system; paper; phone/fax via applicable QIO", "confidence": "high", "source": "https://ahca.myflorida.com/medicaid/quality-management-contracts.html" }, "pbm": "Magellan Medicaid Administration (FFS pharmacy; ePA via CoverMyMeds)", "managedCare": { "share": 70, "year": "2024", "plans": [ "Aetna Better Health (CVS Health/Aetna)", "AmeriHealth (AmeriHealth Caritas)", "Community Care Plan", "Florida Community Care", "Humana Healthy Horizons (Humana)", "Molina Healthcare of Florida (Molina Healthcare)", "Simply Healthcare Plans (Elevance Health)", "Sunshine State Health Plan (Centene)", "UnitedHealthcare Community Plan (UnitedHealth Group)", "Children's Medical Services Network" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": { "date": null, "status": "paused", "vendor": "HHS Technology Group, LLC / FX Provider Services Release" }, "events": [ { "date": "2025-02-25", "summary": "The FX Executive Steering Committee decided to terminate Gainwell Technologies’ FX Core contract; formal notice followed. Legacy FMMIS remains in operation while AHCA evaluates an RFI and future Core or takeover procurement.", "source": "https://ahca.myflorida.com/content/download/26819/file/FL-2025-04-01-MMIS-IAPDU-FX%20Program_Approval_Letter-Final-Signed.pdf" }, { "date": "2026-03-20", "summary": "AHCA terminated HHS Technology Group’s EXD115 contract, cancelling the FX Provider Services Release. The FX roadmap entered a planned pause while operations and maintenance continued.", "source": "https://ahca.myflorida.com/content/download/28594/file/260320_FX_ESC_Meeting_Summary.pdf" } ], "contractEnd": "2027-12-31", "contractEndNote": "extension", "verified": "2026-10-13" }, { "code": "GA", "name": "Georgia", "vendor": "gainwell", "portal": "GAMMIS (Georgia Medicaid Management Information System)", "portalUrl": "https://www.mmis.georgia.gov/portal/", "note": "No replacement award verified in the sources reviewed; this does not establish that no procurement is underway.", "confidence": "high", "source": "https://www.mmis.georgia.gov/portal/", "pa": { "vendor": "Alliant Health Solutions", "detail": "Alliant Health Solutions / Georgia Medical Care Foundation (FFS medical review)", "portal": "Georgia Web Portal Prior Authorization / Provider Workspace", "portalUrl": "https://www.mmis.georgia.gov/portal/", "channels": "Web portal; supporting-document upload; paper/other methods per request type", "confidence": "high", "source": "https://www.mmis.georgia.gov/portal/ResourceProxy.aspx?iCProxyTo=MC1BdHRhY2htZW50cy9UcmFpbmluZy9GRlMlMjBQQSUyMFdlYiUyMEVudHJ5JTIwTWFudWFsJTIwdjIuNC5wZGY%3D" }, "pbm": "OptumRx (FFS pharmacy PA)", "managedCare": { "share": 69, "year": "2024", "plans": [ "Amerigroup Community Care (Elevance Health)", "CareSource", "Peach State Health Plan (Centene)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "HI", "name": "Hawaii", "vendor": "conduent", "portal": "DHS Medicaid Online (DMO)", "portalUrl": "https://hiweb.statemedicaid.us/Account/Login.aspx?ReturnUrl=%2F", "note": "No replacement award verified from the supplied evidence; current fiscal-agent/claims-operator status is based on the referenced 2026 bulletin, and no contrary official evidence was retrieved.", "confidence": "low", "source": "https://medquest.hawaii.gov/content/dam/formsanddocuments/resources/Provider-Resources/DMOEligibilityandEnrollmentUserManual.pdf", "pa": { "vendor": "State agency", "detail": "State agency; Koan Risk Solutions (SHOTT)", "portal": "DHS Medicaid Online (DMO)", "portalUrl": "https://hiweb.statemedicaid.us/Account/Login.aspx?ReturnUrl=%2F", "channels": "DMO inquiry/status; forms/fax/mail; SHOTT fax and Koan portal for SHOTT", "confidence": "high", "source": "https://medquest.hawaii.gov/content/medquest/en/plans-providers/provider-resources.html" }, "pbm": "Conduent State Healthcare LLC (pharmacy fiscal agent)", "managedCare": { "share": 100, "year": "2024", "plans": [ "AlohaCare", "HMSA QUEST (Hawaii Medical Service Association/Blue Cross Blue Shield affiliate)", "Kaiser Permanente (Kaiser Foundation Health Plan)", "Ohana Health Plan (WellCare/Centene)", "UnitedHealthcare Community Plan (UnitedHealth Group)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "IA", "name": "Iowa", "vendor": "noridian", "portal": "Iowa Medicaid Portal Access (IMPA) for provider functions/attachments; EDISS for electronic claims", "portalUrl": "https://secureapp.dhs.state.ia.us/impa/", "note": "Iowa's current Core MMIS Services operator is identified as Noridian Healthcare Solutions. Iowa is pursuing MMIS modernization and has documented planning and procurement activity, including a provider enrollment/data-management module, but no replacement award or implementation date for the core claims MMIS was verified. Any modular awards should not be treated as replacement of the current core MMIS unless separately confirmed.", "confidence": "medium", "source": "https://medicaidmonitor.org/state/ia", "pa": { "vendor": "State agency", "detail": null, "portal": "Iowa Medicaid Portal Access (IMPA)", "portalUrl": "https://secureapp.dhs.state.ia.us/impa/", "channels": "IMPA; fax 515-725-1356; email paservices@hhs.iowa.gov; uniform forms", "confidence": "medium", "source": "https://hhs.iowa.gov/medicaid/provider-services/covered-services-rates-and-payments/prior-authorization" }, "pbm": "Optum Rx", "managedCare": { "share": 93, "year": "2024", "plans": [ "Iowa Total Care (Centene)", "Molina Healthcare of Iowa (Molina Healthcare)", "Wellpoint Iowa (Elevance Health)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "ID", "name": "Idaho", "vendor": "gainwell", "portal": "Idaho Medicaid Health PAS Online", "portalUrl": "https://www.idmedicaid.com/default.aspx", "note": "No replacement award verified in the sources reviewed; this does not establish that no procurement is underway.", "confidence": "high", "source": "https://healthandwelfare.idaho.gov/providers/idaho-medicaid-providers/information-medicaid-providers", "pa": { "vendor": "Telligen", "detail": "Telligen (Qualitrac) for most medical PA; Gainwell/Idaho Medicaid for operational support; service-specific transitions noted", "portal": "Qualitrac Provider Portal", "portalUrl": "https://id.qualitrac.com", "channels": "Qualitrac web portal; exceptions/appeals via MedicaidQIO@dhw.idaho.gov; Telligen support phone/fax", "confidence": "high", "source": "https://idmedicaid.telligen.com/wp-content/uploads/2025/02/2025_Provider-Manual.pdf" }, "pbm": "Prime Therapeutics", "managedCare": { "share": 6, "year": "2024", "plans": [ "Blue Cross of Idaho", "Molina of Idaho (Molina)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. The 6% share includes CMS-classified comprehensive dual-eligible plans; KFF does not otherwise count Idaho as an MCO state. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": null, "events": [ { "date": "2025-12-01", "summary": "Behavioral Modification and Consultation services stopped being managed by Magellan Healthcare. Providers submit authorizations through Telligen’s Qualitrac Provider Portal and bill Idaho Medicaid directly through Gainwell Technologies; existing authorizations were transferred or extended.", "source": "https://healthandwelfare.idaho.gov/providers/home-and-community-based-services-children-developmental-disabilities/childrens" } ], "verified": "2026-10-13" }, { "code": "IL", "name": "Illinois", "vendor": "state", "portal": "MEDI / Internet Electronic Claims (IEC)", "portalUrl": "https://medi.hfs.illinois.gov/", "note": "Replacement of core legacy MMIS elements awarded to CNSI (now Acentra Health) in 2021; production go-live as of October 13, 2026 not verified. HFS identifies itself as managing and operating the MMIS.", "confidence": "medium", "source": "https://hfs.illinois.gov/content/dam/soi/en/web/hfs/sitecollectiondocuments/illinoishitsmhpu2021final50.pdf", "pa": { "vendor": "State agency", "detail": "State agency; Acentra Health (selected surgery reviews)", "portal": "MEDI (HFS medical PA processes); eQSuite for Acentra service-specific reviews", "portalUrl": null, "channels": "HFS forms/fax/phone; eQSuite online 24/7 for CABG/back surgery", "confidence": "high", "source": "https://hfs.illinois.gov/content/dam/soi/en/web/hfs/info/reports/miscellaneous/ilcy2025pamreport.pdf" }, "pbm": "HFS directly administers FFS pharmacy PA; ILLINOIS Rx Portal / MEDI", "managedCare": { "share": 76, "year": "2024", "plans": [ "Aetna Better Health of Illinois (CVS Health/Aetna)", "Blue Cross Community Health Plans (Elevance Health)", "CountyCare (Cook County Health)", "MeridianHealth (Centene)", "Molina Healthcare of Illinois (Molina Healthcare)", "YouthCare (Aetna/CVS Health)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": { "vendor": "Acentra Health (CNSI award, 2021)", "date": null, "status": "awarded" }, "events": [], "verified": "2026-10-13" }, { "code": "IN", "name": "Indiana", "vendor": "gainwell", "portal": "IHCP Provider Healthcare Portal", "portalUrl": "https://portal.indianamedicaid.com/", "note": "No replacement award verified in the sources reviewed; no conclusion is made about whether procurement activity is underway.", "confidence": "medium", "source": "https://www.in.gov/medicaid/partners/medicaid-partners/gainwell-technologies/", "pa": { "vendor": "Acentra Health", "detail": "Acentra Health (FFS nonpharmacy PA-UM contractor)", "portal": "Atrezzo Provider Portal", "portalUrl": "https://atrezzo.acentra.com", "channels": "Atrezzo web; fax/mail; telephone; 278 electronic transaction", "confidence": "high", "source": "https://www.in.gov/medicaid/providers/clinical-services/prior-authorization/" }, "pbm": "OptumRx", "managedCare": { "share": 82, "year": "2024", "plans": [ "Anthem (Elevance Health)", "CareSource", "Managed Health Services (MHS) (Centene)", "UnitedHealthcare Community Plan (UnitedHealth Group)", "Humana Healthy Horizons (Humana)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "KS", "name": "Kansas", "vendor": "gainwell", "portal": "KMAP/KMMS Provider Portal", "portalUrl": "https://portal.kmap-state-ks.us/", "note": "No replacement award verified in the sources reviewed; current MMIS fiscal-agent status was not independently confirmed from the supplied evidence.", "confidence": "low", "source": "https://www.kancare.ks.gov/providers/training-resources/frequently-asked-questions", "managedCare": { "share": 79, "year": "2024", "plans": [ "Sunflower Health Plan (Centene)", "UnitedHealthcare Community Plan (UnitedHealth Group)", "Healthy Blue (Elevance Health)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "KY", "name": "Kentucky", "vendor": "gainwell", "portal": "KY HealthNet provider portal", "portalUrl": "https://home.kymmis.com/", "note": "Kentucky’s planned MCAFS replacement implementation was stopped or paused. Gainwell remains the current MMIS fiscal agent and no replacement award or go-live was verified. The available evidence does not establish that no procurement is underway.", "confidence": "high", "source": "https://www.chfs.ky.gov/agencies/dms/dca/waivers/waiverapplicationABILTC.pdf", "pa": { "vendor": "Gainwell Technologies", "detail": "Gainwell Technologies (FFS medical PA)", "portal": "KyHealth Net PA", "portalUrl": "https://home.kymmis.com/", "channels": "KyHealth Net web PA; phone; forms/fax (service-specific)", "confidence": "high", "source": "https://www.chfs.ky.gov/agencies/dms/dpo/bpb/pages/physicians.aspx" }, "pbm": "MedImpact", "managedCare": { "share": 90, "year": "2024", "plans": [ "Aetna Better Health of Kentucky (CVS Health/Aetna)", "Humana", "Passport by Molina (Molina Healthcare)", "UnitedHealthcare Community Plan (UnitedHealth Group)", "WellCare of Kentucky (Centene)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": { "date": null, "status": "paused", "vendor": "MCAFS replacement (vendor not established; current MMIS retained)" }, "events": [ { "date": "2025-01-23", "summary": "Kentucky stopped implementation of the MCAFS replacement and will maintain the current MMIS; future changes will be announced to stakeholders.", "source": "https://www.chfs.ky.gov/agencies/dms/mac/Documents/MACMinutesJan.pdf" } ], "verified": "2026-10-13" }, { "code": "LA", "name": "Louisiana", "vendor": "gainwell", "portal": "Louisiana Medicaid Provider Portal / lamedicaid.com", "portalUrl": "https://www.lamedicaid.com/account/login.aspx", "note": "No replacement award verified in the sources reviewed; this does not establish that no procurement is underway.", "confidence": "medium", "source": "https://ldh.la.gov/medicaid/claims-and-billing", "pa": { "vendor": "Gainwell Technologies", "detail": "Gainwell Technologies (medical e-PA)", "portal": "Louisiana Medicaid Electronic Prior Authorization (e-PA)", "portalUrl": "https://www.lamedicaid.com", "channels": "Online e-PA; fax; phone; mail", "confidence": "high", "source": "https://www.lamedicaid.com/provweb1/forms/userguides/epahelp.pdf" }, "pbm": "FFS: Gainwell Technologies; pharmacy PA clinical review: University of Louisiana Monroe; MCO PBMs plan-specific", "managedCare": { "share": 84, "year": "2024", "plans": [ "Aetna Better Health Louisiana (CVS Health/Aetna)", "AmeriHealth Caritas Louisiana (AmeriHealth Caritas/Independence Blue Cross)", "Healthy Blue of Louisiana (Elevance Health)", "Humana Healthy Horizons Louisiana (Humana)", "Louisiana Healthcare Connections (Centene)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "MA", "name": "Massachusetts", "vendor": "gainwell", "portal": "MassHealth Provider Online Service Center (POSC)", "portalUrl": "https://mmis-portal.ehs.state.ma.us/EHSProviderPortal", "note": "NewMMIS was built by EDS/HP and maintained by HP Enterprise Services → DXC → Gainwell; current M&O contractor not confirmed in public sources. Migrated to AWS Mar 2025.", "confidence": "low", "source": "https://www.mass.gov/mmis-and-posc-information-for-masshealth-providers", "pa": { "vendor": "State agency", "detail": null, "portal": "MassHealth Provider Online Service Center (POSC)", "portalUrl": "https://mmis-portal.ehs.state.ma.us/EHSProviderPortal", "channels": "POSC online; paper/mail only with approved waiver", "confidence": "high", "source": "https://www.mass.gov/how-to/request-prior-authorization-for-nonpharmacy-services" }, "pbm": "Conduent for MassHealth FFS/PCC pharmacy (POPS); MCO plan PBMs", "managedCare": { "share": 46, "year": "2024", "plans": [ "Fallon 365 Care", "BeHealthy Partnership Plan", "Berkshire Fallon Health Collaborative", "Commonwealth Care Alliance", "East Boston Neighborhood Health WellSense Alliance (Boston Medical Center Health Plan)", "Fallon Health - Atrius Health Care Collaborative", "Mass General Brigham Health Plan with Mass General Brigham ACO", "Navicare HMO", "Senior Whole Health (Molina Healthcare)", "Tufts Health Plan (Point32Health)", "Tufts Health Together with Cambridge Health Alliance (Point32Health)", "Tufts Health Together with UMass Memorial Health (Point32Health)", "UnitedHealthcare (UnitedHealth Group)", "WellSense Beth Israel Lahey Health Performance Network ACO (Boston Medical Center Health Plan)", "WellSense Boston Children's ACO (Boston Medical Center Health Plan)", "WellSense Care Alliance (Boston Medical Center Health Plan)", "WellSense Community Alliance (Boston Medical Center Health Plan)", "WellSense Health Plan (Boston Medical Center Health Plan)", "WellSense Mercy Alliance (Boston Medical Center Health Plan)", "WellSense Signature Alliance (Boston Medical Center Health Plan)", "WellSense Southcoast Alliance (Boston Medical Center Health Plan)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": null, "events": [ { "date": "2025-03-17", "summary": "MassHealth completed the MMIS and POSC migration to AWS; the POSC reopened and transactions were redirected to AWS.", "source": "https://www.mass.gov/info-details/message-text-march-2025" } ], "verified": "2026-10-13" }, { "code": "MD", "name": "Maryland", "vendor": "state", "portal": "eMedicaid", "portalUrl": "https://emedicaid.health.maryland.gov/emedicaid/", "note": "MDH runs the legacy MMIS II and eMedicaid portal in-house; the 2012 CSC/CNSI replacement never went live. New MES procurement planned.", "confidence": "medium", "source": "https://emedicaid.health.maryland.gov/emedicaid/", "pa": { "vendor": "State agency", "detail": null, "portal": null, "portalUrl": null, "channels": "Fax and online submission", "confidence": "medium", "source": "https://health.maryland.gov/mmcp/provider/Documents/transmittals/PT99-26_Updated_Prior_Authorization_Process_for_Special_Pediatric_Hospitals.pdf" }, "pbm": "FFS pharmacy: Conduent; MCO pharmacy PBMs contracted by each MCO", "managedCare": { "share": 95, "year": "2024", "plans": [ "Aetna Better Health of Maryland (CVS Health/Aetna)", "CareFirst Community Health Plan Maryland (CareFirst/Blue Cross Blue Shield)", "Jai Medical Systems (Jai Medical Group)", "Kaiser Permanente (Kaiser Foundation Health Plan)", "Maryland Physicians Care (UnitedHealthcare)", "MedStar Family Choice (MedStar Health)", "Priority Partners (Johns Hopkins HealthCare)", "University of Maryland Health Partners (University of Maryland Medical System)", "UnitedHealthcare Community Plan (UnitedHealth Group)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": { "date": null, "status": "procuring", "vendor": null }, "events": [], "verified": "2026-10-13" }, { "code": "ME", "name": "Maine", "vendor": "gainwell", "portal": "MaineCare Partner Portal", "portalUrl": "https://mainecare.maine.gov/", "note": "The MaineCare Partner Portal replaced the HealthPAS Online Portal and went live on October 12, 2026. This is a portal/MMIS access upgrade, not evidence of a fiscal-agent replacement; no current fiscal-agent replacement award was verified.", "confidence": "low", "source": "https://www.maine.gov/dhhs/oms/providers/provider-bulletins/attention-trading-partners-mainecare-partner-portal-live-2026-10-12", "pa": { "vendor": "Gainwell Technologies", "detail": "Gainwell Technologies (fiscal intermediary)", "portal": "MaineCare Health PAS-OnLine / My HealthPAS provider portal", "portalUrl": "https://mainecare.maine.gov/Default.aspx", "channels": "Online portal; forms/fax where specified; phone support", "confidence": "high", "source": "https://mainecare.maine.gov/_layouts/15/help.aspx?Lcid=1033&Key=Health%20PAS%20Online%20Help_Provider_Default&ShowNav=false" }, "pbm": "Change Healthcare pharmacy resources; Optum eWEBS for electronic pharmacy PA (Aug. 18, 2025)", "managedCare": { "share": 0, "year": "2024", "plans": [], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": { "date": "2026-10-12", "status": "live", "vendor": "MaineCare Partner Portal" }, "events": [ { "date": "2026-10-12", "summary": "MaineCare Partner Portal went live and replaced the HealthPAS Online Portal; Gainwell support channels are provided for portal and MIHMS questions.", "source": "https://www.maine.gov/dhhs/oms/providers/provider-bulletins/attention-trading-partners-mainecare-partner-portal-live-2026-10-12" } ], "verified": "2026-10-13" }, { "code": "MI", "name": "Michigan", "vendor": "acentra", "portal": "CHAMPS via MiLogin", "portalUrl": "https://milogintp.michigan.gov/", "note": "Acentra Health is the current CHAMPS/MMIS contractor under a state contract effective February 1, 2026, with a term through September 30, 2031. The contract history identifies CNSI as the predecessor; CNSI is now Acentra Health. No separate replacement award or split claims-processing scope was verified.", "confidence": "high", "source": "https://www.michigan.gov/dtmb/-/media/Project/Websites/dtmb/Procurement/Contracts/003/6200168%20CN19toPresent.pdf", "pa": { "vendor": "State agency", "detail": null, "portal": "CHAMPS Prior Authorization", "portalUrl": "https://milogintp.michigan.gov/", "channels": "CHAMPS direct entry; fax forms", "confidence": "high", "source": "https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers/champs-a/champs/accordion/pages-functions/prior-authorization" }, "pbm": "Prime Therapeutics (FFS pharmacy PBM and pharmacy PA)", "managedCare": { "share": 98, "year": "2024", "plans": [ "Aetna Better Health of Michigan (CVS Health)", "Blue Cross Complete of Michigan (Independence Health Group)", "HAP CareSource (CareSource/HAP)", "McLaren Health Plan (McLaren Health Care)", "Meridian Health Plan of Michigan (Centene)", "Molina Healthcare of Michigan (Molina Healthcare)", "Priority Health Choice (Priority Health)", "UnitedHealthcare Community Plan (UnitedHealth Group)", "Upper Peninsula Health Plan (UP Health System)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": null, "events": [], "contractEnd": "2028-09-30", "contractEndNote": "options to Sep 2031", "verified": "2026-10-13" }, { "code": "MN", "name": "Minnesota", "vendor": "state", "portal": "MN–ITS", "portalUrl": "https://mn-its.dhs.state.mn.us/", "note": "DHS and MNIT operate the 1994 MMIS in-house; MN–ITS and MPSE are its provider front ends. Modular replacement in planning.", "confidence": "high", "source": "https://www.house.mn.gov/comm/docs/FiFLN4Emk0WO-365xKHq2Q.pdf", "pa": { "vendor": "State agency", "detail": null, "portal": "MN-ITS / MHCP MMIS", "portalUrl": "https://mn-its.dhs.state.mn.us/", "channels": "MN-ITS/MMIS electronic; service-specific phone/fax", "confidence": "medium", "source": "https://www.dhs.state.mn.us/main/idcplg/j/main/https/www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=id_008992" }, "pbm": "Prime Therapeutics (FFS pharmacy PA agent); MCO PBMs plan-specific", "managedCare": { "share": 83, "year": "2024", "plans": [ "Blue Plus (Blue Cross and Blue Shield of Minnesota)", "HealthPartners", "Hennepin Health (Hennepin County)", "Itasca Medical Care (Itasca County)", "Medica", "South Country Health Alliance (county-based purchasing coalition)", "UCare", "UnitedHealthcare Community Plan (UnitedHealth Group)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": { "vendor": "Modular replacement in planning", "date": null, "status": "procuring" }, "events": [], "verified": "2026-10-13" }, { "code": "MO", "name": "Missouri", "vendor": "wipro", "portal": "eMOMED", "portalUrl": "https://www.emomed.com/portal/wps/portal/", "note": "Wipro Infocrossing is evidenced as the current Missouri MO HealthNet claims-processing support vendor. Missouri budget documents show ongoing MMIS modernization, security, prior-authorization, pharmacy-solution, and operational projects, but do not establish a replacement fiscal-agent award or live replacement. Gainwell evidence relates to Missouri preferred-drug-list and diabetic-supply services and does not establish that Gainwell replaced Wipro Infocrossing as the claims fiscal agent; scopes may therefore be split.", "confidence": "medium", "source": "https://dss.mo.gov/mhd/hot-tips/electronic-claim-submission", "pa": { "vendor": "State agency", "detail": null, "portal": "eMOMED MO HealthNet Web Portal", "portalUrl": "https://www.emomed.com/portal/wps/portal/", "channels": "eMOMED; service-specific paper/fax/phone", "confidence": "medium", "source": "https://www.emomed.com/" }, "pbm": "MO HealthNet Pharmacy Administration/FFS pharmacy; external PBM not verified", "managedCare": { "share": 84, "year": "2024", "plans": [ "Healthy Blue (Elevance Health)", "Home State Health (Centene)", "UnitedHealthcare Community Plan (UnitedHealth Group)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "MS", "name": "Mississippi", "vendor": "gainwell", "portal": "MESA Portal for Providers", "portalUrl": "https://portal.ms-medicaid-mesa.com/", "note": "Gainwell Technologies replaced Conduent as Mississippi Medicaid's fiscal agent/MMIS operator, with full MESA operations beginning October 3, 2022. No newer MMIS replacement award was verified; this does not establish that no procurement is underway.", "confidence": "low", "source": "https://medicaid.ms.gov/the-mississippi-medicaid-mmis-replacement-project/", "pa": { "vendor": "Telligen", "detail": "Telligen (FFS medical/non-pharmacy PA); Gainwell Technologies (pharmacy PA)", "portal": "Telligen Mississippi Medicaid medical PA portal; MESA Provider Portal for pharmacy", "portalUrl": "https://msmedicaid.telligen.com/", "channels": "Telligen portal; MESA; fax/phone by PA type", "confidence": "high", "source": "https://medicaid.ms.gov/prior-authorization/" }, "pbm": "Gainwell Technologies single Pharmacy Benefit Administrator", "managedCare": { "share": 74, "year": "2024", "plans": [ "Magnolia Health Plan (Centene)", "Molina Healthcare of Mississippi (Molina Healthcare)", "TrueCare (Mississippi True)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "MT", "name": "Montana", "vendor": "conduent", "portal": "Montana Access to Health (MATH); MPATH provider services", "portalUrl": "https://portal.mt.healthinteractive.net/icapPortal/", "note": "Gainwell awarded replacement Montana Healthcare Claims System; December 14, 2026 soft launch and spring 2027 claims-processing go-live planned. Conduent remains current claims operator at the cutoff.", "confidence": "high", "source": "https://dphhs.mt.gov/assets/montanahealthcareprograms/PrepareFortheMontanaHealthcareClaimsSystemTransition.pdf", "pa": { "vendor": "Mountain-Pacific Quality Health", "detail": "Mountain-Pacific Quality Health (Qualitrac for physician-administered medical drugs)", "portal": "Qualitrac Medicaid Portal", "portalUrl": "https://www.mpqhf.org/corporate/medicaid-portal-home/medicaid-portal-document-library/", "channels": null, "confidence": "high", "source": "https://medicaidprovider.mt.gov/priorauthorization" }, "pbm": "No PBM; Conduent POS/claims and Mountain-Pacific drug PA", "managedCare": { "share": 0, "year": "2024", "plans": [], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": { "vendor": "Gainwell Technologies (Montana Healthcare Claims System)", "date": "2026-12-14", "status": "scheduled" }, "events": [ { "date": "2026-07-27", "summary": "Provider notice stated that EDI transactions will move from Conduent to Gainwell and the MATH Portal will be retired as functions move to new provider portals.", "source": "https://medicaidprovider.mt.gov/docs/providernotices/2026/TradingPartnerChangesComingin2027_MontanaHealthcareClaimsSystemMTHCSProviderNotice.pdf" }, { "date": "2026-09-30", "summary": "DPHHS announced the MTHCS transition from Conduent to Gainwell; soft launch is planned for December 14, 2026, with claims-processing go-live planned for spring 2027.", "source": "https://dphhs.mt.gov/assets/montanahealthcareprograms/PrepareFortheMontanaHealthcareClaimsSystemTransition.pdf" } ], "verified": "2026-10-13" }, { "code": "NC", "name": "North Carolina", "vendor": "gdit", "portal": "NCTracks Provider Portal", "portalUrl": "https://www.nctracks.nc.gov/", "note": "GDIT is the current NCTracks MMIS fiscal agent under a June 2024 contract extension. North Carolina is replacing NCTracks through a phased Medicaid Integrated Modular Solution (MIMS/MES), but no replacement medical-claims fiscal-agent vendor or live-date award was verified. Pharmacy benefit administration for NC Medicaid Direct is scheduled to transition to Prime Therapeutics State Government Solutions LLC on May 2, 2026; this is a separate pharmacy scope, not confirmation of replacement of the medical-claims MMIS.", "confidence": "low", "source": "https://www.gdit.com/about-gdit/press-releases/gdit-awarded-usd524-million-north-carolina-medicaid-management-information/", "pa": { "vendor": "GDIT", "detail": "GDIT / NCTracks (with service-specific DHB contractors possible)", "portal": "NCTracks Provider Portal", "portalUrl": "https://www.nctracks.nc.gov/", "channels": "Online secure portal; paper mail/fax for some forms; NCTracks Call Center", "confidence": "high", "source": "https://www.nctracks.nc.gov/content/public/providers/prior-approval.html" }, "pbm": "Prime Therapeutics State Government Solutions (PBA effective 2026-05-02; pharmacy PA administration); prior NC pharmacy functionality was in NCTracks", "managedCare": { "share": 79, "year": "2024", "plans": [ "Alliance Behavioral Healthcare", "AmeriHealth Caritas (Independence Health Group)", "Carolina Complete Health (Centene)", "Healthy Blue of North Carolina", "Partners Behavioral Health Management", "Trillium Health Resources", "UnitedHealthcare (UnitedHealth Group)", "Vaya Health", "WellCare (Centene)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": null, "events": [ { "date": "2026-05-02", "summary": "Prime became the NC Medicaid Direct pharmacy benefit administrator; providers were directed to discontinue NCTracks pharmacy functionality and use the Prime Pharmacy Provider Portal.", "source": "https://medicaid.ncdhhs.gov/providers/programs-and-services/prescription-drugs/pharmacy-benefit-administrator" } ], "verified": "2026-10-13" }, { "code": "ND", "name": "North Dakota", "vendor": "conduent", "portal": "ND Health Enterprise MMIS Web Portal", "portalUrl": "https://mmis.nd.gov/", "note": "Conduent Health Enterprise MMIS, infrastructure upgraded under a 2021 agreement; Noridian handles provider enrollment.", "confidence": "high", "source": "https://investor.conduent.com/news-releases/news-release-details/conduent-upgrade-medicaid-management-information-system", "pa": { "vendor": "Acentra Health", "detail": "Acentra Health (formerly Kepro), for medical service authorization", "portal": "Acentra Health Atrezzo Online Provider Portal", "portalUrl": "https://atrezzo.kepro.com/Account/Login.aspx", "channels": null, "confidence": "high", "source": "https://nddhs.acentra.com/" }, "pbm": "Acentra Health (pharmacy PA vendor; not a claims PBM identified in source)", "managedCare": { "share": 23, "year": "2024", "plans": [ "North Dakota Medicaid Expansion (Blue Cross Blue Shield of North Dakota)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "NE", "name": "Nebraska", "vendor": "state", "portal": "Nebraska Medicaid EDI / Provider Portal", "portalUrl": "https://dhhs.ne.gov/Pages/Medicaid-Provider-Electronic-Data-Interchange.aspx", "note": "DHHS runs claims in-house (trading partners submit direct); Maximus holds the provider-enrollment module under a NASPO MSA. Modular replacement underway.", "confidence": "medium", "source": "https://maximus.com/news/nebraska-mmis-provider-contract", "pa": { "vendor": "Acentra Health", "detail": "Acentra Health (medical utilization management); Department for injectable medication PA; service-specific MCO vendors for managed care", "portal": "Acentra Health Provider Portal (portal.kepro.com)", "portalUrl": "https://portal.kepro.com/", "channels": "Acentra portal; phone 888-498-0939; fax 800-316-0021; injectable medication fax/email to Nebraska DHHS", "confidence": "high", "source": "https://dhhs.ne.gov/Pages/Utilization-Management.aspx" }, "pbm": "Prime Therapeutics State Government Solutions (Nebraska FFS pharmacy); managed-care plans handle their own pharmacy PA", "managedCare": { "share": 100, "year": "2024", "plans": [ "Molina Healthcare of Nebraska (Molina)", "Nebraska Total Care (Centene)", "UnitedHealthcare Community Plan of Nebraska (UnitedHealth Group)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": { "vendor": "Modular replacement", "date": null, "status": "procuring" }, "events": [ { "date": "2025-06-01", "summary": "Nebraska Medicaid ended paper provider-enrollment applications; electronic enrollment moved to Maximus's Provider Data Management System.", "source": "https://dhhs.ne.gov/Pages/Medicaid-Provider-Screening-and-Enrollment-Forms.aspx" } ], "verified": "2026-10-13" }, { "code": "NH", "name": "New Hampshire", "vendor": "conduent", "portal": "New Hampshire MMIS Health Enterprise Portal", "portalUrl": "https://nhmmis.nh.gov/portals/wps/portal/ProviderLogin", "note": "Conduent's fiscal-agent/provider-relations role is reported, but no current replacement award or live transition was verified in the reviewed evidence.", "confidence": "medium", "source": "https://www.dhhs.nh.gov/conduent-provider-relations", "pa": { "vendor": "State agency", "detail": null, "portal": "New Hampshire MMIS Health Enterprise Portal", "portalUrl": "https://nhmmis.nh.gov/portals/wps/portal/ProviderLogin", "channels": null, "confidence": "medium", "source": "https://www.dhhs.nh.gov/programs-services/medicaid/medicaid-provider-relations" }, "pbm": "Prime Therapeutics State Government Solutions (pharmacy benefit administrator; NH DHHS page)", "managedCare": { "share": 91, "year": "2024", "plans": [ "AmeriHealth Caritas of New Hampshire (Independence Health Group)", "New Hampshire Healthy Families (Centene)", "WellSense Health Plan (Boston Medical Center Health Plan)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "NJ", "name": "New Jersey", "vendor": "gainwell", "portal": "NJMMIS", "portalUrl": "https://www.njmmis.com/", "note": "Gainwell Technologies is identified as the current NJMMIS provider-services contact and supports the live NJMMIS portal. New Jersey separately announced an intent to join a cooperative Provider Services Module procurement to replace aging legacy components; no resulting replacement award or live date was verified. The cooperative module may represent a split scope rather than a confirmed replacement of all current MMIS fiscal-agent services.", "confidence": "high", "source": "https://test2.njmmis.com/downloadDocuments/MA-2026-02.pdf", "managedCare": { "share": 92, "year": "2024", "plans": [ "Aetna Better Health NJ (CVS Health)", "Fidelis Care/Wellcare (Centene)", "Horizon NJ Health", "UnitedHealthcare Community Plan (UnitedHealth Group)", "Wellpoint (Elevance Health)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": { "date": null, "status": "procuring", "vendor": null }, "events": [], "verified": "2026-10-13" }, { "code": "NM", "name": "New Mexico", "vendor": "conduent", "portal": "New Mexico Medicaid Provider Web Portal", "portalUrl": "https://nmmedicaid.syst.portal.conduent.com/static/providerlogin.htm", "note": "Live as of March 23, 2026. Turquoise Claims replaced OmniCaid and the New Mexico Medicaid Provider Web Portal for Medicaid claims, with the transition period ending June 15, 2026. Conduent remains identified as the entity designing and maintaining the MMIS and serving as fiscal agent. New Mexico's modular MMISR architecture also includes other vendors, including Spruce/KPMG as system integrator; this does not establish a replacement of Conduent's claims-fiscal-agent scope.", "confidence": "high", "source": "https://www.hca.nm.gov/wp-content/uploads/Turquoise-Claims-Important-Transition-Information.pdf", "pa": { "vendor": "Comagine Health", "detail": "Comagine Health (FFS utilization management / PA); service-specific reviewers may also apply", "portal": "Comagine Health Provider Portal (CHPP/Jiva)", "portalUrl": null, "channels": "Comagine Health Provider Portal; HCA forms and other service-specific submission channels; NM Medicaid web portal supports PA inquiry", "confidence": "high", "source": "https://comagine.org/program/new-mexico-medicaid" }, "pbm": "Conduent (New Mexico Medicaid FFS pharmacy); managed-care Turquoise Care plans use Prime or plan-specific pharmacy administration", "managedCare": { "share": 82, "year": "2024", "plans": [ "Blue Cross Blue Shield of NM (Health Care Service Corporation)", "Molina Healthcare (Molina)", "Presbyterian Health Plan", "UnitedHealthcare Community Plan (UnitedHealth Group)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": { "date": "2026-03-23", "status": "live", "vendor": "Turquoise Claims (New Mexico Health Care Authority system)" }, "events": [ { "date": "2026-03-23", "summary": "Turquoise Claims went live at YES.NM.GOV, replacing OmniCaid and the NM Medicaid Provider Web Portal for claims submission.", "source": "https://www.hca.nm.gov/wp-content/uploads/Turquoise-Claims-Important-Transition-Information.pdf" } ], "verified": "2026-10-13" }, { "code": "NV", "name": "Nevada", "vendor": "gainwell", "portal": "Nevada Medicaid Provider Web Portal", "portalUrl": "https://www.medicaid.nv.gov/", "note": "Current live MMIS/provider portal; no replacement award verified. This does not establish that no procurement is underway.", "confidence": "low", "source": "https://www.medicaid.nv.gov/providers/edi", "pa": { "vendor": "Gainwell Technologies", "detail": "Gainwell Technologies / Nevada Medicaid Provider Web Portal for most medical services; Prime Therapeutics Management for medical-benefit specialty drugs", "portal": "Nevada Medicaid Provider Web Portal (PWP); GatewayPA for Prime medical pharmacy", "portalUrl": "https://www.medicaid.nv.gov/", "channels": null, "confidence": "high", "source": "https://www.medicaid.nv.gov/Downloads/provider/NV_EVS_User_Manual_Ch4.pdf" }, "pbm": "Prime Therapeutics State Government Solutions (pharmacy PBM); Prime Therapeutics Management (medical pharmacy PA)", "managedCare": { "share": 74, "year": "2024", "plans": [ "Anthem Blue Cross and Blue Shield Healthcare Solutions", "CareSource", "Health Plan of Nevada", "Molina Healthcare of Nevada", "SilverSummit Healthplan" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "NY", "name": "New York", "vendor": "gdit", "portal": "eMedNY Provider Portal", "portalUrl": "https://portal.emedny.org/provider/", "note": "CSRA State and Local Solutions LLC is the documented current eMedNY MMIS fiscal-agent contractor under contract C014305 X22, extended for December 1, 2024 through November 30, 2025, with two one-year renewal options. New York is continuing to align its procurement strategy with its Medicaid Enterprise Systems roadmap, but no replacement award or live replacement vendor was verified in the reviewed sources. GDIT materials describe historical and ongoing eMedNY support, but do not establish that GDIT replaced CSRA under the current state contract.", "confidence": "medium", "source": "https://health.ny.gov/funding/single_source/c014305_x22.htm", "pbm": "Prime Therapeutics (NYRx pharmacy program)", "managedCare": { "share": 68, "year": "2024", "plans": [ "AmidaCare Special Needs", "Capital District Physician's Health Plan", "Centers Plan", "ElderPlan", "ElderServe (Riverspring)", "Excellus Health Plan", "Fidelis Care (Centene)", "Hamaspik", "Healthfirst Health Plan", "HealthPlus (Elevance Health)", "Highmark Western & Northeastern NY (Highmark)", "HIP", "Independent Health Association", "MetroPlus Health Plan", "Molina Healthcare of New York (Molina)", "MVP Health Plan", "Partners Health Plan - FIDA-IDD", "Senior Whole Health (Molina)", "UnitedHealthcare (UnitedHealth Group)", "VillageCareMAX", "VNS Choice" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "extension", "note": "Official April 28, 2026 eMedNY notice states NYS was granted an extension for new prior-authorization determination timelines, effective January 1, 2027. This extension concerns operational decision timelines, NOT evidence of an extension of the January 1, 2027 API deadline; FFS PA/Payer-to-Payer API readiness remains unverified. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": "https://www.emedny.org/listserv/eMedNYGeneralUpdates/new_comm_4-28-26.pdf" }, "transition": null, "events": [], "contractEnd": "2025-11-30", "contractEndNote": "plus two one-year options", "verified": "2026-10-13" }, { "code": "OH", "name": "Ohio", "vendor": "gainwell", "portal": "Ohio Medicaid Information Technology System (MITS), accessed through the Provider Network Management (PNM) module", "portalUrl": "https://ohpnm.omes.maximus.com/OH_PNM_PROD/Account/Login.aspx", "note": "Gainwell Technologies is the current Fiscal Intermediary vendor for Ohio Medicaid fee-for-service claims, including adjudication and payment. Deloitte operates the separate Electronic Data Interchange (EDI), which serves as the claims transaction exchange point and routes managed-care claims through the Fiscal Intermediary to the applicable managed-care entity. The Gainwell FI contract is reported as renewable through June 30, 2027. No supported replacement award or planned replacement date for the Gainwell FI was verified.", "confidence": "low", "source": "https://managedcare.medicaid.ohio.gov/wps/wcm/connect/gov/bcdc71a3-1c7f-4b89-9590-6594e7292ed2/Claim+and+Prior+Authorization+Submission+FAQ_July+2023_V4.pdf?CVID=oCoBlHH&MOD=AJPERES", "pa": { "vendor": "State agency", "detail": "Ohio Department of Medicaid (ODM); Gainwell Technologies is the Fiscal Intermediary that processes and adjudicates all FFS claims and prior authorizations. No separate statewide medical-service PA reviewer is identified.", "portal": "Ohio Medicaid Provider Network Management (PNM) module for FFS medical prior authorizations", "portalUrl": "https://ohpnm.omes.maximus.com/OH_PNM_PROD/Account/Login.aspx", "channels": null, "confidence": "medium", "source": "https://managedcare.medicaid.ohio.gov/providers/Submitting+Claims+and+Prior+Authorizations" }, "pbm": "Gainwell Technologies (Ohio Medicaid Single Pharmacy Benefit Manager)", "managedCare": { "share": 90, "year": "2024", "plans": [ "Aetna Better Health of Ohio (CVS Health)", "AmeriHealth (Independence Health Group)", "Anthem Blue Cross and Blue Shield (Elevance Health)", "Buckeye Health Plan (Centene)", "CareSource", "Humana", "Molina Healthcare of Ohio, Inc. (Molina)", "UnitedHealthcare Community Plan of Ohio (UnitedHealth Group)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": null, "events": [ { "date": "2024-06-30", "summary": "Ohio implemented new Ohio Medicaid Enterprise System features in the Provider Network Management module. The Fiscal Intermediary began processing and adjudicating fee-for-service claims and prior authorizations.", "source": "https://managedcare.medicaid.ohio.gov/managed-care/ohio-next-generation-managed-care-2/01-implementation-of-the-next-generation-program" } ], "contractEnd": "2027-06-30", "contractEndNote": "renewable to", "verified": "2026-10-13" }, { "code": "OK", "name": "Oklahoma", "vendor": "gainwell", "portal": "SoonerCare Provider Portal", "portalUrl": "https://www.ohcaprovider.com/hcp/", "note": "Project NEXUS is an identified MES/MMIS modernization effort, but no supported replacement awardee, go-live date, or replacement date was found in the reviewed sources. Gainwell Technologies is the current OHCA MMIS fiscal agent and operates the claims and eligibility system. OHCA's 2026 EDEA indicates the agreement was extended through June 30, 2027. Any future modernization award or split scope remains unresolved.", "confidence": "high", "source": "https://oklahoma.gov/content/dam/ok/en/okhca/docs/providers/claim-tools/electronic-data-interchange/2026%20EDEA%20Agreement.pdf", "pa": { "vendor": "State agency", "detail": null, "portal": "SoonerCare Provider Portal", "portalUrl": "https://www.ohcaprovider.com/hcp/", "channels": "Secure provider portal; paper/forms; phone 1-800-522-0114; fax 1-866-574-4991", "confidence": "medium", "source": "https://pharmacy.ouhsc.edu/pharmacy-services/pharmacy-management-consultants" }, "pbm": "University of Oklahoma College of Pharmacy Pharmacy Management Consultants", "managedCare": { "share": 55, "year": "2024", "plans": [ "Aetna Better Health of Oklahoma (CVS Health)", "Humana Healthy Horizons of Oklahoma (Humana)", "Oklahoma Complete Health (Centene)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": { "date": null, "status": "procuring", "vendor": "NEXUS MES modernization" }, "events": [], "contractEnd": "2027-06-30", "contractEndNote": "extension", "verified": "2026-10-13" }, { "code": "OR", "name": "Oregon", "vendor": "gainwell", "portal": "Oregon Medicaid Provider Portal", "portalUrl": "https://www.or-medicaid.gov/", "note": "Gainwell holds the MMIS mainframe maintenance blanket PO (DASPS-1522-18); OHA is procuring a Medicaid Enterprise System integrator.", "confidence": "medium", "source": "https://oregonbuys.gov/bso/external/purchaseorder/poSummary.sdo?docId=DASPS-1522-18&external=true", "pa": { "vendor": "State agency", "detail": null, "portal": "Oregon Medicaid MMIS Provider Portal", "portalUrl": "https://www.or-medicaid.gov/", "channels": null, "confidence": "medium", "source": "https://www.oregon.gov/oha/hsd/ohp/pages/pa.aspx" }, "managedCare": { "share": 98, "year": "2024", "plans": [ "Advanced Health", "AllCare Health Plan", "Cascade Health Alliance", "Columbia Pacific", "Eastern Oregon CCO", "HealthShare of Oregon", "InterCommunity Health Network", "Jackson Care Connect", "PacificSource Community Solutions - Central Oregon", "PacificSource Community Solutions - Columbia Gorge", "PacificSource Community Solutions - Lane", "PacificSource Community Solutions - Marion Polk", "Trillium Community Health Plan - Southwest (Centene)", "Trillium Community Health Plan - Tri-County (Centene)", "Umpqua Health Alliance", "Yamhill Community Care" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": { "date": null, "status": "procuring", "vendor": "OHA Medicaid Enterprise System/mainframe modernization (vendor not identified)" }, "events": [], "verified": "2026-10-13" }, { "code": "PA", "name": "Pennsylvania", "vendor": "gainwell", "portal": "PROMISe Provider Portal", "portalUrl": "https://promise.dhs.pa.gov/portal/provider/Home/tabid/135/Default.aspx", "note": "Gainwell Technologies is the current PROMISe/MMIS processing-services vendor. Pennsylvania is modernizing PROMISe through multiple modules; some modules have been implemented and others are being competitively procured. No replacement of the live claims-processing vendor was verified, and the existing Gainwell-supported system remains necessary while modules are implemented. The scope is therefore potentially split across future modular procurements.", "confidence": "high", "source": "https://www.emarketplace.state.pa.us/PrintVersion.aspx?id=54632&m=SS", "pa": { "vendor": "Telligen", "detail": "Telligen (Qualitrac) for non-drug FFS prior authorization and program exception submissions; Pennsylvania Department of Human Services for pharmacy prior authorization", "portal": "Qualitrac Prior Authorization Provider Portal", "portalUrl": "https://pamedicaid.telligen.com", "channels": null, "confidence": "medium", "source": "https://www.pa.gov/agencies/dhs/resources/for-providers/prior-authorization-portal" }, "managedCare": { "share": 93, "year": "2024", "plans": [ "Geisinger Health Plan", "Health Partners Plan", "Highmark Wholecare (Highmark)", "Pennsylvania Health & Wellness (Centene)", "UnitedHealthcare Community Plan (UnitedHealth Group)", "UPMC Health Plan", "Vista Health Plan (AmeriHealth Caritas Pennsylvania and Keystone First) (Independence Health Group)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": null, "events": [ { "date": "2025-09-22", "summary": "EDIaaS production go-live for interactive transactions, replacing BES WebBBS; PROMISe Internet was not impacted.", "source": "https://www.pa.gov/agencies/dhs/resources/for-providers/promise/faq-ediaas" }, { "date": "2025-10-20", "summary": "EDIaaS production go-live for batch transactions.", "source": "https://www.pa.gov/agencies/dhs/resources/for-providers/promise/faq-ediaas" } ], "verified": "2026-10-13" }, { "code": "RI", "name": "Rhode Island", "vendor": "gainwell", "portal": "Rhode Island Medicaid Healthcare Portal", "portalUrl": "https://www.riproviderportal.org/", "note": "Rhode Island is transitioning from its legacy MMIS to the modular RI Medicaid OASIS system. The state has active or planned procurements for separate modules, including a System Integrator and Operational Data Store and Electronic Visit Verification; no award replacing Gainwell as the current medical-claims/MMIS fiscal agent was verified. These modular procurements may create split scopes rather than a single MMIS replacement.", "confidence": "high", "source": "https://eohhs.ri.gov/OASIS", "pa": { "vendor": "Gainwell Technologies", "detail": null, "portal": "Rhode Island Medicaid Healthcare Portal", "portalUrl": "https://www.riproviderportal.org/", "channels": "Healthcare Portal; paper/fax/mail PA forms; EOHHS/Gainwell provider support", "confidence": "high", "source": "https://eohhs.ri.gov/providers-partners/billing-and-claims/prior-authorization" }, "pbm": "Gainwell Technologies (FFS pharmacy administrator; no separate PBM identified)", "managedCare": { "share": 84, "year": "2024", "plans": [ "Neighborhood Health Plan of Rhode Island", "Tufts Health Public Plans (Point32Health)", "UnitedHealthcare of Rhode Island Community Plan (UnitedHealth Group)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": { "date": null, "status": "procuring", "vendor": "RI Medicaid OASIS modular MES; Gainwell remains legacy fiscal agent during transition" }, "events": [ { "date": "2024-07", "summary": "OASIS records the tentative TPL award as rescinded and the procurement as cancelled.", "source": "https://eohhs.ri.gov/OASIS" }, { "date": "2024-08", "summary": "OASIS SI/ODS solicitation RFP25004569 posted.", "source": "https://eohhs.ri.gov/OASIS" } ], "verified": "2026-10-13" }, { "code": "SC", "name": "South Carolina", "vendor": "state", "portal": "South Carolina Medicaid Portal", "portalUrl": "https://portal.scmedicaid.com/", "note": "The live Core MMIS is developed, maintained, and hosted by Clemson University and continues to support South Carolina Medicaid fee-for-service claims. A prior Optum administrative-services/MMIS replacement effort was canceled, so Optum is not a current claims replacement vendor. SCDHHS is pursuing a modular MES modernization with planned procurements covering financial and capitation management, beneficiary and benefit-plan management, fee-for-service claims, and encounter processing. No awarded replacement claims operator or confirmed replacement go-live date was verified. The modernization is expected to decommission Core MMIS incrementally; final decommissioning depends on implementation of replacement capabilities and either cessation of FFS programs or transition of FFS claims processing.", "confidence": "high", "source": "https://www.scdhhs.gov/sites/dhhs/files/20260429%20Vendor%20Conference%20Deck.pdf", "pa": { "vendor": "State agency", "detail": "Prime Therapeutics Management (physician-administered drug PA); SCDHHS for other medical services", "portal": "GatewayPA", "portalUrl": "https://gatewaypa.com", "channels": "GatewayPA web; phone 1-800-424-8219; SCDHHS forms/portal for other medical PA", "confidence": "high", "source": "https://scdhhs-dev.sc.gov/communications/updated-prior-authorization-expansion-physician-administered-drugs-7" }, "pbm": "Prime Therapeutics", "managedCare": { "share": 60, "year": "2024", "plans": [ "Absolute Total Care, Inc. (Centene)", "First Choice by Select Health of South Carolina (Independence Health Group)", "Healthy Blue by Blue Choice", "Humana Healthy Horizons (Humana)", "Molina Healthcare of South Carolina (Molina)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": { "date": null, "status": "procuring", "vendor": "SCDHHS DASH modular MES program; individual module vendors/awards vary" }, "events": [], "verified": "2026-10-13" }, { "code": "SD", "name": "South Dakota", "vendor": "state", "portal": "South Dakota Medicaid Provider Online Portal", "portalUrl": "https://dss.sd.gov/medicaid/providers/", "note": "DSS and the state Bureau of Information and Telecommunications own and operate the MMIS; CNSI built the 2010 replacement, modernised module by module.", "confidence": "medium", "source": "https://mylrc.sdlegislature.gov/api/Documents/Attachment/122601.pdf?Year=2019", "pa": { "vendor": "State agency", "detail": null, "portal": "South Dakota Medicaid Provider Portal", "portalUrl": "https://dss.sd.gov/medicaid/portal.aspx", "channels": null, "confidence": "high", "source": "https://dss.sd.gov/medicaid/providers/pa/Physician_Administered_Drugs.aspx" }, "pbm": "Optum Rx (administrative pharmacy claims/PA processor)", "managedCare": { "share": 0, "year": "2024", "plans": [], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "TN", "name": "Tennessee", "vendor": "gainwell", "portal": "TennCare Online Services / TCMIS", "portalUrl": "https://tcmisweb.tenncare.tn.gov/tcmis/public/main.asp", "note": "Gainwell Technologies is the documented MMIS/TCMIS contractor for operations, management, enhancement, and claims processing. Tennessee contract records also identify a separate Gainwell Provider Enrollment Data Solution scope. No current replacement award for the MMIS was verified in the reviewed sources; this does not establish that no procurement activity exists.", "confidence": "high", "source": "https://www.tn.gov/tenncare/information-statistics/tenncare-contracts.html", "pa": { "vendor": "State agency", "detail": null, "portal": "TennCare Online Services / TCMIS", "portalUrl": "https://tcmisweb.tenncare.tn.gov/tcmis/public/main.asp", "channels": null, "confidence": "medium", "source": "https://www.tn.gov/tenncare/providers/managed-care-contractors/pharmacy-benefits-manager.html" }, "pbm": "OptumRx", "managedCare": { "share": 94, "year": "2024", "plans": [ "BlueCare Tennessee (BlueCross BlueShield of Tennessee)", "UnitedHealthcare Community Plan of Tennessee (UnitedHealth Group)", "Wellpoint Tennessee (Elevance Health)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "TX", "name": "Texas", "vendor": "accenture", "portal": "TMHP TexMedConnect", "portalUrl": "https://secure.tmhp.com/TexMedConnect", "note": "HHSC terminated Conduent’s contract for convenience, while Accenture continued operating as the TMHP claims vendor until further notice. Current Texas provider materials identify TMHP as the Medicaid fee-for-service claims administrator and fiscal agent. No separate MMIS replacement award was verified in the reviewed sources. MAXIMUS’s enrollment-broker role is distinct from medical claims administration.", "confidence": "high", "source": "https://www.hhs.texas.gov/provider-news/2024/04/05/new-texas-medicaid-healthcare-partnership-contracts-update", "pa": { "vendor": "TMHP (Accenture)", "detail": "Texas Medicaid & Healthcare Partnership (TMHP; Accenture)", "portal": "TMHP PA on the Portal / TexMedConnect", "portalUrl": "https://secure.tmhp.com/PA", "channels": "PA on the Portal; secure provider portal/TexMedConnect; fax, mail, telephone depending service", "confidence": "medium", "source": "https://www.tmhp.com/topics/prior-authorization" }, "managedCare": { "share": 93, "year": "2024", "plans": [ "Aetna Better Health of Texas, Inc. (CVS Health)", "Baylor Scott & White Health Plan (Scott & White Health Plan and FirstCare Health Plans)", "Blue Cross and Blue Shield of Texas (Health Care Service Corporation)", "Community First Health Plans, Inc.", "Community Health Choice Texas, Inc.", "Cook Children's Health Plan", "Dell Children's Health Plan", "Driscoll Children's Health Plan", "El Paso Health", "Molina Healthcare of Texas, Inc. (Molina)", "Parkland Community Health Plan, Inc.", "Superior HealthPlan (Centene)", "Texas Children's Health Plan, Inc.", "UnitedHealthcare Community Plan (UnitedHealth Group)", "Wellpoint (Elevance Health)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "UT", "name": "Utah", "vendor": "acentra", "portal": "PRISM", "portalUrl": "https://medicaid.utah.gov/prism/", "note": "PRISM is Utah Medicaid’s live replacement for the legacy MMIS, implemented in 2023. No additional replacement award was verified in the reviewed sources.", "confidence": "low", "source": "https://medicaid.utah.gov/prism/", "pa": { "vendor": "State agency", "detail": null, "portal": "PRISM", "portalUrl": "https://prism.health.utah.gov/", "channels": "PRISM electronic PA request", "confidence": "medium", "source": "https://medicaid.utah.gov/prism/" }, "managedCare": { "share": 79, "year": "2024", "plans": [ "Health Choice", "University of Utah Health Plans (Healthy U, HOME)", "Molina (Molina)", "Select Health" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "live", "note": "Utah Medicaid’s interoperability page states it has a new secure FHIR data-sharing tool under CMS-0057-F that allows health plans to exchange patient records when members switch plans, with developer registration instructions. Interpreted as production Payer-to-Payer availability; no dated go-live or separate Prior Authorization API launch is stated. Reviewed as of 2026-10-13. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": "https://medicaid.utah.gov/interoperability/" }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "VA", "name": "Virginia", "vendor": "conduent", "portal": "Virginia Medicaid MES", "portalUrl": "https://login.vamedicaid.dmas.virginia.gov/", "note": "Conduent is the current Virginia Medicaid Fiscal Agent Services contractor. Virginia announced a new Conduent contract on August 6, 2026, extending the existing relationship and covering continued operations and modernization of claims processing, finance, call-center, reporting, and related Medicaid enterprise functions. The announced structure includes a two-year design and implementation phase, a six-year base term, and six one-year options; no live implementation date was identified.", "confidence": "high", "source": "https://www.dmas.virginia.gov/for-providers/", "pa": { "vendor": "Acentra Health", "detail": null, "portal": "Atrezzo Next Generation (ANG) / MES FFS Service Authorization", "portalUrl": "https://login.vamedicaid.dmas.virginia.gov/", "channels": "MES SSO/ANG, direct entry, phone, fax, paper/mail", "confidence": "medium", "source": "https://vamedicaid.dmas.virginia.gov/sa" }, "pbm": "Prime Therapeutics State Government Solutions LLC", "managedCare": { "share": 93, "year": "2024", "plans": [ "Aetna Better Health of Virginia (CVS Health)", "Anthem Healthkeepers (Elevance Health)", "Molina Healthcare of Virginia (Molina)", "Sentara Health Plans", "UnitedHealthcare (UnitedHealth Group)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": { "date": null, "status": "awarded", "vendor": "Conduent" }, "events": [ { "date": "2026-08-06", "summary": "Virginia DMAS awarded Conduent a contract to continue operating and modernize Medicaid enterprise and fiscal-agent systems; the agreement includes a two-year design and implementation phase, followed by a six-year base term and six one-year options.", "source": "https://www.news.conduent.com/news/virginia-awards-conduent-contract-to-manage-and-modernize-medicaid-program-delivery-systems" } ], "verified": "2026-10-13" }, { "code": "VT", "name": "Vermont", "vendor": "gainwell", "portal": "Provider+ Portal", "portalUrl": "https://vtmedicaid.com/", "note": "Gainwell is the current MMIS and fiscal-agent contractor under contract 42868, with a term from January 1, 2022 through December 31, 2026 and two optional one-year extensions by agreement. Vermont is planning a Medicaid Enterprise Solution (MES) procurement, formerly called Core Claims and Fiscal Agent Services; the State anticipated releasing an RFP by the end of summer 2026. No replacement award or successor vendor has been verified. The future MES may include claims, fiscal-agent, workflow, case-management, care-management, and related scopes.", "confidence": "low", "source": "https://dvha.vermont.gov/sites/dvha/files/documents/Administration/Gainwell_Technologies_Contract__42868_Executed.pdf", "pa": { "vendor": "State agency", "detail": null, "portal": "Provider+ Portal; eWEBS", "portalUrl": "https://providerportal-vtgov.optum.com", "channels": "Portal, fax, telephone", "confidence": "high", "source": "https://dvha.vermont.gov/sites/dvha/files/documents/PharmacyProviderManual_20250520.pdf" }, "pbm": "Optum", "managedCare": { "share": 0, "year": "2024", "plans": [], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. CMS reports 100% for the public managed-care model; 0 is used here because Vermont has no contracted comprehensive MCO program. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": { "date": null, "status": "procuring", "vendor": "MES replacement vendor not yet awarded; Gainwell Technologies remains current MMIS provider" }, "events": [ { "date": "2026-02-13", "summary": "Amendment 6 updated Vermont’s Gainwell Technologies MMIS contract and retained the 2022-01-01 through 2026-12-31 MMIS operations budget period.", "source": null } ], "contractEnd": "2026-12-31", "contractEndNote": "two optional one-year extensions", "verified": "2026-10-13" }, { "code": "WA", "name": "Washington", "vendor": "acentra", "portal": "ProviderOne", "portalUrl": "https://www.waproviderone.org/", "note": "ProviderOne is Washington’s Medicaid MMIS and payment system, overseen by the Health Care Authority. CNSI built ProviderOne, which went live in May 2010, and has run its operations and maintenance since. In March 2021 the Health Care Authority extended the CNSI contract through June 2026. CNSI merged with Kepro in 2023 to form Acentra Health, so Acentra Health is the current operator. No contract action after June 2026 was found in public sources as of 2026-10-16.", "confidence": "medium", "source": "https://www.executivegov.com/articles/cnsi-receives-five-year-providerone-mmis-contract-extension-from-washington-state-health-care-authority-ceo-todd-stottlemyer-quoted", "pa": { "vendor": "State agency", "detail": null, "portal": "ProviderOne", "portalUrl": "https://www.waproviderone.org/", "channels": "ProviderOne direct data entry, fax, telephone", "confidence": "medium", "source": "https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/step-step-guide-prior-authorization" }, "managedCare": { "share": 84, "year": "2024", "plans": [ "Wellpoint Washington (Elevance Health)", "Community Health Plan", "Coordinated Care of Washington (Centene)", "Molina Healthcare of Washington (Molina)", "UnitedHealthcare (UnitedHealth Group)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "WI", "name": "Wisconsin", "vendor": "gainwell", "portal": "ForwardHealth Portal", "portalUrl": "https://www.forwardhealth.wi.gov/WIPortal/", "note": "Gainwell Technologies is Wisconsin Medicaid’s fiscal agent and MMIS contract vendor, supporting the ForwardHealth interChange claims-processing system. Wisconsin is also re-procuring MMIS and CARES-related contracts, but no future full-MMIS replacement vendor was verified. Separately, Gainwell replaced Wisconsin Physicians Service as the Children’s Long-Term Support Program claims processor effective April 28, 2025; this is a program-specific transition, not a full MMIS replacement.", "confidence": "high", "source": "https://docs.legis.wisconsin.gov/misc/lfb/budget/2025_27_biennial_budget/302_budget_papers/425_health_services_foodshare_and_medical_assistance_administration_medicaid_and_foodshare_contracts.pdf", "pa": { "vendor": "State agency", "detail": null, "portal": "ForwardHealth Portal", "portalUrl": "https://www.forwardhealth.wi.gov/WIPortal/", "channels": null, "confidence": "high", "source": "https://vamedicaid.dmas.virginia.gov/sa" }, "pbm": "DHS/ForwardHealth", "managedCare": { "share": 67, "year": "2024", "plans": [ "Anthem Blue Cross Blue Shield (Elevance Health)", "Chorus Community Health Plans", "Community Care Health Plan", "Dean Health Plan, Inc.", "Group Health Cooperative of Eau Claire", "Group Health Cooperative of South Central WI", "Independent Care (iCare) Health Plan (Humana)", "MercyCare Health Plans", "MHS Health Wisconsin (Centene)", "Molina Healthcare of Wisconsin (Molina)", "My Choice Wisconsin (Molina)", "Network Health Plan", "Quartz", "Security Health Plan of Wisconsin", "UnitedHealthcare Community Plan (UnitedHealth Group)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "in_progress", "note": "ForwardHealth publishes phased CMS-0057 implementation through January 1, 2027, covering FFS prior authorization. Public roadmap evidence, not verified production PA/Payer-to-Payer API; reviewed as of 2026-10-13. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": "https://www.forwardhealth.wi.gov/WIPortal/content/provider/pdf/PriorAuthorizationFAQ.pdf.spage" }, "transition": null, "events": [ { "date": "2025-04-28", "summary": "Gainwell replaced WPS as Wisconsin CLTS claims processor; providers began submitting claims and adjustments through the ForwardHealth Portal.", "source": "https://www.dhs.wisconsin.gov/publications/p02442-2025-01.pdf" } ], "verified": "2026-10-13" }, { "code": "WV", "name": "West Virginia", "vendor": "gainwell", "portal": "Health PAS-OnLine", "portalUrl": "https://www.wvmmis.com/default.aspx", "note": "No replacement award verified in sources reviewed; current fiscal-agent vendor is Gainwell Technologies.", "confidence": "high", "source": "https://bms.wv.gov/providers/gainwell-technology", "pa": { "vendor": "Acentra Health", "detail": null, "portal": "Health PAS-OnLine", "portalUrl": "https://www.wvmmis.com/default.aspx", "channels": "Acentra phone/fax/email; RDTP fax/phone; Health PAS", "confidence": "high", "source": "https://bms.wv.gov/prior-authorization-criteria" }, "pbm": "Gainwell Technologies", "managedCare": { "share": 76, "year": "2024", "plans": [ "Aetna Better Health of WV (CVS Health)", "The Health Plan of WV", "Unicare of Health Plan of WestVirginia (Elevance Health)" ], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" }, { "code": "WY", "name": "Wyoming", "vendor": "acentra", "portal": "Wyoming Medicaid Secure Provider Portal", "portalUrl": "https://evobrix.wyomingmedicaid.us/evoBrix/SSOControlServlet", "note": "Acentra Health is Wyoming Medicaid's fiscal agent for the Benefit Management System portion of the modular WINGS Medicaid Enterprise System and processes medical claims and adjustments, excluding pharmacy. WINGS launched on October 25, 2021. The reviewed evidence does not independently verify the reported April 15, 2026 Optum Rx go-live date; no PBM is therefore confirmed.", "confidence": "high", "source": "https://wyomingmedicaid.com/portal/Wyoming_BMS", "pa": { "vendor": "Acentra Health", "detail": null, "portal": "Wyoming Medicaid Secure Provider Portal; Optum Rx pharmacy portal", "portalUrl": "https://evobrix.wyomingmedicaid.us/evoBrix/SSOControlServlet", "channels": "Acentra portal/fax/phone; Optum Rx electronic POS/fax/phone", "confidence": "high", "source": "https://www.wymedicaid.org/" }, "pbm": "Optum Rx", "managedCare": { "share": 0, "year": "2024", "plans": [], "source": "https://download.medicaid.gov/data/share-of-medicaid-enrollees-in-managed-care.2024-table5.csv" }, "cms0057": { "status": "none_found", "note": "No qualifying state Medicaid FFS Prior Authorization or Payer-to-Payer API production, procurement, vendor award, implementation roadmap, or API-specific CMS extension found in the reviewed public sources as of 2026-10-13. This is an evidence gap, not a determination of noncompliance. Plan names use the 2024 CMS/KFF roster unless a newer state roster was identified; full current-contract verification is incomplete.", "source": null }, "transition": null, "events": [], "verified": "2026-10-13" } ] }