@pipeworx/medicaid-intelligence

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Tools: 8

Medicaid drug utilization, managed-care enrollment and state enrollment operations from the CMS Medicaid Open Data API. Keyless.

Tools

Auth

None. Every endpoint is public CMS infrastructure at data.medicaid.gov.

Reading these numbers correctly

This source is easy to misread, and most of the pack’s design is about preventing that. Each response carries an interpretation field stating the caveat that applies to it.

• Reimbursement is gross, before rebates. total_amount_reimbursed is what state Medicaid programs paid pharmacies. It is neither manufacturer revenue nor net price — Medicaid rebates are substantial and are not in this data. Treating these figures as a manufacturer’s Medicaid revenue overstates it, often by a lot.
• Suppressed is not zero. CMS suppresses small cells (DS, *, --, or a suppression_used flag). Those become null, never 0, and a channel that is entirely suppressed is reported as unavailable rather than as an absence of utilization. Tests guard this specifically.
• Fee-for-service and managed care are separate measures and stay separate. Adding them is not meaningful for most questions, because a state’s mix shifts over time.
• Managed-care program categories overlap and must not be summed. A beneficiary can appear under comprehensive MCO and MLTSS and behavioral health. medicaid_managed_care_program_mix says so in its interpretation.
• Enrollment counts are state-reported program enrollment, not covered lives attributable to a particular insurer. They do not map cleanly onto a payer’s book of business.
• A zero in the plan file can be confidentiality suppression, not an empty plan. medicaid_plan_market returns a bounded sample plus the authoritative total row count, so a short list never implies a small market.

Argument conventions

The underlying datasets disagree about how a state is written — the drug files use two-letter codes, the enrollment and managed-care files use full names. Both forms are accepted on every tool and converted internally. This matters: before that, asking the managed-care summary for "CA" matched nothing and returned a confident total: 0, which reads as “California has no managed care” rather than as a wrong argument.

ndc takes an exact 11-digit National Drug Code, hyphenated or not. A brand or ingredient name returns {found:false, reason:'ndc_expected_got_name'} with a hint pointing at openfda_drug_label or rxnorm to resolve it first.

Failure shapes

A recoverable caller mistake resolves to {found:false, reason, hint} naming what to do instead. An upstream failure or a genuine defect resolves to {error, hint}. The two are deliberately distinguishable, so a monitoring sweep can tell “CMS refused us” apart from “we returned garbage”.

Data sources

All datasets are queried through the CMS Medicaid Open Data datastore API, https://data.medicaid.gov/api/1/datastore/query:

• State Drug Utilization Data — one dataset per year, 2020 through 2026
• Managed Care Enrollment Summary and enrollment by program
• Managed Care Plan and Program data
• Monthly Medicaid and CHIP managed-care enrollment
• Medicaid and CHIP enrollment and operations reports

Tools

• medicaid_drug_utilization — Return quarterly state Medicaid utilization rows for an exact 11-digit NDC, separated into fee-for-service and managed-care records. Reimbursement is gross before Medicaid rebates and is not manufactu
• medicaid_drug_state_market — Aggregate one exact NDC across states for a year, keeping fee-for-service and managed-care measures separate. Suppressed rows remain unavailable and totals are gross pharmacy reimbursement before reba
• medicaid_drug_trend — Show annual Medicaid prescription, unit, and gross reimbursement trends for an exact 11-digit NDC from 2020 onward, split between fee-for-service and managed care. Suppressed values are never converte
• medicaid_managed_care_summary — Show annual state Medicaid enrollment and enrollment in any or comprehensive managed care. Counts are state-reported program enrollment, not covered lives attributable to a particular insurer.
• medicaid_managed_care_program_mix — Show state Medicaid enrollment by managed-care program type, including comprehensive MCO, PCCM, MLTSS, behavioral health, dental, transportation, and PACE. Program counts overlap and must not be summe
• medicaid_plan_market — Return a bounded API-order sample of Medicaid managed-care plan/program rows by state and optional year, with the authoritative matching-row count. Zero may represent confidentiality suppression in th
• medicaid_monthly_managed_care — Show monthly Medicaid/CHIP enrollment for one state and managed-care participation category. Data-quality flags and confidentiality suppression are preserved.
• medicaid_enrollment_operations — Show monthly Medicaid and CHIP enrollment and application-processing indicators for one state. Values are preliminary or updated state reports and may include footnotes or missing periods.