@pipeworx/medicaid-intelligence
Medicaid drug utilization, managed-care enrollment and state enrollment operations from the
CMS Medicaid Open Data API. Keyless.
| Tool | What it returns |
|---|
medicaid_drug_utilization | Quarterly state utilization rows for one NDC, fee-for-service and managed care kept separate |
medicaid_drug_state_market | One NDC aggregated across states for a year |
medicaid_drug_trend | Annual prescriptions, units and gross reimbursement for one NDC from 2020 |
medicaid_managed_care_summary | Annual state enrollment, and enrollment in any or comprehensive managed care |
medicaid_managed_care_program_mix | State enrollment by program type β comprehensive MCO, PCCM, MLTSS, behavioral health, dental, transportation, PACE |
medicaid_plan_market | Bounded sample of managed-care plan/program rows by state, with the authoritative matching-row count |
medicaid_monthly_managed_care | Monthly Medicaid/CHIP enrollment for one state and participation category |
medicaid_enrollment_operations | Monthly enrollment and application-processing indicators for one state |
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 β 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 β 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:
Quick Start
Add to your MCP client (Claude Desktop, Cursor, Windsurf, etc.):
{
"mcpServers": {
"medicaid-intelligence": {
"url": "https://gateway.pipeworx.io/medicaid-intelligence/mcp"
}
}
}
Or connect to the full Pipeworx gateway for access to all 1395+ data sources:
{
"mcpServers": {
"pipeworx": {
"url": "https://gateway.pipeworx.io/mcp"
}
}
}
Using with ask_pipeworx
Instead of calling tools directly, you can ask questions in plain English:
ask_pipeworx({ question: "your question about Medicaid Intelligence data" })
The gateway picks the right tool and fills the arguments automatically.
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License
MIT