Nine companies have submitted bids to enter Pennsylvania's Medicaid market, which has grown substantially this year since Gov. Wolf expanded access to coverage.

But only one of the new applicants seeking to offer managed care to lower-income Pennsylvanians beginning in 2017 is a national player.

"Pennsylvania should be more attractive, in theory, to Medicaid-focused insurers, since it has an established statewide mandatory managed Medicaid program coupled with the recent eligibility expansion," said Mark Cherry, principal analyst for Florida and Pennsylvania at Decision Resources Group, a health-care data firm.

The only national Medicaid-focused insurer attempting to break into Pennsylvania, which started Medicare HMOs in 1997, is Centene Corp., a St. Louis firm with Medicaid plans in 21 states and six million members.

Other big national players - Anthem Inc., which is planning to buy Cigna Corp.; Molina Healthcare Inc.; and WellCare Health Plans Inc. - did not bid.

Under Medicaid managed-care programs for physical health, such as Pennsylvania's HealthChoices, insurers receive a monthly per-member fee to cover all medical care for their members.

The presence of strong regional Blue Cross Blue Shield companies, such as Independence Blue Cross, and hospital-owned insurers, including Health Partners Plans Inc., is among factors that have "made it hard for outsider insurance companies to get a foothold in the state, or establish strong provider networks," Cherry said.

The new Medicaid managed-care contracts, which will be awarded in five zones in January, will require insurers to do more to coordinate care, and to pay hospitals and doctors based on the quality of outcomes rather than on the volume of procedures.

That could make the state "tougher to crack into as insurers align more closely (or even exclusively) with health systems," Cherry said.

The three newcomers, in addition to Centene, are: Accenda Health, a subsidiary of Capital Blue Cross, of Harrisburg; Meridian Health Plan, which has operations in five Midwestern states; and Trusted Health Plan, a Medicaid managed-care plan in Washington.