Managed Care | Medicaid
Managed Care is a health care delivery system organized to manage cost, utilization, and quality. Medicaid managed care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per member per …
types (i.e., MCO, PIHP, PAHP, NEMT PAHP, PCCM, PCCM entity, HIO) to which the requirement applies; 4) the governing statutory, regulatory, and/or other policy citation(s); and 5) the date by which CMS will enforce the contract requirement. Sections II and III . of this guide provide additional resources to help states in their contract development
Jul 1, 2011 · Care Organization (MCO) per region, to one of island-wide coverage and choice of four (4) MCOs, with the goal of improving access to care and choice of providers. Plan Vital also implemented a model of stratified capitated payments to MCOs, with focused resources for High Cost High Need conditions which is expected to result
Notes: Managed Care Organization (MCO); Prepaid Inpatient Health Plans (PIHP); Prepaid Ambulatory Health Plan (PAHP); Mental Health/Substance UseDisorder (MH/SUD); Healthcare Effectiveness Data and Information Set (HEDIS); Consumer Assessment of Healthcare Providers and Systems (CAHPS); Federal Poverty Level (FPL).
Managed Care Authorities | Medicaid
States can implement a managed care delivery system using three basic types of federal authorities:State plan authority [Section 1932(a)]Waiver authority [Section 1915 (a) and (b)]Waiver authority [Section 1115]Regardless of the authority, states must comply with the federal regulations that govern managed care delivery systems.
a MCO program that covers acute, primary, and specialty services, and prescription drugs contracting health through maintenance organization (HMOs). The CHCP is available statewide on a mandatory basis for most beneficiary groups, including foster care children who were added to the program in 2009, who are enrolled except for dual eligibles
State Drug Utilization Review Reporting | Medicaid
Feb 24, 2025 · In 2019, CMS released the FFS and Managed Care Organization (MCO) Surveys for FFY 2018 and at that time, CMS introduced the Medicaid Drug Programs (MDP) system, a more efficient way for CMS and states to manage DUR annual FFS and MCO surveys.
(enrollment is optional for foster care children). MCO availability varies by region, but some plans are available statewide. Behavioral health services are carved out of the PCCM benefit packageand provided through the mental health PHP, while MCO members receive behavioral health care through the MCO plan. In 2004, Massachusetts expanded the
Page 6 of 66 1. General Information A. Rate Development Standards i. Unless otherwise stated, all standards and documentation expectations outlined in this
Medicaid and CHIP Managed Care Final Rules
The Centers for Medicare & Medicaid Services (CMS) has updated regulations for Medicaid and CHIP Managed Care in 2016, 2017, 2020 and 2024.