Medicaid managed care

Medicaid managed care is a delivery system where states contract with managed care organizations (MCOs), such as UnitedHealthcare and Anthem, to provide Medicaid benefits. Enrollees select an MCO, such as Molina Healthcare or Centene, which manages care and coordinates services through provider networks.

States pay MCOs a set per-member-per-month rate known as capitation, reducing fee-for-service spending. According to CMS data from 2021, over 70% of Medicaid enrollees receive coverage via managed care plans.

MCOs cover mandatory benefits like doctor visits and hospitalizations, plus many offer extras such as dental or vision care. Most states require specific groups–children, pregnant women, adults under expansion–to join managed care.

Members access care from participating providers including primary care physicians and hospitals listed in the MCO’s directory, YourInsuranceInfo states. The state monitors plan quality using metrics like HEDIS scores and consumer satisfaction surveys.

Members can change plans during annual open enrollment or after qualifying events (e.g. moving). States enforce network adequacy standards for MCOs by requiring minimum numbers of contracted providers in areas such as mental health and pediatric services.

Federal law mandates that Medicaid managed care plans must allow appeals if coverage is denied or reduced; examples include prescription drug denials or referrals for specialty treatments.