Medicaid Managed Care
A way states deliver Medicaid services through private health plans paid a set rate per member each month.
Medicaid Managed Care is the most common way states now deliver Medicaid benefits. Instead of paying providers fee-for-service, states contract with managed care organizations (MCOs) — usually private health plans — and pay them a set monthly rate per enrolled member (a 'capitation' payment). The MCO is then responsible for arranging covered care through its provider network. About three-quarters of Medicaid enrollees nationwide are in some form of managed care. Models include comprehensive managed care for medical and behavioral health, primary care case management (PCCM), and managed long-term services and supports (MLTSS). Each state's program has its own enrollment process, plan choices, and grievance and appeal rights. New members usually get a short window to pick a plan, after which the state may auto-assign one. Members can switch plans during open enrollment or for cause, and can appeal coverage decisions to the plan first and then to the state.
In real life
- A new Medicaid member picks one of three MCOs in her state during her plan-choice window.
- An MCO denies a service; the member appeals to the plan first and then requests a state fair hearing.
- A state launches MLTSS to manage Medicaid long-term services through MCOs.
Also known as
Frequently asked questions about Medicaid Managed Care
Do I have to choose a plan?+
In most states yes. If you don't pick during the choice window, the state may auto-assign one.
Can I switch plans?+
Yes — usually during an annual open enrollment or for cause (like a needed provider not in network).
What if my MCO denies care?+
Use the plan's appeal process first; if still denied, you can request a state fair hearing.
Where do I find my plan choices?+
Your state Medicaid website or member services line.
Source: medicaid.gov