Understanding Managed Care Organization Medicaid Programs

Managed care organization Medicaid programs are designed to provide comprehensive health coverage to low-income individuals and families. These programs are often a result of state Medicaid agencies contracting with private companies to manage and deliver healthcare services.

In the United States, the majority of Medicaid beneficiaries are enrolled in managed care organization Medicaid programs, which cover over 75% of all Medicaid enrollees.

These programs are typically governed by a set of rules and regulations, including the Medicaid managed care regulations, which were established by the Centers for Medicare and Medicaid Services (CMS).

The Department of Community Health is required to post various reports on its website, including the Managed Care Program Annual Report (MCPAR) for each managed care program it administers. These reports must be posted by December 27th of each year.

The MCPAR reports for 2024, including those for Planning for Healthy Babies (P4HB), Georgia Families 360° (GF360°), Georgia Families (GF), and Georgia Pathways to Coverage ™, were all posted on December 27th, 2024.

The department also periodically conducts audits of Care Management Organizations and posts the results on its website. Encounter data reports, which show claims paid by Care Management Organizations to healthcare providers, are also available. Reports from prior years can be accessed on the website.

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The Managed Care Program Annual Report (MCPAR) is a must-read for anyone interested in the performance of managed care programs. It's posted on the Department of Community Health's website as required by federal regulations.

Reports from prior years can be accessed on the website. The MCPAR for 2024 has already been posted for several programs, including Planning for Healthy Babies, Georgia Families 360°, Georgia Families, and Georgia Pathways to Coverage.

You can find Encounter Data Reports on the website, which provide claims data for health care services rendered to members enrolled with Care Management Organizations. These reports are valuable for understanding health care utilization patterns.

The Encounter Data Reports cover a specific time period, from October 2022 to September 2024, and are posted on the website. For example, the GACMO Encounter Report for Amerigroup Georgia Families and Georgia Families 360° is available.

Care Management Organizations are required to provide Hospital Statistical and Reimbursement (HS&R) Reports to hospitals within 30 days of request. These reports are also available on the website, covering various quarters for the current and previous fiscal years.

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Here's a list of some of the available HS&R Reports:

Annual Ownership and Control Interest and Criminal Conviction Information Reports are also available on the website. These reports provide valuable information about the ownership and control interest of Care Management Organizations.

Managed care organizations are subject to periodic audits to ensure the accuracy and completeness of their data.

These audits are mandated by federal regulations, specifically 42 CFR§ 438.602(e) and (g), which require the Department of Community Health to conduct or contract for an independent audit.

The audit must be conducted at least once every three years, and the results must be posted on the Department's website.

The goal of these audits is to verify the truthfulness of the encounter and financial data submitted by MCOs.

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Managed care organizations (MCOs) are required to submit quality and performance reports to ensure they're meeting the needs of Medicaid beneficiaries.

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These reports are available on the Medicaid Quality Reports page, where you can find Quality Strategic Plans, Quality Performance Dashboards, and External Quality Review Organization Reports.

These reports provide valuable insights into how MCOs are doing in terms of quality and performance, helping to identify areas for improvement and ensure that beneficiaries receive the care they need.

Accreditation Status is a crucial aspect of evaluating the quality and performance of Care Management Organizations (MCOs). The National Committee for Quality Assurance (NCQA) is the accrediting body that evaluates MCOs based on their performance in various areas.

Amerigroup, a subsidiary of Anthem, Inc., has been accredited through 09/22/2025. This accreditation status indicates that Amerigroup meets the basic requirements of NCQA's rigorous standards for consumer protection and quality improvement.

Amerigroup 360°, another subsidiary of Amerigroup Corporation, is not separately accredited from Amerigroup. This means that Amerigroup 360° shares the same accreditation status as Amerigroup.

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CareSource, a nonprofit model of managed care, has been accredited through 12/21/2024. This accreditation status is a testament to CareSource's commitment to quality and performance.

Peach State Health Plan, a subsidiary of the Centene Corporation, has been accredited through 06/05/2026. This accreditation status is a reflection of Peach State's dedication to delivering high-quality services to its members.

WellCare, a subsidiary of Centene Corporation, has been accredited through 09/18/2023. However, it's worth noting that WellCare's accreditation status will expire soon, and it will need to undergo re-accreditation to maintain its accreditation.

Here is a summary of the accreditation status of the Care Management Organizations mentioned in this article:

Medicaid Quality Reports are a great resource for understanding the performance of Managed Care Organizations (MCOs). You can find these reports on the Medicaid Quality reports page.

One of the key aspects of Medicaid Quality Reports is the Quality Performance Dashboards. These dashboards provide a snapshot of an MCO's performance on various quality metrics.

External Quality Review Organization Reports are also an important part of Medicaid Quality Reports. These reports provide an independent review of an MCO's quality performance.

To get the most out of Medicaid Quality Reports, it's a good idea to review the Quality Strategic Plans. These plans outline an MCO's goals and objectives for improving quality and performance.

Here are some key components of Medicaid Quality Reports:

These reports can help you understand an MCO's strengths and weaknesses, and make informed decisions about your healthcare needs.

If you're a provider looking for support, Managed Care Entity Support Services are available to help with policies and billing procedures.

Questions about specific Managed Care Entities (MCEs) should be directed to them, as they have their own policies and procedures.

You can find more information about MCEs by contacting them directly.

Questions about MCE policies and billing procedures can be directed to the MCE itself.

MCOs play a crucial role in the Medicaid system, and understanding their enrollment and benefits is essential for healthcare providers and members alike.

Providers must verify eligibility information, including managed care participation, before providing services to avoid denied claims. This includes checking if a member is enrolled in a Health First Colorado Managed Care Entity (MCE) and ensuring they have authorization to provide non-exempt services.

Here are the benefits available through MCOs:

Additionally, MCOs cover emergency mental health services, substance use disorder services, and other behavioral health services as outlined in the State Behavioral Health Services Billing Manual.

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Georgia Families Contracts provide a foundation for understanding the MCO enrollment and benefits process.

To review current contracts, visit the Georgia Families webpage.

Georgia Families and Georgia Families 360° contracts are available on the webpage, offering a comprehensive look at the contracts.

Reviewing these contracts can help you stay up-to-date on any changes or updates to the MCO enrollment and benefits process.

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Health First Colorado members are automatically enrolled in the Community Behavioral Health Program, except for some select populations/individuals.

Providers must always verify eligibility information, including managed care participation, before providing services to avoid denied claims.

The name and telephone number of the Managed Care Entity (MCE) is identified on the eligibility verification response, which providers must comply with.

The MCE network or authorization to provide non-exempt services is required for service providers to be enrolled.

Five publicly traded firms account for half of MCO enrollment in the United States, with Centene, UnitedHealth Group, Anthem, Molina, and Aetna/CVS being the top five firms.

These five firms are all publicly traded companies ranked in the Fortune 500, with four of them ranked in the top 100.

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Enrolling in a Managed Care Organization (MCO) can be a great way to access healthcare benefits, but it's essential to understand what's covered.

Acute Home Health, Ambulance, and Durable Medical Equipment and Disposable Supplies are just a few of the many benefits available through an MCO.

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Family Planning Services, Inpatient Hospital, and Laboratory and X-ray are also included in the MCO benefits package.

Note that adult vision benefits are only available through an MCO, so if you need eye care, this is an important benefit to consider.

Here's a list of some of the specific benefits you can expect from an MCO:

If you're enrolled in the Medical Assistance Program Fee-For-Service Only, you have access to a different set of benefits.

Dental Care, Home and Community Based Services, and Hospice Services are just a few examples of the benefits available through this program.

It's worth noting that some benefits, like Long-Term Care, are only available through the Fee-For-Service Only program.

Here's a list of some of the specific benefits you can expect from the Fee-For-Service Only program:

Health First Colorado contracts with Managed Care Organizations (MCOs) to provide benefits to Medical Assistance Program members enrolled in the MCO. MCOs have their own provider networks and benefits, which may differ from one another.

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MCO-enrolled members must obtain available services from the MCO with which they have been assigned. This means they need to choose a primary care physician (PCP) within their MCO's network.

MCOs provide most of the Health First Colorado benefits to enrolled members for physical health conditions. Benefits not covered by the MCO may be provided through fee-for-service (FFS) reimbursement, but only if they are a covered Health First Colorado benefit.

Provider networks play a crucial role in the healthcare system, and it's essential to understand how they work. Insurance plan companies like UnitedHealth Group negotiate with providers in periodic contract negotiations, and contracts can be discontinued at any time.

High-profile contract disputes can affect provider networks across the nation, as seen in the 2018 dispute between UnitedHealth Group and Envision Healthcare. This can lead to patients receiving care from doctors who are out of network, resulting in balance billing.

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Maintaining up-to-date provider directories is necessary, as CMS can fine insurers with outdated directories. UnitedHealthcare requires providers to notify them of changes, and they also have a Professional Verification Outreach program to proactively request information from providers.

The total cost of maintaining these directories is estimated at $2.1 billion annually, and a blockchain initiative began in 2018 to share the directory. This is a significant burden on providers, who must maintain their information with multiple networks.

Preferred provider organizations (PPOs) are another type of network that providers can contract with. By joining a PPO, providers can earn a substantial discount on their regularly charged rates.

PPOs earn money by charging an access fee to the insurance company for the use of their network. This is different from traditional insurance, where the insurance provider pays a portion of the medical bills.

In a PPO, patients typically pay a deductible and coinsurance feature, rather than a copayment. This means they pay a percentage of the allowed provider fee after meeting the deductible.

HMOs, on the other hand, have a more restrictive network and require patients to see a primary care physician (PCP) for non-emergency care. The PCP acts as a gatekeeper, referring patients to specialists and requiring pre-authorization for hospital admissions.

In an HMO, services are not covered if performed by a provider not an employee of or specifically approved by the HMO, unless it defines the situation as an emergency.

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An Independent Practice Association (IPA) is a legal entity that contracts with a group of physicians to provide service to HMO members.

This type of association is often paid on a capitation basis, where a set amount is paid for each enrolled person assigned to that physician or group of physicians, regardless of whether or not they seek care.

The contract is typically non-exclusive, allowing individual doctors or groups to sign contracts with multiple HMOs.

Physicians who participate in IPAs often also serve fee-for-service patients who are not associated with managed care.

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Point of Service (POS) plans offer more flexibility and freedom of choice than standard HMOs, which is why they're becoming increasingly popular.

Patients in a POS plan don't make a choice about which system to use until the service is being used, making it a hybrid of different plan features.

A POS plan has levels of progressively higher patient financial participation as the patient moves away from the more managed features of the plan.

If patients stay within a network of providers and seek a referral to use a specialist, they may only have to pay a copayment.

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