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- 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 month (capitation) payment for these services By contracting
- Drug Utilization Review Annual Report | Medicaid
On an annual basis, states are required to report on their practitioners prescribing habits, cost savings generated from their Drug Utilization Review (DUR) programs and their program’s operations, including adoption of new innovative DUR practices via the Medicaid Drug Utilization Review Annual Report Survey Please visit the Drug Utilization Review page for more inf
- 2025-2026 Medicaid Managed Care Rate Development Guide
Introduction The Centers for Medicare Medicaid Services (CMS) is releasing the 2025-2026 Medicaid Managed Care Rate Development Guide for use in setting rates for rating periods starting between July 1, 2025, and June 30, 2026, for managed care programs subject to the actuarial soundness requirements in 42 CFR § 438 4 3,4 This guidance is released in accordance with 42 CFR § 438 7(e) This
- Medicaid Managed Care State Guide
January 18, 2022 This guide covers the standards that are used by the Centers for Medicare Medicaid Services (CMS) Division of Managed Care Operations (DMCO) staff to review and approve State contracts with Medicaid managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), prepaid ambulatory health plans (PAHPs), non-emergency medical transportation prepaid ambulatory health
- Managed Care in Pennsylvania - Medicaid. gov
Pennsylvania began experimenting with various managed care arrangements in the 1970’s, beginning with the introduction of its Voluntary Managed Care Program, a comprehensive risk-based MCO program available to most Medicaid beneficiaries in certain counties in 1972
- Managed Care Entities | Medicaid
Federal Managed Care regulations at 42 CFR 438 recognize four types of managed care entities:Managed Care Organizations (MCOs)Comprehensive benefit packagePayment is risk-based capitationPrimary Care Case Management (PCCM)Primary care case managers contract with the state to furnish case management (location, coordination, and monitoring) servicesGenerally, paid fee-for-service for medical
- Medicaid Managed Care Enrollment and Program Characteristics 2022
Because Medicaid beneficiaries may be concurrently enrolled in more than one type of managed care program (e g , a Comprehensive MCO and a BHO), users should not sum enrollment across all program types, since the total would count individuals more than once and, in some states, exceed the actual number of Medicaid enrollees
- Coordination of Benefits Third Party Liability | Medicaid
It is possible for Medicaid beneficiaries to have one or more additional sources of coverage for health care services Third Party Liability (TPL) refers to the legal obligation of third parties (for example, certain individuals, entities, insurers, or programs) to pay part or all of the expenditures for medical assistance furnished under a Medicaid state plan By law, all other available
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