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Managed Care | Medicaid 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
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 package Payment is risk-based capitation Primary Care Case Management (PCCM)
Managed Long-Term Services and Supports | Medicaid Medicaid MLTSS programs can be operated under multiple federal Medicaid managed care authorities at the discretion of the state and as approved by CMS, including 1915a, 1915b, and 1115
Managed Care Authorities | Medicaid States are able to require dual eligibles, American Indians, and children with special health care needs to enroll in a managed care delivery system States must demonstrate that the managed care delivery system is cost-effective, efficient and consistent with the principles of the Medicaid program
State Directed Payments | Medicaid These types of payment arrangements permit states under 42 CFR 438 6 (c) to direct specific payments made by managed care plans to healthcare providers and can assist states in furthering the goals and priorities of their Medicaid programs
Medicaid Managed Care State Guide CMS utilizes the term “managed care plan” to encompass all types of managed care delivery (i e MCO, HIO, PIHP, PAHP, NEMT PAHP, PCCM, PCCM entity) to which a federal requirement applies
Quality of Care External Quality Review - Medicaid. gov Recommendations for improving the quality of health care services furnished by each managed care plan and recommendations for how the state can target goals and objectives in the State quality strategy Methodologically appropriate, comparative information about all managed care plans
Medical Loss Ratio (MLR) | Medicaid CMS has published the MLR credibility adjustment factors for Medicaid and CHIP managed care plans—managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), and prepaid ambulatory health plans (PAHPs)—with contract rating periods starting on or after July 1, 2017
In Lieu of Services and Settings | Medicaid States’ and managed care plans’ have the ability to cover services or settings that are substitutes for services or settings covered under the state plan as “in lieu of services and settings” (also known as ILOSs) in accordance with 42 CFR §§ 438 3 (e) (2) and 438 16
Managed Care Quality Improvement | Medicaid As the dominant delivery system for Medicaid and the Children's Health Insurance Program (CHIP), managed care has enormous potential to achieve state priorities and improve health care quality and outcomes