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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
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 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
State Drug Utilization Review Reporting | Medicaid In 2019, CMS released the FFS and Managed Care Organization (MCO) Surveys for FFY 2018 and at that time, CMS introduced the Medicaid Drug Programs (MDP) system, a more efficient way for CMS and states to manage DUR annual FFS and MCO surveys
2024-2025 Medicaid Managed Care Rate Development Guide a way that the MCO, PIHP, or PAHP would reasonably achieve a medical loss ratio standard greater than 85 percent, as calculated under 42 CFR § 438 8, as long as the capitation rates are adequate for reasonable, appropriate, and attainable non-benefit costs
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
Enrollment Report | Medicaid The Medicaid Managed Care Enrollment Report provides plan-specific enrollment statistics on Medicaid managed care programs The managed care enrollment report includes statistics, in point-in-time counts, on enrollees receiving comprehensive and limited benefits Plan-specific data include:Plan nameManaged care entityReimbursement arrangementOperating authorityGeographic area servedNumber of
Quality of Care External Quality Review | Medicaid An External Quality Review (EQR) is the analysis and evaluation by an external quality review organization (EQRO) of aggregated information on quality, timeliness, and access to the health care services that a managed care organization (MCO), prepaid inpatient health plan (PIHP), prepaid ambulatory health plan (PAHP), or their contractors, furnish to Medicaid or CHIP recipients