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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 package Payment is risk-based capitation Primary Care Case Management (PCCM)
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
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
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
Managed Care in Colorado - Medicaid. gov Colorado has used both MCO and PCCM managed care delivery models for over three decades Its longest currently running program, the Managed Care Organization (MCO) program, began in 1983, and now covers acute, primary, and specialty services to Medicaid beneficiaries in Denver County and surrounding areas