How does managed care work

This is known as comprehensive or capitated care. As of July 1, , 40 states including D. Approximately 40 percent of Medicaid patients are enrolled in MCO plans, and as Medicaid expands, these enrollment numbers are also likely to grow. However, many of these patients are those who require long-term care and other more expensive services, which becomes a funding issue that providers must maneuver their way through. This is also one reason why many organizations are beginning to emphasize preventive care techniques.

Using MCOs for care programs like Medicaid and Medicare has improved the predictability of healthcare organization operating budgets, but it has not entirely improved the funding issues that many are facing. Healthcare costs are becoming one of the biggest spending and debating points in the federal government, surpassing even the cost of public education. Even with shifts in finances and the MCO model, maneuvering through the logistics and regulations of Medicaid can be difficult for a healthcare organization.

We understand the ins and outs of healthcare reimbursement and revenue cycle management. Our staff is well-trained and knowledgeable and can help provide answers on the front lines of the medical field, addressing both patient and provider concerns. We advocate for the needs of patients and get their information in order to set them on the right financial path. However, there has been significant movement across states to carve these services in to MCOs. The MCO share of spending ranged from a low of 0.

As states expand Medicaid managed care to include higher-need, higher-cost beneficiaries, expensive long-term services and supports, and adults newly eligible for Medicaid under the ACA, the share of Medicaid dollars going to MCOs will continue to increase. Figure 6: Payments to comprehensive MCOs account for almost half of total national Medicaid spending. Of the 17 parent firms, eight are publicly traded, for-profit firms while the remaining nine are non-profit companies.

Federal rules require that states establish network adequacy standards. States have a great deal of flexibility to define those standards. The CMS Medicaid managed care final rule included specific parameters for states in setting network adequacy standards, although regulations proposed by the Trump administration in would loosen these requirements.

KFF conducted a survey of Medicaid managed care plans in 14 and found that responding plans reported a variety of strategies to address provider network issues, including direct outreach to providers, financial incentives, automatic assignment of members to PCPs, and prompt payment policies. However, despite employing various strategies, plans reported more challenges in recruiting specialty providers than in recruiting primary care providers to their networks.

Plans reported that these challenges were more likely due to provider supply shortages than due to low provider participation in Medicaid. To help ensure participation, many states require minimum provider rates in their contracts with MCOs that may be tied to fee-for-service rates. In a KFF survey of Medicaid directors, about one-half of MCO states indicated that they mandate minimum provider reimbursement rates in their MCO contracts for inpatient hospital, outpatient hospital, or primary care physicians.

For providers in states that rely heavily on managed care, states are making payments to plans but those funds may not be flowing to providers where utilization has decreased. States can direct that managed care plans make payments to their network providers using methodologies approved by CMS to further state goals and priorities, including response to the COVID pandemic.

For example, states could require plans to adopt a uniform temporary increase in per-service provider payment amounts for services covered under the managed care contract, or states could combine different state directed payments to temporarily increase provider payments Figure More than three quarters of MCO states 34 of 40 reported having initiatives in place in FY that make MCO comparison data publicly available up from 23 states in These plans are pricier, though, since they give you more of a choice.

Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment.

As always, you should consult with your healthcare provider about your specific health needs.