10 Things to Know About Medicaid Managed Care

Issue Brief
  1. PCCM is a managed fee-for-service (FFS) based system in which beneficiaries are enrolled with a primary care provider who is paid a small monthly fee to provide case management services in addition to primary care.

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  2. While MCOs are the predominant form of Medicaid managed care, millions of other beneficiaries receive at least some Medicaid services, such as behavioral health or dental care, through limited-benefit risk-based plans, known as prepaid inpatient health plans (PIHPs) and prepaid ambulatory health plans (PAHPs).

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  3. As of February 2022, the state has enrolled nearly 1.7 million Medicaid beneficiaries in its MCO program. For more information, see: North Carolina Department of Health and Human Services, Dashboard, Raleigh, NC, February 2022: https://medicaid.ncdhhs.gov/reports/dashboards#enroll

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  4. Michael Sparer, Medicaid Managed Care, (Washington, DC: Robert Wood Johnson Foundation, September 4, 2012), https://www.rwjf.org/en/library/research/2012/09/medicaid-managed-care.html

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  5. Daniel Franco Montoya, Puneet Kaur Chehal, and E. Kathleen Adams, “Medicaid Managed Care’s Effects on Costs, Access, and Quality: An Update,” Annual Review of Public Health 41:1 (2020):537-549

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  6. A parent firm is a firm that owns Medicaid MCOs in two or more states.

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  7. WellCare was acquired by Centene in January 2020.

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  8. CVS Health, “CVS Health Reports Strong Fourth Quarter and Full-Year 2021 Results, Confirms 2022 Full-Year EPS Guidance,” (Woonsocket, RI: CVS Health, February 2022), https://www.cvshealth.com/sites/default/files/media-gallery/cvs-health-earnings-report-2021-q4.pdf

    Anthem, “Anthem Reports Fourth Quarter and Full Year 2021 Results,” (Indianapolis, IN: Anthem, January 2022), https://ir.antheminc.com/static-files/e8a4417d-9aff-4159-8223-0e19ffa5cb91

    Centene Corporation, “Centene Corporation Reports 2021 Results,” (St. Louis, MO: Centene Corporation, February 2022), https://investors.centene.com/_assets/_1393b4dac0f01b87badb57b193032819/centene/news/2022-02-08_CENTENE_CORPORATION_REPORTS_2021_1017.pdf

    Molina Healthcare, “Molina Healthcare Reports Fourth Quarter and Year-End 2021 Financial Results,” (Long Beach, California: Molina Healthcare, February 2022): https://investors.molinahealthcare.com/node/21941/pdf

    UnitedHealth Group, “UnitedHealth Group Reports 2021 Results,” (Minnetonka, MN: UnitedHealth Group, January 2022): https://www.unitedhealthgroup.com/content/dam/UHG/PDF/investors/2021/UNH-Q4-2021-Release.pdf

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  9. For example, in Pennsylvania, the APM target for the HealthChoices physical health MCO program and the behavioral health managed care program is 50% and 20%, respectively, for calendar year 2021. Likewise, Virginia sets a lower percentage (10%) for its MLTSS program, Commonwealth Coordinated Care Plus, than for its Medallion 4.0 Medicaid physical and behavioral health managed care program that serves the state’s low-income children and families and the APM target is set at 25%.

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  10. The thirteen states are Arizona, District of Columbia, Hawaii, Louisiana, Michigan, New Hampshire, North Carolina, Oregon, Pennsylvania, South Carolina, Texas, Virginia, and Washington.

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  11. Health Care Payment Learning & Action Network, “Alternative Payment Model (APM) Framework,” (McLean, VA: The MITRE Corporation, 2017), https://hcp-lan.org/workproducts/apm-refresh-whitepaper-final.pdf. CMS launched the LAN in 2015 to encourage alignment across public and private sector payers by providing a forum for sharing best practices and developing common approaches to designing and monitoring of APMs, as well as by developing evidence on the impact of APMs.

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  12. Aaron Mendelson et al., “The Effects of Pay-for-Performance Programs on Health, Health Care Use, and Processes of Care: A Systematic Review,” Annals of Internal Medicine 166 no. 5 (March 2017): 341-353, doi:10.7326/M16-1881

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  13. California Health Care Foundation, “Making Quality Matter in Medi-Cal Managed Care: How Other States Hold Health Plans Financially Accountable for Performance,” (Sacramento, CA: California Health Care Foundation, February 2019), https://www.chcf.org/wp-content/uploads/2019/02/MakingQualityMatterMediCalManagedCare.pdf

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  14. New York State Department of Health, 2017 Quality Incentive for Medicaid Managed Care Plans, Albany, NY: New York State Department of Health, 2017, https://www.health.ny.gov/health_care/managed_care/reports/docs/quality_incentive/quality_incentive_2017.pdf

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