10 Things to Know About Medicaid Managed Care
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.
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).
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
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
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
A parent firm is a firm that owns Medicaid MCOs in two or more states.
WellCare was acquired by Centene in January 2020.
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
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%.
The thirteen states are Arizona, District of Columbia, Hawaii, Louisiana, Michigan, New Hampshire, North Carolina, Oregon, Pennsylvania, South Carolina, Texas, Virginia, and Washington.
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.
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
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
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