UPDATE: In 2020, Medicaid requirements and application steps are largely the same.
Medicaid managed care plans provide the benefit of Medicaid coverage with the management of a local provider. Providing state-funded care to some 80 million people, Medicaid covers a wide scope of services. However, where possible, many people are turning to Medicaid managed care by state, due to the increased ease and efficiency by which they can access medical services.
Medicaid managed care enrollment was implemented in 1982, though it was not until the 1990s that beneficiaries began to take notice of its advantages. The state-specific program was enacted to address issues pertaining to the quality of care provided by participating organizations by way of partnering with private health insurance companies. As such, Medicaid managed care providers came to include health insurance organizations previously limited to servicing only the privately insured.
Read on for further information about Medicaid managed care by state, including the following topics:
- What is a managed care organization (MCO)?
- Medicaid managed care plans: Which states offer it?
- Recent regulations for managed care organizations (MCOs)
- The challenges faced by state MCOs
What is a managed care organization (MCO)?
An MCO is an organization that partners with a state Medicaid agency in order to make more efficient use of its medical services and delivery of those services. This benefits all parties involved, including the beneficiary, the MCO, and the state Medicaid agency. Medicaid managed care providers serve to improve consumer rights and encourage local state innovation when it comes to family care. At a state level, Medicaid managed care plans allow for reduced program costs and improved management of utilization of medical services. For beneficiaries, this means better and more appropriate health care services. Medicaid managed care by state allows beneficiaries to select an MCO doctor or primary care practitioner (PCP) who will be in charge of coordinating their health care. In the event that certain medical procedures are required, the doctor will refer the beneficiary to participating approved providers.
Medicaid Managed Care Plans: Which states offer it?
Medicaid managed care enrollment is not available in every state. However, approximately 55 million individuals are currently estimated to be covered by Medicaid Managed Care plans. The percentage of Medicaid managed care enrollment grew from 2.7 million recipients in 1991 to 27 million in 2004.Below is an overview of Medicaid managed care enrollment statistics by the state in which it is offered:
- Arizona – 1,503,359
- California – 10,288,604
- Florida – 3,167,583
- Georgia – 1,316,269
- Hawaii – 328,484
- Illinois – 1,809,440
- Indiana – 1,064,548
- Iowa – 560,612
- Kentucky – 1,198,425
- Louisiana – 1,086,071
- Maryland – 1,041,965
- Massachusetts – 828,565
- Michigan – 1,683,445
- Minnesota – 725,639
- Mississippi – 507,404
- Missouri – 472,086
- Nevada – 423,839
- New Hampshire – 136,854
- New Mexico – 666,204
- New York – 4,456,259
- Ohio – 2,353,585
- Oregon – 980,042
- Pennsylvania – 2,219,275
- South Carolina – 718,796
- Tennessee – 1,525,229
- Texas – 3,516,705
- Washington – 1,418,794
- West Virginia – 374,969
- Wisconsin – 763,211
Recent Regulations for Managed Care Organizations (MCOs)
The federal government relies heavily on Medicaid managed care by state, and in a bid to keep up with the ever-increasing demand, the Centers for Medicare and Medicaid Services (CMS) has recently modernized the rules. Final regulations were issued by CMS on April 21, 2016 in relation to Medicaid managed care organization rules. In order to confirm Medicaid managed care enrollment fees are sufficient for beneficiary care, actuarial soundness standards have been reinforced. Medicaid managed care providers are now required to contribute 85 percent of their revenue into healthcare and medical services. Smarter spending and better care will be delivered as a result.
Additional highlights associated with the new regulations for Medicaid managed care plans include:
- Protection for enrollment and disenrollment. In order to switch plans, MCOs must provide its beneficiaries with a 90-day notice period. Beneficiaries will have the opportunity to disenroll from the fee-for-service (FFS) system if employment or residence is affected by Long Term Services and Supports (LTSS).
- Service continuity during appeals. Under Medicaid managed care enrollment, beneficiaries can still receive medical services amid appeals of denials.
- Managed Long-term Services and Supports (MLTSS). When an enrollee is diagnosed with LTSS needs, comprehensive assessments will take place to determine whether or not MLTSS should be supplied by the MCO.
- Consumer rights and protections are improved as a result of the services offered by Medicaid managed care by state, which also extend to state-written quality strategies and continuity of care policies. Additionally, participation in marketplace plan subsidy programs is encouraged.