Managed Care

When exploring managed care, it's essential to consider various aspects and implications. 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.

Additionally, 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). Managed care technical assistance is available to assist state Medicaid agencies in developing, enhancing, implementing, and evaluating managed care programs.

Final Rules CMS has updated regulations for Medicaid and CHIP Managed Care in 2016, 2017, 2020 and 2024. Medicaid Managed Care State Guide. This guide is designed specifically for review of managed care plan (MCP) contracts serving the Medicaid population. The State Guide to CMS Criteria for Children’s Health Insurance Program (CHIP) Managed Care Contract Review and Approval provides separate guidance specific to the review of CHIP managed care provisions. Managed Care Authorities | Medicaid.

States can implement a managed care delivery system using three basic types of federal authorities:State plan authority [Section 1932 (a)]Waiver authority [Section 1915 (a) and (b)]Waiver authority [Section 1115]Regardless of the authority, states must comply with the federal regulations that govern managed care delivery systems. This perspective suggests that, these regulations include requirements for a managed care plan ... State Managed Care Quality Strategies | Medicaid. The performance improvement projects implemented by the managed care plan, including a description of any interventions the State proposes to improve access, quality, or timeliness of care for beneficiaries enrolled in a managed care plan.

Quality of Care External Quality Review | Medicaid. An External Quality Review (EQR) is the analysis and evaluation by an external quality review organization (EQRO) of aggregated information on quality, timeliness, and access to the health care services that a managed care organization (MCO), prepaid inpatient health plan (PIHP), prepaid ambulatory health plan (PAHP), or their contractors, furnish to Medicaid or CHIP recipients. 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) Primary care case managers contract with the state to furnish case management (location, coordination, and monitoring ...

Enrollment Report | Medicaid. The Medicaid Managed Care Enrollment Report provides plan-specific enrollment statistics on Medicaid managed care programs. The managed care enrollment report includes statistics, in point-in-time counts, on enrollees receiving comprehensive and limited benefits.Plan-specific data include:Plan nameManaged care entityReimbursement arrangementOperating authorityGeographic area servedNumber of ... Managed Care Quality Improvement | Medicaid. Managed Care Quality Improvement As the dominant delivery system for Medicaid and the Children's Health Insurance Program (CHIP), managed care has enormous potential to achieve state priorities and improve health care quality and outcomes.