How does Medicaid Managed Care Work?

A Medicaid Managed Care Organization (MCO) is an insurance plan designed to lower health care costs for both patients and providers. Medicaid Managed care is a network of providers who have contracted with Medicaid.

Medicaid recipients may select from a choice of MCO plans provided by their state. To use their benefits, individuals who meet Medicaid eligibility requirements must select a Primary Care Provider (PCP) who is a part of the MCO network.

The Medicaid program only pays for services performed at an in-network provider. The PCP is the provider who coordinates the benefic ariary’s care such as routine checkups and preventive care. If an individual needs specialty care beyond what the PCP offers, the provider refers the patient to another provider in the network. If you are a Medicaid recipient and would like more information on Managed Medicaid plans, keep reading for how the program works and how to select a plan for your family.

What is Medicaid Managed care?

The Medicaid Managed Care program is a type of insurance aimed at lowering costs for both program participants and providers. The cost savings is accomplished through a network of MCO Medicaid service providers and facilities that agree to provide care for program participants. Medicaid contracts with these providers to offer care at reduced rates. Under this arrangement, the program pays providers in the network a set fee for services provided. Plan participants must use providers within the network for their care, as the program will only cover services rendered by network providers.

The program goes by different names depending on the state in which the beneficiary resides. However, most states offer the Medicaid Managed Care plans through several health care plans from which a cardholder may select for their benefits.

How do Medicaid Managed plans work?

In most states, Medicaid recipients are required to use a Medicaid Managed Care plan. They may select from the healthcare options available in their state. In some states, not only is enrollment in an MCO Medicaid plan required, but participants are automatically enrolled once approved for the program.

Related Article: Becoming a Medicaid Beneficiary

Once enrolled, program participants must select a primary care provider (PCP) who is responsible for the individual’s primary care. Enrollees may only select a PCP from the network outlined by the managed care organization. The primary care provider (PCP) is who the beneficiary sees for routine doctor visits, health screenings and laboratory tests. If an enrollee requires special services, they must get a referral from their PCP. The Medicaid Managed Care program does not pay for services if the enrollee was not authorized to see the provider. Nor will they pay if an individual receives care from a specialty provider outside of the MCO’s network.

How to Choose Between Managed Medicaid Plans

Beneficiaries must select a managed Medicaid insurance plan based on a list provided by Medicaid. During Medicaid managed care enrollment, participants may choose any eligible plan offered if it is one that has contracted with Medicaid. When evaluating plans, beneficiaries must weigh a variety of factors such as:

Doctor

Program participants may only use a doctor within a plan’s network. If an individual already has a PCP, they may want to select a plan in which their PCP participates. Or, they may elect to find a new PCP that is a part of one of the healthcare networks designated by the program. Also, if a beneficiary sees a specialist for certain medical conditions, they should select a plan which their Medicaid Managed Care specialty provider participates. Doing so ensures that the program participant continues with a provider who is familiar with their care so that there is no disruption in medical treatment.

Services Required

Although most plans offer a set of basic services, each varies in the optional services provided. For example, some plans offer dental and vision coverage benefits while others do not. Program participants should consider if their family requires these services and select a plan that provides the appropriate coverage.

Proximity to Required Services

Because Medicaid recipients must choose a provider within a specific network, they should ensure that the provider they wish to see is convenient for them to reach. Individuals should consider picking managed Medicaid that are easily accessible from where they live. Selecting a provider too far away could cause a beneficiary to miss regular checkups that are beneficial to their health.

How to Use Your Benefits in a Medicaid Managed Care Plan

Some states issue a Medicaid Managed Care card that is separate from the Medicaid card given to beneficiaries. Beneficiaries must keep both the Medicaid card and the Medicaid Managed Care card on hand when requesting care with a provider, as they may be asked to present both during a visit. The reason for this is that Medicaid may cover services that the managed care plan does not. The below outlines how to get care with the Medicaid Managed Care card:

Routine Care

Routine visits include things such as check-ups, lab work and X-rays. For these types of visits, program participants must call their PCP.

Preventive Care

Taking steps to avoid health problems is referred to as preventive care. Services such as blood pressure screenings and diabetes screenings fall into this category. Participants must call their MCO Medicaid PCP to receive preventive care.

After-Hours

If a beneficiary needs care beyond regular business hours, they must still ensure that the managed Medicaid provider they see is in the plan’s network. Program participants should first call the member services customer care line listed on their card. The customer service agent can provide advice on how to get care and which providers the individual may use to get after-hours care.

Urgent Care

Services that are non-emergencies but require immediate attention are best handled at an urgent care facility. Program participants should first contact their insurance plan to locate a facility that is in the plan’s network.

Emergencies

In an emergency, beneficiaries should visit the nearest emergency facility. However, as soon as medically possible, the beneficiary must call the Medicaid Managed Care plan to notify them of the visit. Those non-citizens who do not qualify for Medicaid coverage can still qualify for emergency Medicaid benefits when necessary.

Care Away from Home

Individuals may get care at a network provider even if they are away from their home provider. A beneficiary may locate a physician in another area by contacting their insurance plan for a list of acceptable providers.

Related Article: Medical Help Programs

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