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 …
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 …
In 1997, the Partnership Program 1115 waiver authorized the statewide Medicaid Managed Care program, which covers acute, primary, specialty, limited long term care and limited behavioral health …
January 18, 2022 This guide covers the standards that are used by the Centers for Medicare & Medicaid Services (CMS) Division of Managed Care Operations (DMCO) staff to review and approve State …
Pennsylvania began experimenting with various managed care arrangements in the 1970’s, beginning with the introduction of its Voluntary Managed Care Program, a comprehensive risk-based MCO …
Coordination of Benefits & Third Party Liability | Medicaid
It is possible for Medicaid beneficiaries to have one or more additional sources of coverage for health care services. Third Party Liability (TPL) refers to the legal obligation of third parties (for example, …
Managed Care Entities | Medicaid
Federal Managed Care regulations at 42 CFR 438 recognize four types of managed care entities:Managed Care Organizations (MCOs)Comprehensive benefit packagePayment is risk …
Medicaid and CHIP Managed Care Reporting
The May 2016 Medicaid and CHIP managed care final rule strengthened the federal oversight of state managed care programs in several ways, one of which was to create new reporting requirements for …
a way that the MCO, PIHP, or PAHP would reasonably achieve a medical loss ratio standard greater than 85 percent, as calculated under 42 CFR § 438.8, as long as the capitation rates are adequate …
State Drug Utilization Review Reporting | Medicaid
Aug 18, 2025 · In 2019, CMS released the FFS and Managed Care Organization (MCO) Surveys for FFY 2018 and at that time, CMS introduced the Medicaid Drug Programs (MDP) system, a more …