What is a Managed Medicaid Plan?

A managed Medicaid plan is a type of health insurance plan that is designed for individuals who are enrolled in the Medicaid program. These plans are managed by private insurance companies, known as Managed Care Organizations (MCOs), that have contracts with state Medicaid agencies to provide health coverage and other services to eligible individuals.
Managed Medicaid plans are similar to managed care plans offered in the private sector, such as Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). They provide a network of healthcare providers, hospitals, and other providers that members can use for their healthcare needs. They also provide member services such as case management, care coordination, and utilization review to ensure that members are receiving appropriate care.

The main goal of a Managed Medicaid plan is to provide comprehensive and coordinated care to members, while controlling costs and improving the quality of care. They are also intended to improve the overall health outcomes for Medicaid beneficiaries. It’s important to note that the availability and the specific features of Managed Medicaid plans may vary depending on the state and the MCO, and it’s best to check with the state Medicaid agency for more information about the specific plans that are available in your area. Usually, a state establishes criteria and a process for eligible individuals such as an eligible individual receives the state Medicaid insurance and has three months to select a managed Medicaid plan. If the individual does not select a managed Medicaid plan at the end of the three months, the state process usually randomly assigns one of the plans.

For example, in Pennsylvania, there are several managed Medicaid plans that are available to eligible individuals. These plans are designed to provide comprehensive health coverage and other services to individuals who are enrolled in the state’s Medicaid program. The Managed Medicaid plans offer a wide range of benefits, including inpatient and outpatient care, prescription drug coverage, and preventive services. Some of the managed Medicaid plans that are available in Pennsylvania include:
Keystone First: Keystone First is a Medicaid Managed Care Organization that provides health insurance and other services to eligible individuals in the state of Pennsylvania.
UPMC for You: This plan is offered by the University of Pittsburgh Medical Center and provides health coverage and other services to eligible individuals and families in the state.
Health Partners Plans: Health Partners Plans is a Medicaid Managed Care Organization that started in Philadelphia County, PA, increased the offering to most counties in the Philadelphia Area and starting in 2022 is a managed Medicaid Plan offering for all areas within the state of Pennsylvania.
Gateway Health Plan: Originally established as a Managed Medicaid plan in the local Pittsburgh area, as of 2022, this Managed Medicaid plan is an option to all areas in the state of Pennsylvania.

Provider Networks: Managed Medicaid Plans have their own provider networks and the provider’s list may vary. It’s important to check with the specific plan to see if your preferred providers are in their network.
Benefits: Managed Medicaid Plans offer a wide range of benefits, such as inpatient and outpatient care, prescription drug coverage, and preventive services. However, the specific benefits and coverage may vary between each plans.
Member Services: Managed Medicaid Plans offer member services, such as case management, care coordination, and utilization review, to ensure that members are receiving appropriate care. However, the specifics of these services may vary between plans.

The reimbursements for services to providers varies by Managed Medicaid plan. Each Pediatric practice should evaluate the managed Medicaid plan to identify if the reimbursements and the requirements of the plan align to the approach by the Pediatric practices. Due to the variation by Managed Medicaid plan, some Pediatric practices accept a limited number of Managed Medicaid plans and/or do not accept managed Medicaid insurances.