Obligations of Medicaid Managed Care Organizations

Learn more information on Medicaid Managed Care Organizations.

Learn more information on Medicaid Managed Care Organizations.

 

In our ongoing campaign to protect and promote access to Complex Rehab Technology, NCART wants to talk about Managed Care in hopes of demystifying this often misunderstood entity.

What is Managed Care? By definition, Managed Care is a health care delivery system. These Managed Care Organizations, or MCOs, were designed to manage cost, utilization, and quality. We understand that the mention of the term MCO, like HMO, often rubs people the wrong way, but these MCOs are a valuable part in the delivery of services. It’s the job of the Medicaid managed care groups to provide for the delivery of Medicaid health services and benefits through contracted arrangements between Medicaid agencies and managed care organizations.

While MCOs are a managed care administrative mechanism, they are NOT a substitute different program than the fee-for-service Medicaid program in your state and more importantly, Medicaid recipients do not lose benefits by being enrolled in managed care.  In other words, don’t fear the MCO.

How many people are enrolled in MCO’s?  Probably more than you think. It’s estimated that about 70 percent of those enrolled in Medicaid are being served by MCOs.  Are you enrolled?

The MCO makes the services it provides timely, adequate in duration and need of the person needing the service. It is important to note that the MCO’s authority or responsibility does not have to extend to all covered Medicaid services. For the services the MCO does cover, there are some strict rules they must abide by. The regulations state that each contract with an MCO must identify, define and specify the amount, duration and scope of each service that the MCO is required to offer. Those regulations are to ensure that the recipients receive the care and services they need.

For each of those services covered by Medicaid and administered through an MCO contract, there are rules. For instance (and a great thing for complex rehab equipment users) the MCO is required to cover every item of DME that is covered under the state Medicaid program.  That means the MCO may not use criteria to determine eligibility for DME items that are more restrictive than, or that otherwise lead to a different outcome than would result from application of the criteria applied by the fee-for-service Medicaid program. In other words, the MCO cannot decide that a person needing a complex rehab wheelchair will be given a cheaper wheelchair to save Medicaid or the provider money. The person needing the complex wheelchair will get what they need (services and equipment) and for as long as they need.

NCART is here to help the people who need us most; the men, women and children who need medically necessary and individually configured manual and power wheelchairs, seating and positioning systems, and other adaptive equipment to live their healthiest and best lives possible. Please contact NCART if you have questions about Managed Care Organizations or other concerns.

NCART - 54 Towhee Court - East Amherst, NY 14051 - Office: (716) 839-9728 - Fax: (716) 839-9624

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