|Description||In managed care, patients select an insurance plan to manage all of their health benefits. The insurance plan contracts with a network of providers to deliver services. Enrollees are limited to receiving care from network providers only, except in limited circumstances.|
All and increasingly for Medicaid populations with long term services and support needs that had traditionally been excluded from managed care
Commercial Managed Care Organizations; Large Providers, e.g., Hospitals, Large Physician Groups, and Integrated Delivery Systems for Provider-Led Variation
|Role of Home Health||Home health providers contract with MCOs to provide a subset of services. MCOs are generally not restricted by the same rules as government payers (Medicare and Medicaid). Therefore, home health agencies may contract with MCOs to provide a broader range of services.|
|Reimbursement Model||Payers reimburse MCOs on a capitated per member per month basis. MCOs generally accept full risk for costs associated with managing their enrolled population.
MCOs contract with providers through a variety of mechanisms. While most contract on a fee-for-service basis, MCOs are increasingly looking at value-based payment methodologies, including capitated payments for primary care services, and pay-for-performance for other providers.
|Minimum Infrastructure Requirements||
|Variations||Provider-led MCOs, which are generally operated either by a large provider (e.g., hospital, large physician group) alone or in partnership with an existing MCO serving in an administrative capacity.|