Managed Care

With the implementation of the Affordable Care Act, many new Medicaid recipients will be added, and the impact of these new members will affect providers, payers, and government entities.  With the demise of fee-for-service, the movement toward performance based payment, and the need for government to reduce costs, managed care is one of the strategies that will reshape the landscape.


States have traditionally provided people Medicaid benefits using a fee-for-service system. However, in the past 15 years, states have more frequently implemented a managed care delivery system for Medicaid benefits. In a managed care delivery system, people get most or all of their Medicaid services from an organization under contract with the state. Almost 50 million people receive benefits through some form of managed care, either on a voluntary or mandatory basis. When states implement a managed care program, it can use any one of the following types of entities:

  • Managed Care Organizations (MCOs) – like HMOs, these companies agree to provide most Medicaid benefits to people in exchange for a monthly payment from the state.
  • Limited benefit plans – these companies may look like HMOs but only provide one or two Medicaid benefits (like mental health or dental services).
  • Primary Care Case Managers – these individual providers (or groups of providers) agree to act as an individual’s primary care provider, and receive a small monthly payment for helping to coordinate referrals and other medical services.”

Ann Boughtin Consulting, LLC has among it team, years of leadership experience in Medicaid and Medicaid managed care, and has assisted clients to develop and implement strategies to face the challenges of Medicaid managed care.