Understanding managed care and Medicaid managed care organizations (MCOs) is essential for insurance agents. MCOs play a key role in providing high-quality health care services for millions of Medicaid beneficiaries, many of which are also dual eligible for Medicare.
Below we will help simplify what MCOs are, how they work, and why they’re critical for you to understand.
If you’ve ever struggled to explain managed care plans to clients (you’re not alone), this article will provide an easy-to-follow breakdown plus an FAQ section to address some common questions.
What is Managed Care?
Managed care is a type of health care delivery system designed to control costs, improve the quality of care, and connect enrollees with the right health care providers. Instead of paying for every service separately (known as fee-for-service), managed care plans receive a fixed monthly payment, known as capitation, to provide Medicaid services to beneficiaries.
Think of an MCO (Managed Care Organization) like a team manager who organizes and pays for care, ensuring enrollees have access to doctors, hospitals, behavioral health services, and even long-term care when needed.
What is Medicaid Managed Care?
Medicaid managed care is a system where state Medicaid agencies contract with MCOs to deliver health care benefits to Medicaid beneficiaries. Instead of the government paying directly for care, the state Medicaid agency pays MCOs to provide services, such as:
- Primary care and specialist care
- Hospital stays
- Behavioral health services
- Long-term services and nursing facility care
According to Kaiser, currently, over 74% of Medicaid beneficiaries receive care through Medicaid MCOs across the country.
How Do MCOs Work?
Here’s a simple breakdown:
- Capitation Payments: The government gives the MCO a set amount of money (capitation) each month to care for each enrollee.
- Care Coordination: MCOs connect enrollees with doctors, specialists, and other health care providers.
- Rules and Networks: MCOs work with providers within their network and set rules, like requiring prior authorization for specific treatments.
- Focus on Quality: Many MCOs use quality improvement programs to ensure high-quality care while managing costs.
Why is Managed Care Important for Agents?
As an agent, understanding Medicaid managed care helps you guide clients effectively. Here’s why it matters:
- Most Medicaid Beneficiaries Use MCOs: In most states, the majority of beneficiaries are enrolled in MCOs for their Medicaid services.
- Improved Care Coordination: MCOs help clients access primary care, specialists, and even social support through community-based services.
- State-Specific Rules: Each state’s Medicaid program is different, and agents need to understand their state’s rules for enrollment and eligibility.
For more on how managed care impacts health outcomes, check out this resource on Medicaid Managed Care Outcomes.
Key Questions Answered: FAQs
What does MCO stand for with Medicaid?
MCO stands for Managed Care Organization. It is a company that provides health care services to Medicaid enrollees under a contract with the state.
What is the difference between MCO and Medicaid?
Medicaid is a government-funded health insurance program. An MCO is a private or non-profit organization that manages and provides Medicaid benefits to Medicaid beneficiaries.
What is an example of an MCO?
Some of the largest Medicaid MCOs include UnitedHealthcare, Aetna, Elevance Health (formerly Anthem), Molina Healthcare, Humana, and Centene.
What role does Care Coordination play?
Care coordination ensures that patients receive the right care at the right time. For example, if a beneficiary needs mental health support or long-term care, the MCO helps connect them with the appropriate provider.
How do I choose the best Medicaid MCO for my healthcare needs?
Clients should consider:
- The MCO’s network of doctors, specialists, and hospitals.
- Coverage for additional services like behavioral health services or long-term services.
- State-specific benefit plans and flexibilities.
How does Medicaid MCO enrollment affect access to specialists?
MCOs typically require enrollees to see a primary care provider first for referrals to specialists. This helps manage costs and ensures coordinated care.
How do I enroll in a Medicaid MCO?
Beneficiaries can enroll through their state Medicaid agency during open enrollment periods or special enrollment windows based on eligibility.
Are newborns in State Custody automatically enrolled?
Yes, in certain states like New Mexico, newborns in state custody may be automatically enrolled in a specific health plan, like the Presbyterian Health Plan.
What is the start date for newly selected MCOs?
Start dates for new MCO contracts vary by state and are typically announced by the state Medicaid agency during their procurement process.
When will MCOs deliver member lists to providers?
Providers typically receive member lists shortly after enrollment or during the start of a new managed care program year.
MCOs by State
Below is a reference list that will help you identify the brands you are seeing in the market that would indicate the MCO your prospect is currently using for their state Medicaid. This list evolves, so make sure you are verifying their status.
Alabama:
- Alabama Medicaid Agency
Alaska:
- Alaska does not utilize MCOs for Medicaid services.
Arizona:
- Arizona Complete Health
- UnitedHealthcare Community Plan
- Mercy Care
Arkansas:
- Arkansas Total Care
- Ambetter
California:
- Anthem Blue Cross
- Molina Healthcare
- Kaiser Permanente
Colorado:
- Colorado Access
- Rocky Mountain Health Plans
Connecticut:
- Connecticut does not utilize MCOs for Medicaid services.
Delaware:
- Highmark Health Options
- AmeriHealth Caritas Delaware
Florida:
- Sunshine Health
- Humana Medical Plan
- Simply Healthcare Plans
Georgia:
- Peach State Health Plan
- Amerigroup Community Care
- CareSource
Hawaii:
- AlohaCare
- HMSA QUEST Integration
Idaho:
- Blue Cross of Idaho
- Molina Healthcare
Illinois:
- Blue Cross Community Health Plans
- Meridian Health Plan
- CountyCare Health Plan
Indiana:
- Anthem Hoosier Healthwise
- MDwise
- MHS
Iowa:
- Iowa Total Care
- Amerigroup Iowa
Kansas:
- Sunflower Health Plan
- UnitedHealthcare Community Plan
Kentucky:
- WellCare of Kentucky
- Passport Health Plan
- Aetna Better Health of Kentucky
Louisiana:
- Healthy Blue
- Louisiana Healthcare Connections
- AmeriHealth Caritas Louisiana
Maine:
- Maine does not utilize MCOs for Medicaid services.
Maryland:
- Maryland Physicians Care
- Priority Partners
- Amerigroup Maryland
Massachusetts:
- BMC HealthNet Plan
- Tufts Health Together
Michigan:
- Meridian Health Plan
- Molina Healthcare
- UnitedHealthcare Community Plan
Minnesota:
- Blue Plus
- HealthPartners
- UCare
Mississippi:
- Magnolia Health Plan
- UnitedHealthcare Community Plan
Missouri:
- Home State Health
- Missouri Care
- UnitedHealthcare Community Plan
Montana:
- Montana does not utilize MCOs for Medicaid services.
Nebraska:
- Nebraska Total Care
- UnitedHealthcare Community Plan
Nevada:
- SilverSummit Healthplan
- Anthem Blue Cross and Blue Shield Healthcare Solutions
New Hampshire:
- New Hampshire Healthy Families
- Well Sense Health Plan
New Jersey:
- Horizon NJ Health
- Amerigroup New Jersey
- UnitedHealthcare Community Plan
New Mexico:
- Blue Cross Community Centennial
- Presbyterian Health Plan
- Western Sky Community Care
New York:
- Fidelis Care
- Healthfirst
- MetroPlus Health Plan
North Carolina:
- WellCare of North Carolina
- Healthy Blue
- UnitedHealthcare Community Plan
North Dakota:
- North Dakota does not utilize MCOs for Medicaid services.
Ohio:
- Buckeye Health Plan
- CareSource
- UnitedHealthcare Community Plan
Oklahoma:
- Oklahoma does not utilize MCOs for Medicaid services.
Oregon:
- Health Share of Oregon
- Trillium Community Health Plan
Pennsylvania:
- UPMC for You
- Keystone First
- AmeriHealth Caritas Pennsylvania
Rhode Island:
- Neighborhood Health Plan of Rhode Island
- UnitedHealthcare Community Plan
South Carolina:
- Healthy Blue
- Molina Healthcare of South Carolina
- Select Health of South Carolina
South Dakota:
- South Dakota does not utilize MCOs for Medicaid services.
Tennessee:
- BlueCare Tennessee
- UnitedHealthcare Community Plan
- Amerigroup Tennessee
Texas:
- Superior HealthPlan
- Molina Healthcare of Texas
- Amerigroup Texas
Utah:
- Healthy U
- Molina Healthcare of Utah
- SelectHealth Community Care
Vermont:
- Vermont does not utilize MCOs for Medicaid services.
Virginia:
- Anthem HealthKeepers Plus
- UnitedHealthcare Community Plan
- Virginia Premier
Washington:
- Community Health Plan of Washington
- Molina Healthcare of Washington
- Coordinated Care
West Virginia:
- The Health Plan of West Virginia
- UniCare Health Plan
- Aetna Better Health of West Virginia
Wisconsin:
- Anthem Blue Cross and Blue Shield
- Molina Healthcare of Wisconsin
- UnitedHealthcare Community Plan
Wyoming:
- Wyoming does not utilize MCOs for Medicaid services.
Medicaid MCO State Summary
- MCOs are active in 41 states and the District of Columbia.
- States like Connecticut, Montana, North Dakota, South Dakota, Vermont, and Wyoming still operate Medicaid primarily under fee-for-service systems.
- Some of the largest MCOs across the U.S. include UnitedHealthcare, Molina Healthcare, Anthem Blue Cross, Amerigroup, and Centene.
This list highlights how Medicaid managed care varies across the country, with MCOs serving as the key coordinators for health care services in most states.
Agents working in Medicaid markets should always verify state-specific rules and understand which health plans are available to serve clients, especially in 2025 with the changes in the low income subsidy special election period.
Takeaways for Agents
- Understand the Basics: MCOs manage care for most Medicaid beneficiaries, ensuring access to health care services through coordinated networks.
- State-Specific Rules: Stay updated on training requirements, eligibility, and enrollment processes in your state.
- Simplify the Message: Explain managed care like a coach managing a team—organizing care and keeping costs predictable.
- Focus on Care Coordination: Highlight how MCOs simplify access to specialists, long-term services, and extra benefits for clients.
By mastering Medicaid managed care and the role of MCOs, you’ll be better equipped to serve your clients, answer their questions, and build trust.
For more insights on managed care and its impact, visit the official MACPAC resource.
