Medicaid Managed Care State Guide

DEPARTMENT OF HEALTH AND HUMAN SERVICES. Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12. Baltimore, MD 21244-1850. State Guide to CMS Criteria for Medicaid Managed care Contract Review and Approval January 20, 2017. This Guide covers the standards that are used by the Centers for Medicare & Medicaid Services (CMS). Regional Office staff to review and approve State contracts with Medicaid Managed care organizations (MCO), prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), non-emergency medical transportation prepaid ambulatory health plans (NEMT PAHP), primary care case managers (PCCM), primary care case manager entities (PCCM entity), and health insuring organizations (HIO). 1. The Guide is intended to provide transparency on the criteria for contract approvals and to help states verify that contracts with Medicaid Managed care entities meet all CMS requirements.

CMS utilizes the term “managed care plan” to encompass all types of managed care delivery (i.e. MCO, HIO, PIHP, PAHP, NEMT PAHP, PCCM, PCCM entity) to which a federal requirement applies. 3. This guide is not intended as a substitute for legal advice or review of the applicable law; it does not grant rights or impose obligations.

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