Most Medicaid enrollees—about 72%—receive their healthcare through private insurance companies rather than directly from the state. This arrangement, known as managed care, differs significantly from the traditional fee-for-service model. Understanding the distinction is crucial for finding doctors, obtaining referrals, and navigating the process when your plan denies care.
Fee-for-Service: The Original Model Under fee-for-service (FFS), the state government pays healthcare providers directly for each service rendered. Patients can see any provider that accepts Medicaid, and there are no network restrictions. However, FFS can lead to higher costs and fragmented care since there is no central coordination.
Managed Care: Capitation and Networks Managed care organizations (MCOs) contract with states to provide coverage for a fixed monthly payment per enrollee, known as capitation. These MCOs create networks of doctors and hospitals, and enrollees must typically choose a primary care physician (PCP) and obtain referrals for specialists. The goal is to coordinate care and control costs.
The Five Largest Managed Care Companies The biggest MCOs in Medicaid include:
- UnitedHealthcare
- Anthem (now Elevance Health)
- Centene
- Molina Healthcare
- WellCare (now part of Centene)
These companies cover millions of beneficiaries across numerous states.
Finding Doctors, Getting Referrals, and Switching Plans Enrollees in managed care must use in-network providers to receive coverage. To see a specialist, a referral from your PCP is usually required. If you want to switch plans, you can typically do so during open enrollment or if you have a qualifying event. Contact your state's Medicaid office for guidance.
When Your Plan Denies Care: Grievances and Appeals If your managed care plan denies a service, you have the right to file a grievance and appeal. The process involves:
- Filing an internal appeal with the plan.
- If denied, requesting an external review by an independent entity.
- Continuing to the state fair hearing if necessary.
Time limits are strict, so act promptly. Assistance is available from your state's Medicaid ombudsman or legal aid.
Understanding these basics can help you navigate Medicaid coverage and ensure you receive the care you need.