Medicaid Managed Care Organizations Help Millions of Enrollees with Complex Health Conditions
Approximately 80 million Americans rely on Medicaid. As a result of disability, complex medical conditions, or chronic illness, a significant number of enrollees require ongoing, specialized, advanced, and integrated health care services.
Medicaid managed care organizations (MCOs) support enrollees with high health needs by improving access to and coordination of a broad array of essential and high-quality healthcare services. In addition, MCOs are accountable for meeting state-determined quality and performance standards. As of 2023, 40 states and DC deliver Medicaid benefits through MCOs that cover more than 80 million individuals, or 81% of all Medicaid enrollees nationally.1 More than 28 million of these enrollees have one or more chronic conditions, including hypertension, diabetes, cardiovascular disease and others.
MCOs Cover Millions of Enrollees with Complex Needs, 2023¹
7.2M
have hypertension
4.5M
have diabetes
3.5M
have intellectual and developmental disabilities
7.4M
have depression
2.8M
have cardiovascular disease
9.5M
have three or more chronic conditions
4M
people qualifying based on disability have a chronic condition
3.2M
seniors (ages 65+) have a chronic condition
14.3M
low-income children have a chronic condition
16.4M
low-income adults (ages 19-64) have a chronic condition
28.3M
have one or more chronic conditions
How MCOs Support Enrollees with Complex Health Needs
Care Management and Service Coordination
MCOs assign dedicated care management teams who help identify enrollees’ needs, develop care plans, and link enrollees with health-related resources. In addition, MCOs help enrollees set up appointments and coordinate enrollees’ health information across providers.
Disease Management Programs
MCOs have programs to support enrollees with specific chronic conditions by providing services like self-monitoring equipment and education, medication management, and appointment reminders.
Value Added Benefits
MCOs provide supplemental services, such as healthy food, transportation to medical services, and nutritional services, not traditionally covered by Medicaid to improve health outcomes and healthy lifestyles.
How MCOs Support State Medicaid Programs
Focus on State Priorities
States select MCOs for their Medicaid programs using criteria determined by the state. In addition, plans also help develop and implement each state’s quality strategies, which sets measurable targets for quality improvement and network adequacy.
Quality and Accountability
MCOs must meet strict quality and accountability standards set by states and accreditation organizations, including annual reviews by independent external quality review organizations.
Cost Containment and Budget Predictability
Unlike payments under a fee-for-service approach that are based on utilization of services, states pay MCOs based on a specific amount per member per month, providing greater predictability for state budgets. By contracting with MCOs, states are also able to use financial incentives for state priorities, set accountability standards, and limit financial risk, which contribute to the long-term sustainability of their Medicaid programs.
The Enrollee Perspective: Jennifer’s Story
Jennifer Kucera was born with a form of Muscular Dystrophy called Spinal Muscular Atrophy. Through integrated care provided by her Medicaid managed care plan, Jennifer has a team to support her health needs, including a designated case manager and a streamlined process for requesting transportation to appointments. See how Medicaid managed care has made daily independence possible for Jennifer.