Kaiser Family Foundation Survey on State Medicaid Managed Care ...

States with PCCM programsKey Section Findings:A total of 31 states operate PCCM programs. In most PCCM programs, states pay PCPs a smallfee such as $3.00 per person per month for case management in addition to regular fee-forservicepayments. A limited number of states incorporate a pay-for-performance feature intheir PCCM program reimbursement.Many states have PCCM administrative services contracts for services ranging from casemanagement and disease management to outreach and education, enrollment broker services,and claims administration.Nine states operate Enhanced PCCM (EPCCM) programs that incorporate strengthened qualityassurance, case management, and care coordination.PCCM is a Medicaid managed care alternative to MCOs in which the state itself administers acomprehensive health plan, establishing and contracting directly with its network of PCPs andperforming many of the administrative and management functions that MCOs perform under contractto states. States operate PCCM programs for different reasons. A state may prefer to operate and havemore direct control over its managed care arrangements, and have the administrative capacity to do so.A state may operate a PCCM managed care model in rural or other areas where the population isinsufficient to attract MCOs, or as an alternative managed care model to provide a choice of plans. Or astate may adopt a PCCM because it may be more acceptable to some provider communities thantraditional risk-based managed care.Dimensions of PCCM programsNearly as many states have PCCM programs as have contracts with MCOs. Thirty-one states operatePCCM programs, compared with 36 that have MCO contracts. PCCM programs exist alongside MCOs in19 states and are the sole managed care arrangement in 12 states. In PCCM programs, states contractwith PCPs to provide, manage, and monitor the primary care of Medicaid beneficiaries who select themor, in some cases, are assigned to them. In addition to serving as a medical home for primary andpreventive care, PCPs in most cases are also contractually responsible for authorizing referrals whenspecialty care is needed. PCPs typically receive a small monthly fee for this case management function,but they are generally not at financial risk and are paid fee-for-service for the care they provide.Most states recognize certain providers in addition to primary care physicians as PCPs in their PCCMprograms. The PCP is the backbone of a PCCM program. Having a sufficient number of participatingPCPs is necessary to ensure both access to primary care and coordination of needed specialty care. Toincrease the availability of PCPs, many state Medicaid programs permit providers other than primarycare physicians to participate as PCPs, such as ObGyns, nurse practitioners, and safety-net healthcenters. Table 8 shows the number of states recognizing specified types of providers as PCPs in PCCMprograms.Appendix 9 provides additional state-by-state detail on providers recognized PCPs.Contracts with PCPs include extra requirements beyond those in regular Medicaid provideragreements, to ensure access to primary care for Medicaid beneficiaries. A large majority of the stateswith PCCM programs (27) reported that 24/7 coverage is a PCP requirement. About half (15 states)28 00