Managed Care OrganizationsA managed care organization (MCO) is an entity that specializes in provider network development, credentialing and contracting. On an ongoing basis, MCOs manage the provider network, claims pre-processing and utilization.

Before we get to the MCO lists, we’ll cover some relevant background information.

State Medicaid Programs and MCOs

Medicaid programs are an area in which U.S. states exercise their autonomy in diverse ways.

Many state governments contract their Medicaid programs to a group of private MCOs. This is partly because healthcare organizations have to adhere to special requirements around hiring practices, budgeting and general decision-making. Database systems, including those for eligibility and for CRM, must be implemented or upgraded. The administrative and technical requirements can be onerous for a public agency to manage.

Outsourcing Medicaid programs can spur competition. Private healthcare organizations that compete with one another have a incentive to be more efficient than the others. Those that offer lower prices and higher quality services are more likely to get a contract or get their contract renewed.

On the other hand, Connecticut found that outsourcing Medicaid programs can require considerable oversight. In 2012, the state moved from outsourcing to an administrative services organization (ASO) model. In this model, a state agency manages Medicare programs. Vermont and Maine, as less populous states, are able to more easily assume an active role in healthcare management and they do so.

Federal Medicaid Guidelines

Each state establishes and administers its own Medicaid programs. A state determines the type, amount, duration, and scope of services within a broad set of federal guidelines. Federal law requires states to provide certain mandatory benefits. Each state has the choice of whether to cover a group of optional benefits.

Mandatory benefits include:

  • Inpatient and outpatient hospital services
  • Physician services
  • Laboratory and x-ray services
  • Home health services

Optional benefits include:

  • Prescription drugs
  • Case management
  • Physical therapy
  • Occupational therapy

Here is a list of all mandatory and optional benefits for Medicaid programs.

How MCOs Work

Managed care plans pay healthcare providers directly. Those enrolled in a program do not have to pay out-of-pocket for covered services, nor do they have to submit claim forms.

Managed care plans can require that co-payments are paid directly to the provider at the time of service.

Some MCOs are Medicaid-only, whereas others, such as Tufts Health Plan and Health Insurance Plan of Greater New York, also sell commercial health insurance. Other MCOs have child health and behavioral health programs.

Below are managed care organization lists for the New England states and for New York.

Massachusetts MCO List

MassHealth has contracts with Boston Medical Center Health Plan (BMCHP) and Tufts Health Public Plans (Tufts) to manage primary, behavioral, pharmacy and specialty care for approximately 150,000 to 200,000 members in the MassHealth Managed Care Organization (MCO) program.

The MCO contracts were effective on March 2018 and go through through December 2022. The combined value is approximately $1 billion a year.

Tufts Health Plan
Boston Medical Center HealthNet Plan

Other Massachusetts MCOs include:

CeltiCare Health Plan of Massachusetts
Fallon Community Health Plan
Health New England
Neighborhood Health Plan

Rhode Island MCO List

The Rhode Island Executive Office of Health and Human Services awarded a five year contract to three MCOs in 2017.

Neighborhood Health Plan of Rhode Island
Tufts Health Public Plans
UnitedHealthcare Community Plan

New Hampshire MCO List

According to the New Hampshire Department of Health and Human Services, “most NH Medicaid Program recipients receive health care services through the Medicaid Care Management (MCM) program.”

New Hampshire’s MCM program uses the following two Health Plans to manage health care for recipients. Some care is managed directly through NH Medicaid.

NH Healthy Families Health Plan
Well Sense Health Plan

As in Massachusetts and Rhode Island, Tufts Health Plan is licensed in the state.

Connecticut Managed Care Organization List

In 2012, the Connecticut state government made the decision to move from outsourcing managed care to an ASO model.

The 2018 Managed Care Report (PDF) from Connecticut Insurance Commissioner Katharine Wade lists the following licensed (non Medicaid) MCOs:

Aetna Health, Inc.
Aetna Life Insurance Company
Anthem Blue Cross & Blue Shield of CT, Inc.
CIGNA Health & Life Insurance Company
CIGNA Healthcare of Connecticut, Inc.
ConnectiCare, Inc.
ConnectiCare Insurance Company, Inc.
ConnectiCare Benefits, Inc.
Connecticut General Life Insurance Company
Golden Rule Insurance Company
Harvard Pilgrim Healthcare of CT
HPHC Insurance Company
Oxford Health Insurance, Inc.
Oxford Health Plans (CT), Inc.
United HealthCare Insurance Company

Vermont Managed Care

The Vermont Department of Vermont Health Access (DVHA) operates a public Medicaid managed care model. As such, Vermont has direct relationships with providers. In 2017, the state implemented its All-Payer Accountable Care Organization (ACO) Model. In the case of Vermont, we found an MCO list of one, Green Mountain Care.

Maine Managed Care

As does Vermont, Maine contracts directly with primary care providers and Community Care Teams (CCTs) to manage care for Medicaid enrollees. Primary care providers are paid a monthly per-member case management fee in addition to the regular Medicaid fee-for service reimbursement.

Patient-Centered Medical Homes (PCMHs), health homes, and CCTs receive per member per month case management fees from Medicaid and other payers that participating in multi-payer collaborative efforts.

New York MCO List

The table below was consolidated from a by-county MCO list on the New York State website. Each row indicates whether each MCO offers one or more of the following programs:

CHP Child Health Plus
COMM Commercial (Individuals and corporations)
HARP Health and Recovery Plans (Behavioral Health)
MCAID Medicaid

By virtue of population, New York State has more MCOs listed than any of the New England states.

Affinity Health Plan, Inc. Y N Y Y
Amida Care, Inc. N N N Y
Capital District Physicians’ Health Plan, Inc. (CDPHP) Y Y Y Y
Crystal Run Health Plan, LLC N Y N Y
Empire HealthChoice HMO, Inc. N Y N N
Excellus Health Plan, Inc. Y Y Y Y
Health Insurance Plan of Greater New York, Inc. Y Y Y Y
Healthfirst Health Plan, Inc. N Y N N
Healthfirst PHSP, Inc. Y N Y Y
HealthNow of New York, Inc. Y Y N Y
HealthPlus HP, LLC Y Y Y Y
Independent Health Association, Inc. Y Y Y Y
MetroPlus Health Plan, Inc. Y N Y Y
Molina Healthcare of New York, Inc. Y N Y Y
MVP Health Plan, Inc. Y Y Y Y
New York State Catholic Health Plan, Inc. Y N Y Y
UnitedHealthcare of New York, Inc. Y N Y Y
VNS (d/b/a VNSNY Choice) and Subsidiary N N N Y
WellCare of New York, Inc. Y N N Y
YourCare Health Plan, Inc. Y N Y Y

As can be seen, there is considerable variation in Medicaid programs and MCO lists from state to state. The list of MCOs will continue to evolve with consolidation in the private marketplace and with changes in state policy.

About the Author

John RousevilleJohn Rounseville is Co-Founder and VP of Business Development at Saxa Solutions in Boston, MA. Saxa specializes in consulting services for Salesforce Health Cloud customers. To learn more about Health Cloud, contact John.

John Rounseveille LinkedIn