Federal Managed Care regulations at 42 CFR 438 recognize four types of managed care entities:
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Managed Care Organizations (MCOs)
- Comprehensive benefit package
- Payment is risk-based/capitation
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Primary Care Case Management (PCCM)
- Primary care case managers contract with the state to furnish case management (location, coordination, and monitoring) services
- Generally, paid fee-for-service for medical services rendered plus a monthly case management fee
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Prepaid Inpatient Health Plan (PIHP)
- Limited benefit package that includes inpatient hospital or institutional services (example: mental health)
- Payment may be risk or non-risk
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Prepaid Ambulatory Health Plan (PAHP)
- Limited benefit package that does not include inpatient hospital or institutional services (examples: dental and transportation)
- Payment may be risk or non-risk