Managed Care Entities

Federal Managed Care regulations at 42 CFR 438 recognize four types of managed care entities:

• Managed Care Organizations (MCOs)

  • Comprehensive benefit package
  • Payment is risk-based/capitation

• 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    

• 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

• 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