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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