M
Reimbursement

MCO (Managed Care Organization): Managed Care Organization

Definition
A health insurance company (e.g., UnitedHealthcare, Aetna, Centene) that receives a fixed monthly payment (Capitation) from the State Medicaid agency to provide all health services, including NEMT, for its members.

Overview

Why it Matters

In most states, you don't bill the State; you bill the MCO (or the Broker the MCO hired). MCOs have different rates, rules, and prior authorization requirements.

How it Works

The State pays the MCO. The MCO hires a Broker (like Modivcare) to manage transport. The Broker hires the Provider.

Code Comparison

Comparison: MCO vs. FFS (Fee For Service)

FFS: The State pays the provider directly for every trip.

MCO: The State pays the Insurance Company, who manages the budget.

Common Questions

  • Network Status: Being credentialed with Medicaid does not mean you are credentialed with every MCO. You must contract with each one (or their broker) individually.
  • ID Cards: Confusion when a member has a "State Medicaid Card" but is actually enrolled in an MCO. You must bill the MCO, not the State.
  • Always ask "Which Plan are you with?" during intake, not just "Do you have Medicaid?"
  • Maintain a "Payer Matrix" showing which MCOs utilize which Brokers in your service area.

Sources

Medicaid.gov - Managed Care