Family caregivers bear the brunt of healthcare management for aging family members. And many times, caregiving becomes overwhelming. Managed care organizations (MCOs) are critical to healthcare delivery in the United States. MCOs coordinate patient care and control costs through contracts with selected healthcare providers and facilities. Understanding how MCOs function accesses needed services for family caregivers managing the care of loved ones and alleviates the burden.
A managed care organization (MCO) is a type of health care company or plan that uses managed care to control costs and maintain quality care. Managed care is a system that involves coordinating and overseeing the health care services that a patient receives, such as choosing providers, setting fees, requiring prior authorization, and encouraging preventive care. There are different kinds of MCOs, such as Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Point of Service (POS) plans, and Exclusive Provider Organizations (EPOs).
MCO is not the same as Medicaid. MCO contracts with Medicaid to provide health care services to Medicaid beneficiaries. Medicaid is a joint federal and state program that helps pay for health care for low-income people, people with disabilities, children, pregnant women, and some seniors. Depending on their state's policies, Medicaid beneficiaries can enroll in an MCO or receive benefits through the traditional fee-for-service system. MCOs are designed to offer better access, quality, care coordination for Medicaid beneficiaries, and more predictable and controlled costs for states and the federal government.
Some Medicaid waivers allow states to implement a managed care delivery system using different types of authorities, such as state plan amendments, 1915 (a) contracts, 1915 (b) waivers, or 1115 demonstrations. These authorities allow states to design their managed care programs according to their specific needs and goals, such as improving access, coordination, and outcomes for Medicaid enrollees. Some examples of how states use Medicaid waivers to implement MCOs are:
Medicaid-managed care is a healthcare program that helps family caregivers care for their loved ones who need long-term services and support. Medicaid MCOs work with state Medicaid agencies to provide better care and benefits to those using the program.
This model makes getting good quality care and benefits easier than traditional Medicaid. For caregivers caring for relatives with complex needs, Medicaid MCOs make it simpler to navigate the system.
MCOs assign each enrollee a care coordinator who oversees the care plan, arranges needed services, and supports transitions between care settings. For caregivers, having a dedicated care coordinator to call is invaluable.
The care coordinator can explain covered benefits, connect the enrollee to network providers, assist with scheduling appointments, arrange transportation, and obtain equipment. This centralized coordination simplifies the complicated Medicaid bureaucracy.
Medicaid MCOs offer supplemental benefits beyond traditional Medicaid to fill care gaps. These may include respite care to give family caregivers a break, nutritional supplements, palliative care, transport assistance, and support groups.
MCOs also have the flexibility to provide non-medical support to enhance quality of life, such as installing grab bars, ramps, or stair lifts in the home. Caregivers work with the care coordinator to access these extra services tailored to their loved one's needs.
MCOs emphasize regular provider visits to monitor health, preventive screening, immunizations, and evidence-based care for chronic illnesses like diabetes or dementia. This proactive care helps avoid crises leading to poor outcomes and higher costs.
Care coordinators ensure the enrollee gets recommended preventive care and help the caregiver understand the enrollee's condition, warning signs to watch for, and how to avoid complications or exacerbations.
Healthcare providers need to know the rules well to work successfully with managed care. Managed care groups have specific ways of operating costs and resources by controlling how much care patients get. Providers need to follow these rules to avoid penalties or losing money.
One way is for family caregivers to talk with managed care staff like doctors and coordinators. This communication helps providers get the correct permissions for treatment and check the plans to follow the rules. Sometimes, everyone must meet to discuss what's best for a patient.
Giving patients the necessary care is challenging when managed care limits what's covered. Providers have to be creative and flexible to find ways to help their patients. Your loved one might need to try new, less expensive treatments that still work well. Providers might also have to explain why they need more money or care for a patient.
Healthcare providers need to follow specific rules when working with managed care to avoid getting in trouble and not getting paid. They need to work closely with the managed care staff to confirm they get permission to provide the proper care and get paid for it. It's essential to use resources wisely and provide affordable quality care.
Overall, managed care has transformed US healthcare, bringing oversight and valuable care coordination. MCOs will likely continue growing in Medicaid and private insurance.
When you care for a family member, it's helpful to understand how different organizations work and how they affect the care patients receive. By working closely with the staff of these organizations, you make sure that you use their policies and resources wisely to get the health services you need. Provide better care for your loved one.
