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Prior Authorization Denials in Medicaid Managed Care

Managed care organizations (MCOs) contract with State Medicaid agencies to provide Medicaid coverage for enrollees. Each MCO must cover services for at least the same amount, duration, and scope that would be covered under Medicaid fee-for-service. However, capitated payment models in managed care may create an incentive for MCOs to inappropriately limit or deny access to covered services in order to increase profits. We will review the extent to which selected MCOs denied requests for the prior authorization of services, and the extent to which those denials were upheld or overturned on appeal. We will also examine selected aspects of State oversight of MCOs' denial and appeals processes, and the extent to which States offered external medical reviews as an appeal option for enrollees.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
Completed Centers for Medicare and Medicaid Services Prior Authorization Denials in Medicaid Managed Care Office of Evaluation and Inspections OEI-09-19-00350 2023