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Overturned Denials in Medicaid Managed Care

Managed care organizations (MCOs) contract with State Medicaid agencies to provide beneficiaries with Medicaid services. MCOs must cover services in 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 to increase profits. We will review the extent to which selected MCOs' denied services and payments were overturned upon appeal. We will also review any concerns about the selected MCOs' performance related to denials and appeals that were identified through State oversight and monitoring efforts.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
June 2019 Centers for Medicare & Medicaid Services Overturned Denials in Medicaid Managed Care Office of Evaluation and Inspections OEI-09-19-00350 2021