Emerging Practices in Medicaid Primary Care Case Management Programs. Chapter 3: Organizational Structure and Administration


Several of the case-study states have made significant changes in the administration of their PCCM programs, creating organizational arrangements that more closely resemble contracted managed care networks. Whether state-administered or through contract agreements, these states have identified distinct functions for administration, such as enrollment, member services, provider network development, quality improvement, and medical management. In many instances, states are choosing to contract out for these program functions instead of administering them internally. The result is that PCCM programs have gained a new level of sophistication and importance as managed care delivery systems in state Medicaid programs. Chart H shows the range of delivery systems used in the case-study states.

State Program Model
Chart H:
Service Delivery Model
Alabama Patient 1st Mandatory
Florida MediPass 1/3 of Medicaid beneficiaries in PCCM, 1/3 in MCOs, 1/3 institutional/other; PCCM members in 6 counties also enrolled in BHO
Iowa MediPASS PCCM in 92 (of state's 99) counties; choice of MCO or PCCM in 43 counties; behavioral health organization (BHO)
Maine Maine PrimeCare PCCM is the only managed care delivery system (as of December 2000) — will be statewide by 2001
MaineNET/ Partnership MaineNET: PCCM; Partnership: PCCM with external care coordination entity
North Carolina ACCESS I

1 county - mandatory MCO; 5 counties - choose between MCO/PCCM (default to PCCM); rest of 99 counties - PCCM only

ACCESS II and III build upon ACCESS I, have all ACCESS I features

Oklahoma SoonerCare Choice PCCM Model PCCM in rural areas; MCO in urban areas
Texas Texas Health Network In STAR, can choose between MCO or PCCM (Texas Health Network); one area has BHO; one area has partially capitated PHP being phased out
STAR+PLUS Choose between MCO/PCCM
Virginia MEDALLION PCCM and MCO in different areas (PCCM in more rural areas)

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