Emerging Practices in Medicaid Primary Care Case Management Programs. Characteristics


In typical PCCM programs, the PCP is paid a monthly case management fee for each enrolled Medicaid beneficiary, in addition to fee-for-service reimbursement for all non-emergency primary care services that he/she provides. In return, the PCP is responsible for providing primary care and for prior authorizations to hospitals and specialty care providers.6 Hospitals and specialists are also paid fee-for-service, as long as prior authorization has been obtained.

In many ways, early PCCM programs were more like traditional fee-for-service Medicaid than their managed care counterpart, risk-based programs. For example, a 1995 NASHP study of PCCM programs found that provider requirements were usually very minimal, PCP selection was non-competitive, and most states maintained existing fee-for-service payment rules (such as prior authorization and hospital pre-admission review) but added the requirement that a specified set of services must either be provided or authorized by the PCP.7

View full report


"report.pdf" (pdf, 314.91Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®