KFF July 27, 2023
Medicaid managed care organizations (MCOs) deliver care to more than two-thirds of all Medicaid enrollees nationally. Managed care plans often require patients to obtain approval of certain health care services or medications before the care is provided—an insurance practice commonly referred to as “prior authorization” (or PA). This allows the health plan to evaluate whether care is covered and medically necessary. If the health plan determines the requested service (or medication) isn’t appropriate or medically necessary, they may deny the request (fully or partially). While Medicaid MCOs may limit services based on medical necessity or utilization management tools (e.g., prior authorization), federal rules specify services must be no less (in amount, duration, and scope) than offered under fee-for-service and MCOs...
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