Managed care is the arrangement in which a payer hands your benefits to a private plan, usually for a fixed amount per member per month, and the plan then manages what gets delivered. It is the default shape of health coverage in the United States, and it explains the two features people complain about most.
The network exists because the plan negotiates rates with a set of providers rather than paying whoever you choose.
Prior authorization exists because the plan carries the financial risk and reviews what it will pay for before it happens.
Neither is a hostile invention. Both follow from the payment structure, and knowing that makes them easier to argue with, because the argument is about whether a rule was applied correctly rather than about whether it should exist.
In New York: most people on Medicaid are in a managed care plan, and the practical consequences are specific.
Your plan is not the state. Questions about a service, an authorization or a network go to the plan. Questions about eligibility, renewals and spend-down go to the local district or NY State of Health. Sending a question to the wrong one costs days. Where to apply, and why it matters.
Pharmacy is the exception. Since April 1, 2023 the Medicaid pharmacy benefit runs through NYRx, the statewide fee-for-service program, not through your managed care plan. One drug list statewide. This does not apply to managed long-term care, the Essential Plan or Child Health Plus.
Denials have their own ladder. A managed care denial normally goes to the plan’s internal appeal first, then a fair hearing with the state. The deadline that matters most is not the 60 days to request the hearing; it is the roughly 10 days to keep an existing service running, which requires asking for aid continuing in those words.
Two specialised plan types sit inside the same framework: a HARP for adults with serious behavioral health needs, and a managed long-term care plan that authorises and pays for home care.
Also called: MCO, managed care organization, health plan. Full guide: Medicaid in New York.
More in Glossary of health coverage and billing terms
- Prior authorization — Prior authorization is a plan's approval before it pays for care. Who asks for it, what a denial says, where the deadlines are, and New York's appeal route.
- Explanation of benefits (EOB) — An explanation of benefits (EOB) is your plan's record of a claim, not a bill. How to read each line, which one a bill must match, and what a denial means.
- Chargemaster — A hospital's internal list price for every service. Almost nobody pays it — except the uninsured who don't ask.
This page explains how the system works. It is not medical advice. More.