CMS to Allow Managed Care Organizations to Participate in Direct Contracting

The professional direct contracting option offers primary care capitation, which is a risk-adjusted monthly payment for enhanced primary care services. The global option gives two payment options: primary care capitation or total care capitation that offers payments for all services made by a provider.

Any MCO that participates in direct contracting needs to get a letter of support from their state Medicaid agency to ensure participation aligns with any state-managed plans.

They also have to have an active contract with the state.

An applicable MCO must also cover any long-term support and services such as being at risk for nursing home costs “and/or behavioral health services for people with serious mental illness/substance use disorder—unless the state managed care program excludes such individuals,” according to a fact sheet on the initiative.