A Managed Care Organization (MCO) is a health insurance company that contracts with a state government to provide comprehensive medical services to enrolled members for a fixed, per-person payment. This model manages healthcare costs while ensuring access to covered benefits. For Maryland residents seeking coverage through public health programs, choosing the “best” MCO requires assessing objective quality data, performance metrics, and provider networks to find the optimal fit for individual medical needs.
The Role of Managed Care Organizations in Maryland HealthChoice
Maryland’s Medicaid program, HealthChoice, operates almost entirely through the MCO structure. This system mandates that nearly all eligible recipients must enroll in a contracted MCO to receive medical care. This framework shifts the responsibility for coordinating and managing the delivery of all covered services from the state to the private health plan.
The MCO ensures the member receives all necessary medical care, including primary care, specialty visits, hospital stays, and prescription drugs. The organization acts as the central hub for the member’s healthcare journey, managing utilization and promoting preventative services. MCOs contract directly with doctors, hospitals, and other providers to form a network from which members must seek care.
State oversight, guided by regulations, establishes the parameters for MCO operation, network requirements, and the scope of covered services. The MCO must adhere to strict state standards to maintain its contract and continue serving the HealthChoice population. This structure aims to improve health outcomes by managing care efficiently and focusing on wellness.
Current MCO Options Available to Maryland Residents
The Maryland Department of Health contracts with a specific group of MCOs to deliver HealthChoice services across the state. Currently, there are nine MCOs actively participating in the program, though availability may vary by county.
The contracted MCOs are:
- Aetna Better Health of Maryland
- CareFirst BlueCross BlueShield Community Health Plan of Maryland
- Jai Medical Systems
- Kaiser Permanente
- Maryland Physicians Care
- MedStar Family Choice
- Priority Partners MCO (Note: This plan is not currently accepting new enrollment)
- UnitedHealthcare Community Plan
- Wellpoint Maryland, Inc.
Prospective members must first verify that an MCO operates in their specific geographic region. The primary step in selection involves checking that the MCO’s provider directory includes any current or desired primary care physicians, specialists, or hospitals. This initial check ensures continuity of care before delving into comparative quality data.
Key Metrics for Evaluating MCO Performance
Determining the “best” MCO involves an objective review of performance data, which the state compiles and publishes in the HealthChoice Report Card. These ratings provide a standardized comparison across all contracted organizations, focusing on quality of care, patient experience, and access to services. This data allows members to make a choice based on documented results.
A primary quality metric is the Healthcare Effectiveness Data and Information Set (HEDIS), which quantifies an MCO’s success in providing preventative care and managing chronic conditions. HEDIS measures include the percentage of members who receive timely immunizations, appropriate cancer screenings, or necessary follow-up care after hospitalization. High HEDIS scores indicate a plan that effectively facilitates compliance with established clinical guidelines.
Another core component is the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, which captures the member’s direct experience with the plan. CAHPS scores reflect patient satisfaction with communication, ease of getting appointments, and the quality of interactions with doctors and staff. High CAHPS scores suggest a positive member experience and responsive administrative support.
Network adequacy is also monitored by the state to ensure MCO members have reasonable access to all necessary providers, including specialists and behavioral health providers. This metric considers the number of providers in the network, their geographic distribution, and appointment wait times. While not always a score on a report card, a plan’s commitment to a broad and accessible network is a practical measure of its ability to deliver comprehensive care.
Navigating Enrollment and Switching Plans
The process of enrolling in or changing an MCO is managed by the HealthChoice Enrollment Broker, which operates under the Maryland Department of Health. New members select an MCO after their Medicaid eligibility is determined through the Maryland Health Connection. Enrollment can be completed online, via a mobile application, or by calling the HealthChoice Enrollment Line.
New HealthChoice members have an initial 90-day window from the start of coverage to switch to a different MCO for any reason. This period allows beneficiaries to test a plan’s network and services. If a choice is not made within the initial 90 days, or if the member is automatically assigned, they must generally remain with that MCO for a full 12 months.
After the initial 90-day period, members can change their MCO once per year during the annual open enrollment period. Switching outside of this window is permitted only under specific “just cause” exceptions approved by the state. These exceptions often include scenarios such as moving to a new county where the current MCO does not operate, or needing to consolidate all family members into a single plan.
The HealthChoice Enrollment Broker is the primary point of contact for assistance with both initial selection and any subsequent changes. They can provide an MCO comparison chart and procedural guidance to ensure the member’s choice is properly registered with the state.