TMA strongly advocates continuation of the PCCM to ensure maximum patient and provider choice within the Medicaid managed care program. Through this model, the state introduces patients and physicians to managed care concepts, such as enhanced utilization review, but patients' retain a broad choice of physicians and facilities. In exchange for coordinating and managing patients' care, PCPs receive a monthly per patient case management in addition to the traditional Medicaid fee schedule. Specialists also are reimbursed at the Medicaid rate. The PCCM utilizes basic utilization management protocols to discourage inappropriate use of hospital emergency rooms, inpatient hospitalizations, and specialty services.
Patients retain the right to choose where they receive specialty services.
Of the three models, the HMO is the most restrictive. A Pre-paid Health Plan combines elements of both models. In the PHP, a medical group or provider network is capitated for physician, lab, and x-ray services. Individual physicians, however, may or may not be capitated. Hospitals are contracted separately.