The Bureau of Managed Care Operations (BMCO) administers and provides oversight of the mandatory Physical HealthChoices managed care programs, the Medical Assistance Transportation Program (MATP), and the Enrollment Assistance Contractor that provides information for consumers to choose their Physical HealthChoices managed care organization (MCO).
BMCO is responsible for oversight of the Physical HealthChoices MCO agreements and monitors compliance with agreement requirements, reviews and approves subcontracts, identifies areas of noncompliance, approves and implements MCO corrective action plans, and recommends sanctions or other penalties. Oversight includes monitoring of quality and utilization metrics to ensure that consumers have access to quality health care. BMCO provides oversight of the MATP administrators to ensure counties and subcontractors follow standards and guidelines for the program. This includes review, analysis, and evaluation of state and federal initiatives to ensure program compliance. Training and technical support is provided to the county MATP administrators, as necessary. BMCO also provides oversight of the MCO plan’s care management programs, quality and utilization management, performance data, value-based payment arrangements, enhanced medical supports, case management, and the complaints, grievance and fair hearing processes.
Physical Health Managed Care Organizations
Pennsylvania's physical health managed care organizations (MCOs) are health plans that utilize a managed care system to offer high quality health services while limiting costs for participants.
Divisions
This division monitors the Physical HealthChoices managed care program to ensure compliance with MCO agreement requirements and federal and state Medicaid regulations to ensure access to and quality of care for consumers. In addition, this division oversees and monitors the Enrollment Assistance Program contract that provides Medicaid beneficiaries choice counseling in the selection of Physical HealthChoices MCOs.
This division manages inquiries related to the Physical HealthChoices program, MATP, and Right-to-Know Law requests. The Division also manages annual updates to the Physical HealthChoices Agreements, assists with the development of bureau-wide procurement processes, provides updates to the DHS websites, and produces reports that support the Physical HealthChoices program. Additional responsibilities include oversight of the MATP in all 67 counties to ensure program compliance amongst MATP Administrators and the provision of transportation services to Medicaid recipients that are the least costly and most appropriate.
This division collects, analyzes and reports MCOs’ performance data including quality measures which is used to drive improvement and quality of care. Other responsibilities include overseeing the MCO’s clinical operations, quality, utilization, special needs functions, complaint, grievance and fair hearing process, and MCO value-based purchasing programs. Additionally, this division oversees the MCOs’ community-based care management and maternal home visiting programs.