Is Blue Plus Medicaid or a Managed Care Plan?

Individuals seeking healthcare coverage through government programs often encounter health plans like Blue Plus, leading to questions about their direct relationship with Medicaid. This article clarifies the distinction between Blue Plus and Medicaid, explaining how Blue Plus operates within the broader framework of Medicaid managed care.

Medicaid Managed Care Explained

Medicaid managed care is a system where state Medicaid agencies partner with private health insurance companies, known as Managed Care Organizations (MCOs), to deliver healthcare services to eligible beneficiaries. MCOs accept a predetermined per-member, per-month payment for these services, often referred to as capitation. The primary objective of this system is to enhance care coordination, control costs, and improve access to services for individuals enrolled in Medicaid. This approach differs from traditional fee-for-service Medicaid, where the state directly pays healthcare providers for each service rendered.

Under a managed care model, beneficiaries receive their healthcare through a network of providers established and managed by the MCO. MCOs are private entities that administer Medicaid benefits on behalf of the state government. While MCOs manage the delivery of care, the underlying eligibility requirements and scope of benefits are still determined by the state’s Medicaid program. This system has become the most common healthcare delivery method within Medicaid across many states.

Blue Plus’s Role in Medicaid

Blue Plus is a private health insurance company that operates as a Managed Care Organization (MCO) in various states. When an individual has “Blue Plus Medicaid,” it means they are a Medicaid beneficiary whose healthcare benefits are administered through a Blue Plus managed care plan. This arrangement is based on a contract between Blue Plus and the respective state’s Medicaid program, allowing Blue Plus to provide services to Medicaid members.

Beneficiaries enrolled in a Blue Plus Medicaid plan access doctors, hospitals, and other healthcare services through the plan’s specific provider network. They also adhere to Blue Plus’s administrative procedures for accessing care. While Blue Plus manages the service delivery, the fundamental eligibility criteria and the comprehensive range of covered benefits remain governed by the state’s Medicaid program. The specific offerings, covered services, and the availability of Blue Plus Medicaid plans can vary significantly from one state to another, reflecting diverse state-level agreements and regulations.

Enrolling in a Medicaid Managed Care Plan

Eligibility for Medicaid is determined at the state level, based on factors such as income, family size, and other specific criteria. Once an individual’s Medicaid eligibility is established, they typically proceed to the enrollment process for a managed care plan. Many states offer beneficiaries the opportunity to choose from a selection of MCOs, which may include Blue Plus, that operate within their designated service area. Information about available plan options is usually communicated through state health departments, online portals, or mail.

Should a beneficiary not select a plan within a specified timeframe, they may be automatically assigned to an MCO. States generally allow new enrollees a period to change to a different plan after their initial enrollment. Additionally, beneficiaries typically have an annual open enrollment period to switch plans, or they may be able to change plans outside of these periods for specific “for cause” reasons as permitted by state rules. State Medicaid agencies often provide independent enrollment counselors or hotlines to assist beneficiaries in understanding their options and completing the enrollment process.