What are Medicare Coordinated Care Plans?

Coordinated Care Plans are Medicare Advantage plans or Medicare Health plans that offer health care through an established provider network and are approved by the Centers for Medicare and Medicaid Services (CMS).

Medicare Advantage plans that are classified as Coordinated Care Plans include:

• HMOs or Health Maintenance Organizations
• HMO-POS or HMOs with a Point of Service option
• PPOs or Preferred Provider Organizations (this includes both local PPOs and regional PPOs
• SNPs or Medicare Advantage Special Needs Plans

As background:
The Medicare manuals (Medicare Managed Care Manual Chapter 1 - General Provisions (Rev. 125, 02-10-17)) notes that Medicare Advantage plans can be organized into three basic types:

(1) Coordinated-Care plans (CCPs),
(2) Medicare Savings Accounts (MSAs), and
(3) Private fee-for-service plans (PFFS).

The Medicare manual also continues on to state:

"Two other types of MA plans characterized by special enrollment are the [Religious Fraternal Society (RFB)] societies which are affiliated with a church and may only enroll RFB members... and Part B-only plans which restrict enrollment to beneficiaries who only have Part B of original Medicare...."

The Medicare manuals continues on to note that, Coordinated Care Plans are

"defined at 42 CFR 422.4(a)(1), a CCP is a plan that includes a network of providers that are under contract or arrangement with the [Medicare Advantage plan] organization to deliver the benefit package approved by CMS. A CCP must at least
(i) furnish all Part A and Part B services (except for hospice) (42 CFR 422.101(a));
(ii) conduct quality improvement activities (42 CFR 422.152(a)–(b));
(iii) provide sufficient access, as defined by CMS, to services including continuity of care (42 CFR 422.112(a)–(b)); and
(iv) disclose required information about benefits and costs to enrollees (42 CFR 422.111(b)(2)).

CCPs may use mechanisms to control enrollee utilization of services. Mechanisms may include requiring referrals from a gatekeeper (usually the enrollee’s primary care provider (PCP)) or prior authorization for an enrollee to receive certain covered services (42 CFR 422.4(a)(1)(ii))."

(sources include: Medicare Managed Care Manual Chapter 1 - General Provisions (Rev. 125, 02-10-17), https://www.cms.gov/ Regulations-and-Guidance/ Guidance/Manuals/ downloads/mc86c01.pdf)