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Medicaid Managed Care Organizations' Denials

The State Medicaid agency and the Federal Government are responsible for the financial risk for the costs of Medicaid services. State Medicaid agencies contract with managed care organizations (MCOs) to ensure that beneficiaries receive covered Medicaid services. The contractual arrangement shifts the financial risk from the State Medicaid agency and the Federal Government to MCOs, which can create an incentive for MCOs to deny beneficiaries' access to covered services. Our audits will determine whether Medicaid MCOs complied with Federal requirements when denying access to requested medical and dental services, behavioral health services, and associated drug prescriptions that required prior authorization.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
Completed (partial) Centers for Medicare and Medicaid Services Medicaid Managed Care Organizations' Denials Office of Audit Services W-00-19-31535;
W-00-20-31535;
A-03-20-00201;
W-00-21-31535;
W-00-22-31535;
W-00-24-31535;
A-02-21-01016;
A-07-22-07007		 2025