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Serving State Medicaid Programs

What is Medicaid?

Title XIX of the Social Security Act provides a legal base for Medicaid, a medical assistance program for individuals and families with low incomes and resources. Title XIX became law in 1965 as a jointly funded cooperative venture between federal and state governments to assist in the provision of adequate medical care to eligible needy persons. States may choose to administer the Medicaid program directly or enter into contractual agreements with outside entities to administer the program.

What services does HCE provide on Medicaid contracts?

HCE currently manages five Medicaid contracts, providing various services under each state’s Medicaid program. 

• Arizona Medicaid Contract, External Quality Review Organization (EQRO)
  As an EQRO for the Arizona Health Care Cost Containment System Administration, HCE QualityQuest, a subsidiary of HCE, is responsible for providing analysis and evaluation of the following activities.  
   
  • Performance improvement projects
  • Managed Care Organization (MCO) and Prepaid Inpatient (PIHP) performance measures
  • MCO and PIHP’s compliance with Standards (e.g., operational and financial reviews)
     
• Indiana Medicaid Surveillance and Utilization Review and Pharmacy Audits (IMSA)
  HCE manages Surveillance and Utilization Review and pharmacy audits functions for the Indiana Office of Medicaid Policy and Planning. Cost containment activities promote consistency and improvement, identify abuse, and support the overall integrity of Indiana Medicaid.
   
• Iowa Medicaid Enterprise Contract, Surveillance and Utilization Review
  HCE manages the Surveillance and Utilization Review function—one of 10 functions total—of the Iowa Department of Human Services’ Iowa Medicaid Enterprise. HCE is responsible for making sure that Medicaid providers are properly billing the Iowa Medicaid Program and for recouping funds paid in error to providers.
   
• MO HealthNet Contract, Utilization Review Services
  As a Utilization Review contractor for the State of Missouri, HCE conducts reviews of Inpatient Hospital Prior Authorization and Utilization, Certification of Need, and Augmentative Communication Devices.  Through the reviews, HCE works to ensure that quality, cost-effective care is provided within the most appropriate setting. HCE also provides general medical assistance and consultations.
   
• Ohio Medicaid Contract, Utilization Review Services
  HCE is responsible for the oversight of the Utilization Review of Inpatient Psychiatric Care for the Ohio Department of Mental Health. The three components of the program include preadmission certification, post-payment reviews, and provider education.

To learn more about the Medicaid program, visit the Centers for Medicare & Medicaid Services (CMS).