Home -- Medicaid

Serving State Medicaid Programs

What is Medicaid?

Title XIX of the Social Security Act provides the 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 analyses 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 applicable standards (e.g., operational and financial reviews)
     
• 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.
   
• Kentucky Medicaid Contract, Surveillance and Utilization Review System
  HCE manages the Surveillance and Utilization Review function for the Kentucky Department for Medicaid Services, which is part of the Kentucky Cabinet for Health and Family Services. HCE provides technical and educational support to Kentucky to fully identify fraud, rules out potential erroneous or fraudulent billing through clinical reviews and audits, and identifies opportunities for system payment edits and audits. As a result of our clinical expertise and experience, HCE uses Kentucky Medicaid policy-appropriate algorithms, conducts medical record and on-site audits, manages a provider prepayment program, and has established a methodology for provider self-audits.
   
• 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’s physicians review medical records of special cases. At the state’s request the company conducts specified focused studies on an as-needed basis.
   
• Ohio Medicaid Contract, Utilization Review Services
  HCE is responsible for the oversight of the Utilization Review of Inpatient Psychiatric (URIP) 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).