Medicaid Managed Care vs. Fee-for-Service: How Each Option Affects Your Coverage

If you have Medicaid or you’re applying, you may be asked to choose between Managed Care and Fee-for-Service (FFS). The terms can sound technical, but the choice affects which doctors you can see, how you get care, and sometimes how easy it is to use your benefits.

This guide explains, in plain language, what Medicaid Managed Care and Medicaid Fee-for-Service usually mean, how they work, and what it could mean for you and your family.

HowToGetAssistance.org is an informational resource only. It is not a government agency, not an enrollment site, and not an official Medicaid office. For decisions, enrollment, and case questions, you will need to contact your state’s Medicaid agency or local office.

Medicaid Basics: Where Managed Care vs. Fee-for-Service Fits In

Medicaid is a public health coverage program for people with low incomes and limited resources, including many:

• Children and teens
• Pregnant people
• Older adults
• People with disabilities
• Some parents and caregivers
• Some other adults with low income, depending on the state

Each state runs its own Medicaid program, within federal rules. That’s why:

• Covered services can vary
• Who qualifies can vary
• Whether you’re in Managed Care or Fee-for-Service can vary

Most states use Managed Care for at least some groups, but Fee-for-Service is still used in many situations (for example, while a person is first being enrolled or for certain types of coverage).

You do not choose between Medicaid and private insurance here; this is about how your Medicaid coverage is delivered.

What Is Medicaid Managed Care?

In Medicaid Managed Care, your state contracts with private or nonprofit health plans, often called:

• Managed Care Organizations (MCOs)
• Health plans
• Medicaid plans

You are usually assigned to or asked to choose a plan, and that plan is responsible for arranging and paying for most of your Medicaid-covered care.

How Managed Care Typically Works

Under Medicaid Managed Care, you usually:

• Pick a health plan from a list (or one is assigned if you don’t choose by a deadline)
• Choose a Primary Care Provider (PCP) within that plan’s network
• Use doctors, clinics, hospitals, and pharmacies that are in your plan’s network
• Often need referrals or prior authorizations for some specialists or services

The state pays the health plan a set amount per member each month. The plan then pays your doctors and other providers.

Common Features of Managed Care

While details differ by state and plan, Managed Care may include:

• Care coordination: Help managing multiple doctors, medications, or chronic conditions
• Member services line: A number to call on your card for help finding providers
• Extra support services (varies by plan and state):
  • Nurse advice lines
  • Transportation to medical appointments (where offered by Medicaid or the plan)
  • Health education programs

Costs to you:
Most Medicaid members still pay no premiums or have very low copays, depending on state rules. Managed Care does not turn Medicaid into regular private insurance, but it uses an insurance-like structure.

What Is Medicaid Fee-for-Service (FFS)?

In Medicaid Fee-for-Service, the state Medicaid agency pays providers directly for each covered service they give you. There is no health plan in the middle.

You usually receive a card that says Medicaid or your state program name, not a specific plan name.

How Fee-for-Service Typically Works

Under Fee-for-Service:

• You can often see any doctor or provider who accepts your state Medicaid
• Providers bill the state Medicaid agency directly
• There is no separate health plan network, but you must still find providers who accept Medicaid
• There is often no PCP requirement, but some states may still encourage having a main doctor

Costs to you:
As with Managed Care, many people have no or very low copays. Exact costs depend on state rules and which group you qualify under.

Side‑by‑Side Comparison: Medicaid Managed Care vs. Fee-for-Service

Below is a general comparison. Actual details vary by state and plan, so always confirm with your state Medicaid agency or plan’s member services.

This table is a general guide, not a promise of benefits. Always verify details with your official Medicaid office or plan.

Who Typically Ends Up in Managed Care vs. Fee-for-Service?

Each state decides who is placed in Managed Care and who stays in Fee-for-Service. Some patterns are common:

Often in Managed Care (in many states)

• Children and parents
• Pregnant individuals
• Adults in expanded Medicaid groups (in states that expanded Medicaid)
• Some people with chronic conditions or special health needs

In many states, being in a Managed Care plan is the default for most new Medicaid members.

Often in Fee-for-Service (in some states or situations)

• People in the process of enrolling, while the state is confirming eligibility
• Certain people with very complex medical needs who receive special programs or waivers
• Some people in long-term care facilities or with specific disabilities
• People in “carve-out” programs for behavioral health or specialized services

Your state’s Medicaid handbook, official website, or customer service line can tell you which populations are in Managed Care or FFS where you live.

What This Choice Means for You Day-to-Day

Whether you’re in Managed Care or Fee-for-Service can affect:

1. Which Doctors You Can See

• Managed Care:

  • You typically must see in-network providers
  • If your favorite doctor isn’t in the plan network, you may need to:
    • Choose a different doctor, or
    • Request a change to a plan that your doctor accepts (if allowed during your choice period)

• Fee-for-Service:

  • You can usually see any provider who takes your state Medicaid, but not all providers do
  • You may need to call around and ask: “Do you accept [State] Medicaid?”

2. How Coordinated Your Care Feels

• Managed Care:

  • You often have one main PCP who oversees your general care
  • Care coordinators or case managers may help with referrals and follow-up

• Fee-for-Service:

  • You may have more freedom to go directly to specialists (depending on your state)
  • You may have to coordinate your own care between different doctors

3. Extra Services and Support

Some Managed Care plans may offer:

• 24/7 nurse phone lines
• Help arranging transportation to medical appointments (where allowed and funded)
• Health coaching or education for conditions like diabetes or asthma

Fee-for-Service usually focuses on core covered services defined by the state, without extra plan-based programs.

How Do You Know Which One You Have?

If you already have Medicaid, you may be unsure which system you’re in. Some ways to check:

1. Look at your card

   • If it lists a health plan name (for example, “XYZ Health Plan” or “[Health Plan] Medicaid”), you’re likely in Managed Care.
   • If it lists only your state Medicaid program, you may be in Fee-for-Service, or you may have FFS for some services and a plan for others.

2. Review letters you received

   • Enrollment packets often use terms like “Managed Care Organization (MCO)”, “health plan selection”, or “plan assignment”.

3. Call member services or your state Medicaid agency

   • The phone number is usually on your card or on official notices.
   • You can ask directly:
     • “Am I in Medicaid Managed Care or Fee-for-Service?”
     • “Which services are through my plan and which are through state Medicaid?”

When You May Be Asked to Choose a Plan

In many states, once you are approved for Medicaid, you will:

1. Get a packet in the mail explaining your choices
2. Be given a deadline to choose a Managed Care plan
3. Be told what will happen if you do not choose by the deadline (you may be automatically assigned to a plan)

Important:

• The choice of plan is usually done through your state’s official enrollment broker, benefits portal, or a state-contracted selection line, not through any private website or general information site.
• Look for the state seal or official agency name on letters and portals.

If you are not offered a choice and are simply given a Medicaid card, you may be in Fee-for-Service, or your state may have a different process. Calling your local Medicaid office is the best way to confirm.

What Documents You May Need (For Enrollment and Plan Choice)

To get to the point where you can use Medicaid at all—whether through Managed Care or FFS—you usually must first apply and be approved for Medicaid.

Typical documents you may need to apply for Medicaid include:

• Proof of identity:
  • Driver’s license, state ID, passport, or another accepted ID
• Proof of citizenship or immigration status (if required by your state):
  • Birth certificate, passport, or immigration documents
• Proof of income:
  • Pay stubs, employer letter, unemployment statements, Social Security award letters
• Proof of residence:
  • Lease, utility bill, or official mail with your name and address
• Social Security numbers (or documentation of application) for household members applying

To choose or change a Managed Care plan, you usually do not need to submit all these documents again. Instead, you the plan selection process usually asks for:

• Your name and date of birth
• Your Medicaid ID number or case number
• Sometimes your address and phone number for verification

The exact process and required details vary by state, so checking with your official Medicaid agency, enrollment broker, or benefits portal is essential.

How and Where to Apply for Medicaid (Before You Pick a Plan)

Because HowToGetAssistance.org is not an enrollment site, you will need to use an official channel to apply or manage your case. Typical options include:

• Your state’s official online benefits portal
  • Many states let you apply online and check your application status.
• Local Medicaid or social services office
  • You can often apply in person or drop off documents.
• Mail or fax
  • Some states allow paper applications to be submitted by mail or fax.
• Phone applications
  • Many states have a toll-free Medicaid or health coverage hotline where you can start an application or ask questions.

To find the correct office or website:

1. Search for your state name + “Medicaid” + “official site”.
2. Confirm the website ends in “.gov” or is clearly identified as a state government agency.
3. You can also dial 211 in many areas to ask for the official Medicaid office contact information.

What Happens After You Apply

Once you submit a Medicaid application:

1. Eligibility review
   • The state reviews your income, household size, and other factors.
2. Approval or denial notice
   • You should receive a letter or online notice telling you if you’re approved, what type of Medicaid you have, and when it starts.
3. Plan selection (if Managed Care is used)
   • If your state uses Managed Care for your group, you may receive a packet asking you to select a plan or informing you which plan you’ve been assigned to.
4. Receiving your card(s)
   • You may receive a state Medicaid card and, if Managed Care, a separate health plan card. Sometimes the plan card arrives separately.

If your state uses Fee-for-Service, you may only get a state Medicaid card and instructions on how to use it.

Common Reasons for Delays or Problems

People experience delays or issues with Medicaid coverage for a variety of reasons. Some common ones include:

• Missing documents or incomplete application
  • For example, not providing pay stubs or missing signatures
• Address changes not reported
  • Notices and cards go to the wrong address, causing missed deadlines
• Not responding to requests for more information
  • If the agency asks for more proof and you do not send it by the deadline, your case may be delayed or closed
• Not choosing a plan by the deadline (in Managed Care states)
  • You may be automatically assigned to a plan you would not have chosen

If you’re unsure about your status, it is usually best to contact:

• Your state Medicaid customer service line, or
• The number on any official letters you receive, or
• Your local social services or Medicaid office

Always use official numbers listed on government websites or letters, not numbers found in ads or on unofficial sites.

Can You Change from Managed Care to Fee-for-Service (or Vice Versa)?

This depends heavily on state rules and your eligibility group.

In some states:

• Most members must stay in Managed Care except in special circumstances.
• You may be allowed to change Managed Care plans during a
  • “choice period” when you first enroll, and
  • annual open enrollment period or for certain “good cause” reasons (like your doctor leaving the network).

Moving from Managed Care to Fee-for-Service is often limited and may only be available if:

• You have specific medical needs covered by a special program
• You qualify for a waiver or special category
• Your state decides that FFS is more appropriate for your situation

To understand your options:

• Call the plan’s member services number on your card, and
• Contact your state Medicaid agency or enrollment broker for official rules.

What If Your Coverage or Services Are Denied?

If you:

• Are denied Medicaid entirely, or
• Are denied a service you think should be covered, or
• Disagree with a Managed Care plan’s decision (for example, a treatment is not approved),

You often have the right to:

1. Request an appeal with your plan (for Managed Care)
2. Request a fair hearing with the state Medicaid agency

Typical steps (varies by state):

• Read the denial notice carefully.
  • It should list a reason and explain how to appeal and the deadline.
• Submit an appeal in writing or by phone (as allowed) within the stated timeframe.
• You may be able to submit additional documents from your doctor to support your case.

Appeal and hearing processes can be complex. Some people seek help from:

• Legal aid organizations
• Disability rights groups
• Health insurance consumer assistance programs (names vary by state)

These organizations are often listed on your state’s official Medicaid website or through 211.

Alternatives if You Don’t Qualify for Medicaid

If you learn that you do not qualify for Medicaid, there may be other options to explore:

• Children’s Health Insurance Program (CHIP)
  • For children and sometimes pregnant people in families whose income is too high for Medicaid but still limited.
• Marketplace health plans
  • Depending on income and immigration status, you may be able to buy coverage through the federal or state health insurance marketplace and possibly get financial assistance.
• Community health centers and free/low-cost clinics
  • These may offer sliding-scale fees regardless of insurance status.
• Local public health departments
  • Often provide services such as immunizations, STI testing, and basic care.

To find local options, you can:

• Contact your local health department
• Call 211 and ask for health coverage and low-cost clinic referrals
• Ask your state Medicaid or social services office what other programs you may qualify for

How to Make Sure You’re Using an Official Channel (Avoiding Scams)

Because Medicaid is a public program, it can sometimes attract scam websites or unofficial “helpers” who charge fees or ask for sensitive information.

To protect yourself:

• Look for “.gov” websites when searching online.
• Verify that letters and emails include the name of your state agency (for example, Department of Human Services, Department of Health, or similar) and an official return address.
• Be cautious if someone:
  • Guarantees approval for a fee
  • Asks for your bank account or credit card to “process” a Medicaid application
  • Contacts you out of the blue and asks for full Social Security numbers or other personal information

If unsure, you can:

• Call the phone number listed on your state government’s official website to confirm the communication is legitimate.
• Ask a local social services office to confirm any instructions you’ve received.

Understanding the difference between Medicaid Managed Care and Fee-for-Service can help you:

• Know which doctors and providers you can use
• Understand why you have a particular card or plan
• Ask the right questions when you talk to your plan or state agency

For decisions about your specific case, plan options, or coverage details, your best next step is to contact your state Medicaid agency, local social services office, or the member services number on your Medicaid or plan card.