Delivery System Reform

The National Health Law Program (NHeLP) Delivery Systems team focuses on the policy, payment, and legal structures that dictate how Medicaid operates, including which providers participate, how prior authorizations are handled, and other important specifics about how people enrolled in Medicaid access their benefits on a day-to-day basis. NHeLP has long been an influential advocacy and litigation leader that pushes for transparency, accountability, and due process to protect access to care for low-income people enrolled in Medicaid. 

Over time, managed care models have replaced fee-for-service as the dominant Medicaid delivery system. Currently, more than three out of four people with Medicaid receive their services through a contracted managed care organization. 

Different delivery systems present different obstacles for access to care. In managed care plans, enrollees may struggle to find new providers due to error-filled provider directories and narrow plan networks. They face administrative hurdles like lengthy prior authorization processes or wrongful denials that often cause delays or foregone care. NHeLP advocates for active accountability measures, effective quality metrics, enrollee protections, and other policy solutions on a state and federal level to work toward a system that prioritizes people over plan profits.

Access to care problems stemming from Medicaid managed care and other delivery systems disproportionately affect underserved communities, including Black, Indigenous, and people of color, people with disabilities, older adults, and LGBTQI+ individuals. We see this in clinical assessment tools that reproduce the biases embedded in historical data used to develop them. It shows up when provider networks fail to accommodate the needs of people with disabilities and people with Limited English Proficiency. Our advocacy persistently demands delivery systems that effectively and transparently prioritize health equity as a core program goal.

Finally, as states explore new, alternative methods of delivering and paying for Medicaid services, our team works to make them equitable, transparent, and effective for low-income and underserved communities.

Major Types of Delivery Systems

Managed care: Under managed care, state Medicaid agencies contract with private companies to coordinate health care delivery for their residents. States typically pay these companies a fixed amount each month for each covered enrollee, regardless of how many services that enrollee actually uses, and allow plans to limit their provider networks.

Fee-for-service: In Fee-for-Service (FFS) systems, states contract with individual providers and pay them directly for the services or items they provide. This means that when a Medicaid member receives a service, such as a doctor’s visit, the doctor charges Medicaid an amount based on the state’s fee schedule.

Alternative Payment Models: Alternative payment models (APMs) are payment approaches that reward providers for delivering high-quality, cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. States experiment with payment approaches that differ from the above approaches, such as linking payment to specific quality outcomes or paying a fixed amount for a whole episode of care, like delivering a baby, as opposed to each individual service. These approaches can exist within FFS or managed care delivery systems.

Intersection of Federal Policy and Delivery Systems

Our Delivery Systems team advocates for Medicaid delivery system models that prioritize people over plan profits. On the federal level, NHeLP is a longstanding influential advocacy and litigation leader that pushes for transparency, accountability, and due process to protect access to care for low-income people enrolled in Medicaid. 

In addition to federal advocacy, NHeLP also works on policy in California. For more information about our California policy work, please visit our California Delivery System Reform page.

Featured Delivery System Reform Resources