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Appendix A: Additional State Managed Care Plan Landscape Tables
ICR 202609-0938-004 · OMB 0938-1281 · Object 172967200.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Appendix A: Additional State Managed Care Plan Landscape Tables |
| Author | Hannah Klukoff |
| Last Modified By | Writer |
| File Modified | 2026-04-15 |
| File Created | 2026-09-16 |
| Conversion State | complete |
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APPENDIX A: ADDITIONAL STATE MANAGED CARE PLAN LANDSCAPE TABLES Table 4. State managed care landscape Managed care program name: Insert text here. Program covered Choose an item. Population(s) covered. More than one can be selected. Choose an item. Managed care plans offered through the program* List plans Does the program cover dental benefits? Choose an item. Does the program cover Long Term Services and Supports (LTSS) benefits? Choose an item. Does the program cover behavioral health (BH) benefits? Choose an item. Does the program cover pharmacy benefits? Choose an item. Specify other benefits coverage. Insert text here. Additional information about this program. Insert text here. *The MAC QRS requirements only apply to a managed care organization (MCO), prepaid inpatient health plan (PIHP), or prepaid ambulatory health plan (PAHP) as identified in § 438.505(b). Any additional comments on your managed care program(s) can be included below: Insert text here. Table 5. State managed care landscape Managed care program name: Insert text here. Program covered Choose an item. Population(s) covered. More than one can be selected. Choose an item. Managed care plans offered through the program* List plans Does the program cover dental benefits? Choose an item. Does the program cover Long Term Services and Supports (LTSS) benefits? Choose an item. Does the program cover behavioral health (BH) benefits? Choose an item. Does the program cover pharmacy benefits? Choose an item. Specify other benefits coverage. Insert text here. Additional information about this program. Insert text here. *The MAC QRS requirements only apply to a managed care organization (MCO), prepaid inpatient health plan (PIHP), or prepaid ambulatory health plan (PAHP) as identified in § 438.505(b). Any additional comments on your managed care program(s) can be included below: Insert text here. Table 6. State managed care landscape Managed care program name: Insert text here. Program covered Choose an item. Population(s) covered. More than one can be selected. Choose an item. Managed care plans offered through the program* List plans Does the program cover dental benefits? Choose an item. Does the program cover Long Term Services and Supports (LTSS) benefits? Choose an item. Does the program cover behavioral health (BH) benefits? Choose an item. Does the program cover pharmacy benefits? Choose an item. Specify other benefits coverage. Insert text here. Additional information about this program. Insert text here. *The MAC QRS requirements only apply to a managed care organization (MCO), prepaid inpatient health plan (PIHP), or prepaid ambulatory health plan (PAHP) as identified in § 438.505(b). Any additional comments on your managed care program(s) can be included below: Insert text here. Table 7. State managed care landscape Managed care program name: Insert text here. Program covered Choose an item. Population(s) covered. More than one can be selected. Choose an item. Managed care plans offered through the program* List plans Does the program cover dental benefits? Choose an item. Does the program cover Long Term Services and Supports (LTSS) benefits? Choose an item. Does the program cover behavioral health (BH) benefits? Choose an item. Does the program cover pharmacy benefits? Choose an item. Specify other benefits coverage. Insert text here. Additional information about this program. Insert text here. *The MAC QRS requirements only apply to a managed care organization (MCO), prepaid inpatient health plan (PIHP), or prepaid ambulatory health plan (PAHP) as identified in § 438.505(b). Any additional comments on your managed care program(s) can be included below: Insert text here. Table 8. State managed care landscape Managed care program name: Insert text here. Program covered Choose an item. Population(s) covered. More than one can be selected. Choose an item. Managed care plans offered through the program* List plans Does the program cover dental benefits? Choose an item. Does the program cover Long Term Services and Supports (LTSS) benefits? Choose an item. Does the program cover behavioral health (BH) benefits? Choose an item. Does the program cover pharmacy benefits? Choose an item. Specify other benefits coverage. Insert text here. Additional information about this program. Insert text here. *The MAC QRS requirements only apply to a managed care organization (MCO), prepaid inpatient health plan (PIHP), or prepaid ambulatory health plan (PAHP) as identified in § 438.505(b). Any additional comments on your managed care program(s) can be included below: Insert text here. Table 9. State managed care landscape Managed care program name: Insert text here. Program covered Choose an item. Population(s) covered. More than one can be selected. Choose an item. Managed care plans offered through the program* List plans Does the program cover dental benefits? Choose an item. Does the program cover Long Term Services and Supports (LTSS) benefits? Choose an item. Does the program cover behavioral health (BH) benefits? Choose an item. Does the program cover pharmacy benefits? Choose an item. Specify other benefits coverage. Insert text here. Additional information about this program. Insert text here. *The MAC QRS requirements only apply to a managed care organization (MCO), prepaid inpatient health plan (PIHP), or prepaid ambulatory health plan (PAHP) as identified in § 438.505(b). Any additional comments on your managed care program(s) can be included below: Insert text here. Table 10. State managed care landscape Managed care program name: Insert text here. Program covered Choose an item. Population(s) covered. More than one can be selected. Choose an item. Managed care plans offered through the program* List plans Does the program cover dental benefits? Choose an item. Does the program cover Long Term Services and Supports (LTSS) benefits? Choose an item. Does the program cover behavioral health (BH) benefits? Choose an item. Does the program cover pharmacy benefits? Choose an item. Specify other benefits coverage. Insert text here. Additional information about this program. Insert text here. *The MAC QRS requirements only apply to a managed care organization (MCO), prepaid inpatient health plan (PIHP), or prepaid ambulatory health plan (PAHP) as identified in § 438.505(b). Any additional comments on your managed care program(s) can be included below: Insert text here. Table 11. State managed care landscape Managed care program name: Insert text here. Program covered Choose an item. Population(s) covered. More than one can be selected. Choose an item. Managed care plans offered through the program* List plans Does the program cover dental benefits? Choose an item. Does the program cover Long Term Services and Supports (LTSS) benefits? Choose an item. Does the program cover behavioral health (BH) benefits? Choose an item. Does the program cover pharmacy benefits? Choose an item. Specify other benefits coverage. Insert text here. Additional information about this program. Insert text here. *The MAC QRS requirements only apply to a managed care organization (MCO), prepaid inpatient health plan (PIHP), or prepaid ambulatory health plan (PAHP) as identified in § 438.505(b). Any additional comments on your managed care program(s) can be included below: Insert text here.