Prior authorization isn’t one system.
It’s eight categories, deployed in different combinations across every state.

Alaska Medicaid is branded as "DenaliCare"; the CHIP companion is "Denali KidCare". Administered directly by the Alaska Department of Health — Division of Public Assistance handles applications/eligibility, Division of Health Care Services designs the program and manages provider payments. No managed care contracts — confirms the FFS + state_centralized_portal shape classification.

AL Medicaid: NO comprehensive risk-based MCO program — AL is one of a handful of states that remain largely FFS. Care delivery: Patient 1st PCMH (Primary Care Case Management since 1997) is the foundation; Alabama Coordinated Health Network (ACHN, 7 regional networks since 2019) provides care coordination + select services on top of FFS. ACHNs are NOT full-risk MCOs — they receive PMPM care-coordi

AR Medicaid: largely FFS-based for general population. Intensive BH and IDD members are enrolled in one of 4 PASSEs (Provider-led Arkansas Shared Savings Entities) — provider-led organizations that coordinate care + share in savings/losses (NOT traditional full-risk MCOs). FFS PA goes through DMS via Arkansas Medicaid Provider Portal. PASSE-enrolled members get BH + LTSS through PASSE. Pharmacy is

AZ AHCCCS: FFS PA reviews handled by DFSM (Division of Fee-for-Service Management). Managed-care PA goes to the member's AHCCCS Complete Care plan; LTSS-eligibles route through ALTCS. NO unified PBM carve-out — each MCO administers its own pharmacy. WISeR Medicare-FFS pilot state since 2026-01-05 (vendor: eviCore) — affects Medicare-FFS providers, NOT AHCCCS Complete Care members.

CA Medi-Cal: pharmacy benefit carved out to Medi-Cal Rx (Magellan) since 2022 — drug PA decisions go to Medi-Cal Rx, NOT the Medi-Cal MCO. Service PA goes to the member's Medi-Cal MCO (Anthem, Health Net, HPSM, Molina, etc.; county-specific). FFS coverage is residual (newborns, certain waiver populations). 1115 waiver brand: CalAIM. NOT a WISeR pilot state.

Accountable Care Collaborative (ACC) with 4 Regional Accountable Entities (RAEs) as PCCM+PIHP; physical-health claims paid FFS by HCPF; behavioral-health capitated to RAE; two full-risk MCOs (RMHP PRIME, Denver Health Elevate) operate as carve-outs.

No risk-bearing MCOs. State retains full financial risk; contracts with non-risk ASOs for medical, behavioral health, dental, and fiscal-agent functions.

DC Medicaid: FFS PA goes through DHCF. Managed-care PA goes to one of 3 DC Medicaid MCOs (AmeriHealth Caritas DC, CareFirst BlueChoice DC, MedStar Family Choice DC). DC Healthy Families is the program brand. Pharmacy is per-MCO PBM. NOT a WISeR pilot state.

DE Medicaid (Diamond State Health Plan): FFS PA through DMMA. Managed-care PA goes to one of 2 DSHP MCOs (AmeriHealth Caritas DE, Highmark Health Options). DSHP-Plus integrates LTSS for aged/disabled/duals into the MCOs. Pharmacy is largely state-administered. NOT a WISeR pilot state.

FL Medicaid (Statewide Medicaid Managed Care, SMMC): nearly all enrollees are in SMMC. Three SMMC components: MMA (Managed Medical Assistance — physical health), LTC (Long-Term Care), Specialty (CMS Plan = Sunshine Health for kids with chronic conditions). FFS PA goes through AHCA via FMMIS. Managed-care PA goes to the member's SMMC plan (8+ plans active). Pharmacy is per-plan PBM; FFS pharmacy th

GA Medicaid (Georgia Families): FFS PA goes through DCH via GAMMIS. Managed-care PA goes to the member's Care Management Organization (CMO) — 4 CMOs (Amerigroup, CareSource, Peach State, WellCare). Georgia Families 360° is the specialty single-MCO carve-out for kids in DFCS custody, adopted from foster care, or in juvenile justice (Amerigroup-operated). Pharmacy is per-CMO PBM. NOT a WISeR pilot s

HI Medicaid (Med-QUEST): 100% MCO state via QUEST Integration (since 2015). 5 QUEST Integration MCOs integrate PH + BH + LTSS under one MCO. PA goes to the member's QUEST Integration plan. Pharmacy is per-MCO PBM. NOT a WISeR pilot state. Confirmed mco_only in pauth-options.

IA Medicaid (IA Health Link): FFS PA goes through IA HHS via IMPA. Managed-care PA goes to one of 3 IA Health Link MCOs (Iowa Total Care, Molina, Wellpoint). Pharmacy is state-administered. NOT a WISeR pilot state. hawk-i = IA's CHIP brand.

ID Medicaid: FFS-dominant with PCMH overlay (Healthy Connections Value Care). PA for medical services goes through DHW directly. BH services carved out to Optum Idaho ASO statewide since 2013. Idaho Medicare-Medicaid Coordinated Plan (MMCP) for duals demonstration. Pharmacy is state-administered. NOT a WISeR pilot state.

IL Medicaid (HealthChoice Illinois): FFS PA goes through HFS via the MEDI provider portal. Managed-care PA goes to the member's HealthChoice plan — six plans total: Aetna Better Health, BCBSIL, CountyCare (Cook County only), Meridian (Centene), Molina, YouthCare (kids in DCFS care, statewide). Pharmacy is per-MCO PBM (no statewide carve-out); FFS pharmacy via HFS-direct PDL. Dual eligibles route t

IN Medicaid: FFS PA goes through OMPP via CoreMMIS. Three managed-care programs: Hoosier Healthwise (kids + pregnant women), HIP (Healthy Indiana Plan, expansion population), Hoosier Care Connect (aged/blind/disabled non-LTSS). PathWays for Aging is the LTSS managed-care for adults 60+ launched 2024-07-01 (3 plans: Anthem, Humana, UnitedHealthcare). PHARMACY IS CARVED OUT to MyOptumRx statewide si

KS Medicaid (KanCare): 100% MCO state. All KanCare members are in one of 3 MCOs (Aetna Better Health, Sunflower Health/Centene, UnitedHealthcare Community Plan). FFS PA goes through KDHE via KMAP for residual cases. PA goes to the member's MCO. HCBS waivers + LTSS were CARVED INTO MCOs at KanCare launch 2013 — among the earliest LTSS carve-IN states. Pharmacy is per-MCO PBM. NOT a WISeR pilot stat

KY Medicaid: FFS PA goes through DMS via KYHealthNet Provider Portal. Managed-care PA goes to one of 6 KY Medicaid MCOs (Aetna Better Health, Anthem, Humana Healthy Horizons, Molina, Passport Health Plan/Molina, UnitedHealthcare). PHARMACY IS CARVED OUT to MedImpact statewide since 2021-07-01 — drug PA decisions go to MedImpact for FFS + all MCOs. NOT a WISeR pilot state. KCHIP = KY's CHIP brand.

LA Medicaid (Healthy Louisiana): FFS PA goes through LDH via LaMedicaid Provider Portal. Managed-care PA goes to one of 5 Healthy Louisiana MCOs. Pharmacy is per-MCO PBM since 2024 transition (was state-administered before). NOT a WISeR pilot state.

ACO-dominant: 15 ACPPs (MCO-backed) + 2 PCACOs cover ~1.3M of 2.4M members; 1 standalone MCO (WellSense Essential) post-1/1/2026; PCC Plan and FFS for residual

MD Medicaid: FFS PA goes through MDH via eMedicaid. Managed-care PA goes to the member's HealthChoice MCO (9 plans). PHARMACY uses a Common Formulary state-administered by MDH across all HealthChoice MCOs since 2019. BEHAVIORAL HEALTH (mental health + SUD specialty) is carved OUT of HealthChoice MCOs to the Public Behavioral Health System (PBHS, statewide ASO administered by Optum Maryland under B

ME Medicaid (MaineCare): FFS-only with PCCM (Primary Care Case Management) for assigned members. No comprehensive risk-based MCO program. PA goes through Office of MaineCare Services (OMS) via MIHMS. Behavioral Health Homes (BHHs) provide care coordination. Pharmacy is state-administered. NOT a WISeR pilot state. Cub Care = ME's CHIP brand.

MI Medicaid (Medicaid Health Plans, MHPs): FFS PA goes through MDHHS via CHAMPS. Managed-care PA goes to the member's MHP (9 plans statewide). Specialty BH, IDD, and SUD services are CARVED OUT of MHPs to 10 regional PIHPs (Prepaid Inpatient Health Plans) — mild-to-moderate BH stays with MHP, specialty goes to PIHP. MI Choice Waiver (HCBS LTSS for aged/disabled) routed through Area Agencies on Agi

MN Medicaid (Medical Assistance, MA): FFS PA goes through MN DHS via MN-ITS. Managed-care PA goes to the member's PMAP (Prepaid Medical Assistance Program) plan — 8 plans total. Seniors have integrated D-SNP options: MSC+ (Medicaid-only seniors 65+), MSHO (dual-eligible seniors 65+ with Medicare Advantage integration). SNBC (Special Needs BasicCare) for non-senior duals. Pharmacy is per-PMAP-plan

MO Medicaid (MO HealthNet): FFS PA goes through MO HealthNet Division via eMOMED. Managed-care PA goes to one of 3 plans (Healthy Blue, Home State Health, UnitedHealthcare). Pharmacy uses MO's SMART PA program (state-administered with Conduent as fiscal agent) — closer to a state-administered shape than per-MCO PBM. Aged/Blind/Disabled (ABD) members are largely FFS-based. NOT a WISeR pilot state.

MS Medicaid: FFS PA goes through DOM via MS Envision. Managed-care PA goes to one of 3 MississippiCAN (Coordinated Access Network) MCOs (Magnolia Health, Molina, UnitedHealthcare). MS Medicaid Access to Wellness (MAW) is for limited special populations. Pharmacy is largely state-administered with state PDL alignment. NOT a WISeR pilot state.

MT Medicaid: FFS-dominant with PCCM (Passport to Health). NO comprehensive risk-based MCO. Health Improvement Program (HIP) added care coordination for expansion population. PA goes through DPHHS. Pharmacy is state-administered. Healthy Montana Kids = CHIP brand. NOT a WISeR pilot state.

NC Medicaid: managed-care launched 2021-07-01 (Standard Plans) and 2024-07-01 (Tailored Plans). FFS PA goes through NC Medicaid via NCTracks. Standard Plan PA goes to one of 5 Standard Plans (Healthy Blue, AmeriHealth Caritas, Carolina Complete Health, UnitedHealthcare, WellCare). Tailored Plan PA goes to one of 5 regional Tailored Plans (Alliance, Eastpointe, Partners, Trillium, Vaya) — mandatory

Medicaid Expansion population enrolled in a single capitated MCO (BCBSND); all other populations (children, pregnant, ABD, duals, foster, 19-20 year olds, medically frail expansion adults) covered as state-administered FFS. PCCM ended 12/31/2023 per HB 1044.

NE Medicaid (Heritage Health): FFS PA through NE DHHS. Managed-care PA goes to one of 3 Heritage Health MCOs (Healthy Blue/Anthem, Nebraska Total Care/Centene, UnitedHealthcare). Heritage Health Adult Family Services is for ABD/LTSS-needers. Pharmacy is per-MCO PBM. NOT a WISeR pilot state.

Mandatory MCO enrollment (MCM) for medical/BH/pharmacy with FFS carve-outs for LTSS (CFI 1915(c)), nursing facility, DD/ABD/IHS, and adult dental

NJ Medicaid (NJ FamilyCare): FFS PA goes through DMAHS via NJMMIS. Managed-care PA goes to the member's NJ FamilyCare MCO (Aetna Better Health, Amerigroup/Wellpoint, Horizon NJ Health, UnitedHealthcare Community Plan, or WellCare). MLTSS (Managed Long-Term Services and Supports) is carved INTO the MCOs since 2014 — MLTSS-eligible members access LTSS through their MCO's MLTSS package, not through a

NM Medicaid (Turquoise Care, rebranded from Centennial Care 2024-07-01): 100% MCO. 4 Turquoise Care MCOs (BCBS NM, Molina, Presbyterian, UnitedHealthcare). LTSS integrated INTO MCOs (continuing Centennial Care pattern). Pharmacy is per-MCO PBM. Confirmed mco_only in pauth-options. NOT a WISeR pilot state.

NV Medicaid: FFS PA through DHCFP. Managed-care PA goes to one of 4 NV MCOs (Anthem BCBS, Health Plan of Nevada, Molina, SilverSummit/Centene). Rural areas + special pops remain FFS. Pharmacy is per-MCO PBM. NV Check Up = NV's CHIP brand. NOT a WISeR pilot state.

NY Medicaid: pharmacy benefit carved INTO FFS effective 2023-04-01 as NY Medicaid Rx (DOH-administered) — drug PA goes to NY Medicaid Rx, NOT the MCO. Service PA: MMC for general, HARP for adults with serious BH (opt-in), MLTC for LTSS (mandatory for dual-LTSS), FFS for the rest. State PA rules codified in 18 NYCRR. NOT a WISeR pilot state.

OH ODM: pharmacy benefit carved out to the Single Pharmacy Benefit Manager (SPBM, Gainwell) since 2023-07-01 — drug PA decisions go to SPBM, NOT the MCO. Service PA goes to the member's Next Generation MCO. OhioRISE (Aetna) handles BH for kids/youth with complex needs since 2022-07-01. State PA criteria codified in OAC Title 5160. WISeR Medicare-FFS pilot state since 2026-01-05 — vendor mapping no

OK Medicaid (SoonerCare): managed care launched 2024-04-01 as SoonerSelect — most members in one of three SoonerSelect plans (Aetna Better Health, Humana Healthy Horizons, Oklahoma Complete Health). SoonerCare Choice = the residual PCMH-based primary-care case management for members not yet in SoonerSelect (FFS-like). FFS PA goes through OHCA. Managed-care PA goes to the SoonerSelect plan. SoonerS

OR Medicaid (Oregon Health Plan, OHP): 100% MCO via 16 Coordinated Care Organizations (CCOs). CCOs are full-risk PROVIDER-LED regional plans (most are nonprofit organizations governed by community providers, not commercial insurers). Each CCO covers a specific Oregon county/region. CCOs integrate physical health + behavioral health + dental + (in many cases) some Medicare+Medicaid integration. Ope

PA Medicaid (HealthChoices): FFS PA goes through DHS via PROMISe. Managed-care PA goes to the member's HealthChoices physical-health MCO (6 plans, zone-based). BH services are CARVED OUT to county-administered Behavioral Health Managed Care Organizations (BH-MCOs) — each PA county contracts with one BH-MCO; member's BH-MCO depends on county of residence. Community HealthChoices (CHC) is the mandat

RI Medicaid (RIte Care): 3 MCOs (Neighborhood Health Plan, Tufts Health, UnitedHealthcare). LTSS for aged/disabled integrated through Rhody Health Options. FFS PA through EOHHS. Pharmacy is per-MCO PBM. NOT a WISeR pilot state. RIte Smiles = dental program.

SC Medicaid (Healthy Connections): FFS PA goes through SCDHHS via Healthy Connections Provider Portal. Managed-care PA goes to one of 6 Healthy Connections MCOs (Absolute Total Care, First Choice/Select Health, Healthy Blue, Humana Healthy Horizons, Molina, Select Health). Pharmacy is state-administered. Healthy Connections Choices is the enrollment broker. Healthy Connections Prime is the FAI dua

SD Medicaid: FFS-only — no comprehensive risk-based managed care. Health Home program for chronic conditions. PA goes through SD DSS Division of Medical Services. Pharmacy state-administered. Tribal Health for AI/AN. CHIP = administered separately. NOT a WISeR pilot state.

TN Medicaid (TennCare): 100% MCO state — virtually all TennCare members are in one of three MCOs (Amerigroup/Wellpoint, BlueCare, UnitedHealthcare). FFS coverage is residual (newborns, transition-of-coverage, certain transition periods). TennCare Select (BlueCare-operated specialty plan) for kids in DCS custody + kids receiving SSI + certain medically-complex. PA goes to the member's MCO. CHOICES

TX Medicaid: FFS PA goes through TMHP (Texas Medicaid Healthcare Partnership) — Accenture-led contractor running provider portal + claims + PA submission. Managed-care PA goes to one of four STAR-family plans depending on the member: STAR (general), STAR+PLUS (aged/disabled with LTSS), STAR Kids (children with disabilities), STAR Health (foster care). FFS pharmacy is HHSC-administered via the Vend

UT Medicaid: FFS PA goes through DHHS Medicaid via PRISM. Managed-care PA goes to one of 4 ACOs (Healthy U, Molina, SelectHealth Community Care, Health Choice Utah) — provider-led integrated care plans similar to MA ACO model but smaller panel. BH services are CARVED OUT to county Local Mental Health Authorities (LMHAs) operating Prepaid Mental Health Plans (PMHPs) — 13 PMHPs cover all 29 UT count

VA Medicaid (Cardinal Care, unified 2023 brand replacing Medallion 4.0 + CCC Plus): FFS PA goes through DMAS via VAMMIS. Managed-care PA goes to one of 6 Cardinal Care MCOs. LTSS for duals + NF-level-care members is integrated into Cardinal Care (no separate LTSS plan since unification). Pharmacy is per-MCO PBM with state PDL alignment. NOT a WISeR pilot state.

Single state-administered 'managed care-like' model under 1115 waiver. DVHA is the only Medicaid Care Entity (MCE), classified by CMS as a non-risk PIHP. No commercial MCOs.

WA Apple Health: FFS PA goes through HCA via ProviderOne. Managed-care PA goes to the member's IMC (Integrated Managed Care) plan — IMC integrates physical + behavioral health. BHSO-enrolled members route BH services through BHSO plan; PH stays elsewhere. FFS pharmacy is HCA-administered via WashPDL (NOT a PBM carve-out); IMC plans run their own pharmacy through PBMs (mixed model). LTSS routed thr

Mandatory MCO HMO enrollment for BadgerCare Plus and most SSI Medicaid; pharmacy carved out to state FFS; LTSS in separate Family Care/Partnership/PACE MCO program; foster care to Care4Kids PIHP

WV Medicaid (Mountain Health Trust): 5 MCOs serve members. FFS PA through WV BMS. Pharmacy is per-MCO PBM. WVCHIP = WV's CHIP brand. NOT a WISeR pilot state.

WY Medicaid: PURE FFS — NO comprehensive risk-based managed care. PA goes through WY DOH Division of Healthcare Financing. EqualityCare is the program brand. Tribal Health for AI/AN. Pharmacy state-administered. Confirmed ffs_only in pauth-options. Kid Care CHIP = CHIP brand. NOT a WISeR pilot state.