Medicaid Managed Care - U.S. Senate Special Committee on Aging

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review by including appropriate grievance and appeals mechanisms.
<strong>Managed</strong> care systems/plans must include mechanisms for avoiding discrimination in the provision
of services. This includes the prohibition of arbitrary limits through reasonable accommodations
in such areas as benefits, location of services, length of treatment, and geographical location.
<strong>Managed</strong> care systems should be required to provide health care services in accordance with
nationally accepted prevention and treatment protocols, e.g. protocols for prenatal care, well-baby
care, and childhood immunization schedules, or current best-practices.
<strong>Managed</strong> care systems/plans must communicate to enrollees and prospective enrollees which
services are covered and which are excluded in a consistent format that is clear and easily
understood. Included must be information on co-payments, deductibles, the existence of any
utilization review requirements, as well as any financial incentives that restrict or require the use
of specific providers, facilities, services, or products.
<strong>Managed</strong> care systems/plans that utilize provider risk sharing-arrangements or other incentives
related to utilization of services must have established mechanisms in place for monitoring quality
of care.
<strong>Managed</strong> care systems must include the option to disenroll for those participants who are not
receiving adequate and timely services.
<strong>Managed</strong> care systems/plans must be required to collect and report a uniform set of data that
allows public officials and consumers to evaluate and compare performance, including
longitudinal data to measure outcomes for people with disabilities. Community agencies and
consumers must be involved in design of and ongoing participants in quality assurance systems
which focus on appropriate outcomes for the individual.
<strong>Managed</strong> care systems must have strict quality assurance provisions that require internal and
external review mechanisms by independent assessors and the results of these reviews should be
available to consumers to assist them in choosing a managed care plan. Individually focused
outcome reviews should be a key component of this process.
Consumer Education
In order to avoid marketing abuses by managed care plans, states must be required to prohibit
direct enrollment by plans and instead set up an independent enrollment and counseling process
which permits enrollees -- in the public and private markets -- to explore options in choosing
among plans. All such efforts must be designed to respond in a non-discriminatory manner to the
varying abilities and needs of people with disabilities.
<strong>Managed</strong> care systems/plans must disclose in a clear and easily understood manner to enrollees
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