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

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We implement these QI goals through a variety of strategies.
Most importantly, we have established basic contract requirements,
some of which apply to all managed care enrollees and some of
which are unique. The contract requirements are routinely and rigorously
monitored.
Examples of contract requirements are ensuring around-the-clock
easy access to appropriate care; assuring the location of health care
providers within 20 miles of consumers' residences-we believe this
is the strictest requirements in the Nation; requiring that managed
care organizations offer a comprehensive range of services equivalent
to <strong>Medicaid</strong> fee-for-service; assuring culturally responsive
health care providers education and communication; requiring formal
and informal complaint and grievance processes, and requiring
managed care organizations to maintain a comprehensive internal
QI system. Almost all State <strong>Medicaid</strong> managed care programs include
such requirements.
Examples of contract requirements that are unique to Wisconsin
include the following. We use an independent enrollment contractor
to assure that <strong>Medicaid</strong> recipients enrolling in HMOs are fully informed
about how to choose an HMO that best meet their needs.
Our enrollment contractor also assists recipients with formal and
informal complaints and grievances.
Our contract requires each HMO to hire at least one full-time
<strong>Medicaid</strong> advocate to help enrollees navigate the managed care system.
We contract with two ombudsmen to help Medicare enrollees
with more systemic complaints and grievances. We enroll voluntary
HMO participation for children who qualify for the Federal birth
to 3 program, a program targeted for children with special health
care needs. By the way, most parents and caregivers opt to give
their children the HMO program.
Specific targeted contract requirements for the elderly and disabled
include the following. Each managed care organization must
have a board of directors including <strong>Medicaid</strong> consumer representatives.
Our plans must have working memoranda of understanding
with affected counties, because in Wisconsin, many behavioral
health and supportive home care services are county-based. Required
quality studies must reflect some subjects of importance to
consumers.
All of our special managed care programs are undergoing extensive
quality evaluations by outside evaluators. This has been the
Wisconsin way. We start slowly, evaluate and improve, and then
expand to larger numbers.
Every year, Wisconsin produces the HMO fee-for-service comparison
report, an extensive document-I brought a copy so you can see
how big it is. This report is based on a combination of survey and
encounter data submitted and processed by HMOs. The report is
always made public, with the results discussed in many public forums.
Areas needing improvement may be further studied by work
groups and audited. We will be producing similar reports for our
other programs also. We have a strong audit and utilization reporting
components. We regularly conduct comprehensive medical chart
reviews. We cover twice as many chart reviews from managed care
enrollees as for fee-for-service enrollees. All of these strategies can