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

Strong Oualitv Assurance Measures
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1 <strong>Managed</strong> care systems/plans must comply with the protections offered by Section 504 of the
Rehabilitation Act of 1973, as amended, the Americans with Disabilities Act, and other civil
rights statutes.
I <strong>Managed</strong> care systems/plans must provide participants with clear information on policies,
procedures, grievance mechanisms, and appeals and must ensure consumer participation in the
establishment of such procedures.
I <strong>Managed</strong> care systems/plans must provide access to independent organizations that provide
ombudsman and rights protection services.
1X1 <strong>Managed</strong> care systems/plans must have in place a mechanism for responding to adverse
utilization review by including appropriate grievance and appeals mechanisms.
M <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.
1X <strong>Managed</strong> care systems/plans 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.
1 <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 easilyf
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, fcilities, services, or products.
13 <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.
U <strong>Managed</strong> care systems/plans must include the option to disenroll for those participants who are
not receiving adequate and timely services.
I <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.