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

Table l.: Federal Regulations,
Rtqulretenta. end Guidanc for
Selected Accountability Measures and
Process Within States' <strong>Medicaid</strong>
<strong>Managed</strong> Cars Programs
415
Apendi, t
Fedra .u State r-rigt lRai of
ttl -d Can
Accountabflity measure or
Additional HCFA
requirements aind
procns Federal regultn guidance
Pauent-to-primary-carephysician
ratio
Plans must ensure that For demonstration waivers.
beneficiaries in managed states must meet maximum
care have tlie same access 2.50010o 1 raveo For
to providers ann services piuyi af waivers, HCFA
as beneficiaries in suggests ratios be
fee-farsemce plans.
(42 C.F.R. 434.20(c)(2))
evaluated.
Availability of specialists Services are to be the same HCFA suggests that states
as these provided under have a system for
fee-for semce plans. (42 authorizing and
C.F.R. 434.20(c)(2)) coordinaing specialty
services.
Utilization statisucs and
encounter data
Requires plans to maintain . HCFA requires all stales
appropriate record systems with demonstration waivers
for services provided to to collect 10D% encounter
enrollees. (42 C.F.R. data and requires all states
436.6(a)(7)) to quarterlyrepon
aggregated statistics on
selected services.
Clinical studies Plans must have an internal HCFA Suggests states
quality assurance system, conduct quafity-of-c~are
(42 C.F.R. 434.34) studies.
Medical record audits States must annually HCFA requires states to
conduct an audit of medical comply with federal
records. (42 C.F.R. 434.53) regulation far medical
record audits.
Beneficiary satisfaction Plans must have an internal For demonstration waivers,
suiveys quality assuraten system.
(42 C.F.R. 434.34)
a state may be required to
conduct a survey as HCFA
prescribes For program
waivers. HCFA suggests
plans conduct periodic
surveys.
Grievance procedures Plans must have an internal HCFA requires states to
grievance procedure report grievance data
appruned by the state thut quarterly.
provides for prompt
resolution. (42 C.F.R.
434.32)
Disenrollment studies States must monitor HCFA suggests states
enrollment and termination
practices. (42 C.F.R. 434.63)
analyze erollment statistics.
SFr demonstrateton aises. additional requirnewnts and guidance are in the term aind
caneltimis that HCSFA aderlaps when at appinses a state's maere request, These terms and
conditimns can vaty tby sWate Fm rinkihaned managed care plans. schi aSt prTghea earers.
HCFA'sguiaanceamanteed a Monitiin itskB.tSetManaedCaePlans A Guideha State
Medicasid Aqars. mintpn prepared undeV r canacTha te rh tdcaid Eureauir-HtA tiy am
M Oegfdiuidtn nt Instroe atf w Americrn Public Wellare Aueciaaten (Washingtr. D.C.:
HHS. July 1993l.
PWF 35
GA tnEHS-o7-s Medici tdud Ca- Aumabilty