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

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who have a disability. Finally, this State specifies that the committee must review
and analyze all complaints on a quarterly basis, "including review of persistent and
significant complaints from OMAP members (or their representatives) who are
Aged, Blind, Disabled or Children Receiving SOSCF or OYA Services."
Many other states take an approach similar to Tennessee's. This State seeks to
ensure that the plan's quality assurance program is comprehensive for all <strong>Medicaid</strong>
beneficiaries enrolled in the plan. Specifically, the Tennessee contract states that
these activities must "review the entire range of care provided by the organization,
by assuring that all demographic groups, care settings, and types of services are
included in the scope of the review." Tennessee's contract goes on to further specify
that for the clinical studies the plan must perform, "...reflects the population served
by the managed care organization in terms of age groups, disease categories, and
special risk status." Finally, continuing this theme Tennessee specifies that the plan
must develop clinical guidelines for the "full spectrum of populations enrolled in
the plan."
External Reviews
In addition to standards for a plan's internal quality assurance/improvement
system, states perform their own studies to directly examine the care provided to
<strong>Medicaid</strong> enrollees. Federal regulations require that states hire an external quality
review organization (EQRO) to review the care provided by comprehensive health
plans on an annual basis. In addition many states undertake their own studies to
directly examine some aspects of the care delivered by plans. These studies were
discussed in detail in the last chapter of Volume II, so that discussion will not be
repeated here. Rather this section discusses some of the studies two states that have
programs that serve special populations (Oregon and Arizona) are undertaking.
State Experience with EQRO Reviews
Under <strong>Medicaid</strong>, the state agency must contract with a peer review organization
(PRO), a PRO-like entity or an accreditation agency to evaluate the quality of care
within reach plan serving <strong>Medicaid</strong> beneficiaries. There are no federal prescriptions
for the scope of work conducted under the external quality review function for
<strong>Medicaid</strong>, and, over time, states have broadened this activity to include focused
studies, random record reviews, assessments of a plan's internal quality
management program and member surveys.39
In Oregon the EQRO contract is overseen by the Research and Analysis team within
the State's quality assurance unit. This team also reviews plan solvency, reviews
39 The Balanced Budget Act of 1997 expands the types of entities that are qualified to
conduct the external independent review of managed care plans. Also, HCFA, in coordination with the
National Governors' Association and The National <strong>Committee</strong> for Quality Assurance, will develop the
protocols for the external quality review function.
The National Academy for State Health Policy * t 8/97 IV-70