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

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attained this ability through use of an 1115 waiver that identifies the State as HCFA's
agent for the Medicare program, at least for those <strong>Medicaid</strong> beneficiaries that enroll
in this program. Some other states (e.g., Maine and Massachusetts) are working
with HCFA to obtain and analyze information about fee-for-service claims paid for
<strong>Medicaid</strong> beneficiaries.
An overarching issue that directly relates to plans that contract with both <strong>Medicaid</strong>
and Medicare to serve dual eligibles is that these plans have to meet both Medicare
and <strong>Medicaid</strong> requirements for quality assurance. Although there are many
similarities between the two sets of requirements they are not identical and plans
may be frustrated by having to deal with multiple 'government' regulations and
entities. Also, given that both agencies are attempting to ensure quality this could
become a singular opportunity for both the State and federal government to
maximize resources by combining (or at least avoiding duplication of) their
oversight activities.
Medicare Quality Standards
This section describes Medicare quality standards in order to provide <strong>Medicaid</strong>
agencies with information they may need if they enroll dual eligibles into <strong>Medicaid</strong>
managed care plans. HCFA's quality standards for Medicare HMOs are contained in
the requirements for approving risk contracts and are consistent with many
<strong>Medicaid</strong> contract requirements. Examples of Medicare requirements include: plans
must demonstrate the adequacy of their network; make arrangements for after
hours care; implement monitoring systems to evaluate waiting times for
appointments for routine scheduled and urgent care, member complaint
procedures, inappropriate use of emergency rooms, the number of requests to
change primary care physicians and the volume of out of plan referrals by specialty
and service; and plans must ensure continuity of care among health care
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providers.
HCFA's protocol reviews the HMO's written program for continuous quality
improvement which includes emphasis on health outcomes, peer review,
systematic data collection and steps for remedial action. In addition, the quality
assurance program must include a process for determining whether problems exist
and for evaluating the implementation of corrective action. Health outcomes must
be examined by focusing on diagnoses or procedures which are prevalent in the
plan, and the effectiveness of mechanisms designed to influence the behavior of
physicians. Peer review committees are required. The data collection system must
collect performance data, patient results and interpret the results to clinicians.
42 , The Balanced Budget Act of 1997 defines the elements of a Medicare risk contractors
quality assurance program. Greater emphasis is placed on health outcomes and the dissemination of
information on quality and outcome measures "to facilitate beneficiary comparison and choice of health
care coverage option.'
The National Academy for State Health Policye * 8/97 IV-74