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

773
quest, am awilablefor review by plan Members plan Members shall receive
infornation describing the methodfor obtaining access to the criteria and
,guadlines. 1 '
G- Link to an Appeal System
Regardless of how well the plan does, there will always be occasions
of dispute between the plan and members about decisions on medical necessity.
The contract should therefore clearly spell out an appropriate
grievance and appeal mechanism, and the contract's definition of meditally
necessary' should form the basis for resolving such disputes.
(a) decisions as to wvhether a particular sermce, supply or technique is
medicaly necessary shall be subject to appeal by a Member ander secion
_(appalprovisions); the definition of medical necessity setforth in _
shallform the basisfor resolving such disputes;
(b)Members mayalso use thegrietanceprocess set out in _ (grievance
process) to complain about medical necesiqy decsions. The definition
of medical necessity setforth in Section _ shallform the basisfor resolving
such grievances,
Sanctions In developing contracts for managed mental health care, states will
need to address the issue of what sanctions areapplied should the plan
fail to comply with the provisions of the contract: Unless specific sanctions
apply if a plan violates the requirements of the medical-necessity
criteria, the state will have only limited options: to ignore the violations,
to pressure the plan to address the violations or to cancel the entire
contract. A better approach would be to delineate specific interim
sanctions, such as monetary penalties, for failure to follow the medicalnecessity
criteria appropriately.
Failure of a plan to deliver services according to the above criteria shall be Cause
for sanctious, as dscribed in Section - ofthe contract
CONCLUSION TIhe material in this-doement covers a significant range of issues,
expanding the concept of medically necessary beyond the definitions in
most current state contracts. It is intended to stimulate new thinking
about decisionmaking regarding what services will be furnished to an in-
Defining Medically Necessary' Services to Protect Plan Members 1
POLICY ANALYSIS BY THE BAZELON CENTER FOR MENTAL HEALTH LAW 19