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

Accessibility, Availability,
Referral and Triage
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f) Program Effectiveness (QI 10)
NCQA fails to require that information from the plan's assessment
of its overall effectiveness be shared on a regular basis with the public
payor and made available to the public.
a) Accessibility of Services (ARI 1)
The standards regarding accessibility are very limited and generally
do not address accessibility issues as understood in the public sector.
NCQA standards focus on measures of availability suitable for a work-
ing population (e.g., how quickly telephone queries are answered and
whether members get appointments when they should). While these are
useful, public payors will want to consider issues such as outreach, ser-
vices to homeless persons, cultural barriers to access, language barriers,
the need for assertive follow-up for members who have not kept ap-
pointments, etc. Public purchasers should consider setting their own de-
tailed standards regarding the availability and effectiveness of critical
services for special populations.
NCQA does not require the information collected about plan per-
formance on measures of access to be made available to the payor or to
the public. However, stakeholders should have the opportunity to re-
view how well a plan is doing in reaching the covered population, in-
cluding hard-to-serve groups.
b) Referral and Triage (AR 3)
In public-sector systems, referral and triage should include considera-
tion of the need for various services furnished through various systems,
such as health care, social services, housing and education. The NCQA
standards address only referral to behavioral health services within the
managed care plan and do not address the need for referrals to external
agencies and programs providing related services. A definition of what
is meant by referral and triage would be beneficial, along with specific
standards with respect to referral for various support services.
Utilization Management a) Utilization Management (UM 1)
NCQA requires that there be a written description of the utilization-
management program outlining its structure and accountability. This de-
scription should be made available to the public payor and the public.
NCQA Accreditation Standards for <strong>Managed</strong> Behavioral Healthcare Oreanirarions 6
POLICY ANALYSIS BY THE BAZELON CENTER FOR MENTAL HEALTH LAW 6