Negotiating the New Health Care System, 4th Edition

Medicaid Managed Care General Service Agreements

TABLE OF CONTENTS

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States

Chapter 1. Enrollment

Table 1.1 Managed Care Enrolled Population

• AFDC
• AFDC-related
• Poor children
• Poor pregnant women
• Persons with disability
• Homeless persons
• Refugees
• Persons with mental illness
• Persons with addictive disorders
• Elderly
• Residents of long-term care facilities
• Persons needing long-term home and community care
• Children in foster care or out-of-home placement
• Other individuals
• Persons with dual diagnosis
• Pregnant women with addictive disorders

Table 1.2 Enrollment Procedure

• Enrollee selection of plan
• Time-line for plan selection
• Enrollee ability to change plans

Table 1.3 Auto-enrollment Procedure

• Auto-enrollment process
• Time-line for auto-enrollment
• Prohibited populations
• Limits on proportion of eligible population to be auto-enrolled
• Enrollee ability to change plans
• Existence of algorithm for allocation of enrollees

Table 1.4 Special Enrollment Procedures

• Adults with mental illness
• Adults with addictive disorders
• Children with addictive disorders
• Children with mental illness
• Children in foster care or out-of-home placement
• Homeless persons
• Migrant families
• Newborns
• Non-English speakers
• Persons in ongoing treatment
• Persons in inpatient settings
• Persons in residential treatment
• Pregnant women

Table 1.5 Information for Enrollees on Coverage Rules and Provider Participation

• Service coverage, limits, and exclusions
• Obtaining Medicaid covered services not in plan contract
• Urgent care
• Emergency care
• Translation services
• Transportation services
• Participating provider
• Primary care provider openings
• Other

Table 1.6 Information for Enrollees on Plan Policies and Procedures

• Prior authorization procedures
• Grievances and complaints procedures
• Disenrollment by plan procedures
• Disenrollment by enrollee procedures
• Confidentiality policies
• Physician incentive agreements

Table 1.7 Plan Disenrollment of Members

• Plan disenrollment for loss of coverage or eligibility
• Plan disenrollment for cause
• Agency approval process for plan disenrollment
• Protections against plan disenrollment

Chapter 2. Coverage and Benefits

Table 2.1 General Services

• Hospital inpatient services
• Hospital outpatient services
• Laboratory and X-ray
• Physician services
• Nurse midwife services
• FQHC and rural health clinics
• EPSDT
• Home health care
• Nurse practitioners
• Dental care
• Durable medical equipment (DME)
• Mental health and substance abuse
• Prescription drugs
• Case management
• Other
• Treatment services for individuals with dual diagnosis

Table 2.2 Mental Health and Substance Abuse Duties

• Care coordination/case management
• Crisis care
• Family therapy
• Individual therapy
• Group therapy
• Hospital detoxification
• Inpatient services for persons under 21
• Long-term residential
• Medication management
• Non-hospital residential detoxification
• Outpatient treatment
• Partial day treatment programs
• Prescribed drugs
• Preventive health services
• Referrals
• Screening, assessment and diagnosis
• Short-term residential(includes hospital)
• Transportation
• Other
• Mental health parity requirements

Table 2.3 Reproductive Health Services

• Maternity coverage
• Enhanced prenatal care
• Parenting Education
• Family planning services
• IUD
• Depo provera
• Norplant
• Other contraceptives
• Infertility services
• Other gynecological services

Table 2.4 EPSDT Services

• General definition
• Immunization
• Medical and developmental screens/interperiodic screening
• Vision services
• Hearing services
• Dental services
• Other diagnosis and treatment
• Other activities
• Exclusions

Table 2.5 Communicable Disease Services

• Sexually transmitted diseases (STD)
• HIV/AIDS
• Tuberculosis
• Public health immunizations

Table 2.6 Urgent Care and Emergency Care Services

• Urgent care: Coverage
• Urgent care: Definition
• Emergency care: Coverage
• Emergency care: Definition
• Coverage for urgent and emergency services out-of-plan
• Definition of emergency specific to mental health or substance abuse
• Definition of pediatric emergency
• Definition of pregnancy-related emergency

Table 2.7 Medical Necessity Standards

• General coverage rule
• Medical necessity standard
• Pediatric medical necessity standard
• Mental health or substance abuse related standard
• Pregnancy medical necessity standard
• TB-related medical necessity standard
• Dual diagnosis medical necessity standard

Table 2.8 Services in Treatment Plans of Other Agencies and Court Orders

• Individualized Family Service Plan -IFSP (birth to 3 years)
• Individualized Education Plan-IEP (3 to 21 years)
• Children in foster care or out-of-home placement
• Services in court orders or justice system plans
• Mental health agency treatment plan
• Substance abuse agency treatment plan

Chapter 3. Service Duties

Table 3.1 Provider Network Composition

• Hospitals and other institutions
• Mental health and substance abuse providers
• Obstetric providers
• Pediatric providers
• Pharmacies
• Primary care providers
• Primary care provider/patient ratios
• Specialty care providers
• Specialty care provider/patient ratios
• Traditional and safety net providers
• Dual diagnosis providers

Table 3.1.1 Provider Coordination and Standards

• Hospitals and other institutions
• Mental health and substance abuse providers
• Obstetric providers
• Pediatric providers
• Pharmacies
• Role of primary care providers
• Specialty care providers
• Traditional and safety net providers
• Dual diagnosis providers

Table 3.2 Plan Service Area Standards

• Service areas defined
• Plan analysis of service area needs

Table 3.3 Selection and Assignment of Primary Care Providers

• Selection process
• Selection guarantee
• Selection for patients under treatment
• Selection time limit for member
• Assignment of non-selecting members
• Changes in primary care provider selection/assignment

Table 3.4 Self-referrals to Selected Providers

• Mental health
• Substance abuse
• Obstetrics
• Family planning
• Other

Table 3.5 Utilization Review and Prior Authorization

• Utilization review process
• Prior authorization prohibited for certain procedures
• Reviewers clinically competent
• Time limits for prior authorization
• 24-hour telephone access for prior authorization
• Assessment of under-utilization required
• Required to use review or authorization for mental health and substance abuse
• Required to use review or authorization for dual diagnosis
• Provision for expedited prior authorization

Table 3.6 Translation Services and Cultural Competence

• Multi-lingual providers in network
• Disability-communication capacity required in network
• Materials in other language or in form useful to people with disabilities
• Services for persons whose primary language is not English
• Services for persons with speech, language, hearing, or vision related disabilities
• Provision of easily understood information
• Cultural competence requirement
• Cultural competence defined

Table 3.7 Access Time Standards

• Emergency care
• First appointments for new enrollees
• Medically necessary adult visits
• Medically necessary pediatric visits
• Specialty specific services
• Preventive pediatric visits
• Preventive adult visits
• Services for mental illness
• Services for pregnant women
• Services for substance abuse disorders
• Urgent care

Table 3.8 Geographic Access Standards

• For primary care providers
• For specialty or inpatient care providers
• For other benefits or services

Table 3.9 Drug Formularies

• Drug formulary permitted
• Time limits for approval of off-formulary drugs
• Prior authorization for drugs on formulary
• Periodic review and update of formulary
• Substitution of therapeutic equivalence
• Drug use/utilization review

Table 3.10 Anti-discrimination provisions

• Age
• Anticipated need for health care
• Disability
• Gender
• Income
• Language
• Medicaid status
• Mental health status
• Pre-existing condition or health status
• Race/ethnicity
• Sexual preference
• Substance abuse status
• Other

Chapter 4. Public Health and Social Service Agency Relationships

Table 4.1 Relationships with Other Public Agencies

• Adult correction
• Adult welfare
• Child welfare
• Children with special health care needs
• Early intervention
• Homeless health
• Juvenile justice
• School health clinics
• Special education
• State/local public health
• State/local mental health
• State/local substance abuse
• State senior services
• WIC Supplemental Nutrition
• Head Start
• Other

Table 4.2 Population-based services and reporting

• Needs assessment in plan service area
• Reporting of selected notifiable diseases and conditions

Chapter 5. Quality Assurance, Data, and Reporting

Table 5.1 Quality Assurance

• Internal QA system
• External review of plan's performance
• Clinical studies
• Clinical guidelines
• Profiling provider performance
• Evaluation of grievances and complaints
• Corrective action plan
• Linkage between performance measures and services duties

Table 5.2 General Data Reporting

• Access data
• Complaints and grievances
• Encounter data
• Financial data
• General authorization
• Outcomes data
• Performance data
• Utilization data
• Other

Table 5.3 Mental Health and Substance Abuse Data Reporting

• Care process and outcome data for mental health and substance abuse treatment
• Discharge data for addictive disorder
• Hospitalization for addictive disorder
• Hospitalization for mental illness
• Identified substance abuse
• Identified domestic abuse
• QA/Utilization measures for mental health/substance abuse treatment
• Other

Table 5.4 Maternal and Child Health Data Reporting

• Prenatal care
• EPSDT
• Immunization

Chapter 6. Business Terms and Relationships

Table 6.1 General Qualifications and Requirements

• State licensure/Accreditation
• Federally qualified HMO status
• Initial capitalization
• Reinsurance
• Reserve
• Limits on allowable administrative costs
• Limits on profits
• MIS requirements
• Other

Table 6.2 Beneficiary Grievance Procedures

• Internal grievance process
• Time lines for grievance response
• Expedited grievance process
• External appeal to state

Table 6.3 Network Provider/Plan Relationship

• Grievance process for providers
• Provider selection standards
• Provider termination standards
• Risk-adjustment in provider evaluations
• Stop-loss insurance for providers
• Prohibition on plan delegation of liability to subcontractor
• Restrictions on physician incentive agreements
• Restrctions on provider communications with enrollees
• Use of unique physician identifiers
• Scope of duties delegated to subcontractors

Table 6.4 Sanctions

• Adjustment to current enrollment
• Adjustment in payment
• Change in covered services
• Corrective action plan
• Liquidated/exemplary damages
• Mandated payment for medically necessary out-of-plan care
• Receivership
• Revocation of license
• State payment to out-of-plan provider furnishing necessary care, recouped from plan
• Suspension or freezing new enrollment
• Termination
• Withholding of capitation
• Withholding of shared savings
• Other

Chapter 7. Payment

Table 7.1 Plan Payment Terms

• Premium includes all covered services
• Fee-for-service for some or all covered services
• Withholding of payments
• State delegation of third party liability collection
• Actuarial sound capitation rate

Table 7.2 Provider Payment Terms

• Time lines for payment to network providers
• Special payments for certain classes of providers
• Payment rules for non-network providers
• Cost sharing