Negotiating the New Health Care System, 4th Edition

 

Table of Contents

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States

Chapter 1.  Enrollment

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

1.2 Enrollment Procedure

• Enrollee selection of provider
• Time-line for provider selection
• Enrollee ability to change providers

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

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

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

1.6 Information for Enrollees on Plan Policies and Procedures

• Prior authorization procedures
• Grievances and complaints procedures
• Disenrolled by plan procedures
• Disenrolled by enrollee procedures
• Confidentiality policies
• Physician incentive agreements
• Access to fair hearings

1.7 Plan Disenrollment of Enrollees

• 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

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

2.6 Urgent Care and Emergency Care Services

Urgent care

• Urgent care: Coverage
• Urgent care: Definition

Emergency care

• 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

2.7 Medical Necessity Standards

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

Chapter 3. Service Duties

3.1.1 Provider Coordination and Standards

• Hospitals and other institutions
• Mental health substance abuse providers
• Obstetric providers
• Pediatric providers
• Pharmacies
• Role of primary care providers
• Definition of primary care
• Definition of case management and scope of case management duties
• Specialty care/other providers
• Traditional and safety net providers
• Dual diagnosis providers

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

• Cultural competence requirement
• Cultural competence defined

3.7 Access Time Standards

• Emergency care
• First appointments for new enrollees
• Medically necessary/acute care adult visits
• Medically necessary/acute care 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

3.8 Geographic Access Standards

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

Chapter 4. Public Health and Social Service Agency Relationships

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

Chapter 5. Quality Assurance, Data, and Reporting

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 service duties

5.2 General Data Reporting

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

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

5.4 Maternal and Child Health Data Reporting

• Prenatal care
• EPSDT
• Immunization

Chapter 6. Business Terms and Relationships

6.1 General Qualifications and Requirements

• Contract term and termination, for cause; without cause