Advocate Requirements. The HMO must employ a BadgerCare Plus and/or Medicaid SSI HMO Advocate(s) during the entire contract term. The HMO Advocate(s) must work with both enrollees and providers to facilitate the provision of benefits to enrollees. The advocate is responsible for making recommendations to management on any changes needed to improve either the care provided or the way care is delivered. The advocate position must be in an organizational location within the HMO that provides the authority needed to carry out these tasks. The detailed requirements of the HMO Advocate are listed below:
a. Functions of the BadgerCare Plus and/or Medicaid SSI HMO Advocate(s)
1) Investigate and resolve access and cultural sensitivity issues identified by HMO staff, State staff, providers, advocate organizations, and enrollees.
2) Monitor formal and informal grievances with the grievance personnel for purposes of identification of trends or specific problem areas of access and care delivery. The monitoring function includes ongoing participation in the HMO grievance committee.
3) Recommend policy and procedural changes to HMO management including those needed to ensure and/or improve enrollee access to and quality of care. The recommended changes can be for both internal administrative policies and subcontracted providers.
4) Act as the primary contact for enrollee advocacy groups. Work with enrollee advocacy groups on an ongoing basis to identify and correct enrollee access barriers.
5) Act as the primary contact for local community based organizations (local governmental units, non-profit agencies, etc.). Work with the local community based organizations on an ongoing basis to acquire knowledge and insight regarding the special health care needs of enrollees.
6) Participate in the Department’s advocacy program for Managed Care. Such participation includes working with DHCAA Managed Care staff assigned to the HMO on issues of access to medical care, quality of medical care, and working with the enrollment specialist, ombudsmen, and the Department’s approved external advocate on issues of access to medical care, quality of medical care, and enrollment and disenrollment.
7) Analyze on an ongoing basis internal HMO system functions that affect enrollee access to medical care and quality of medical care.
8) Organize and provide ongoing training and educational materials for the HMO staff and providers to enhance their understanding of the values and practices of all cultures with which the ...
Advocate Requirements. The PIHP must employ a FCMH Member Advocate(s) during the entire contract term. The Advocate(s) must work with both members and providers to facilitate the provision of benefits to members. The advocate is responsible for making recommendations to management on any changes needed to improve either the care provided or the way care is delivered. The advocate position must be in an organizational location within the PIHP that provides the authority needed to carry out these tasks. The detailed requirements of the FCMH Advocate are listed below:
1. Functions of the FCMH Member Advocate(s)
a. Investigate and resolve access and cultural sensitivity issues identified by PIHP staff, State staff, providers, advocate organizations, and members.
b. Monitor formal and informal grievances for purposes of identification of trends or specific problem areas of access and care delivery. The monitoring function includes ongoing participation in the PIHP grievance committee.
c. Recommend policy and procedural changes to PIHP management including those needed to ensure and/or improve member access to and quality of care. The recommended changes can be for both internal administrative policies and subcontracted providers.
d. Act as the primary contact for member advocacy groups. Work with member advocacy groups on an ongoing basis to identify and correct member access barriers.
e. Act as the primary contact for local community based organizations (local governmental units, non-profit agencies, etc.). Work with local community based organizations on an ongoing basis to acquire knowledge and insight regarding the special health care needs of members.
f. Participate in working with DHCAA Managed Care staff assigned to the PIHP on issues of access to medical care, quality of medical care, and working with the enrollment specialist, ombudsmen, and the Department’s approved external advocate on issues of access to medical care, quality of medical care, and enrollment and disenrollment.
g. Analyze on an ongoing basis internal PIHP system functions that affect member access to medical care and quality of medical care.
