Common use of Advocate Requirements Clause in Contracts

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 HMO interacts. 9) Provide ongoing input to the HMO management on how changes in the HMO provider network will affect enrollee access to medical care and enrollee quality and continuity of care. Participate in the development and coordination of plans to minimize any potential problems that could be caused by provider network changes. 10) Review and approve the HMO’s informing materials to be distributed to enrollees to assess clarity and accuracy. 11) Assist enrollees and their authorized representatives for the purpose of obtaining their medical records. 12) The lead advocate position is responsible for overall evaluation of the HMO’s internal advocacy plan and is required to monitor any contracts the HMO may enter into for external advocacy with culturally diverse associations or agencies. The lead advocate is responsible for training the associations or agencies and ensuring their input into the HMO’s advocacy plan. b. Staff Requirements and Authority of the BadgerCare Plus and/or Medicaid SSI HMO Advocate At a minimum, the HMO must have one HMO Advocate for BadgerCare Plus and one for Medicaid SSI depending on HMO certification. The advocate(s) must be located in the organizational structure so that they have the authority to perform the functions and duties listed in Section 1, a, 1)-12) above. The HMO certification application requires the HMO to state the staffing levels to perform the functions and duties listed in Subsection 1, a, 1)-12) above in terms of number of full and part time staff and total full time equivalents (FTEs) assigned to these tasks. The Department assumes that an HMO acting as an Administrative Service Organization (ASO) for another HMO will have at least one advocate or FTE position for each ASO contract as well as maintain their own internal advocate(s). The HMO may employ less than a FTE advocate position, but must justify to the satisfaction of the Department why less than one FTE position will suffice for the HMO’s enrollee population. The HMO must also regularly evaluate the advocate position, work plan(s), and job duties and allocate an additional FTE advocate position or positions to meet the duties listed in Subsection 1, a, 1)-12) above if there is significant increase in the HMO’s enrollee population or in the HMO service area. The Department reserves the right to require the HMO to employ an FTE advocate position if the HMO does not demonstrate the adequacy of a part-time advocate position. In order to meet the requirement for the advocate position statewide, the Department encourages the HMO to contract or have a formal memorandum of understanding for advocacy and/or translation services with associations or organizations that have culturally diverse populations within the HMO service area. However, the overall or lead responsibility for the advocate position must be within each HMO. The HMO must monitor the effectiveness of the associations and agencies under contract and may alter the Contract(s) with written notification to the Department. The Medicaid SSI advocate must be knowledgeable and have experience working with disabled persons and shall have adequate time to advocate for the target Medicaid SSI populations.

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 members and providers to facilitate the provision of benefits to enrolleesmembers. 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 enrolleesmembers. 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 member 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 member advocacy groups. Work with enrollee member advocacy groups on an ongoing basis to identify and correct enrollee member 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 enrolleesmembers. 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 member 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 HMO interacts. 9) Provide ongoing input to the HMO management on how changes in the HMO provider network will affect enrollee member access to medical care and enrollee member quality and continuity of care. Participate in the development and coordination of plans to minimize any potential problems that could be caused by provider network changes. 10) Review and approve the HMO’s informing materials to be distributed to enrollees members to assess clarity and accuracy. 11) Assist enrollees members and their authorized representatives for the purpose of obtaining their medical records. 12) The lead advocate position is responsible for overall evaluation of the HMO’s internal advocacy plan and is required to monitor any contracts the HMO may enter into for external advocacy with culturally diverse associations or agencies. The lead advocate is responsible for training the associations or agencies and ensuring their input into the HMO’s advocacy plan. b. Staff Requirements and Authority of the BadgerCare Plus and/or Medicaid SSI HMO Advocate At a minimum, the HMO must have one HMO Advocate for BadgerCare Plus and one for Medicaid SSI depending on HMO certification. The advocate(s) must be located in the organizational structure so that they have the authority to perform the functions and duties listed in Section 1, a, 1)-12) above. The HMO certification application requires the HMO to state the staffing levels to perform the functions and duties listed in Subsection 1, a, 1)-12) above in terms of number of full and part time staff and total full time equivalents (FTEs) assigned to these tasks. The Department assumes that an HMO acting as an Administrative Service Organization (ASO) for another HMO will have at least one advocate or FTE position for each ASO contract as well as maintain their own internal advocate(s). The HMO must consider and monitor current enrollment levels when evaluating the number of advocates necessary to meet the needs of members. The HMO may employ less than a FTE advocate position, but must justify to the satisfaction of the Department why less than one FTE position will suffice for the HMO’s enrollee member population. The HMO must also regularly evaluate the advocate position, work plan(s), and job duties and allocate an additional FTE advocate position or positions to meet the duties listed in Subsection 1, a, 1)-12) above if there is significant increase in the HMO’s enrollee population or in the HMO service area. The Department reserves the right to require the HMO to employ an FTE advocate position if the HMO does not demonstrate the adequacy of a part-time advocate position. In order to meet the requirement for the advocate position statewide, the Department encourages the HMO to contract or have a formal memorandum of understanding for advocacy and/or translation services with associations or organizations that have culturally diverse populations within the HMO service area. However, the overall or lead responsibility for the advocate position must be within each HMO. The HMO must monitor the effectiveness of the associations and agencies under contract and may alter the Contract(s) with written notification to the Department. The Medicaid SSI advocate must be knowledgeable and have experience working with disabled persons and shall have adequate time to advocate for the target Medicaid SSI populations.1)-

Advocate Requirements. The Each HMO must employ a Medicaid/BadgerCare Plus and/or Medicaid SSI HMO Advocate(s) Advocate during the entire contract term. The HMO Advocate(s) Advocate must work with both enrollees and providers to facilitate the provision of Medicaid benefits to enrollees. The , and 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 Medicaid/BadgerCare Plus and/or Medicaid SSI HMO Advocate(s) 1) Investigate and resolve access and cultural sensitivity issues identified by HMO staff, State 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 Advocacy Program for Managed Care. Such participation includes working with DHCAA Managed Care the Department’s managed care staff person assigned to the HMO on issues of access to medical care and quality of medical care and working with the Enrollment Specialist and Medicaid Ombudsmen 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 enrollment/disenrollment. 7) Analyze on an ongoing basis internal HMO system functions, with HMO staff, these 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 HMO interacts. 9) Provide ongoing input to the HMO management on how changes in the HMO provider network will affect enrollee access to medical care and enrollee quality and continuity of care. Participate in the development and coordination of plans to minimize any potential problems that could be caused by provider network changes. 10) Review and approve the HMO’s all HMO informing materials to be distributed to enrollees to assess clarity and accuracy. 11) Assist enrollees and their authorized representatives for the purpose of obtaining their medical records. 12) The lead advocate position is responsible for overall evaluation of the HMO’s internal advocacy plan and is required to monitor any contracts the HMO may enter into for external advocacy with culturally diverse associations or agencies. The lead advocate is responsible for training the associations or agencies and ensuring their input into the HMO’s advocacy plan. b. Staff Requirements and Authority of the Medicaid/BadgerCare Plus and/or Medicaid SSI HMO Advocate Advocate 1) At a minimum, the HMO must have one (1) HMO Advocate for BadgerCare Plus and one for Medicaid SSI depending on HMO certification. The advocate(s) must be located in the organizational structure so that they have the Advocate has the authority to perform the functions and duties listed in Section subsection section 1, a, 1)-12) above. The HMO certification application Certification Application requires the HMO HMOs to state the staffing levels to perform the functions and duties listed in Subsection subsection section 1, a, 1)-12) above in terms of number of full and part time staff and total full time equivalents Full Time Equivalents (FTEs) assigned to these tasks. The Department assumes that an HMO acting as an Administrative Service Organization (ASO) for another HMO will have at least one advocate Advocate or FTE position for each ASO contract as well as maintain their own internal advocate(s). The An HMO may employ less than a FTE advocate position, but must justify to the satisfaction of the Department why less than one (1) FTE position will suffice for the HMO’s enrollee population. The HMO must also regularly evaluate the advocate position, work plan(sworkplan(s), and job duties and allocate an additional FTE advocate position or positions to meet the duties listed in Subsection subsection section 1, a, 1)-12) above if there is significant increase in the HMO’s enrollee population or in the HMO service area. The Department reserves the right to require the an HMO to employ an FTE advocate position if the HMO does not demonstrate the adequacy of a part-time advocate position. In order to meet the requirement for the advocate Advocate position statewide, the Department encourages the HMO HMOs to contract or have a formal memorandum of understanding for advocacy and/or translation services with associations or organizations that have culturally diverse populations within the HMO service area. However, the overall or lead responsibility for the advocate position must be within each HMO. The HMO HMOs must monitor the effectiveness of the associations and agencies under contract and may alter the Contract(scontract(s) with written notification to the Department. . 2) The Medicaid SSI advocate HMO Advocate is responsible for facilitating and ensuring access to all medically necessary services for each enrollee as stipulated in this Contract. 3) The HMO Advocate staffing levels submitted in the HMO Certification Application must be knowledgeable maintained, and have experience working solely devoted to the functions and duties listed subsection 1, a, 1) 12) above throughout the contract term. Changes in the HMO Advocate staffing levels must be approved by the Department 30 days prior to the effective date of the change. 4) Prior to contract signing, the HMO Advocate must develop a Medicaid and BadgerCare HMO Advocacy workplan, with disabled persons the timelines and shall have adequate time to advocate for activities specified, and must maintain and modify it as necessary, throughout the target Medicaid SSI populationscontract term.

Advocate Requirements. The Each HMO must employ a Medicaid/BadgerCare Plus and/or Medicaid SSI HMO Advocate(s) Advocate during the entire contract term. The HMO Advocate(s) Advocate must work with both enrollees and providers to facilitate the provision of Medicaid benefits to enrollees. The , and 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 Medicaid/BadgerCare Plus and/or Medicaid SSI HMO Advocate(s) 1) Investigate and resolve access and cultural sensitivity issues identified by HMO staff, State 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 Advocacy Program for Managed Care. Such participation includes working with DHCAA Managed Care the Department’s managed care staff person assigned to the HMO Contract for February 1, 2006 - December 31, 2007 HMO on issues of access to medical care and quality of medical care and working with the Enrollment Specialist and Medicaid Ombudsmen 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 enrollment/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 HMO interacts. 9) Provide ongoing input to the HMO management on how changes in the HMO provider network will affect enrollee access to medical care and enrollee quality and continuity of care. Participate in the development and coordination of plans to minimize any potential problems that could be caused by provider network changes. 10) Review and approve the HMO’s all HMO informing materials to be distributed to enrollees to assess clarity and accuracy. 11) Assist enrollees and their authorized representatives for the purpose of obtaining their medical records. 12) The lead advocate position is responsible for overall evaluation of the HMO’s internal advocacy plan and is required to monitor any contracts the HMO may enter into for external advocacy with culturally diverse associations or agencies. The lead advocate is responsible for training the associations or agencies and ensuring their input into the HMO’s advocacy plan. b. Staff Requirements and Authority of the Medicaid/BadgerCare Plus and/or Medicaid SSI HMO Advocate Advocate 1) At a minimum, the HMO must have one HMO Advocate for BadgerCare Plus and one for Medicaid SSI depending on HMO certification. The advocate(s) must be located in the organizational structure so that they have the Advocate has the authority to perform the functions and duties listed in Section subsection section 1, a, 1)-12) above. The HMO certification application Certification Application requires the HMO HMOs to state the staffing levels to perform the functions and duties listed in Subsection subsection 1, a, 1)-12) above in terms of number of full HMO Contract for February 1, 2006 - December 31, 2007 and part time staff and total full time equivalents (FTEs) assigned to these tasks. The Department assumes that an HMO acting as an Administrative Service Organization (ASO) for another HMO will have at least one advocate or FTE position for each ASO contract as well as maintain their own internal advocate(s). The An HMO may employ less than a FTE advocate position, but must justify to the satisfaction of the Department why less than one FTE position will suffice for the HMO’s enrollee population. The HMO must also regularly evaluate the advocate position, work plan(sworkplan(s), and job duties and allocate an additional FTE advocate position or positions to meet the duties listed in Subsection subsection 1, a, 1)-12) above if there is significant increase in the HMO’s enrollee population or in the HMO service area. The Department reserves the right to require the an HMO to employ an FTE advocate position if the HMO does not demonstrate the adequacy of a part-time advocate position. In order to meet the requirement for the advocate position statewide, the Department encourages the HMO HMOs to contract or have a formal memorandum of understanding for advocacy and/or translation services with associations or organizations that have culturally diverse populations within the HMO service area. However, the overall or lead responsibility for the advocate position must be within each HMO. The HMO HMOs must monitor the effectiveness of the associations and agencies under contract and may alter the Contract(scontract(s) with written notification to the Department. 2) The HMO advocate is responsible for facilitating and ensuring access to all medically necessary services for each enrollee as stipulated in this Contract. 3) The HMO advocate staffing levels submitted in the HMO Certification Application must be maintained, and solely devoted to the functions and duties listed in subsection 1, a, 1)-12) above throughout the contract term. The Medicaid SSI Changes in the HMO advocate staffing levels must be approved by the Department 30 days prior to the effective date of the change. 4) Prior to contract signing, the HMO advocate must be knowledgeable develop a Medicaid and have experience working BadgerCare HMO advocacy workplan, with disabled persons the timelines and shall have adequate time to advocate activities specified, and must maintain and modify it as necessary, throughout the contract term. HMO Contract for the target Medicaid SSI populations.February 1, 2006 - December 31, 2007