MCO Requirements Sample Clauses
The MCO Requirements clause sets out the specific obligations and standards that a Managed Care Organization (MCO) must meet under an agreement. Typically, this clause details compliance with applicable laws, reporting duties, quality assurance measures, and operational protocols that the MCO must follow. For example, it may require the MCO to maintain certain accreditation, submit regular performance reports, or adhere to state and federal healthcare regulations. The core function of this clause is to ensure that the MCO consistently delivers services at the required level of quality and in accordance with regulatory expectations, thereby protecting the interests of both the contracting party and the end recipients of care.
MCO Requirements. The MCO must present SDS as a choice to all members as specified in s DHS 10.44(6) Wis. Admin. Code. Specific responsibilities of the MCO are to:
1. Ensure that SDS funds are not used to purchase residential services that are included as part of a bundled residential services rate in a long-term care facility. Members who live in residential settings can self-direct services that are not part of the residential rate. The cost of residential services may be used in establishing the member’s SDS budget if the MCO would have authorized residential services for the member if the member were not participating in SDS.
2. Continue to expand the variety of choices and supports available within SDS.
3. Ensure that all IDT staff understand SDS, how to create a budget with a member and how to monitor SDS with a member and their support team, or ensure team staff have access to someone within the MCO who has expertise in SDS to assist with setting budgets and monitoring for quality and safety.
4. Collaborate with the Department in its efforts to develop systems for evaluating the quality of SDS, including members’ experiences with SDS.
5. Develop and implement a Department-approved policy and procedure describing conditions under which the MCO may restrict the level of self-management exercised by a member where the team finds any of the following:
a. The health and safety of the member or another person is threatened.
b. The member’s expenditures are inconsistent with the established plan and budget.
c. The conflicting interests of another person are taking precedence over the outcomes and preferences of the member.
d. Funds have been used for illegal purposes.
e. Additional criteria for restricting the level of self-management exercised by a member may be approved by the Department in relation to other situations that the MCO has identified as having negative consequences. The MCO’s policy and procedure for limiting SDS shall be submitted to the Department for approval prior to implementation, whenever a change occurs, and upon request. The MCO shall share SDS materials with the resource centers in their service areas that will allow the resource centers to provide appropriate options counseling about the SDS option to potential enrollees.
MCO Requirements. The MCO must establish internal grievance and appeal procedures (informal and formal steps) that permit an eligible enrollee, or a provider on behalf of an enrollee, to challenge the denials of coverage of medical assistance or denials of payment for medical assistance:
a. The MCO must establish and maintain a grievance and appeal procedure, which has been approved by the State, to provide adequate and reasonable procedures for the expeditious resolution of grievances initiated by enrollees or their providers concerning any matter relating to any provision of the MCO’s health maintenance contracts, including, but not limited to, claims regarding the scope of coverage for health care services; denials, reductions, cancellations or nonrenewals of enrollee coverage; failure to provide services in a timely manner, observance of an enrollee’s rights as a patient; and the quality of the health care services rendered.
b. A detailed description of the MCO’s enrollee grievance and appeal procedure must be included in the member handbook provided to enrollees. This procedure must be administered at no cost to the enrollee.
c. As part of MCO’s enrollee grievance and appeal procedure, the MCO must:
i. Make available both informal and formal steps to resolve the grievance;
ii. Designate at least one grievance coordinator;
iii. Permit that both grievances and appeals can be filed orally or in writing;
iv. Provide reasonable assistance in completing the procedure, including but not limited to completing forms and toll-free phone numbers as specified by the MCO;
v. Acknowledge receipt of grievances and appeals;
vi. Involve some person with problem solving authority at each level of the grievance procedure;
vii. Ensure that individuals reviewing and making decisions on grievances and appeals were not previously involved in decisions related to the grievance or appeal under review;
viii. Ensure that individuals reviewing medically related grievances or denials of expedited resolution of an appeal have appropriate clinical expertise, as determined by the State in treating the enrollee’s condition or disease;
ix. Process and provide notice to affected parties regarding the enrollee grievance in a reasonable length of time not to exceed 45 days from the day the MCO receives the grievance, unless the enrollee requests an extension or the MCO shows that a delay is necessary and in the interest of the enrollee;
x. Ensure that standard resolution and notice occurs with the timefra...