Ongoing Managed Care Organization Monitoring. To ensure the quality of care, the Department will undertake the following monitoring activities including, but not limited to:
1. Analyze the MCO’s access enhancement programs, financial and utilization data, and other reports to monitor the value the MCO is providing in return for the State’s capitation revenues. Such efforts will include audits of the MCO and its subcontractors. .
2. Conduct regular recipient surveys addressing issues such as satisfaction and reasons for disenrollment.
3. Review MCO certifications on a regular basis.
4. At its discretion, commission or conduct additional objective studies of the effectiveness of the MCO.
5. Monitor the enrollment and termination practices.
6. Assure the proper implementation of the required grievance procedures.
7. Conduct periodic reviews of the MCO provider credentialing process and network to ensure that providers excluded from Medicaid participation are excluded from the MCO Medicaid provider network. These monitoring activities will take place at least once per year. The Department or its contractors must provide to the MCO summaries, at the Department’s expense, of all monitoring activity reports, surveys, audits, studies, reviews, and analyses.
Ongoing Managed Care Organization Monitoring. To ensure the quality of care, the Department will undertake monitoring activities outlined in 42 CFR 438.66 including, but not limited to:
1. Analyze the MCO’s access enhancement programs, financial and utilization data, and other reports to monitor the value the MCO is providing in return for the State’s capitation revenues. Such efforts will include audits of the MCO and its Subcontractors.
2. Conduct regular enrollee surveys addressing issues such as satisfaction and reasons for disenrollment.
3. Review MCO certifications on a regular basis.
4. At DHHR’s discretion, commission or conduct additional objective studies of the effectiveness of the MCO.
5. Monitor the enrollment and termination practices.
6. Assure the proper implementation of the required grievance procedures.
7. Conduct periodic reviews of the MCO provider credentialing process and network to ensure that providers excluded from Medicaid and BCF participation are excluded from the MCO provider network. These monitoring activities will take place at least once per year. The state will also perform a readiness review at least three (3) months prior to implementing a managed care program or the addition of a new eligibility group. The Department or its contractors must provide to the MCO summaries, at the Department’s expense, of all monitoring activity reports, surveys, audits, studies, reviews, and analyses. The Department will submit to CMS a report on the managed care program no later than one hundred eighty (180) days after the end of each contract year and the report will be posted on the state’s website and provided to the state’s Medical Care Advisory Committee.
Ongoing Managed Care Organization Monitoring. To ensure the quality of care, BMS will undertake the following monitoring activities including, but not limited to:
1. Analyze the MCO’s access enhancement programs, financial and utilization data, and other reports to monitor the value the MCO is providing in return for the State’s capitation revenues. Such efforts will include audits of the MCO and its Subcontractors.
2. Conduct regular enrollee surveys addressing issues such as satisfaction and reasons for disenrollment.
3. Review MCO certifications on a regular basis.
4. At its discretion, commission or conduct additional objective studies of the effectiveness of the MCO.
Ongoing Managed Care Organization Monitoring. To ensure the quality of care, the Department will undertake the following monitoring activities:
1. Analyze the MCO’s access enhancement programs, financial and utilization data, and other reports to monitor the value the MCO is providing in return for the State’s capitation revenues. Such efforts will include audits of the MCO and its subcontracted providers.
2. Conduct regular recipient surveys addressing issues such as satisfaction and reasons for disenrollment.
3. Review MCO certifications on a regular basis.
4. At its discretion, commission or conduct additional objective studies of the effectiveness of the MCO.
5. Monitor the enrollment and termination practices.
6. Assure the proper implementation of the required grievance procedures.
7. Conduct periodic reviews of the MCO provider credentialing process and network to ensure that providers excluded from Medicaid participation are excluded from the MCO Medicaid provider network. These audits will take place at least once per year. The Department or its contractors must provide to the MCO summaries, at the Department’s expense, of all monitoring activity reports, surveys, audits, studies, reviews, and analyses.
