Current through September 17, 2024
The Department has implemented systems for the ongoing
assessment of the quality and appropriateness of care and services furnished to
all Medicaid enrollees under the health plan contracts. These systems enable
the Department's monitoring of data related to the access of Medicaid clients
to comprehensive, cost-effective health services, including evidence-based care
options that emphasize early intervention and community-based treatment and
reduced rates of costly and avoidable emergency and inpatient hospital levels
of care. Through the implementation of these assessment systems, the Department
can monitor trends, demonstrate success and identify challenges in achieving
the objectives of the Heritage Health program.
003.01
ASSESMENT.
The Department assesses the quality and appropriateness of care through
multiple processes that comprise a comprehensive system of oversight:
(A) Quarterly reporting of provider
accessibility analyses, timely access standards monitoring, grievances and
appeals process compliance, utilization management monitoring, results of
service verification monitoring, out of network referrals monitoring and case
management results.
(B) Annual
reporting of Medicaid selected performance measure results and trends related
to quality of care, service utilization and member and provider
satisfaction.
(C) Annual reporting
of performance improvement projects data and results.
(D) Annual, external independent reviews of
the quality outcomes, timeliness of and access to, the services covered by the
plan through its external quality review organization.
(E) Annual state-staff-conducted onsite
operational reviews that include validation of reports and data previously
submitted by the plan and in-depth review of areas that have been identified as
potentially problematic.
(F)
Medicaid requires the plan to attend annual Quality Management Committee
meetings, during which data and information designed to analyze the objectives
of the Quality Strategy are reviewed. The Quality Management Committee
recommends actions to improve quality of care, access, utilization, and client
satisfaction, and to review the results of the performance improvement projects
and recommend future performance improvement projects topics. The Quality
Management Committee also reviews the state's overall Quality Strategy and
makes recommendations for improvement.
003.02
OPERATIONAL ON-SITE
REVIEW. Operational reviews are conducted for each health plan
annually by the Department. Additionally, random reviews of each health plan
notification of adverse actions will be completed. The Department and other
agencies may use the operational review to validate a plan's accreditation.
003.02(A)
COMPONENTS OF THE
OPERATIONAL REVIEWS. Operational reviews include, but are not
limited to, an in-depth review of each health plan's quality management work
plan, review of cultural competency, general administration, and delivery
system.
003.03
EXTERNAL QUALITY REVIEW. The Department is required to
contract with a qualified External Quality Review Organization to perform an
annual external quality review for each contracting health plan. The External
Quality Review Organization is independent from the Department and from the
health plans.
003.03(A)
EXTERNAL
QUALITY REVIEW ORGANIZATION DUTIES. The External Quality Review
Organization will annually:
(i) Validate
performance improvement projects required by the Department that were underway
during the preceding 12 months;
(ii) Validate the health plans performance
measures reported to the Department during the preceding 12 months;
and
(iii) Conduct a review to
determine the health plans compliance with standards.
003.03(B)
EXTERNAL QUALITY REVIEW
ORGANIZATION RESULTS. The Department will use the results of the
reviews in assessing and monitoring the quality and appropriateness of care
provided to members as part of the Department's quality
strategy.
003.04
DETERMINATION OF CONTRACT COMPLIANCE. The Department
will monitor the health plans contract for compliance. A plan is noncompliant
if it falls below the established standards for quality of care, access, client
satisfaction, utilization, and encounter submission.
003.04(A)
VIOLATIONS SUBJECT TO
INTERMEDIATE SANCTIONS. The following violations are grounds for
intermediate sanctions that may be imposed when a health plan acts or fails to
act as follows:
(i) The health plan fails
substantially to provide medically necessary services that the health plan is
required to provide, under law or under its contract with the State, to an
enrollee covered under the contract;
(ii) The health plan imposes on enrollees
premiums or charges that are in excess of the premiums or charges permitted
under the Medicaid program;
(iii)
The health plan acts to discriminate among enrollees on the basis of their
health status or need for health care services;
(iv) The health plan misrepresents or
falsifies information that it furnishes to the Centers for Medicare and
Medicaid Services or to the State;
(v) The health plan misrepresents or
falsifies information that it furnishes to an enrollee, potential enrollee, or
health care provider;
(vi) The
health plan fails to comply with the requirements for physician incentive
plans, if applicable;
(vii) The
health plan has distributed directly, or indirectly through any agent or
independent contractor, marketing materials that have not been approved by the
State or that contain false or materially misleading information; or
(viii) The health plan has violated any of
the other applicable requirements of sections 1903(m) or 1932 of the Social
Security Act and any implementing regulations.
003.04(B)
ENFORCEMENT. The health plans that are determined to
be performing below quality standards through periodic reporting, performance
measures, member satisfaction surveys, encounter data submission, on-site
operational review, and/or review and analysis of the quality management work
plan will be required to submit a plan of correction which addresses each
deficiency specifically and provides a timeline by which corrective action will
be completed. Medicaid requires follow-up reporting by the health plan to
assess progress in implementing the plan of correction.
003.04(B)(i)
ADDITIONAL
ACTIONS. If the health plan has not come into compliance upon
completion of the plan of correction, the Department will take additional
actions against the health plan. These additional actions include:
(1) Instituting a restriction on the types of
enrollees;
(2) Changing the auto
assignment algorithm to limit the number of enrollees into the plan, when
applicable; or
(3) Ban new
auto-assignments to the plan, when applicable.
003.04(C)
INTERMEDIATE
SANCTIONS. The Department will impose the following sanctions for
violations subject to intermediate sanctions listed in 482 NAC 6-003.04(A):
(i) Civil monetary penalties in the following
specified amounts:
(1) A maximum of $25,000
for each determination of failure to provide services; misrepresentation or
false statements to members, potential members, or health care providers;
failure to comply with physician incentive plan requirements; or marketing
violations;
(2) A maximum of
$100,000 for each determination of discrimination; or misrepresentation or
false statement to the Centers for Medicare and Medicaid Services or the
Department;
(3) A maximum of
$15,000 for each recipient the Department determines was not enrolled because
of a discriminatory practice, subject to the $100,000 overall limit;
(4) A maximum of $25,000 or double the amount
of the excess charges, whichever is greater, for charging premiums or charges
in excess of the amounts permitted under the Medicaid program. The Department
must deduct from the penalty the amount of overcharge and return it to the
affected client member.
(ii) Appointment of temporary management as
described in Section III.Y Early Termination of the health plan's
contract;
(iii) Granting members
the right to terminate enrollment without cause and notifying the affected
members of their right to disenroll;
(iv) Suspension of all new enrollment,
including default enrollment, after the date of the effective date of the
sanction; and
(v) Suspension of
payment for members enrolled after the effective date of the sanction and until
the Centers for Medicare and Medicaid Services or the Department is satisfied
that the reason for imposition of the sanction no longer exists and is not
likely to occur.
