360-10.8 Managed care plan requirements.
A managed care plan must satisfy the MCP requirements of section 360- 10.4 of this
Subpart, and must:
(a) identify and document the specific problems which the MCP is
designed to address. This must include a description of he current sources and
distribution of primary care practitioners which are available to MA recipients within the
social services district and a reasonable estimate of the MCP's cost-effectiveness;
(b) identify the selected managed care providers which will participate
in the MCP and assure that such providers are accessible to MCP participants, taking into
account differences between rural, suburban, and urban settings, and available in
sufficient numbers to provide MA services to participants;
(c) describe how the MCP will provide for the continuity and quality of
services which are delivered to participants. This must include considering a
participant's existing relationship with a medical services provider, especially a primary
care practitioner;
(d) demonstrate that MA recipients, health care providers, managed care
providers, insurers, and the general public were provided the opportunity to participate
in developing the plan;
(e) describe the enrollment process and any marketing materials that
the social services district plans to use and indicate whether the district or some other
entity will enroll participants;
(f) demonstrate that MA recipients who are eligible to participate in
an MCP will be fully informed of how an MCP provides services, and provide enough
information, in a form which is reasonably understandable to persons of the varying
cultural backgrounds represented in the MA recipient population, to assure that such
recipients can make informed choices of managed care providers and primary care providers;
(g) describe how the MCP will provide emergency medical care and
services if such care and services are included in the managed care plan. This must
include: how access to emergency medical care and services will be made available 24 hours
a day and seven days a week; the procedures, including payment criteria, that managed care
providers and hospitals will use to assure appropriate use of emergency medical care and
services; and any provision for payment for non-emergency care which is furnished in
hospital emergency rooms. Emergency medical care and services must include, at a minimum,
care or services which are needed immediately because of an injury or sudden illness;
(h) describe the efforts the social services district made to enroll
managed care providers and demonstrate that the district provided public notice of its
intent to contract with managed care providers and negotiated in good faith with any
potential managed care provider, possessing appropriate professional qualifications,
licensure, or certification, which expressed interest in becoming a managed care provider;
(i) provide for an adequate grievance procedure to be carried out by
the managed care provider for MA recipients who participate in the MCP;
(j) describe the efforts the social services district made to enroll
primary care practitioners and other medical services providers in the MCP. This must
include specific activities which were designed to recruit practitioners possessing
appropriate professional qualifications, licensure or certification, on a
non-discriminatory basis;
(k) provide for sufficient numbers and distribution of primary care
practitioners and other medical services providers to meet the needs of all participants
adequately, and include as many provider types as possible;
(l) describe how preventive care services, such as the periodic
assessment and early treatment of children's health conditions, will be provided or
coordinated under the Child/Teen Health Plan; and
(m) establish goals that seek enrollment of at least:
(1) 10 percent of the non-MCP excluded or
exempt MA recipients in the social services district within one year of approval of the
plan;
(2) 25 percent of the non-MCP excluded or
exempt MA recipients in the social services district within three years of approval of the
plan; and
(3) 50 percent of the non-MCP excluded or
exempt MA recipients in the social services district within five years of approval of the
plan.
If a social services district's reasonable efforts fail to achieve these enrollment goals,
such failure will not be grounds for the imposition of a penalty by the commissioner. The
commissioner may approve a plan that may not achieve these enrollment goals, but would
improve the quality and cost- effectiveness of care provided to MA recipients residing in
the social services district.