360-10.9 Managed care plan review criteria.
(a) The commissioner will assess a social services district's managed
care plan by determining whether:
(1) the plan reasonably relates to the specific
problems which the MCP is designed to address, including a reasonable estimate of the
MCP's cost-effectiveness;
(2) the plan includes enough managed care
providers, and an adequate network of primary care practitioners and other medical
services providers, which are geographically accessible to the MA recipients who are
eligible to participate in an MCP;
(3) the MCP provides adequate grievance
procedures;
(4) the MCP adequately assures the continuity
and quality of care which is delivered to a participant;
(5) the plan adequately documents that the
community participated in developing the plan;
(6) the MCP includes appropriate procedures to
enroll participants, including the provision of information which meets the requirements
of section 360-10.8(f) of this Subpart;
(7) the MCP provides adequate access to
emergency medical care and services, if included in the plan, and establishes adequate
procedures between managed care providers and hospitals to assure appropriate use of such
care and services;
(8) the plan provides sufficient documentation
that managed care providers, primary care practitioners and medical services providers,
possessing appropriate professional qualifications, licensure or certification, were given
the opportunity to participate in the MCP;
(9) the MCP assures the provision of preventive
care services in accordance with the Child/Teen Health Plan; and
(10) the plan adequately describes how managed
care providers will be enrolled in the MCP.
(b) The commissioner, in consultation with the Department of Health,
will assess the adequacy of the information submitted as a result of the requirements of
paragraphs (2), (4) and (7) of subdivision (a) of this section.