To: Health Advocates
Re: Medicaid Managed Care: Health Plan Monitoring
The following are suggestions for legal services and community-based advocates who want to monitor the implementation and operation of Medicaid managed care at the health plan level. These suggestions are taken from activities undertaken by advocates across the country, and we have given examples in parenthesis. Please let us know about your activities so that we can share these suggestions with other advocates.
1. Ask your state to conduct pre-enrollment readiness reviews of health plans seeking to contract with the state. Tell the state you want to be involved in the development of the tool and in the reviews, including site visits. (E.g., MI, PA).
2. Ask the health plans serving your area and the state to share drafts of written education and enrollment materials (e.g., handbooks, policies, notices, forms) so you can "pre-test" them for consumer friendliness (e.g., Ohio).
3. Inform health plans, beneficiaries, communities, and providers about impending changes in federal/state laws.
4. Encourage Medicaid beneficiaries to request information from their health plans/providers on physician incentives. Health plans that use physician incentives plan to cover services provided to Medicare and Medicaid patients and that place physicians and physician groups at "substantial financial risk" must disclose to beneficiaries, on request, the types of incentives used and the results of consumer satisfaction surveys. 42 C.F.R. § 434.67.
5. After enrollment has begun, ask Medicaid beneficiaries about their experiences. The information you get can be used to identify and monitor systemic problems, as well as to provide individual legal services. A sample questionnaire is attached. (E.g., North Carolina).
6. Meet regularly with beneficiaries to monitor activities. Hold trainings and identify beneficiaries who can, in turn, train others. (E.g., DC, NYC, NC).
7. Post descriptions of consumers' managed care rights in your offices. A sample posting of consumer rights is attached. (E.g., North Carolina).
8. Develop and disseminate a comment form for providers, consumers, and others to anonymously report problems about the plan (e.g., the plan is denying medically necessary care). Make the form returnable to your organization. A sample comment form is attached. (E.g., Ohio).
9. Ask plans serving your community to establish consumer advisory boards. Seek appointment to these boards. Let consumers know about this opportunity. Mentor consumers who serve on these boards (e.g., training in public speaking, orientation to managed care, ongoing briefing) (E.g., Ohio).
10. Identify key personnel at the plan and seek regular discussions with them. Share information you have learned about problems consumers are facing.
11. File Public Records Act requests for copies of grievance and appeal logs, disenrollments, and audits of health plans serving your community. (The National Health Law Program is completing An Advocate's Guide to Using Managed Care Data.)
12. Use the Medicaid Managed Care Monitoring Guides developed by the Health Care Financing Administration. These Guides provide regional HCFA offices a set of monitoring questions on the following: state organization/administration; marketing, member services, enrollment/disenrollment; delivery systems; access to care; special populations; eligibility; quality assurance; fiscal management; and EPSDT. For a copy of the Guides and NHeLP's suggestions for additional questions, contact the National Health Law Program (310/ 204-6010).
13. Compile a list of individuals willing to talk to the media and others about their experiences.
14. Organize public forms to share information with (and from) HCFA, state, and health plan representatives. (E.g., New York City Medicaid Managed Care Task Force; Family Voices, CA).
15. To the extent that it does not create a conflict of interest, contract with the state or seek foundation support to serve as the state-wide or area ombudsperson. (E.g., San Mateo, CA; Sacramento, CA -- Center for Health Care Rights).
16. To the extent that it does not create a conflict of interest, contract with the state or seek foundation support to serve as the state hotline. (E.g., Tennessee Crisis Intervention Advocacy Line).
17. Seek funding for all of the above. For information on grants, check the "Foundations" link on the "Links" page of our website, www.healthlaw.org.
July 14, 1997
