Oversight must be comprehensive and coordinated

Structures must be in place to ensure that integrated models are performing contracted duties and delivering high quality services. Oversight and monitoring should be a coordinated and complementary effort by state Medicaid agencies, CMS, an independent advocate for enrollees, and stakeholder committees.

A three-way contract between the state Medicaid agency, CMS, and the integration model in which the state and CMS each retain responsibility for overseeing the plan provides the most beneficiary protections by utilizing the respective expertise of each government agency. Both the state and CMS should retain the authority to issue corrective action plans, impose enrollment and marketing sanctions, levy civil monetary penalties and, if necessary, terminate an integrated model. Federal and state investigative bodies should also have authority to monitor and report on the models.

It is particularly important that CMS, with its expertise in Medicare services and in Medicare managed care, continue to be active in setting standards and monitoring program compliance. There is a large body of existing Medicare regulation and guidance, including, for example, the entire Medicare Managed Care Manual, which developed and evolved in response to specific needs or abuses. Although a new model might waive or adapt some of these procedures, it is important not to undertake a wholesale waiver of provisions that have been hammered out over many years. And it is equally important that systems currently in place for CMS monitoring and enforcement of compliance not be abandoned.

In addition to determining its role in relation to CMS, the state Medicaid agency will need to define what roles different divisions within its own agency will play in providing oversight and monitoring. A state Medicaid agency may have divisions related to managed care, delivery system reform, long term care, behavioral health, and home and community based services that could all provide valuable insight and expertise. The state agency may also consider other state agencies, such as departments committed to monitoring managed care organizations or regulating insurance and marketing, that could participate to ensure a comprehensive oversight and monitoring scheme.

However oversight and monitoring are divided, agency authority must be clear and agencies must have systems in place that allow them to respond quickly to problems that impede access to benefits. This rapid response capability will be especially important as these new models are being introduced or expanded.

Establishing an independent member advocate for enrollees can create a valuable complement to oversight and monitoring provided by the authorizing state and federal agencies. The enrollee advocate’s primary task would be to advocate for enrollees in the model by collecting and reviewing complaints, assisting enrollees in appeals processes and helping enrollees understand their rights under the plan. The enrollee advocate could also assist enrollees in maintaining eligibility for the model (for example, maintaining Medicaid eligibility) and help with advising potential members on enrollment options. In addition, the enrollee advocate can report to state and federal agencies on dual eligible experiences within the integrated model in order to assist the oversight functions of those agencies.

A final layer of oversight and monitoring is provided by stakeholder committees. Each integration model should have a process for soliciting and incorporating stakeholder input. Actual beneficiaries and their advocates must be part of any stakeholder group and need to be provided the opportunity to provide input on the group’s agenda. Stakeholder input is necessary both during development of the model and when it is fully operational. Effective stakeholder involvement incorporates standing stakeholder committees with a mandate to monitor the performance of the model and to contribute to policies and model design, as well as broader opportunities for involvement by any members of the community, such as periodic open forums and on-going invitations to community members to comment on plans and procedures. To ensure informed stakeholder participation, MMCO, the state and the integrated model must operate in a transparent manner disclosing publicly contract terms, models of care, assessment tools and program evaluation results.


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