Participating Plan Contract Management. As more fully discussed in Appendix 7, CMS and California agree to designate representatives to serve on a CMS-State Contract Management team which shall conduct plan contract management activities related to ensuring access, quality, program integrity, program compliance, and financial solvency. These activities shall include but not be limited to: • Reviewing and analyzing Health Care Effectiveness Data and Information Set (HEDIS) data, Consumer Assessment of Health Care Providers and Systems (CAHPS) Survey data, Health Outcomes Survey (HOS) data, enrollment and disenrollment reports for Participating Plans. • Reviewing any other performance metrics applied for quality withhold or other purposes, including shared accountability strategies for virtual integration of Medi-Cal covered services and benefits not included in the capitated payment to Prime Contractor Plans. • Reviewing reports of enrollee complaints, reviewing compliance with applicable CMS and/or State Medicaid Agency standards, and initiating programmatic changes and/or changes in clinical protocols, as appropriate. • Reviewing and analyzing reports on Participating Plans’ fiscal operations and financial solvency, conducting program integrity studies to prevent and detect fraud, waste and abuse as may be agreed upon by CMS and California, and ensuring that Participating Plans take corrective action, as appropriate, including corrective action imposed on Prime Contractor Plans for the deficiencies of Subcontracted Plans. • Reviewing and analyzing Prime Contractor Plan oversight and monitoring of delegated functions to Subcontracted Plans. • Reviewing and analyzing reports on Participating Plans’ network adequacy, including the network adequacy of each plan benefit package, as well as the Plans’ ongoing efforts to replenish their networks and to continually enroll qualified providers. • Reviewing any other applicable ratings and measures. • Reviewing reports from the Ombudsman. • Reviewing direct stakeholder input into both plan-specific and systematic performance. • Responding to and investigating beneficiary complaints and quality of care issues.
Participating Plan Contract Management. CMS and the State agree to designate representatives to serve on a CMS-State Contract Management Team which shall conduct MSHO contract management activities related to ensuring access, quality, program integrity, program compliance, and financial solvency. Contract management activities shall include but not be limited to: Reviewing reports of beneficiary complaints, reviewing compliance with applicable CMS and/or State Medicaid agency standards, and initiating programmatic changes as appropriate. Reviewing and analyzing reports on MSHO Plans’ network adequacy, including the Plans’ ongoing efforts to replenish their networks and to continually enroll qualified providers. Reviewing input from stakeholders and the Minnesota Ombudsman for Managed Care on both plan-specific and systematic performance. Responding to and investigating beneficiary complaints and quality of care issues. Addressing issues or concerns that arise from changes in policy that may impact the Demonstration and/or cause misalignment of the Medicare and Medicaid programs that may harm Beneficiaries’ access to care and services.
Participating Plan Contract Management. As more fully discussed in Appendix 7, CMS and the State agree to designate representatives to serve on a CMS-State Contract Management team which shall conduct Participating Plan contract management activities related to ensuring access, quality, program integrity, program compliance, and financial solvency. These activities shall include but not be limited to: • Reviewing and analyzing relevant data as agreed in Appendix 7 and the three-way contracts, enrollment and disenrollment reports.2 • Reviewing any other performance metrics applied for quality withhold or other purposes. • Reviewing reports of Enrollee complaints, reviewing compliance with applicable integrated CMS and State Medicaid Agency standards as outlined in this MOU and the three-way contracts, and initiating programmatic changes and/or changes in clinical protocols, as appropriate.
