42 CFR § 438.66 - State monitoring requirements.
(a) General requirement. The State agency must have in effect a monitoring system for all managed care programs.
(1) Administration and management.
(2) Appeal and grievance systems.
(3) Claims management.
(5) Finance, including medical loss ratio reporting.
(6) Information systems, including encounter data reporting.
(8) Medical management, including utilization management and case management.
(9) Program integrity.
(11) Availability and accessibility of services, including network adequacy standards.
(12) Quality improvement.
(14) All other provisions of the contract, as appropriate.
(2) Member grievance and appeal logs.
(3) Provider complaint and appeal logs.
(4) Findings from the State's External Quality Review process.
(6) Performance on required quality measures.
(7) Medical management committee reports and minutes.
(10) The medical loss ratio summary reports required by § 438.8.
(i) Started at least 3 months prior to the effective date of the events described in paragraph (d)(1) of this section.
(ii) Completed in sufficient time to ensure smooth implementation of an event described in paragraph (d)(1) of this section.
(3) Readiness reviews described in paragraphs (d)(1)(i) and (ii) of this section must include both a desk review of documents and on-site reviews of each MCO, PIHP, PAHP, or PCCM entity. Readiness reviews described in paragraph (d)(1)(iii) of this section must include a desk review of documents and may, at the State's option, include an on-site review. On-site reviews must include interviews with MCO, PIHP, PAHP, or PCCM entity staff and leadership that manage key operational areas.
(i) Operations/Administration, including -
(A) Administrative staffing and resources.
(D) Grievance and appeals.
(E) Member services and outreach.
(F) Provider Network Management.
(G) Program Integrity/Compliance.
(ii) Service delivery, including -
(A) Case management/care coordination/service planning.
(B) Quality improvement.
(C) Utilization review.
(iii) Financial management, including -
(A) Financial reporting and monitoring.
(B) Financial solvency.
(iv) Systems management, including -
(A) Claims management.
(B) Encounter data and enrollment information management.
(1) The State must submit to CMS no later than 180 days after each contract year, a report on each managed care program administered by the State, regardless of the authority under which the program operates.
(i) The initial report will be due after the contract year following the release of CMS guidance on the content and form of the report.
(ii) For States that operate their managed care program under section 1115(a) of the Act authority, submission of an annual report that may be required by the Special Terms and Conditions of the section 1115(a) demonstration program will be deemed to satisfy the requirement of this paragraph (e)(1) provided that the report includes the information specified in paragraph (e)(2) of this section.
(2) The program report must provide information on and an assessment of the operation of the managed care program on, at a minimum, the following areas:
(ix) Activities and performance of the beneficiary support system.
(x) Any other factors in the delivery of LTSS not otherwise addressed in (e)(2)(i)-(ix) of this section as applicable.
(3) The program report required in this section must be:
(i) Posted on the Web site required under § 438.10(c)(3).
(ii) Provided to the Medical Care Advisory Committee, required under § 431.12 of this chapter.
(f) Applicability. States will not be held out of compliance with the requirements of paragraphs (a) through (d) of this section prior to the rating period for contracts starting on or after July 1, 2017, so long as they comply with the corresponding standard(s) codified in 42 CFR 438.66 contained in the 42 CFR, parts 430 to 481, edition revised as of October 1, 2015.
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