Iowa Admin. Code r. 441-73.2 - Contracts with a managed care plan (MCP)
(1) The
department may enter into a contract with an MCP licensed under the provisions
of insurance division rules set forth in 191-Chapter 40 for the scope of
services as described in rule
441-73.6 (249A).
(2) The department shall determine that the
MCP meets the following requirements:
a. The
MCP shall make available the services it provides to enrollees as established
in the contract .
b. The MCP shall
provide satisfaction to the department against the risk of insolvency and
ensure that neither Medicaid members nor the state shall be responsible for the
MCP 's debts if the MCP becomes insolvent. The MCP shall comply with insurance
division provisions set forth in rule
191-40.12 (514B) regarding net
worth and rule 191-40.14 (514B) containing
reporting requirements.
c. The MCP
shall attain and maintain accreditation by the National Committee for Quality
Assurance (NCQA) or URAC (formerly known as the Utilization Review
Accreditation Commission).
(3) If not already accredited, the MCP must
demonstrate it has initiated the accreditation process as of the contract
effective date and must achieve accreditation at the earliest date allowed by
NCQA or URAC. Prior to the contract effective date, the MCP must be licensed
and in good standing in the state of Iowa as a health maintenance organization
in accordance with insurance division rules set forth in 191-Chapter
40.
(4) The contract shall meet the
following minimum requirements. The contract shall:
a. Be in writing.
b. Specify the duration of the contract
period.
c. List the services that
must be covered.
d. Describe
service access and provide access information.
e. List conditions for nonrenewal,
termination, suspension, and modification.
f. Specify the method and rate of
reimbursement.
g. Provide for
disclosure of ownership and subcontracted relationships.
h. Specify that all subcontracts shall be in
writing, shall comply with the provisions of the contract between the
department and the MCP , and shall include any general requirements of the
contract that are appropriate to the service or activity covered by the
subcontract.
i. Specify appeal and
grievance rights.
j. Specify all
operational and service delivery expectations.
k. Specify reporting requirements.
l. Specify requirements for utilization
management and quality improvement.
m. Specify requirements for program
integrity.
n. Specify termination
requirements and assessment of penalties.
o. Require the MCP and the fee-for-service
Medicaid program to utilize a uniform prior authorization process.
The process will include forms, information requirements, and time frames.
Notes
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