Improving the Medicare Market Adding Choice and Protections (1996) / Chapter Skim
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K Medicare Managed Care: Current Requirements and Practices to Ensure Accountability
K Medicare Managed Care: Current Requirements and Practices to Ensure Accountability
Pages 326-337
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From page 326... ...
The 1985 TEFRA regulations, implementing the 1982 changes, defined a system for Medicare contracting that was much more comparable to the processes that managed care organizations use to conduct their private sector, non-Medicare business. Thus, TEFRA provided the foundation for substantial growth of Medicare managed care arrangements.
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From page 327... ...
Number of Medicare Beneficiaries in Managed Care HCFA data as of November 1, 1995, show a total of just over 3.7 million beneficiaries enrolled in prepaid care under 272 contracts.1 The bulk of these beneficiaries -- 3,030,000 -- are in 182 plans with risk contracts. Between October 1 and November 1, 1995, enrollment in risk-based plans increased 2.1 percent, a rapid growth phenomenon experienced throughout 1995.2 Over the years, Medicare managed care enrollment has fluctuated greatly.
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From page 328... ...
A detailed Medicare contract application, available in paper or diskette format from HCFA's OMC, must contain narrative descriptions in numerous areas, as well as accompanying documentation materials. An idea of the requirements can be seen by reviewing Appendix A, which contains the Table of Contents for the Documents Section and the Narrative Section for the Medicare Contract Application.
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From page 329... ...
5Membership requirements are located in the Commercial Marketing and Medicare Marketing Sections of the Medicare Contract Application.
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From page 330... ...
, and marketing that misleads or misrepresents the plan.8 6Medical service requirements are located in the Organizational and Contractual and Health Service Delivery sections of the Medicare Contract Application. 7Enrollment requirements are located in the Health Services Delivery section of the Medicare Contract Application.
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From page 331... ...
Plans must accept electronic funds from the Treasury Department on the first day of every month.9 Quality Assurance A plan's internal quality assurance program must be the same for Medicare and commercial patients. The contract requirements center around traditional process measures, which call for systematic data collection of performance and patient results, peer review, and ongoing monitoring and evaluation with written procedures for remedial action.10 Since 1987, peer review organizations (PROs)
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From page 332... ...
Ongoing Monitoring by HCFA Both regional and central HCFA office staff monitor managed care contracts through monthly reports and biennial onsite visits. In 1996, HCFA will begin annual targeted on-site reviews.
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From page 333... ...
These are handled in a case work fashion, working through the problem with the beneficiary and the health plan. When HCFA identifies a major problem, a fullscale on-site investigation is launched, with as many as 10 HCFA employees spending 2 weeks or more at a plan.16 Other HCFA Approaches to Medicare Managed Care Communications and Accountability HCFA has under way a number of activities to help Medicare beneficiaries better understand that they may be able to choose different types of medical service arrangements.
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From page 334... ...
A new HCFA publication currently under development has been reviewed by advocacy organizations and focus groups and is scheduled for publication in 1996. Finally, a brochure describing managed care choices to be sent out with the initial enrollment package17 is being developed and will be tested in coming months.18 Information to Assist in Purchasing Managed Care HCFA is developing comparability charts on a state-by-state basis to show in a standard format comparisons with plan benefits, copayments, premiums, geographic areas served, and so forth.
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From page 335... ...
Many states have also developed written pamphlets and materials. For example, comparability charts have been developed by ICA program grantees in several geographic areas, including Chicago, to better explain features of Medicare managed care plans.20 HCFA Research and Demonstrations HCFA's Office of Research and Demonstrations has under way a series of projects to learn more about effective Medicare managed care programs and to refine current program elements.
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From page 336... ...
In the area of quality, for example, the demonstrations will favor new continuous quality improvement models, using Health Plan Employer Data and Information Set, version 3.0, reports when they are available.22 Additional Future HCFA Plans HCFA Online, an umbrella plan developed by the agency as a vision of state-of-the-art communications and data transmission for the 21st century, includes many features designed to provide more and better information about Medicare and choices to beneficiaries. This includes such features as toll-free telephone service, additional market research to better meet beneficiary needs, and more printed and database information about insurance, health care services, and managed care plans.
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From page 337... ...
1993a. Medicare Contract Application: Competitive Medi cal Plans.
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