From Families USA
September 2000

A Guide to Monitoring Medicaid Managed Care

Introduction

Want to know how well managed care plans are serving Medicaid beneficiaries in your state? This guide can help you find answers to the following questions:

1) What do consumers experience as the positive and negative aspects of managed care? 
2) How carefully does your state oversee managed care plans?
3) Do many consumers leave managed care plans due to dissatisfaction?
4) How does managed care affect consumers' access to providers and services?
5) How does managed care affect consumers' use of health care services and the quality of those services?
6) What problems do managed care enrollees complain about, and what has been done to remedy the problems?
7) What is the financial condition of managed care organizations in your state, and how do managed care organizations spend Medicaid dollars?

The guide is intended as a reference tool, not as a document to be read from cover to cover. The first chapter describes ways that community organizations can collect their own data about Medicaid managed care. These do-it-yourself monitoring projects help to make consumers aware of their rights and active in managed care policy discussions. The second chapter provides an overview of government monitoring activities and orients the reader to the data described more thoroughly in Chapters 3 through 7. Chapters 3 through 7 are each meant to be read independently. They explain types of data collected by the government and how advocates can use the data. 

If you find problems with access to services or the quality of care under Medicaid managed care, you can advocate for improvements through the plan, your state, and/or the federal government. Under federal law, if Medicaid managed care organizations "fail substantially to provide medically necessary items and services" required under law or contract, states may sanction them. In fact, states must sanction managed care organizations that repeatedly fail to meet standards. Sanctions can include monetary penalties, the suspension of enrollment, appointment of temporary management, allowing members to disenroll without cause, or ultimately, terminating the contract. The federal government can be a helpful ally in your advocacy. Regional offices of the Health Care Financing Administration (HCFA) oversee state Medicaid managed care programs. HCFA must approve state plan amendments regarding Medicaid managed care, waiver requests and renewals, and Medicaid managed care contracts. In response to problems, HCFA has taken action such as ordering a state to stop mandatory managed care enrollment until the state improved consumer information and enrollment procedures. The Department of Health and Human Services' Office for Civil Rights can also act to stop practices that discriminate among Medicaid beneficiaries based on race, ethnicity, gender, age, or disability status.

For a copy of this report, contact Families USA.