From Families USA
September 2000
A Guide to Monitoring Medicaid Managed Care
NOTE: This Guide has been posted in sections to allow for easy on-line viewing. To obtain a complete hard copy of the guide, contact Families USA.
INTRODUCTION
CHAPTER 1: DO-IT-YOURSELF MONITORING PROJECTS
- Focus Groups
- Consumer Surveys
- Compiling Case Stories and Investigating Complaints
CHAPTER 2: HOW THE STATE AND FEDERAL GOVERNMENTS MONITOR MEDICAID MANAGED CARE
- Managed Care Plans' Internal Quality Assurance Procedures
- State Monitoring Activities
- Federal Government Monitoring Policies and Procedure
CHAPTER 3: ENROLLMENT AND DISENROLLMENT DATA
- Disenrolling from Medicaid Managed Care Plans
- Usefulness of Enrollment/Disenrollment Data
- Federal Requirements for Enrollment/Disenrollment Data
- How Your State Should Keep Enrollment/Disenrollment Statistics
- What You Can Learn From Enrollment/Disenrollment Data
- Sources for Enrollment/Disenrollment Statistics
- Step-by-Step Analysis
CHAPTER 4: MONITORING ACCESS TO CARE
- Federal Requirements Related to Access to Care
- State Requirements Regarding Access to Care
- Sources of Data
- Step-by-Step Analysis
- Developing and Presenting Recommendations
CHAPTER 5: HEALTH CARE UTILIZATION AND QUALITY
- Encounter Data
- Utilization Data
- Interpreting Utilization Data
- Clinical Performance Measures
- Consumers' Assessment of Care
- Early and Periodic Diagnosis, Screening, and Treatment (EPSDT)
CHAPTER 6: COMPLAINTS, GRIEVANCES, AND FAIR HEARINGS
- Defining Complaints, Grievances, and Fair Hearings
- Common Problems with Complaint Data
- Federal Requirements for Managed Care Plans and States
- Data Sources and Potential Problems
- Analysis and Use of Complaint Data
- Making Recommendations to Improve the Complaint System
CHAPTER 7: FINANCIAL DATA
- Financial Requirements for Medicaid Managed Care Organizations
- Obtaining Data on Managed Care Organizations' Finances
- Examining the Overall Financial Status of Medicaid Managed Care Organizations
- Calculating Overall Profit Margins and Operating Margins
- Determining the Amount of Managed Care Payments That Go to Patient Care
- Examining State Medicaid Managed Care Capitation Rates
- Examining the Total Cost of Managed Care
