Medicaid (Title XIX of the Social Security Act)
Medicaid Managed Care Organizations

If the state contracts with Medicaid managed care organizations to provide services to enrollees, the state must develop and implement a quality assessment and improvement strategy127 that includes:128

• Procedures for monitoring and evaluating the quality and appropriateness of care and services and;
• Requirements for the provision of quality assurance data.

Managed care contracts must provide for an annual external independent review of the quality outcomes and timeliness of and access to the items and services for which the organization is responsible.  The results of each review will be available to providers, potential and current enrollees of the organization; the identity of any individual patient must not be disclosed in these results.129  The state must establish intermediate sanctions that may be imposed if the managed care organization:130

• Substantially fails to provide required and medically necessary items and services;
• Acts to discriminate among enrollees on the basis of their health status or requirements for health care services;
• Engages in any practice that would reasonably be expected to deny or discourage eligible individuals who, on the basis of their medical record or history, will need substantial medical services from enrolling with the organization; and/or
• Misrepresents or falsifies information to an enrollee, a potential enrollee, or the state.