CurrentURACPolicy N/A

Medicaid Health Plan v1.1 - Focus Areas and Operational Requirements

This document summarizes focus areas, requirements, and operational expectations for Medicaid Health Plans (v1.1), including benefits and services, care coordination and continuity, quality services, and enrollee communications; it is intended for plan administrators, care coordinators, and provider relations staff.

Policy Summary

PayerURAC

PolicyMedicaid Health Plan v1.1 - Focus Areas and Operational Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUse an evidence-based health risk assessment tool to collect risk factors, comorbidities, and social needs and share results with the state and providers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4primary focus areas listed

90 daysmax continued care

Encouragedtelehealth stance

14-dayonetime extension

30 daysprovider directory update

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Coverage Principles

High-level coverage principles and federal requirements

Services must not be denied or reduced on the basis of an enrollee’s illness or condition (scope of services).

No referral required to access family planning services.

Federal requirements must be observed including out-of-network coverage and second opinions from out-of-network providers, advanced directives, network provider hours of operation, and grievance and appeals documentation.

Care Continuation and Transitions

Continuity and transition of care requirements

Continued care through a terminated provider is allowed up to 90 calendar days or through the current active course of treatment, whichever is less.

Coverage of services continues pending the outcome of a state fair hearing when applicable.

Written transition summaries must be shared prior to or at the time of transition and sent to the enrollee and/or caregiver and to the next provider or health professional.

Operational criteria for care transitions, quality, utilization management, and communications

Operational coverage-related criteria and program requirements referenced in this portion of the policy include:

Transitions of care must include defined eligibility criteria, a proactive plan for TOC services, and engagement of the enrollee and/or caregivers.

Identify enrollees at risk for readmission and implement strategies to reduce readmission as part of TOC follow-up.

Promote medication safety during transitions, including medication reconciliation and education for enrollees and/or caregivers.

Standardize provider data collection processes for quality improvement and use data received from providers to guide suggestions and improvements in serving enrollees.

Document how providers are supported regarding network issues and make information available to providers about the enrollee complaint system (provider relations).

Operational and Member Information Requirements

Operational requirements and enrollee information topics included in this document section:

Provide cost information to enrollees including cost of covered benefits, how to communicate with the plan about costs, and tools for weighing cost and benefit information.

Inform enrollees of rights and responsibilities including the right to disenroll, freedom of choice among network providers, state fair hearing rights, reporting suspected fraud/waste/abuse, and notification requirements for state-defined significant changes.

Maintain provider directories updated within 30 calendar days of credentialing and contracting; make directories available in multiple formats and include required data in the online directory.

Coding and Timeframe Key Facts

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inv-08: Continuation of care time limit — 90 calendar days or through current active treatment (whichever is less)

Continuation of care time limitContinued care through a terminated provider up to 90 calendar days or through current active treatment, whichever is less.

ScopeApplies when a provider is terminated; includes continued coverage of services pending a state fair hearing when applicable.

Applicability triggerInitiated upon provider termination or when enrollee is mid-course of treatment.

inv-09: Onetime extension length — 14 days

One-time extension lengthThe Medicaid Plan may allow a one-time 14-day extension at the enrollee's request if the plan determines it is necessary and in the enrollee's best interest.

Conditions for approvalRequires enrollee request and plan determination that extension is necessary and in the enrollee's best interest.

Effect on timeframesExtension applies to specified review or transition timeframes as described by the plan; does not alter other appeal deadlines unless specified.

inv-10: Provider directory update window — 30 calendar days

Provider directory update windowProvider directories must be updated within 30 calendar days of credentialing and contracting.

Formats requiredDirectories must be available in multiple formats (e.g., online and alternative formats) as required by the plan and state.

Directory contentsOnline directory must include specific provider data elements as specified by the plan/state requirements.

Provider Responsibilities and Required Actions

Note

Scope and Out-of-Network / Second Opinion Access

Scope of Services and Out-of-Network / Second Opinion Access: Providers must ensure that services are not denied, limited, or reduced because of the enrollee's illness or condition. Enrollees do not need a referral to access family planning services and should be made aware of this. Plans must allow access to second opinions, including from out-of-network providers when applicable under federal or state rules. Out-of-network coverage must be available per plan requirements and applicable regulations; providers should document when out-of-network referrals or second opinions are provided or recommended. Plans must also comply with requirements for advanced directives, publish network provider hours of operation, and maintain grievance and appeals documentation accessible to providers and enrollees.

No denial or reduction of services due to condition
No referral required for family planning
Second opinion access including out-of-network when required
Document advanced directives and grievance/appeals procedures

Prior Authorization

Utilization Management and Appeals Actions

Utilization Management and Appeals Actions: Plans must publish and follow clear initial clinical review criteria for utilization management decisions and make those criteria available to providers. If the organization does not provide LTSS services, it must state this explicitly. A one-time 14-day extension to review timelines may be granted when the enrollee requests it and the plan determines the extension is in the enrollee's best interest. When appeal requirements are not met and the internal appeals process is exhausted, initiate the State Fair Hearing process. External reviews, when applicable, must be independent, optional to the enrollee, provided at no cost to the enrollee, and do not extend existing time frames.

Publish clinical review criteria and make available to providers
Provide statement if LTSS services are not offered
Allow one-time 14-day extension when requested and in enrollee's best interest
Initiate State Fair Hearing when appeals exhausted
External review independent, no cost, no timeframe extension

Documentation Required

Provider Directory Maintenance

Provider Directory Maintenance: Maintain and update provider directories within 30 calendar days of credentialing or contracting changes. Directories must be available in multiple formats (including online) and contain the specific data elements required by plan and regulatory standards so enrollees and providers can identify network providers and services. Ensure online directory information is kept current and includes required contact, specialty, and availability details.

Update within 30 calendar days of credentialing/contracting changes
Provide directory in multiple formats including online
Include required contact, specialty, hours/availability, and other mandated data elements

Key Terms and Definitions

inv-16: Health Risk Assessment Tool — definition of the tool and its purpose

DefinitionHealth Risk Assessment Tool: an evidence-based instrument that collects enrollee risk factors, comorbidities, and identifies health disparities and other social needs.

PurposeUsed to identify clinical and social risk to inform care planning and interventions.

Use and sharingResults are reviewed, approved, and shared with the state and providers for care coordination and oversight.

inv-17: Telehealth encouragement — policy stance on telehealth and related technologies

Policy stanceTelehealth and related technologies are encouraged by the Medicaid Plan.

Documentation requirementPlan documentation should describe how telehealth and related technologies are encouraged.

Compliance demonstrationCompliance with telehealth encouragement is demonstrated on Desktop Review only, per the document.

inv-18: Transitions of Care (TOC) — definition and expectations for proactive planning and written transition summaries

DefinitionTransitions of Care (TOC): proactive planning for transitions with written transition summaries sent to the enrollee/caregiver and the next provider prior to or at the time of transition.

Planning expectationsPlans must define eligibility criteria for TOC services and maintain a proactive plan that engages the enrollee and/or caregivers.

CommunicationWritten transition summaries must be shared with the enrollee/caregiver and the next provider or health professional at or before transition time.

inv-19: Key operational terms and expectations — operational expectations including planning for transitions, engagement, written summaries

Operational planning for transitionsPlans must establish eligibility criteria, proactive TOC plans, and engage enrollees and caregivers in transition planning.

Written transition summariesSummaries are to be shared prior to or at the transition with the enrollee/caregiver and next provider to support continuity and medication safety.

Medication safetyMedicaid Plan promotes medication reconciliation during transitions and education for enrollees/caregivers on medication safety.

Data and reporting expectationsStandardize provider data collection and maintain compliance pathways including reporting (e.g., FWA) and oversight through committees and audits.

inv-20: Cost Information (MESC 1-3) — topics on cost of covered benefits and communicating cost information

Topics coveredCost information includes cost of covered benefits, communicating cost information with the plan, and weighing cost and benefit information.

Member communicationPlans must provide mechanisms for enrollees to communicate with the plan regarding cost information to support informed decision-making.

Decision supportEnrollees are expected to weigh cost and benefit information when choosing services; plans should provide necessary explanatory information.

inv-21: Enrollee Rights and Responsibilities (MESC 1-4) — rights include disenroll, freedom of choice, state fair hearing, remedies

Enrollee rightsRights include the right to disenroll, freedom of choice among network providers, and the right to a state fair hearing.

Responsibilities and reportingEnrollees are expected to report suspected fraud, waste, and abuse and comply with notification requirements for state-defined significant changes.

Enrollment informationUpon enrollment, the Medicaid Plan provides information needed for enrollees to optimize use of health services, including rights and remedies.

inv-22: Provider Directories (MESC 2-1) — update requirements, multiple formats, required contents

Update timeframeProvider directories must be updated within 30 calendar days of credentialing and contracting.

Multiple formatsDirectories must be provided in multiple formats to meet enrollee needs and accessibility requirements.

Required contentsOnline directory must include specific provider data elements as specified by plan/state guidance.

OpenPayer

Medicaid Health Plan v1.1 - Focus Areas and Operational Requirements

Coverage Principles and Operational Criteria

Coding and Timeframe Key Facts

Provider Responsibilities and Required Actions

Key Terms and Definitions