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- July 23, 2013
Consumer-Oriented Approaches to Problem Solving in Medicaid Managed Care
Read moreThis working paper answers some of the questions surrounding the use of ombudsprograms and member advocates in the Medicaid context.
- July 23, 2013
Model Medicaid Managed Care Contract Provisions — Medical Necessity Definition
Read moreIntroduction The definition of "medical necessity" raises two general issues of concern to consumers: What benefits are covered? (E.g., are they limited to diagnosis and treatment, or do they also include preventive care? Are experimental services excluded? Does the definition recognize and mandate the…
- July 23, 2013
Model Medicaid Managed Care Contract Provisions — A Primer on Medicaid Managed
Read moreBrief Introduction to Medicaid Managed Care Contracting To control Medicaid expenditures and expand access to health care, states are requiring Medicaid recipients to enroll in risk-based managed care programs. Although to date mandatory enrollment has affected mostly poor women and children, the behavioral health and…
- July 23, 2013
Model Medicaid Managed Care Contract Provisions — Member Advocates
Read moreNHeLP Model Member Advocate Requirements -- The health plan must employ one or more member advocate(s), as specified in section 3(c) below, during the entire contract term. The member advocate(s) will work with enrollees, providers, and plan personnel to facilitate the provision of Medicaid benefits…
- July 23, 2013
Model Medicaid Managed Care Contract Provisions — Third Party Beneficiaries
Read moreNHeLP Model Medicaid recipients enrolled in managed care are the intended third-party beneficiaries of contracts between the state and MCOs and of any subcontracts or provider agreements entered into by MCOs with subcontracting providers and, as such, enrollees are entitled to the remedies accorded to…
- July 23, 2013
HCFA Letter re BBA
External Source LetterRead moreDear State Medicaid Director providing guidance re waiver requirements under BBA 1997.