Protocol 3:Review of Compliance with Medicaid and CHIP Managed Care Regulations
Activities 4 and 5
Start
Protocol 3: Review of Compliance
Protocol 3 Activities
Protocol 3 Activities
Activity 1: Establish Compliance Thresholds
Activity 2: Perform the Preliminary Review (Pre-Site Visit)
Activity 3: MCP Site Visit
Activity 4: Compile and Analyze Findings (Post-Visit)
Activity 5: Report Findings to State
Protocol 3: Review of Compliance
Activity 3: Conduct MCP Site Visit
Activity 4: Compile and Analyze Findings (Post-Site Visit)
- After the site visit, the EQRO collects information compiled during the compliance assessment process.
- The EQRO also analyzes data collected during the pre, during, and post-site visit activities to determine compliance for each regulatory provision.
Protocol 3: Review of Compliance
Activity 4: Compile and Analyze Findings (Post-Site Visit)
Activity 4: Compile and Analyze Findings (Post-Site Visit)
Step 2: Compile Data and Information
Step 3: Analyze Findings
Step 1: Collect Supplemental Information
Step 1: Collect Supplemental Information
Protocol 3: Review of Compliance
Step 1: Collect Supplemental Information
In addition to information collected during the site visit, the EQRO should consider other sources of information that confirm the MCP's compliance with federal and state standards.
Protocol 3: Review of Compliance
Step 1: Collect Supplemental Information
Step 1 Collect Supplemental Information
Supplemental sources of information should include the following:
Results of independent assessments of the MCP's information systems
Results of independent assessments of encounter data
Results of Medicaid and CHIP beneficary surveys
Additional materials requested during or after the site visit
Results of independent validations of MCP performance measures
Results of independent validation of PIPs
Step 2: Compile Data and Information
Protocol 3: Review of Compliance
Step 2: Compile Data and Information
- EQROs, using Worksheet 3.1 or a similar template, should document additional information they review.
- Additional information includes sources of the information, and their findings about the MCP's compliance.
- EQROs will score compliance using the scoring scale approved by the state. The scale may be "met", or "not met", or a three or five point scale that takes into consideration provisions that may be partially met.
Step 3: Analyze Findings
Protocol 3: Review of Compliance
Step 3: Analyze Findings
- The EQRO will analyze their findings and assign a score based on the degree of compliance with a given regulatory provision.
- The EQRO documents a compliance score for each regulatory provision, including their justification for the determination.
Protocol 3: Review of Compliance
Activity 5: Report Results to the State
Activity 5: Report Results to the State
Step 2: Submit Final Determination Report to the State
Step 3: Submit Other Reports Requested by the State
Step 1: Submit Report Outline to the State
Protocol 3: Review of Compliance
Step 1: Submit a Final Report to the State
Step 1: Submit a Final Report to the State
- The EQRO should develop a report outline and submit it to the state for approval.
- The outline will be used by the EQRO to draft a report to the state with the results of the MCP's compliance with state and federal regulations.
Protocol 3: Review of Compliance
Step 2: Submit a Final Determination to the State
Step 2: Submit a Final Determination to the State
- The state may use the report to meet its reporting requirements for federal or state agencies, local advocacy groups, and other interested parties.
- The state may require certain types of information to be presented in a certain format.
- The report should include an overall summary of findings for compliance with regulatory provisions.
Protocol 3: Review of Compliance
Step 3: Submit Other Reports Requested by the State
Step 3: Submit Other Reports Requested by the State
The state may request a specific format for reporting results to the MCP. Some options include the following: Click on the icons for additional information
Compliance Issues Specific to Regulatory Provisions
Compliance Issues Only
Compliance Determinations and Deficiency Report
Protocol 3: Review
Review of Protocol 3
Review of Protocol 3
We have covered a lot of information about Protocol 3! So, let's take a few minutes to review some highlights from the lessons.
Protocol 3 Review
Review of Protocol 3
Review of Protocol 3
- Protocol 3 is used to determine if Medicaid and CHIP MCPs are in compliance with federal standards.
- CMS developed standards for MCPs which are codified in 42 CFR 438, and 42 CFR 457.
- States have the option to apply nonduplication to this EQR-related activity.
Protocol 3 Review
Review of Protocol 3
Regulations Subject to Compliance Review
The standards listed below may be found in 42 CFR 438, parts 56, 100, 114, Subpart D, and QAPI
- Availability of HCBS services
- Assurance of adequate capacity and services
- Coordination and continuity of care
- Coverage and authorization of services
- Provider selection (credentialing)
- Confidentiality (HIPAA)
- Grievance and appeals
- Subcontractional relationships and delegation
- Practice guidelines
- Health information systems
- QAPI program
Protocol 3 Review
Review of Protocol 3
Regulations Subject to Compliance Review
Three standards were added to Protocol 3 in the 2020 Final Rule, and listed in the 2023 EQR Protocols
- Disenrollment requirements and limitations (438.56)
- Enrollee rights requirements (438.100)
- Emergency and post-stabilization services (438.114)
Protocol 3 Review
Review of Protocol 3
Additional Standards for Compliance Review
CMS encourages states to expand the scope of the review to cover compliance with federal and state requirements beyond those specified in the CFR. Other areas include state statutory, regulatory, or contractual requirements in the following areas:
Availability of HCBS Services
Credentialing of LTSS Providers
Accessability
Person Centered Assessment and Care Planning
Integration of Managed Medical, Behavioral Health and LTSS
Protocol 3 Review
Review of Protocol 3
Frequency of Compliance Review
Federal regulations mandate that MCPs undergo a review every three years, with states able to coordinate with the EQRO for a staggered review.
Protocol 3 Review
Review of Protocol 3
Frequency of Compliance Review
If the EQRO spreads the review over a three-year cycle, the technical report must include:
- The three-year period covered by the current review cycle
- A list of standards not included in the in current report
- Summary of findings from previous reviews in the current review cycle
- The state's schedule for review of remaining standards
Protocol 3 Review
Review of Protocol 3
Protocol 3 Activities
Activity 1: Establish Compliance Thresholds
Activity 2: Perform the Preliminary Review
Activity 3: MCP Site Visit
Activity 5: Report Results to the State
Activity 4: Compile and Analyze Findings (Post-Site Visit)
Protocol 3 Review
Review of Protocol 3
Activity 1: Establish Compliance Thresholds
Step 1
Step 2
Collect Information from the State
Define Benchmarks for Compliance
Protocol 3 Review
Review of Protocol 3
Activity 2: Perform the Preliminary Review
Step 1
Step 2
Establish Early Contact with the MCP
Perform a Document Review
Protocol 3 Review
Review of Protocol 3
Activity 3: MCP Site Visit
Step 3
Step 2
Step 1
ID the Number and Types of Reviewers Needed
Establish Early Contact with the MCP
Develop a Site Visit Agenda
Conduct Exit MCP Interviews
Step 5
Step 6
Step 4
Conduct Exit MCP Interviews
Provide Prep Instructions to the MCP
Conduct MCP Interviews
Protocol 3 Review
Review of Protocol 3
Activity 4: Compile and Analyze Findings (Post-Site Visit)
Step 1
Step 2
Collect Supplemental Information
Compile Data and Information
Protocol 3 Review
Review of Protocol 3
Activity 4: Compile and Analyze Findings (Post-Site Visit)
Step 1
Step 2
Collect Supplemental Information
Compile Data and Information
Protocol 3 Review
Review of Protocol 3
Activity 5: Report Results to the State
Step 1
Step 2
Step 3
Submit a Report Outline to the State
Submit a Final Determination Report to the State
Submit Other Reports Requested by the State
Review of Protocol 3
Knowledge Check
Knowledge Check
Review of Protocol 3
Knowledge Check
Knowledge Check
Protocol 3: Activity 3
Knowledge Check
Knowledge Check
Protocol 3: Activty 3
Knowledge Check
Knowledge Check
Protocol 3: Activty 3
Knowledge Check
Knowledge Check
Review of Protocol 3
Congratulations!
Congratulations!
You have completed Protocol 3
Now you are ready to proceed to Protocol 4: Validation of Network Adequacy If you have any questions or comments about this lesson please reach out to your Program Manager, Course Instructor or leave a message in the Chat Boards.
📌 Course Instructor: Michelle Hoover
📌 email: mhoover@qsource.org
Protocol 3: Activities 4 and 5
Michelle Hoover
Created on April 5, 2023
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Transcript
Protocol 3:Review of Compliance with Medicaid and CHIP Managed Care Regulations
Activities 4 and 5
Start
Protocol 3: Review of Compliance
Protocol 3 Activities
Protocol 3 Activities
Activity 1: Establish Compliance Thresholds
Activity 2: Perform the Preliminary Review (Pre-Site Visit)
Activity 3: MCP Site Visit
Activity 4: Compile and Analyze Findings (Post-Visit)
Activity 5: Report Findings to State
Protocol 3: Review of Compliance
Activity 3: Conduct MCP Site Visit
Activity 4: Compile and Analyze Findings (Post-Site Visit)
Protocol 3: Review of Compliance
Activity 4: Compile and Analyze Findings (Post-Site Visit)
Activity 4: Compile and Analyze Findings (Post-Site Visit)
Step 2: Compile Data and Information
Step 3: Analyze Findings
Step 1: Collect Supplemental Information
Step 1: Collect Supplemental Information
Protocol 3: Review of Compliance
Step 1: Collect Supplemental Information
In addition to information collected during the site visit, the EQRO should consider other sources of information that confirm the MCP's compliance with federal and state standards.
Protocol 3: Review of Compliance
Step 1: Collect Supplemental Information
Step 1 Collect Supplemental Information
Supplemental sources of information should include the following:
Results of independent assessments of the MCP's information systems
Results of independent assessments of encounter data
Results of Medicaid and CHIP beneficary surveys
Additional materials requested during or after the site visit
Results of independent validations of MCP performance measures
Results of independent validation of PIPs
Step 2: Compile Data and Information
Protocol 3: Review of Compliance
Step 2: Compile Data and Information
Step 3: Analyze Findings
Protocol 3: Review of Compliance
Step 3: Analyze Findings
Protocol 3: Review of Compliance
Activity 5: Report Results to the State
Activity 5: Report Results to the State
Step 2: Submit Final Determination Report to the State
Step 3: Submit Other Reports Requested by the State
Step 1: Submit Report Outline to the State
Protocol 3: Review of Compliance
Step 1: Submit a Final Report to the State
Step 1: Submit a Final Report to the State
Protocol 3: Review of Compliance
Step 2: Submit a Final Determination to the State
Step 2: Submit a Final Determination to the State
Protocol 3: Review of Compliance
Step 3: Submit Other Reports Requested by the State
Step 3: Submit Other Reports Requested by the State
The state may request a specific format for reporting results to the MCP. Some options include the following: Click on the icons for additional information
Compliance Issues Specific to Regulatory Provisions
Compliance Issues Only
Compliance Determinations and Deficiency Report
Protocol 3: Review
Review of Protocol 3
Review of Protocol 3
We have covered a lot of information about Protocol 3! So, let's take a few minutes to review some highlights from the lessons.
Protocol 3 Review
Review of Protocol 3
Review of Protocol 3
Protocol 3 Review
Review of Protocol 3
Regulations Subject to Compliance Review
The standards listed below may be found in 42 CFR 438, parts 56, 100, 114, Subpart D, and QAPI
Protocol 3 Review
Review of Protocol 3
Regulations Subject to Compliance Review
Three standards were added to Protocol 3 in the 2020 Final Rule, and listed in the 2023 EQR Protocols
Protocol 3 Review
Review of Protocol 3
Additional Standards for Compliance Review
CMS encourages states to expand the scope of the review to cover compliance with federal and state requirements beyond those specified in the CFR. Other areas include state statutory, regulatory, or contractual requirements in the following areas:
Availability of HCBS Services
Credentialing of LTSS Providers
Accessability
Person Centered Assessment and Care Planning
Integration of Managed Medical, Behavioral Health and LTSS
Protocol 3 Review
Review of Protocol 3
Frequency of Compliance Review
Federal regulations mandate that MCPs undergo a review every three years, with states able to coordinate with the EQRO for a staggered review.
Protocol 3 Review
Review of Protocol 3
Frequency of Compliance Review
If the EQRO spreads the review over a three-year cycle, the technical report must include:
Protocol 3 Review
Review of Protocol 3
Protocol 3 Activities
Activity 1: Establish Compliance Thresholds
Activity 2: Perform the Preliminary Review
Activity 3: MCP Site Visit
Activity 5: Report Results to the State
Activity 4: Compile and Analyze Findings (Post-Site Visit)
Protocol 3 Review
Review of Protocol 3
Activity 1: Establish Compliance Thresholds
Step 1
Step 2
Collect Information from the State
Define Benchmarks for Compliance
Protocol 3 Review
Review of Protocol 3
Activity 2: Perform the Preliminary Review
Step 1
Step 2
Establish Early Contact with the MCP
Perform a Document Review
Protocol 3 Review
Review of Protocol 3
Activity 3: MCP Site Visit
Step 3
Step 2
Step 1
ID the Number and Types of Reviewers Needed
Establish Early Contact with the MCP
Develop a Site Visit Agenda
Conduct Exit MCP Interviews
Step 5
Step 6
Step 4
Conduct Exit MCP Interviews
Provide Prep Instructions to the MCP
Conduct MCP Interviews
Protocol 3 Review
Review of Protocol 3
Activity 4: Compile and Analyze Findings (Post-Site Visit)
Step 1
Step 2
Collect Supplemental Information
Compile Data and Information
Protocol 3 Review
Review of Protocol 3
Activity 4: Compile and Analyze Findings (Post-Site Visit)
Step 1
Step 2
Collect Supplemental Information
Compile Data and Information
Protocol 3 Review
Review of Protocol 3
Activity 5: Report Results to the State
Step 1
Step 2
Step 3
Submit a Report Outline to the State
Submit a Final Determination Report to the State
Submit Other Reports Requested by the State
Review of Protocol 3
Knowledge Check
Knowledge Check
Review of Protocol 3
Knowledge Check
Knowledge Check
Protocol 3: Activity 3
Knowledge Check
Knowledge Check
Protocol 3: Activty 3
Knowledge Check
Knowledge Check
Protocol 3: Activty 3
Knowledge Check
Knowledge Check
Review of Protocol 3
Congratulations!
Congratulations!
You have completed Protocol 3
Now you are ready to proceed to Protocol 4: Validation of Network Adequacy If you have any questions or comments about this lesson please reach out to your Program Manager, Course Instructor or leave a message in the Chat Boards.
📌 Course Instructor: Michelle Hoover
📌 email: mhoover@qsource.org