State and Federal Oversight and Monitoring

Structures must be in place to ensure that MCOs are performing contracted duties and delivering high quality services. Oversight and monitoring should be a coordinated and complementary effort by CMS, state agencies, an independent advocate for enrollees, and stakeholder committees.  Where the MCO is also providing Medicare benefits, Medicare must also be involved.

  • States must have an oversight and monitoring plan that clarifies what role each of the relevant agencies will play.  In most states, numerous agencies have been involved in the delivery of long term services supports.  Expertise from each of these agencies should be leveraged in a managed LTSS program, but roles need to be delineated and a clear lead agency ultimately responsible for the program should be identified.
  • States must restructure and rehire as necessary to ensure that staff have expertise in overseeing, monitoring and contracting with MCOs.
  • The oversight and monitoring plan must include activities to monitor MCO performance over time as well as activities that can quickly identify and resolve current problems.
  • Specific activities for overseeing and monitoring delivery of LTSS must be developed.  For example:
    • A dashboard that monitors the delivery of HCBS.  Beneficiaries would have the ability to call into the state-run dashboard if a personal care attendant did not report to work and the state would have the ability to send a replacement worker immediately.  The dashboard would track over time the MCOs ability to provide timely access to HCBS.
    • Secret shopper surveys that test the adequacy of LTSS networks.
    • Audits of MCO operations related to LTSS delivery.
    • Review and analysis of LTSS encounter data submitted by MCOs.
  • States must utilize stakeholder groups and independent ombudsman in its monitoring and oversight plan.
  • MCO performance and quality data collected via the states oversight and monitoring efforts must be made publicly available in a timely and regular way.
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