KEPRO uses the mandatory compliance validation protocol to determine, in a manner consistent with standard industry practices, the extent to which Medicaid managed care entities are in compliance with Federal quality standards mandated by the Balanced Budget Act of 1997 (BBA). This validation process is conducted triennially. The 2017 compliance reviews were structured based on program requirements as outlined in 42 CFR 438. In addition, compliance with provisions in contracts as they relate to 42 CFR 438 between MassHealth and each One Care plan were assessed. Appropriate provisions in the Code of Massachusetts Regulations (CMR) were included in the reviews as indicated. The most stringent of the requirements were used to assess for compliance when State and Federal requirements differed. One Care activity and services occurring for calendar year 2016 were subject to review. Based on regulatory and contract requirements, compliance reviews were divided into the following 14 standards: Enrollee Rights and Protections; Enrollee Information; Availability and Accessibility of Services; Coordination and Continuity of Care; Coverage and Authorization of Services;
KEPRO uses the mandatory compliance validation protocol to determine, in a manner consistent with standard industry practices, the extent to which Medicaid managed care entities are in compliance with Federal quality standards mandated by the Balanced Budget Act of 1997 (BBA). This validation process is conducted triennially. The 2017 compliance reviews were structured based on program requirements as outlined in 42 CFR 438. In addition, compliance with provisions in contracts as they relate to 42 CFR 438 between MassHealth and each One Care plan were assessed. Appropriate provisions in the Code of Massachusetts Regulations (CMR) were included in the reviews as indicated. The most stringent of the requirements were used to assess for compliance when State and Federal requirements differed. One Care activity and services occurring for calendar year 2016 were subject to review. Based on regulatory and contract requirements, compliance reviews were divided into the following 14 standards: Enrollee Rights and Protections; Enrollee Information; Availability and Accessibility of Services; Coordination and Continuity of Care; Coverage and Authorization of Services;
2017-onecare-eqr-technical-report.docx