OHP managed care: EQRO requirements from CMS

• EQRO Introduction
• Protocols from CMS
• Attachments

NOTE:The documents listed below are in Adobe Acrobat (pdf) format. If you do not already have the free Acrobat Reader software, you can download it now.

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Introduction

Following the passage of the 1997 Balanced Budget Act, the Centers for Medicare and Medicaid Services (CMS) finalized External Quality Review Oversight (EQRO) requirements related to Medicaid managed care that went into effect beginning August 2003.

States can use managed care organizations with the complexity of a demonstration waiver to federal regulation. CMS requires assurances of the state programs through reviews and reports in three areas:

• MCO and PIHP compliance with state and federal standards
• Validating performance measures
• Validation performance improvement projects

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CMS Protocols

The protocols that states must use as guidelines for these reviews must be consistent with the CMS protocols below:

• Administering or Validating Survey  (PDF)
• Calculating Performance Measures (PDF)
• Conducting Focused Studies of Health Care Quality (PDF)
• Conducting Performance Improvement Projects (PDF)
• Monitoring Medicaid Managed Care Organizations (MCOs) and Prepaid Inpatient Health Plans (PIHPs) (PDF)
• Validation of Performance Improvement Projects (PDF) — This protocol describes the activities that must be used when validating Performance Improvement Projects of clinical and non-clinical health care services provided by MCOs and PIHPs.
• Validating Performance Measures (PDF)

Attachments

• Attachment B. Compliance Determination Activities for Individual Regulatory Provisions (PDF)
• Attachment C: Sample Documentation and Reporting Tool (PDF) — for recording MCO/PIHP compliance with Medicaid managed care regulatory provisions.
• Appendix Z. Information Systems Capabilities Assessment for Managed Care Organizations and Prepaid Health Plans  (PDF)  

If you have questions, contact charles.a.gallia@state.or.us or call 1-800-527-5772.   

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