3. (40 points) Use the sample managed care contract of the Illinois Department of Healthcare and Family Services (the Illinois Medicaid agency) in the following link to answer the following questions:

3. (40 points) Use the sample managed care contract of the Illinois Department of Healthcare and Family Services (the Illinois Medicaid agency) in the following link to answer the following questions:

https://www.illinois.gov/hfs/SiteCollectionDocuments/201824001MCOModelContractRev3RedLine.pdf .

A. (2 points) Identify the section of the contract that names the parties to the contract.

i. Who are the parties to the contract?

ii. Which party is the Medicaid agency and which party is the managed care plan?

B. (2 points) Which party is paying for the services in the contract?

C. (6 points) Identify the sections of the contract which describe the following payment methodologies and describe the payment methodologies:

i. the base payment methodology

ii. sanction methodology

iii. bonus methodology

D. (30 points) Chapters 8, 10 and 11, respectively, discuss improving patient safety, utilization management, and organizing for quality.

i. (9 points) Organizing for Quality

a. Identify the section(s) of the contract that mandate that the managed care plan has a quality management system in place

b. Describe the quality management system that the contractor is required to implement

c. Identify the stakeholders involved and give an opinion as to why you think there is a mandate in the contract to include these stakeholders

d. Identify the topics selected for performance measure and improvement activities

ii. (9 points) Patient Safety Management

a. Identify the sections and describe two topic areas where patient safety is required

b. Describe the patient safety quality requirements

c. Identify the stakeholders involved and give an opinion as to why you think there is a mandate in the contract to include these stakeholders

d. Identify the sections where performance improvement tools are recommended for the patient safety guidelines and describe the tools

e. Identify the sections where data sources are recommended for the patient safety guidelines and describe the sources

f. Identify the sections and describe two performance measures used

iii. (9 points) Utilization Management

a. Identify the section(s) and describe the utilization review guidelines

b. Identify the sections and describe 2 of the following:

– the performance measures and standards used

– benchmarks used

– tools used

c. Identify the section and definition of the utilization management program

d. Identify one section where continuous improvement is required and describe the improvement

e. How and where is medical necessity defined?

f. Identify and describe one section of the contract that mandates

– prospective medical necessity review

– concurrent medical necessity review

– retrospective medical necessity review

g. Identify the section and describe the medical conditions for which clinical practice guidelines and best practices are required

h. Identify the section and describe the organizations and committees used to establish the basis for the clinical practice guidelines

Explanation & Answer

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