763.1. Medicaid agency monitoring of the ADvantage program

317:30-5-763.1. Medicaid agency monitoring of the ADvantage program

Revised 7-1-13

(a) The OHCA's monitoring of the ADvantage Program is a quality assurance activity. The agency evaluates the ADvantage program on a continual basis to ensure quality, through the review of various performance measures set forth in the waiver document. The areas evaluated include:

(1) Member eligibility determination;
(2) Member "freedom of choice";
(3) Member health and welfare;
(4) ADvantage certified and SoonerCare contracted providers on the plan;
(5) Member acceptance of the plan;
(6) Qualified case managers;
(7) Plan services are goal-oriented services; and,
(8) Plan of care costs are within cost cap guidelines.

(b) Deficiencies found by the OHCA are reported to the AA for correction and/or explanation. Additionally, a quality management report is submitted to the Centers for Medicare and Medicaid Services annually.

Library: Policy