Letter to CMS - Medicaid Managed Care Policies - Agency for ...

Emergency management plan
Independently certified audited financial statements
Pro forma financial statements broken down by line of business and prepared on an
accrual basis by month for the first three years of the anticipated contract execution date
Bank account statements for required accounts for start-up, reserves and insolvency
protection and a description of how those accounts will be appropriately maintained
Attestation that no assets have been pledged to secure personal loans
Review of general insurance coverage for contract-required types of insurance
If applicants do not provide documentation of meeting the minimum financial, organizational,
prior experience and network requirements in Phase I, they are given an opportunity to remedy
the application and then, if not remedied, the application review is terminated. If the applicant
does meet these requirements, they move on to a review of policies and procedures (Phase II)
to ensure all contract requirements are met. If Phase I and Phase II requirements are met, a
site visit be scheduled to ensure that the health plan is operationally ready for contract. This
site visit includes a review of administrative functions as well as medical, behavioral health and
fraud and abuse functions.
If the health plan applicant’s ownership changes during the application process, the Agency
may reject the application.
The Health Plan Application includes a description of the application process in order to ensure
all applicants are sufficiently aware of the state’s application process and criteria.
See Appendix A for links to the most current Health Plan Application, agency model
documents and checklists
Agency staff reviews the health plan application using an application checklist based on
application and contract requirements. See Appendix B
See current Agency Health Plan Application Phase I application review checklist attached.
Overview of Current Health Plan Oversight Requirements:
To help ensure current health plans remain stable and turnover is minimized, the Agency
reviews the following areas as indicated below:
Plan activities and performance, reviewed in monthly leadership meetings and quarterly
meetings of those Agency bureau staff responsible for contract oversight. Discussion
includes but is not limited to:
• Corrective action taken or needed
• Sanctions and appeals
• Expansion and withdrawal requests
• Financial, surplus and solvency issues
• Complaints, grievances and appeals
• Fraud and abuse issues
• Reporting timeliness and accuracy
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