Managed Care

State Plan Amendment - Title XIX of the Social Security Act

Supplement 10 - Interventions and Sanctions

Provider Interventions and Sanctions are utilized when OMS determines that a PCP acts or fails to act according to requirements set forth in Supplement 5, the Addendum to the Provider Agreement or violates any of the requirements of section 1932 and 1905(t) of the Act and implementing regulations. Interventions and sanctions listed are specific to the services covered within this SPA, PCCM (case-management) services.

Interventions

Interventions are considered an informal process to seek program compliance for PCPs that OMS determines are out of compliance. Utilization of these processes does not restrict the State’s ability to initiate sanctions. Informal interventions may consist but are not limited to the following:

• Provide education and informal mailings.
• Initiate telephone and/or mail inquiries and follow-up.
• Request primary care case manager’s response to identified problems.
• Refer to program staff for further investigation.
• Send warning letters to primary care case managers.
• Refer to State's medical staff for investigation.
• Institute corrective action plans and follow-up.
• Change a beneficiary's primary care case manager.

Sanctions

The OMS determination to impose a sanction may be based on findings from onsite survey, enrollee or other complaints, or any other source when OMS determines that a PCP acts or fails to act according to requirements set forth in Supplement 5, the Addendum to the Provider Agreement or violates any of the requirements of section 1932 and 1905(t) of the Act and implementing regulations. Sanctions under this SPA are limited to the following:

• Institute a restriction on the types of beneficiaries.
• Further limit or ban the number of assignments.
• Transfer some or all assignments to different primary care case managers.
• Recover or withhold case management fees.
• Suspend or terminate as primary care case managers.

OMS has the authority to terminate a PCP agreement and enroll that provider’s enrollees with another PCP or provide their Medicaid benefits through other options included in the State plan. This sanction may be applied if the State determines that PCP has failed to carry out the substantive terms of its agreement (Addendum to the Provider Agreement), requirements set forth in the Managed Care Provider Manual or has failed to meet applicable requirements in sections 1932 and 1905(t) of the Act.

Before terminating the PCP agreement, OMS must provide the PCP predetermination hearing. OMS must:

• Give the PCP written notice of its intent to terminate, the reason for termination, and the time and place of the hearing;
• After the hearing, give the PCP written notice of the decision affirming or reversing the proposed termination of the contract and, for an affirming decision, the effective date of termination;
• For an affirming decision, give enrollees of the PCP notice of the termination and provide information regarding their options for receiving Medicaid services following the effective date of termination.

Beneficiaries

Interventions

The State utilizes a number of interventions other than denial of services not covered through this SPA to enforce compliance with beneficiary requirements listed in Supplement 4. Beneficiary interventions include the following:

• Provide education and informal mailings.
• Initiate telephone and/or mail inquiries and follow-up.
• Refer to program staff for further investigation.
• Refer to other agencies for assistance.
• Change or adjust PCP enrollment.