Strong Consumer Protections

It is vitally important to ensure consumer protections in the design of Medicaid ACOs. While this list is not exhaustive, below are a few key priorities.

Compliance

Does your state Medicaid ACO program do the following?

  • Establish policies and procedures for complying with the federal law, including the the Americans with Disabilities Act (ADA) and the Mental Health Parity and Addiction Equity Act (MHPAEA).

  • Ensure that policies are in place to protect consumers’ health information when they transition from one ACO to another.

  • Implement policies to protect consumers and ensure continuity of care in case the ACO faces financial losses or closure

    • In Massachusetts, organizations that want to take on financial risk must certify to the Department of Insurance that they have sufficient capital and reserves to do so.

Enrollment Attribution

In an ACO model, patients are attributed to an ACO and a specific provider within an ACO.  Advocates should ensure that consumers have the opportunity to proactively opt into the program or that the state is moving in that direction to ensure choice.

Does your state Medicaid ACO program do the following?

  • Provide consumers with the opportunity to proactively opt in to the program.

  • Prohibit lock-in periods that prevent consumers from leaving an ACO.

  • Clearly describe the process for opting out of attribution to an ACO and remaining in traditional fee-for-service.

  • Provide consumers with comprehensive, accessible information about attribution that explains what an ACO is and what it means to be attributed to one. Including:

    • Information about what it means to affirmatively opt into an ACO and a choice between ACOs if there is more than one ACO operating in a given area.

    • The rights and protections of ACO participants.

    • Details about the provider network, such as language spoken by providers, details about the pediatric network, the network for substance use disorders and mental health providers, including the specific type of service, and information about physical accessibility.

    • Present information in culturally and linguistically appropriate ways. Take the health literacy levels of consumers and their caregivers into account.

Grievances and Appeals

A robust grievance and appeals system is an important component of an ACO. Does your state Medicaid ACO program do the following?

  • Have a formal grievance and appeals system that is easily understandable and accessible online and on paper for consumers and caregivers.

  • Provide comprehensive information to consumers on their rights related to grievances and appeals. This includes how to file a grievance, who to file with, and if there are consumer assistance programs like an ombudsman that will assist them through the process.

  • Provide continuation of service provision in the same amount, duration and scope during appeals.

  • Establish mechanisms to track grievances, and maintain records of all grievances received. This information should be aggregated, analyzed for patterns of problems that show a need for policy or practice change, publicly reported, and shared with the ombudsman and oversight agencies

    • A Vermont  law,  Act 113 of 2016, includes significant ACO-related consumer protections that may serve as a model for other states. The law requires ACOs to maintain a hotline for complaints and grievances; provides members with contact information for the Office of the Health Care Advocate, an organization in Vermont that provides consumer assistance; and requires ACOs to share complaint and grievance information with the Office of the Health Care Advocate at least twice annually.

Ombudsman

An ombudsman program is a critical protection for ACO enrollees, and should also provide feedback to the state on systemic issues. Does your state Medicaid ACO program do the following?

  • Contract with and fully fund an independent, conflict-free entity to serve as the ombudsman. This entity could be a community-based organization. .

  • Provide consumers and stakeholders with information on how the ombudsman will function and the criteria by which its success will be measured.

  • Provide sufficient funding to allow the ombudsman to meet the needs of consumers and provide timely trend reports. Require that the ombudsman report to and collect information from state, ACO stakeholders, and consumers. 

    • MassHealth has specific ombudsman programs for different health care plans, including its Medicaid ACO, assisted living, community care, and long-term care plans.

  • Ensure the ombudsman is trained in the requirements of mental health and substance use parity, the Americans with Disabilities Act, and other anti-discrimination laws and regulations.

Does your state ombudsman do the following?

  • Provide accurate and up-to-date information for members on how to navigate the ACO enrollment process, and troubleshoot issues with enrollment and provision of care.

  • Coordinate with other entities and individuals in the community and within provider organizations, including enrollment assisters, who already provide enrollment and provider navigation assistance to members.

  • Track and report systemic issues, report data in real time, and conduct outreach and training for members about their rights and responsibilities. Reporting should be stratified by race, ethnicity, primary language, gender identity, sexual orientation and disability status to track system-wide trends that identify and measure gaps in service.

  • Track and document an enrollee's case from start to final outcome, and report aggregated data to ACO advisory bodies and the state. This data should also be presented in the form of a public-facing dashboard that provides objective comparisons of enrollee complaints, resolutions and outcomes across ACOs.

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