DATE	December 1, 1999
TO	Medicare+Choice Organizations
FROM	Jean D. LeMasurier for Gary A. Bailey Director, Health Plan Purchasing and Administration Group
SUBJECT	Medicare+Choice Monitoring Guide

I am pleased to announce that the Health Care Financing Administration (HCFA) has completed its work on the Monitoring Guide for Medicare + Choice (M+C) Organizations offering coordinated care plans. The development of the guide has been a collaborative effort across HCFA components and has included staff from the Central Office and Regional Offices. The guide has also been enhanced by a review by industry representatives.

The M+C Monitoring Guide combines the requirements of the Part C regulations from June 1998 and February 1999 as well as the Quality Improvement System for Managed Care (QISMC) into one document. This guide represents a comprehensive statement of HCFA's expectations for M+C Organization compliance with the coordinated care plan program requirements. I think you will find the guide useful as a blueprint for developing your internal compliance programs, and I strongly recommend that your organization use the guide to identify risk areas and conduct self-audits.

Since the passage of the Balanced Budget Act in August of 1997, HCFA has been examining its methods for monitoring M+C Organizations. The M+C Monitoring Guide represents one piece of HCFA's long-term strategy for improving its monitoring efforts. The Health Plan Purchasing Administration Group (HPPA) has also chartered a workgroup responsible for developing a new overall strategy for monitoring M+C Organizations' compliance with program requirements. This workgroup is currently reviewing the many types of data collected by HCFA and developing methods for analysis of this data, all in an effort to create a comprehensive, data-driven monitoring system. It is HPPA's goal to implement this new strategy within the next twelve months.

Specifics on the Guide

• The M+C monitoring guide is structured similarly to the 1997-1998 Contractor Performance Monitoring System. Some sections (e.g., health services delivery and quality assurance) of the 1997-1998 document have been incorporated into the QISMC section of the new guide.
• The effective date for use of the new guide is January 1, 2000.

Compliance Requirements
In a February 1, 1999 letter to industry, M+C Organizations were informed that, until the M+C Monitoring Guide was released, HCFA would focus its reviews on those Section 1876 requirements which were retained in the Part C regulations. These requirements cover such areas as: claims processing; marketing; enrollment; disenrollment; membership; health services delivery and appeals and grievances. We will continue to monitor plan activities in these areas using current HCFA standards of compliance through the end of 1999. On January 1, 2000 HCFA will begin using the M+C Monitoring Guide and will continue to monitor M+CO performance through the established M+C contractor review process.

HCFA provided M+C Organizations one year to achieve compliance with provider contracting, compliance plan, and QISMC quality assurance and performance improvement (QAPI) requirements. HCFA expects M+C Organizations to be in compliance with these requirements by January 1, 2000, unless otherwise noted in the monitoring protocol. Compliance with these requirements will be determined through the routine monitoring process.

HCFA recognizes that while provider contracting requirements are stated in Operational Policy Letter (OPL) 77, and QISMC requirements are articulated in OPL 72, similar guidance regarding the compliance plan requirements has not been released. After publication of the final Part C regulations, HCFA will issue guidance regarding how compliance plans will be assessed. In the interim, M+C Organizations are expected to have developed formal compliance plans using the interim final regulations as guidance for the development of a plan. M+C Organizations may also refer to the Office of Inspector General's (OIG) guidance as one model of a compliance plan.

One additional area of operational policy development is Domain 4 of QISMC, which outlines Delegation requirements. HCFA is presently working on this guidance and will develop an OPL. However, as with the compliance plan requirement, M+C Organizations must meet the requirements of Domain 4 as of January 1, 2000.

There are a number of elements in the M+C Monitoring Guide, which are labeled as "new elements". These are labeled to assist you in recognizing new items that HCFA will be monitoring. Please note that "new elements may not be totally new, but may reflect clarification of federal expectations on previous program requirements. HCFA expects full compliance with "new elements" beginning January 1, 2000.

We hope you will find this new guide useful as a tool for improving your organization=s methods for ensuring compliance with HCFA regulations and, in turn, ensuring the provision of the best quality of services to Medicare beneficiaries.

You may download a copy of the M+C Monitoring Guide via the Internet at www.hcfa.gov/medicare/mgdmonit.htm. It will be available in both MS Word and Adobe formats. Please contact your regional HCFA office to obtain a WordPerfect version of the document.

If you have any questions, please contact your regional HCFA office.

You must download all files to view them. They are available in Word and PDF formats. Due to the Word formatting, some of the PDF files are slightly cropped around the margins. If you have trouble reading the information, please contact your regional office for a hard copy. A few of the worksheets are in Excel97.

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Last Updated December 5, 1999