360-10.9 Managed care plan review criteria.

    (a) The commissioner will assess a social services district's managed care plan by determining whether:

        (1) the plan reasonably relates to the specific problems which the MCP is designed to address, including a reasonable estimate of the MCP's cost-effectiveness;

        (2) the plan includes enough managed care providers, and an adequate network of primary care practitioners and other medical services providers, which are geographically accessible to the MA recipients who are eligible to participate in an MCP;

        (3) the MCP provides adequate grievance procedures;

        (4) the MCP adequately assures the continuity and quality of care which is delivered to a participant;

        (5) the plan adequately documents that the community participated in developing the plan;

        (6) the MCP includes appropriate procedures to enroll participants, including the provision of information which meets the requirements of section 360-10.8(f) of this Subpart;

        (7) the MCP provides adequate access to emergency medical care and services, if included in the plan, and establishes adequate procedures between managed care providers and hospitals to assure appropriate use of such care and services;

        (8) the plan provides sufficient documentation that managed care providers, primary care practitioners and medical services providers, possessing appropriate professional qualifications, licensure or certification, were given the opportunity to participate in the MCP;

        (9) the MCP assures the provision of preventive care services in accordance with the Child/Teen Health Plan; and

        (10) the plan adequately describes how managed care providers will be enrolled in the MCP.

    (b) The commissioner, in consultation with the Department of Health, will assess the adequacy of the information submitted as a result of the requirements of paragraphs (2), (4) and (7) of subdivision (a) of this section.

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