§ 40-8.5-1.1 - Managed health care delivery systems.
SECTION 40-8.5-1.1
§ 40-8.5-1.1 Managed health care deliverysystems. – (a) To ensure that all medical assistance beneficiaries, including the elderlyand all individuals with disabilities, have access to quality and affordablehealth care, the department of human services is authorized to implementmandatory managed care health systems.
(b) "Managed care" is defined as systems that: integrate anefficient financing mechanism with quality service delivery; provides a"medical home" to assure appropriate care and deter unnecessary services; andplace emphasis on preventive and primary care. For purposes of MedicalAssistance, managed care systems are also defined to include a primary carecase management model in which ancillary services are provided under thedirection of a physician in a practice that meets standards established by thedepartment of human services. Those medical assistance recipients who havethird-party medical coverage or insurance may be exempt from mandatory managedcare in accordance with rules and regulations promulgated by the department ofhuman services. The department is further authorized to redesign benefitpackages for medical assistance beneficiaries subject to appropriate federalapproval.
(c) The department is authorized to obtain any approvalthrough waiver(s) and/or state plan amendments, from the secretary of theUnited States department of health and human services, that are necessary toimplement mandatory managed health care delivery systems for all medicalassistance recipients, including the primary case management model in whichancillary services are provided under the direction of a physician in apractice that meets standards established by the department of human services.The waiver(s) and/or state plan amendments shall include the authorization toexempt beneficiaries with third-party medical coverage or insurance frommandatory managed care in accordance with rules and regulations promulgated bythe department of human services.
(d) To ensure the delivery of timely and appropriate servicesto persons who become eligible for Medicaid by virtue of their eligibility fora U.S. social security administration program, the department of human servicesis authorized to seek any and all data sharing agreements or other agreementswith the social security administration as may be necessary to receive timelyand accurate diagnostic data and clinical assessments. Such information shallbe used exclusively for the purpose of service planning, and shall be held andexchanged in accordance with all applicable state and federal medical recordconfidentiality laws and regulations.