QUALITY ASSURANCE STANDARDS.

SEC. 4705. QUALITY ASSURANCE STANDARDS. (a) In General.—Section 1932 is further amended by adding at the end the following: “(c) Quality Assurance Standards.— “(1) Quality assessment and improvement strategy.— “(A) In general.—If a State provides for contracts with medicaid managed care organizations under section 1903(m), the State shall develop and implement a quality assessment and improvement strategy consistent with this paragraph. Such strategy shall include the following: “(i) Access standards.—Standards for access to care so that covered services are available within reasonable timeframes and in a manner that ensures continuity of care and adequate primary care and specialized services capacity. “(ii) Other measures.—Examination of other aspects of care and service directly related to the improvement of quality of care (including grievance procedures and marketing and information standards). “(iii) Monitoring procedures.—Procedures for monitoring and evaluating the quality and appropriateness of care and services to enrollees that reflect the full spectrum of populations enrolled under the contract and that includes requirements for provision of quality assurance data to the State using the data and information set that the Secretary has specified for use under part C of title XVIII or such alternative 111 STAT. 499data as the Secretary approves, in consultation with the State. “(iv) Periodic review.—Regular, periodic examinations of the scope and content of the strategy. “(B) Standards.—The strategy developed under subparagraph (A) shall be consistent with standards that the Secretary first establishes within 1 year after the date of the enactment of this section. Such standards shall not preempt any State standards that are more stringent than such standards. Guidelines relating to quality assurance that are applied under section 1915(b)(1) shall apply under this subsection until the effective date of standards for quality assurance established under this subparagraph. “(C) Monitoring.—The Secretary shall monitor the development and implementation of strategies under subparagraph (A). “(D) Consultation.—The Secretary shall conduct activities under subparagraphs (B) and (C) in consultation with the States. “(2) External independent review of managed care activities.— “(A) Review of contracts.— “(i) In general.—Each contract under section 1903(m) with a medicaid managed care organization shall provide for an annual (as appropriate) external independent review conducted by a qualified independent entity of the quality outcomes and timeliness of, and access to, the items and services for which the organization is responsible under the contract. The requirement for such a review shall not apply until after the date that the Secretary establishes the identification method described in clause (ii). “(ii) Qualifications of reviewer.—The Secretary, in consultation with the States, shall establish a method for the identification of entities that are qualified to conduct reviews under clause (i). “(iii) Use of protocols.—The Secretary, in coordination with the National Governors’ Association, shall contract with an independent quality review organization (such as the National Committee for Quality Assurance) to develop the protocols to be used in external independent reviews conducted under this paragraph on and after January 1, 1999. “(iv) Availability of results.—The results of each external independent review conducted under this subparagraph shall be available to participating health care providers, enrollees, and potential enrollees of the organization, except that the results may not be made available in a manner that discloses the identity of any individual patient. “(B) Nonduplication of accreditation.—A State may provide that, in the case of a medicaid managed care organization that is accredited by a private independent entity (such as those described in section 1852(e)(4)) or that has an external review conducted under section 1852(e)(3), the external review activities conducted under subparagraph (A) with respect to the organization shall 111 STAT. 500not be duplicative of review activities conducted as part of the accreditation process or the external review conducted under such section. “(C) Deemed compliance for medicare managed care organizations.—At the option of a State, the requirements of subparagraph (A) shall not apply with respect to a medicaid managed care organization if the organization is an eligible organization with a contract in effect under section 1876 or a Medicare+Choice organization with a contract in effect under C of title XVIII and the organization has had a contract in effect under section 1903(m) at least during the previous 2-year period. (b) Increased FFP for External Quality Review Organizations.—Section 1903(a)(3)(C) (42 U.S.C. 1396b(a)(3)(C)) is amended— (1) by inserting “(i)” after “(C)”, and (2) by adding at the end the following new clause: “(ii) 75 percent of the sums expended with respect to costs incurred during such quarter (as found necessary by the Secretary for the proper and efficient administration of the State plan) as are attributable to the performance of independent external reviews conducted under section 1932(c)(2); and”. (c) Studies and Reports.— (1) GAO study and report on quality assurance and accreditation standards.— (A) Study.—The Comptroller General of the United States shall conduct a study and analysis of the Quality assurance programs and accreditation standards applicable to managed care entities operating in the private sector, or to such entities that operate under contracts under the medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.). Such study shall determine— (i) if such programs and standards include consideration of the accessibility and quality of the health care items and services delivered under such contracts to low-income individuals; and (ii) the appropriateness of applying such programs and standards to medicaid managed care organizations under section 1932(c) of such Act. (B) Report.—The Comptroller General shall submit a report to the Committee on Commerce of the House of Representatives and the Committee on Finance of the Senate on the study conducted under subparagraph (A). (2) Study and report on services provided to individuals with special health care needs.— (A) Study.—The Secretary of Health and Human Services, in consultation with States, managed care organizations, the National Academy of State Health Policy, representatives of beneficiaries with special health care needs, experts in specialized health care, and others, shall conduct a study concerning safeguards (if any) that may be needed to ensure that the health care needs of individuals with special health care needs and chronic conditions who are enrolled with medicaid managed care organizations are adequately met.111 STAT. 501 (B) Report.—Not later than 2 years after the date of the enactment of this Act, the Secretary shall submit to Committees described in paragraph (1)(B) a report on such study.