Proactive Safeguards and Protections

Medical Necessity

Criteria for determining whether a service is reasonable, necessary and appropriate based on evidence-based practices or standards of service. Because an MLTSS contractor may use these criteria as a basis for authorizing services, a state will want to carefully review and revise its medical necessity criteria to incorporate the full range of services it wishes to promote under MLTSS (e.g., services required to improve health status, functional status, etc.), and ensure that the MLTSS contractor is using substantially similar criteria.

Member Rights

Standards requiring that members be able to participate in their service planning, choose providers, receive adequate notice when services are changed or eliminated, and appeal decisions.

Qualified Providers

Criteria for determining if a provider is qualified to provide an MLTSS service. Standards may use state licensure/certification requirements as the minimum standard for participation. Some states may add to existing state standards or, in cases where a provider type is not otherwise licensed or certified, develop new qualifying standards such as in the case of direct care workers.

Marketing and Communication

Standards governing how MLTSS contractors communicate with members, the accessibility of information in formats that can be understood by everyone, and the elimination of potential biases when presenting information and options.

Complaint and Grievance

Standards specifying the role of the MLTSS contractor and state in soliciting, documenting, and resolving member complaints and grievances in a defined timeframe.

Data Reporting

Specification of data and data formats for the routine submittal of member, service and cost information. Comprehensive, accurate and timely data are critical to the early identification of problems at the member, provider, and MLTSS contract levels.

Service Delivery

Specifications defining the scope of services, including criteria for determining appropriate access to services and time frames for service delivery.