ries, looking at such measures as annual eye examinations and blood glucose control to determine how ambulatory care can be improved. This effort to develop outcomes measures for other clinical conditions will be expanded in the future.11

Beneficiary Rights

The beneficiary has the right to remain enrolled in a plan for the duration of the government contract, except for cause which must have prior HCFA approval. Beneficiaries may appeal decisions about coverage or services. Through a contractor, HCFA reviews all decisions that are adverse to a member. Appeals to an administrative law judge and the federal court system may follow.12

The lock-in is one of the most difficult concepts for many beneficiaries who are used to fee-for-service medicine. Plans therefore are required to explain the lock-in to potential enrollees, and HCFA strongly recommends (but does not require) face-to-face discussion of this feature. HCFA itself provides an explanation of the lock-in when the beneficiary receives notice that he or she has been enrolled in a managed care plan.13 As noted, beneficiaries can disenroll monthly, effective the first day of the month after request, either through the managed care plan directly or through a local Social Security office.

Ongoing Monitoring by HCFA

Both regional and central HCFA office staff monitor managed care contracts through monthly reports and biennial onsite visits. In 1996, HCFA will begin annual targeted on-site reviews. HCFA's overall ongoing monitoring involves the following:

11  

Interview with Paul Elstein, HCFA Office of Managed Care, November 30, 1995.

12  

Interviews with Gary Bailey and Rae Loen, HCFA Office of Managed Care, December 1995 and January 1996.

13  

Interview with Gary Bailey, HCFA Office of Managed Care, December 13, 1995.



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement