Performance & Enrollment

Plan-Specific Reports of NYS Medicaid Managed Care Plans

New York State (NYS) is dedicated to providing and maintaining the highest quality of care for enrollees in managed health care plans. The New York State Department of Health (NYSDOH) Division of Managed Care and Program Evaluation (DMCPE) employs an ongoing strategy to improve the quality of care provided to plan enrollees, ensure the accountability of these plans and maintain the continuity of care to the public.

The Plan-Specific Reports (PSRs) are twenty-five (25) individualized reports on the managed care organizations (MCOs) certified to provide Medicaid coverage in NYS. In accordance with federal requirements, these reports summarize the results of the 2006 External Quality Review (EQR) to evaluate access to, timeliness of and quality of care provided to NYS Medicaid beneficiaries. Mandatory EQR-related activities (as per federal regulation 42 CFR §438.358) reported include validation of performance improvement projects, validation of plan-reported and NYSDOH-calculated performance measures and review for plan compliance with NYSDOH structure and operation standards. Optional EQR-related activities (as per federal regulation 42 CFR §438.358) reported include administration of a consumer survey of quality of care (CAHPS®) by an NCQA-certified vendor, one clinical focused study conducted on behalf of NYSDOH by the NYS External Quality Review Organization (EQRO), and technical assistance by the NYS EQRO to plans regarding performance improvement projects and reporting performance measures. Other data incorporated to provide additional background on the MCOs include the following: health plan corporate structure, enrollment and disenrollment data, provider network description, encounter data summaries, quality/satisfaction points and incentive, appeals summaries and financial ratios.

These reports are organized into the following domains: health plan corporate structure, enrollment and provider network information, utilization data, quality of care indicators, deficiencies and appeals, selected financial data, and MCO strengths and opportunities for improvement as described in the next paragraph.  Although the reports focus primarily on Medicaid data, selected sections of these reports also include data from the plans' Family Health Plus, Commercial and Child Health Plus product lines. Additionally, when available and appropriate, the plans' data are compared with statewide benchmarks. When benchmarks are utilized for rates other than QARR, comparative statements are based on differences determined by standard deviations: a difference of one standard deviation is used to determine rates that are higher or lower than the statewide average.

Section VIII provides an assessment of the MCO’s strengths and opportunities for improvement in the areas of accessibility, timeliness and quality of services. For areas in which the plan has opportunities for improvement, recommendations are provided for improving the quality of health care services. To achieve full compliance with federal regulations, this section also includes an assessment of the degree to which the MCO has addressed effectively the recommendations for quality improvement made by the NYS EQRO in the previous year’s EQR report. The MCO was given the opportunity to describe current and proposed interventions that address areas of concern, as well as an opportunity to explain areas that the MCO did not feel were within its ability to improve. The response by the MCO is appended to this section of the report.

In an effort to provide the most consistent presentation of this varied information, the PSR is prepared based on data for the most current calendar year available. Where possible, data for prior calendar years may also be included for trending purposes. This report includes data for Reporting Year 2006.

Reporting Year 2006