The URAC Guide to Medicaid Managed Care External Quality Review
URAC is a private national accrediting organization approved by the Centers for Medicare and Medicaid Services (CMS) pursuant to 42 CFR 158 (71 Federal Register 30422-30423; May 26, 2006). Several states, including Florida, Georgia, Hawaii, Indiana, Michigan, Minnesota, South Carolina, Virginia, and Wisconsin currently recognize one or more URAC accreditation programs in their Medicaid statutes, regulations, or contracts.
URAC accreditation may also help state Medicaid agencies evaluate Medicaid managed care organizations as part of the external quality review process (42 CFR 438.358). URAC encourages state Medicaid agencies to use URAC accreditation standards in developing state quality strategies for external quality review activities as well as in evolving state Medicaid managed care reforms. To facilitate this process, URAC developed the URAC Guide to Medicaid Managed Care External Quality Review (Guide).
The Guide includes a crosswalk between the federal Medicaid managed care regulations and URAC’s Health Plan Accreditation Standards (Version 5.1). URAC found that the Health Plan Accreditation Standards are comparable to 81 percent of the regulatory standards subject to operational review under the mandatory External Quality Review activities.
CMS' Center for Medicaid and State Operations (CMSO) has reviewed the URAC Guide and noted its agreement with URAC claims of comparability between URAC accreditation standards and federal Medicaid managed care requirements. CMS references the URAC Guide online at www.cms.gov/MedicaidCHIPQualPrac/ under "Tips, Tools and Protocols."
For questions about the Guide and to request a copy of the URAC standards, please email urac.gr@urac.org
Click here to download Document 1:
- Introduction
- Background: Medicaid Managed Care Oversight
- Overview of URAC
- Appendix A: Summary Table
- Appendix B: CMS Protocol Bibliography and Key
Click here to download Document 2:
- Appendix C: Federal Medicaid Managed Care Regulations Crosswalk to URAC Health Plan Standards (Version 5.1, 2007)
- Appendix D: Sample Documentation and Onsite Survey Questions