(a) General rule. To avoid duplication, the State may use, in place of a Medicaid review by the State, its agent, or EQRO, information about the MCO or PIHP obtained from a Medicare or private accreditation review to provide information otherwise obtained from the mandatory activities specified in Sec. 438.358 if the conditions of paragraph (b) or paragraph (c) of this section are met.
(b) MCOs or PIHPs reviewed by Medicare or private accrediting organizations. For information about an MCO's or PIHP's compliance with one or more standards required under Sec. 438.204(g), (except with respect to standards under Sec. 438.240(b)(1) and (2), for the conduct of performance improvement projects and calculation of performance measures respectively) the following conditions must be met:
(1) The MCO or PIHP is in compliance with standards established by CMS for Medicare + Choice or a national accrediting organization. The CMS or national accreditation standards are comparable to standards established by the State to comply with Sec. 438.204(g) and the EQR-related activity under Sec. 438.358(b)(3).
(2) Compliance with the standards is determined either by--
(i) CMS or its contractor for Medicare; or
(ii) A private national accrediting organization that CMS has approved as applying standards at least as stringent as Medicare under the procedures in Sec. 422.158.
(3) The MCO or PIHP provides to the State all the reports, findings, and other results of the Medicare or private accreditation review applicable to the standards provided for in Sec. 438.204(g); and the State provides the information to the EQRO.
(4) In its quality strategy, the State identifies the standards for which the EQR will use information from Medicare or private accreditation reviews, and explains its rationale for why the standards are duplicative.
(c) Additional provisions for MCOs or PIHPs serving only dually eligibles. The State may use information obtained from the Medicare program in place of information produced by the State, its agent, or EQRO with respect to the mandatory activities specified in Sec. 438.358 (b)(1) and (b)(2) if the following conditions are met:
(1) The MCO or PIHP serves only individuals who receive both Medicare and Medicaid benefits.
(2) The Medicare review activities are substantially comparable to the State-specified mandatory activities in Sec. 438.358(b)(1) and (b)(2).
(3) The MCO or PIHP provides to the State all the reports, findings, and other results of the Medicare review from the activities specified under Sec. 438.358(b)(1) and (b)(2) and the State provides the information to the EQRO.
(4) In its quality strategy, the State identifies the mandatory activities for which it has exercised this option and explains its rationale for why these activities are duplicative.