Each health plan’s governing entity should incorporate a board, advisory committee, or policy making and influencing group representative of the consumer populations served and the community at large, including age and ethnicity. In this manner, the community served will guide policy formulation and decision making, including Request for Proposals development and vendor selection. The administrator responsible for the Health Plan should be accountable for its successful implementation, including its cultural competence provisions.
The service site, or management care organization shall not have final authority over all appeals and grievances. Appeals and grievances should be taken to the appropriate system.
Specific strategies for appeals and grievances beyond the managed care system’s appeals and grievance procedures is defined to include the participation of tribal sovereign nations prior to any federal or state intervention. In the development of appeals and grievances, a determination must be made who has final authority on the reservation. Tribal court? State court? Federal court?
2. Urban/Suburban and Rural/Reservation:
The Health Plan should include a formal grievance procedure in accordance with state and federal law with minority community and professional input, participation, and involvement at all levels, including fair hearings. Consumers should be informed of this procedure in their own language at intake and at the time of any steps in the complaint and grievance process.
3. Urban/Suburban and Rural/Reservation:
The Health Plan should make available a culturally competent group of ombudspersons (minimally comprised of consumer, family member, and regional representatives) to be involved in all appeals and concerns from the community served. The group of ombudspersons should have independence from the Health Plan, and there should be formalized procedures for resolving differences of opinion between the ombudsperson and the Health Plan administration’s governance.
4. Urban/Suburban and Rural/Reservation:
The governing entity should determine for each Health Plan an equitable percentage of profit or savings to be reinvested in minority community-based services and preventive programs on an ongoing basis. A financial penalty or termination of contracts is applicable when gross inequities to access and/or comparability of benefits exist.
The Health Plan should develop interagency and cross-system agreements or pool funding to coordinate services with other agencies (e.g., public health, social services, corrections and juvenile justice, youth services, education, substance abuse, developmentally disabled services).
With primary recognition of the authority of tribal sovereign nations, the Health Plan should develop interagency and cross-system agreements or pool funding to coordinate services with other agencies (e.g., public health, social services, corrections and juvenile justice, youth services, education, substance abuse, developmentally disabled services) and including state and federal agencies.
Policies governing practitioner ethics and behavior (e.g., gift giving by consumers) should provide for differences relevant to the context of Native American cultural values.
Policies governing practitioner ethics and behavior (e.g., gift giving by consumers) should provide for differences relevant to the context of Native American cultural values. These policies should acknowledge the importance of participation in community events to communicate authenticity and respect for the Native community.
7. Urban/Suburban and Rural/Reservation:
Contract continuation and renewal should be contingent upon successful achievement with. performance standards which demonstrate effective service, equitable access and comparability of benefits for Native American and other underserved populations.
Recommended Performance Indicators
- The governing entity’s board, advisory committee, and other policy making and influencing groups have composition reflective of the demographics of the service area.
- Native American consumer awareness of Health Plan benefits, appeals procedures and ombudsperson, as demonstrated by comparable rate of grievances and complaints.
- Percent of complains and grievances of individual practitioners is tracked and factored into performance evaluations.
- Presence of culturally-informed policies of practitioner behavior and performance based demonstrations of implementation.
- Proportion of grievances and complains by Native American consumers
Benchmark: Comparable to overall service population
- Final disposition of grievances and appeals for Native American consumers
Benchmark: Comparable to service population
- Percent of Native American consumers receiving blended, coordinated, or wrap-around services
Benchmark: Comparable to overall service population and increasing over time
- Percent of reports of practitioner unethical behavior for practitioners serving Native American populations
Benchmark: Comparable to overall service population
- Sanctions and incentives reinforce movement toward cultural competence
Benchmark: Decreased rates of sanction over time