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DELAWARE HEALTHY CHILDREN PROGRAM (DHCP) 22
Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009
Section 7. Quality and Appropriateness of Care
Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 8.
7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(A)(7)(A)) 42 CFR 457.495(a))
Quality Assurance Structure
The MCO's utilization management and quality assurance program will consist of internal monitoring by the MCOs, oversight by DSS and the federal government, and evaluation by an independent, external review organization (EQRO). These programs are in place for the MCOs currently contracting for Title XIX clients and the same programs will be used for Title XXI. Future RFPs for Managed Care Organizations will include the need to provide services for both the Title XIX and the Title XXI programs. All MCOs must have a quality assurance structure composed of:
(a) An internal system of monitoring services;
(b) Designated staff with expertise in quality assurance; and
(c) Written policies and procedures for quality assurance and utilization management.
Quality Assurance System
As with Title XIX, MCOs are required to establish, implement, and adhere to the Quality Assurance and Utilization Management review systems approved by the Department and based on the current HCFA guidelines (A Health Care Quality Improvement System for Medicaid Managed Care issued July 6, 1993) or subsequent revisions thereof, and shall:
(a) Ensure that health care is provided as medically necessary in an effective and efficient manner;
(b) Assess the appropriateness and timeliness of care provided;
(c) Evaluate and improve, as necessary, access to care and quality of care with a focus on improving patient outcomes;
(d) Focus on the clinical quality of medical care rendered to enrollees; and