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DELAWARE HEALTHY CHILDREN PROGRAM (DHCP) 24

Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

range of clinical and health service delivery areas. Emphasis must be placed on, but need not be limited to, clinical areas relating to well baby care, well child care, pediatric and adolescent development, as well as on key access or other priority issues for [Title XXI] patients such as teen age pregnancy and immunizations.

All MCOs are to structure their internal QAPs in a manner consistent with the standards as outlined in the Federal Government's "Quality Assurance Reform Initiative Guide for States" (QARI) or subsequent revisions thereof, for internal and external quality assurance reviews.

Provider Profiling

The MCO must have written credentialing and re-credentialing policies and procedures for determining and assuring that all providers under contract to the plan are licensed by the State and qualified to perform their services according to CMS's "A Health Care Quality Improvement System for Medicaid Managed Care: A Guide for the States", or subsequent revisions thereof. The MCO also must have written policies and procedures for monitoring its providers and for disciplining providers who are found to be out-of-compliance with the MCO's medical management standards.

Quality Assurance Report

As with the existing Title XIX program, plans will also be required to submit periodically to DSS reports regarding results of their internal monitoring. This will include the reporting of The Health Plan Employer Data and Information Set (HEDIS), version 3.0 or subsequent revisions, and other targeted health indicators that shall be monitored by DSS as well as other specific quality data periodically requested by the federal government. The MCO must agree to submit a quality assurance report six (6) months after the contract effective date and semi-annually thereafter. These reports will distinguish clearly between the Title XIX and the Title XXI programs.

Outcomes Objectives

The State, in conjunction with the MCOs, will develop a system of incentives for reaching outcome objectives in certain key areas to be defined by the State and MCOs. These outcome objectives will include, at a minimum, childhood immunizations, well baby and well child care pediatric asthma, and behavioral health care. MCOs will be required to submit on a periodic basis objective numerical data and/or narrative reports describing clinical and related information on health services and outcomes of health care for the Title XXI and Title XIX enrolled populations. Each program will be handled as separate programs for reporting.