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Application for the State of Indiana Children’s Health Insurance Program Amendment #7

Effective Date:

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Approval Date: 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)) (42CFR 457.495(a))

External Quality Review The State contracts with an evaluation consultant who develops and updates performance criteria, and also provides assistance in producing the evaluation and annual reports. The performance criteria are an important tool for measuring quality of care, particularly with respect to well-baby care, well-child care, and immunizations. Hoosier Healthwise uses NCQA’s HEDIS measures to monitor quality.

Quality Improvement Programs Quality assurance requirements are imposed on MCOs that contract with the State under Hoosier Healthwise. MCOs must have quality improvement (QI) programs in place that meet the federal requirements (42 CFR 438 Subpart D) and the National Committee for Quality Assurance (NCQA) standards. The QI programs must be based on annual plans that are approved by the OMPP. In addition, MCOs must meet a number of other QI requirements, including: establishing a QI Committee overseen by the MCO Medical Director; submitting Quarterly QI reports; conducting focused studies, including medical data abstraction and data entry, in areas of clinical priority for the Indiana Medicaid population; establishing internal systems for monitoring services; conducting a quality of care chart audit of providers of services; attending monthly Hoosier Healthwise Quality Improvement Committee (QIC) meetings; submitting QI data to the State; and taking other steps to improve quality of services.

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)

7.1.1.

Quality standards

 MCOs that provide services under Hoosier Healthwise must have QI programs in place that meet NCQA standards.  PMPs will be required to comply with universally accepted standards for preventive care, as endorsed by the American Academy of Pediatrics, the Academy of Family Physicians, the American College of Obstetrics and Gynecology, and the American Society of Internal Medicine. Specifically, these standards apply to the following areas: childhood immunizations, pregnancy, lead toxicity, comprehensive well child periodic health assessment, HIV status, asthma, diabetes, ETOH and drug abuse, sexually transmitted diseases, motor vehicle accidents, pregnancy prevention, prevention of influenza, smoking prevention and cessation, and others. Clinical practice guidelines from the Agency for Healthcare Research and Quality and the Indiana Medicaid Coordinated Care Technical