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Model Application Template for the State Children’s Health Insurance Program

Effective Date:

25 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))

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

Performance measurements developed by the Bureau as part of Utilization Reporting and the Primary Care Physician Incentive Payment program (discussed in detail Section 7.1.2) were modeled on both national (NCQA) standards and standards developed specifically for the State of Maine.

The Bureau of Medical Services has also adopted the Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents to assure quality and appropriateness of care with respect to well-baby care, well-child and adolescent care (through age 21) and administration of age appropriate immunizations. The Bureau has developed and distributed a Bright Futures forms that contain age appropriate periodicity schedules for well-child checks and immunizations to providers. These 19 age appropriate forms serve many purposes including, but not limited to:

• Serves as reminder for primary care providers on age appropriate screening services; • May serve as the provider’s medical record, provided it is complete; • Provides MaineCare with information about needed follow-up services that can be provided by MaineCare Member Services.

(Use of these forms is discussed in more detail in Section 7.1.4.)

Additionally, the Bureau has also formed a committee (MaineCare Immunization Sub-Committee) whose charge is to monitor the rate of immunizations for all MaineCare children and to determine appropriate interventions for increasing the rate of immunizations. The committee is comprised of staff from MaineCare Member Services and