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Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 28 - 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)) 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 7.1.2  Performance measurement 7.1.3 □ Information strategies 7.1.4  Quality improvement strategies Response: SCHIP 1 and SCHIP 2 is not a MO HealthNet entitlement but it will be implemented as a MO HealthNet look-alike program. SCHIP 1 and SCHIP 2 will use MO HealthNet's comprehensive benefit package, with the exception of not providing NEMT for children in families with income above 150% FPL, MO HealthNet Managed Care, and the Fee-For-Service delivery system, all quality and appropriateness of care measures, and grievance procedures. In keeping with federal and state regulations, the MCOs must meet program standards for monitoring and evaluating systems as outlined in the MO HealthNet Managed Care contract. Each MCO must implement a Quality Improvement (QI) strategy that addresses the standards as noted but is not limited to the requirements within the MO HealthNet Managed Care QI Strategy or the MO HealthNet Managed Care contract. The MCOs provide the State with regular reports of utilization and quality assessment including special needs; lead poisoning prevention; member grievances and appeals; provider complaints; grievances and appeals; and fraud and abuse detection. An annual evaluation contains information related to utilization and clinical performance, accessibility standards, quality indicators, performance improvement projects, care management, and subcontractor oversight. Performance measures are reported in accordance with Health Plan Employer Data and Information Set (HEDIS) specifications. The required HEDIS measures are outlined in the QI Strategy. Please see Attachment 4. The DHSS grants access to Missouri Health Strategic Architectures and Information Cooperative (MOHSAIC), DHSS' integrated public health information system, to public health staff, health care providers, and others who have a legal right to the information to better provide care and services. DHSS is responsible