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Effective Date: April 1, 2009

Approval Date: ____________ 39

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))

The methods used to assure the quality and appropriateness of care include both internal and external monitoring. Contracted HMOs must meet stringent quality specifications detailed in the contract. The State identifies, defines and specifies the standards for quality measurement and improvement with reference to practice guidelines, the quality assessment and performance improvement program and health information systems. Pursuant to the Modified QARI/QISMC standards, the HMO must ensure that its practice guidelines be based on reasonable medical evidence, consider the needs of the enrollees, be developed in consultation with contracting health care professionals and be reviewed and updated periodically. The HMO’s quality improvement program must include annual quality improvement projects specific to measurable improvement goals. At the beginning of each contract year, the HMO must present a plan to the State for designing and implementing its strategies followed by submission of semiannual progress reports summarizing performance relative to each of the defined objectives. The HMO must have procedures in place for monitoring the quality and adequacy of medical care which would include assessing utilization of services. On an annual basis, the HMO must submit a report on quality assurance activities which demonstrate its accomplishments, compliance and/or deficiencies in meeting its previous year’s work plan and should include studies undertaken, subsequent actions, and aggregate data on utilization and clinical quality of medical care rendered.

External review of the HMOs’ provision of quality and appropriate care is accomplished through routine surveys, medical audits and other administrative functions by DMAHS staff as well as focused quality studies conducted by an external quality review organization, the Peer Review Organization (PRO). Annual evaluations of the HMOs’ performance are conducted through a joint review process with State staff and the PRO.

State staff monitoring activities of the HMOs include:

• Maintenance of a toll free hotline for HMO members for questions and complaints which are investigated and resolved. • Assurance that marketing materials, member notices, newsletters, and handbooks are accurate and complete through a review and prior approval process.