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Effective Date: April 1, 2009

Approval Date: ____________ 41

and methods. Every HMO is required annually to submit performance and outcome measures that objectively demonstrate the HMO’s performance in delivering health care to its members. The results of the HMO’s performance are made public by the Department of Health and Senior Services through release of a HMO “report card.” The report card will include HEDIS measures and the results from the Consumer Assessment of Health Plans (CAHPS) survey. The use of CAHPS for this purpose represents the first use of this tool for a commercial population. In the future, consideration may be given to combining the Medicaid and commercial reporting requirements.

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 As indicated above, routine surveys and medical audits are conducted by DMAHS staff and the PRO under contract with the State. Based on the Modified QARI/QISMC standards located in the Medicaid contract, 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. HMO operations are formally reviewed annually through a joint review by the State and the PRO. Accreditation is not required.

7.1.2.

Performance measurement HMOs must conduct annual member satisfaction surveys. In addition, DMAHS conducts annual consumer satisfaction surveys that address issues of access, overall satisfaction and system performance. New Jersey Medicaid is participating in CAHPS, which will be extended to cover Title XXI services. HEDIS standards for measurement are utilized for the focused studies by the PRO wherever possible.

7.1.3.

Information strategies Under the Medicaid program, New Jersey has a highly developed system for providing consumer information. These successful strategies of providing detailed information on the benefits provided, rights and responsibilities, plan benefits and plan selection/enrollment will be extended to Title XXI as much as practical. Distribution of specific member notifications and disclosure of information about benefits and member rights and responsibilities are required of the HMOs; extensive marketing/enrollment outreach and education is provided through State agents.

7.1.4.

Quality improvement strategies As indicated above, the contract specifications require that HMOs develop an approved Quality Assurance Plan, which is monitored on an ongoing basis by