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

Effective Date:

Approval Date: 7-1 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

Health plans are responsible for ensuring that the services and providers under CHPlus meet the quality of care standards required in the Public Health Law and related regulations.

Health plans must have internal quality assurance programs and written quality improvement or assurance plans (Quality Improvement Programs/Quality Assurance Programs (QAP)) for monitoring and improving the quality of care furnished to members. Such plans must address all of the following:

● Description of quality assurance committee structure; ● Identification of departments/individuals responsible for QAP implementation; ● Description of manner in which network providers may participate in QAP; ● Credentialing/re-credentialing procedures; ● Standards of care; ● Standards of service accessibility; ● Medical records standards; ● Utilization review procedures; ● Quality indicator measures and clinical studies; ● Quality assurance plan documentation methods; and ● Description of the manner in which quality assurance/quality improvement activities are integrated with other management functions.

Also, health plans are required to institute a credentialing process for their providers that includes, at a minimum, obtaining and verifying the following information:

● Evidence of valid current license and valid DEA certificate, as applicable; ● Names of hospitals, health maintenance organizations (HMOs), prepaid health services plans (PHSPs), and medical groups with which the provider has been associated; ● Reasons for discontinuance of such associations; ● Level of malpractice coverage; ● Pending professional misconduct proceedings or malpractice actions and