Page 39

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

Effective Date:

Approval Date: 7-3

Quality ● Prenatal care: low birth weight, entry in first trimester, initial prenatal care visit, number of prenatal care visits, stage of pregnancy at time of enrollment ● HIV education (age 12-18) ● Substance abuse counseling (age 12-18) ● Mental health follow-up

Access & Member Satisfaction

● Utilization of primary care providers by children ● Availability (waiting times for scheduled appointments) ● Uniform member satisfaction ● Provision of urgent and emergency medical care

General Health Plan Management

● Quality and service improvement studies ● Case management ● Utilization management ● Risk management ● Provider compensation ● New member orientation/education ● Language services ● Arrangements with public health, education and social services

7.1.3.

Information strategies

Department sponsored quality assurance studies may be conducted during the contract period. The participating health plans in the Child Health Plus program have a contractual responsibility to work with the Department or its agent to complete the quality assurance study within the specified time frames. This includes supplying the medical records of enrolled children who are selected for the study sample and responding to inquires from the contractor.

7.1.4.

Quality improvement strategies

Health plan performance based on the annual performance data submissions are compared to the statewide average as well as previous year’s performance of the individual plan. Based on this information as well as information obtained from various other required reporting provided by the health plans, such as enrollee satisfaction surveys and provider network submissions, the Department identifies areas where improvement in plan performance is required or has occurred. When necessary, health plans are required to submit root cause analysis and improvement strategies that will be implemented by the plan to improve plan performance, especially in the areas of access to well child care and childhood and adolescent immunizations as detailed previously.