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

Effective Date:

Approval Date: 45 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)) For CHIP OHP Plus, DMAP contracted prepaid managed care plans results of consumer satisfaction surveys, EQRO and site review identify areas that need system improvements in quality of or access to care. DMAP measures well-baby care/child/adolescent care and childhood immunizations through the use of HEDIS performance measures. The results of these measures are reported by FCHP, as well as fee-for- service. In addition, access to primary care provider and measures of early childhood cavities prevention efforts are measured. Health KidsConnect private option plans are licensed and regulated by the Department of Consumer and Business Services (DCBS), Oregon’s insurance division. The regulations for Health insurers require the carriers to report annually to DCBS on grievance and appeals, utilization review policies, quality assessments activities and health promotion and disease prevention activities, including a summary of screening and prevention health care activities covered by the insurer, as well as the scope of the insurers network and to the accessibility of services. Health insurers measure well-baby care/child/adolescent care and childhood immunizations through the use of HEDIS performance measures.

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

7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a)) CHIP OHP Plus: CHIP services will be provided through Oregon’s existing OHP Medicaid Demonstration delivery system. The managed