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

Effective Date:

Approval Date: 46 care plans are contracted directly with DMAP (described in Section 3.1).Since 1994, health plans that contract with the state to provide Title XIX services have been required to adhere to established quality assurance methods and protocols. As the state of the art of managed care quality assurance has changed and become more sophisticated, so have Oregon’s requirements for plan participation. Activities of the OHP Medicaid Demonstration quality improvement program extend to CHIP OHP Plus coverage. This assures CHIP OHP Plus members will receive the same quality of care and access to care currently provided to OHP Medicaid members. Specific studies of the quality of care and access to care of CHIP OHP Plus members are conducted within the context of ongoing DMAP quality improvement and evaluation efforts. As described in DMAPs Oregon Health Plan Administrative Rules and the General Rules, Prepaid Health Plans (PHPs) that contract with DMAP must meet specific mandatory obligations designed to assure quality, medically appropriate care for all OHP enrollees. The data specifications and reporting requirements outlined in the Rules are consistent with CMS’s quality initiatives for Medicaid managed care. All services provided to children enrolled in Oregon’s CHIP OHP Plus program will meet the same standards of quality assurance and medically appropriate care as currently provided by OHP Medicaid. With respect to health care delivery systems, DMAP has many contractual requirements for plan participation. PHPs must meet various quality assurance reporting requirements, including the following:

Reporting Area Quality Assurance Requirement

Plan Infrastructure and Management Solvency plan and financial reporting ♦ Medical and dental record keeping system ♦ Utilization control requirements and review procedures ♦ Credentialing and recredentialing procedures ♦ Information materials for the orientation of new members and the continuing education of existing members ♦ Provider compensation and turnover rates

Access/Availability Utilization of Medically Appropriate Covered Services, including: ♦ Inpatient/Outpatient care; ♦ Maternity and newborn care; ♦ Ambulatory care; ♦ Preventive care; and