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

Effective Date:

Approval Date: 48 health plan. These measures are used as part of our periodic on-site reviews of each health plan to promote access to necessary services. DMAP does not currently sanction plans for not meeting minimum performance levels for these measures. However, DMAP has both a Quality Improvement Coordinator and a Prepaid Health Plan coordinator assigned to each plan to monitor access to services and performance on these critical indicators. If problems are encountered, these staff members work with the health plans to establish and monitor corrective action plans in order to achieve acceptable performance.

Contracted health plans are required to have written policies and procedures and monitoring systems that provide for emergency and urgent services for all DMAP Members on a 24-hour, 7-day-a-week basis.

Contracted health plans are required to have written policies, procedures and monitoring systems that ensure the provision of Case Management Services for all OHP clients, to coordinate and manage services, and to ensure that referrals made are noted in the patient’s clinical record. Plans are required to develop and maintain a formal referral system consisting of a network of consultation and referral providers, including applicable Alternative Care Settings, for all services covered by agreements with DHS. Health plans must ensure that access to and quality of care provided in all referral settings is monitored.

Other Efforts to Improve Quality of and Access to OHP Services:

Quality DMAP coordinates the activities of the Department of Human Services' Oregon Health Plan Quality Improvement Committee (OHPQIC). The OHPQIC is responsible for advising and guiding the quality improvement efforts of all administrative components of the OHP and will serve a similar role in assessing the CHIP OHP Plus. The overall mechanism for quality improvement, administered by DMAP requires PHPs to have an active Quality Improvement Process (QIP) in place and integrated with other management functions. QIP performance is evaluated annually and involves review against standards in the following areas:

♦ Member Care is measured against current, relevant, criteria for care. ♦ Medical and Dental Records are reviewed for structure and completeness. ♦ Quality Improvement Program Policies and Standards are reviewed and refined to meet changing conditions and needs. ♦ Comorbidities and Special Needs are reviewed before denial of a