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Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

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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))

CHIP provides services to enrolled children primarily through a managed care model. By state law and regulation, all of the CHIP Contractor delivery systems are state licensed managed care organizations (predominantly HMOs, though two of them use PPO delivery systems in limited counties) which, as a condition of licensure, must undergo periodic external reviews of their quality assurance systems and the quality of care provided to their members. These reviews are required within one year of licensure and again at three-year intervals or for cause. The reviews are performed by the National Committee for Quality Assurance (“NCQA”) with Health Department participation. The scope of review includes a detailed examination of the plan’s quality assurance/improvement program including access, availability, continuity of care, and preventive and health maintenance services to members, including CHIP-enrolled children. With the assistance of the Department of Health, the Department identified opportunities for improvement are the responsibility of Health Department staff. These staff also independently assess managed care compliance with current state regulations on a periodic basis.

CHIP enrollees also have access to a complaint and grievance resolution process through their managed care plans. This process is mandated by state laws (Act 1998- 68) for all managed care organizations and requires members to go through a two-step process at the HMO level, with the second level including one-third member representation in the decision-making process. If the member is still dissatisfied, he or she has the right to appeal the plan’s decision to the Department of Health. The Contractor is required to have a data system in place capable of tracking and trending all complaints and grievances. In addition to assuring that appropriate care is accessible to members, this process also enables the Department to track and identify patterns of inappropriate care or service.

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)