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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))

CoverKids will use the expertise of an independent evaluation contractor in the assessment of the CoverKids program. Quality and appropriateness of care will be assessed through the use of enrollee surveys, review of claims data, and medical record review. Both process and outcome measures will be considered when assessing the quality and appropriateness of care. Among the items to be used in tracking are claims data indicators such as whether children have a usual source of care, whether children are receiving the recommended well-child exams and are appropriately immunized; whether non-trauma based emergency room use is going down, how referrals are being made, whether specialty care and related services are being received, and patterns of prescription drug use. CoverKids plans to monitor consumer and provider satisfaction through surveys and informal communications with families, advocacy groups, and providers. In addition to these monitoring strategies, the State assures access to care through monitoring of the geographic distribution of providers.

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 The State ensures quality through contracted performance measures. 7.1.3

Information strategies The contracted insurer will be required to provide key health indicators information. 7.1.4

Quality improvement strategies The contracted insurer will be required to maintain an effective quality improvement program.

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