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STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 7-49

Effective Date: 07/01/05

49 Approval Date: _____________/06 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))

The Commonwealth will use numerous methods to assure that FAMIS recipients receive quality services that are appropriate to their needs. These methods may include the following:

• Verification that the health insurers develop and maintain quality assurance and quality improvement programs. • Verification that health insurers have sufficient network providers and procedures to ensure that children have access to routine, urgent, and emergency services. • Verification that health insurers maintain a member complaint system and provide access to a grievance process to appeal a plan action.

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

Health insurers are required to follow standards established by the Commonwealth in the development and maintenance of their quality improvement programs.

7.1.2. ⌧ Performance measurement

A. Submission of a quality improvement plan.

B. Adherence to NCQA, JCAHO, or other nationally recognized accrediting organization.

C. Results of HEDIS or other.

D. CAHPS Survey.

E. Clinical focus studies.