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

STATE: Virginia Page 7-50

Effective Date: 07/01/05

50 Approval Date: _____________/06

7.1.3. ⌧ Information strategies

Each managed care organization will establish a system to monitor compliance with access standards set forth by DMAS and a data management system to meet DMAS data collection requirements. DMAS annually requires managed care organization to report the percentage of children who received all expected well- child care visits according to the benefits schedule, during the period that each child was enrolled and the percent of two-year old children who have received each immunization specified in the most current ACIP recommendations.

7.1.4. ⌧ Quality improvement strategies

Health insurers may perform the following:

A. Documentation of current MCHIP quality certification or documentation of a comparable accreditation

B. Develop and maintain a Quality Improvement Program (QIP) which meets standards and reporting requirements set out by the Commonwealth.

C. Cooperate and show compliance with the DMAS Quality Improvement Program, which may require calculation and reporting of performance measures and the implementation of performance improvement projects as well as cooperate with DMAS or a designated agent in conducting quality reviews. Managed care organizations are required to have a written utilization management (UM) program that reflects the National Committee for Quality Assurance standards to include mechanisms to detect under-utilization and/or over-utilization of care. Managed care organizations must show implementation of an approved system to monitor and address complaints and grievances.

7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

Each MCO and PCCM provider will meet the requirements by the contract with DMAS to ensure access to well baby care, well adolescent care, and childhood immunizations. By contract MCOs and PCCM providers are responsible for arranging and administering