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40 Effective Date: July 1, 2009

Approval Date: 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 quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and age appropriate immunizations provided under the plan, are addressed for managed care coverage through contract requirements for participating Managed Care Organization (MCOs). Requirements and monitoring criteria are the same as those for the current HO and the fee-for-service (FFS) programs. The state contracts only with MCOs that are regulated by the Office of the Insurance Commissioner (OIC), which regulates and monitors financial solvency and other consumer protection safeguards. MPA monitors the quality and appropriateness of care through: • Monitoring and analysis of quality standards and performance measures for well-baby care, well-child care, and immunizations required through encounter data, chart review, HEDIS reporting, and a variety of other contract monitoring activities listed below; • Client interviews; • Biennial client satisfaction/health status surveys for managed care clients; • Complaint management system; • Exemption/disenrollment/fair hearing database; • Standards for health plan internal quality improvement programs; • Network adequacy standards; and • On-site contract compliance monitoring and technical assistance. Contract monitoring is performed through the following actions: • Requiring the same encounter data reporting (form, format, periodicity) as required under Medicaid HO; • Generating HEDIS reporting and the above mentioned quality measures with the same criteria as Medicaid HO and similar FFS review;