Page 34

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)) (42 CFR 457.495(a))

Quality assurance mechanisms

BadgerCare Plus will include several quality assurance mechanisms to evaluate and improve the quality of medical care provided to BadgerCare Plus recipients. Every managed care organization under contract with the State will be required to have an active quality assurance system, including designated quality assurance staff devoted to evaluation of the care provided to BadgerCare Plus recipients.

The quality assurance activities carried out in BadgerCare Plus will focus on specific medical service delivery concerns. These medical and service delivery concerns will include the following:

• Access to care • Timeliness of care • Appropriateness of care • Appropriateness of setting • Appropriateness of amount of care • Consistency with current standards of medical practice • Education and communication with recipients • Ethnic and cultural responsiveness

Improvements to Care and Service

In addition, each BadgerCare Plus managed care organization will be required to demonstrate how the organization has attempted to improve care and service for BadgerCare recipients enrolled in their program. The state will monitor compliance with the contract standards for BadgerCare Plus (as with Medicaid) in a number of ways:

• An independent contractor will review a sample of recipient medical records annually to determine the adequacy of care and services being provided. The

WISCONSIN

Effective Date:

Approval Date: 34