Page 38

• General and specialty inpatient care, including maternity, surgical, medical, psychiatric, substance abuse and neonatal) • General and specialty outpatient care (including emergency department care without admission, vision, primary care, audiology care, and general dental care) • Dental preventive care; • Women’s health measures, including screening mammograms, Pap tests (and malignancy detection rates), maternity care, perinatal substance abuse care and HIV screening, prenatal care coordination)

Data on Medicaid HMOs is collected and published annually, and audit findings indicate steady improvement in the provision of primary care by managed care organizations.

In linking BadgerCare Plus recipients to a “medical home” and in requiring strong quality assurance efforts, Wisconsin Medicaid plans to continue this progress and improvement in health care outcomes in the BadgerCare program.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42 CFR 457.495(c))

MEDDIC-MS includes a clinical performance measure for each of the following, which is monitored program-wide and on an HMO-specific basis annually: • Ambulatory care for diabetes (including HbA1c and lipid profiles) • Asthma care including monitoring of prevalence, inpatient and ED care for asthma • Follow-up ambulatory care by specialists and PCPs for mental health and substance abuse diagnoses within 7 days and 30 days of discharge from inpatient care for those conditions; • Mental health and substance abuse evaluations and day/outpatient care by specialists and PCPs.

WISCONSIN

Effective Date:

Approval Date: 38