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61 With the transition of MRMIB programs to DHCS, quality improvement strategies, quality standards, and performance measurement information strategies are conducted in the same manner as Medi-Cal. Medi-Cal is addressed in California’s Title XIX plan.

Measuring Clinical Quality: The model health plan contract requires contractors to provide the state with audited clinical measures consisting of the National Committee for Quality Assurance’s Health Plan Employer Data and Information Set (HEDIS) 3.0 Performance Measures as well as any age relevant HEDIS measures which are included in versions of HEDIS numbered higher than 3.0. Plans must also report the number of subscribers who received a health assessment visit within 120 days or four consecutive months after their effective date of coverage. These data must be measured or audited by an independent third party and reported annually. DHCS may use the data to provide information to subscribers in its annual open enrollment or program application materials.

Standards Designed to Improve to Quality of Care: Health plans are required to assure that its providers will use the most recent recommendations of the American Academy of Pediatrics (AAP) with regard to recommendations for preventive pediatric health care. Annually, the plan must inform the caretakers of its enrollees of the AAP’s recommended schedule of preventive care visits. The notice must be in English, Spanish and any other language which is spoken in more than 5 percent of the plan’s enrollee’s households.

Quality Management Processes: The contractor must assure the State that its Quality Management processes have been reviewed and found to be satisfactory by either the National Committee on Quality Assurance, the Joint Commission on the Accreditation of Healthcare Organizations, or the State of California’s Medi-Cal Managed Care Program. The contractor must also maintain a system of accountability for quality improvement activities which includes the participation of the contractor’s governing body, the designation of a Quality Improvement Committee, supervision of the activities of the Medical Director, and the inclusion of contracted physicians and other providers in the process of quality improvement development and performance.

Quality Assurance Measures

Virtually all of the plans are regulated by California’s Department of Managed Health Care (DMHC) under the Knox-Keene Act - established specifically for managed care plans licensing. The Knox-Keene Act prescribes rules for the organization of HMOs and other managed care entities. It specifies plan standards, marketing rules, and consumer disclosure requirements. It also establishes fiscal solvency requirements and quality assurance standards.

California’s separate CHIP populations rely on the quality assurance requirements of the Knox-Keene Act which regulates health plans. Quality assurance requirements specifically require that plans have quality assurance programs, and that providers