Medicaid Managed Care - U.S. Senate Special Committee on Aging

572
Internal Quality Program Standards
Internal quality program standards refer to the standards that states require each
plan's quality assurance/improvement program to meet. 37 Ensuring that plan
internal systems work to ensure the delivery of quality care is an important first step
in ensuring that the overall program delivers quality care. In general, states require
plans to establish a committee to oversee all plan activity, including establishing
standards for participating providers, identifying issues for study, conducting
studies, and developing the plan's response to study findings. Most states specify
some aspects of the committee's structure, some of the sources of information the
committee must use to identify study topics and may sometimes even identify a
specific study topic. Although most states include specifications for the same types
of issues, some states that enroll special populations into <strong>Medicaid</strong> managed care
plans have modified their specific requirements to better accommodate the health
care needs of these populations. As demonstrated by Chart H, in 1996 many states
based these standards either on NCQA's standards or the previously discussed QARI
guidelines.
Oregon, for example, includes C H
several provisions in its National Academy for State Health Policy
administrative code to ensure that <strong>Medicaid</strong> Manged Cae
each.plan.s internal quality QQuality Improvement Strategies
each plan's internal quality Risk-Baud Coltr duig
assurance system will meet the 100% [AMC & 0 SS N
needs of the elderly and persons 90S ROt.atd l25 019y
with disabilities. Specifically, this 80S . t.
State specifies that the 70 W % 63% 61% S,
membership of the quality
assurance committee shall include
60
<
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.
20.
... a . 9%
or have access to consultation e*
from individuals with knowledge _ a
of all populations served
.t .
including those who are elderly or
who have a disability. In addition,
20.
10 .
Oregon specifies that several of the 0% .j
reviews 38 each plan is required to QAlU~ State-specified NCQA Platn
performmus eaddresans t theqneds to
requtred to
guidelines standards standards perform enrollee
perform must address the needs of satisfaction surveys
plan members who are elderly or Standards Used for Plan's Internal QI Program
37 Under the Batanced Budget Act of 1997, HCFA will develop quality assurance standards
for use by states in preparing a quality assessment or improvement strategy. Internal quality program
standards must be at least as extensive as those imposed by HCFA.
38 Areas that plans must review include: an annual review of the plan's entire quality
assurance program, utilization of services and its relationship to adverse or unexpected outcomes, and
review of member educational programs.
The National Academy for State Health Policy* 0 8/97 IV-69