Letter to CMS - Medicaid Managed Care Policies - Agency for ...

AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
MCO Health Plan: Contract Number:
Contract Manager: Date(s) of Monitoring:
Standard VIII: Quality Improvement Program
CONTRACT SECTION CONTRACT REQUIREMENT COMPLIANT SCORING
1. Quality Improvement
(QI) Program
42 CFR 438.204
42 CFR 438.240
CC-VIII.A.1.a
2. Written QI Plan
CC-VIII.A.1.b
3. Using the QI Plan to
Develop Performance
Improvement Projects
(PIPs)
CC-VIII.A.1.b
4. Resolving Problems not
in PIPs
CC - VIII.A.1.b
5. Policies and Procedures
The health plan has an ongoing QI
Program that objectively and
systematically monitors and evaluates
the quality and appropriateness of care
and services rendered to enrollees.
The health plan develops and submits to
the Bureau of Managed Health Care
(BMHC) a written quality improvement
plan within 30 calendar days from
execution of the initial contract and
resubmits it annually by April 1 for
written approval from the Agency.
The QI plan includes sections defining
how the QI Committee used any of the
following programs to develop its PIPs:
credentialing processes, case
management, utilization review, peer
review, review of grievances, and review
and response to adverse events.
Any problems/issues identified but not
included in a PIP must be addressed and
resolved by the QI committee.
The health plan’s written policies and
procedures address components of
effective health care management
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
State of Florida Compliance Monitoring_Standard_VIII_F2_07_11
Page 1
FINDINGS