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

Standard VIII: Quality Improvement Program
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT SECTION CONTRACT REQUIREMENT COMPLIANT SCORING
CC-VIII.A.1.c
6. Quality Improvements
CC - VIII.A.1.d
7. Interventions
CC - VIII.A.1.e
8. Agency Approval of the
QI Plan
CC - VIII.A.1.g
9. Overall Responsibility of
the Governing Body
CC-X.1
10. Governing Body
CC-VIII.A.2.a
11. Role of Governing Body
CC-VIII.A.2.a
including, but not limited to anticipation,
identification, monitoring, measurement,
evaluation of enrollee’s health care
needs, and effective action to promote
quality of care.
The health plan defines and implements
improvements in processes that enhance
clinical efficiency, provide effective
utilization, and focus on improved
outcomes management achieving the
highest level of success.
The health plan and its QI Plan
demonstrate specific interventions in its
care management to better manage the
care and promote healthier enrollee
outcomes.
Prior to implementation, the Agency
reviews the health plan’s QI Plan.
The health plan’s governing body sets
policy and has overall responsibility for
the organization of the health plan.
The health plan’s governing body
oversees and evaluates the QI Program.
The role of the health plan’s governing
body includes providing strategic
direction to the QI Program, as well as
ensuring the QI Plan is incorporated into
the operations throughout the health
plan.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
DOCUMENTS
REVIEWED
State of Florida Compliance Monitoring_Standard_VIII_F2_07_11
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
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FINDINGS