Use of HUSKY Name; HUSKY Logo and Mandatory Language Requirements. MCOs will be allowed use of the HUSKY logo and name for use in their marketing materials, subject to the following: a) must be used in conjunction with the following language unless alternative language has been prior approved by the DEPARTMENT. ▇▇▇▇▇ gives families the freedom of choice to enroll in one of several participating health plans. Toll-free information: 1-877-CT-HUSKY; b) the above mandatory language must be placed in the vicinity of the HUSKY logo; and c) the font size for the HUSKY phone number cannot be smaller than the MCOs member services phone number. 1 General HUSKY marketing materials X 2 General, MCO advertising/marketing X 3 MCO advertising in provider care sites X 4 MCO advertising in all DEPARTMENT- eligibility offices, including hospital-based (Must be made available only through the DEPARTMENT or its agent) X 5 Provider communications with Medicaid patients about MCO options X 6 Member-initiated telephone conversations with MCO and Provider staff X 7 Member-initiated one-on-one meetings with MCO staff prior to enrollment X 8 Mailings by MCO in response to Member requests X 9 Unsolicited MCO mailings to Members X 10 Telemarketing X 11 MCO group meetings, held at MCO X 12 MCO group meetings held in public facilities such as churches, health fairs, WIC program or other community sites X 13 MCO group meetings held in private clubs or homes X 14 Individual solicitation at residences X 15 Items of nominal value along with written information about the MCO or general health education information to potential Members (given at such places as health fairs, community forums or other events approved by the Department) or included in new Member information packets. X 16 Gifts to Members (e.g. baby T-shirt showing immunization schedule) based on specific health events unrelated to enrollment X 17 Phoning by Members from health care provider locations X 18 Non-alcoholic beverages and light refreshments (e.g. fruit, cookies) for potential Members at meetings (may not mention refreshments in advertisements for meetings) X Appendix G The organization has a written description of its Quality Assurance Program (QAP). This written description meets the following criteria: A. Goals and objectives - There is a written description of the QA program with detailed goals and annually developed objectives that outline the program structure and design and include a timetable for implementation and accomplishment.
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Use of HUSKY Name; HUSKY Logo and Mandatory Language Requirements. MCOs will be allowed use of the HUSKY logo and name for use in their marketing materials, subject to the following:
a) must be used in conjunction with the following language unless alternative language has been prior approved by the DEPARTMENT. ▇▇▇▇▇ gives families the freedom of choice to enroll in one of several participating health plans. Toll-free information: 1-877-CT-HUSKY;.
b) the above mandatory language must be placed in the vicinity of the HUSKY logo; and
c) the font size for the HUSKY phone number cannot be smaller than the MCOs member services phone number. 1 General HUSKY marketing materials X 2 General, MCO advertising/marketing X 3 MCO advertising in provider care sites X 4 MCO advertising in all DEPARTMENT- eligibility offices, including hospital-based (Must be made available only through the DEPARTMENT or its agent) X 5 Provider communications with Medicaid patients about MCO options X 6 Member-initiated telephone conversations with MCO and Provider staff X 05/07 7 Member-initiated one-on-one meetings with MCO staff prior to enrollment X 8 Mailings by MCO in response to Member requests X 9 Unsolicited MCO mailings to Members X 10 Telemarketing X 11 MCO group meetings, held at MCO X 12 MCO group meetings held in public facilities such as churches, health fairs, WIC program or other community sites X 13 MCO group meetings held in private clubs or homes X 14 Individual solicitation at residences X 15 Items of nominal value along with written information about the MCO or general health education information to potential Members (given at such places as health fairs, community forums or other events approved by the Department) or included in new Member information packets. X 16 Gifts to Members (e.g. baby T-shirt showing immunization schedule) based on specific health events unrelated to enrollment X 17 Phoning by Members from health care provider locations X 18 Non-alcoholic beverages and light refreshments (e.g. fruit, cookies) for potential Members at meetings (may not mention refreshments in advertisements for meetings) X Appendix G The organization has a written description of its Quality Assurance Program (QAP). This written description meets the following criteria:
A. Goals and objectives - There is a written description of the QA program with detailed goals and annually developed objectives that outline the program structure and design and include a timetable for implementation and accomplishment.
B. Scope -
1. The scope of the QAP is comprehensive, addressing both the quality of clinical care and quality of non-clinical aspects of services, such as and including: availability, accessibility, coordination, and continuity of care.
2. The QAP methodology provides for review of the entire range of care provided by the organization, by assuring that all demographic groups, care settings (e.g. inpatient, ambulatory, [including care provided in private practice offices] and home care), and types of services (e.g. preventive, primary, specialty care and ancillary) are included in the scope of the review. This review should be carried out over multiple review periods and not on just a concurrent basis.
C. Specific activities - The written description specifies quality of care studies and other activities to be undertaken over a prescribed period of time, and methodologies and organizational arrangements to be used to accomplish them. Individuals responsible for the studies and other activities are clearly identified and are appropriate.
D. Continuous activity - The written description provides for continuous performance of the activities, including tracking of issues overtime.
E. Provider review - The QAP provides:
1. Review by physicians and other health professionals of the process followed in the provision of health services;
2. Feedback to health professionals and health plan staff regarding performance and patient results.
F. Focus on health outcomes - The QAP methodology addresses health outcomes to the extent consistent with existing technology. Page l of 13(9/06) The QAP objectively and systematically monitors and evaluates the quality and appropriateness of care and service provided members, through quality of care studies and related activities, and pursues opportunities for improvement on an ongoing basis.
A. Specification of clinical or health services delivery areas to be monitored
1. Monitoring and evaluation of clinical issues reflects the population served by the health plan, in terms of age groups, disease categories, and special risk status.
2. For the Medicaid population, the QAP monitors and evaluates at a minimum, care and services in certain priority areas of concern selected by the State. It is recommended that these be taken from among those identified by the Health Care Financing Administration's (HCFA's) Medicaid Bureau and jointly determined by the State and the Managed Care Organization (MCO).
3. At its discretion and/or as required by the State Medicaid agency, the MCO's QAP also monitors and evaluates other aspects of care and service.
B. Use of quality indicators Quality indicators are measurable variables relating to a specified clinical or health services delivery area, which are reviewed over a period of time to monitor the process of outcomes of care delivered in that area.
1. The MCO identifies and uses quality indicators that are measurable, objective, and based on current knowledge and clinical experiences.
2. For the priority area selected by the State from the HCFA Medicaid Bureau's list of priority clinical and health service delivery areas of concern, the MCO monitors and evaluates quality of care through studies, which include, but are not limited to, the quality indicators also specified by the HCFA Medicaid Bureau.
3. Methods and frequency of data collection are appropriate and sufficient to detect need for program change.
C. Use of clinical care standards/practice guidelines
1. The QAP studies and other activities monitor quality of care against clinical care or health services delivery standards or practice guidelines specified for each area identified.
2. The clinical standards/practice guidelines are based on reasonable scientific evidence and are developed or reviewed by plan providers.
3. The clinical standards/practice guidelines focus on the process and outcomes of health care delivery, as well as access to care.
4. A mechanism is in place for continuously updating the standards/practice guidelines.
5. The clinical standards/practice guidelines shall be included in provider manuals developed for use by HMO providers or otherwise disseminated to the providers as they are adopted.
6. The clinical standards/practice guidelines address preventive health services.
7. The clinical standards/practice guidelines are developed for the full spectrum of populations enrolled in the plan.
8. The QAP shall use these clinical standards/practice guidelines to evaluate the quality of care provided by the MCO's providers, whether the providers are organized in groups, as individuals, as IPAs, or in a combination thereof.
D. Analysis of clinical care and related services
1. Appropriate clinicians monitor and evaluate quality through review of individual cases where there are questions about care and through studies analyzing patterns of clinical care and related service. For quality issues identified in the QAP's targeted clinical areas, the analysis includes the identified quality indicators and uses clinical care standards or practice guidelines.
2. Mulitdisciplinary teams are used, where indicated, to analyze and address system issues.
3. For the D.1. and D.2. above, clinical and related services requiring improvement are identified.
E. Implementation of remedial/corrective actions The QAP includes written procedures for taking appropriate remedial action whenever, as determined under the QAP, inappropriate or substandard services are furnished, or services that should have been furnished were not. These written remedial/corrective action procedures include:
1. Specification of the types of problems requiring remedial/corrective action.
2. Specification of the person(s) or body responsible for making the final determinations regarding quality problems.
3. Specific actions to be taken.
4. Provision of feedback to appropriate health professionals, providers and staff.
5. The schedule and accountability for implementing corrective actions.
6. The approach to modify the corrective action if improvements do not occur.
7. Procedures for terminating the affiliation with the physician, or other health professional or provider.
F. Assessment of effectiveness of corrective actions
1. As actions are taken to improve care, there is monitoring and evaluation of corrective actions to assure that appropriate changes have been made. In addition, changes in practice patterns are tracked.
2. The MCO assures follow-up on identified issues to ensure that actions for improvement have been effective.
G. Evaluation of continuity and effectiveness of the QAP
1. The MCO conducts a regular and periodic examination of the scope and
2. At the end of each year, a written report on the QAP is prepared which addresses: QA studies and other activities completed, trending of clinical and services indicators and other performance data; demonstrated improvements in quality; areas of deficiency and recommendations for corrective action; and an evaluation of the overall effectiveness of the QAP
3. There is evidence that QA activities have contributed to significant improvements in the care and services delivered to members. The QA committee is accountable to the governing body of the managed care organization. The governing body should be the board of directors, or a committee of senior management may be designated in instances in which the board's participation with QA issues is not direct. There is evidence of a formally designated structure, accountability at the highest levels of the organization, and ongoing and/or continuous oversight of the QA program. Responsibilities of the Governing Board for monitoring, evaluating, and making improvements to care include:
A. Oversight of the QAP - There is documentation that the governing body has approved the overall QAP and the annual QAP.
B. Oversight of entity - The Governing Body has formally designated an accountable entity or entities within the organization to provide oversight of QA, or has formally decided to provide such oversight as a committee of the whole.
C. QAP progress reports - The Governing body routinely receives written reports from the QAP describing actions taken, progress in meeting QA objectives, and improvements made.
D. Annual QAP review - The Governing Body formally reviews on a periodic basis (but no less frequently than annually) a written report on the QAP which includes: studies undertaken, results, subsequent actions, and aggregate data on utilization and quality of services rendered, to assess the QAP's continuity, effectiveness and current acceptability.
E. Program modification - Upon receipt of regular written reports from the QAP delineating actions taken and improvements made, the Governing Body takes actions when appropriate and directs that the operational QAP be modified on an ongoing basis to accommodate review findings and issues of concern within the MCO. Minutes of the meetings of the Governing Board demonstrate that the Board has directed and followed up on necessary actions pertaining to QA. The QAP delineates an identifiable structure responsible for performing QA functions within the MCO. The committee or other structure has:
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