| (a) Each MCO must develop and implement an ongoing
quality assessment and performance improvement (QAPI) program for
services it furnishes to its enrollees. The MCO must maintain and
provide documentation of its compliance for HHSC's or its contracted
External Quality Review Organization's (EQRO's) review, including
performance measurement data. The MCO's quality assessment and performance
improvement program must meet the requirements contained in 42 CFR §438.240
and, at a minimum, include:
(1) a program of performance improvement projects that
focus on clinical and non-clinical areas;
(2) mechanisms to assess the quality and appropriateness
of care furnished to enrollees with special health care needs;
(3) mechanisms to detect both under and over-utilization
of services;
(4) practice guidelines that meet CMS requirements
under 42 CFR §438.236.
(b) An MCO may subcontract QAPI functions. An MCO must
not delegate responsibility for QAPI compliance.
(c) HHSC monitors and reviews systems and procedures
to ensure MCO compliance with MCO contracts, this subchapter, and
all related state and federal rules, regulations, and guidelines,
including QAPI standards.
(1) An MCO must submit QAPI information at regular
and periodic intervals.
(2) An MCO must submit to periodic inspection and review
to determine compliance with all contract terms, and state and federal
rules and policies.
(d) HHSC periodically evaluates each MCO's quality
of services in each Medicaid managed care service area and the cost-effectiveness,
member access, and quality of care under each federal waiver.
(1) A quality evaluation must be conducted at least
annually.
(2) The assessment of cost-effectiveness, member access,
and quality of care under each federal waiver must be conducted according
to the terms of an approved federal waiver.
(3) HHSC will determine the need for additional evaluations
after completing the evaluations described in paragraphs (1) and (2)
of this subsection.
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| Source Note: The provisions of this §353.417 adopted to be effective December 18, 1996, 21 TexReg 11822; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective August 10, 2005, 30 TexReg 4466; amended to be effective September 1, 2006, 31 TexReg 6629; amended to be effective March 1, 2012, 37 TexReg 1283; amended to be effective September 1, 2014, 39 TexReg 5873 |
