[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR438.204]



[Page 226]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 438_MANAGED CARE--Table of Contents

 

        Subpart D_Quality Assessment and Performance Improvement

 

Sec.  438.204  Elements of State quality strategies.



    At a minimum, State strategies must include the following:

    (a) The MCO and PIHP contract provisions that incorporate the 

standards specified in this subpart.

    (b) Procedures that--

    (1) Assess the quality and appropriateness of care and services 

furnished to all Medicaid enrollees under the MCO and PIHP contracts, 

and to individuals with special health care needs.

    (2) Identify the race, ethnicity, and primary language spoken of 

each Medicaid enrollee. States must provide this information to the MCO 

and PIHP for each Medicaid enrollee at the time of enrollment.

    (3) Regularly monitor and evaluate the MCO and PIHP compliance with 

the standards.

    (c) For MCOs and PIHPs, any national performance measures and levels 

that may be identified and developed by CMS in consultation with States 

and other relevant stakeholders.

    (d) Arrangements for annual, external independent reviews of the 

quality outcomes and timeliness of, and access to, the services covered 

under each MCO and PIHP contract.

    (e) For MCOs, appropriate use of intermediate sanctions that, at a 

minimum, meet the requirements of subpart I of this part.

    (f) An information system that supports initial and ongoing 

operation and review of the State's quality strategy.

    (g) Standards, at least as stringent as those in the following 

sections of this subpart, for access to care, structure and operations, 

and quality measurement and improvement.



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