[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: 42CFR438.240]



[Page 231-232]

 

                         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.  438.240  Quality assessment and performance improvement program.



    (a) General rules. (1) The State must require, through its 

contracts, that each MCO and PIHP have an ongoing quality assessment and 

performance improvement program for the services it furnishes to its 

enrollees.

    (2) CMS, in consultation with States and other stakeholders, may 

specify performance measures and topics for performance improvement 

projects to be required by States in their contracts with MCOs and 

PIHPs.

    (b) Basic elements of MCO and PIHP quality assessment and 

performance improvement programs. At a minimum, the State must require 

that each MCO and PIHP comply with the following requirements:

    (1) Conduct performance improvement projects as described in 

paragraph (d) of this section. These projects must be designed to 

achieve, through ongoing measurements and intervention, significant 

improvement, sustained over time, in clinical care and nonclinical care 

areas that are expected to have a favorable effect on health outcomes 

and enrollee satisfaction.

    (2) Submit performance measurement data as described in paragraph 

(c) of this section.

    (3) Have in effect mechanisms to detect both underutilization and 

overutilization of services.

    (4) Have in effect mechanisms to assess the quality and 

appropriateness of care furnished to enrollees with special health care 

needs.

    (c) Performance measurement. Annually each MCO and PIHP must--



[[Page 232]]



    (1) Measure and report to the State its performance, using standard 

measures required by the State including those that incorporate the 

requirements of Sec.  438.204(c) and Sec.  438.240(a)(2);

    (2) Submit to the State, data specified by the State, that enables 

the State to measure the MCO's or PIHP's performance; or

    (3) Perform a combination of the activities described in paragraphs 

(c)(1) and (c)(2) of this section.

    (d) Performance improvement projects. (1) MCOs and PIHPs must have 

an ongoing program of performance improvement projects that focus on 

clinical and nonclinical areas, and that involve the following:

    (i) Measurement of performance using objective quality indicators.

    (ii) Implementation of system interventions to achieve improvement 

in quality.

    (iii) Evaluation of the effectiveness of the interventions.

    (iv) Planning and initiation of activities for increasing or 

sustaining improvement.

    (2) Each MCO and PIHP must report the status and results of each 

project to the State as requested, including those that incorporate the 

requirements of Sec.  438.240(a)(2). Each performance improvement 

project must be completed in a reasonable time period so as to generally 

allow information on the success of performance improvement projects in 

the aggregate to produce new information on quality of care every year.

    (e) Program review by the State. (1) The State must review, at least 

annually, the impact and effectiveness of each MCO's and PIHP's quality 

assessment and performance improvement program. The review must 

include--

    (i) The MCO's and PIHP's performance on the standard measures on 

which it is required to report; and

    (ii) The results of each MCO's and PIHP's performance improvement 

projects.

    (2) The State may require that an MCO or PIHP have in effect a 

process for its own evaluation of the impact and effectiveness of its 

quality assessment and performance improvement program.