HFS – 2011 Annual Report Page 63
Managed Care - External Quality Review Organization
The Department is federally required to contract with an External Quality Review Organization (EQRO), as defined in 42 CFR Part 438 Subpart E. The EQRO provides quality assurance oversight of MCOs.
As a result of a competitive procurement, the Department entered into a contract with Health Services Advisory Group (HSAG) beginning June 1, 2006, and ending May 31, 2009. HFS executed its second renewal with HSAG through May 31, 2011, and then extended the contract initially through a sole source and subsequently through an emergency extension ending on December 31, 2012. The Department is currently in the process of finalizing a Request for Proposals to secure a new EQRO contract.
HSAG provides the federally required, External Quality Review (EQR) activities, as well as technical assistance, to the MCOs under contract with the Department. This includes three contracted MCOs for Voluntary Managed Care Program and two contracted MCOs contracted for the Integrated Care Program. The EQRO annually performs an external quality review including the mandatory activities using CMS protocols. The areas reviewed include:
• Quality Assurance Plan Compliance Review;
• Validation of Performance Measures;
• Validation of Performance Improvement Projects;
• Overall Evaluation of the Quality Strategy; and
• Technical Assistance on Quality Assurance Monitoring to MCOs and the Department, at the direction of the Department.
State Quality Strategy for Managed Care
As federally required, the HFS developed a written strategy for assessing and improving the quality of Medicaid MCOs and prepaid inpatient health plan services. The MCO State Quality Strategy was developed with input from stakeholders, including provider groups, advocates, MCOs and the Department. The quality strategy was reviewed by the Centers for Medicare and Medicaid Services (CMS) who offered valuable feedback. The Department is in the process of updating the MCO State Quality Strategy to include integrated care and expand on performance goals, measurable targets, and satisfactory progress toward those targets. As contractually required, HSAG will perform an EQR to assess the completeness of the updated MCO State Quality Strategy.
EQR Technical Report
HSAG provided the Department with their 2009-2010 EQR Technical Report and will provide their 2010-2011 EQR Technical Report describing the manner in which data from external quality review activities were aggregated and analyzed. The technical report focuses on the three federally mandated external quality review activities: 1) compliance monitoring evaluation; 2) validation of performance measures; and 3) validation of performance improvement projects. The EQR Technical Report focuses on an analysis of each MCO’s performance in the area of quality assurance and quality monitoring and identifies recommendations for improvement. Previous reports are available on the Department’s Web site at: http://www.hfs.illinois.gov/managedcare/eqrtr.html
Emergency Department Diversion Program
On April 14, 2008, the Department was awarded a grant made under the authority of Section 6043 of the Deficit Reduction Act of 2005 via funding through DHS/CMS. As a result of the grant process, the Department entered into grant agreements with
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