5160-26-07.1 Managed health care programs: Quality assessment and performance improvement program (QAPI).

(A) Each MCP must have an ongoing QAPI program that is annually prior-approved by ODJFS. As part of the QAPI program, the MCP must, at a minimum:

(1) Conduct performance improvement projects (PIPs), including those specified by CMS or ODJFS. The PIPS must achieve, through periodic measurement and intervention, significant and sustained improvement in clinical and non-clinical care areas that are expected to have a favorable effect on health outcomes and member satisfaction. The PIPs must include the following components:

(a) Measurement of performance using objective quality indicators;

(b) Implementation of system interventions to achieve improvement in quality;

(c) Evaluation of the effectiveness of the interventions;

(d) Planning, initiation, and implementation of activities for increasing or sustaining improvement;

(e) Clinical and non-clinical areas that are relevant to the MCP member population and reflect the members served in terms of age, disease categories and risk status; and

(f) Completion in a reasonable time period in order to produce new information on quality of care every year.

(2) Have in effect mechanisms to detect both underutilization and overutilization of services.

(3) Have in effect mechanisms to assess the quality and appropriateness of care furnished to members with special health care needs.

(4) Report on the status and/or results of each PIP to ODJFS, at least annually, including a report on the mechanisms specified in paragraphs (A)(2) and (A)(3) of this rule.

(5) Submit performance measurement data as required by ODJFS that:

(a) Enables ODJFS to calculate standard measures; and/or

(b) Uses standard measures as required by ODJFS.

(B) ODJFS will review the impact and effectiveness of each MCP's QAPI program at least annually. The review will include an assessment of:

(1) MCP performance, based on encounter data and other performance measurement data;

(2) The MCP's report on the status and/or results of each PIP; and

(3) The MCP's self-evaluation of the impact and effectiveness of its QAPI, including the mechanisms specified in paragraphs (A)(2) and (A)(3) of this rule.

(C) Each MCP must establish appropriate administrative oversight arrangements and accountability for the QAPI program. MCPs must be able to document, upon request, that such arrangements include:

(1) The assignment of a senior official responsible for the QAPI program;

(2) Provision for and a record of ongoing communication and coordination between the area that oversees the QAPI program and relevant functional areas of the organization; and

(3) Assurance that the medical director is involved in all clinically-related projects and that all staff responsible for QAPI implementation have education, experience, and training appropriate to their position.

Effective: 09/15/2008
R.C. 119.032 review dates: 07/01/2008 and 09/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.17
Rule Amplifies: 5111.01 , 5111.02 , 5111.17
Prior Effective Dates: 4/1/85, 5/2/85, 10/1/87, 2/15/89 (Emer), 5/8/89, 11/1/89 (Emer), 2/1/90, 5/1/92, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 7/1/00, 7/1/01, 7/1/03