Quality Standards

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  • In accordance with federal regulations, MCO must maintain Quality Assessment and Performance Improvement (QAPI) program: Arizona a, Hawaii b, Minnesota c, New York d, Texas e
  • In accordance with federal regulations, state annually must review effectiveness of MCO’s QAPI program: Hawaii f
  • MCO must have quality improvement program: Florida g, Massachusetts h, New Mexico i, New York j
  • MCO must conduct performance improvement projects: Florida k, Tennessee l
  • Each MCO must designate person as MCO’s Quality Improvement Professional: Florida m
  • In accordance with federal regulations state will contract with External Quality Review Organization (EQRO) to evaluate MCO quality and performance: Hawaii n, New Mexico o

  • State will monitor MCO’s records of when LTSS at-home visits have been late or missed: Tennessee p
  • MCO must meet performance measure targets set by state: Florida q, Kansas r, Minnesota s, New Mexico t
  • MCO must collect and report specified performance measures: Florida u, Hawaii v
  • Each MCO must develop and implement critical incident reporting and management system: Florida w, Tennessee x
  • MCO must contract for annual survey for Consumer Assessment of Healthcare Providers and Systems (CAHPS): Florida y, Kansas ``, New Mexico aa
  • At its discretion, state shall release aggregate results of quality improvement/audit functions to public and federal government: New Mexico bb

  • State may offer incentives to high-performing MCOs: Florida cc
  • Possible incentives for improved quality include quality designations, quality awards, and enhanced auto-assignments: Florida dd
  • State pays incentive payments if MCO exceeds performance standards: Tennessee ee

  • Sanctions for MCO noncompliance include plans of correction, directed plans of correction, money penalties, adjustment of automated assignment formula, suspension of new enrollments, state monitor, temporary management, payment denials, cessation of marketing activity, actual damages, liquidated damages, termination of contract, and right of members to disenroll: New Mexico ff
  • Sanctions for MCO noncompliance include plans of correction, accelerated monitoring, audits, actual or liquidated damages, temporary management, suspension of enrollment, disenrollment, withholding of payment, forfeiture of bond, or termination of contract: Texas gg
  • Sanctions for MCO noncompliance include money penalties, suspension of new enrollments, temporary management, right of members to disenroll, recovery of capitation payments, and termination of contract: Wisconsin hh
  • If MCO fails to meet performance measure target, state may require MCO to submit performance measure action plan and/or assess sanctions: Florida ii
  • State may restrict MCO’s enrollment activities if MCO does not meet quality standards: Florida jj
  • Liquidated damages for MCO’s failure to meet performance standards: Florida kk, Kansas ll, Tennessee mm
  • Initial withhold of percentage of MCO’s capitated payment; withheld amount paid subsequently if MCO meets performance standards: Minnesota nn, Tennessee oo, Texas pp


  • For credentialing of providers, MCO must follow standards of National Committee for Quality Assurance: Hawaii qq, Minnesota rr, Tennessee ss
  • MCO must have written protocols for credentialing: Massachusetts tt
  • MCO’s credentialing policies must include credentialing committee, verification of credentialing criteria, and identification of deficiencies resulting in sanctions: Florida uu
  • Criminal background checks required for direct service providers: Florida vv, Minnesota ww
  • MCO must monitor quality of each participating provider: Florida xx
  • MCO must conduct quality oversight over assisted living facilities, but not as replacement for licensing and certification oversight provided by state: New Mexico yy
  • MCO must conduct on-site review of assisting living facility as part of credentialing or recredentialing process: Florida ```
  • Every other year, MCO must review assisted living facility’s case records: Florida aaa
  • MCO must train all community LTSS providers in contract requirements pertaining to LTSS: Texas bbb

  • MCO must not contract with providers designated as chronic poor performers under MCO’s policies: Florida ccc
  • MCO must notify each provider of metrics used to evaluate provider’s performance: Florida ddd
  • MCO must transition consumer out of assisted living facility that does not meet quality requirements, if consumer wishes to remain enrolled in MCO: Florida eee
  1. Ariz. Contract, p. 44.  (back)
  2. Haw. RFP, p. 204.  (back)
  3. Minn. Contract, p. 165.  (back)
  4. N.Y. Medicaid Advantage Plus Contract, Sect. 16, p. 1; Medicaid Partnership Contract, pp. 21-23.  (back)
  5. Tex. Contract, pp. 8-45 through 8-48.  (back)
  6. Haw. RFP, p. 63.  (back)
  7. Fla. Contract, Atch. II, p. 39.  (back)
  8. Mass. Contract, p. 51.  (back)
  9. N.M. Contract, pp. 34-37.   (back)
  10. N.Y. Medicaid Advantage Plus Contract, Sect. 18, p. 5.  (back)
  11. Fla. Contract, Atch. II, pp. 88-89.  (back)
  12. Tenn. Contract, pp. 257-58.  (back)
  13. Fla. Contract, Atch. II, p. 104.  (back)
  14. Haw. RFP, pp. 65, 216.  (back)
  15. N.M. Contract, pp. 41-42  (back)
  16. Tenn. Contract, pp. 347, 377-78.  (back)
  17. Fla. Contract, Atch. II, p. 90.  (back)
  18. Kan. RFP, pp. 65-68.  (back)
  19. Minn. Contract, p. 89.  (back)
  20. N.M. Contract, p. 37.  (back)
  21. Fla. Contract, Atch. II, Exh. 8, pp. 74-75.  (back)
  22. Haw. RFP, pp. 207-11.  (back)
  23. Fla. Contract, Atch. II, Exh. 8, pp. 73-74.  (back)
  24. Tenn. Contract, pp. 262-64, 384.  (back)
  25. Fla. Contract, Atch. II, pp. 91-92.  (back)
  26. Kan. RFP, p. 101.  (back)
  27. N.M. Contract, pp. 40-41.  (back)
  28. N.M. Contract, p. 43.  (back)
  29. Fla. Contract, Atch. II, p. 93.  (back)
  30. Fla. Contract, Atch. II, p. 93.  (back)
  31. Tenn. Contract, pp. 404-407.  (back)
  32. N.M. Contract, pp. 120-25.  (back)
  33. Tex. Contract, pp. 44-46.  (back)
  34. Wis. Contract, pp. 212-213, 269-72.  (back)
  35. Fla. Contract, Atch. II, pp. 90, 132-34.  (back)
  36. Fla. Contract, Atch. II, p. 39.  (back)
  37. Fla. Contract, Atch. II, Exh. 18, pp. 117-30.  (back)
  38. Kan. RFP, pp. 143-44, Atch. G.  (back)
  39. Tenn. Contract, pp. 342, 389-403, 484-96  (back)
  40. Minn. Contract, pp. 89-90.  (back)
  41. Tenn. Contract, pp. 367-68.  (back)
  42. Tex. Contract, pp. 6-5 through 6-7.  (back)
  43. Haw. RFP, p. 88.  (back)
  44. Minn. Contract, p. 168.  (back)
  45. Tenn. Contract, p. 216.  (back)
  46. Mass. Contract, p. 30.  (back)
  47. Fla. Contract, Atch. II, pp. 78-79.  (back)
  48. Fla. Contract, Atch. II, Exh. 7, pp. 60-61.  (back)
  49. Minn. Contract, p. 137.  (back)
  50. Fla. Contract, Atch. II, p. 92.  (back)
  51. N.M. Contract, p. 36.  (back)
  52. Fla. Contract, Atch. II, Exh. 5, p. 27.  (back)
  53. Fla. Contract, Atch. II, Exh. 8, pp. 75-76.  (back)
  54. Tex. Contract, pp. 8-141 through 8-142.  (back)
  55. Fla. Contract, Atch. II, Exh. 7, p. 57.  (back)
  56. Fla. Contract, Atch. II, p. 92.  (back)
  57. Fla. Contract, Atch. II, Exh. 5, p. 27.  (back)

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