1. (a) Each health maintenance organization (HMO) must develop and implement an ongoing quality assessment and performance improvement program for services it furnishes to its enrollees. The HMO must maintain and provide documentation of its compliance for the Commission's review, including performance measurement data. The HMO's quality assessment and performance improvement program must meet the requirements contained in 42 CFR §438.240 and, at a minimum, include:

   1. (1) a program of performance improvement projects that focus on clinical and non-clinical areas;
   2. (2) mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs;
   3. (3) mechanisms to detect both under and over-utilization of services;
   4. (4) practice guidelines that meet CMS requirements under 42 CFR §438.236.
2. (b) The Quality Assessment Performance Improvement (QAPI) functions may be subcontracted but the responsibility for QAPI compliance cannot be delegated by the HMO.

3. (c) The Commission will develop monitoring and review systems and procedures to ensure HMO compliance with HMO contracts, this subchapter, and all related state and federal rules, regulations, and guidelines. Commission monitoring and review will include, but not be limited to, the following.

   1. (1) The Commission will monitor each HMO to ensure it is following its QAPI standards.
   2. (2) The Commission will require HMO to submit QAPI information at regular and periodic intervals.
   3. (3) The Commission will require all HMOs to submit to periodic inspection and review to determine compliance with all contract terms, and state and federal rules, regulations, and policies.
4. (d) Evaluation of each HMOs quality of services in each Medicaid managed care service area and the cost-effectiveness, member access, and quality of care under each waiver shall be conducted by independent, external entities after initial implementation of Medicaid managed care in a particular service delivery area. The quality evaluation must be conducted at the end of the first year following initial implementation; and the assessment of cost-effectiveness, member access, and quality of care under each waiver must be conducted once during the first two years of the time period for which a waiver has been approved. The Commission will reevaluate the periodicity of both evaluation types after each evaluation is initially completed in a managed care service delivery area.

Source Note:The provisions of this §353.417 adopted to be effective December 18, 1996, 21 TexReg 11822; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective August 10, 2005, 30 TexReg 4466.