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California Medicaid Quality of Care Monitoring, Evaluation, and Improvement Plan Requirements – Cal. Code Regs. tit. 22 § 53860

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Quality of Care

California’s Medicaid plan is administered through a two plan mode, where one plan is a prepaid plan awarded by competitive bidding and the other is a prepaid plan organized or designated by the county government.  Each of these plans must monitor and evaluate quality of care and undertake any improvements in quality of care by providers.  Each plan must implement a quality improvement plan, including:
  1. A system of accountability, that includes a quality improvement committee, supervision of the plan through a medical director, and the inclusion of participating providers.
  2. Objective and systematic monitoring and evaluation of quality and studies that address the quality of clinical care as well as the quality of health care service delivery. 
  3. A utilization management program.

The Department of Health Services must conduct an external quality of care review annually, and must issue reports that detail the findings, recommendations, corrective actions and sanctions.

Current as of June 2015