| | | 1.__Quality of care.__The agency shall establish a quality | | assurance program and shall adopt rules to implement that | | program.__Rules adopted pursuant to this subsection are routine__ | | technical rules as defined in Title 5, chapter 375, subchapter 2- | | A.__The program must include, but is not limited to: |
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| | | A.__Operation of the plan; |
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| | | B.__Use of covered health care services of participating and | | nonparticipating providers; |
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| | | C.__Evaluation of the performance of participating | | providers; |
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| | | D.__Standards and continuity of care; |
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| | | E.__A plan for increased delivery of preventive and primary | | care; |
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| | | F.__Access to information and data for the agency; |
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| | | G.__A plan to ensure that the open plan and organized | | delivery systems address public health needs; |
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| | | H.__Plan member involvement in policy decisions; and |
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| | | I.__An efficient complaint resolution process regarding | | quality of care and utilization and rate controls. |
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| | | 2.__Affordability of care.__The agency shall establish an | | affordability assurance program and shall adopt rules to | | implement that program.__Rules adopted pursuant to this | | subsection are routine technical rules as defined in Title 5, | | chapter 375, subchapter 2-A.__The program must include, but is | | not limited to: |
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| | | A.__Rates of compensation for participating providers in | | organized delivery systems and in the open plan; |
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| | | B.__Operation of the Small Business Hardship Fund to assist | | employers for which the plan constitutes a hardship; |
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| | | C.__Maintenance of a prescription drug formulary; and |
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| | | D.__Cost containment mechanisms for organized delivery | | systems and for the open plan.__Cost containment mechanisms | | may include primary care case management, guaranteed | | provider payment, variable reimbursement rates for | | providers, review of treatment and services concurrent with | | the provision of the treatment and services, expenditure | | targets, practice parameters and treatment norms. |
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