Regulations of Connecticut State Agencies
(a) Quality Management
(1) The ASO shall develop an annual Quality Management Program Plan that outlines the objectives and scope of its quality management activities, subject to the review and approval of the department.
(2) The ASO Quality Management Program Plan shall, at a minimum, include:
(A) recipient and provider satisfaction surveys;
(B) clinical issues studies that examine quality and access-related issues and resulting recommendations if any;
(C) ongoing quality management activities including, but not limited to, prioritizing, monitoring, and analyzing problems identified through the utilization management, intensive care management, member services, and complaints and grievance processes;
(D) quality improvement initiatives designed to address specific issues related to health care quality or access; and
(E) a quality management program evaluation.
(b) Utilization Management
(1) Hospital services administered by the department.
(A) Inpatient hospital services provided under the SAGA program shall be subject to the prior authorization requirements described in section 17-134d-80 of the Regulations of Connecticut State Agencies.
(B) Outpatient hospital services provided under the SAGA program shall be subject to the requirements described in the Department of Social Services Medical Services Policy section 150.2 through section 150.2.A.V.
(2) Services provided by the ASO as listed in section 17b-192-6(c) of the Regulations of Connecticut State Agencies shall be subject to utilization management as permitted under the contract between the department and the ASO.
(3) The ASO shall provide, on an annual basis, a Utilization Management Program Plan for approval by the department.
(4) Utilization management policies and procedures shall include, but not be limited to, criteria for authorization decisions and protocols for hospital discharge planning.
(5) No authorization shall be required for the following covered services:
(A) preventive care;
(B) family planning services, including, but not limited to:
(i) preventive family planning services;
(ii) oral contraceptives; and
(C) emergency ambulance services or emergency care.
(c) Intensive Care Management.
The ASO shall develop policies and procedures for the provision of intensive care management for individuals with complex health care needs, including, but not limited to, the criteria for undertaking intensive care management activities on behalf of a member. Such policies and procedures shall be subject to the review and approval of the department.
(d) Physician Incentive Plan.
The ASO may establish a physician incentive plan in accordance with its contract with the department.
(e) Coordination of Medical and Behavioral Health Services.
The ASO shall develop policies and procedures for the coordination of medical services with behavioral health services, including those services that may be provided by other state agencies or their agents. Such policies and procedures shall be subject to the review and approval of the department.
(Adopted effective October 12, 2005)