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State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10, 7/1/11, 7/1/12 87 Florida Healthy Kids requires that the Healthy Kids dental plans include specific standards for the delivery of services, including standards for access to appointments and geographic requirements for primary care and specialty care providers. Plans are also required to submit quarterly claims data on which annual quality measures are scored, including the number of enrollees who received a dental visit and any dental services during the year. Low scores on these measures are often a pre-cursor to network or service issues.

Families contact the KidCare Call Center with concerns when there is immediate access to care issues. Florida Healthy Kids Corporation staff can trouble-shoot these issues as they arise and also tracks them on a long term basis in order to identify systematic problems. Contract provisions provide for Healthy Kids to send children to any willing provider if the Plan is not able to meet contract standards at the Plan’s expense. Corrective action plans can also be implemented when necessary.

Both Healthy Kids dental plans have a grievance process in place for enrollees to dispute any denial of services. These processes have also been vetted by Healthy Kids. The processes include informal resolution of issues, as well as formal procedures for when the other avenues have not provided the family the relief being sought. Both plans also have an expedited process for emergency or urgent issues. The dental plans’ internal grievance process used for the Healthy Kids program is the same internal grievance process used for the plans’ Medicaid population.

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1.  The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.  The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre- existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4 Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)