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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 92 • Access Standards Both health and dental plans under contract with Healthy Kids are required to meet certain access standards regarding accessibility of primary care medical and dental providers. The contract standard for geographical access to primary care medical and dental providers is twenty (20) minutes driving time from the enrollee’s residence to their provider. This time limit is reasonably extended in certain areas of the state. For specialty care access, the geographic standard is sixty (60) minutes driving time. This standard can also be extended where specialty care services cannot be reasonably obtained within this standard. • Preventive Care Standards One of the missions of FHKC is the provision of preventive health services to children. To ensure that children are receiving adequate preventive care, the minimum benefit package was designed in accordance with the “Recommendations for Preventive Pediatric Health Care” as established by the American Academy of Pediatrics. • Medical Quality Review The FHKC contracts with an independent quality auditor to evaluate and monitor the quality of care provided by the health plan providers. Objectives of the review are as follows:  Review medical records of enrollees to determine compliance with standard elements of documentation supporting the provision of appropriate, quality care.  Review care sites to determine compliance with basic safety and infection control requirements and ability to provide access to care within FHKC standards.  Use review data to determine the sites with specific needs for improvement.  Assess the effect of the health plan’s quality evaluation process on care provided to FHKC enrollees in each county. Children’s Medical Services Network The CMSN has a series of standards that are used to designate specialty components of the network, such as standards for cardiac programs, craniofacial programs, transplant programs, etc. CMSN also has standards for