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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 96 monitors these functions on a regular basis to ensure compliance. All of the FHKC’s insurers are also regulated by the Agency for Health Care Administration and the Agency also monitors these functions on a regular basis to ensure compliance with other state and federal requirements. 7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c)) Healthy Kids All health and dental plans under contract with Healthy Kids are required to maintain a network of primary care, specialty care and tertiary providers adequate to meet the needs of the Healthy Kids enrollment in a given area. These networks are reviewed closely at the time of bidding and are monitored throughout the contract term. Contracted health plans must be able to provide all of the required benefits, preferably through a network of contracted providers, but may also do so through out of network providers when necessary. Additionally, FHKC’s health plans hold a certificate of authority from the state’s Agency for Health Care Administration that also monitors network sufficiency. Both the health and dental plans under contract with Healthy Kids are required to submit quarterly utilization information to FHKC. 7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

Healthy Kids In its contracts with its health and dental insurers, Healthy Kids requires its plans to assure their compliance with time standards as well as all other applicable federal or state regulations. This, of course, includes compliance with 42 CFR 495(d).

All decisions related to prior authorization are completed in accordance with state law. The Agency for Health Care Administration monitors these functions on a regular basis to ensure compliance.