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Model Application Template for the State Children‟s Health Insurance Program

Effective Date:

Approval Date: 3 MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM ............................................................................................................................ 4 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101) ................................................................ 5 Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B)) .. 10 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4)) ........... 18 Section 4. Eligibility Standards and Methodology. (Section 2102(b)) ......................... 20 Section 5. Outreach (Section 2102(c)) ......................................................................... 30 Section 6. Coverage Requirements for Children‟s Health Insurance (Section 2103) .. 34 Section 7. Quality and Appropriateness of Care ............................................................. 40 Section 8. Cost Sharing and Payment (Section 2103(e)) ............................................ 44 Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107) .................................................................................................................... 53 Section 10. Annual Reports and Evaluations (Section 2108) ...................................... 62 Section 11. Program Integrity (Section 2101(a)) ........................................................... 63 Section 12. Applicant and Enrollee Protections (Sections 2101(a)) .............................. 64 Attachment 2 Referral Process ..................................................................................... 65 Attachment 10 Plan Appeal and Grievance Procedures................................................ 71 Attachment 11 Delta Dental of Iowa .............................................................................. 76 Attachment 12 Wellmark Health Plan of Iowa (WHPI) .................................................. 77 Attachment 14 hawk-i Health and Dental Plan Disaster Coverage Area ....................... 83 Attachment 15 Outreach Results ................................................................................... 84 Attachment 16 Iowa hawk-i Dental Plan ........................................................................ 87