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

Effective Date:

Approval Date: 41

obtain information about emergency care, prior authorization, scheduling appointments, and standard benefit/services information; current provider directory; hours of service of the plan; appeal procedures; policies on the use of emergency services; information on the sue of non-participating providers; access of after-hours care; enrollee rights and responsibilities; procedures for notifying enrollees of changes in the benefits or delivery of services; and procedures for recommending changes in policies and procedures.

7.1.4.

Quality improvement strategies All health plans participating in the hawk-i program are required to have quality improvement plans in place, including mechanisms that allow enrollees to provide input as to how the delivery of services and other aspects of the plan could be improved. The Clinical Advisory Committee meets quarterly to review data, reports and medical audit results. The committee makes recommendations to the hawk-i Board on program quality standards and improvement strategies. The nine-member committee is comprised of community medical professionals representing pediatricians, family practice, dental, mental health, nutrition and pharmacy.

7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a)) All health plans are contractually required to provide well-baby care and well-child care, well-adolescent care and childhood and adolescent immunization services. All participating health plans send reminder notices to families that their child(ren) is due for immunizations or well-child visits. Additionally, newsletters are sent to families educating them about the importance of preventative services.