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

Effective Date:

Approval Date: 42

The hawk-i Program collects encounter claims data from participating health and dental plans monthly. HEDIS performance measurements for well-child and adolescent care have been selected for results based analysis (see 9.1). Effective July 1, 2005, the Department has a contract with Iowa Foundation for Medical Care to validate the encounter claims data with a medical record review. hawk-i„s Functional Health Assessment Survey is an excellent tool to evaluate health status of children enrolled in the hawk-i program.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b)) DHS examines access to care through the IFMC contract. Additionally, DHS uses Geographic Information Systems (GIS) maps to examine the distribution of primary care, dental, and mental health providers for each participating health plan at the county level of geography. The map tracks the geographical distribution of providers in comparison to the number of beneficiaries served in a particular coverage area as well as the distance and time to get to the provider. Access standards utilized for the GIS are 30 minutes/30 miles for primary care provider and dental services, 60 minutes/60 miles for specialty services including mental health and substance abuse. As noted above, health plans are contractually required to include written procedures in the member handbook on accessing emergency services. Contracted health and dental plans are required to submit complaint/grievance reports to the Department on a quarterly basis. Additionally, assessment surveys ask specific questions about the member‟s satisfaction with emergency services.

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))

Contractually, health plans are required to ensure patient care that is coordinated and continuous, including at a minimum: systems to assure timely and appropriate referrals for Medically Necessary, specialty, secondary and tertiary care including subspecialization for pediatric care as well as health education services for members; and