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

Effective Date:

Approval Date: 43

systems to assure provision of care in situations requiring treatment for an emergency medical condition, including an education process to help assure that members know where and how to obtain medically necessary care in an emergency. systems to assure that the plan shall not limit providers from disclosing all information about services available to the member related to their medical condition irrespective of the plans coverage or provider network. Iowa House File (HF2517), the bill that created the hawk-i program, mandated that a Special Needs Committee be established to make recommendations to the board and to the general assembly concerning the provision of health insurance coverage to children with special health care needs under the program. The purpose of the Committee is to address the following: 1) Define the target population of children with special health care needs for the purposes of determining eligibility under the program. 2) Eligibility options for and assessment of children with special health care needs for eligibility. 3) Benefit options for children with special health care needs. 4) The appropriateness and quality of care for children with special health care needs. 5) Coordination of health services provided for children with special health care needs under the program with services provided by other publicly funded programs. The Special Needs Committee has periodic meetings with contracted health plans to discuss case management services for members with long-term health care needs. The Functional Health Assessment Survey asks questions related specifically to a child with chronic medical conditions (see 7.1.2).

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))

The following language is included in all health plan contracts follows: “If the Plan has Prior Authorization of health services, in accordance with the medical needs of the patient, the Plan shall complete the Prior authorization within fourteen (14) days after receipt of a request for services. An extension of up to fourteen (14) days may be permitted if the Enrollee requests the extension or if the physician or Plan determines that additional information is needed.“