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

Effective Date:

Approval Date: September 19, 2002 37 services, including a description of how the state will assure the quality and appropriateness of the care provided. The state should consider whether there are sufficient providers of care for the newly enrolled populations and whether there is reasonable access to care: (2102(a)(7)(B)) (42CFR 457.495)

In addition to the methods described in Sections 7.2 and 9, the State maintains a toll-free telephone hotline that provides assistance in explaining programs and benefit coverage, completing applications for assistance, locating providers for health care services, and allows recipients to identify any problems, including accessing health services and emergency room services. The Department also uses surveys to identify patterns that may be indicative of problems in accessing necessary medical services.

The Department believes the State’s current Medicaid network is adequate to add an additional 100,000 children. However, to increase access even further, the Department has significantly reformed its payment methodology for outpatient and physician services, effective July 1, 1998. To more accurately reflect the resources used in outpatient services, the Department increased from four to twelve the number of reimbursement groupings. Along with the increase in reimbursement groups, total reimbursement rates on outpatient services were increased by 42%. The Department has also significantly increased physician reimbursement rates. Overall the Department increased physician rates by 10% with certain basic procedures receiving increases as high as 61%. Dental rates have also been increased an average of 50%.

The Department closely monitors provider capacity in order to assure appropriate access. Initiatives undertaken to increase provider capacity and access include: • contracting with a physician referral provider in portions of Cook County and surrounding counties; • FQHC rate increases; • Physician referrals through the KidCare hotline; the hotline handles approximately 1,000 physician referral calls a month; • continued support of the American Academy of Pediatrics project to eduate pediatricians and pediatric office staff about KidCare in order to encourage them to enroll with KidCare; and • increased dental rates and an improved dental referral system with Doral Dental.

The State employs staff specialists to recruit and provide technical assistance to medical providers. A provider hotline answers questions and provides member eligibility information and preventive health