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Application for the State of Indiana Children’s Health Insurance Program Amendment #7

Effective Date:

26

Approval Date:

 The State employs an External Quality Review Organization (EQRO) that monitors and assesses the quality of and access to health care enabled by Hoosier Healthwise. Advising the monitoring process is a Quality Improvement Committee, a Clinical Advisory Committee, and a few Focused Study Workgroups. The Focused Study Workgroups include neonatal outcomes, management of members with complex needs, and behavioral health. The Health Plan Employer Data Information Set (HEDIS) is being utilized for tracking health plan performance on an annual basis. Several quarterly reports based on HEDIS specifications are also provided to OMPP by the Hoosier Healthwise MCOs. The State’s EQRO is also the CHIP’s independent evaluation consultant. Data collected by the vendor for the EQR are refined for the purpose of assessing CHIP’s programmatic effectiveness in this area.  CHIP monitors the size of Primary Physician panels monthly.

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))

The evaluation consultant is responsible for updating and developing tools to measure the utilization of health services. The measurement set will be intended to assess how often, how effectively and how appropriately enrollees are utilizing services under the program.

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))

All Hoosier Healthwise members are allowed to select a Primary Medical Provider. If one is not selected within 30 days, a PMP will be assigned to them. By ensuring that all members have a medical home, chronic, complex, or serious medical conditions can be closely monitored and appropriate referrals can be made when necessary. In addition, When the network is not adequate for the enrollee’s medical condition, managed care organizations are required to allow members to access to out-of-network providers.

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))

Decisions related to the prior authorization of health services are completed in accordance with the CHIP administrative rules, found in Title 407 of the Indiana Administrative Code, Section 3-3-2:

―The procedures and requirements set forth in 405 IAC 5-3 and 405 IAC 5-7 for Medicaid