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

Effective Date:

29 Approval Date: use of the form. Each form contains age-appropriate health measures and immunizations and is used for children from birth through age 21.

The BF19 forms are also used by providers and the Bureau to provide members with any needed assistance to comply with treatment plans, e.g., assistance with accessing follow-up treatment or diagnostic testing. The BF19s are reviewed by Department nursing staff on a daily basis for requested follow-up with the member. Forms are then shared with EPSDT staff for actual follow-up with the family. Once follow-up has occurred, notification is sent to the provider.

The Bureau also furnishes providers (as is noted in Section 7.1.2) with information on emergency room visit rates for his/her practice to enable the provider to address the issue of inappropriate use of the emergency room with his/her patients.

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))

Please see Sections 7.1.1-7.1.4.

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))

Please see Sections 7.1.1-7.1.4.

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))

One method used to monitor and enhance treatment of members with chronic/serious medical conditions is the use of the Utilization Report provided to primary care providers. As is noted in Section 7.1.2., the Utilization Report, provided to each primary care provider at least twice a year, contains information on potentially avoidable hospitalizations for particular chronic/serious medical conditions. The information presents a comparison of the particular PCP’s practice against other statewide providers in the same specialty (admission rates per 1000 MaineCare