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

Effective Date:

Approval Date: 13 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

The State of North Carolina provides health insurance benefits through a plan managed by the NCDHHS with health benefits provided through the Teachers and State Employees Comprehensive Major Medical Plan, from hereon referred to as the State Employees Health Plan - a program offering fee-for-service to any willing provider for indemnity health insurance. Benefits and claims processing are administered by the State Employees Health Plan, and eligibility is determined by county departments of social service (DSS). Upon determination of eligibility (and receipt of any applicable enrollment fee), the county Medicaid eligibility specialist enters the member’s information into the statewide Eligibility Information System (EIS). Through the Division of Medical Assistance (DMA), EIS then electronically forwards Title XXI eligibility information to the State Employees Health Plan and sends notification of eligibility to families. The State Employees Health Plan then sends families information about the Plan of Benefits and processes claims.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

The same utilization controls used in the State Employees Health Plan are also used in the Title XXI program. The State Employees Health Plan is established and operated under North Carolina General Statute 135-37 through 135-41.3. Medical necessity, pre-certification, prior approval, fraud detection, auditing and extensive reporting detailing utilization are provided for by the State Employees Health Plan and through its contract with its claims processing contractor, Blue Cross/ Blue Shield of North Carolina.