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

Effective Date:

Approval Date: 43 health care delivery.

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))

Review of paid claims data, in-house focused studies, independent studies by researchers, parent surveys, comparison with state immunization registry.

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))

Review of paid claims data. Department of Insurance laws on access with prudent layperson standards on emergency care. Recent studies have shown that the most frequent reasons for emergency room visits are ear infection, fever, and upper respiratory infection. Materials have been developed to assist families in caring for their children with these conditions and to know when the situation warrants an Emergency Room visit and which does not. Other focused studies on asthma have led to dramatic decreases in ER visits for asthma patients.

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))

NC Health Choice is an any-willing-provider indemnity plan. Therefore, there are no network providers. There is an internal review of every denied claim to assess whether or not it meets Medicaid criteria. If it does, it is paid according to Medicaid criteria. Families and providers may also appeal any denial of service. DMA, DPH and the State Health Plan periodically conduct focused studies on high cost or high incidence conditions and develop strategic preventive or early intervention protocols. Should a problem exist, an education campaign targeted to providers is conducted.