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

Effective Date: August 26, 2006

1 Approval Date: _________________

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available; we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Form CMS-R-211

OMB #: 0938-0707 Exp. Date:

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

Effective Date: August 26, 2006

2 Approval Date: _________________

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

Effective Date: August 26, 2006

3 Approval Date: _________________

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory: As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b)) North Dakota (Signature of Governor, or designee, of State/Territory, Date Signed) submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department. The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: David J. Zentner

Position/Title: Director, Medical Services Name: David Skalsky

Position/Title: Director, Healthy Steps Program Name:

Position/Title: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

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

Effective Date: August 26, 2006

4 Approval Date: _________________

Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1.

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR 1.1.2.

Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR

1.1.3.

A combination of both of the above. 1.2

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d)) 1.3

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130) 1.4 Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65): Original SCHIP State Plan Date Plan Submitted: July 24, 1998 Date Plan Approved: September 28, 1998 Effective Date: October 1, 1998

State Plan Amendment #1 –Establish Separate Child Health Program. Effective Date: October 1, 1999 Implementation Date: October 1, 1999

State Plan Amendment #2 – Expand Eligibility, Eliminate Assets Test. Effective date: January 1, 2002 Implementation date: January 1, 2002;

State Plan Amendment #3 –Compliance Plan. Approval Date: September 27, 2002

.

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

Effective Date: August 26, 2006

5 Approval Date: _________________

State Plan Amendment #4 - Amended Section 4. Effective date: July 1, 2005 Implementation date: July 1, 2005

This change will result in moving some families from the current private coverage option to the Medicaid Program. It will be advantageous to these families because they will no longer be subject to any co-payments and will have access to the full array of Medicaid program benefits that are move generous than the current private insurance option.

These children will be required to participate in the North Dakota Access to Care program. Each will be required to select a primary care provider who can be a primary care physician, a rural health clinic, a Federally Qualified Health Center or the Indian Health Service. The primary care provider will provide direct primary care and make referrals for specialty care and other specified medical services. All services are paid using a fee for service process. In addition, children residing in Grand Forks County may also select the “capitated” health plan known as AltruCare. The Department makes a monthly per member per month payment to this managed care plan who provides all appropriate medical services contained in the contract. Services not covered in the contract are covered through the regular fee for service payment process.

State Plan Amendment #5 – Amended Section 4.

Effective date: September 1, 2007 Implementation date: September 1, 2007

This amendment made revisions to Section 4.1.3 on income deductions and disregards.

Effective date: October 1, 2008 Implementation date: October 1, 2008

Increase Poverty Level from 140% to 150%.

State Plan Amendment #6 – Amended Section 4.

Effective date: October 1, 2008 Implementation date: October 1, 2008

This amendment will make revisions to Section 4.1.3 page 19, regarding wages paid by the Census Bureau for decennial temporary employment.

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

Effective Date: 10-01-2009 6 Approval Date: ________________ Supersedes Effective Date: 07-01-2009

State Plan Amendment #7 – Amended Section 4.

Effective Date: July 1, 2009 Implementation Date: July 1, 2009

Increase Poverty Level from 150% to 160%.

State Plan Amendment #8 – Amended Section 4.

Effective Date: October 1, 2009 Implementation Date: October 1, 2009

Alternate Payment Methodology with FQHCs and RHCs.

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

Effective Date: August 26, 2001 7 Approval Date: ______________

Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B)) 2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a)) The Department has used a 1998 survey of the uninsured conducted in conjunction with the Robert Wood Johnson Foundation to estimate the number of insured and uninsured children in North Dakota. While this data is now more than three years old, it remains the most reliable information for North Dakota at this time. We have considered the use of other national data sources but have found that due to sampling errors for small states much of the information is not accurate. For example, the U.S. Census Bureau Health Insurance Coverage Status indicates that the number of children under 18 years of age in 2000 was 127,000. The actual 2000 census data indicates that North Dakota has 160,849 children under 18 years of age. This is a significant difference of more than 26%. This also makes suspect the number of insured and uninsured children because the sampling error for total number of children will also affect the estimated number of children without health insurance. For the above reason we will continue to utilize the 1998 survey as an estimate of the number of uninsured children in North Dakota until a more accurate national survey tool becomes available for small population states. The following table provides information on the number of children 0 through 18 years of age residing in North Dakota in 1998, the number who were uninsured, the total number of insured, the number insured by Medicaid and the number of children insured by private plans. As noted above, the data was obtained through a 1998 survey that was conducted under the auspices of the Robert Wood Johnson Foundation Family Survey.

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

Effective Date: August 26, 2001 8 Approval Date: ______________

1998 Insured and Uninsured North Dakota Children by Poverty Level, Age, and Race/Ethnicity

Demographic Subgroups

Population Distribution

Number of Insured Children*

Number of Uninsured Children

Number of Children with Unknown Status

Number Insured by Medicaid

Number Insured by Private Plans

Number Covered by HIS, Military and Other 1998 North Dakota Population 175,822 160,448 14,633 710 14,833 134,791 24,131 Household Poverty Level Unknown <100 100% - 133% 134% - 200% Overall 200% Total Children <=18

16,004 17,689 16,011 32,868 93,250

13,951 14,448 12,920 29,309 89,820

1,754 2,975 3,091 2,558 3,285

299 266 0 0 145

1,186 7,694 3,122 1,881 950

11,435 5,253 7,250 25,534 85,319

2,031 4,664 4,701 5,014 7,721 Age Group Less than 1 Year 1 to 5 Years 6 to 12 years 13 to 18 Years Total Children <=18

7,265 38,992 66,971 62,594

6,905 35,673 59,976 57,894

231 3,203 6,818 4,411

129 115 177 289

1,029 4,791 6,271 2,742

5,467 28,501 50,189 50,634

818 5,408 8,567 9,338 Race/Ethnicity Unknown White Black Native American Asian/Pacific Islander Other Total Children <=18

838 158,462 1,742 11,832 832 2,116

607 144,641 1,684 11,157 832 1,527

199 13,200 58 675 0 531

32 620 0 0 0 58

30 9,995 475 3,904 90 339

295 128,532 856 3,751 599 758

314 13,545 759 8,831 190 492

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

Effective Date: August 26, 2001 9 Approval Date: ______________

The survey indicates that 14,663 children where uninsured in 1998. Of that number, 2,975 children resided in families with income below 100% of the poverty level and 6,649 children resided in families with incomes between 100% and 200% of the federal poverty level. At the time Phase II of the State Children’s Health Insurance Program was implemented in North Dakota on October 1, 1999, a total of 20,516 nondisabled children were enrolled in the Medicaid Program. As of May 31, 2002, the number of enrolled non-disabled children had increased to 22,916, an increase of 11.7% or 2,400 children. In addition, a total of 2,452 children were eligible for Phase II, Healthy Steps, of the Title XXI program. Therefore, after 31 months an additional 4,852 children or an increase of 16.3% were covered through Medicaid or Healthy Steps. While the exact number of uninsured is unknown at this time because of the imprecise national data available to small states, the fact that 4,852 additional children have coverage when the number of children in North Dakota is declining indicates that the two programs have experienced success in reducing the number of uninsured children in North Dakota. PUBLIC HEALTH COVERAGE The Medicaid Program remains the primary public health insurance program available for families in North Dakota. It provides an array of services to individuals and families, who are eligible through the 1931 provision, individuals who are aged, blind or disabled and receive Supplemental Security Income if they meet 209b criteria established by the Department of Human Services. Coverage is also provided for children in foster care and subsidized adoption. In addition, aged, blind and disabled individuals and children and certain caretakers in families who have sufficient income to meet their basic maintenance needs, as defined by the State, (Medically Needy) may be eligible for Medicaid. North Dakota also provides poverty level coverage for pregnant women and children under 6 years of age in families with adjusted net income at or below 133% of the federal poverty level and children 6 through 18 years of age with adjusted net income at or below 100% of the federal poverty level. This group also includes 18-year-old children who are eligible for Medicaid by virtue of the initial SCHIP Medicaid expansion that was approved in October 1998. Children, adult caretakers and pregnant women who are enrolled in Medicaid through the 1931 provision, poverty level, medically needy or SCHIP expansion categories are required to choose a primary care provider who delivers primary care services and makes referrals for many of the other medical services available through the program. Primary Care Providers receive a monthly administrative fee for managing care and providers receive a fee for service payment for services provided to Medicaid recipients.

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

Effective Date: 8-26-2001 10 Approval Date: ______________

In Grand Forks County, children in the above named categories are required to choose between the Primary Care Provider Program and a capitated Health Plan. As of July 1, 2001 a total of 18,500 children were enrolled in the Primary Care Provider Program and 365 children were enrolled in the Health Plan. Beginning on January 1, 2002, the asset test for Medicaid was eliminated for the children and family coverage groups. Children in families with income within the Medicaid eligibility guidelines that were previously eligible for Healthy Steps because family assets exceeded the Medicaid limits are now eligible for the Medicaid Program. These children are included within the SCHIP Medicaid Expansion Group that was approved by CMS. The second public program available to children is the Healthy Steps Program, Phase II of SCHIP in North Dakota. It provides private insurance coverage to about 2,450 children whose family net adjusted income is at or below 140% of the federal poverty level and who are not otherwise eligible for the Medicaid Program. The benchmark insurance coverage for this group is the coverage available for State Employees plus preventive dental and vision coverage. The insurance contractors make payments on a fee for service indemnity basis. PUBLIC PRIVATE HEALTH INSURANCE PARTNERSHIPS While not considered a true public/private partnership, the Department does cooperate with Blue Cross/Blue Shield of North Dakota who operates the Caring Program. This program provides limited health and dental coverage to children who are not eligible for Medicaid or Healthy Steps and have gross family income under 200% of the poverty level. Premiums for coverage come from corporate and private donations. If children are not eligible for Medicaid or Healthy Steps, the family is referred to the Caring Program for possible enrollment in that program. Conversely, the Caring Program will encourage families to apply for Medicaid or Healthy Steps if families who apply to that program appear eligible for the two government programs. 2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b)) 2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state- only child health insurance): The following are the steps being taken to identify and enroll children who are eligible to participate in the North Dakota Medicaid Program and the Healthy Steps Program.

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

Effective Date: 9-01-2007 11 Approval Date: ________________ Supersedes Effective Date: July 1, 2005

The Department has established partnerships with numerous other state and local programs that serve children and families. In addition, the Department has reached out to other public health programs to find children who may be eligible for public health programs. The North Dakota Medicaid and Healthy Steps programs, Women, Infants and Children Program, (WIC), Community Healthcare Association, Maternal and Child Health (MCH), Immunization, Health Passport Smart Card Project, Optimal Pregnancy Outcome Project (OPOP) and the Children’s Special Health Services (CSHS) have a statewide interagency agreement that allows exchange of information and coordination both on the state and local levels. This agreement allows the state to share common information that encourages easier access to services, such as eligibility information on behalf of children’s health.

Public Health Programs - All 53 counties in North Dakota have local public health units that are enrolled Medicaid Providers. This gives them a direct link to the Medicaid program as providers and connects them to the local county social service offices that determine eligibility. If a child is referred and determined ineligible for Medicaid, the public health clinic refers them to other appropriate programs. WIC - All local WIC programs are required to refer all potentially eligible recipients to Medicaid. Current WIC guidelines also denote Medicaid income guidelines. Those not participating in Medicaid, but appear potentially eligible are given program information along with the telephone numbers for referral to the nearest county social service agency. WIC will also make referrals to the Healthy Steps Program if families are not eligible for Medicaid. Other state WIC program mandatory contacts include County Social Service Agencies, Homeless and Ministerial health providers, Substance Abuse Centers, Food Pantries, Public Health Units and Indian and Migrant Health Services. Children’s Special Health Services (CSHS) - The CSHS program conducts a variety of outreach and enrollment activities through a network of state and local staff. The CSHS program serves children who may have a chronic or disabling condition. Medicaid and Healthy Steps status is monitored on the 1,700 children served through all areas of the program. For the 500 to 600 children served through the diagnostic and treatment programs, Medicaid eligibility is automatically checked. For children who are not eligible for Medicaid or private insurance, CSHS will link families to other resources such as Healthy Steps, Caring Program for Children and SSI. The Caring Program for Children - Is a private initiative administered by Blue .

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

Effective Date: 9-01-2007 12 Approval Date: ________________ Supersedes Effective Date: July 1, 2005

Cross/Blue Shield that provides basic health coverage to children aged 18 and under. The program covers its costs with private donations. The Caring Program will refer families to Medicaid or Healthy Steps if individuals appear eligible for either program. Medicaid and Healthy Steps eligibility workers make referrals when a family is not eligible for those two programs. Rural Health Clinics (RHC's) - North Dakota has approximately 110 Medicaid enrolled Rural Health Clinics that includes border state providers from Montana, South Dakota and Minnesota. The RHC's provide services on a sliding fee scale. Referrals are made to local county social service agencies if a family appears eligible for Medicaid and to the Department of Human Services if the family appears eligible for Healthy Steps. Federally Qualified Health Center (FQHC) - North Dakota has one designated federally qualified health center in Fargo. The FQHC conducts a financial screen to determine when to refer to other public health insurance programs such as Medicaid and Healthy Steps. Family Planning Clinics – Family Planning Clinics refer clients to appropriate providers for necessary services that are outside the scope of their practice. Included are referrals for clients in need of primary and preventive services and those who may be eligible for Medicaid, Healthy Steps, WIC and OPOP. Indian Health Services (IHS) - There are four IHS facilities and one Indian Service Area facility in North Dakota. Each site uses a benefits coordinator to identify and refer potentially eligible children and families to the Medicaid and Healthy Steps Programs. IHS staff receive training designed to identify families who may need referral to other health care programs including Medicaid and Healthy Steps. This allows families to access health care information at different entry points within the IHS system at different times. Continued training occurs between the Department and Benefits Coordinators at Reservation sights. Optimal Pregnancy Outcome Program (OPOP) - OPOP is a primary prevention program designed to empower pregnant women to make informed health and lifestyle choices for healthy babies. There are 10 OPOP sites in North Dakota. All sites are Medicaid enrolled providers and deliver nursing, dietitian and other appropriate health services to pregnant women. Target populations include pregnant adolescents who may be considered high risk. As part of the OPOP intake process, insurance status is identified and referrals made to the Medicaid or Healthy Steps Programs. Healthy Start of North Dakota – The Healthy Start program is a Native American case management program located on the four reservations and the one area service unit in North Dakota. The program is

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

Effective Date: 9-01-2007 13 Approval Date: ________________ Supersedes Effective Date: July 1, 2005

intended to prevent infant mortality in these areas and is funded by a federal grant. Part of the intake assessment for services of this program is to determine if there is Medicaid or Healthy Steps eligibility. The Healthy Start programs are enrolled Medicaid providers who provide certain services through Medicaid. Healthy Start has established referral protocols for both Medicaid and Healthy Steps as part of their case management activity to high-risk pregnant women. Migrant Health Centers – Migrant Health Centers are located along the North Dakota/Minnesota border and they provide health services to seasonal migrant families. The health centers refer families to the local county social service agencies if it appears they may meet Medicaid eligibility guidelines or refer them to the Healthy Steps enrollment office if appropriate. Head Start Programs - Local Head Start programs review income and insurance status of all children who apply for that program. They specifically ask if a child is Medicaid eligible. If the family is not currently enrolled, Head Start will refer the family to the local county social service office for an eligibility determination for Medicaid. Head Start also makes referrals to Healthy Steps and the Caring Program for Children if income is above Medicaid income guidelines. 2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public- private partnership: North Dakota does not have any public/private health insurance programs operating at this time. 2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c)) The only other public health insurance program available to citizens of North Dakota is Medicaid. We also coordinate outreach efforts with the Caring Program for Children operated by Blue Cross/Blue Shield of North Dakota. Strategies to coordinate Medicaid with Healthy Steps include the following:

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

Effective Date: 9-01-2007 14 Approval Date: ________________ Supersedes Effective Date: July 1, 2005

1. As of May 1, 2002, a joint application for Medicaid and Healthy Steps has been developed and is available to applicants. The application is designed to be used for all Medicaid children and family coverage groups including adults and the stand alone SCHIP Healthy Steps Program. In addition, we will continue to utilize the Healthy Steps only application but will no longer be printing any additional forms. When the Department receives an application, it is screened to determine if potential Medicaid eligibility exists. The family receives a notice that the application has been forwarded to the appropriate county social service board office that determines Medicaid eligibility. The Department sends all pertinent information to the appropriate county office. That office reviews the application and makes the final decision regarding Medicaid eligibility. 2. Supplying local county social service offices that determine Medicaid eligibility with outreach materials regarding the Healthy Steps Program. 3. Conducting statewide training forums for outreach partners including county staff who determine Medicaid eligibility. 4. Make referrals to the Caring Program if families are not eligible for Medicaid or Healthy Steps. 5. Through cooperative agreements work closely with other agencies who have an interest in uninsured children such as the Title V Program to share information and coordinate outreach activities for all public insurance programs and the Caring Program. (Additional details regarding these relationships are detailed in 2.1 above).

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

Effective Date: 10-01-2009 15 Approval Date: ________________ Supersedes Effective Date: 09-0-2007

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 stand alone SCHIP in North Dakota provides a comprehensive array of services through a contract with Noridian Mutual Insurance Company. This company was chosen to pay for necessary medical, dental and vision services through a competitive Request for Proposal process. Noridian Mutual Insurance Company was formally known as Blue Cross/Blue Shield of North Dakota. They are the primary health insurance entity doing business in North Dakota. They cover more than 50% of all insured individuals in North Dakota. They have an extensive provider network throughout North Dakota. For this reason children eligible for Healthy Steps have excellent access to the services covered under the plan. North Dakota CHIP has developed an Alternate Payment Methodology (APM) with the Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC). The APM will be reviewed on a periodic basis with the FQHCs and RHCs to ensure satisfaction. For the CHIP APM, Blue Cross Blue Shield of North Dakota pays Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) based on a Fee For Service (FFS) basis. The State receives the CHIP claims data from Blue Cross Blue Shield of North Dakota. The State compares the payments made to the FQHC/RHC’s from the Blue Cross Blue Shield of North Dakota fee schedule to what the FQHC/RHC’s would have been paid under the Medicaid PPS rate. If the facility was paid more than the Medicaid PPS rate, no additional payments are made. If the analysis demonstrates that what the FQHC/RHC’s have been paid from the Blue Cross Blue Shield of North Dakota fee schedule was less than what they would have received with the Medicaid PPS, a supplemental payment, for the difference, is issued to the facility. The claims data is obtained every four months from Blue Cross Blue Shield of North Dakota. The contract is an indemnity product based on a monthly premium that is adjusted every two years to coincide with the biennial budget. The fee structure used by Noridian is identical to what is used to pay for its other commercial insurance coverage. Fee increases are determined actuarially by Noridian and the increases are reviewed and certified as reasonable by the North Dakota Department of Insurance.

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

Effective Date: 10-01-2009 16 Approval Date: ________________ Supersedes Effective Date: 09-0-2007

We have executed three separate contracts with Nordian for medical, dental and vision coverage. The contracts detail the responsibilities of the insurance company to pay for all approved services in accordance with contract provisions. All non-covered services and limits on services are delineated in the contract and are made available to each enrolled family through coverage handbooks provided by the contractor. The contracts include language that access to medical services must be available 7 days a week, 24 hours a day and requires the carrier to monitor access, service delivery, client satisfaction and quality assurance for enrollees. Surveys conducted by the contractor indicate excellent client satisfaction with the program. 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 contractor for the Healthy Steps program performs utilization management functions approved by the department for the fee for service payment process. These functions will ensure that children receive health care that is appropriate, medically necessary and delivered in a cost effective and efficient manner. The contractor conducts quality and utilization reviews that determine if services provided are medically necessary including but not limited to relationship edits for procedure and diagnosis codes. Any improper claims are denied and where appropriate overpayments will be recouped for claims that have already been paid. The contractor conducts physician profiling. This process reviews the utilization of services of like specialties across the state. Each specialty is severity adjusted. A comparison and efficiency index is assigned on an episode case basis. If a physician is not within the normal limits of care provided within the specialty group as compared to peers, a review is conducted and if appropriate, an audit is conducted to determine if the services billed are medically necessary.

In addition, focused reviews will be completed in conjunction with studies being performed by the Department for the primary care case management program, aka North Dakota Access to Care Program, and reviews related to services provided by Managed Care Organizations.

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

Effective Date: 7-01-2009 17 Approval Date: 9-4-2009 Supersedes Effective Date: 9-1-2007

Section 4. Eligibility Standards and Methodology. (Section 2102(b))

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 5. 4.1 The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102(b)(1)(A)) (42 CFR 457.305(a) and 457.320(a)) 4.1.1

Geographic area served by the Plan: The plan is available to all eligible children on a statewide basis. 4.1.2

Age: The plan is available to children zero through 18 years of age. Coverage for children who are 18 years of age will continue through the end of the month in which they turn 19 years of age. 4.1.3

Income:

Healthy Steps program will cover children whose family adjusted gross income is no more than 160% of the federal poverty level.

Financial responsibility will be based on spouse for spouse and parents for children. The income of the spouse and parents are considered available to the child. Natural and adoptive parents, but not stepparents are treated as parents. Under North Dakota law, a stepparent has no legally enforceable obligation to support stepchildren. Therefore, the stepparent’s own personal income cannot be considered available in determining Healthy Steps eligibility for a stepchild. To determine eligibility, the stepparent’s net income must first be applied against the appropriate income level for the stepparent, spouse and the stepparent’s children or children in common. If the stepparent’s income is adequate to meet their needs, the natural parent’s net earned income is considered in relation to the children for whom the Healthy Steps application is being made. Except as noted below, all earned income of each family member is in a Healthy Steps household must be counted when calculating adjusted gross income including, but not limited to, wages, salaries, commissions, tips, self-employment income and income received under a contract. Except as noted below, all gross income of each family member of a Healthy Steps household must be counted when calculating adjusted gross income. The following income is excluded from family income:

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

Effective Date: 9-1-2007 18 Approval Date: ________________

1. Income which is required to be excluded under other federal statues and by Public Law; 2. Occasional small gifts; 3. In-kind earned income, except in-kind income received in lieu of wages; 4. Educational loans, scholarships, grants, awards, Workforce Safety & Insurance vocational rehabilitation payments, fellowships or gifts used to 767 pay the cost of tuition and fee’s at educational institutions, and work study received by a student. A student is described as an individual who regularly attends and makes satisfactory progress in an elementary or secondary educations environment, college, university, vocation or trade school. A child must be a student at the time of application or if the application occurs during a summer vacation period must intend to return to school in the fall; 5. Income earned by a child who is a full-time student or a part-time student who is not employed more than 100 hours per month. Student status must be established as described in paragraph four of this section; 6. Money payments made by the Department of Human Services including foster care or subsidized adoption, subsidized guardianship, temporary assistance for needy families payments, vocational rehabilitation training funds, family subsidy program and the low income home energy assistance program; 7. Loans from any source that are subject to a written agreement requiring repayment by a household member; 8. Payments from the Child and Adult Food Program for meals and snacks to licensed families who provide day care in their home; 9. County General Assistance payments; 10. Income Tax refunds; earned income credits or homestead tax credits; 11. Non-recurring unearned lump sum payments; 12. Needs-based payments, support services, and relocation expenses provided through programs established under

.

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

Effective Date: 9-01-2005 19 Approval Date: ____________ Supersedes Effective Date: July 1, 2005

the Workforce investment Act (WIA), and through the Job Opportunities and Basic Skills program; 13. Housing allowance received from United State Department of Housing and Urban Development or rent supplements or utility payments provided through the housing assistance program; 14. Refugee cash assistance or grant payments; 15. Americorps income other than the living allowance portion; 16. Income of an individual living in the parental home if the individual is not included in the Healthy Steps unit; 17. Extra checks received by individuals who are paid weekly or bi-weekly; 18. Supplemental Security Income (SSI); 19. Compensation received by volunteers participating in the action program as stipulated in the Domestic Volunteer Service Act of 1973, including foster grandparents, older American Community Service program, Retired Senior Volunteer Program, Service Corps of retired Executives, Volunteers In Service to America (VISTA), and University Year for Action; 20. Payments made to recipients under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970; 21. All income, allowance, and bonuses received as a result of participation in the Job Corps Program; 22. Payments received for the repair or replacement of lost, damaged, or stolen assets, 23. The Medicare Part B premium refunded by the Social Security Administration; 24. Training allowances of up to thirty dollars per week provided through a tribal native employment works program, or the Job Opportunities and Basic Skills Training program; 25. Training stipends provided to victims of domestic violence by private, charitable organizations, for attending

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

Effective Date: 7-01-2009 20 Approval Date: 9-4-2009 Supersedes Effective Date: 10/1/2008

their educational programs; 26. Crime Victims Reparation payments; 27. Assistance received under the Disaster Relief and Emergency Assistance Act of 1974 or some other Federal statute, because of a presidentially declared disaster (but not disaster assistance unemployment compensation), and interest earned on that assistance; 28. The first $2,000 per year of lease payments deposited in IIM accounts; 29. Interest or dividend income earned on liquid assets; 30. Additional pay received by military personnel as a result of deployment to a combat zone; 31. Up to fifty dollars per family, per month, of current child support received on behalf of children in the Health Steps unit; 32. Reimbursement from an employer, training agency or other organization for past or future training, or volunteer related expenses ; and 33. All wages paid by the Census Bureau for temporary employment related to decennial census activities. Income Standard: Adjusted gross countable family income must be equal to or less than 160% of the federal poverty guidelines based on family size. Calculating Adjusted Gross Income: After all countable gross income is determined; the following adjustments will be allowed to determine the adjusted gross income for each Healthy Steps household: 1. For family members with earned income, the actual mandatory payroll deductions including federal, state and social security taxes mandatory retirement and mandatory union dues, or $90 per month, whichever is greater. 2. Reasonable child care expenses, not otherwise reimbursed by other third parties if necessary to engage in employment or training.

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

Effective Date: 10-01-2008 20a Approval Date: ____________ Supersedes Effective Date: 9/01/2007

3. Court ordered child and spousal support payments if actually paid by a member of the family on behalf of an individual who is not a member of the Healthy Steps household. 4. With respect to each individual in the unit who is employed or in training, $30 may be deducted as a work or training allowance, but only if the individual’s income is counted in the eligibility determination. 5. The cost of premiums for health insurance may be deducted in the month paid or prorated and deducted in the months for which the premium affords coverage. 6. the cost of medical expenses for necessary medical or remedial care for members of the unit who are not eligible for Health Steps coverage. Determination of Adjusted Income for Self-Employed Individuals: The following method will be used to calculate adjusted gross income for self-employed individuals as prescribed by State statue. 1. For all self employed individuals, calculate the average net income after expenses based on either the average of the previous three years of adjusted gross income or the previous year’s adjusted gross income, whichever is most advantageous to the applicant, which means the adjusted gross income as computed for an individual for Federal Income Tax purposes under the Internal Revenue Code. If a household has been in business for less than three consecutive years, use the actual number of year(s) the individual was in business and calculate the average yearly income. If the family is currently self employed, but has not previously filed any self employment Federal Income Tax report in the last year, use the best information available to calculate estimated revenue and business expenses to calculate adjusted gross self- employment income.

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

Effective Date August 26, 2001 21 Approval Date:_______________

Budgeting: The department shall determine family income prospectively for each 12-month certification period at the time of application and at each renewal to determine if eligibility can continue. Gross countable income of all family members is counted as family income. An adjusted gross income amount is then calculated based on the disregards and deductions described previously. Unearned income that is received less often than monthly will be prorated over the months the income is intended to cover to determine average monthly income. Earned income that is intended to cover more than one month will be prorated over Farm and other self-employment income will be divided by 12 to determine the monthly income for the upcoming certification period. If an individual started a business in the previous year that did not cover an entire year, the pro-ration of the monthly income will be based on the actual number of months the business operated during the previous year. If a family has self-employed income and other earned or unearned income, the two must be added together to arrive at total adjusted gross income. The monthly income from self-employment income should first be calculated. If the average self-employment income is a negative amount, that amount will be subtracted from other earned or unearned income to arrive at total adjusted gross income.

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

Effective Date August 26, 2001 22 Approval Date:_______________

4.1.4.

Resources (including any standards relating to spend downs and disposition of resources): There will be no resource test for Healthy Steps eligibility.

4.1.5.

Residency (so long as residency requirement is not based on length of time in state):

1. To be eligible to receive Healthy Steps benefits, an individual must be a citizen of the United States or a qualified alien as defined in Public Law 104-193 (401) through (423), (431) and (435), and amended by Public Law 105-33 (5302)(b) and (c), (5303), (5305)(b), (5306), (5562), (5563) and (5571). 2. A qualified alien as defined in Public Law 104-193, as amended, may receive Healthy Steps insurance coverage. 3. Unless ineligible for benefits under section 403 of Public Law 104- 193, as amended, a qualified alien may receive Healthy Steps insurance coverage after five years have passed from the child’s date of entry into the United States, if the child can be credited with 40 qualifying quarters of social security coverage. State Residency: 1. To be eligible to receive benefits from Healthy steps, a child must be a resident of the state of North Dakota. 2. An individual is considered a resident of North Dakota if they are temporarily absent from North Dakota for purposes of employment, schooling, vacation or medical treatment. 4.1.6

Disability Status (so long as any standard relating to disability status does not restrict eligibility): Disability is not a determining factor when establishing eligibility for Healthy Steps and coverage will be provided to children no matter what type of disability or medical condition a child may have. 4.1.7

Access to or coverage under other health coverage: A child who is covered under a group health plan or a single family plan or under other health insurance coverage including coverage which is available through a parent’s or legal guardian’s employer, as defined by HIPAA, is ineligible for Healthy Steps insurance coverage. A child will not be eligible if the parent of the child is a State employee unless the parent does not have access to State health insurance coverage. Any child that meets current Medicaid eligibility criteria is not eligible for Healthy Steps except that children who would otherwise be eligible for the medically needy program with a

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

Effective Date August 26, 2001 23 Approval Date:_______________ recipient liability, the family may choose to enroll in the Healthy Steps program. 4.1.8

Duration of eligibility: The eligibility period in accordance with State law will begin the first day of the month following the date eligibility is established and will end on the last day of the 12th calendar month after the month in which enrollment in Healthy steps started or the end of the month a child reaches its 19th birthday or the family acquired credible health insurance coverage for the child or a child no longer resides in the household. Any subsequent eligibility period will continue for 12 calendar months.

4.1.9

Other standards (identify and describe): Household Composition: 1. The following individuals who reside together are included in a household when determining the size of a household and the income to be counted whether or not a household member is actually eligible to receive Healthy steps benefit coverage.

a. A natural child, adopted child, or step-child age 0 through 20 years of age, and the family size is increased for each unborn when determining the appropriate household size; b. Parents of any child identified in “a” above; c. Children of any child identified in “a” above. 2. Any individual identified in paragraph 1 who is temporarily absent from the household by reason of employment, school, training, or medical treatment will be considered as a member of the household. 3. If an adult is providing care to an unrelated child of a divorced, separated, or deceased spouse, the household may include the child if the child is expected to continue to reside in the household, and meets age requirements outlined in paragraph “a”. 4. Children who are inmates of public institutions or children who are residing in Institutions for Mental Diseases will be denied coverage under the Healthy Steps program, at application and redetermination. 5. Parents are allowed to opt any child out of the household if that child’s income causes other children in the household to fail eligibility. 4.2 The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b)) 4.2.1.

These standards do not discriminate on the basis of diagnosis. 4.2.2.

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a

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

Effective Date: August 26, 2001 24 Approval Date: ______________ lower family income.

4.2.3.

These standards do not deny eligibility based on a child having a pre-existing medical condition.

4.3 Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2))(42CFR457.350)

Enrollment Procedures: As of May 1, 2002, North Dakota is utilizing joint Medicaid and Healthy Steps applications. The joint applications are available at county social service offices, medical providers, other public programs such as Head Start, child advocacy organizations, schools, Indian Health Services and Tribal offices, and childcare programs. These entities have received training to assist families to complete the application forms. Applicants have the option of submitting the joint application forms to the appropriate county social service office in their community or sending the application to the Department of Human Services. The date of the application is the date the application is received either by the Department of Human Services, or the appropriate county social service office. Children determined eligible for Healthy Steps are eligible for a 12-month period unless a child turns 19, leaves the household, loses state residency, or obtains credible health insurance coverage. Families are required to report any change in circumstances that could affect eligibility. Families receive reminders during the fourth and eighth months of eligibility asking if any changes in family circumstances have occurred. No information regarding income is requested. 4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42 CFR 457.305(b))

Check here is this section does not apply to your state. 4.4 Describe the procedures that assure that: 4.4.1 Through the screening procedures used at intake and follow-up eligibility determination, including any periodic predetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health insurance assistance under the state child health plan. (Section 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42 CFR 457.350(a)(1) (42CFR 457.80(c)(3)) When an application is received, verified income and deduction information is entered into the eligibility computer system, which first determines whether the children are Medicaid eligible. If the results indicate that any of the children are eligible for Medicaid, Healthy Steps eligibility is not pursued for those children unless the children are Medicaid eligible with a recipient liability, in which case the family is given a choice as to which program they want coverage under.

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

Effective Date: August 26, 2001 25 Approval Date: ______________ Healthy Steps eligibility is pursued for all other children. The joint application requests information regarding any current health care coverage a family may have available to them. If the applicant indicates that the children have creditable health care coverage, they are denied coverage under the Healthy Steps Program. If an application is received from a family who has a family member employed with the State of North Dakota, the application will be denied for Healthy Steps unless it can be documented that the family is not eligible to participate in the coverage offered to state employees. In those instances where benefits are not offered to temporary or other similar employees, families will be allowed to participate in the Healthy Steps Program if they otherwise meet all other eligibility criteria. Approximately 35 days before the end of the eligibility period, each eligible family is mailed a renewal asking for income information and any other changes that could affect continued eligibility. Information received is entered into the eligibility computer system, which follows the same eligibility determination process as at application. 4.4.2 The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102(b)(3)(B)) (42 CFR 457.350(a)(2)) As noted in 4.4.1 above, eligibility for Medicaid is determined without the need for a separate application process. Joint applications may be submitted to either the county social service offices or the Department of Human Services for a Medicaid eligibility determination in the eligibility computer system to determine eligibility for Medicaid. This process ensures that all joint applications where potential Medicaid eligibility is indicated go through an official eligibility determination process. 4.4.3 The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42 CFR 431.636(b)(4)) As noted in 4.4.1, any children who are ineligible for Medicaid, or who are eligible for Medicaid with a recipient liability, are automatically processed to determine whether they are eligible for Healthy Steps. This process assures that joint applications where potential Healthy Steps eligibility exists will receive an eligibility determination. 4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102(b)(3)(C))) (42 CFR 457.810(a)-(c)) 4.4.4.1

Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution. The joint application utilized by the Healthy Steps Program asks applicants if anyone in the family is covered by creditable health insurance within the last six months. The applicant provides the information through a self-declaration. If any children were covered by creditable health insurance within the last six

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

Effective Date: August 26, 2001 26 Approval Date: _______________

months, the child is determined not to be eligible for Healthy Steps. Families are informed to reapply after the six-month period has expired. The Department allows exceptions to this rule that permits this requirement to be waived if loss of health care coverage occurred because of no fault of the family. Examples include loss of job, accepting another job where coverage is not available and in the case of farm families, residing in a county where a federal disaster has been declared and is currently in affect. 4.4.4.2

Coverage provided to children in families over 200% and up to 250% of FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable. 4.4.4.3

Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution. 4.4.4.4

If the state provides coverage under a premium assistance program, describe:

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a)) Children who are also eligible to receive services through the Indian Health Service (IHS) or through Section 638 Tribal contracts will be eligible to enroll in Healthy Steps. Through various outreach processes including the Robert Wood Johnson covering kids grant, a TANF outreach grant and a community access program grant we have encouraged eligible families to enroll in the program. In addition, we have worked directly with Tribal and Indian Health Service staff to provide information and conduct on-site training sessions to ensure that American Indians are aware of the availability of Healthy Steps and the Medicaid Program. The Department employs an individual whose job is to act as a liaison with Tribes. This individual is used extensively to provide advice, provide assistance on cultural issues and assist in providing training. It is important that American Indian children have the opportunity to obtain appropriate and necessary health care and we are committed to inform them about the availability of Healthy Steps and encourage them to apply for the program. American Indian children, as defined in section 4(c) of the Indian Health Care Improvement Act, 25 USC 1603 c and who are members of Federally recognized tribes as determined by the Bureau of Indian Affairs, will be exempt from any cost sharing obligations.

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

Effective Date: August 26, 2001 27 Approval Date:_______________

Section 5. Outreach (Section 2102(c)) Describe the procedures used by the state to accomplish: Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90) Outreach efforts for the SCHIP plan is designed to be a collaborative effort between families and both the state and federal governments to assure children receive health care. North Dakota uses established relationships with a variety of entities to help identify potentially eligible children and invite them to help put together an outreach system. North Dakota has developed new relationships with a variety of entities to help identify and enroll potentially eligible children into the North Dakota Medicaid SCHIP programs. Certain assumptions about the target population for the expanded Medicaid group of children are based on experiences of the North Dakota Medicaid program, The Caring Program for Children, County Social Service Agencies, public and private health care agencies. The plan must invite families who have regular contact with social service agencies, and to other families who have traditionally avoided government programs. Identification of Target Populations of Potential SCHIP Enrollees The Department of Human Services will work with existing Economic Assistance programs, such as TANF and Food Stamps, to identify children in families who are not eligible for Medicaid, but may be eligible for SCHIP. Outreach Strategies for Potential Enrollees Outreach through Maternal Child Health Programs Maternal and Child Health Programs coordinates outreach activities with the Department of Human Services through their programs, such as Family Planning, OPOP, WIC, local Public Health Agencies, and Children with Special Health Services. Activities include distribution of written materials such as posters, brochures, and flyers, distribution and assistance in completion of applications. MCH programs that participate in health fairs include SCHIP and Medicaid materials onsite. MCH programs will use their intake processes to include information on public insurance programs.

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

Effective Date: August 26, 2001 28 Approval Date:_______________

A toll-free number is in place within the state MCH agency. The toll free is used to answer questions related to Child Find activities and also includes information and referral processes for the Healthy Steps and Medicaid programs. Outreach Through Private Providers Healthy Steps coordinates outreach activities with Primary Care Providers and Medicaid recipients. A new recipient newsletter has been developed for all Medicaid Primary Care Physician enrollees. The North Dakota Medicaid Program publishes a quarterly newsletter sent to over 20,000 Medicaid providers statewide. Healthy Steps information has been and will continue to be included in these publications on a routine basis. The North Dakota Medical Association, Academy of Pediatrics, Dental Association, and Primary Care Association received Healthy Steps program information and has shared this information with their members. The information describes program benefits and how to access services. Providers, such as clinics, hospitals, and dental offices, received Healthy Steps and Medicaid program information, such as flyers, brochures, and applications, to identify and refer potential eligible children to these programs. Outreach Grant Programs The North Dakota Covering Kids Grant utilizes at least three full time outreach workers in three regions, including two Indian reservations. The workers conduct face to face outreach with groups and individuals to assist in enrollment of children in Medicaid and Healthy Steps. The workers target rural counties hardest hit by the agricultural crisis. Agriculture programs, such as Extension Services, Farmers Union, Farm Credit Agencies, Farm Implement Dealers, Rural Electric Cooperatives, through the statewide Coalition of Rural Survivor’s Task Force, are helping to deliver the message of Medicaid and Healthy Steps to farm and other rural families. The Community Access Partnership (CAP) grant, a multi-year initiative to hire and place 14 resource coordinators in clinic and hospital settings to perform outreach and enrollment activities began on July 1, 2001. The Department is coordinating training activities with the newly hired resource coordinators and will also provide ongoing technical assistance and support to grant personnel.

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

Effective Date: August 26, 2001 29 Approval Date:_______________ Outreach Through Native American Health Programs The Department will continue to work with Tribal leaders to develop outreach strategies for North Dakota's Native American population. IHS facilities use their benefits or business office procedures for determining third party payment sources including Medicaid and Healthy Steps. Native American MCH programs use their connections with other providers and programs to facilitate referral to Medicaid and Healthy Steps. The Healthy Start program uses their broad-based network as case managers to access coverage for Healthy Steps and Medicaid for their clients. The Medical Assistance Division collaborated with the North Dakota TANF program to provide funding for two reservation outreach workers. The two sites are located on reservations that were not included in the North Dakota Covering Kids pilot projects. Training and technical assistance will be provided on an ongoing basis to the TANF funded outreach workers. Outreach Through Schools The Department coordinates outreach activities with the Department of Public Instruction and local school districts using the following methods: 1. The State Department of Public Instruction included a tear off on the Free and Reduced Meals Application for the current school year that explains the Healthy Steps program. Each school has a supply of applications for Healthy Steps and the schools give each family an application for Healthy Steps if they have indicated interest on the tear off portion of the Free and Reduced Meals Application. 2. The North Dakota Principals, Teachers, and School Counselors Association will include Healthy Steps information in newsletters and gatherings through their activities. 3. The North Dakota PTA (Parent and Teacher Associations) will distribute information to their local schools. Public health nurses who provide services in local schools will have Healthy Steps information and applications available on site. Outreach Through Business

The Healthy Steps and Medicaid programs will use a variety of outreach strategies targeted through state and local business, including the printing Healthy Steps information on milk cartons, educational forums to human resource managers, flyers and printed information on

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

Effective Date: August 26, 2001 30 Approval Date:_______________ store receipts through retail businesses, information included in utility bills and presentations at small business owners State Tax Department seminars. Outreach Through Head Start Programs The North Dakota Head Start Collaboration Coordinator has been a part of the Healthy Steps and Medicaid outreach group from its inception. Local Head Start programs will use the following strategies to conduct outreach and assist in enrollment for both programs including: 1. Healthy Steps and Medicaid brochures and applications are provided to Head Start families during Head Start enrollment and to new Head Start families throughout the year 2. Assist families in completing the Healthy Steps and Medicaid applications by making copies of social security and income verifications and helping families locate required verification information. 3. Training parent volunteers to assist families during the enrollment process, and sharing Healthy Steps and Medicaid program information with local Head Start Health Advisory Committees. Outreach Through State and Local Advocacy Groups The following advocacy groups and associations have been involved and will continue their involvement with outreach planning for the North Dakota Healthy Steps and Medicaid programs, North Dakota Board of Social Welfare, Family Voices, Federation of Families, North Dakota Mental Health Association, and Department of Human Services Tribal Liaison offices. Outreach strategies will include the following: Assistance to families in completion of applications, distribution of Healthy Steps and Medicaid written materials at state and local gatherings, including eligibility information in newsletters, and technical assistance in writing more family friendly, culturally relevant and simple program information. Outreach Through Child Care Programs Updated Information on public insurance programs will be distributed to all 3,082 licensed, registered, and self-certified centers, preschool, family day care, group day care, multi-licensed, and reservation based childcare programs throughout North

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

Effective Date: August 26, 2001 31 Approval Date:_______________ Dakota. The Department will also work through the three health nurse consultants contracted with the North Dakota Resource and Referral Centers to provide health information to licensed childcare providers. The nurses will help providers distribute written materials about public insurance programs. Outreach Through Religious Groups The North Dakota Catholic Conference has been an active participant in development of public insurance programs. They distribute written material to their local communities and churches through articles in church bulletins, newsletters, and group gatherings. Outreach Through Other Methods Pediatrician outreach through an AAP (American Academy of Pediatrics) Grant. A North Dakota AAP affiliated pediatrician was awarded a grant to conduct one on one outreach to each of the state’s 77 pediatricians. The outreach includes two visits to each of the pediatric offices throughout North Dakota. The first visit was to assess the physician’s awareness of coverage programs, provide education about the programs, determine the type and amount of printed outreach materials in each office, and provide them with additional materials. The second visit is to assess the physician’s awareness of coverage programs and look at the outreach materials in each office in order to determine if the initial contacts were effective. Outreach will be coordinated through North Dakota Extension Programs, Community Action Programs, and North Dakota Rural Survivors Task Force members. The outreach will be through distribution of written information including the Healthy Steps and Medicaid brochures and applications. Outreach Through Written and Network Media The North Dakota Department of Human Services will coordinate with the public information director to develop timely press releases through weekly and daily newspapers, newsletters of professional associations, advocacy groups, and Chambers of Commerce. All written outreach materials, such as brochures, flyers, and posters, will display the 1-800 number to call and receive the information necessary to apply for public insurance programs. A communication plan to address short and long term

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

Effective Date: August 26, 2001 32 Approval Date:_______________ media outreach is in place. The North Dakota Department of Human Services has a website for Healthy Steps that allows the user to print an application that can be competed and mailed in for processing. Coordination of outreach efforts between the North Dakota Healthy Steps Program, Medicaid, other children's public/private health insurance programs and services will be ongoing. The Medical Services Division (Medicaid, Healthy Steps and Children With Special Health Services), and Children and Family Services Division are within the Department of Human Services. The Title V and Title X programs are within the same physical building as Human Services. The Title V, Medicaid, and CSHS programs meet on a quarterly basis to discuss mutual program issues. Children can enroll or receive assistance in enrolling at our single FQHC in Fargo and Rural Health Clinics throughout the state. Local county social service agencies will inform families who have been denied Medicaid eligibility of the Health Steps program and share information collected in the eligibility determination process with Healthy Steps if the county and family agree to do so. Healthy Steps will refer applicants who appear to be Medicaid eligible to local county social service agencies and conduct follow up of these children. Coordination and enrollment activities for Medicaid and Healthy Steps have been enhanced since the joint application was implemented in May 2002. The Department conducts training for county social services and gives these offices Healthy Steps flyers, brochures and applications for children who are not eligible for Medicaid but may be eligible for Healthy Steps. Education sessions for all outreach partners were held August through November 2001. The purpose of the sessions were to provide information that allows the partners to identify families who may be eligible for Healthy Steps or Medicaid, assist families in completing applications for Healthy Steps and Medicaid, explain the benefits of both programs, enabling families to make informed choices and introduction of the new joint application for the Medicaid and Healthy Steps programs. Coordination efforts have also been described in Section 2.3.

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

Effective Date: August 26, 2001 33 Approval Date:_______________ Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

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 7. 6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a)) 6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1.

FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach

copy of the plan.) 6.1.1.2.

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3.

HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions. North Dakota uses the Public Employees Retirement System Health Care Plan (PERS) as the benchmark coverage for Healthy Steps. Most state employees have the option to obtain coverage through this plan that provides comprehensive family health care coverage with no required premium payment. All services in the current plan will be available to enrolled children except for the cost of delivery of newborns. In addition to the standard PERS coverage, Healthy Steps enrolled children will receive a package of preventive dental services and vision care. Also, an extensive number of deductibles and coinsurance amounts required in the PERS plan were replaced with a modest package of cost-sharing for eligible families. The signed actuarial report has previously been provided to CMS. 6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If an existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

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

Effective Date: August 26, 2001 34 Approval Date:_______________

6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1.

Coverage the same as Medicaid State plan 6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3.

Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage 6.1.4.5.

Coverage that is the same as defined by Αexisting comprehensive state- based coverage 6.1.4.6.

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7.

Other (Describe) 6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490) 6.2.1.

Inpatient services (Section 2110(a)(1)) Inpatient services include all bed, board, general nursing, special care units when medically appropriate and necessary, ancillary services when appropriate and necessary, anesthesia and all medical and surgical services provided by a physician except that no payment will be made for the costs associated with the delivery of a child for either the hospital or the attending physician. These services also include appropriate services provided by hospitals operated by the Indian Health Service or Tribal Section 638 facilities. Reconstructive surgery to restore bodily function or correct deformity resulting from diseases, trauma, congenital or developmental anomalies or previous therapeutic processes are covered. Coverage for organ transplants include kidney, heart, heart-lung, single or double lung, liver, cornea and pancreas if medically appropriate. Requires prior authorization and must be provided at an approved transplant center.

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

Effective Date: August 26, 2001 35 Approval Date:_______________ Bone marrow transplants or other forms of stem cell rescue with related services and supplies are limited to certain diseases and conditions as follows: 1. Autologous bone marrow transplants are only allowed for the following diagnoses: non-Hodgkin’s lymphoma, stage III or IV; Hodgkin’s disease (lymphoma) stage III or IV; neuroblastoma, stage III or IV; acute lymphocytic or non-lymphocytic leukemia in first or subsequent remission; germ cell tumors and breast cancer. 2. Allogeneic bone marrow transplants are only allowed for the following diagnoses: non-Hodgkin’s lymphoma, stage III or IV; Hodgkin’s disease (lymphoma) stage III or IV; neuroblastoma, stage III or IV; chronic myelogenous leukemia in blast crisis or chronic phase; and acute lymphocytic or non-lymphocytic leukemia (acute myelocytic leukemia) in first or subsequent remission, but at high risk for relapse. 3. Allogeneic bone marrow transplants for non-malignancies are only allowed for the following diagnoses: severe aplastic anemia; homozygous beta- thalassanemia; Wiskott-Aldrich syndrome; severe combined immunodeficiencies; infantile malignant osteopetrosis; mucopolysaccharidoses; mucolipidoses; and myelodysplastic syndromes. All other forms of bone marrow transplants or peripheral stem cell transplants are not covered including related services and supplies. Related services and supplies include all services and supplies that are not medically appropriate and necessary for a child’s receipt of chemotherapy or radiation therapy requiring stem cell support, and includes specifically and without limitation, chemotherapy and radiation therapy when supported by transplant or other stem cell rescue procedures. Coverage is not available for chemotherapy or radiation therapy together with all related services and supplies when the dose or manner of administration is expected to result in damage to or suppression of the bone marrow, the blood or blood forming systems, warranting or requiring receipt by the patient of autologous, allogeneic or syngeneic

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

Effective Date: August 26, 2001 36 Approval Date:_______________ stem cells, or that are derived from the bone marrow or the peripheral blood, unless the procedure is specifically allowed as a covered service detailed above. Prior approval is required for all bone marrow transplants and must be performed at an approved transplant center. Coverage is not available for small intestine transplants or donor organs or tissue other than human donor organs or tissue. Limitations: Cosmetic surgery will not qualify as reconstructive surgery when performed for the treatment of a psychological or psychiatric condition. Surgery and related services primarily intended to improve appearance and not to restore bodily function or correct deformities resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes are not considered a covered service. Sterilization procedures or procedures to evaluate and reverse sterilization are not covered. Surgery for morbid obesity is limited to one lifetime operative procedure per enrollee. No benefits are available for repair or modification of any or all types of surgical morbid obesity procedures unless there are special circumstances. Coverage is not available for services that are primarily for diagnostic examinations, physical therapy, rest care, convalescent care, custodial care, maintenance care and sanitaria care or inpatient services performed primarily for the purpose of administering allergy, sensitivity, food challenge or related testing, clinical ecology, and vitamins or dietary nutritional supplements. Coverage is not available for routine circumcisions for either the hospital or the professional performing the surgery. Each family will be responsible for a $50 deductible for the first day for each individual inpatient hospital stay. American Indian children are exempt from this requirement. Preauthorization is required for all inpatient hospital admissions unless the admission is the result of a medical emergency. An emergency is defined as a medical condition which most non-medical people think is

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

Effective Date: August 26, 2001 37 Approval Date:_______________ life-threatening or could cause death or severe permanent damage to a person or unborn baby if not treated immediately. Exclusions No coverage is available when a child is admitted to an inpatient facility prior to the effective date of the child’s eligibility for the Healthy Steps Program. 6.2.2.

Outpatient services (Section 2110(a)(2)) Outpatient services including outpatient surgery services are covered including emergency care. These services also include services provided through hospitals operated by the Indian Health Services or Section 638 Tribal operations. Families are responsible to pay a $5 co-payment for each visit to an outpatient hospital emergency room. American Indian children are exempt from this requirement. 6.2.3.

Physician services (Section 2110(a)(3)) Physician services include medical office and home visits, consultations and similar services that are medically necessary and appropriate at no cost to the family of enrolled children. Coverage is available for second surgical opinions, radiation and chemotherapy services except where otherwise prohibited, dialysis treatment and home infusion therapy services. Home infusion therapy must be preauthorized. Services covered include the provision of nutrients, antibiotics and other drugs and fluids intravenously, through a feeding tube, or by inhalation, necessary supplies and therapeutic drugs or other substances. Allergy services are available including direct skin testing and patch testing when ordered by a physician and are performed in accordance with guidelines and criteria for specific IgE testing (RAST), Rinkel Immunotherapy (Serial Endpoint Dilution Titration), the fluorescent allergosorbent test (FAST), total serum IgE concentration, bronchial challenge testing, conjunctival challenge testing and food challenge testing when specific indications are present.

Coverage is not available for nasal challenge testing, provocative/neutralization testing for food and food additive allergies,

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

Effective Date: August 26, 2001 38 Approval Date:_______________ leukocyte histamine release, Rebuck skin window test, passive transfer or Prausnitz-Kustner test, cytotoxic food testing, metabisulfite testing, candidiasis hypersensitivity syndrome testing, IgE level testing for food allergies, general volatile organic screening test and mauve urine test. Coverage is not available for desensitization treatment, provocation/neutralization therapy for food/chemical or inhalant allergies by sublingual, intradermal and subcutaneous routes, urine autoinjections, repository emulsion therapy, candidiasis hypersensitivity syndrome treatment or IV vitamin C therapy. Coverage is not available for clinical ecology, orthomolecular therapy, vitamins, dietary nutritional supplements, food challenge, or related testing rendered on an outpatient basis. Preventive care that includes all appropriate immunizations and wellness services are covered. This includes all recommended immunizations by the North Dakota Health Department. Wellness visits include up to 7 physician visits in the first year of life, newborn hearing screening, no more than two home nursing visits for newborns if requested by physicians and the family, developmental screening at ages 9 months and two years and coverage of nutrition services for diabetes, hyperlipidemia, eating disorders, chronic renal failure, and phenylketonuria . Coverage for nutritional care is limited to no more than 2 office visits per year for hyperlipidemia and gestational diabetes and 4 office visits for the other covered conditions. Other wellness services include up to three well care and immunization visits for enrolled children 13 through 24 months of age and one visit per year for enrolled children 25 months through 18 years of age. Children 6 through 18 years of age are also allowed one preventive screening service per year that can include a sports or school physical. Wellness services include diabetic education services. These services are limited to one five day intensive program or a 16 hour outpatient program limited to 2 sessions per lifetime. Coverage is not available for any other annual, periodic or routine examinations except those specified above or for immunizations required because of a child’s employment, occupation or immunizations required for foreign travel. Costs associated with the delivery of a child are not included in this health benefit package.

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

Effective Date: August 26, 2001 39 Approval Date:_______________ Coverage is not available for any form of thermography for any use or indication. Coverage is not available for acupuncture performed by any provider. Coverage is not available for any outpatient provider for palliative or cosmetic foot care, foot support devices, except custom made support devices, or subluxation of the foot, care of corns, bunions, except for capsular or bone surgery, calluses, toenails, fallen arches, weak feet, chronic foot strain and symptomatic complaints of the feet, except that services are available for the care of corns, calluses and toenails when medically appropriate and necessary for children with diabetes or circulatory disorders of the legs or feet. 6.2.4.

Surgical services (Section 2110(a)(4)) Covered for all necessary and appropriate medical procedures whether performed in an inpatient hospital, outpatient hospital, ambulatory surgical center, Indian Health Service Hospital or Clinic or Tribal Section 638 Facility or office setting in accordance with any requirements set forth in sections 6.2.1 and 6.2.2 relating to inpatient and outpatient hospital surgical services. Coverage is not available for treatment leading to or in connection with sex change or transformation surgery and related complications. Surgical services are covered without any cost sharing requirement unless they occur as part of an inpatient hospital stay or a hospital emergency room visit. 6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) Covered for all appropriate and necessary services for all certified Federally Qualified Health Centers, Rural Health Clinics, Indian Health Services or Tribal Section 638 outpatient clinic services. 6.2.6.

Prescription drugs (Section 2110(a)(6)) Covered for all appropriate and medically necessary prescription drugs that are authorized by a professional licensed to write prescriptions. Coverage for diabetic supplies, syringes, lancets and test strips are included in this benefit.

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

Effective Date: August 26, 2001 40 Approval Date:_______________ There is no coverage for any medication or device designed to prevent pregnancy including any oral or other forms of contraceptive drugs, contraceptive devices or appliances or delivery. Coverage is not available for any medications obtained without a prescription order or any charges for the administration of legend drugs or insulin that may be self administered. A co-payment of $2 per prescription will be required for each prescription and refill dispensed under the insurance plan. American Indian children are exempt from this requirement. 6.2.7.

Over-the-counter medications (Section 2110(a)(7)) 6.2.8.

Laboratory and radiological services (Section 2110(a)(8)) Covered for all appropriate and necessary services that have been ordered by a physician or other practitioners within the scope of their practice as authorized by state law. There is no cost sharing for this service. 6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) Covers prenatal care provided by a physician or certified nurse/midwife, prenatal nutritional counseling limited to one visit per pregnancy and one ultrasound per pregnancy unless additional services are determined to be medically necessary. There is no coverage for the cost of the delivery of a vaginal delivery or cesarean section for the hospital, physician, nurse midwife, birthing center or any other services directly associated with the birth of a child. Coverage is not available for any costs associated with surrogate pregnancy, gestational carrier pregnancy, assisted conception or any other services related to conception or pregnancy in anything other than the genetic mother’s uterus, donor sperm utilized for artificial insemination or any and all extraordinary procedures to induce fertilization or enhance conception with professional or technical assistance, including gamete intrafallopian transfer, zygote intrafallopian transfer, in vitro fertilization, peritoneal oocyte and sperm transfer, tubal ovum transfer or intracytoplasmic sperm injection. Postnatal and interruptions of pregnancy including miscarriage is a covered service.

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

Effective Date: August 26, 2001 41 Approval Date:_______________ Coverage is not available for the insertion and routine removal of intrauterine devices, contraceptive delivery systems, evaluations and procedures to evaluate sterilization reversals, reversal of sterilization procedures or any other procedures or supplies designed to prevent pregnancy including oral and other forms of contraceptive drugs, contraceptive devices and appliances. 6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) Covers up to 60 days per year for either psychiatric or substance abuse inpatient hospital treatment for mental illness. Prior authorization is required for all admissions. Covers up to 120 days per year for Residential Treatment Services. Prior authorization is required for all admissions. Each family will be responsible for a $50 deductible for the first day of every inpatient hospital stay. The deductible does not apply to residential treatment services. 6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11) Covers partial hospitalization for no more than 120 days per child per year. Preauthorization is required. Available inpatient days may be traded for additional days of partial hospitalization beyond the 120 limit described above at a rate of two days of partial care for each day of inpatient hospital care. No more than 46 days of inpatient services may be traded for additional partial hospitalization services. Preauthorization is required.

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

Effective Date: August 26, 2001 42 Approval Date:_______________ Covers up to 30 hours per year for outpatient psychiatric services including diagnostic, evaluation and treatment services provided by a physician, licensed clinical psychologist, social worker and treatment services provided by a psychiatric nurse. Group psychotherapy is also available. Two hours of group therapy reduce available outpatient benefits by one hour. Preauthorization is required. Coverage is also available for the intensive outpatient program. This service is a formal program for a child who requires more than one visit per week for mental health services but does not require the intensity of inpatient hospital or partial hospitalization. Generally more than one treatment modality is used and a plan must identify a treatment goal that is related to the child=s diagnosis. Preauthorization is required. Exclusions: Coverage is not available for services provided by a social worker who does not meet the qualifications required by state law or a psychologist who is not eligible for listing in the National Register of Health Service Providers. Special education, counseling or care of learning disorders or behavioral problems whether or not associated with a manifest mental disorder or other disturbance. Sex therapy services. Bereavement, codependency, marital, family, sex or interpersonal relationship, gambling addiction or nicotine addiction counseling services or services provided by a vocational residential rehabilitation center or a community reentry program. 6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) Rental or purchase of home medical equipment is covered when prescribed by a physician and required for therapeutic use. No benefits are allowed for motorized equipment except wheelchairs with prior approval. No coverage is available for batteries required for home equipment. Covered services include replacement and repairs when medically appropriate and necessary. Coverage is available for the purchase, fitting and necessary

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

Effective Date: August 26, 2001 43 Approval Date:_______________ adjustments of prosthetic appliances and supplies that replace all or part of a body part. Benefits are available only for standard appliances. Covered services include replacement and repairs when medically appropriate and necessary. Coverage is not available for any testicular prostheses regardless of the cause of the absence of the testicle. The rental of medically appropriate and necessary oxygen equipment and the administration of the oxygen is a covered service. Orthotic devices that are medically appropriate and necessary when ordered by a physician or podiatrist are covered. Benefits are not available for leisure or recreational activities or to allow a child to participate in a sports activity. Coverage is not available for personal hygiene and convenience items including air conditioners, humidifiers or physical fitness equipment. Hearing Aids are covered when medically necessary and appropriate. Benefits are limited to $3,000 per enrolled child every three years. Prior approval is required. Coverage is not available for electronic speech aids, robotization devices, robotic prosthetics, myoelectronic prosthetics, customized cutaneal dermal protective covers, and endolite prosthetic systems or artificial organs. Coverage is available for one set of eyeglass frames every 24 months and one set of lenses every 12 months for each child. The amount allowed for each frame is $80. Any amount over that cost is the responsibility of the family. If desired, contact lenses may be substituted for eyeglass frames and lenses. Payment allowances are limited to the allowance for frames and prescribed lenses that are considered appropriate and medically necessary. Medically appropriate and necessary medical equipment and supplies are subject to a maximum benefit allowance of $6,000 per member per year for all covered services received.

6.2.13.

Disposable medical supplies (Section 2110(a)(13))

Coverage is provided for medically and necessary supplies

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

Effective Date: August 26, 2001 44 Approval Date:_______________ for the administration of prescription medications or drugs such as hypodermic needles and syringes and ostomy supplies Medically appropriate and necessary medical equipment and supplies are subject to a maximum benefit allowance of $6,000 per member per year for all covered services received. 6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14)) Coverage is provided for a homebound child in the child’s place of residence. The service must be on a part-time visiting basis in accordance with a physician’s prescribed plan of treatment that is approved prior to admission into home health care. Services are available only if, in the absence of home health care, a child would require inpatient hospital or skilled nursing facility services. Covered services include registered nurse, licensed vocational nurse or licensed practical nurse; physical, occupational or speech therapy; medical and surgical supplies; administration of prescribed drugs; oxygen, including administration; and home health aide services when a child is receiving daily covered skilled nursing services or therapy services. Coverage is not available for dietitian services, homemaker services, maintenance care, custodial care, food or home delivered meals, respite care or home health care or supplies for children who are ventilator dependent unless a skilled nursing facility bed is not available. In the event a skilled nursing facility bed is not available, the maximum benefit allowance will be the average semi-private room rate for a skilled nursing facility bed. 6.2.15.

Nursing care services (See instructions) (Section 2110(a)(15))

PRIVATE DUTY NURSING SERVICES Coverage is available for services provided by a registered nurse or licensed practical nurse when ordered by a physician, Payment is not available to a nurse who lives in the child’s home or is a member of the child’s immediate family.

Coverage is not available for maintenance care.

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

Effective Date: August 26, 2001 45 Approval Date:_______________ 6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) Coverage is limited to abortions that are necessary to prevent the death of a woman. Coverage is not available for other abortions including abortions for removal of all or part of a multiple gestation. 6.2.17.

Dental services (Section 2110(a)(17)) Coverage is provided for emergency, diagnostic and well child dental care including preventive and restorative services. These services include emergency palliative treatment, simple extractions, pulpotomies on deciduous teeth, routine oral examinations, dental x-rays that include bitewing, full-mouth and panoramic, routine prophylaxis, sealants, topical fluoride applications, space maintainers, amalgam and resin restorations, stainless steel crowns and administration of anesthesia. Routine oral examinations and topical fluoride applications are limited to no more than twice per year. Prophylaxis is limited to no more than four per year. Bitewing x-rays are limited to no more than once during a year. Full mouth and panoramic x-rays are limited to once every three years. No coverage is available for orthodontic services or any other services not specifically identified above. Coverage is also available for appropriate and necessary treatment of an accidental injury to the jaw, sound natural teeth, dentures, mouth or face that occurs after the date a child is enrolled in Health Steps. Treatment must occur within 12 months of the date of injury. Injury is defined as an external force that causes a specific impairment to the areas described above. Injury that is a result of chewing or biting is not considered an accidental injury. 6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services. (Section 2110(a)(18)) Covers up to 60 days per year for each enrolled child for inpatient substance abuse and mental illness services. Each family will be responsible for a $50 deductible amount applied to the first day of admission for every inpatient hospital stay. American Indian children are exempt from this requirement.

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

Effective Date: August 26, 2001 46 Approval Date:_______________ Admission for detoxification is limited to 5 days per admission unless further acute care is medically appropriate and necessary. Days of detoxification will county against the 60 day per year limit whether the service was provided in an inpatient hospital or a substance abuse facility.

6.2.19.

Outpatient substance abuse treatment services. (Section 2110(a)(19)) Coverage for partial hospitalization for mental illness and substance abuse is available, but is limited to no more than 120 days per year, except when substitution for inpatient days occurs. Preauthorization is required. Available inpatient days may be traded for additional days of partial hospitalization. Each inpatient day is equivalent to two days of partial care. No more than 46 days of inpatient hospital services may be traded for additional partial hospitalization services for mental illness or substance abuse services. Preauthorization is required. Coverage is provided for outpatient substance abuse services. Coverage is limited to no more than 20 visits per child per year that includes diagnostic, evaluation and treatment services provided by a physician, licensed clinical psychologist or licensed addiction counselor. Coverage for group psychotherapy services is available. Two group psychotherapy visits will reduce available substance abuse benefits by one visit. Preauthorization is required.

6.2.20.

Case management services (Section 2110(a)(20))

6.2.21.

Care coordination services (Section 2110(a)(22)) 6.2.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing and language disorders. (Section 2110(a)(22))

PHYSICAL THERAPY Coverage is available for physical therapy services performed by or under the direct supervision of a physical therapist to restore maximum function following disease, injury or loss of body part. Services will be limited based on a predetermined number of visits based on the presenting condition.

Coverage is available for treatment of chronic conditions such as

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

Effective Date: August 26, 2001 47 Approval Date:_______________ multiple sclerosis, progressive rheumatoid arthritis or cerebral palsy when medically appropriate and necessary. Coverage is not available for maintenance care including such care related to the treatment of chronic conditions. Coverage is not available for massage therapy provided by a masseuse or masseur. OCCUPATIONAL THERAPY Coverage is available for occupational services performed by or under the direct supervision of a licensed occupational therapist for the treatment of a physically disabled child by means of constructive activities designed and adapted to promote the restoration of a child’s ability to satisfactorily accomplish the ordinary tasks of daily living. Coverage is limited to a maximum of 90consective days per condition beginning on the day the first service was provided. After 90 days, services will be reviewed to determine if additional services should be available based on medical appropriateness and need. Coverage is not available for maintenance care. SPEECH THERAPY Coverage is available for speech therapy services performed by or under the direct supervision of a certified speech therapist for the correction of a speech impairment resulting from disease, surgery, injury, congenital anomaly or previous therapeutic process. Prior authorization is required and services must be provided in accordance with prescribed plan of treatment ordered by a physician Coverage is not available for maintenance care or for group speech therapy services. Care must be delivered based on a prescribed treatment plan ordered by a physician. Preauthorization is required and service must be delivered in accordance with a prescribed plan of treatment. Coverage is not available for physical, occupational or speech therapy associated with work hardening programs, prevocational evaluations or functional capacity evaluations.

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

Effective Date: August 26, 2001 48 Approval Date:_______________

6.2.23.

Hospice care (Section 2110(a)(23)) Coverage is available for hospice benefits when provided through an organized and approved hospice program. Preauthorization is required. Services are limited to treatment of children who have been diagnosed with a condition where there is a life expectancy of 6 months or less. 6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) PROFESSIONAL VISION SERVICES PROVIDED BY AN OPTOMETRIST Coverage is available for emergency and well child services that include treatment of sore eyes, foreign body removal and sudden impairment of vision, annual routine complete examinations and visits to supervise patching progress and orthoptics for children with amblyopia. Benefits are limited to a lifetime maximum of 16 visits per child.

Examinations are limited to no more than one per year.

Coverage is not available for any other service or material that may be provided through an optometrist

CHIROPRACTIC SERVICES Coverage is available for medically appropriate and necessary services provided within the scope of licensure and practice of a chiropractor to the extent services would be covered if provided by a physician.

Benefits are not available for maintenance care.

BIOFEEDBACK Coverage is available for chronic headaches, gastrointestinal disorders, neuromuscular disorders and panic disorders. Coverage is limited to no more than four sessions per child per year. TEMPOROMANDIBULAR (TMJ) OR CRANIOMANDIBULAR JOINT TREATMENT (CMJ)

Coverage is available for TMJ and CMJ that includes surgical and

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

Effective Date: August 26, 2001 49 Approval Date:_______________ Nonsurgical services when treatment is medically appropriate and necessary. Services must be prior authorized. Coverage for surgical services are subject to a lifetime maximum of $10,000 per child. Coverage for nonsurgical services including diagnostic and biofeedback services, supplies and outpatient treatments are subject to a lifetime maximum of $2,500 per child. Coverage for splints are limited to no more than $275 and are subject to the nonsurgical service lifetime maximum. Coverage is not available for orthodontic services or osseointegrated implant surgery or related services performed for the treatment of temporomandibular or craniomandibular joint disorder(s). 6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.26.

Medical transportation (Section 2110(a)(26)) Coverage is available for medically appropriate and necessary ambulance services to the nearest facility equipped to provide the required level of care. Coverage is provided from the home or site of accident or emergency, between hospitals, or between a hospital and a skilled nursing facility. Coverage for air ambulance is available only if it is not medically appropriate and necessary to transport by ground ambulance. Preauthorization is required. 6.2.27.

Enabling services (such as transportation, translation, and outreach services) (See instructions) (Section 2110(a)(27)) 6.2.28.

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28)) Skilled nursing facility services that are medically appropriate and necessary that include skilled nursing services and supplies generally provided in a skilled nursing facility are covered. Preauthorization is required.

Coverage is not available for maintenance or custodial care. The following is a general list of exclusions not associated with a particular service. 1. Services not prescribed or performed by or under the direct supervision of a professional health care provider consistent with the professional health care provider’s licensure and scope of practice.

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

Effective Date: August 26, 2001 50 Approval Date:_______________ 2. Services provided and billed by a registered nurse (other than an advanced practice registered nurse), physician extender, intern, licensed athletic trainer or other paramedical personnel.

3. Any drug, device, medical treatment or procedure that is experimental or investigative.

4. Services, treatment or supplies that the contractor determines are not medically appropriate or necessary.

5. Standby services provided or billed by a health care provider.

6. Services when benefits are provided by any governmental unit or social agency. Medicare Part A and B will be considered the primary payor with respect to benefit payments unless otherwise required by federal law.

7. Illness or injury caused directly or indirectly by war or an act of war or sustained while performing military services, if benefits for such illness or injury are available under the laws of the United States or any political subdivision thereof.

8. Illness or bodily injury that arises out of and in the course of child’s employment if benefits are compensation for such illness or injury are available under the provisions of a state workers’ compensation act, the laws of the United States or any state or political subdivision thereof.

9. Loss caused or contributed by a child’s commission or attempted commission of a felony or a child’s involvement in an illegal occupation.

10. Any services when benefits are provided by a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, or similar person or group.

11. Services provided by a health care provider who is a member of the child’s immediate family.

12. Telephone consultations or charges for failure to keep a scheduled visit or charges for completing of any forms required by the contractor.

13. Health screening assessment programs or health education services, including services provided through the rental or purchase of TV, audiovisual tapes or pamphlets.

14. Health and athletic club membership or facility use, and all services provided by the facility, including physical therapy, sports medicine therapy and physical exercise.

15. Complications resulting from noncovered services received by a child.

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

Effective Date: August 26, 2001 51 Approval Date:_______________ 16. Services prescribed by, performed by or under the direct supervision of a nonpayable health care provider.

17. Services that a child has no legal obligation to pay in the absence of this or any similar coverage.

18. Cost sharing amounts.

19. Services, treatments, or supplies not specified as a covered service in this coverage plan.

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1.

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR

6.3.2.

The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2 of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4 Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: Section 2105(c)(s) and (3)) (42 CFR 457.1005 and 457.1010)

6.4.1.

Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42CFR 457.1005(a));

6.4.1.1 Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 – 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

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

Effective Date: August 26, 2001 52 Approval Date:_______________ 6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above.; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

6.4.1.3 The coverage must be provided through the use of a community- based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

6.4.2.

Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3))A)) (42CFR 457.1010(a))

6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b))

6.4.2.3 The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

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

Effective Date: August 26, 2001 53 Approval Date:_______________ Section 7. Quality and Appropriateness of Care

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 8.

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495.495(a))

Will the state utilize any of the following tools to assure quality?

(Check all that apply and describe the activities for any categories unutilized.)

7.1.1.

Quality standards

The Department of Human Services contracts with Noridian Mutual Health Insurance to provide medical, dental and vision services to eligible children. The contractor has a current Certificate of Authority from the Insurance Department. The contractor is also required to maintain a Quality Assurance/Quality Improvement Plan that summarized the contractor’s quality assurance system including but not limited to the following standards for the entire range of clinical care and services provided:

• Detailed quality objectives and timetables for accomplishing these objectives. Section 9 contains many of the quality indicators the Department will be using to measure the quality of services provided to children eligible for Healthy Steps. • Description of the quality assurance committee structure. • Identification of contractor staff responsible for quality assessment and improvement. • Description of the manner in which providers participate in quality assurance and improvement activities. The contractor uses provider profiling on a statewide basis to identify quality issues and bring them to the attention of practitioners. • Credentialing procedures. • Standards of clinical care that address preventive services and are based on reasonable scientific evidence and are regularly reviewed by clinicians and distributed to providers. The contractor periodically sends information to providers relating to standards based on the Academy of Immunization Practices and educational materials relating to specific disease states such as asthma, diabetes, and lipid lowering agents. • Standards of service accessibility. The contractor has an extensive provider network that includes 100% of hospitals, 99.6% of all physicians actively practicing in North Dakota, 99.1% of optometrists and 64.1% of dentist participate in the provider network that provides services to eligible children.

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

Effective Date: August 26, 2001 54 Approval Date:_______________ • Medical records standards, including medical records confidentially provisions. • Utilization review standards and processes. The contractor has developed this requirement and it is on file with the Department of Insurance. • Quality indicator measures and clinical study designs. Quality measures and clinical study have been designed and incorporated into the quality objectives covered in Section 9 of the plan. HEDIS standards will be utilized where appropriate. Other standards were developed based on the agreement between the Department and the Contractor that are designed to improve the delivery of services for enrolled children.

The Department is especially aware of the need to encourage the use of preventive services for eligible children. As such, we have established goals that are designed to track and improve the delivery of preventive services that include immunizations, well baby and well childcare. A Healthy Steps report card has been developed that will be used to track the progress made to improve the delivery of preventive care services to enrolled children. Goals have been established that will encourage the contractor to educate families and providers about the importance of preventive care and encourage families to seek appropriate immunization and well baby, well child visits in order to ensure that children remain healthy during their formative years.

In addition, the contractor will also have goals for other preventive service improvement including dental and vision visits and hospital emergency service usage. The contractor will also be monitoring with the plan of reducing the rate of institutional psychiatric and chemical dependency services, improving the management of asthma and diabetes, thus reducing the need for expensive hospital interventions.

• Quality Assurance and Quality improvement plan documentation methods. This information is included in the Health Steps Report Card process. • Description of how quality improvement activities are integrated with other plan or management functions. The contractor and the Department have periodic discussions regarding quality measures in order to improve or change the quality improvement process. In many instances the Department is using similar measures when establishing quality indicators for the Medicaid program. We are then able to draw comparisons between the programs to assist in identifying issues and improving performance. • Monitoring the effectiveness of the client grievance process, including identification of contractor staff with specific responsibility to resolve problems. The contractor maintains a quarterly grievance report. The Medical Director for the contractor is responsible for resolving any grievances received from the families of enrolled children.

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

Effective Date: August 26, 2001 55 Approval Date:_______________

7.1.2.

Performance measurement

The contractor for the Healthy Steps program will assure that high quality and appropriate services are provided to enrolled children. The contractor is required to collect and report data for the following areas that are similar to that required by the Department from our capitated service providers. Modified HEDIS measures will be acceptable, if available.

• Childhood Immunizations • Adolescent Immunizations • Well Baby Visits • Well Child Visits • Newborn Hearing Screenings • Developmental Screenings • Preventive Dental Services • Optometric Services • Preventive Health Promotion Activities • Membership Surveys • Indicators of contractor financial stability

Most of the measurements noted above are included in the Healthy Steps Report Care, a required reporting tool by the contractor used to track progress in meeting specific goals for quality improvement. The contractor has encouraged preventive health promotion activities such as sending out annual birthday cards for enrolled children reminding them to make appointments for preventive dental and vision services. The contractor has completed two membership surveys that are used to evaluate the quality of services being provided to enrolled children.

7.1.3.

Information strategies

The contractor has developed Healthy Steps enrollee education materials to ensure those children and their families are informed of their benefits, their rights and their responsibilities. The educational material includes information regarding covered services, limitations, grievance procedures, toll-free numbers available to answer questions about covered services and grievance procedures and policies on referrals and after hours care.

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

Effective Date: August 26, 2001 56 Approval Date:_______________

7.1.4.

Quality improvement strategies

The contractor has developed an internal measurement and monitoring system that is used to inform providers with emphasis on preventive and coordinated care according to clinical standards and guidelines that includes annual HEDIS information that is shared with providers.

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))

The Department is committed to ensure that enrolled children have access to preventive services. Several of the objectives outlined in Section 9 of this plan are designed to monitor the provision of these services and to devise ways of improving the number of preventive services if targets are not being met including educational efforts for families and providers.

The contractor also conducts yearly surveys that assists in identifying preventive service usage and needs and will be used to correct any issues raised by families concerning access to important preventive services that include preventive physician visits and appropriate immunizations for enrolled children.

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 contractor survey of families seeks information regarding the availability and use of services including hospital emergency room services. The surveys are monitored to determine if any deficiencies exist and action is then taken to correct any apparent problems with access to services.

Emergency room services must be available to all enrollees and are not subject to any prior approval requirements.

The contractor has an extensive provider network that includes all licensed hospitals in the state and more than 99% of practicing physicians. This network allows enrolled children the opportunity to receive needed care throughout the state including rural areas.

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

Effective Date: August 26, 2001 57 Approval Date:_______________ 7.2.3. Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, and 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))

Children with chronic, complex or serious medical conditions may seek the services of any specialist participating in the contractor’s provider network without the need to seek prior approval. Since more than 99% of all physicians participate in that network, access to specialty care is excellent.

While most conditions can be treated by specialists within the contractor’s network, there are certain instances when out of network specialty services are indicated. These services are available from providers located in Minneapolis or Rochester, Minnesota. Participating physicians in North Dakota may make appropriate referrals to these specialists if the services are not available in North Dakota.

The yearly survey conducted by the contractor has a section dedicated to availability of specialty care. Responses are monitored to ensure that specialty services are readily available to enrolled children.

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))

The contractor follows the Utilization Review Accrediting Council of Facilities regarding prior authorization of services and adheres to the 14-day time frame.

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

Effective Date: August 26, 2001 58 Approval Date:_______________ Section 8. Cost Sharing and Payment (Section 2103(e))

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 the Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)

8.1.1.

YES

8.1.2.

NO, skip to question 8.8

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate.

(Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) & (c), 457.515(a) & (c))

8.2.1. Premiums: No premiums are imposed on covered children.

8.2.2. Deductibles: A $50 deductible is applied for the first day of each inpatient hospital admission in a general hospital, an inpatient psychiatric facility or a substance abuse inpatient facility.

8.2.3. Coinsurance or copayments: A $5 co-payment will be applied for each emergency room visit to a hospital. A $2 co-payment will be applied for each allowable prescription drug.

8.2.4. Other: There are no other cost-sharing requirements in the Healthy Steps Program.

8.3. Describe how the public will be notified, including the public schedule, of the cost- sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b))

All eligible families of enrolled children will receive a handbook from the insurance carrier that includes information regarding their cost sharing responsibilities. The information is distributed during the first month the children are enrolled in the program. Each family receives notice of the amount of their cumulative maximum at the time they are determined eligible for the Healthy Steps Program.

Cost sharing information is available for the general public through brochures that are distributed throughout the state to various advocacy groups, government agencies, providers and others interested in promoting health care coverage,. Information regarding cost sharing is also posted on the Department’s Website.

8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

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

Effective Date: August 26, 2001 59 Approval Date:_______________

8.4.1.

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457-530)

8.4.2.

No cost-sharing applies to well-baby and well-child care, including age- appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520)

8.4.3.

No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

Cost sharing is limited to no more than 5% of gross income for each eligible family. Each family receives a notice that lists the children who are eligible for Healthy Steps. The notice also informs families of the maximum amount of cost-sharing each family is responsible to pay each year. They are advised to keep track of the cost sharing expenditures and when the cost-share payments reach the limit they are told to inform the department and provide documentation. At that time we ill inform the insurance carrier that the children are no longer subject to any cost-sharing for the remainder of the year and the department will authorize a premium increase to the insurance carrier to cover the additional costs because cost-sharing no longer applies for those children. The insurance carrier issues new cards indicating that the family is no longer subject to any cost sharing.

8.6. Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

North Dakota uses a self-declaration process to ensure that American Indian children are excluded from cost-sharing. The application requests race information for each applicant. If the applicant indicates that the child is American Indian, it is assumed that they meet the definition as described in the Indian Health Care Improvement Act of 1976.

North Dakota has four recognized Reservations and one Indian Service Area. Nearly all Indians in the state either reside on these reservations or have moved to other areas from the reservations. They originate from tribes that are recognized under the Indian Health Care Improvement Act. Therefore, the department concluded that self-declaration of race is appropriate.

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

Effective Date: August 26, 2001 60 Approval Date:_______________

If a child is identified as American Indian, the insurance carrier is notified. The Department makes a premium payment to the carrier that is slightly higher in order to cover the extra costs of not applying co-payments for services provided to enrolled children. The insurance cards issued by the insurance carrier, informs providers that the child is not subject to any of the co-payments that apply to other enrolled children.

8.7. Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c)

Enrolled children in the Healthy Steps Program are not subject to disenrollment if they fail to pay cost-sharing to providers. It is the responsibility of the parents of an enrolled child to pay the cost-sharing amount directly to the provider of service. The provider may take any ordinary means available to collect the amount due. Program enrollment will continue as long as a child is eligible for the Healthy Steps whether or not the family pays the cost sharing amounts to the appropriate providers.

8.7.1. Please provide an assurance that the following disenrollment protections are being applied:

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non payment of cost-sharing charges. (42CFR 457.570(b))

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

8.8. The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.

No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFS 457.220)

8.8.2.

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5)

8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1))

8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5))

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

Effective Date: August 26, 2001 61 Approval Date:_______________ 8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105(c)(7)(B)) (42CFR 457.475) 8.8.6.

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105(c)(7)(A)) (42CFR 457.475)

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

Effective Date: August 26, 2001 62 Approval Date:_______________ Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107) 9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

Strategic Objective 1: Reduce the number of North Dakota children, from birth to age 19 who are uninsured.

Strategic Objective 2: Improve access to health care services for North Dakota children enrolled in SCHIP.

Strategic Objective 3: Ensure that children enrolled in SCHIP receive timely and comprehensive preventive health care services.

Strategic Objective 4: Ensure that children enrolled in SCHIP receive high-quality health care services.

Strategic Objective 5: Improve the health status among children enrolled in SCHIP. 9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

The Department is acutely aware that outcome measurements are an integral part of SCHIP. We realize that merely making services available does not ensure that children are receiving necessary services or that they are receiving quality health care services. The performance measures outlined below are designed to ensure that enrolled children receive appropriate and necessary health care services.

In order to meet yearly federal reporting requirements we intend to gather information based on services provided between July 1 and June 30 of each year, our state fiscal year. This will permit us to ensure that data provided to CMS is accurate and meaningful.

Performance Measures for strategic Objective 1: Reduce the number of North Dakota children from birth to age 19 who are uninsured 1.1 By December 31, 2002, at least 660 additional previously uninsured low-income children will be enrolled in Medicaid and Healthy Steps Programs. 1.2 By December 31, 2002, the percentage of children from birth to 19 years of age without health insurance will be decreased by about 5% in the overall uninsured rate based on the 1998 survey conducted with the cooperation of the Robert Wood Johnson Foundation.

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

Effective Date: August 26, 2001 63 Approval Date:_______________ Performance Measures for Strategic Objective 2: Improve access to health care services for North Dakota children enrolled in SCHIP. 2.1 By June 30, 2002 and annually thereafter, at least 90% of children enrolled in SCHIP will have an identified primary care location. 2.2 By June 30, 2003 and annually thereafter, there will be a decrease in the proportion of enrolled children in SCHIP who were unable to obtain needed medical care during the previous year as measured through a survey of enrolled families. 2.3 By June 30, 2003 and annually thereafter, at least 40% of children enrolled in SCHIP will have received a preventive dental service before age 8. Performance Measures for Strategic Objective 3: Ensure that children enrolled in SCHIP receive timely and comprehensive preventive health care services. .3.1 By June 30, 2004 and annually thereafter, at least 50% of the children who turned two years of age during the preceding year and were continuously enrolled in SCHIP will have received at least four well-child visits during the first 24 months of life. 3.2 By June 30, 2003 and annually thereafter, at least 40% of three through six-year- old children who were continuously enrolled in SCHIP during the preceding year will have received one or more well care visits with a primary care provider. 3.3 By June 30, 2003 and annually thereafter, at least 80% of two-year-old children enrolled in SCHIP will have received all age appropriate immunizations using the HEDIS measure definition. 3.4 By June 30, 2003 and annually thereafter, at least 50% of 13-year-old children enrolled in SCHIP will have received a second dose of MMR and the appropriate dose of Hepatitis B vaccine. 3.5 By June 30, 2003 and annually thereafter, at least 45% of eight-year-old children enrolled in SCHIP will have received a vision screening examination. Performance Measures for Strategic Objective 4: Insure the children enrolled in this Medicaid Expansion receive high quality health care services. 4.1 By June 30, 2004, the annual readmission rate for asthma hospitalizations among children enrolled in SCHIP will have decreased compared to the rate during the previous year. 4.2 By June 30, 2003 and annually thereafter, the average number of emergency room hospital visits will decline for children enrolled in SCHIP.

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

Effective Date: August 26, 2001 64 Approval Date:_______________ 4.3 By June 30, 2003, at least 80% of families with children enrolled in SCHIP who are surveyed will report overall satisfaction with their health care. Performance Measures for Strategic Objective 5: Improve health status among children enrolled in this Medicaid Expansion. 5.1 In order to track improvement in oral health hygiene, by June 30, 2003 and yearly thereafter, the average number of fillings for enrolled children age 6 through 18 who have been continuously eligible for the last 12 months will be reduced by 10% when comparing the first six months of eligibility to the last six months of eligibility for each calendar year. 5.2 By June 30, 2003, establish baseline quality indicators and measurement standards for enrolled children with a diagnosis of diabetes and by June 30, 2004 and annually thereafter, track improvements to ensure that the health status of these children improve over time. 5.3 In order to track improvements in the delivery of mental health services in the least restrictive setting, by June 30, 2003 and yearly thereafter, the rate of admissions for inpatient hospitalizations and the number of admissions and length of stay residential treatment services for enrolled children with mental illness will have decreased compared to the rate during the previous year. 5.4 In order to improve the overall health of enrolled children currently and into their adulthood, by June 30, 2003 develop baseline quality indicators and measurement standards for enrolled children with a diagnosis of obesity and by June 30, 2004 and annually thereafter, track improvement to ensure that the health status of these children improve over time. 9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state’s performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B) (42CFR 457.710(d))

Strategic Objective 1: Reduce the number of North Dakota children from birth to 19 years of age who are uninsured. The Department will compare the actual number of children enrolled in the Medicaid and Healthy Steps Programs with the number of children enrolled as of January 1, 2002. The Department will show that the percentage of uninsured children has decreased by about 5% based on the 1998 survey conducted in cooperation with the Robert Wood Johnson Foundation.

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

Effective Date: August 26, 2001 65 Approval Date:_______________ Strategic Objective 2: Improve access to health care services for North Dakota children enrolled in SCHIP. The Department will collect report data that will show how many eligible children have selected a primary care provider. The Department will conduct a survey on a periodic basis of families with children enrolled in the program to determine if families have access to needed care. The Department through evaluation of paid provider claims will identify those children who have received preventive dental care compared to those who have not received this service. Strategic Objective 3: Ensure the children enrolled in SCHIP receive timely and comprehensive preventive health care services. The Department will use information from our claims data and the immunization registry to track the age appropriate services and report how well the children are receiving the identified preventive services. Strategic Objective 4: Ensure the children enrolled in SCHIP receive high quality health care services. The Department will track and report the rate of readmissions for asthma hospitalization for enrolled children. The Department will track and report using claims data information on the trends in the use of emergency room services by enrolled children. The Department through the use of a family survey will determine the satisfaction level of medical services received by children enrolled in the Medicaid Expansion Program. Strategic Objective 5: Improve health status among children enrolled in SCHIP The Department through analysis of claims data will track children with a diagnosis of diabetes and obesity to determine if improvement in selected quality indicators have improved over time. The Department will track the number of dental fillings received by enrolled children and report results with the anticipation that regular dental care and proper oral hygiene will reduce the number of cavities in children over time. The Department will track children with mental illness diagnosis and report progress in the reduction of hospitalizations and residential treatment service admissions and lengthy of stay over time. Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4))

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

Effective Date: August 26, 2001 66 Approval Date:_______________ 9.3.1.

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2.

The reduction in the percentage of uninsured children. 9.3.3.

The increase in the percentage of children with a usual source of care. 9.3.4.

The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5.

HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6.

Other child appropriate measurement set. List or describe the set used. 9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as:

9.3.7.1.

Immunizations

9.3.7.2.

Well child care

9.3.7.3

Adolescent well visits

9.3.7.4.

Satisfaction with care

9.3.7.5.

Mental health

9.3.7.6

Dental care 9.3.7.7

Other, please list: Other areas of performance measurement include access to primary care, vision care, asthma inpatient hospital reductions, reduction in emergency room visits, quality improvement for children with diabetes and those with an obesity diagnosis.

9.3.8.

Performance measures for special targeted populations. 9.4.

The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720) 9.5.

The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750) The state assures that it will comply with the annual assessment and evaluation required under Section 10.1 and 10.2. The state will on an annual basis assess and evaluate the operation and effectiveness of this plan and report all findings to CMS by January 1 of each year. The data sources will include but are not limited to, claims data available through the decision support system obtained from Noridian Mutual Health

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

Effective Date: August 26, 2001 67 Approval Date:_______________ Insurance Company, other reports provided by Noridian, and other information available through the North Dakota Department of Human Services, the North Dakota Department of Health, the Indian Health Service, the Census Bureau and other entities who might have accurate data concerning the number of uninsured children residing in North Dakota. 9.6.

The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720) 9.7.

The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.135) 9.8. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135) 9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3.

Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4.

Section 1132 (relating to periods within which claims must be filed) 9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(A0 and (b))

During the last legislative session, the Healthy Steps program was thoroughly discussed including the use of a joint application for Medicaid and SCHIP. Any major changes concerning the operation of the Healthy Steps Program will require legislative approval. In North Dakota, the legislative process is open to anyone who wishes to testify on any bill and all bills must be voted on by the legislature. This process provides the citizens of North Dakota with ample opportunity to provide input before final action is taken by the legislature. In addition, the Department will provide an opportunity for public input whenever major changes in the state plan are finalized and before the plan is submitted for approval. Comments from all interested parties will be solicited either in writing or orally. These comments will be reviewed and considered prior to the submission of any substantial change to the state plan. Ongoing input from the public will continue. For example, a legislative interim committee is monitoring the State Children’s Health Insurance Program in North Dakota to determine if any changes need to be made in the future. Interim committee meetings are open to any interested party who wishes to provide input bout this program.

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

Effective Date: August 26, 2001 68 Approval Date:_______________ The Department will also utilize the Medical Care Advisory Committee which is made up of providers, advocates and recipients to provide input and advice regarding the ongoing operation of the Medicaid Expansion and the separate Healthy Steps Program. 9.9.1. Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c))

Whenever a major change in the state plan is anticipated, the Department will send a letter to the tribal chairman in each of the four Indian Reservations and one Indian Service Area. They will receive information about the proposed changes in the title XXI Program and will be requested to provide any written comments about the propose changes.

In addition, if requested, we will schedule informational meetings regarding the proposed changes at any Reservation or Service Area requesting a meeting. We will accept both written and oral comments from any interested party concerning the proposed changes. All comments received will be analyzed and considered prior to the submittal of any substantial change in the state plan. 9.9.2. For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided and required in 457.65(b) through (d).

Prior to any change in eligibility or benefits procedures are implemented, the Department will schedule a series of public meetings throughout the state. All interested parties will be invited to provide comments regarding the proposed changes. Written and oral comments will be accepted. The Department will analyze and consider all comments before implementing any changes that could adversely affect the eligibility or benefits of children currently enrolled in the program. 9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

Planned use of funds, including –

-Projected amount to be spent on health services;

-Projected amount to be spent on administrative costs, such as

outreach, child health initiatives, and evaluation, and

-Assumptions on which the budget is based, including cost per child

and expected enrollment.

Projected sources of non-Federal plan expenditures, including any

requirements for cost-sharing by enrollees.

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

Effective Date: August 26, 2001 69 Approval Date:_______________ Section 10. Annual Reports and Evaluations (Section 2108) 10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including : (Section 2108(a)(1),(2) (42CFR 457.750) 10.1.1.

The progress made in reducing the number of uncovered low-income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and 10.2.

The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e)) 10.3.

The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

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

Effective Date: August 26, 2001 70 Approval Date:_______________ Section 11. Program Integrity (Section 2101(a))

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 to Section 12. 11.1.

The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (section 2101(a)) (42CFR 457.940(b)) 11.2. The state assures, to the exteny they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6 – 9.8.9) 11.2.1.

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2.

Section 1124 (relating to disclosure of ownership and related information) 11.2.3.

Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4.

Section 1128A (relating to civil monetary penalties) 11.2.5.

Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6

Section 1128E (relating to the National health care fraud and abuse data collection program)

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

Effective Date: August 26, 2001 71 Approval Date:_______________ Section 12. Applicant and Enrollee Protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters 12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

Requirements for the processing of SCHIP applications in contained in North Dakota Administrative Code, Chapter 75-02-02.2. The state operates a program specific review process. The Department is required to promptly make an eligibility determination. In almost all cases the review is completed before the end of the month in which the Department receives the application.

The Department provides a written notice to each applicant whenever the department denies, suspends or terminates eligibility. The notice includes the effective date of the action taken, the reason for the action taken and the appeal rights available to the applicant. The appeal rights information includes information on filing a written appeal with the appeals supervisor within thirty days after the date of the notice of decision.

If a timely filed appeal is received, the department must conduct an administrative hearing in accordance with requirements outlined in 42 CFR 457.985. Health Services Matters 12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120.

North Dakota operates a statewide standard review process that is contained in Chapter 26.1-36-42 of the North Dakota Century Code that meets the requirements prescribed in 42 CFR 427.1120. This chapter requires all health insurance companies to establish and maintain a procedure for resolving complaints by covered persons regarding any aspect of the plan. In addition to the above statewide standard review, the department also permits enrollees that are dissatisfied with the final decision of the insurance carrier to appeal that decision to the department.

Premium Assistance Programs 12.3 If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

Not applicable in North Dakota.

NORTH DAKOTA TITLE XXI PROGRAM FACT SHEET

Name of Plan:

Healthy Steps Program

Date Plan Submitted:

July 24, 1998

Date Plan Approved:

September 28, 1998

Effective Date:

October 1, 1998

Date Amendment #1 Submitted: July 12, 1999 Date Amendment #1 Approved: November 12, 1999 Date Amendment #1 Effective: October 1, 1999

Date Amendment #2 Submitted: November 28, 2001 Date Amendment #2 Approved: February 25, 2002 Date Amendment #2 Effective: January 1, 2002

Date Amendment #3 Submitted: July 1, 2002 Date Amendment #3 Approved: September 27, 2002

Date Amendment #4 Submitted: October 28, 2005 Date Amendment #4 Approved: February 13, 2006 Date Amendment #4 Effective: July 1, 2005

Date Amendment # 5 Submitted: March 3, 2008 Date Amendment #5 Approved: April 10, 2008 Date Amendment # 5 Effective: September 1, 2007

Date Amendment # 6 Submitted: December 2, 2008 Date Amendment # 6 Approved: March 6, 2008 Date Amendment #6 Effective: October 1, 2008

Date Amendment #7 Submitted: June 23, 2009 Date Amendment #7 Approved: September 3, 2009 Date Amendment #7 Effective: July 1, 2009

Date Amendment #8 Submitted: July 7, 2010 Date Amendment #8 Approved: October 29, 2010 Date Amendment #8 Effective: October 1, 2009

Background

• On July 24, 1998, North Dakota submitted its title XXI State plan to expand Medicaid eligibility under title XXI for uninsured children who are age 18, whose family income is at or below 100 percent of the Federal Poverty Level (FPL).

Amendments

• On July 12, 1999, North Dakota submitted the first amendment to its title XXI State plan, to establish a separate child health program. The separate child health program covers children from age 5 with family incomes between 133 percent and 140 percent of the FPL and children age 6 through age 18 with family incomes between 100 percent and 140 percent of the FPL.

• On November 28, 2001, North Dakota submitted the second amendment to its title XXI State plan, which expanded eligibility in the Medicaid expansion program by eliminating the Medicaid assets test.

• On July 1, 2002, North Dakota submitted its third amendment. This amendment updates and amends the SCHIP state plan to indicate the State’s compliance with the final SCHIP regulations.

• On October 28, 2005, North Dakota submitted its fourth amendment. This amendment redefined certain eligibility standards related to income and residency. The amendment specifically revises the budget methodology to comply with state statute for determining adjusted gross income; adds new income disregards consistent with those in the Medicaid State plan; and redefines the state residency requirement, where the eligibility is now based on the child’s residence in the state rather than the parent(s).

• On October 28, 2005 North Dakota submitted its fourth amendment. The amendment was approved on March 10, 2006 and became effective on July 1, 2005. The implementation date was July 1, 2005. This change resulted in moving some families from the private coverage option to the Medicaid Program. These families were no longer subject to any co- payments and received access to the full array of Medicaid program benefits. These children were required to participate in the North Dakota Access to Care program and to select a primary care provider who can be a primary care physician, a rural health clinic, a Federally Qualified Health Center or the Indian Health Service. All services are paid using a fee for service process.

• On March 3, 2008, North Dakota submitted its fifth amendment. Effective on September 1, 2007 and implemented on September 1, 2007, this amendment made revisions to Section 4.1.3 on income deductions and disregards. It was effective on September 1, 2008 and implemented on October 1, 2008. It increased the top poverty level from 140% to 150% at which children could become eligible for SCHIP.

• On December 3, 2008, North Dakota submitted its sixth amendment. Effective and implemented on October 1, 2007, this amendment will make revisions to Section 4.1.3 page 19, regarding wages paid by the Census Bureau for temporary employment.

• On June 23, 2009, North Dakota submitted its seventh amendment. Effective July 1, 2009, this amendment increased the eligibility level from 150 percent of the FPL to 160 percent of the FPL.

• On July 7, 2010, North Dakota submitted its eighth amendment. Effective retroactively to October 1, 2009, the amendment establishes an alternative payment methodology for Federally Qualified Health Centers and Rural Health Centers. This is an amendment

designed to comply with a provision of the Children’s Health Insurance Program Reauthorization Act of 2009.

Children Covered Under the Program

• The State reported that 6,966 children were ever enrolled in its program during Federal fiscal year (FFY) 2009.

Administration

• The North Dakota Department of Human Services administers the Healthy Steps program.

Health Care Delivery System

• Children in the Medicaid expansion are enrolled in the North Dakota Access and Care Program, the Section 1915(b) freedom of choice waiver that requires most children and families to select a primary care provider (PCP) who delivers primary care and makes referral for other identified medical services. Providers are paid on a fee for service basis for delivering services to these children.

• In Grand Forks County, beneficiaries can choose between the current PCP program and the capitated Health Maintenance Program (HMO).

• In the title XXI separate child health program, children obtain services from a health insurance carrier indemnity program. The carrier must be able to provide statewide coverage for the benefit package based on a monthly premium for each child. Providers receive fee for service payment for services provided to beneficiaries.

Benefit Package

• The Medicaid expansion program provides the current Medicaid benefit package.

• The separate child health program provides a benefit package that is actuarially equivalent to the package available to North Dakota State Employees. The package is enhanced by the addition of a basic preventive dental and vision package. Additionally, it includes medical preventive services not offered by the Public Employee Retirement System Health Care Plan.

Crowd-Out Strategy

• In the separate child health program, the title XXI application, quarterly questionnaire and annual renewal forms all contain questions to obtain information regarding whether applicants have dropped insurance coverage during the last 6 months. The State uses these documents to monitor substitution of coverage. Children with health insurance coverage in the last 6 months are not eligible for Healthy Steps. Exceptions to the 6-month crowd-out period are made when the loss of health care coverage occurred because of no fault of the family.

Cost Sharing

• In the Medicaid expansion program, Medicaid rules apply and no cost sharing is imposed.

• CHIP enrollees in both the Medicaid expansion and the separate child health program pay no premiums.

• In the separate child health program copayments are applicable. The copayment schedule is as follows:

• $50 for the first day in an inpatient hospital or a psychiatric or substance abuse inpatient facility.

• $5 per visit to a hospital emergency room $2 for each allowable drug prescription.

• North Dakota exempts American Indian/Alaska Native (AI/AN) children from cost sharing.

• At the time of approval, families are informed of cost sharing responsibilities when they receive enrollment information that includes a handbook from the insurance carrier that provides coverage and other information including cost-sharing requirements.

State Outreach and Enrollment Activities

The Department of Human Services conducts the following activities:

• Works with economic assistance programs, such as TANF, and Food Stamps to identify children in families who are not eligible for Medicaid, but may be eligible for title XXI.

• Coordinates outreach and information through the Maternal and Child Health Programs (MCH) established throughout the State, both on statewide and local levels. A toll-free number is developed with the State MCH agency to answer questions related to title XXI.

• Distributes a bulletin to all Medicaid providers and professional medical and dental association discussing the Healthy Steps Program.

• Works with tribal leaders to develop outreach materials; the State Department of Instruction to identify local school districts; and the Department of Economic Development and Finance to provide information on the title XXI plan in meetings, flyers, grocery bags, milk cartons, etc.

• North Dakota also coordinates outreach activities with the Department of Public Instruction and local school districts, as well as through state and local businesses, local Head Start programs, advocacy groups, child care programs, religious groups, and written and network media.

Financial Information

Total FFY 2010 SCHIP allotment -- $16,595,628 FFY 2010 Enhanced Federal matching rate – 74.11%

Date Last Updated November 4, 2010

_____________________________________________________________________________ Table of Contents State/Territory Name: North Dakota State Plan Amendments (SPA) #: ND-18-0012-CHIP This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES : Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-01-16 q LY S Baltimore, MD 21244-1850

(CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

AUG 2 9 2019

Jodi Hulm

Administrator, Health Tracks and Healthy Steps

North Dakota Department of Human Services, Medical Services Division 600 East Boulevard Avenue, Department 325

Bismarck, ND 58505-0250

Dear Ms. Hulm:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA), ND- 18-0012-CHIP, submitted on June 29, 2018, with additional information submitted on August 22, 2019, has been approved. Through this SPA, North Dakota implements mental health parity requirements to ensure that treatment limitations applied to mental health (MH) and substance use disorder (SUD) benefits are no more restrictive than those applied to medical/surgical (M/S) benefits. This SPA has an effective date of October 1, 2017 with the exception of the changes described below.

Sections 2103(c)(7)(A) of the Social Security Act (the Act), as implemented through regulations at 42 CFR 457.496(d)(3)-(5), requires states that provide both M/S and MH/SUD benefits to ensure that financial requirements and treatment limitations applied to MH/SUD benefits covered under the state child health plan are consistent with the mental health parity requirements of section 2705(a) of the Public Health Service Act, in the same manner that such requirements apply to a group health plan. North Dakota demonstrated compliance by providing the necessary assurances and supporting documentation that the state’s application of non- quantitative treatment limitations (NQTLs) and financial requirements to MH/SUD benefits are consistent with section 2103(c)(7)(A) of the Act.

In order to comply with parity requirements, the state’s managed care organization (MCO) made the following NQTL policy changes:

e Effective July 1, 2018, the MCO adopted InterQual guidelines for MH/SUD benefits, which are already applied to M/S benefits.

e Effective January 1, 2019, pre-certification of in-network inpatient and outpatient MH/SUD benefits is no longer required. Instead, retrospective reviews are applied to all MH/SUD inpatient admissions, consistent with the policies applied to inpatient M/S admissions.

This SPA approval relates only to benefits provided under the CHIP state plan; Medicaid benefits will be analyzed separately.

Page 2 — Ms. Jodi Hulm

Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: $2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

E-mail: Joyce.Jordan@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Jordan and to Mr. Richard Allen, Director, Division of Medicaid Field Operations West. Mr. Allen’s address is:

Centers for Medicare & Medicaid Services

1961 Stout Street

Room 08-148 Denver, Colorado 80294

If you have additional questions, please contact Amy Lutzky, Director, Division of State Coverage Programs at (410) 786-0721.

We look forward to continuing to work with you and your staff. Sincerely,

/signed Anne Marie Costello/

‘Aine Marie’Costello” ~ Director

ce: Mr. Richard Allen, Director, Division of Medicaid Field Operations West

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

Effective Date: August 26, 2006

1 Approval Date: _________________

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available; we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Form CMS-R-211

OMB #: 0938-0707 Exp. Date:

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

Effective Date: August 26, 2006

2 Approval Date: _________________

(This page left intentionally blank.)

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

Effective Date: 7-1-2011

3 Approval Date: _________________ Supersedes Effective Date: 8-26-2006

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory: North Dakota As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b)) (Signature of Governor, or designee, of State/Territory, Date Signed) submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department. The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Maggie D. Anderson Position/Title: Director, Medical Services Name: Jodi Hulm

Position/Title: Healthy Steps Program Administrator Name:

Position/Title: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

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

Effective Date: August 26, 2006

4 Approval Date: _________________

Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1.

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR 1.1.2.

Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR 1.1.3.

A combination of both of the above. 1.2

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d)) 1.3

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130) 1.4 Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65): Original SCHIP State Plan Date Plan Submitted: July 24, 1998 Date Plan Approved: September 28, 1998 Effective Date: October 1, 1998

State Plan Amendment #1 –Establish Separate Child Health Program. Effective Date: October 1, 1999 Implementation Date: October 1, 1999

State Plan Amendment #2 – Expand Eligibility, Eliminate Assets Test. Effective date: January 1, 2002 Implementation date: January 1, 2002;

State Plan Amendment #3 –Compliance Plan. Approval Date: September 27, 2002

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

Effective Date: August 26, 2006

5 Approval Date: _________________

State Plan Amendment #4 - Amended Section 4. Effective date: July 1, 2005 Implementation date: July 1, 2005

This change will result in moving some families from the current private coverage option to the Medicaid Program. It will be advantageous to these families because they will no longer be subject to any co-payments and will have access to the full array of Medicaid program benefits that are more generous than the current private insurance option.

These children will be required to participate in the North Dakota Access to Care program. Each will be required to select a primary care provider who can be a primary care physician, a rural health clinic, a Federally Qualified Health Center or the Indian Health Service. The primary care provider will provide direct primary care and make referrals for specialty care and other specified medical services. All services are paid using a fee for service process. In addition, children residing in Grand Forks County may also select the “capitated” health plan known as AltruCare. The Department makes a monthly per member per month payment to this managed care plan who provides all appropriate medical services contained in the contract. Services not covered in the contract are covered through the regular fee for service payment process.

State Plan Amendment #5 – Amended Section 4.

Effective date: September 1, 2007 Implementation date: September 1, 2007

This amendment made revisions to Section 4.1.3 on income deductions and disregards.

Effective date: October 1, 2008 Implementation date: October 1, 2008

Increase Poverty Level from 140% to 150%.

State Plan Amendment #6 – Amended Section 4.

Effective date: October 1, 2008 Implementation date: October 1, 2008

This amendment will make revisions to Section 4.1.3 page 19, regarding wages paid by the Census Bureau for decennial temporary employment.

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

Effective Date: 07-01-2014 6 Approval Date:

Supersedes Effective Date: 07-01-2012

State Plan Amendment #7 – Amended Section 4.

Effective Date: July 1, 2009 Implementation Date: July 1, 2009

Increase Poverty Level from 150% to 160%.

State Plan Amendment #8 – Amended Section 4.

Effective Date: October 1, 2009 Implementation Date: October 1, 2009

Alternate Payment Methodology with FQHCs and RHCs.

State Plan Amendment #9 – Amended Section 6

Effective Date: July 1, 2011 Implementation Date: July 1, 2011

Add orthodontia services. Remove limits on mental health and substance abuse services. Update quality measures.

State Plan Amendment #10 – Amended Section 4

Effective Date: July 1, 2012 Implementation Date: July 1, 2012

This amendment implements provisions for temporary adjustments to redetermination policies for children in families living or working in Governor or federally declared disasters areas.

State Plan Amendment #11

Effective Date: July 1, 2014 Implementation Date: July 1, 2014

This amendment updates services based on a new contract.

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

Effective Date: August 26, 2001 7 Approval Date: ______________

State Plan Amendment #12

Effective Date: October 1, 2017 Implementation Date: October 1, 2017

This amendment incorporates the Mental Health Parity and Addiction Equity Act (MHPAEA) section.

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. TN No:

18-0100 Effective Date: October 1, 2017 Implementation Date: October 1, 2017

A letter was sent to all tribal leaders on June 8, 2018 describing the MHPAEA SPA that the state of North Dakota will be submitting to CMS. The tribal consultation letter was also posted on the Department of Human Services website on June 8, 2018.

Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B)) 2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a)) The Department has used a 1998 survey of the uninsured conducted in conjunction with the Robert Wood Johnson Foundation to estimate the number of insured and uninsured children in North Dakota. While this data is now more than three years old, it remains the most reliable information for North Dakota at this time. We have considered the use of other national data sources but have found that due to sampling errors for small states much of the information is not accurate. For example, the U.S. Census Bureau Health Insurance Coverage Status indicates that the number of children under 18 years of age in 2000 was 127,000. The actual 2000 census data indicates that North Dakota has 160,849 children under 18 years of age. This is a significant difference of more than 26%. This also makes suspect the number of insured and uninsured children because the sampling error for total number of children will also affect the estimated number of children without health insurance. For the above reason we will continue to utilize the 1998 survey as an estimate of the number of uninsured children in North Dakota until a more accurate national survey tool

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

Effective Date: August 26, 2001 8 Approval Date: ______________

becomes available for small population states. The following table provides information on the number of children 0 through 18 years of age residing in North Dakota in 1998, the number who were uninsured, the total number of insured, the number insured by Medicaid and the number of children insured by private plans. As noted above, the data was obtained through a 1998 survey that was conducted under the auspices of the Robert Wood Johnson Foundation Family Survey.

1998 Insured and Uninsured North Dakota Children by Poverty Level, Age, and Race/Ethnicity

Demographic Subgroups

Population Distribution

Number of Insured Children*

Number of Uninsured Children

Number of Children with Unknown Status

Number Insured by Medicaid

Number Insured by Private Plans

Number Covered by HIS, Military and Other 1998 North Dakota Population 175,822 160,448 14,633 710 14,833 134,791 24,131 Household Poverty Level Unknown <100 100% - 133% 134% - 200% Overall 200% Total Children <=18

16,004 17,689 16,011 32,868 93,250

13,951 14,448 12,920 29,309 89,820

1,754 2,975 3,091 2,558 3,285

299 266 0 0 145

1,186 7,694 3,122 1,881 950

11,435 5,253 7,250 25,534 85,319

2,031 4,664 4,701 5,014 7,721 Age Group Less than 1 Year 1 to 5 Years 6 to 12 years 13 to 18 Years Total Children <=18

7,265 38,992 66,971 62,594

6,905 35,673 59,976 57,894

231 3,203 6,818 4,411

129 115 177 289

1,029 4,791 6,271 2,742

5,467 28,501 50,189 50,634

818 5,408 8,567 9,338 Race/Ethnicity Unknown White Black Native American Asian/Pacific Islander Other Total Children <=18

838 158,462 1,742 11,832 832 2,116

607 144,641 1,684 11,157 832 1,527

199 13,200 58 675 0 531

32 620 0 0 0 58

30 9,995 475 3,904 90 339

295 128,532 856 3,751 599 758

314 13,545 759 8,831 190 492

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

Effective Date: August 26, 2001 9 Approval Date: ______________

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

Effective Date: August 26, 2001 10 Approval Date: ______________

The survey indicates that 14,663 children where uninsured in 1998. Of that number, 2,975 children resided in families with income below 100% of the poverty level and 6,649 children resided in families with incomes between 100% and 200% of the federal poverty level. At the time Phase II of the State Children’s Health Insurance Program was implemented in North Dakota on October 1, 1999, a total of 20,516 nondisabled children were enrolled in the Medicaid Program. As of May 31, 2002, the number of enrolled non-disabled children had increased to 22,916, an increase of 11.7% or 2,400 children. In addition, a total of 2,452 children were eligible for Phase II, Healthy Steps, of the Title XXI program. Therefore, after 31 months an additional 4,852 children or an increase of 16.3% were covered through Medicaid or Healthy Steps. While the exact number of uninsured is unknown at this time because of the imprecise national data available to small states, the fact that 4,852 additional children have coverage when the number of children in North Dakota is declining indicates that the two programs have experienced success in reducing the number of uninsured children in North Dakota. PUBLIC HEALTH COVERAGE The Medicaid Program remains the primary public health insurance program available for families in North Dakota. It provides an array of services to individuals and families, who are eligible through the 1931 provision, individuals who are aged, blind or disabled and receive Supplemental Security Income if they meet 209b criteria established by the Department of Human Services. Coverage is also provided for children in foster care and subsidized adoption. In addition, aged, blind and disabled individuals and children and certain caretakers in families who have sufficient income to meet their basic maintenance needs, as defined by the State, (Medically Needy) may be eligible for Medicaid. North Dakota also provides poverty level coverage for pregnant women and children under 6 years of age in families with adjusted net income at or below 133% of the federal poverty level and children 6 through 18 years of age with adjusted net income at or below 100% of the federal poverty level. This group also includes 18-year-old children who are eligible for Medicaid by virtue of the initial SCHIP Medicaid expansion that was approved in October 1998. Children, adult caretakers and pregnant women who are enrolled in Medicaid through the 1931 provision, poverty level, medically needy or SCHIP expansion categories are required to choose a primary care provider who delivers primary care services and makes referrals for many of the other medical services available through the program. Primary Care Providers receive a monthly administrative fee for managing care and providers receive a fee for service payment for services provided to Medicaid recipients.

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

Effective Date: 8-26-2001 11 Approval Date: ______________

In Grand Forks County, children in the above named categories are required to choose between the Primary Care Provider Program and a capitated Health Plan. As of July 1, 2001 a total of 18,500 children were enrolled in the Primary Care Provider Program and 365 children were enrolled in the Health Plan. Beginning on January 1, 2002, the asset test for Medicaid was eliminated for the children and family coverage groups. Children in families with income within the Medicaid eligibility guidelines that were previously eligible for Healthy Steps because family assets exceeded the Medicaid limits are now eligible for the Medicaid Program. These children are included within the SCHIP Medicaid Expansion Group that was approved by CMS. The second public program available to children is the Healthy Steps Program, Phase II of SCHIP in North Dakota. It provides private insurance coverage to about 2,450 children whose family net adjusted income is at or below 140% of the federal poverty level and who are not otherwise eligible for the Medicaid Program. The benchmark insurance coverage for this group is the coverage available for State Employees plus preventive dental and vision coverage. The insurance contractors make payments on a fee for service indemnity basis. PUBLIC PRIVATE HEALTH INSURANCE PARTNERSHIPS While not considered a true public/private partnership, the Department does cooperate with Blue Cross/Blue Shield of North Dakota who operates the Caring Program. This program provides limited health and dental coverage to children who are not eligible for Medicaid or Healthy Steps and have gross family income under 200% of the poverty level. Premiums for coverage come from corporate and private donations. If children are not eligible for Medicaid or Healthy Steps, the family is referred to the Caring Program for possible enrollment in that program. Conversely, the Caring Program will encourage families to apply for Medicaid or Healthy Steps if families who apply to that program appear eligible for the two government programs. 2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b)) 2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance): The following are the steps being taken to identify and enroll children who are eligible to participate in the North Dakota Medicaid Program and the Healthy Steps Program.

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

Effective Date: 9-01-2007 12 Approval Date: ________________ Supersedes Effective Date: July 1, 2005

The Department has established partnerships with numerous other state and local programs that serve children and families. In addition, the Department has reached out to other public health programs to find children who may be eligible for public health programs. The North Dakota Medicaid and Healthy Steps programs, Women, Infants and Children Program, (WIC), Community Healthcare Association, Maternal and Child Health (MCH), Immunization, Health Passport Smart Card Project, Optimal Pregnancy Outcome Project (OPOP) and the Children’s Special Health Services (CSHS) have a statewide interagency agreement that allows exchange of information and coordination both on the state and local levels. This agreement allows the state to share common information that encourages easier access to services, such as eligibility information on behalf of children’s health.

Public Health Programs - All 53 counties in North Dakota have local public health units that are enrolled Medicaid Providers. This gives them a direct link to the Medicaid program as providers and connects them to the local county social service offices that determine eligibility. If a child is referred and determined ineligible for Medicaid, the public health clinic refers them to other appropriate programs. WIC - All local WIC programs are required to refer all potentially eligible recipients to Medicaid. Current WIC guidelines also denote Medicaid income guidelines. Those not participating in Medicaid, but appear potentially eligible are given program information along with the telephone numbers for referral to the nearest county social service agency. WIC will also make referrals to the Healthy Steps Program if families are not eligible for Medicaid. Other state WIC program mandatory contacts include County Social Service Agencies, Homeless and Ministerial health providers, Substance Abuse Centers, Food Pantries, Public Health Units and Indian and Migrant Health Services. Children’s Special Health Services (CSHS) - The CSHS program conducts a variety of outreach and enrollment activities through a network of state and local staff. The CSHS program serves children who may have a chronic or disabling condition. Medicaid and Healthy Steps status is monitored on the 1,700 children served through all areas of the program. For the 500 to 600 children served through the diagnostic and treatment programs, Medicaid eligibility is automatically checked. For children who are not eligible for Medicaid or private insurance, CSHS will link families to other resources such as Healthy Steps, Caring Program for Children and SSI. The Caring Program for Children - Is a private initiative administered by Blue

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

Effective Date: 7-01-2011 13 Approval Date: ________________ Supersedes Effective Date: 09-01-2007

Cross/Blue Shield that provides basic health coverage to children aged 18 and under. The program covers its costs with private donations. The Caring Program will refer families to Medicaid or Healthy Steps if individuals appear eligible for either program. Medicaid and Healthy Steps eligibility workers make referrals when a family is not eligible for those two programs. Rural Health Clinics (RHC's) - North Dakota has approximately 110 Medicaid enrolled Rural Health Clinics that includes border state providers from Montana, South Dakota and Minnesota. The RHC's provide services on a sliding fee scale. Referrals are made to local county social service agencies if a family appears eligible for Medicaid and to the Department of Human Services if the family appears eligible for Healthy Steps. Federally Qualified Health Center (FQHC) - North Dakota has one designated federally qualified health center in Fargo. The FQHC conducts a financial screen to determine when to refer to other public health insurance programs such as Medicaid and Healthy Steps. Family Planning Clinics – Family Planning Clinics refer clients to appropriate providers for necessary services that are outside the scope of their practice. Included are referrals for clients in need of primary and preventive services and those who may be eligible for Medicaid, Healthy Steps, WIC and OPOP. Indian Health Services (IHS) - There are four IHS facilities and one Indian Service Area facility in North Dakota. Each site uses a benefits coordinator to identify and refer potentially eligible children and families to the Medicaid and Healthy Steps Programs. IHS staff receive training designed to identify families who may need referral to other health care programs including Medicaid and Healthy Steps. This allows families to access health care information at different entry points within the IHS system at different times. Continued training occurs between the Department and Benefits Coordinators at Reservation sights. Optimal Pregnancy Outcome Program (OPOP) - OPOP is a primary prevention program designed to empower pregnant women to make informed health and lifestyle choices for healthy babies. There are 10 OPOP sites in North Dakota. All sites are Medicaid enrolled providers and deliver nursing, dietitian and other appropriate health services to pregnant women. Target populations include pregnant adolescents who may be considered high risk. As part of the OPOP intake process, insurance status is identified and referrals made to the Medicaid or Healthy Steps Programs. Healthy Start of North Dakota – The Healthy Start program is a Native American case management program located on the four reservations and the one area service unit in North Dakota. The program is

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

Effective Date: 9-01-2007 14 Approval Date: ________________ Supersedes Effective Date: July 1, 2005

intended to prevent infant mortality in these areas and is funded by a federal grant. Part of the intake assessment for services of this program is to determine if there is Medicaid or Healthy Steps eligibility. The Healthy Start programs are enrolled Medicaid providers who provide certain services through Medicaid. Healthy Start has established referral protocols for both Medicaid and Healthy Steps as part of their case management activity to high-risk pregnant women. Migrant Health Centers – Migrant Health Centers are located along the North Dakota/Minnesota border and they provide health services to seasonal migrant families. The health centers refer families to the local county social service agencies if it appears they may meet Medicaid eligibility guidelines or refer them to the Healthy Steps enrollment office if appropriate. Head Start Programs - Local Head Start programs review income and insurance status of all children who apply for that program. They specifically ask if a child is Medicaid eligible. If the family is not currently enrolled, Head Start will refer the family to the local county social service office for an eligibility determination for Medicaid. Head Start also makes referrals to Healthy Steps and the Caring Program for Children if income is above Medicaid income guidelines. 2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public- private partnership: North Dakota does not have any public/private health insurance programs operating at this time. 2.3. Describe the procedures the state uses to accomplish coordination of CHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c)) The only other public health insurance program available to citizens of North Dakota is Medicaid. We also coordinate outreach efforts with the Caring Program for Children operated by Blue Cross/Blue Shield of North Dakota. Strategies to coordinate Medicaid with Healthy Steps include the following:

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

Effective Date: 7-01-2014 15 Approval Date: ________________ Supersedes Effective Date: 7-01-2011

1. As of May 1, 2002, a joint application for Medicaid and Healthy Steps has been developed and is available to applicants. The application is designed to be used for all Medicaid children and family coverage groups including adults and the stand alone SCHIP Healthy Steps Program. In addition, we will continue to utilize the Healthy Steps only application but will no longer be printing any additional forms. When the Department receives an application, it is screened to determine if potential Medicaid eligibility exists. The family receives a notice that the application has been forwarded to the appropriate county social service board office that determines Medicaid eligibility. The Department sends all pertinent information to the appropriate county office. That office reviews the application and makes the final decision regarding Medicaid eligibility. 2. Supplying local county social service offices that determine Medicaid eligibility with outreach materials regarding the Healthy Steps Program. 3. Conducting statewide training forums for outreach partners including county staff who determine Medicaid eligibility. 4. Make referrals to the Caring Program if families are not eligible for Medicaid or Healthy Steps. 5. Through cooperative agreements, work closely with other agencies who have an interest in uninsured children such as the Title V Program to share information and coordinate outreach activities for all public insurance programs and the Caring Program. (Additional details regarding these relationships are detailed in 2.1 above). 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 stand alone CHIP in North Dakota provides a comprehensive array of services through a contract with Blue Cross and Blue Shield of ND (BCBS) and Delta Dental of Minnesota (DDMN) . These companies were chosen to pay for necessary medical, dental and vision services through a competitive Request for Proposal process. BCBS is the primary health insurance entity doing business in North Dakota. They cover more than 50% of all insured individuals in North Dakota. They have an extensive provider network throughout North Dakota. For this reason children eligible for Healthy Steps have excellent access to the services covered under the plan. On July 1, 2013 a new contract with Delta Dental of Minnesota was initiated for dental coverage

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

Effective Date: 7-01-2013 16 Approval Date: ________________ Supersedes Effective Date: 7-01-2011

for the Healthy Steps children’s population in North Dakota. As of May, 2014 there are currently 365 unique dentists providing care for this population, and 541 access points throughout the state. Recruitment will continue throughout 2014 to increase the number of providers participating in this program. Delta Dental of Minnesota reaches out to provider offices in a variety of ways including personal office visits to help maintain and grow the number of participating dentists in this important program. The contract is an indemnity product based on a monthly premium that is actuarially certified every year. The fee structure used by BCBS and DDMN is identical to what is used to pay for its other commercial insurance coverage. We have executed three separate contracts for medical, dental and vision coverage. The contracts detail the responsibilities of the insurance companies to pay for all approved services in accordance with contract provisions. All non-covered services and limits on services are delineated in the contract and are made available to each enrolled family through coverage handbooks provided by the contractors. The contracts include language that access to medical services must be available 7 days a week, 24 hours a day and requires the carrier to monitor access, service delivery, client satisfaction and quality assurance for enrollees. Surveys conducted by the contractors indicate excellent client satisfaction with the program. 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 contractors for the Healthy Steps program performs utilization management functions approved by the department for the fee for service payment process. These functions will ensure that children receive health care that is appropriate, medically necessary and delivered in a cost effective and efficient manner. The contractors conducts quality and utilization reviews that determine if services provided are medically necessary including but not limited to relationship edits for procedure and diagnosis codes. Any improper claims are denied and where appropriate overpayments will be recouped for claims that have already been paid. The contractors conducts physician profiling. This process reviews the utilization of services of like specialties across the state. Each specialty is severity adjusted. A comparison and efficiency index is assigned on an episode case basis. If a physician is not within the normal limits of care provided within the specialty group as compared to peers, a review is conducted and if appropriate, an audit is conducted to determine if the services billed are medically necessary.

Section 4. Eligibility Standards and Methodology. (Section 2102(b))

Check here if the state elects to use funds provided under Title XXI only to provide

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

Effective Date: 7-01-2009 17 Approval Date: 9-4-2009 Supersedes Effective Date: 9-1-2007

expanded eligibility under the state’s Medicaid plan, and continue on to Section 5. 4.1 The following standards may be used to determine eligibility of targeted low- income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102(b)(1)(A)) (42 CFR 457.305(a) and 457.320(a))

4.1.1

Geographic area served by the Plan: The plan is available to all eligible children on a statewide basis.

4.1.2

Age: The plan is available to children zero through 18 years of age. Coverage for children who are 18 years of age will continue through the end of the month in which they turn 19 years of age. 4.1.3

Income:

Healthy Steps program will cover children whose family adjusted gross income is no more than 160% of the federal poverty level.

Financial responsibility will be based on spouse for spouse and parents for children. The income of the spouse and parents are considered available to the child. Natural and adoptive parents, but not stepparents are treated as parents. Under North Dakota law, a stepparent has no legally enforceable obligation to support stepchildren. Therefore, the stepparent’s own personal income cannot be considered available in determining Healthy Steps eligibility for a stepchild. To determine eligibility, the stepparent’s net income must first be applied against the appropriate income level for the stepparent, spouse and the stepparent’s children or children in common. If the stepparent’s income is adequate to meet their needs, the natural parent’s net earned income is considered in relation to the children for whom the Healthy Steps application is being made. Except as noted below, all earned income of each family member is in a Healthy Steps household must be counted when calculating adjusted gross income including, but not limited to, wages, salaries, commissions, tips, self-employment income and income received under a contract. Except as noted below, all gross income of each family member of a Healthy Steps household must be counted when calculating adjusted gross income. The following income is excluded from family income:

1. Income which is required to be excluded under other federal statues and by Public Law;

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

Effective Date: 9-1-2007 18 Approval Date: ________________

2. Occasional small gifts; 3. In-kind earned income, except in-kind income received in lieu of wages; 4. Educational loans, scholarships, grants, awards, Workforce Safety & Insurance vocational rehabilitation payments, fellowships or gifts used to 767 pay the cost of tuition and fees at educational institutions, and work study received by a student. A student is described as an individual who regularly attends and makes satisfactory progress in an elementary or secondary educations environment, college, university, vocation or trade school. A child must be a student at the time of application or if the application occurs during a summer vacation period must intend to return to school in the fall; 5. Income earned by a child who is a full-time student or a part-time student who is not employed more than 100 hours per month. Student status must be established as described in paragraph four of this section; 6. Money payments made by the Department of Human Services including foster care or subsidized adoption, subsidized guardianship, temporary assistance for needy families payments, vocational rehabilitation training funds, family subsidy program and the low income home energy assistance program; 7. Loans from any source that are subject to a written agreement requiring repayment by a household member; 8. Payments from the Child and Adult Food Program for meals and snacks to licensed families who provide day care in their home; 9. County General Assistance payments; 10. Income Tax refunds; earned income credits or homestead tax credits; 11. Non-recurring unearned lump sum payments; 12. Needs-based payments, support services, and relocation expenses provided through programs established under the Workforce investment Act (WIA), and through the Job Opportunities and Basic Skills program; 13. Housing allowance received from United State Department of Housing and Urban Development or rent supplements or utility payments provided through the housing assistance program;

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

Effective Date: 9-01-2005 19 Approval Date: ____________ Supersedes Effective Date: July 1, 2005

14. Refugee cash assistance or grant payments; 15. Americorps income other than the living allowance portion; 16. Income of an individual living in the parental home if the individual is not included in the Healthy Steps unit; 17. Extra checks received by individuals who are paid weekly or bi-weekly; 18. Supplemental Security Income (SSI); 19. Compensation received by volunteers participating in the action program as stipulated in the Domestic Volunteer Service Act of 1973, including foster grandparents, older American Community Service program, Retired Senior Volunteer Program, Service Corps of retired Executives, Volunteers In Service to America (VISTA), and University Year for Action; 20. Payments made to recipients under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970; 21. All income, allowance, and bonuses received as a result of participation in the Job Corps Program; 22. Payments received for the repair or replacement of lost, damaged, or stolen assets, 23. The Medicare Part B premium refunded by the Social Security Administration; 24. Training allowances of up to thirty dollars per week provided through a tribal native employment works program, or the Job Opportunities and Basic Skills Training program; 25. Training stipends provided to victims of domestic violence by private, charitable organizations, for attending their educational programs; 26. Crime Victims Reparation payments; 27. Assistance received under the Disaster Relief and Emergency Assistance Act of 1974 or some other Federal statute, because of a presidentially declared disaster (but not disaster assistance unemployment compensation), and interest earned on that assistance;

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

Effective Date: 7-01-2009 20 Approval Date: 9-4-2009 Supersedes Effective Date: 10/1/2008

28. The first $2,000 per year of lease payments deposited in IIM accounts; 29. Interest or dividend income earned on liquid assets; 30. Additional pay received by military personnel as a result of deployment to a combat zone; 31. Up to fifty dollars per family, per month, of current child support received on behalf of children in the Health Steps unit; 32. Reimbursement from an employer, training agency or other organization for past or future training, or volunteer related expenses ; and 33. All wages paid by the Census Bureau for temporary employment related to decennial census activities. Income Standard: Adjusted gross countable family income must be equal to or less than 160% of the federal poverty guidelines based on family size. Calculating Adjusted Gross Income: After all countable gross income is determined; the following adjustments will be allowed to determine the adjusted gross income for each Healthy Steps household: 1. For family members with earned income, the actual mandatory payroll deductions including federal, state and social security taxes mandatory retirement and mandatory union dues, or $90 per month, whichever is greater. 2. Reasonable child care expenses, not otherwise reimbursed by other third parties if necessary to engage in employment or training. 3. Court ordered child and spousal support payments if actually paid by a member of the family on behalf of an individual who is not a member of the Healthy Steps household. 4. With respect to each individual in the unit who is employed or in training, $30 may be deducted as a work or training allowance, but only if the

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

Effective Date: 10-01-2008 20a Approval Date: ____________ Supersedes Effective Date: 9/01/2007

individual’s income is counted in the eligibility determination. 5. The cost of premiums for health insurance may be deducted in the month paid or prorated and deducted in the months for which the premium affords coverage. 6. the cost of medical expenses for necessary medical or remedial care for members of the unit who are not eligible for Health Steps coverage. Determination of Adjusted Income for Self-Employed Individuals: The following method will be used to calculate adjusted gross income for self-employed individuals as prescribed by State statue. 1. For all self employed individuals, calculate the average net income after expenses based on either the average of the previous three years of adjusted gross income or the previous year’s adjusted gross income, whichever is most advantageous to the applicant, which means the adjusted gross income as computed for an individual for Federal Income Tax purposes under the Internal Revenue Code. If a household has been in business for less than three consecutive years, use the actual number of year(s) the individual was in business and calculate the average yearly income. If the family is currently self employed, but has not previously filed any self employment Federal Income Tax report in the last year, use the best information available to calculate estimated revenue and business expenses to calculate adjusted gross self- employment income.

Budgeting: The department shall determine family income prospectively for each 12-month certification period at the time of application and at each renewal to determine if eligibility can continue. Gross countable income of all family members is counted as family income. An adjusted gross income amount is then calculated based on the disregards and deductions described previously. Unearned income that is received less often than monthly will be prorated over the months the income is intended to cover

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

Effective Date August 26, 2001 21 Approval Date:_______________

to determine average monthly income. Earned income that is intended to cover more than one month will be prorated over Farm and other self-employment income will be divided by 12 to determine the monthly income for the upcoming certification period. If an individual started a business in the previous year that did not cover an entire year, the pro-ration of the monthly income will be based on the actual number of months the business operated during the previous year. If a family has self-employed income and other earned or unearned income, the two must be added together to arrive at total adjusted gross income. The monthly income from self-employment income should first be calculated. If the average self-employment income is a negative amount, that amount will be subtracted from other earned or unearned income to arrive at total adjusted gross income.

4.1.4. Resources (including any standards relating to spend downs and disposition of resources): There will be no resource test for Healthy Steps eligibility.

4.1.5. Residency (so long as residency requirement is not based on length of time in state):

1. To be eligible to receive Healthy Steps benefits, an individual must be a citizen of the United States or a qualified alien as defined in Public Law 104-193 (401) through (423), (431) and (435), and amended by Public Law 105-33 (5302)(b) and (c), (5303), (5305)(b), (5306), (5562), (5563) and (5571). 2. A qualified alien as defined in Public Law 104-193, as amended, may receive Healthy Steps insurance coverage. 3. Unless ineligible for benefits under section 403 of Public Law 104- 193, as amended, a qualified alien may receive Healthy Steps insurance coverage after five years have passed from the child’s date of entry into the United States, if the child can be credited with 40 qualifying quarters of social security coverage. State Residency: 1. To be eligible to receive benefits from Healthy steps, a child must

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

Effective Date August 26, 2001 22 Approval Date:_______________

be a resident of the state of North Dakota. 2. An individual is considered a resident of North Dakota if they are temporarily absent from North Dakota for purposes of employment, schooling, vacation or medical treatment. 4.1.6 Disability Status (so long as any standard relating to disability status does not restrict eligibility): Disability is not a determining factor when establishing eligibility for Healthy Steps and coverage will be provided to children no matter what type of disability or medical condition a child may have. 4.1.7 Access to or coverage under other health coverage: A child who is covered under a group health plan or a single family plan or under other health insurance coverage including coverage which is available through a parent’s or legal guardian’s employer, as defined by HIPAA, is ineligible for Healthy Steps insurance coverage. A child will not be eligible if the parent of the child is a State employee unless the parent does not have access to State health insurance coverage. Any child that meets current Medicaid eligibility criteria is not eligible for Healthy Steps except that children who would otherwise be eligible for the medically needy program with a recipient liability, the family may choose to enroll in the Healthy Steps program. 4.1.8

Duration of eligibility: The eligibility period in accordance with State law will begin the first day of the month following the date eligibility is established and will end on the last day of the 12th calendar month after the month in which enrollment in Healthy steps started or the end of the month a child reaches its 19th birthday or the family acquired credible health insurance coverage for the child or a child no longer resides in the household. Any subsequent eligibility period will continue for 12 calendar months.

4.1.9

Other standards (identify and describe): Household Composition: 1. The following individuals who reside together are included in a household when determining the size of a household and the income to be counted whether or not a household member is actually eligible to receive Healthy steps benefit coverage.

a. A natural child, adopted child, or step-child age 0 through 20 years of age, and the family size is increased for each unborn when determining the appropriate household size; b. Parents of any child identified in “a” above; c. Children of any child identified in “a” above. 2. Any individual identified in paragraph 1 who is temporarily absent from the household by reason of employment, school, training, or medical treatment will be considered as a member of the household.

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

Effective Date: 07-01-2012 24 Approval Date: _______________ Supersedes Effective Date: 07-01-2011 3. If an adult is providing care to an unrelated child of a divorced, separated, or deceased spouse, the household may include the child if the child is expected to continue to reside in the household, and meets age requirements outlined in paragraph “a”. 4. Children who are inmates of public institutions or children who are residing in Institutions for Mental Diseases will be denied coverage under the Healthy Steps program, at application and redetermination. Parents are allowed to opt any child out of the household if that child’s income causes other children in the household to fail eligibility. 4.4 Describe the procedures that assure that: 4.4.1 Through the screening procedures used at intake and follow-up eligibility determination, including any periodic predetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health insurance assistance under the state child health plan. (Section 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42 CFR 457.350(a)(1) (42CFR 457.80(c)(3)) When an application is received, verified income and deduction information is entered into the eligibility computer system, which first determines whether the children are Medicaid eligible. If the results indicate that any of the children are eligible for Medicaid, Healthy Steps eligibility is not pursued for those children unless the children are Medicaid eligible with a recipient liability, in which case the family is given a choice as to which program they want coverage under. Healthy Steps eligibility is pursued for all other children.

The joint application requests information regarding any current health care coverage a family may have available to them. If the applicant indicates that the children have creditable health care coverage, they are denied coverage under the Healthy Steps Program.

If an application is received from a family who has a family member employed with the State of North Dakota, the application will be denied for Healthy Steps unless it can be documented that the family is not eligible to participate in the coverage offered to state employees. In those instances where benefits are not offered to temporary or other similar employees, families will be allowed to participate in the Healthy Steps Program if they otherwise meet all other eligibility criteria. Approximately 35 days before the end of the eligibility period, each eligible family is mailed a renewal asking for income information and any other changes that could affect continued eligibility. Information received is entered into the eligibility computer system, which follows the same eligibility determination process as at application. 4.4.2 The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102(b)(3)(B)) (42 CFR 457.350(a)(2)) As noted in 4.4.1 above, eligibility for Medicaid is determined without the need for a separate application process.

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

Effective Date: 07-01-2012 25 Approval Date: _______________ Supersedes Effective Date: 07-01-2011 Joint applications may be submitted to either the county social service offices or the Department of Human Services for a Medicaid eligibility determination in the eligibility computer system to determine eligibility for Medicaid. This process ensures that all joint applications where potential Medicaid eligibility is indicated go through an official eligibility determination process. 4.4.3 The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42 CFR 431.636(b)(4)) As noted in 4.4.1, any children who are ineligible for Medicaid, or who are eligible for Medicaid with a recipient liability, are automatically processed to determine whether they are eligible for Healthy Steps. This process assures that joint applications where potential Healthy Steps eligibility exists will receive an eligibility determination. 4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102(b)(3)(C))) (42 CFR 457.810(a)-(c)) 4.4.4.1

Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution. The joint application utilized by the Healthy Steps Program asks applicants if anyone in the family is covered by creditable health insurance within the last six months. The applicant provides the information through a self-declaration. If any children were covered by creditable health insurance within the last six months, the child is determined not to be eligible for Healthy Steps. Families are informed to reapply after the six-month period has expired.

The Department allows exceptions to this rule that permits this requirement to be waived if loss of health care coverage occurred because of no fault of the family. Examples include loss of job, accepting another job where coverage is not available and in the case of farm families, residing in a county where a federal disaster has been declared and is currently in affect. 4.4.4.2

Coverage provided to children in families over 200% and up to 250% of FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable. 4.4.4.3

Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution. 4.4.4.4

If the state provides coverage under a premium assistance program, describe:

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

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

Effective Date: 07-01-2011 26 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 Children who are also eligible to receive services through the Indian Health Service (IHS) or through Section 638 Tribal contracts will be eligible to enroll in Healthy Steps. Through various outreach processes including the Robert Wood Johnson covering kids grant, a TANF outreach grant and a community access program grant we have encouraged eligible families to enroll in the program. In addition, we have worked directly with Tribal and Indian Health Service staff to provide information and conduct on-site training sessions to ensure that American Indians are aware of the availability of Healthy Steps and the Medicaid Program. It is important that American Indian children have the opportunity to obtain appropriate and necessary health care and we are committed to inform them about the availability of Healthy Steps and encourage them to apply for the program. American Indian children, as defined in section 4(c) of the Indian Health Care Improvement Act, 25 USC 1603 c and who are members of federally recognized tribes as determined by the Bureau of Indian Affairs, will be exempt from any cost sharing obligations.

Section 5. Outreach (Section 2102(c)) Describe the procedures used by the state to accomplish: Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90) Outreach efforts for the CHIP plan is designed to be a collaborative effort between families and both the state and federal governments to assure children receive health care. North Dakota uses established relationships with a variety of entities to help identify potentially eligible children and invite them to help put together an outreach system. North Dakota has developed new relationships with a variety of entities to help identify and enroll potentially eligible children into the North Dakota Medicaid CHIP programs. Certain assumptions about the target population for the expanded Medicaid group of children are based on experiences of the North Dakota Medicaid program, The Caring Program for Children, County Social Service Agencies, public and private health care agencies. The plan must invite families who have regular contact with social service agencies, and to other families who have traditionally avoided government programs. Identification of Target Populations of Potential CHIP Enrollees The Department of Human Services will work with existing Economic Assistance programs, such as TANF and Food Stamps, to identify children in families who are not eligible for Medicaid, but may be eligible for CHIP. Outreach Strategies for Potential Enrollees

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

Effective Date: 07-01-2011 27 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 Outreach through Maternal Child Health Programs Maternal and Child Health Programs coordinates outreach activities with the Department of Human Services through their programs, such as Family Planning, OPOP, WIC, local Public Health Agencies, and Children with Special Health Services. Activities include distribution of written materials such as posters, brochures, and flyers, distribution and assistance in completion of applications. MCH programs that participate in health fairs include CHIP and Medicaid materials onsite. MCH programs will use their intake processes to include information on public insurance programs. Outreach Through Private Providers Healthy Steps coordinates outreach activities with Primary Care Providers and Medicaid recipients. A new recipient newsletter has been developed for all Medicaid Primary Care Physician enrollees. The North Dakota Medicaid Program publishes a quarterly newsletter sent to over 20,000 Medicaid providers statewide. Healthy Steps information has been and will continue to be included in these publications on a routine basis. The North Dakota Medical Association, Academy of Pediatrics, Dental Association, and Primary Care Association received Healthy Steps program information and has shared this information with their members. The information describes program benefits and how to access services. Providers, such as clinics, hospitals, and dental offices, received Healthy Steps and Medicaid program information, such as flyers, brochures, and applications, to identify and refer potential eligible children to these programs. Outreach Through Native American Health Programs The Department will continue to work with Tribal leaders to develop outreach strategies for North Dakota's Native American population. IHS facilities use their benefits or business office procedures for determining third party payment sources including Medicaid and Healthy Steps. Native American MCH programs use their connections with other providers and programs to facilitate referral to Medicaid and Healthy Steps. The Healthy Start program uses their broad-based network as case managers to access coverage for Healthy Steps and Medicaid for their clients. The Medical Assistance Division collaborated with the North Dakota TANF program to provide funding for two reservation outreach workers. The two sites are located on reservations that were not included in the North Dakota Covering Kids pilot projects. Training and technical assistance will be provided on an ongoing basis to the TANF funded outreach workers. Outreach Through Schools

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

Effective Date: 07-01-2011 28 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 The Department coordinates outreach activities with the Department of Public Instruction and local school districts using the following methods: 1. The State Department of Public Instruction includes information on healthcare coverage on the Free and Reduced Price Meals Application each school year that explains the Healthy Steps program. Each school has a supply of applications for Healthy Steps and the schools give each family an application for Healthy Steps if they have indicated interest or families can call 1-877-KIDSNOW. 2. The North Dakota Principals, Teachers, and School Counselors Association will include Healthy Steps information in newsletters and gatherings through their activities. 3. The North Dakota PTA (Parent and Teacher Associations) will distribute information to their local schools. Public health nurses who provide services in local schools will have Healthy Steps information and applications available on site. Outreach Through Business

The Healthy Steps and Medicaid programs will use a variety of outreach strategies targeted through state and local business, including the printing Healthy Steps information on milk cartons, educational forums to human resource managers, flyers and printed information on store receipts through retail businesses, information included in utility bills and presentations at small business owners State Tax Department seminars. Outreach Through Head Start Programs The North Dakota Head Start Collaboration Coordinator has been a part of the Healthy Steps and Medicaid outreach group from its inception. Local Head Start programs will use the following strategies to conduct outreach and assist in enrollment for both programs including: 1. Healthy Steps and Medicaid brochures and applications are provided to Head Start families during Head Start enrollment and to new Head Start families throughout the year 2. Assist families in completing the Healthy Steps and Medicaid applications by making copies of social security and income verifications and helping families locate required verification information. 3. Training parent volunteers to assist families during the enrollment process, and sharing Healthy Steps and Medicaid program information with local Head Start Health Advisory Committees.

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

Effective Date: 07-01-2011 29 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 Outreach Through State and Local Advocacy Groups The following advocacy groups and associations have been involved and will continue their involvement with outreach planning for the North Dakota Healthy Steps and Medicaid programs, North Dakota Board of Social Welfare, Family Voices, Federation of Families, North Dakota Mental Health Association, and Department of Human Services Tribal Liaison offices. Outreach strategies will include the following: Assistance to families in completion of applications, distribution of Healthy Steps and Medicaid written materials at state and local gatherings, including eligibility information in newsletters, and technical assistance in writing more family friendly, culturally relevant and simple program information. Outreach Through Child Care Programs Updated Information on public insurance programs will be distributed to all 3,082 licensed, registered, and self-certified centers, preschool, family child care, group child care, multi-licensed, and reservation based childcare programs throughout North Dakota. The Department will also work through the three health nurse consultants contracted with the North Dakota Resource and Referral Centers to provide health information to licensed childcare providers. The nurses will help providers distribute written materials about public insurance programs. Outreach Through Religious Groups The North Dakota Catholic Conference has been an active participant in development of public insurance programs. They distribute written material to their local communities and churches through articles in church bulletins, newsletters, and group gatherings. Outreach Through Other Methods Pediatrician outreach through an AAP (American Academy of Pediatrics) Grant. A North Dakota AAP affiliated pediatrician was awarded a grant to conduct one on one outreach to each of the state’s 77 pediatricians. The outreach includes two visits to each of the pediatric offices throughout North Dakota. The first visit was to assess the physician’s awareness of coverage programs, provide education about the programs, determine the type and amount of printed outreach materials in each office, and provide them with additional materials. The second visit is to assess the physician’s awareness of coverage programs and look at the outreach materials in each office in order to determine if the initial contacts were effective. Outreach will be coordinated through North Dakota Extension Programs, Community Action Programs, and North Dakota Rural Survivors Task Force

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

Effective Date: 07-01-2011 30 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 members. The outreach will be through distribution of written information including the Healthy Steps and Medicaid brochures and applications. Outreach Through Written and Network Media The North Dakota Department of Human Services will coordinate with the public information director to develop timely press releases through weekly and daily newspapers, newsletters of professional associations, advocacy groups, and Chambers of Commerce. All written outreach materials, such as brochures, flyers, and posters, will display the 1-800 number to call and receive the information necessary to apply for public insurance programs. A communication plan to address short and long term media outreach is in place. The North Dakota Department of Human Services has a website for Healthy Steps that allows the user to print an application that can be competed and mailed in for processing. Coordination of outreach efforts between the North Dakota Healthy Steps Program, Medicaid, other children's public/private health insurance programs and services will be ongoing. The Medical Services Division (Medicaid, and Healthy Steps), and Children and Family Services Division are within the Department of Human Services. The Title V and Title X programs are within the same physical building as Human Services. The Title V, Medicaid, and Children's Special Health Services programs meet on a quarterly basis to discuss mutual program issues. Children can enroll or receive assistance in enrolling at our single FQHC in Fargo and Rural Health Clinics throughout the state. Local county social service agencies will inform families who have been denied Medicaid eligibility of the Health Steps program and share information collected in the eligibility determination process with Healthy Steps if the county and family agree to do so. Healthy Steps will refer applicants who appear to be Medicaid eligible to local county social service agencies and conduct follow up of these children. Coordination and enrollment activities for Medicaid and Healthy Steps have been enhanced since the joint application was implemented in May 2002. The Department conducts training for county social services and gives these offices Healthy Steps flyers, brochures and applications for children who are not eligible for Medicaid but may be eligible for Healthy Steps. Education sessions for all outreach partners were held August through November 2001. The purpose of the sessions were to provide information that allows the partners to identify families who may be eligible for Healthy Steps or Medicaid, assist families in completing applications for Healthy Steps and Medicaid, explain the benefits of both programs, enabling families to make informed choices and introduction of the new joint application for the Medicaid and Healthy Steps programs.

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

Effective Date: August 26, 2001 31 Approval Date:_______________ Coordination efforts have also been described in Section 2.3. Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

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 7. 6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a)) 6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1.

FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2.

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3.

HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions. North Dakota uses the Public Employees Retirement System Health Care Plan (PERS) as the benchmark coverage for Healthy Steps. Most state employees have the option to obtain coverage through this plan that provides comprehensive family health care coverage with no required premium payment. All services in the current plan will be available to enrolled children except for the cost of delivery of newborns. In addition to the standard PERS coverage, Healthy Steps enrolled children will receive a package of preventive dental services and vision care. Also, an extensive number of deductibles and coinsurance amounts required in the PERS plan were replaced with a modest package of cost-sharing for eligible families. The signed actuarial report has previously been provided to CMS. 6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If an existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

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

Effective Date: August 26, 2001 32 Approval Date:_______________ 6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1.

Coverage the same as Medicaid State plan 6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3.

Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage 6.1.4.5.

Coverage that is the same as defined by Αn existing comprehensive state- based coverage 6.1.4.6.

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Provide a sample of how the comparison will be done) 6.1.4.7.

Other (Describe) 6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490) 6.2.1.

Inpatient services (Section 2110(a)(1)) Inpatient services include all bed, board, general nursing, special care units when medically appropriate and necessary, ancillary services when appropriate and necessary, anesthesia and all medical and surgical services provided by a physician except that no payment will be made for the costs associated with the delivery of a child for either the hospital or the attending physician. These services also include appropriate services provided by hospitals operated by the Indian Health Service or Tribal Section 638 facilities. Reconstructive surgery to restore bodily function or correct deformity resulting from diseases, trauma, congenital or developmental anomalies or previous therapeutic processes are covered. Coverage for organ transplants include kidney, heart, heart-lung, single or double lung, liver, cornea and pancreas if medically appropriate. Requires prior authorization and must be provided at an approved transplant center. Bone marrow transplants or other forms of stem cell rescue with related services and supplies are limited to certain diseases and conditions as follows: 1. Autologous bone marrow transplants are only allowed for the following diagnoses: non-Hodgkin’s lymphoma, stage III or IV; Hodgkin’s disease (lymphoma) stage III or IV; neuroblastoma, stage III or IV; acute lymphocytic or non-lymphocytic leukemia in first or subsequent remission; germ cell tumors and breast cancer.

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

Effective Date: 07-01-2013 33 Approval Date: _______________ Supersedes Effective Date: 7-01-2011 2. Allogeneic bone marrow transplants are only allowed for the following diagnoses: non-Hodgkin’s lymphoma, stage III or IV; Hodgkin’s disease (lymphoma) stage III or IV; neuroblastoma, stage III or IV; chronic myelogenous leukemia in blast crisis or chronic phase; and acute lymphocytic or non-lymphocytic leukemia (acute myelocytic leukemia) in first or subsequent remission, but at high risk for relapse. 3. Allogeneic bone marrow transplants for non-malignancies are only allowed for the following diagnoses: severe aplastic anemia; homozygous beta- thalassanemia; Wiskott-Aldrich syndrome; severe combined immunodeficiencies; infantile malignant osteopetrosis; mucopolysaccharidoses; mucolipidoses; and myelodysplastic syndromes. All other forms of bone marrow transplants or peripheral stem cell transplants are not covered including related services and supplies. Related services and supplies include all services and supplies that are not medically appropriate and necessary for a child’s receipt of chemotherapy or radiation therapy requiring stem cell support, and includes specifically and without limitation, chemotherapy and radiation therapy when supported by transplant or other stem cell rescue procedures. Coverage is not available for chemotherapy or radiation therapy together with all related services and supplies when the dose or manner of administration is expected to result in damage to or suppression of the bone marrow, the blood or blood forming systems, warranting or requiring receipt by the patient of autologous, allogeneic or syngeneic stem cells, or that are derived from the bone marrow or the peripheral blood, unless the procedure is specifically allowed as a covered service detailed above. Prior approval is required for all bone marrow transplants and must be performed at an approved transplant center. Coverage is not available for donor organs or tissue other than human donor organs or tissue. Coverage is available for routine circumcision. Limitations: Cosmetic surgery will not qualify as reconstructive surgery when performed for the treatment of a psychological or psychiatric condition. Surgery and related services primarily intended to improve appearance and not to restore bodily function or correct deformities resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes are not considered a covered service. Sterilization procedures or procedures to evaluate and reverse sterilization are not covered. Surgery for morbid obesity is limited to one lifetime operative procedure per enrollee. No benefits are available for repair or modification of any or all types of surgical morbid obesity procedures unless there are special circumstances.

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

Effective Date: 07-01-2013 34 Approval Date: _______________ Supersedes Effective Date: 7-01-2011 Coverage is not available for services that are primarily for diagnostic examinations, physical therapy, rest care, convalescent care, custodial care, maintenance care and sanitaria care or inpatient services performed primarily for the purpose of administering allergy, sensitivity, food challenge or related testing, clinical ecology, and vitamins or dietary nutritional supplements. Each family will be responsible for a $50 deductible for the first day for each individual inpatient hospital stay. American Indian children are exempt from this requirement. Preauthorization is required for all inpatient hospital admissions unless the admission is the result of a medical emergency. An emergency is defined as a medical condition which most non-medical people think is life-threatening or could cause death or severe permanent damage to a person or unborn baby if not treated immediately.

Exclusions No coverage is available when a child is admitted to an inpatient facility prior to the effective date of the child’s eligibility for the Healthy Steps Program. 6.2.2.

Outpatient services (Section 2110(a)(2)) Outpatient services including outpatient surgery services are covered including emergency care. These services also include services provided through hospitals operated by the Indian Health Services or Section 638 Tribal operations. Families are responsible to pay a $5 co-payment for each visit to an outpatient hospital emergency room. American Indian children are exempt from this requirement. 6.2.3.

Physician services (Section 2110(a)(3)) Physician services include medical office and home visits, consultations and similar services that are medically necessary and appropriate at no cost to the family of enrolled children. Coverage is available for second surgical opinions, radiation and chemotherapy services except where otherwise prohibited, dialysis treatment and home infusion therapy services. Services covered include the provision of nutrients, antibiotics and other drugs and fluids intravenously, through a feeding tube, or by inhalation, necessary supplies and therapeutic drugs or other substances. Allergy services are available including direct skin testing and patch testing when ordered by a physician and are performed in accordance with guidelines and criteria for specific IgE testing (RAST), Rinkel Immunotherapy (Serial Endpoint Dilution Titration), the fluorescent allergosorbent test (FAST), total

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

Effective Date: 07-01-2013 35 Approval Date: _______________ Supersedes Effective Date: 7-01-2011 serum IgE concentration, bronchial challenge testing, conjunctival challenge testing and food challenge testing when specific indications are present.

Coverage is not available for nasal challenge testing, provocative/neutralization testing for food and food additive allergies, leukocyte histamine release, Rebuck skin window test, passive transfer or Prausnitz- Kustner test, cytotoxic food testing, metabisulfite testing, candidiasis hypersensitivity syndrome testing, IgE level testing for food allergies, general volatile organic screening test and mauve urine test. Coverage is not available for desensitization treatment, provocation/neutralization therapy for food/chemical or inhalant allergies by sublingual, intradermal and subcutaneous routes, urine autoinjections, repository emulsion therapy, candidiasis hypersensitivity syndrome treatment or IV vitamin C therapy. Coverage is not available for clinical ecology, orthomolecular therapy, vitamins, dietary nutritional supplements, food challenge, or related testing rendered on an outpatient basis. Preventive care that includes all appropriate immunizations and wellness services are covered. This includes all recommended immunizations by the Advisory Committee on Immunization Practices (ACIP) and the North Dakota Department of Health. Wellness visits shall be based on Bright Futures, which includes up to seven physician visits in the first eleven months of life, newborn hearing screening, no more than two home nursing visits for newborns if requested by physicians and the family, developmental screening, mental health screening and coverage of nutrition services for diabetes, hyperlipidemia, eating disorders, chronic renal failure, and phenylketonuria. Coverage for nutritional care is limited to no more than two office visits per year for hyperlipidemia and four office visits for the other covered conditions. Other wellness services include up to six well care and immunization visits for enrolled children 12 through 36 months of age and one visit per year for enrolled children four years of age through 18 years of age. Children six through 18 years of age are also allowed one preventive screening service per year that can include a sports or school physical. Wellness services shall include diabetic education services. These services are limited to 10 hours for initial education and an additional two hours per benefit period. Coverage is not available for any other annual, periodic or routine examinations except those specified above or for immunizations required because of a child’s employment, occupation or immunizations required for foreign travel. Coverage is not available for any other annual, periodic or routine examinations except those specified above or for immunizations required because of a child’s employment, occupation or immunizations required for foreign travel. Costs associated with the delivery of a child are not included in this health benefit package.

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

Effective Date: August 26, 2001 36 Approval Date:_______________ Coverage is not available for any form of thermography for any use or indication. Coverage is not available for acupuncture performed by any provider. Coverage is not available for any outpatient provider for palliative or cosmetic foot care, foot support devices, except custom made support devices, or subluxation of the foot, care of corns, bunions, except for capsular or bone surgery, calluses, toenails, fallen arches, weak feet, chronic foot strain and symptomatic complaints of the feet, except that services are available for the care of corns, calluses and toenails when medically appropriate and necessary for children with diabetes or circulatory disorders of the legs or feet. 6.2.4.

Surgical services (Section 2110(a)(4)) Covered for all necessary and appropriate medical procedures whether performed in an inpatient hospital, outpatient hospital, ambulatory surgical center, Indian Health Service Hospital or Clinic or Tribal Section 638 Facility or office setting in accordance with any requirements set forth in sections 6.2.1 and 6.2.2 relating to inpatient and outpatient hospital surgical services. Coverage is not available for treatment leading to or in connection with sex change or transformation surgery and related complications. Surgical services are covered without any cost sharing requirement unless they occur as part of an inpatient hospital stay or a hospital emergency room visit. 6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) Covered for all appropriate and necessary services for all certified Federally Qualified Health Centers, Rural Health Clinics, Indian Health Services or Tribal Section 638 outpatient clinic services. 6.2.6.

Prescription drugs (Section 2110(a)(6)) Covered for all appropriate and medically necessary prescription drugs that are authorized by a professional licensed to write prescriptions. Coverage for diabetic supplies, syringes, lancets and test strips are included in this benefit. There is no coverage for any medication or device designed to prevent pregnancy including any oral or other forms of contraceptive drugs, contraceptive devices or appliances or delivery. Coverage is not available for any medications obtained without a prescription order or any charges for the administration of legend drugs or insulin that may be self administered. A $2 co-payment will be applied for each allowable generic prescription drug; a $4 co-payment will be applied for each allowable preferred brand prescription drug; and a $8 co-payment will be applied for each allowable non- preferred prescription drug. The same co-pays apply to refills dispensed under

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

Effective Date: 07-01-2013 37 Approval Date: _______________ Supersedes Effective Date: 7-01-2011 the benefit package. American Indian children are exempt from this cost sharing. 6.2.7.

Over-the-counter medications (Section 2110(a)(7)) 6.2.8.

Laboratory and radiological services (Section 2110(a)(8)) Covered for all appropriate and necessary services that have been ordered by a physician or other practitioners within the scope of their practice as authorized by state law. There is no cost sharing for this service. 6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) Covers prenatal care provided by a physician or certified nurse/midwife, prenatal nutritional counseling limited to one visit per pregnancy and one ultrasound per pregnancy unless additional services are determined to be medically necessary. There is no coverage for the cost of the delivery of a vaginal delivery or cesarean section for the hospital, physician, nurse midwife, birthing center or any other services directly associated with the birth of a child. Coverage is not available for any costs associated with surrogate pregnancy, gestational carrier pregnancy, assisted conception or any other services related to conception or pregnancy in anything other than the genetic mother’s uterus, donor sperm utilized for artificial insemination or any and all extraordinary procedures to induce fertilization or enhance conception with professional or technical assistance, including gamete intrafallopian transfer, zygote intrafallopian transfer, in vitro fertilization, peritoneal oocyte and sperm transfer, tubal ovum transfer or intracytoplasmic sperm injection. Postnatal and interruptions of pregnancy including miscarriage is a covered service. Coverage is not available for the insertion and routine removal of intrauterine devices, contraceptive delivery systems, evaluations and procedures to evaluate sterilization reversals, reversal of sterilization procedures or any other procedures or supplies designed to prevent pregnancy including oral and other forms of contraceptive drugs, contraceptive devices and appliances. 6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) As of January 1, 2019, Prior authorization is not required for all admissions. A $50 co-payment applies.

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

Effective Date: 07-01-2013 38 Approval Date: _______________ Supersedes Effective Date: 7-01-2011 6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11) As of January 1, 2019, Preauthorization is not required. Group psychotherapy is also available. Coverage is also available for the intensive outpatient program. This service is a formal program for a child who requires more than one visit per week for mental health services but does not require the intensity of inpatient hospital or partial hospitalization. Generally more than one treatment modality is used and a plan must identify a treatment goal that is related to the child’s diagnosis. Exclusions: Coverage is not available for services provided by a social worker who does not meet the qualifications required by state law or a psychologist who is not eligible for listing in the National Register of Health Service Providers. Special education, counseling or care of learning disorders or behavioral problems whether or not associated with a manifest mental disorder or other disturbance. Sex therapy services. Bereavement, codependency, marital, family, sex or interpersonal relationship, gambling addiction or nicotine addiction counseling services or services provided by a vocational residential rehabilitation center or a community reentry program. 6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) Rental or purchase of home medical equipment is covered when prescribed by a physician and required for therapeutic use. No benefits are allowed for motorized equipment except wheelchairs with prior approval. No coverage is available for batteries required for home equipment. Covered services include replacement and repairs when medically appropriate and necessary. Coverage is available for the purchase, fitting and necessary adjustments of prosthetic appliances and supplies that replace all or part of a body part. Benefits are available only for standard appliances. Covered services

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

Effective Date: 07-01-2014 39 Approval Date: _______________ Supersedes Effective Date: 7-01-2011 include replacement and repairs when medically appropriate and necessary. Coverage is not available for any testicular prostheses regardless of the cause of the absence of the testicle. The rental of medically appropriate and necessary oxygen equipment and the administration of the oxygen is a covered service. Orthotic devices that are medically appropriate and necessary when ordered by a physician or podiatrist are covered. Benefits are not available for leisure or recreational activities or to allow a child to participate in a sports activity. Coverage is not available for personal hygiene and convenience items including air conditioners, humidifiers or physical fitness equipment. Hearing Aids are covered when medically necessary and appropriate. Benefits are limited to $4,000 per enrolled child every three years. Coverage is not available for electronic speech aids, robotization devices, robotic prosthetics, myoelectronic prosthetics, customized cutaneal dermal protective covers, and endolite prosthetic systems or artificial organs. Coverage is available for one set of eyeglass frames and one set of lenses every 12 months for each child. The amount allowed for each frame is $100. Any amount over that cost is the responsibility of the family. If desired, contact lenses may be substituted for eyeglass frames and lenses. Payment allowances are limited to the allowance for frames and prescribed lenses that are considered appropriate and medically necessary. Medically appropriate and necessary medical equipment and supplies are subject to a maximum benefit allowance of $8,000 per member per year for all covered services received.

6.2.13.

Disposable medical supplies (Section 2110(a)(13)) Coverage is provided for medically and necessary supplies for the administration of prescription medications or drugs such as hypodermic needles and syringes and ostomy supplies Medically appropriate and necessary medical equipment and supplies are subject to a maximum benefit allowance of $8,000 per member per year for all covered services received.

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

Effective Date: 07-01-2014 40 Approval Date: _______________ Supersedes Effective Date: 7-01-2011 6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14)) Coverage is provided for a homebound child in the child’s place of residence. The service must be on a part-time visiting basis in accordance with a physician’s prescribed plan of treatment that is approved prior to admission into home health care. Services are available only if, in the absence of home health care, a child would require inpatient hospital or skilled nursing facility services. Covered services include registered nurse, licensed vocational nurse or licensed practical nurse; physical, occupational or speech therapy; medical and surgical supplies; administration of prescribed drugs; oxygen, including administration; and home health aide services when a child is receiving daily covered skilled nursing services or therapy services. Coverage is not available for dietitian services, homemaker services, maintenance care, custodial care, food or home delivered meals, respite care or home health care or supplies for children who are ventilator dependent unless a skilled nursing facility bed is not available. In the event a skilled nursing facility bed is not available, the maximum benefit allowance will be the average semi-private room rate for a skilled nursing facility bed. 6.2.15.

Nursing care services (See instructions) (Section 2110(a)(15))

PRIVATE DUTY NURSING SERVICES Coverage is available for services provided by a registered nurse or licensed practical nurse when ordered by a physician, Payment is not available to a nurse who lives in the child’s home or is a member of the child’s immediate family.

Coverage is not available for maintenance care. 6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) Coverage is limited to abortions that are necessary to prevent the death of a woman. Coverage is not available for other abortions including abortions for removal of all or part of a multiple gestation. 6.2.17.

Dental services (Section 2110(a)(17))

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

Effective Date: 07-01-2014 41 Approval Date: _______________ Supersedes Effective Date: 7-01-2011 Coverage is provided for emergency, diagnostic and well child dental care including preventive and restorative services. These services include emergency palliative treatment, simple extractions, pulpotomies on deciduous teeth, routine oral examinations, dental x-rays that include bitewing, full-mouth and panoramic, routine prophylaxis, sealants, topical fluoride applications, space maintainers, amalgam and resin restorations, stainless steel crowns and administration of anesthesia. Routine oral examinations and topical fluoride applications are limited to no more than twice per year. Prophylaxis is limited to no more than four per year. Bitewing x-rays are limited to no more than once during a year. Full mouth and panoramic x-rays are limited to once every three years. Coverage is available for medically appropriate and necessary orthodontic services. Interceptive Orthodontic treatment is aimed at preventing dental/facial development problems before they occur. Treatment is performed while the patient has only primary teeth. Service is limited to once per lifetime. Comprehensive Orthodontic treatment is for patients who only have permanent teeth and their jaw/facial bones are completely developed. Treatment is comprehensive in nature, meaning a variety of problems have been identified and are being corrected. Orthodontic correction is done to establish correct tooth and jaw positional relationships; proper chewing function; evenly distributed chewing forces; esthetic facial proportions, and an esthetic smile. Service is limited to once per lifetime. Orthodontic services do not apply to the benefit period maximum. Prior authorization is required. Additional requests for orthodontic treatment above the limit, will be reviewed on a case by case basis, in instances of accidental injury or if the child's teeth have moved significantly following orthodontic treatment. Coverage is also available for appropriate and necessary treatment of an accidental injury to the jaw, sound natural teeth, dentures, mouth or face that occurs after the date a child is enrolled in Healthy Steps. Treatment must occur within 12 months of the date of injury. Injury is defined as an external force that causes a specific impairment to the areas described above. Injury that is a result of chewing or biting is not considered an accidental injury. Coverage for medically appropriate and necessary dental services is limited to $1,000 per benefit period. In case of medically necessary care in excess of the $1,000, prior approval will be needed and exceeding the $1,000 limit may be granted. 6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services. (Section 2110(a)(18))

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

Effective Date: 07-01-2011 42 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 As of January 1, 2019 Prior authorization is not required for all admissions. A $50 co-payment applies.

6.2.19.

Outpatient substance abuse treatment services. (Section 2110(a)(19)) Coverage for partial hospitalization for mental illness and substance abuse is available. As of January 1, 2019, Preauthorization is not required. Coverage is provided for outpatient substance abuse services. Coverage for group psychotherapy services is available. As of January 1, 2019, Preauthorization is not required.

6.2.20.

Case management services (Section 2110(a)(20))

6.2.21.

Care coordination services (Section 2110(a)(22)) 6.2.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing and language disorders. (Section 2110(a)(22))

PHYSICAL THERAPY Coverage is available for physical therapy services performed by or under the direct supervision of a physical therapist to restore maximum function following disease, injury or loss of body part. Services will be limited based on a predetermined number of visits based on the presenting condition.

Coverage is available for treatment of chronic conditions such as a multiple sclerosis, progressive rheumatoid arthritis or cerebral palsy when medically appropriate and necessary. Coverage is not available for maintenance care including such care related to the treatment of chronic conditions. Coverage is not available for massage therapy provided by a masseuse or masseur. OCCUPATIONAL THERAPY Coverage is available for occupational services performed by or under the direct supervision of a licensed occupational therapist for the treatment of a physically disabled child by means of constructive activities designed and adapted to promote the restoration of a child’s ability to satisfactorily accomplish the ordinary tasks of daily living. Coverage is limited to a maximum of 90 consecutive days per condition beginning on the day the first service was provided. After 90 days,

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

Effective Date: 07-01-2011 43 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 services will be reviewed to determine if additional services should be available based on medical appropriateness and need. Coverage is not available for maintenance care. SPEECH THERAPY Coverage is available for speech therapy services performed by or under the direct supervision of a certified speech therapist for the correction of a speech impairment resulting from disease, surgery, injury, congenital anomaly or previous therapeutic process. Prior authorization is required and services must be provided in accordance with prescribed plan of treatment ordered by a physician Coverage is not available for maintenance care or for group speech therapy services. Care must be delivered based on a prescribed treatment plan ordered by a physician. Preauthorization is required and service must be delivered in accordance with a prescribed plan of treatment. Coverage is not available for physical, occupational or speech therapy associated with work hardening programs, prevocational evaluations or functional capacity evaluations.

6.2.23.

Hospice Care (Section 2110(a)(23)) Coverage is available for hospice benefits when provided through an organized and approved hospice program. Preauthorization is required. Services are limited to treatment of children who have been diagnosed with a condition where there is a life expectancy of 6 months or less. 6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) PROFESSIONAL VISION SERVICES PROVIDED BY AN OPTOMETRIST Coverage is available for emergency and well child services that include treatment of sore eyes, foreign body removal and sudden impairment of vision, annual routine complete examinations and visits to supervise patching progress and orthoptics for children with amblyopia. Benefits are limited to a lifetime maximum of 16 visits per child.

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

Effective Date: 07-01-2011 44 Approval Date: _______________ Supersedes Effective Date: 8-26-2001

Examinations are limited to no more than one per year.

Coverage is not available for any other service or material that may be provided through an optometrist

CHIROPRACTIC SERVICES Coverage is available for medically appropriate and necessary services provided within the scope of licensure and practice of a chiropractor to the extent services would be covered if provided by a physician.

Benefits are not available for maintenance care.

BIOFEEDBACK Coverage is available for chronic headaches, gastrointestinal disorders, neuromuscular disorders and panic disorders. Coverage is limited to no more than four sessions per child per year. TEMPOROMANDIBULAR (TMJ) OR CRANIOMANDIBULAR JOINT TREATMENT (CMJ) Coverage is available for TMJ and CMJ that includes surgical and Nonsurgical services when treatment is medically appropriate and necessary. Coverage for surgical services are subject to a lifetime maximum of $10,000 per child. Coverage for nonsurgical services including diagnostic and biofeedback services, supplies and outpatient treatments are subject to a lifetime maximum of $2,500 per child. Coverage for splints are limited to no more than $275 and are subject to the nonsurgical service lifetime maximum. Coverage is not available for orthodontic services or osseointegrated implant surgery or related services performed for the treatment of temporomandibular or craniomandibular joint disorder(s). 6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.26.

Medical transportation (Section 2110(a)(26)) Coverage is available for medically appropriate and necessary ambulance services to the nearest facility equipped to provide the required level of care. Coverage is provided from the home or site of accident or emergency, between hospitals, or between a hospital and a skilled nursing facility.

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

Effective Date: August 26, 2001 45 Approval Date:_______________ Coverage for air ambulance is available only if it is not medically appropriate and necessary to transport by ground ambulance. Preauthorization is required. 6.2.27.

Enabling services (such as transportation, translation, and outreach services) (See instructions) (Section 2110(a)(27)) 6.2.28.

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28)) Skilled nursing facility services that are medically appropriate and necessary that include skilled nursing services and supplies generally provided in a skilled nursing facility are covered. Preauthorization is required.

Coverage is not available for maintenance or custodial care. The following is a general list of exclusions not associated with a particular service. 1. Services not prescribed or performed by or under the direct supervision of a professional health care provider consistent with the professional health care provider’s licensure and scope of practice.

2. Services provided and billed by a registered nurse (other than an advanced practice registered nurse), physician extender, intern, licensed athletic trainer or other paramedical personnel.

3. Any drug, device, medical treatment or procedure that is experimental or investigative.

4. Services, treatment or supplies that the contractor determines are not medically appropriate or necessary.

5. Standby services provided or billed by a health care provider.

6. Services when benefits are provided by any governmental unit or social agency. Medicare Part A and B will be considered the primary payor with respect to benefit payments unless otherwise required by federal law.

7. Illness or injury caused directly or indirectly by war or an act of war or sustained while performing military services, if benefits for such illness or injury are available under the laws of the United States or any political subdivision thereof.

8. Illness or bodily injury that arises out of and in the course of child’s employment if benefits are compensation for such illness or injury are available under the provisions of a state workers’ compensation act, the laws of the United States or any state or political subdivision thereof.

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

Effective Date: August 26, 2001 46 Approval Date:_______________

9. Loss caused or contributed by a child’s commission or attempted commission of a felony or a child’s involvement in an illegal occupation.

10. Any services when benefits are provided by a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, or similar person or group.

11. Services provided by a health care provider who is a member of the child’s immediate family.

12. Telephone consultations or charges for failure to keep a scheduled visit or charges for completing of any forms required by the contractor.

13. Health screening assessment programs or health education services, including services provided through the rental or purchase of TV, audiovisual tapes or pamphlets.

14. Health and athletic club membership or facility use, and all services provided by the facility, including physical therapy, sports medicine therapy and physical exercise.

15. Complications resulting from noncovered services received by a child.

16. Services prescribed by, performed by or under the direct supervision of a nonpayable health care provider.

17. Services that a child has no legal obligation to pay in the absence of this or any similar coverage.

18. Cost sharing amounts.

19. Services, treatments, or supplies not specified as a covered service in this coverage plan.

6.2-D The state will provide dental coverage to children through one of the following:

6.2.1-D

State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT) codes are included in the dental benefits: Diagnostic (CDT codes: D0100-D0999) (must follow periodicity schedule). Preventive (CDT codes: D1110-D1206) (must follow periodicity schedule). Restorative (CDT codes: D2000-D2999).

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

Effective Date: 07-01-2011 47 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 Endodontic (CDT codes: D3000-D3999). Periodontic (CDT codes: D4000-D4999). Prosthodontic (CDT codes: D5000-5899 and D5900-D5999 and D6200-6999). Oral and Maxillofacial Surgery (CDT codes: D7000-D7999). Orthodontics (CDT codes: D8000-D8999). Emergency Dental Services. Please note: this form has not been approved by OMB pursuant to the PRA and States are not obligated to use it. 6.2.1.1-D

Periodicity Schedule. Please Select and include a description.

Medicaid

American Academy of Pediatric Dentistry

Other Nationally recognized periodicity schedule: (Please Specify)

6.2.2-D

Benchmark Coverage; (Section 2103(c)(5), 42 CFR 457.410 and 42 CFR 457.420) States must, in accordance with 42 CFR 457.410, provide coverage for dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions if these services are not provided in the chosen benchmark package.

6.2.3-D

FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (if checked, attach a copy of the dental supplemental plan benefits description and the applicable CDT codes. If the necessary dental services are not provided, please include a description of, and the CDT code(s) for, the required service(s).)

6.2.4-D

State employee coverage; (Section 2103(c)(5)(C)(ii)) (if checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If necessary dental services are not provided, please also include a description of, and the CDT code(s) for, the required service(s).)

6.2.5-D HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii)) (if checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If necessary dental services are not provided, please also include a description of, and the CDT code(s) for, the required service(s).) 6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in

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

Effective Date: 07-01-2011 48 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l). 6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i)) 6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard. International Classification of Disease (ICD) Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines (Describe: ) Other (Describe: ) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits? Yes No 6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act) provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act. 6.2.2.1- MHPAEA Does the State child health plan provide coverage of EPSDT? The State must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements, as indicated in section 6.2.26 of the State child health plan in order to answer “yes.” Yes No If the state does provide EPSDT benefits consistent with Medicaid requirements, please continue this section to demonstrate compliance with the statutory requirements of

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

Effective Date: 07-01-2011 49 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 section 2103(c)(6)(B) of the Act and the mental health parity regulations of 42 CFR 457.496(b) related to deemed compliance. Please provide supporting documentation, such as contract language, provider manuals, and/or member handbooks describing the state’s provision of EPSDT. 6.2.2.2- MHPAEA EPSDT benefits are provided to the following: All children covered under the State child health plan. A subset of children covered under the State child health plan. Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements. 6.2.2.3- MHPAEA To be deemed compliant with the MHPAEA parity requirements, States must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act (42 CFR 457.496(b)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan: All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions. (Section 1905(r)) All diagnostic services described in 1905(a) of the Act are provided as needed to diagnose suspected conditions or illnesses discovered through screening services, whether or not those services are covered under the Medicaid state plan. (Section 1905(r)) All items and services described in section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan. (Section 1905(r)(5)) Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness. (Section 1905(r)(5)) Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness. (Section 1905(r)(5)) EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis. (Section 1905(r)(5)) The provision of all requested EPSDT screening services, as well as any corrective treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1902(a)(43))

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

Effective Date: 07-01-2011 50 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A)) Mental Health Parity Analysis Requirements for States Not Providing EPSDT to All Covered Populations Please ensure that changes made to benefit limitations under the State child health plan as a result of the parity analysis are also made in Section 6.2. 6.2.3- MHPAEA In order to conduct the parity analysis, the State must place all medical/surgical and mental health and substance use disorder benefits covered under the State child health plan into one of four classifications: Inpatient, outpatient, emergency care, and prescription drugs. (42 CFR 457.496(d)(2)(ii); 42 CFR 457.496(d)(3)(ii)(B)) 6.2.3.1 MHPAEA Please describe below the standard(s) used to place covered benefits into one of the four classifications. 6.2.3.1.1 MHPAEA The State assures that: The State has classified all benefits covered under the State plan into one of the four classifications. Inpatient: a person confined as a registered patient in a Hospital, Skilled Nursing Facility, Substance Abuse Facility, Psychiatric Care Facility or other Institutional Health Care Provider.

Outpatient: a person treated as a registered Outpatient at a Hospital, clinic or in a Professional Health Care Provider's office, who is not, at the time of treatment, a registered patient in a Hospital, Skilled Nursing Facility, Substance Abuse Facility, Psychiatric Care Facility or other Institutional Health Care Provider.

Prescription Drugs: any legend drug, Payable Over-the-Counter Drug, biologic or insulin that is lawfully dispensed according to federal laws, upon receipt of a Prescription Order and is approved by the U.S. Food and Drug Administration for the treatment of the disease or illness for which the Member Child is receiving care.

Emergency Care: health care services, supplies or treatments furnished or required to screen, evaluate and treat an Emergency Medical Condition.

The same reasonable standards are used for determining the classification for a mental health or substance use disorder benefit as are used for determining the classification of medical/surgical benefits. 6.2.3.1.2- MHPAEA Does the State use sub-classifications to distinguish between office visits and other outpatient services?

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

Effective Date: 07-01-2011 51 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 Yes No 6.2.3.1.2.1- MHPAEA If the State uses sub-classifications to distinguish between outpatient office visits and other outpatient services, the State assures the following: The sub-classifications are only used to distinguish office visits from other outpatient items and services, and are not used to distinguish between similar services on other bases (ex: generalist vs. specialist visits). 6.2.3.2 MHPAEA The State assures that: Mental health/ substance use disorder benefits are provided in all classifications in which medical/surgical benefits are provided under the State child health plan. Annual and Aggregate Lifetime Dollar Limits 6.2.4- MHPAEA A State that provides both medical/surgical benefits and mental health and/or substance use disorder benefits must comply with parity requirements related to annual and aggregate lifetime dollar limits for benefits covered under the State child health plan. (42 CFR 457.496(c)) 6.2.4.1- MHPAEA Please indicate whether the State applies an aggregate lifetime dollar limit and/or an annual dollar limit on any mental health or substance abuse disorder benefits covered under the State child health plan. Aggregate lifetime dollar limit is applied Aggregate annual dollar limit is applied No dollar limit is applied If there are no aggregate lifetime or annual dollar limits on any mental health or substance use disorder benefits, please go to section 6.2.5- MHPAEA. 6.2.4.2- MHPAEA Are there any medical/surgical benefits covered under the State child health plan that have either an aggregate lifetime dollar limit or an annual dollar limit? If yes, please specify what type of limits apply. Yes (Type(s) of limit: ) No 6.2.4.3 – MHPAEA. States applying an aggregate lifetime or annual dollar limit on medical/surgical benefits and mental health or substance use disorder benefits must determine whether the portion of the medical/surgical benefits to which the limit applies is less than one-third, at least one-third but less than two-thirds, or at least two-thirds of all medical/surgical benefits covered under the State plan (42 CFR 457.496(c)). The portion of medical/surgical benefits subject to the limit is based on the dollar amount

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

Effective Date: 07-01-2011 52 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 expected to be paid for all medical/surgical benefits under the State plan for the State plan year or portion of the plan year after a change in benefits that affects the applicability of the aggregate lifetime or annual dollar limits. (42 CFR 457.496(c)(3)) The State assures that it has developed a reasonable methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable. 6.2.4.3.1- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to a lifetime dollar limit: Less than 1/3 At least 1/3 and less than 2/3 At least 2/3 6.2.4.3.2- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to an annual dollar limit: Less than 1/3 At least 1/3 and less than 2/3 At least 2/3 If the State applies an aggregate lifetime or annual dollar limit to at least one-third of all medical/surgical benefits, please continue below to provide the assurances related to the determination of the portion of total costs for medical/surgical benefits that are subject to either an annual or lifetime limit. 6.2.4.3.2.1- MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least 1/3 and less than 2/3 of all medical/surgical benefits, the State assures the following (42 CFR 457.496(c)(4)(i)(B)); (42 CFR 457.496(c)(4)(ii)): The State applies an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no more restrictive than an average limit calculated for medical/surgical benefits. 6.2.4.3.2.2- MHPAEA If at least 2/3 of all medical/surgical benefits are subject to an annual or lifetime limit, the State assures either of the following (42 CFR 457.496(c)(2)(i)); (42 CFR 457.496(c)(2)(ii)): The aggregate lifetime or annual dollar limit is applied to both medical/surgical benefits and mental health and substance use disorder benefits in a manner that does not distinguish between medical/surgical benefits and mental health and substance use disorder benefits; or

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

Effective Date: 07-01-2011 53 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefits is no more restrictive than the aggregate lifetime or annual dollar limit on medical/surgical benefits. Quantitative Treatment Limitations 6.2.5- MHPAEA Does the State apply quantitative treatment limitations (QTLs) on any mental health or substance use disorder benefits in any classification of benefits? If yes, specify the classification(s) of benefits in which the State applies one or more QTLs on any mental health or substance use disorder benefits. Yes (Specify: ) No 6.2.5.1- MHPAEA Does the State apply any type of QTL on any medical/surgical benefits? Yes No 6.2.5.2- MHPAEA Within each classification of benefits in which the State applies a type of QTL on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the classification which are subject to the limitation. More specifically, the State must determine the ratio of (a) the dollar amount of all payments expected to be paid under the State plan for medical and surgical benefits within a classification which are subject to the type of quantitative treatment limitation for the plan year (or portion of the plan year after a mid-year change affecting the applicability of a type of quantitative treatment limitation to any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all medical and surgical benefits within the classification for the plan year. For purposes of this paragraph, all payments expected to be paid under the State plan includes payments expected to be made directly by the State and payments which are expected to be made by MCEs contracting with the State. (42 CFR 457.496(d)(3)(i)(C)) The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above for each classification within which the State applies QTLs to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) 6.2.5.3- MHPAEA For each type of QTL applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of QTL to “substantially all” (defined as at least two-thirds) of the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A)) Yes No

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

Effective Date: 07-01-2011 54 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 6.2.5.3.1- MHPAEA For each type of QTL applied to mental health or substance use disorder benefits, the State must determine the predominant level of that type which is applied to medical/surgical benefits in the classification. The “predominant level” of a type of QTL in a classification is the level (or least restrictive of a combination of levels) that applies to more than one-half of the medical/surgical benefits in that classification, as described in 42 CFR 457.496(d)(3)(i)(B). The portion of medical/surgical benefits in a classification to which a given level of a QTL type is applied is based on the dollar amount of payments expected to be paid for medical/surgical benefits subject to that level as compared to all medical/surgical benefits in the classification, as described in 42 CFR 457.496(d)(3)(i)(C). For each type of quantitative treatment limitation applied to mental health or substance use disorder benefits, the State assures: The same reasonable methodology applied in determining the dollar amounts used to determine whether substantially all medical/surgical benefits within a classification are subject to a type of quantitative treatment limitation also is applied in determining the dollar amounts used to determine the predominant level of a type of quantitative treatment limitation applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of quantitative treatment limitation applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of QTL that exceeds the one-half threshold, the State may combine levels within a type of QTL such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2)) Non-Quantitative Treatment Limitations 6.2.6- MHPAEA The State may utilize non-quantitative treatment limitations (NQTLs) for mental health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all the mental health parity requirements. (42 CFR 457.496(d)(4)); (42 CFR 457.496(d)(5)) 6.2.6.1 – MHPAEA If the State imposes any NQTLs, complete this subsection. If the State does not impose NQTLs, please go to Section 6.2.7-MHPAEA. The State assures that the processes, strategies, evidentiary standards or other factors used in the application of any NQTL to mental health or substance use disorder benefits are no more stringent than the processes, strategies, evidentiary standards or other factors used in the application of NQTLs to medical/surgical benefits within the same classification.

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

Effective Date: 07-01-2011 55 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 BCBS ND has historically been a strong advocate of behavioral health services in North Dakota. Because of BCBS ND’s long-standing predilection for robust behavioral health coverage, implementation of the federal mental health parity laws has not been a challenge. BCBS ND’s certificates of insurance identify consistent financial and quantitative treatment limit application across the board for medical/surgical benefits and behavioral health benefits. Services that require prior approval or preauthorization are identified the same for medical/surgical benefits and behavioral health benefits based on the following strategies, processes, evidentiary standards and other factors including: practice variation/variability, significant drivers of cost trend, outlier performance against established benchmarks, disproportionate utilization, preference/system driven care, gaps in care that negatively affect cost, quality and or utilization and outcome yield from the utilization activity/administrate cost analysis. 6.2.6.2 – MHPAEA The State or MCE contracting with the State must comply with parity if they provide coverage of medical or surgical benefits furnished by out-of-network providers. 6.2.6.2.1- MHPAEA Does the State or MCE contracting with the State provide

coverage of medical or surgical benefits provided by out-of-network providers? Yes No 6.2.6.2.2- MHPAEA If yes, the State must provide access to out-of-network providers for mental health or substance use disorder benefits. Please assure the following: The State attests that when determining access to out-of-network providers within a benefit classification, the processes, strategies, evidentiary standards, or other factors used to determine access to those providers for mental health/ substance use disorder benefits are comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors used to determine access for out- of-network providers for medical/surgical benefits. Availability of Plan Information 6.2.7- MHPAEA The State must provide beneficiaries, potential enrollees, and providers with information related to medical necessity criteria and denials of payment or reimbursement for mental health or substance use disorder services (42 CFR 457.496(e)) in addition to existing notice requirements at 42 CFR 457.1180. 6.2.7.1- MHPAEA Medical necessity criteria determinations must be made available to any current or potential enrollee or contracting provider, upon request. The state attests that the following entities provide this information: State Managed Care entities

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

Effective Date: 07-01-2011 56 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 Both Other

6.2.7.2- MHPAEA Reason for any denial for reimbursement or payment for

mental health or substance use disorder benefits must be made available to the

enrollee by the health plan or the State. The state attests that the following

entities provide denial information: State Managed Care entities Both Other 6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1.

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR

6.3.2.

The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2 of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4 Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: Section 2105(c)(s) and (3)) (42 CFR 457.1005 and 457.1010)

6.4.1.

Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42CFR 457.1005(a));

6.4.1.1 Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery

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

Effective Date: 07-01-2011 57 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 system. The state may cross reference section 6.2.1 – 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above.; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

6.4.1.3 The coverage must be provided through the use of a community- based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

6.4.2.

Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3))A)) (42CFR 457.1010(a))

6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b))

6.4.2.3 The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

Section 7. Quality and Appropriateness of Care

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 8.

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

Effective Date: August 26, 2001 58 Approval Date:_______________ 7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495.495(a))

Will the state utilize any of the following tools to assure quality?

(Check all that apply and describe the activities for any categories unutilized.)

7.1.1.

Quality standards

The Department of Human Services contracts with Noridian Mutual Health Insurance to provide medical, dental and vision services to eligible children. The contractor has a current Certificate of Authority from the Insurance Department. The contractor is also required to maintain a Quality Assurance/Quality Improvement Plan that summarized the contractor’s quality assurance system including but not limited to the following standards for the entire range of clinical care and services provided:

• Detailed quality objectives and timetables for accomplishing these objectives. Section 9 contains many of the quality indicators the Department will be using to measure the quality of services provided to children eligible for Healthy Steps. • Description of the quality assurance committee structure. • Identification of contractor staff responsible for quality assessment and improvement. • Description of the manner in which providers participate in quality assurance and improvement activities. The contractor uses provider profiling on a statewide basis to identify quality issues and bring them to the attention of practitioners. • Credentialing procedures. • Standards of clinical care that address preventive services and are based on reasonable scientific evidence and are regularly reviewed by clinicians and distributed to providers. The contractor periodically sends information to providers relating to standards based on the Academy of Immunization Practices and educational materials relating to specific disease states such as asthma, diabetes, and lipid lowering agents. • Standards of service accessibility. The contractor has an extensive provider network that includes 100% of hospitals, 99.6% of all physicians actively practicing in North Dakota, 99.1% of optometrists and 64.1% of dentist participate in the provider network that provides services to eligible children. • Medical records standards, including medical records confidentially provisions.

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

Effective Date: 07-01-2011 59 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 • Utilization review standards and processes. The contractor has developed this requirement and it is on file with the Department of Insurance. • Quality indicator measures and clinical study designs. Quality measures and clinical study have been designed and incorporated into the quality objectives covered in Section 9 of the plan. HEDIS standards will be utilized where appropriate

CHIPRA initial core set technical specifications manual 2011 will be utilized where appropriate, and are designed to improve the delivery for enrolled children.

The Department is especially aware of the need to encourage the use of preventive services for eligible children. As such, we have established goals that are designed to track and improve the delivery of preventive services that include immunizations, well baby and well childcare. A Healthy Steps report card has been developed that will be used to track the progress made to improve the delivery of preventive care services to enrolled children. Goals have been established that will encourage the contractor to educate families and providers about the importance of preventive care and encourage families to seek appropriate immunization and well baby, well child visits in order to ensure that children remain healthy during their formative years.

In addition, the contractor will also have goals for other preventive service improvement including dental and vision visits and hospital emergency service usage. The contractor will also be monitoring with the plan of reducing the rate of institutional psychiatric and chemical dependency services, improving the management of asthma and diabetes, thus reducing the need for expensive hospital interventions.

• Quality Assurance and Quality improvement plan documentation methods. This information is included in the Healthy Steps Report Card process. • Description of how quality improvement activities are integrated with other plan or management functions. The contractor and the Department have periodic discussions regarding quality measures in order to improve or change the quality improvement process. In many instances the Department is using similar measures when establishing quality indicators for the Medicaid program. We are then able to draw comparisons between the programs to assist in identifying issues and improving performance. • Monitoring the effectiveness of the client grievance process, including identification of contractor staff with specific

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

Effective Date: 07-01-2011 60 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 responsibility to resolve problems. The contractor maintains a quarterly grievance report. The Medical Director for the contractor is responsible for resolving any grievances received from the families of enrolled children.

7.1.2.

Performance measurement

The contractor for the Healthy Steps program will assure that high quality and appropriate services are provided to enrolled children. The contractor is required to collect and report data for the following areas that are similar to that required by the Department from our capitated service providers. Modified HEDIS measures will be acceptable, if available.

• Childhood Immunizations • Adolescent Immunizations • Well Baby Visits • Well Child Visits • Treatment Dental Services • Preventive Dental Services • Optometric Services • Preventive Health Promotion Activities • Membership Surveys • Indicators of contractor financial stability • Pharyngitis • Otitis Media with Effusion • Emergency Department Utilization • Asthma related ER visits • Follow-up care for children prescribed attention- deficit/hyperactivity disorder medication • Follow-up after hospitalization for mental illness • Children and adolescents’ access to primary care practitioners (PCP)

Most of the measurements noted above are included in the Healthy Steps Report Card, a required reporting tool by the contractor used to track progress in meeting specific goals for quality improvement. The contractor has encouraged preventive health promotion activities such as sending out annual birthday cards for enrolled children reminding them to make appointments for preventive dental and vision services. The contractor has completed annual membership surveys that are used to evaluate the quality of services being provided to enrolled children.

7.1.3.

Information strategies

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

Effective Date: August 26, 2001 61 Approval Date:_______________

The contractor has developed Healthy Steps enrollee education materials to ensure those children and their families are informed of their benefits, their rights and their responsibilities. The educational material includes information regarding covered services, limitations, grievance procedures, toll-free numbers available to answer questions about covered services and grievance procedures and policies on referrals and after hours care.

7.1.4.

Quality improvement strategies

The contractor has developed an internal measurement and monitoring system that is used to inform providers with emphasis on preventive and coordinated care according to clinical standards and guidelines that includes annual HEDIS information that is shared with providers.

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))

The Department is committed to ensure that enrolled children have access to preventive services. Several of the objectives outlined in Section 9 of this plan are designed to monitor the provision of these services and to devise ways of improving the number of preventive services if targets are not being met including educational efforts for families and providers.

The contractor also conducts yearly surveys that assists in identifying preventive service usage and needs and will be used to correct any issues raised by families concerning access to important preventive services that include preventive physician visits and appropriate immunizations for enrolled children. 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 contractor survey of families seeks information regarding the availability and use of services including hospital emergency room services. The surveys are monitored to determine if any deficiencies exist and action is then taken to correct any apparent problems with access to services.

Emergency room services must be available to all enrollees and are not subject to any prior approval requirements.

The contractor has an extensive provider network that includes all licensed hospitals in the state and more than 99% of practicing physicians. This network

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

Effective Date: August 26, 2001 62 Approval Date:_______________ allows enrolled children the opportunity to receive needed care throughout the state including rural areas.

7.2.3. Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, and 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))

Children with chronic, complex or serious medical conditions may seek the services of any specialist participating in the contractor’s provider network without the need to seek prior approval. Since more than 99% of all physicians participate in that network, access to specialty care is excellent.

While most conditions can be treated by specialists within the contractor’s network, there are certain instances when out of network specialty services are indicated. These services are available from providers located in Minneapolis or Rochester, Minnesota. Participating physicians in North Dakota may make appropriate referrals to these specialists if the services are not available in North Dakota.

The yearly survey conducted by the contractor has a section dedicated to availability of specialty care. Responses are monitored to ensure that specialty services are readily available to enrolled children.

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))

The contractor follows the Utilization Review Accrediting Council of Facilities regarding prior authorization of services and adheres to the 14-day time frame.

Section 8. Cost Sharing and Payment (Section 2103(e))

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 the Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)

8.1.1.

YES

8.1.2.

NO, skip to question 8.88.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate.

(Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) & (c), 457.515(a) & (c))

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

Effective Date: 7-01-2013 63 Approval Date:_______________ Supersedes Effective Date: 8-26-2001

8.2.1. Premiums: No premiums are imposed on covered children.

8.2.2. Deductibles: No deductibles are imposed on covered children. 8.2.3. Coinsurance or copayments: A $5 co-payment will be applied for each emergency room visit to a hospital. A $2 co-payment will be applied for each allowable generic prescription drug; a $4 co-payment will be applied for each allowable preferred brand prescription drug; and a $8 co-payment will be applied for each allowable non- preferred prescription drug. The same co-pays apply to refills dispensed under the benefit package. American Indian children are exempt from this cost sharing. A $50 copayment is applied for the first day of each inpatient hospital admission in a general hospital, an inpatient psychiatric facility or a substance abuse inpatient facility.

8.2.4. Other: There are no other cost-sharing requirements in the Healthy Steps Program.

8.3. Describe how the public will be notified, including the public schedule, of the cost- sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b))

All eligible families of enrolled children will receive a handbook from the insurance carrier that includes information regarding their cost sharing responsibilities. The information is distributed during the first month the children are enrolled in the program. Each family receives notice of the amount of their cumulative maximum at the time they are determined eligible for the Healthy Steps Program.

Cost sharing information is available for the general public through brochures that are distributed throughout the state to various advocacy groups, government agencies, providers and others interested in promoting health care coverage,. Information regarding cost sharing is also posted on the Department’s Website.

8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1.

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530)

8.4.2.

No cost-sharing applies to well-baby and well-child care, including age- appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520)

8.4.3.

No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

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

Effective Date: 07-01-2013 64 Approval Date: _______________ Supersedes Effective Date: 7-01-2011 8.4.1- MHPAEA There is no separate accumulation of cumulative financial requirements, as defined in 42 CFR 457.496(a), for mental health and substance abuse disorder benefits compared to medical/surgical benefits. (42 CFR 457.496(d)(3)(iii)) 8.4.2- MHPAEA If applicable, any different levels of financial requirements that are applied to different tiers of prescription drugs are determined based on reasonable factors, regardless of whether a drug is generally prescribed for medical/surgical benefits or mental health/substance use disorder benefits. (42 CFR 457.496(d)(3)(ii)(A)) 8.4.3- MHPAEA Cost sharing applied to benefits provided under the State child health plan will remain capped at five percent of the beneficiary’s income as required by 42 CFR 457.560 (42 CFR 457.496(d)(3)(i)(D)). 8.4.4- MHPAEA Does the State apply financial requirements to any mental health or substance use disorder benefits? If yes, specify the classification(s) of benefits in which the State applies financial requirements on any mental health or substance use disorder benefits. Yes (Specify: $50 per inpatient hospitalization, $5 co-payment will be applied for each emergency room visit to a hospital. A $2 co-payment will be applied for each allowable generic prescription drug; a $4 co- payment will be applied for each allowable preferred brand prescription drug; and a $8 co-payment will be applied for each allowable non- preferred prescription drug. The same co-pays apply to refills dispensed under the benefit package. American Indian children are exempt from this cost sharing). No Please ensure that changes made to financial requirements under the State child health plan as a result of the parity analysis are also made in Section 8.2. 8.4.5- MHPAEA Does the State apply any type of financial requirements on any medical/surgical benefits? Yes No 8.4.6- MHPAEA Within each classification of benefits in which the State applies a type of financial requirement on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the class which are subject to the limitation. The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above (Section 6.2.5.2-MHPAEA) for each classification or within

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

Effective Date: 07-01-2013 65 Approval Date: _______________ Supersedes Effective Date: 7-01-2011 which the State applies financial requirements to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) 8.4.7- MHPAEA For each type of financial requirement applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of financial requirement to at least two-thirds (“substantially all”) of all the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A)) Yes No 8.4.8- MHPAEA For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State must determine the predominant level (as defined in 42 CFR 457.496(d)(3)(i)(B)) of that type which is applied to medical/surgical benefits in the classification. For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State assures: The same reasonable methodology applied in determining the dollar amounts used in determining whether substantially all medical/surgical benefits within a classification are subject to a type of financial requirement also is applied in determining the dollar amounts used to determine the predominant level of a type of financial requirement applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of financial requirement applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) 8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the state. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

Cost sharing is limited to no more than 5% of gross income for each eligible family. Each family receives a notice that lists the children who are eligible for Healthy Steps. The notice also informs families of the maximum amount of cost-sharing each family is responsible to pay each year. The contractors are required to track the cost sharing. If a child reaches the cost sharing limit, copayments are no longer charged. The insurance carrier issues new cards indicating that the family is no longer subject to any cost sharing.

8.6. Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

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

Effective Date: August 26, 2001 66 Approval Date:_______________

North Dakota uses a self-declaration process to ensure that American Indian children are excluded from cost-sharing. The application requests race information for each applicant. If the applicant indicates that the child is American Indian, it is assumed that they meet the definition as described in the Indian Health Care Improvement Act of 1976.

North Dakota has four recognized Reservations and one Indian Service Area. Nearly all Indians in the state either reside on these reservations or have moved to other areas from the reservations. They originate from tribes that are recognized under the Indian Health Care Improvement Act. Therefore, the department concluded that self-declaration of race is appropriate.

If a child is identified as American Indian, the insurance carrier is notified. The Department makes a premium payment to the carrier that is slightly higher in order to cover the extra costs of not applying co-payments for services provided to enrolled children. The insurance cards issued by the insurance carrier, informs providers that the child is not subject to any of the co-payments that apply to other enrolled children.

8.7. Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c)

Enrolled children in the Healthy Steps Program are not subject to disenrollment if they fail to pay cost-sharing to providers. It is the responsibility of the parents of an enrolled child to pay the cost-sharing amount directly to the provider of service. The provider may take any ordinary means available to collect the amount due. Program enrollment will continue as long as a child is eligible for the Healthy Steps whether or not the family pays the cost sharing amounts to the appropriate providers.

8.7.1. Please provide an assurance that the following disenrollment protections are being applied:

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non payment of cost-sharing charges. (42CFR 457.570(b))

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

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

Effective Date: August 26, 2001 67 Approval Date:_______________ 8.8. The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.

No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFS 457.220)

8.8.2.

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5)

8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1))

8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5))

8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105(c)(7)(B)) (42CFR 457.475)

8.8.6.

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105(c)(7)(A)) (42CFR 457.475)

Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107) 9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

Strategic Objective 1: Reduce the number of North Dakota children, from birth to age 19 who are uninsured.

Strategic Objective 2: Improve access to health care services for North Dakota children enrolled in SCHIP.

Strategic Objective 3: Ensure that children enrolled in SCHIP receive timely and comprehensive preventive health care services.

Strategic Objective 4: Ensure that children enrolled in SCHIP receive high-quality health care services.

Strategic Objective 5: Improve the health status among children enrolled in SCHIP.

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

Effective Date: 07-01-2011 68 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

The Department is acutely aware that outcome measurements are an integral part of SCHIP. We realize that merely making services available does not ensure that children are receiving necessary services or that they are receiving quality health care services. The performance measures outlined below are designed to ensure that enrolled children receive appropriate and necessary health care services.

In order to meet yearly federal reporting requirements we intend to gather information based on services provided between July 1 and June 30 of each year, our state fiscal year. This will permit us to ensure that data provided to CMS is accurate and meaningful.

Performance Measures for strategic Objective 1: Reduce the number of North Dakota children from birth to age 19 who are uninsured. 1.1 Annually at least 600 previously uninsured low-income children will be enrolled in Medicaid and Healthy Steps Programs. 1.2 By December 31, 2011 the percentage of children from birth to 19 years of age without health insurance will decrease by about .5% using the rate based on the current population survey (CPS). Performance Measures for Strategic Objective 2: Improve access to health care services for North Dakota children enrolled in CHIP. 2.1 Annually at least 90% of children surveyed in CHIP will have an identified primary care provider. 2.2 Annually there will be a 2% decrease in the proportion of enrolled children in CHIP who were unable to obtain needed medical care during the previous year as measured through a survey of enrolled families. 2.3 Annually at least 85% of children enrolled in CHIP will have received a preventive dental service before age 8. 2.4 Annually there will be a 2% increase in the number of enrolled children that received a preventative dental service. Performance Measures for Strategic Objective 3: Ensure that children enrolled in CHIP receive timely and comprehensive preventive health care services. 3.1 Annually there will be a 5% increase in the number of children who turned two years of age during the preceding year and were continuously enrolled in CHIP will have received at least four well-child visits during the first 24 months of life. 3.2 Annually there will be a 2% increase in the number of children ages three through six-year-old children who were continuously enrolled in CHIP during the

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

Effective Date: 07-01-2011 69 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 preceding year that will have received one or more well care visits with a primary care provider. 3.3 Annually there will be a 2% increase in the number of children enrolled in CHIP that have received all age appropriate immunizations using the HEDIS measure definition. 3.4 Annually there will be a 2% increase in the number of 13-year-old children enrolled in CHIP that have received a Meningoccal, , TdaplTD or combination vaccine. 3.5 Annually at least 45% of eight-year-old children enrolled in CHIP will have received a vision screening examination. Performance Measures for Strategic Objective 4: Ensure the children enrolled in this Medicaid Expansion receive high quality health care services. 4.1 The annual readmission rate for asthma hospitalizations among children enrolled in CHIP will be compared and monitored to the rate during the previous year. 4.2 Annually thereafter, the average number of emergency room hospital visits will be monitored for children enrolled in CHIP. 4.3 Annually at least 80% of families with children enrolled in CHIP who are surveyed will report overall satisfaction with their health care. Performance Measures for Strategic Objective 5: Improve health status among children enrolled in CHIP. 5.1 Vacated. 5.2 For children enrolled in Healthy Steps with a diagnosis of diabetes will annually be tracked to ensure that the health status of these children improve over time. 5.3 In order to track improvements in the delivery of mental health services in the least restrictive setting, annually the rate of admissions for inpatient hospitalizations and the number of admissions and length of stay residential treatment services for enrolled children with mental illness will be monitored. 5.4 Vacated. 9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state’s performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B) (42CFR 457.710(d))

Strategic Objective 1: Reduce the number of North Dakota children from birth to 19 years of age who are uninsured.

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

Effective Date: 07-01-2011 70 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 The Department will compare the number of children enrolled on January 1st of each year in the Medicaid and Healthy Steps Programs with the number of children enrolled as of January 1 of the previous year. The Department will show that the percentage of uninsured children has decreased by about .5% based on the current population survey.

Strategic Objective 2: Improve access to health care services for North Dakota children enrolled in CHIP. The Department working with the MCO will conduct a survey on an annual basis of families with children enrolled in the program to determine how many eligible children have selected a primary care provider. The Department working with the MCO will conduct a survey on an annual basis of families with children enrolled in the program to determine if families have access to needed care. The Department working with the MCO through evaluation of paid provider claims will identify those children who have received preventive dental care compared to those who have not received this service. Strategic Objective 3: Ensure the children enrolled in CHIP receive timely and comprehensive preventive health care services. The Department working with the MCO will use information from our claims data and the immunization registry to track the age appropriate services and report how well the children are receiving the identified preventive services. Strategic Objective 4: Ensure the children enrolled in CHIP receive high quality health care services. The Department working with the MCO will track and report the rate of readmissions for asthma hospitalization for enrolled children. The Department working with the MCO will track and report using claims data information on the trends in the use of emergency room services by enrolled children. The Department working with the MCO through the use of a family survey will determine the satisfaction level of medical services received by children enrolled in the Medicaid Expansion Program. Strategic Objective 5: Improve health status among children enrolled in SCHIP The Department working with the MCO through analysis of claims data will track children with a diagnosis of diabetes and obesity to determine if improvement in selected quality indicators have improved over time.

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

Effective Date: 07-01-2011 71 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 The Department working with the MCO will track the number of dental fillings received by enrolled children and report results with the anticipation that regular dental care and proper oral hygiene will reduce the number of cavities in children over time. The Department working with the MCO will track children with mental illness diagnosis and report progress in the reduction of hospitalizations and residential treatment service admissions and length of stay over time. Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4))

9.3.1.

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2.

The reduction in the percentage of uninsured children. 9.3.3.

The increase in the percentage of children with a usual source of care. 9.3.4.

The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5.

HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6.

Other child appropriate measurement set. List or describe the set used. 9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as:

9.3.7.1.

Immunizations

9.3.7.2.

Well child care

9.3.7.3

Adolescent well visits

9.3.7.4.

Satisfaction with care

9.3.7.5.

Mental health

9.3.7.6

Dental care 9.3.7.7

Other, please list: Other areas of performance measurement include access to primary care, vision care, asthma inpatient hospital reductions, reduction in emergency room visits, and quality improvement for children with diabetes.

9.3.8.

Performance measures for special targeted populations.

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

Effective Date: 07-01-2011 72 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 9.4.

The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720) 9.5.

The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750) The state assures that it will comply with the annual assessment and evaluation required under Section 10.1 and 10.2. The state will on an annual basis assess and evaluate the operation and effectiveness of this plan and report all findings to CMS by January 1 of each year. The data sources will include but are not limited to, claims data available through the decision support system obtained from Noridian Mutual Health Insurance Company, other reports provided by Noridian, and other information available through the North Dakota Department of Human Services, the North Dakota Department of Health, the Indian Health Service, the Census Bureau and other entities who might have accurate data concerning the number of uninsured children residing in North Dakota. 9.6.

The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720) 9.7.

The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.135) 9.8. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135) 9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3.

Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4.

Section 1132 (relating to periods within which claims must be filed) 9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(A0 and (b))

During the last legislative session, the Healthy Steps program was thoroughly discussed including the use of a joint application for Medicaid and CHIP. Any major changes

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

Effective Date: 07-01-2011 73 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 concerning the operation of the Healthy Steps Program will require legislative approval. In North Dakota, the legislative process is open to anyone who wishes to testify on any bill and all bills must be voted on by the legislature. This process provides the citizens of North Dakota with ample opportunity to provide input before final action is taken by the legislature. In addition, the Department will provide an opportunity for public input whenever major changes in the state plan are finalized and before the plan is submitted for approval. Comments from all interested parties will be solicited either in writing or orally. These comments will be reviewed and considered prior to the submission of any substantial change to the state plan. Ongoing input from the public will continue. For example, a legislative interim committee is monitoring the Children’s Health Insurance Program in North Dakota to determine if any changes need to be made in the future. Interim committee meetings are open to any interested party who wishes to provide input bout this program. The Department will also utilize the Medical Care Advisory Committee which is made up of providers, advocates and recipients to provide input and advice regarding the ongoing operation of the Medicaid Expansion and the separate Healthy Steps Program. 9.9.1. Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c))

Whenever a major change in the state plan is anticipated, the Department will send a letter to the tribal chairman in each of the four Indian Reservations and one Indian Service Area. They will receive information about the proposed changes in the title XXI Program and will be requested to provide any written comments about the propose changes.

In addition, if requested, we will schedule informational meetings regarding the proposed changes at any Reservation or Service Area requesting a meeting. We will accept both written and oral comments from any interested party concerning the proposed changes. All comments received will be analyzed and considered prior to the submittal of any substantial change in the state plan. 9.9.2. For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided and required in 457.65(b) through (d).

Prior to any change in eligibility or benefits procedures are implemented, the Department will schedule a series of public meetings throughout the state. All interested parties will be invited to provide comments regarding the proposed changes. Written and oral comments will be accepted. The Department will analyze and consider all comments before implementing any changes that could adversely affect the eligibility or benefits of children currently enrolled in the program.9.10. Provide a one year projected budget.

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

Effective Date: August 26, 2001 74 Approval Date:_______________ A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140) • Planned use of funds, including –

-Projected amount to be spent on health services;

-Projected amount to be spent on administrative costs, such as

outreach, child health initiatives, and evaluation, and

-Assumptions on which the budget is based, including cost per child

and expected enrollment. • Projected sources of non-Federal plan expenditures, including any

requirements for cost-sharing by enrollees. Section 10. Annual Reports and Evaluations (Section 2108) 10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2) (42CFR 457.750) 10.1.1.

The progress made in reducing the number of uncovered low-income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and 10.2.

The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e)) 10.3.

The state assures that it will comply with all applicable federal laws and regulations, including but not limited to federal grant requirements and federal reporting requirements. Section 11. Program Integrity (Section 2101(a))

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 to Section 12. 11.1.

The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6 – 9.8.9) 11.2.1.

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2.

Section 1124 (relating to disclosure of ownership and related information) 11.2.3.

Section 1126 (relating to disclosure of information about certain convicted individuals)

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

Effective Date: 07-01-2011 75 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 11.2.4.

Section 1128A (relating to civil monetary penalties) 11.2.5.

Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6

Section 1128E (relating to the national health care fraud and abuse data collection program) Section 12. Applicant and Enrollee Protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters 12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120. Requirements for the processing of CHIP applications in contained in North Dakota Administrative Code, Chapter 75-02- 02.2. The state operates a program specific review process. The Department is required to promptly make an eligibility determination. In almost all cases the review is completed before the end of the month in which the Department receives the application.

The Department provides a written notice to each applicant whenever the department denies, suspends or terminates eligibility. The notice includes the effective date of the action taken, the reason for the action taken and the appeal rights available to the applicant. The appeal rights information includes information on filing a written appeal with the appeals supervisor within thirty days after the date of the notice of decision.

If a timely filed appeal is received, the department must conduct an administrative hearing in accordance with requirements outlined in 42 CFR 457.985. Health Services Matters 12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120.

North Dakota operates a statewide standard review process that is contained in Chapter 26.1-36-42 of the North Dakota Century Code that meets the requirements prescribed in 42 CFR 427.1120. This chapter requires all health insurance companies to establish and maintain a procedure for resolving complaints by covered persons regarding any aspect of the plan. In addition to the above statewide standard review, the department also permits enrollees that are dissatisfied with the final decision of the insurance carrier to appeal that decision to the department.

Premium Assistance Programs

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

Effective Date: 07-01-2011 76 Approval Date: _______________ Supersedes Effective Date: 8-26-2001 12.3 If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

Not applicable in North Dakota.

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

Effective Date: 07-01-2011 77 Approval Date: _______________ Supersedes Effective Date: 8-26-2001

_____________________________________________________________________________ Table of Contents State/Territory Name: North Dakota State Plan Amendments (SPA) #: ND-19-0013 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-01-16 @ iY, | &e, Baltimore, MD 21244-1850

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

AUG 08.2019

Jodi Hulm

Administrator, Health Tracks and Healthy Steps

North Dakota Department of Human Services, Medical Services Division 600 East Boulevard Avenue, Department 325

Bismarck, ND 58505-0250

Dear Ms. Hulm:

I am pleased to inform you that your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA), ND-19-0013, has been approved. ND-19-0013 demonstrates compliance with the CHIP managed care regulations at 42 CFR 457, Subpart L, for utilization of a managed care delivery system. This SPA has an effective date of July 1, 2018.

Sections 2101(a), 2103(f)(3), 2107(b), and 2107(e) of the Social Security Act, as implemented through regulations at 42 CFR 457 Subpart L, describe the application of managed care requirements to CHIP. North Dakota has provided the necessary assurances indicating that the state complies with the managed care requirements in the delivery of CHIP services and benefits covered under the state’s separate child health plan as of July 1, 2018.

This SPA approval does not substitute for CMS review of any contracts between the state and managed care entities that serve the state’s CHIP populations. All managed care contracts for CHIP populations in effect as of the state fiscal year beginning on or after J uly 1, 2018 must comply with the CHIP managed care regulations and be submitted for CMS review.

Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

E-mail: Joyce.Jordan@cms.hhs.gov

/signed Anne Marie Costello/

1 TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:________ North Dakota______________________________________________

(Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))_______________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: __Vacant __________

Position/Title: Director, Medical ______________ Name: __Jodi Hulm______

Position/Title: Healthy Steps Program Administrator _____________

Name: ____________

Position/Title: ______________

*Disclosure. In accordance with the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

2 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010, further modified the program. The HEALTHY KIDS Act and The Bipartisan Budget Act of 2018 together resulted in an extension of funding for CHIP through federal fiscal year 2027.

This template outlines the information that must be included in the state plans and the State plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: • Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. • Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) • Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. • Removed crowd-out language that had been added by the August 17 letter that later was repealed. • Added new provisions related to delivery methods, including managed care, to section 3 (81 FR 27498, issued May 6, 2016) States are not required to resubmit existing State plans using this current updated template. However, States must use this updated template when submitting a new State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete

3 response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR, 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires the State to specify its proposed method of delivery. If the State proposes to use managed care, the State must describe and attest to certain requirements of a managed care delivery system, including contracting standards; enrollee enrollment processes; enrollee notification and grievance processes; and plans for enrolling providers, among others. (Section 2103); (42 CFR Part 457. Subpart L) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42 CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of

4 any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary- approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre- existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

5

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: • Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. • Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State plan amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children’s Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections)

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of

6 poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX. Where the state’s assurance is requested in this document for compliance with a particular requirement of 42 CFR 457 et seq., the state shall place a check mark to affirm that it will be in compliance no later than the applicable compliance date. Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Name of Project Officer Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid and CHIP Services Mail Stop - S2-01-16

7 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)(1)); (42 CFR 457.70):

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

1.1.1. Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3. A combination of both of the above. (Section 2101(a)(2))

1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5))

1.2.

Check to provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3.

Check to provide an assurance that the State complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

8 Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

1.4. Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Original Plan Effective Date: October 1, 1998

Implementation Date: October 1, 1998

SPA #13 Purpose of SPA: Compliance with Managed Care Regulations Proposed effective date: July 1, 2018

Proposed implementation date: July 1, 2018

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. A letter was sent to all tribal leaders on May 8, 2019 describing the Managed Care Regulations SPA that the state of North Dakota will be submitting to CMS. The tribal consultation letter was also posted on the Department of Human Services website on May 8, 2019.

TN No: Approval Date Effective Date July 1, 2018

Section 2. General Background and Description of Approach to Children’s Health Insurance Coverage and Coordination

Guidance: The demographic information requested in 2.1. can be used for State planning and will be used strictly for informational purposes. THESE NUMBERS WILL NOT BE USED AS A BASIS FOR THE ALLOTMENT.

Factors that the State may consider in the provision of this information are age breakouts, income brackets, definitions of insurability, and geographic location, as well as race and

9 ethnicity. The State should describe its information sources and the assumptions it uses for the development of its description. • Population • Number of uninsured • Race demographics • Age Demographics • Info per region/Geographic information

2.1. Describe the extent to which, and manner in which, children in the State (including targeted low-income children and other groups of children specified) identified , by income level and other relevant factors, such as race, ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, distinguish between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (Section 2102(a)(1)); (42 CFR 457.80(a))

Guidance: Section 2.2 allows states to request to use the funds available under the 10 percent limit on administrative expenditures in order to fund services not otherwise allowable. The health services initiatives must meet the requirements of 42 CFR 457.10.

2.2. Health Services Initiatives- Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10)

2.3-TC Tribal Consultation Requirements- (Sections 1902(a)(73) and 2107(e)(1)(C)); (ARRA #2, CHIPRA #3, issued May 28, 2009) Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(1)(C) of the Act was also amended to apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

Describe the process the State uses to seek advice on a regular, ongoing basis from federally-recognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to Medicaid and CHIP programs and for consultation on State Plan

10 Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prior to submission to CMS. Include information about the frequency, inclusiveness and process for seeking such advice. Section 3. Methods of Delivery and Utilization Controls 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 (Eligibility Standards and Methodology). Guidance: In Section 3.1, describe all delivery methods the State will use to provide services to enrollees, including: (1) contracts with managed care organizations (MCO), prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), primary care case management entities (PCCM entities), and primary care case managers (PCCM); (2) contracts with indemnity health insurance plans; (3) fee-for-service (FFS) paid by the State to health care providers; and (4) any other arrangements for health care delivery. The State should describe any variations based upon geography and by population (including the conception to birth population). States must submit the managed care contract(s) to CMS’ Regional Office for review. 3.1. Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L) 3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. No, the State does not use a managed care delivery system for any CHIP populations. Yes, the State uses a managed care delivery system for all CHIP populations. Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care delivery system and some of the CHIP population is included in a fee- for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the

11 State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2. Children that are eligible for the State of North Dakota’s Stand Alone CHIP are enrolled in the managed care delivery system. Children eligible under the CHIP Medicaid Expansion group use the fee-for-service delivery system. Guidance: Utilization control systems are those administrative mechanisms that are 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. Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b)) If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of: • 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); 42 CFR 457.490(a)) • The utilization control 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); 42 CFR 457.490(b))

Guidance: Only States that use a managed care delivery system for all or some CHIP populations need to answer the remaining questions under Section 3 (starting with 3.1.1.2). If the State uses a managed care delivery system for only some of its CHIP population, the State’s responses to the following questions will only apply to those populations.

12 3.1.1.2 Do any of your CHIP populations that receive services through a managed care delivery system receive any services outside of a managed care delivery system? No Yes

If yes, please describe which services are carved out of your managed care delivery system and how the State provides these services to an enrollee, such as through fee-for-service. Examples of carved out services may include transportation and dental, among others. 3.1.2 Use of a Managed Care Delivery System for All or Some of the State’s CHIP Populations 3.1.2.1 Check each of the types of entities below that the State will contract with under its managed care delivery system, and select and/or explain the method(s) of payment that the State will use: Managed care organization (MCO) (42 CFR 457.10) Capitation payment Actuarial sound capitation rates developed by contracted actuary.

Describe population served: CHIP stand along population

Prepaid inpatient health plan (PIHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Guidance: If the State uses prepaid ambulatory health plan(s) (PAHP) to exclusively provide non-emergency medical transportation (a NEMT PAHP), the State should not check the following box for that plan. Instead, complete section 3.1.3 for the NEMT PAHP. Prepaid ambulatory health plan (PAHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Primary care case manager (PCCM) (individual practitioners) (42 CFR 457.10) Case management fee Other (please explain)

13 Primary care case management entity (PCCM Entity) (42 CFR 457.10) Case management fee Shared savings, incentive payments, and/or other financial rewards for improved quality outcomes (see 42 CFR 457.1240(f)) Other (please explain)

If PCCM entity is selected, please indicate which of the following function(s) the entity will provide (as described in 42 CFR 457.10), in addition to PCCM services: Provision of intensive telephonic case management Provision of face-to-face case management Operation of a nurse triage advice line Development of enrollee care plans Execution of contracts with fee-for-service (FFS) providers in the FFS program Oversight responsibilities for the activities of FFS providers in the FFS program Provision of payments to FFS providers on behalf of the State Provision of enrollee outreach and education activities Operation of a customer service call center Review of provider claims, utilization and/or practice patterns to conduct provider profiling and/or practice improvement Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers Coordination with behavioral health systems/providers Other (please describe)

3.1.2.2

The State assures that if its contract with an MCO, PAHP, or PIHP allows the entity to use a physician incentive plan, the contract stipulates that the entity must comply with the requirements set forth in 42 CFR 422.208 and 422.210. (42 CFR 457.1201(h), cross-referencing to 42 CFR 438.3(i)) 3.1.3 Nonemergency Medical Transportation PAHPs Guidance: Only complete Section 3.1.3 if the State uses a PAHP to exclusively provide non- emergency medical transportation (a NEMT PAHP). If a NEMT PAHP is the only managed care entity for CHIP in the State, please continue to Section 4 after checking the assurance below. If the State uses a PAHP that does not exclusively provide NEMT and/or uses other managed care entities beyond a NEMT PAHP, the State will need to complete the remaining sections within Section 3.

14

The State assures that it complies with all requirements applicable to NEMT PAHPs, and through its contracts with such entities, requires NEMT PAHPs to comply with all applicable requirements, including the following (from 42 CFR 457.1206(b)): • All contract provisions in 42 CFR 457.1201 except those set forth in 42 CFR 457.1201(h) (related to physician incentive plans) and 42 CFR 457.1201(l) (related to mental health parity). • The information requirements in 42 CFR 457.1207 (see Section 3.5 below for more details). • The provision against provider discrimination in 42 CFR 457.1208. • The State responsibility provisions in 42 CFR 457.1212 (about disenrollment), 42 CFR 457.1214 (about conflict of interest safeguards), and 42 CFR 438.62(a), as cross-referenced in 42 CFR 457.1216 (about continued services to enrollees). • The provisions on enrollee rights and protections in 42 CFR 457.1220, 457.1222, 457.1224, and 457.1226. • The PAHP standards in 42 CFR 438.206(b)(1), as cross-referenced by 42 CFR 457.1230(a) (about availability of services), 42 CFR 457.1230(d) (about coverage and authorization of services), and 42 CFR 457.1233(a), (b) and (d) (about structure and operation standards). • An enrollee's right to a State review under subpart K of 42 CFR 457. • Prohibitions against affiliations with individuals debarred or excluded by Federal agencies in 42 CFR 438.610, as cross referenced by 42 CFR 457.1285. • Requirements relating to contracts involving Indians, Indian Health Care Providers, and Indian managed care entities in 42 CFR 457.1209.

3.2. General Managed Care Contract Provisions

3.2.1

The State assures that it provides for free and open competition, to the maximum extent practical, in the bidding of all procurement contracts for coverage or other services, including external quality review organizations, in accordance with the procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b); 42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e)) 3.2.2

The State assures that it will include provisions in all managed care contracts that define a sound and complete procurement contract, as required by 45 CFR part 75, as applicable. (42 CFR 457.940(c)) 3.2.3

The State assures that each MCO, PIHP, PAHP, PCCM, and PCCM entity complies with any applicable Federal and State laws that pertain to enrollee rights, and ensures that its employees and contract providers observe and protect

15 those rights (42 CFR 457.1220, cross-referencing to 42 CFR 438.100). These Federal and State laws include: Title VI of the Civil Rights Act of 1964 (45 CFR part 80), Age Discrimination Act of 1975 (45 CFR part 91), Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, Titles II and III of the Americans with Disabilities Act, and section 1557 of the Patient Protection and Affordable Care Act. 3.2.4 The State assures that it operates a Web site that provides the MCO, PIHP, PAHP, and PCCM entity contracts. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(3)) 3.3 Rate Development Standards and Medical Loss Ratio 3.3.1 The State assures that its payment rates are: Based on public or private payment rates for comparable services for comparable populations; and Consistent with actuarially sound principles as defined in 42 CFR 457.10. (42 CFR 457.1203(a)) Guidance: States that checked both boxes under 3.3.1 above do not need to make the next assurance. If the state is unable to check both boxes under 3.1.1 above, the state must check the next assurance. If the State is unable to meet the requirements under 42 CFR 457.1203(a), the State attests that it must establish higher rates because such rates are necessary to ensure sufficient provider participation or provider access or to enroll providers who demonstrate exceptional efficiency or quality in the provision of services. (42 CFR 457.1203(b)) 3.3.2 The State assures that its rates are designed to reasonably achieve a medical loss ratio standard equal to at least 85 percent for the rate year and provide for reasonable administrative costs. (42 CFR 457.1203(c)) 3.3.3 The State assures that it will provide to CMS, if requested by CMS, a description of the manner in which rates were developed in accordance with the requirements of 42 CFR 457.1203(a) through (c). (42 CFR 457.1203(d)) 3.3.4 The State assures that it annually submits to CMS a summary description of the reports pertaining to the medical loss ratio received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(a))

16 3.3.5 Does the State require an MCO, PIHP, or PAHP to pay remittances through the contract for not meeting the minimum MLR required by the State? (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b)(1)) No, the State does not require any MCO, PIHP, or PAHP to pay remittances. Yes, the State requires all MCOs, PIHPs, and PAHPs to pay remittances. Yes, the State requires some, but not all, MCOs, PIHPs, and PAHPs to pay remittances. If the State requests some, but not all, MCOs, PIHPs, and PAHPs to pay remittances through the contract for not meeting the minimum MLR required by the State, please describe which types of managed care entities are and are not required to pay remittances. For example, if a state requires a medical MCO to pay a remittances but not a dental PAHP, please include this information. If the answer to the assurance above is yes for any or all managed care entities, please answer the next assurance: The State assures that it if a remittance is owed by an MCO, PIHP, or PAHP to the State, the State: • Reimburses CMS for an amount equal to the Federal share of the remittance, taking into account applicable differences in the Federal matching rate; and • Submits a separate report describing the methodology used to determine the State and Federal share of the remittance with the annual report provided to CMS that summarizes the reports received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b)) 3.3.6 The State assures that each MCO, PIHP, and PAHP calculates and reports the medical loss ratio in accordance with 42 CFR 438.8. (42 CFR 457.1203(f)) 3.4 Enrollment The State assures that its contracts with MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities provide that the MCO, PIHP, PAHP, PCCM or PCCM entity: • Accepts individuals eligible for enrollment in the order in which they apply without restriction (unless authorized by CMS), up to the limits set under the contract (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(1)); • Will not, on the basis of health status or need for health care services, discriminate against individuals eligible to enroll (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(3)); and • Will not discriminate against individuals eligible to enroll on the basis of race, color, national origin, sex, sexual orientation, gender identity, or disability and will not use

17 any policy or practice that has the effect of discriminating on the basis of race, color, national origin, sex, sexual orientation, gender identity or disability. (42 CFR 457.1201(d), cross-referencing to 438.3(d)(4)) 3.4.1 Enrollment Process 3.4.1.1

The State assures that it provides informational notices to potential enrollees in an MCO, PIHP, PAHP, PCCM, or PCCM entity that includes the available managed care entities, explains how to select an entity, explains the implications of making or not making an active choice of an entity, explains the length of the enrollment period as well as the disenrollment policies, and complies with the information requirements in 42 CFR 457.1207 and accessibility standards established under 42 CFR 457.340. (42 CFR 457.1210(c)) 3.4.1.2

The State assures that its enrollment system gives beneficiaries already enrolled in an MCO, PIHP, PAHP, PCCM, or PCCM entity priority to continue that enrollment if the MCO, PIHP, PAHP, PCCM, or PCCM entity does not have the capacity to accept all those seeking enrollment under the program. (42 CFR 457.1210(b)) 3.4.1.3 Does the State use a default enrollment process to assign beneficiaries to an MCO, PIHP, PAHP, PCCM, or PCCM entity? (42 CFR 457.1210(a)) Yes No

If the State uses a default enrollment process, please make the following assurances: The State assigns beneficiaries only to qualified MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities that are not subject to the intermediate sanction of having suspension of all new enrollment (including default enrollment) under 42 CFR 438.702 and have capacity to enroll beneficiaries. (42 CFR 457.1210(a)(1)(i)) The State maximizes continuation of existing provider-beneficiary relationships under 42 CFR 457.1210(a)(1)(ii) or if that is not possible, distributes the beneficiaries equitably and does not arbitrarily exclude any MCO, PIHP, PAHP, PCCM or PCCM entity from being considered. (42 CFR 457.1210(a)(1)(ii), 42 CFR 457.1210(a)(1)(iii))

3.4.2 Disenrollment

18 3.4.2.1

The State assures that the State will notify enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f)(2)) 3.4.2.2

The State assures that the effective date of an approved disenrollment, regardless of the procedure followed to request the disenrollment, will be no later than the first day of the second month following the month in which the enrollee requests disenrollment or the MCO, PIHP, PAHP, PCCM or PCCM entity refers the request to the State. (42 CFR 457.1212, cross-referencing to 438.56(e)(1)) 3.4.2.3

If a beneficiary disenrolls from an MCO, PIHP, PAHP, PCCM, or PCCM entity, the State assures that the beneficiary is provided the option to enroll in another plan or receive benefits from an alternative delivery system. (Section 2103(f)(3) of the Social Security Act, incorporating section 1932(a)(4); 42 CFR 457.1212, cross referencing to 42 CFR 438.56; State Health Official Letter #09-008) 3.4.2.4 MCO, PIHP, PAHP, PCCM and PCCM Entity Requests for Disenrollment. The State assures that contracts with MCOs, PIHPs, PAHPs, PCCMs and PCCM entities describe the reasons for which an MCO, PIHP, PAHP, PCCM and PCCM entity may request disenrollment of an enrollee, if any. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)) Guidance: Reasons for disenrollment by the MCO, PIHP, PAHP, PCCM, and PCCM entity must be specified in the contract with the State. Reasons for disenrollment may not include an adverse change in the enrollee's health status, or because of the enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the MCO, PIHP, PAHP, PCCM or PCCM entity seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)(2)) 3.4.2.5 Enrollee Requests for Disenrollment. Guidance: The State may also choose to limit disenrollment from the MCO, PIHP, PAHP, PCCM, or PCCM entity, except for either: 1) for cause, at any time; or 2) without cause during the latter of the 90 days after the beneficiary’s initial enrollment or the State sends the beneficiary notice of

19 that enrollment, at least once every 12 months, upon reenrollment if the temporary loss of CHIP eligibility caused the beneficiary to miss the annual disenrollment opportunity, or when the State imposes the intermediate sanction specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Does the State limit disenrollment from an MCO, PIHP, PAHP, PCCM and PCCM entity by an enrollee? (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Yes No

If the State limits disenrollment by the enrollee from an MCO, PIHP, PAHP, PCCM and PCCM entity, please make the following assurances (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)): The State assures that enrollees and their representatives are given written notice of disenrollment rights at least 60 days before the start of each enrollment period. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(1)) The State assures that beneficiary requests to disenroll for cause will be permitted at any time by the MCO, PIHP, PAHP, PCCM or PCCM entity. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(1) and (d)(2)) The State assures that beneficiary requests for disenrollment without cause will be permitted by the MCO, PIHP, PAHP, PCCM or PCCM entity at the following times: • During the 90 days following the date of the beneficiary's initial enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later; • At least once every 12 months thereafter; • If the State plan provides for automatic reenrollment for an individual who loses CHIP eligibility for a period of 2 months or less and the temporary loss of CHIP eligibility has caused the beneficiary to miss the annual disenrollment opportunity; and • When the State imposes the intermediate sanction on the MCO, PIHP, PAHP, PCCM or PCCM entity specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(2)) 3.4.2.6

The State assures that the State ensures timely access to a State review for any enrollee dissatisfied with a State agency determination that there is not good cause for disenrollment. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(2))

20 3.5 Information Requirements for Enrollees and Potential Enrollees 3.5.1

The State assures that it provides, or ensures its contracted MCOs, PAHPs, PIHPs, PCCMs and PCCM entities provide, all enrollment notices, informational materials, and instructional materials related to enrollees and potential enrollees in accordance with the terms of 42 CFR 457.1207, cross-referencing to 42 CFR 438.10. 3.5.2

The State assures that all required information provided to enrollees and potential enrollees are in a manner and format that may be easily understood and is readily accessible by such enrollees and potential enrollees. (42 CFR 457.1207, cross- referencing to 42 CFR 438.10(c)(1)) 3.5.3

The State assures that it operates a Web site that provides the content specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)-(i) either directly or by linking to individual MCO, PIHP, PAHP and PCCM entity Web sites. 3.5.4

The State assures that it has developed and requires each MCO, PIHP, PAHP and PCCM entity to use: • Definitions for the terms specified under 42 CFR 438.10(c)(4)(i), and • Model enrollee handbooks, and model enrollee notices. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(4))

3.5.5

If the State, MCOs, PIHPs, PAHPs, PCCMs or PCCM entities provide the information required under 42 CFR 457.1207 electronically, check this box to confirm that the State assures that it meets the requirements under 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(6) for providing the material in an accessible manner. Including that: • The format is readily accessible; • The information is placed in a location on the State, MCO's, PIHP's, PAHP's, or PCCM's, or PCCM entity's Web site that is prominent and readily accessible; • The information is provided in an electronic form which can be electronically retained and printed; • The information is consistent with the content and language requirements in 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without charge upon request and is provided the information upon request within 5 business days. 3.5.6

The State assures that it meets the language and format requirements set forth in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(d), including but not limited to:

21 • Establishing a methodology that identifies the prevalent non-English languages spoken by enrollees and potential enrollees throughout the State, and in each MCO, PIHP, PAHP, or PCCM entity service area; • Making oral interpretation available in all languages and written translation available in each prevalent non-English language; • Requiring each MCO, PIHP, PAHP, and PCCM entity to make its written materials that are critical to obtaining services available in the prevalent non- English languages in its particular service area; • Making interpretation services available to each potential enrollee and requiring each MCO, PIHP, PAHP, and PCCM entity to make those services available free of charge to each enrollee; and • Notifying potential enrollees, and requiring each MCO, PIHP, PAHP, and PCCM entity to notify its enrollees: o That oral interpretation is available for any language and written translation is available in prevalent languages; o That auxiliary aids and services are available upon request and at no cost for enrollees with disabilities; and o How to access the services in 42 CFR 457.1207, cross-referencing 42 CFR 438.10(d)(5)(i) and (ii).

3.5.7

The State assures that the State or its contracted representative provides the information specified in 42 CFR 457.1207, cross-referencing to 438.10(e)(2), and includes the information either in paper or electronic format, to all potential enrollees at the time the potential enrollee becomes eligible to enroll in a voluntary managed care program or is first required to enroll in a mandatory managed care program and within a timeframe that enables the potential enrollee to use the information to choose among the available MCOs, PIHPs, PAHPs, PCCMs and PCCM entities: • Information about the potential enrollee's right to disenroll consistent with the requirements of 42 CFR 438.56 and which explains clearly the process for exercising this disenrollment right, as well as the alternatives available to the potential enrollee based on their specific circumstance; • The basic features of managed care; • Which populations are excluded from enrollment in managed care, subject to mandatory enrollment, or free to enroll voluntarily in the program; • The service area covered by each MCO, PIHP, PAHP, PCCM, or PCCM entity; • Covered benefits including: o Which benefits are provided by the MCO, PIHP, or PAHP; and which, if any, benefits are provided directly by the State; and o For a counseling or referral service that the MCO, PIHP, or PAHP does not cover because of moral or religious objections, where and how to

22 obtain the service; • The provider directory and formulary information required in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h) and (i); • Any cost-sharing for the enrollee that will be imposed by the MCO, PIHP, PAHP, PCCM, or PCCM entity consistent with those set forth in the State plan; • The requirements for each MCO, PIHP or PAHP to provide adequate access to covered services, including the network adequacy standards established in 42 CFR 457.1218, cross-referencing 42 CFR 438.68; • The MCO, PIHP, PAHP, PCCM and PCCM entity's responsibilities for coordination of enrollee care; and • To the extent available, quality and performance indicators for each MCO, PIHP, PAHP and PCCM entity, including enrollee satisfaction. 3.5.8

The State assures that it will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that the State must notify all enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. 3.5.9

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that: • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity, must make a good faith effort to give written notice of termination of a contracted provider within the timeframe specified in 42 CFR 438.10(f), and • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity must make available, upon request, any physician incentive plans in place as set forth in 42 CFR 438.3(i).

3.5.10

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide enrollees of that MCO, PIHP, PAHP or PCCM entity an enrollee handbook that meets the requirements as applicable to the MCO, PIHP, PAHP and PCCM entity, specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(1)-(2), within a reasonable time after receiving notice of the beneficiary's enrollment, by a method consistent with 42 CFR 438.10(g)(3), and including the following items: • Information that enables the enrollee to understand how to effectively use the managed care program, which, at a minimum, must include: o Benefits provided by the MCO, PIHP, PAHP or PCCM entity; o How and where to access any benefits provided by the State, including any cost sharing, and how transportation is provided; and o In the case of a counseling or referral service that the MCO, PIHP,

23 PAHP, or PCCM entity does not cover because of moral or religious objections, the MCO, PIHP, PAHP, or PCCM entity must inform enrollees that the service is not covered by the MCO, PIHP, PAHP, or PCCM entity and how they can obtain information from the State about how to access these services; • The amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled; • Procedures for obtaining benefits, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the enrollee's primary care provider; • The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition and emergency services; o The fact that prior authorization is not required for emergency services; and o The fact that, subject to the provisions of this section, the enrollee has a right to use any hospital or other setting for emergency care; • Any restrictions on the enrollee's freedom of choice among network providers; • The extent to which, and how, enrollees may obtain benefits, including family planning services and supplies from out-of-network providers; • Cost sharing, if any is imposed under the State plan; • Enrollee rights and responsibilities, including the elements specified in 42 CFR §438.100; • The process of selecting and changing the enrollee's primary care provider; • Grievance, appeal, and review procedures and timeframes, consistent with 42 CFR 457.1260, in a State-developed or State-approved description, including: o The right to file grievances and appeals; o The requirements and timeframes for filing a grievance or appeal; o The availability of assistance in the filing process; and o The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; • How to access auxiliary aids and services, including additional information in alternative formats or languages; • The toll-free telephone number for member services, medical management, and any other unit providing services directly to enrollees; and

24 • Information on how to report suspected fraud or abuse. 3.5.11

The State assures that each MCO, PIHP, PAHP and PCCM entity will give each enrollee notice of any change that the State defines as significant in the information specified in the enrollee handbook at least 30 days before the intended effective date of the change. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(4)) 3.5.12

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available a provider directory for the MCO’s, PIHP’s, PAHP’s or PCCM entity’s network providers, including for physicians (including specialists), hospitals, pharmacies, and behavioral health providers, that includes information as specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(1)-(2) and (4). 3.5.13

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will update any information included in a paper provider directory at least monthly and in an electronic provider directories as specified in 42 CFR 438.10(h)(3). (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(3)) 3.5.14

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available the MCO’s, PIHP’s, PAHP’s, or PCCM entity’s formulary that meets the requirements specified in 42 CFR 457.1207, cross- referencing to 42 CFR 438.10(i), including: • Which medications are covered (both generic and name brand); and • What tier each medication is on. 3.5.15

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity follows the requirements for marketing activities under 42 CFR 457.1224, cross- referencing to 42 CFR 438.104 (except 42 CFR 438.104(c)). Guidance: Requirements for marketing activities include, but are not limited to, that the MCO, PIHP, PAHP, PCCM, or PCCM entity does not distribute any marketing materials without first obtaining State approval; distributes the materials to its entire service areas as indicated in the contract; does not seek to influence enrollment in conjunction with the sale or offering of any private insurance; and does not, directly or indirectly, engage in door-to-door, telephone, email, texting, or other cold-call marketing activities. (42 CFR 104(b)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.5 (3.5.16 through 3.5.18).

25 3.5.16

The State assures that each MCO, PIHP and PAHP protects communications between providers and enrollees under 42 CFR 457.1222, cross-referencing to 42 CFR 438.102. 3.5.17

The State assures that MCOs, PIHPs, and PAHPs have arrangements and procedures that prohibit the MCO, PIHP, and PAHP from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity. (42 CFR 457.1280(b)(2)) Guidance: States should also complete Section 3.9, which includes additional provisions about the notice procedures for grievances and appeals. 3.5.18

The State assures that each contracted MCO, PIHP, and PAHP comply with the notice requirements specified for grievances and appeals in accordance with the terms of 42 CFR 438, Subpart F, except that the terms of 42 CFR 438.420 do not apply and that references to reviews should be read to refer to reviews as described in 42 CFR 457, Subpart K. (42 CFR 457.1260) 3.6 Benefits and Services Guidance: The State should also complete Section 3.10 (Program Integrity). 3.6.1

The State assures that MCO, PIHP, PAHP, PCCM entity, and PCCM contracts involving Indians, Indian health care providers, and Indian managed care entities comply with the requirements of 42 CFR 438.14. (42 CFR 457.1209) 3.6.2

The State assures that all services covered under the State plan are available and accessible to enrollees. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.3

The State assures that it: • Publishes the State’s network adequacy standards developed in accordance with 42 CFR 457.1218, cross-referencing 42 CFR 438.68(b)(1) on the Web site required by 42 CFR 438.10; • Makes available, upon request, the State’s network adequacy standards at no cost to enrollees with disabilities in alternate formats or through the provision of auxiliary aids and services. (42 CFR 457.1218, cross- referencing 42 CFR 438.68(e)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete the remaining assurances in Section 3.6 (3.6.4 through 3.6.20.

26 3.6.4

The State assures that each MCO, PAHP and PIHP meet the State’s network adequacy standards. (42 CFR 457.1218, cross-referencing 42 CFR 438.68; 42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.5

The State assures that each MCO, PIHP, and PAHP includes within its network of credentialed providers: • A sufficient number of providers to provide adequate access to all services covered under the contract for all enrollees, including those with limited English proficiency or physical or mental disabilities; • Women’s health specialists to provide direct access to covered care necessary to provide women’s routine and preventative health care services for female enrollees; and • Family planning providers to ensure timely access to covered services. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b) 3.6.6

The State assures that each contract under 42 CFR 457.1201 permits an enrollee to choose his or her network provider. (42 CFR 457.1201(j), cross-referencing 42 CFR 438.3(l)) 3.6.7

The State assures that each MCO, PIHP, and PAHP provides for a second opinion from a network provider, or arranges for the enrollee to obtain one outside the network, at no cost. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(3)) 3.6.8

The State assures that each MCO, PIHP, and PAHP ensures that providers, in furnishing services to enrollees, provide timely access to care and services, including by: • Requiring the contract to adequately and timely cover out-of-network services if the provider network is unable to provide necessary services covered under the contract to a particular enrollee and at a cost to the enrollee that is no greater than if the services were furnished within the network; • Requiring the MCO, PIHP and PAHP meet and its network providers to meet State standards for timely access to care and services, taking into account the urgency of the need for services; • Ensuring that the hours of operation for a network provider are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid or CHIP Fee-For-Service, if the provider serves only Medicaid or CHIP enrollees; • Ensuring that the MCO, PIHP and PAHP makes available services include in the contract on a 24 hours a day, 7 days a week basis when medically necessary; • Establishing mechanisms to ensure compliance by network providers;

27 • Monitoring network providers regularly to determine compliance; • Taking corrective action if there is a failure to comply by a network provider. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(4) and (5) and (c)) 3.6.9

The State assures that each MCO, PIHP, and PAHP has the capacity to serve the expected enrollment in its service area in accordance with the State's standards for access to care. (42 CFR 457.1230(b), cross-referencing to 42 CFR 438.207) 3.6.10

The State assures that each MCO, PIHP, and PAHP will be required to submit documentation to the State, at the time of entering into a contract with the State, on an annual basis, and at any time there has been a significant change to the MCO, PIHP, or PAHP’s operations that would affect the adequacy of capacity and services, to demonstrate that each MCO, PIHP, and PAHP for the anticipated number of enrollees for the service area: • Offers an appropriate range of preventative, primary care and specialty services; and • Maintains a provider network that is sufficient in number, mix, and geographic distribution. (42 CFR 457.1230, cross-referencing to 42 CFR 438.207(b)) 3.6.11

Except that 42 CFR 438.210(a)(5) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the coverage of services requirements under 42 CFR 438.210, including: • Identifying, defining, and specifying the amount, duration, and scope of each service that the MCO, PIHP, or PAHP is required to offer; and • Permitting an MCO, PIHP, or PAHP to place appropriate limits on a service. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(a) except that 438.210(a)(5) does not apply to CHIP contracts) 3.6.12

Except that 438.210(b)(2)(iii) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the authorization of services requirements under 42 CFR 438.210, including that: • The MCO, PIHP, or PAHP and its subcontractors have in place and follow written policies and procedures; • The MCO, PIHP, or PAHP have in place mechanisms to ensure consistent application of review criteria and consult with the requesting provider when appropriate; and • Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by an individual with appropriate expertise in addressing the enrollee’s medical, or behavioral health needs. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(b), except that 438.210(b)(2)(iii)

28 does not apply to CHIP contracts) 3.6.13

The State assures that its contracts with each MCO, PIHP, or PAHP require each MCO, PIHP, or PAHP to notify the requesting provider and given written notice to the enrollee of any adverse benefit determination to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(c)) 3.6.14

The State assures that its contracts with each MCO, PIHP, or PAHP provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(e)) 3.6.15

The State assures that it has a transition of care policy that meets the requirements of 438.62(b)(1) and requires that each contracted MCO, PIHP, and PAHP implements the policy. (42 CFR 457.1216, cross-referencing to 42 CFR 438.62) 3.6.16

The State assures that each MCO, PIHP, and PAHP has implemented procedures to deliver care to and coordinate services for all enrollees in accordance with 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208, including: • Ensure that each enrollee has an ongoing source of care appropriate to his or her needs; • Ensure that each enrollee has a person or entity formally designated as primarily responsible for coordinating the services accessed by the enrollee; • Provide the enrollee with information on how to contract their designated person or entity responsible for the enrollee’s coordination of services; • Coordinate the services the MCO, PIHP, or PAHP furnishes to the enrollee between settings of care; with services from any other MCO, PIHP, or PAHP; with fee-for-service services; and with the services the enrollee receives from community and social support providers; • Make a best effort to conduct an initial screening of each enrollees needs within 90 days of the effective date of enrollment for all new enrollees; • Share with the State or other MCOs, PIHPs, or PAHPs serving the enrollee the results of any identification and assessment of the enrollee’s needs; • Ensure that each provider furnishing services to enrollees maintains and shares, as appropriate, an enrollee health record in accordance with professional standards; and

29 • Ensure that each enrollee’s privacy is protected in the process of coordinating care is protected with the requirements of 45 CFR parts 160 and 164 subparts A and E. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(b)) Guidance: For assurances 3.6.17 through 3.6.20, applicability to PIHPs and PAHPs is based a determination by the State in relation to the scope of the entity’s services and on the way the State has organized its delivery of managed care services, whether a particular PIHP or PAHP is required to implement the mechanisms for identifying, assessing, and producing a treatment plan for an individual with special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(a)(2)) 3.6.17

The State assures that it has implemented mechanisms for identifying to MCOs, PIHPs, and PAHPs enrollees with special health care needs who are eligible for assessment and treatment services under 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c) and included the mechanism in the State’s quality strategy. 3.6.18

The State assures that each applicable MCO, PIHP, and PAHP implements the mechanisms to comprehensively assess each enrollee identified by the state as having special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(2)) 3.6.19

The State assures that each MCO, PIHP, and PAHP will produce a treatment or service plan that meets the following requirements for enrollees identified with special health care needs: • Is in accordance with applicable State quality assurance and utilization review standards; • Reviewed and revised upon reassessment of functional need, at least every 12 months, or when the enrollee’s circumstances or needs change significantly. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(3)) 3.6.20

The State assures that each MCO, PIHP, and PAHP must have a mechanism in place to allow enrollees to directly access a specialist as appropriate for the enrollee's condition and identified needs for enrollees identified with special health care needs who need a course of treatment or regular care monitoring. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(4)) 3.7 Operations 3.7.1

The State assures that it has established a uniform credentialing and recredentialing policy that addresses acute, primary, behavioral, and substance use

30 disorders providers and requires each MCO, PIHP and PAHP to follow those policies. (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(b)(1)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.7 (3.7.2 through 3.7.9). 3.7.2 The State assures each contracted MCO, PIHP and PAHP will comply with the provider selection requirements in 42 CFR 457.1208 and 457.1233(a), cross- referencing 42 CFR 438.12 and 438.214, including that: Each MCO, PIHP, or PAHP implements written policies and procedures for selection and retention of network providers (42 CFR 457.1233(a), cross- referencing 42 CFR 438.214(a)); MCO, PIHP, and PAHP network provider selection policies and procedures do not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(c)); MCOs, PIHPs, and PAHPs do not discriminate in the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification, solely on the basis of that license or certification (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); If an MCO, PIHP, or PAHP declines to include individual or groups of providers in the MCO, PIHP, or PAHP’s provider network, the MCO, PIHP, and PAHP gives the affected providers written notice of the reason for the decision (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); and MCOs, PIHPs, and PAHPs do not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. (42 CFR 457.1233(a), cross- referencing 42 CFR 438.214(d)).

3.7.3 The State assures that each contracted MCO, PIHP, and PAHP complies with the subcontractual relationships and delegation requirements in 42 CFR 457.1233(b), cross-referencing 42 CFR 438.230, including that: The MCO, PIHP, or PAHP maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its contract with the State; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor specify that all delegated activities or obligations, and related reporting responsibilities, are specified in the contract or written agreement, the subcontractor agrees to perform the delegated activities and reporting responsibilities specified in compliance with the MCO's, PIHP's, or PAHP's contract obligations, and the contract or written arrangement must

31 either provide for revocation of the delegation of activities or obligations, or specify other remedies in instances where the State or the MCO, PIHP, or PAHP determine that the subcontractor has not performed satisfactorily; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor must specify that the subcontractor agrees to comply with all applicable CHIP laws, regulations, including applicable subregulatory guidance and contract provisions; and The subcontractor agrees to the audit provisions in 438.230(c)(3). 3.7.4

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP, adopts and disseminates practice guidelines that are based on valid and reliable clinical evidence or a consensus of providers in the particular field; consider the needs of the MCO's, PIHP's, or PAHP's enrollees; are adopted in consultation with network providers; and are reviewed and updated periodically as appropriate. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(b) and (c)) 3.7.5

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP makes decisions for utilization management, enrollee education, coverage of services, and other areas to which the guidelines apply are consistent with the practice guidelines. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(d)) 3.7.6

The State assures that each contracted MCO, PIHP, and PAHP maintains a health information system that collects, analyzes, integrates, and reports data consistent with 42 CFR 438.242. The systems must provide information on areas including, but not limited to, utilization, claims, grievances and appeals, and disenrollments for other than loss of CHIP eligibility. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.7

The State assures that it reviews and validates the encounter data collected, maintained, and submitted to the State by the MCO, PIHP, or PAHP to ensure it is a complete and accurate representation of the services provided to the enrollees under the contract between the State and the MCO, PIHP, or PAHP and meets the requirements 42 CFR 438.242 of this section. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.8

The State assures that it will submit to CMS all encounter data collected, maintained, submitted to the State by the MCO, PIHP, and PAHP once the State has reviewed and validated the data based on the requirements of 42 CFR 438.242. (CMS State Medicaid Director Letter #13-004) 3.7.9

The State assures that each contracted MCO, PIHP and PAHP complies with the privacy protections under 42 CFR 457.1110. (42 CFR 457.1233(e))

32 3.8 Beneficiary Protections 3.8.1

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity has written policies regarding the enrollee rights specified in 42 CFR 438.100. (42 CFR 457.1220, cross-referencing to 42 CFR 438.100(a)(1)) 3.8.2

The State assures that its contracts with an MCO, PIHP, PAHP, PCCM, or PCCM entity include a guarantee that the MCO, PIHP, PAHP, PCCM, or PCCM entity will not avoid costs for services covered in its contract by referring enrollees to publicly supported health care resources. (42 CFR 457.1201(p)) 3.8.3

The State assures that MCOs, PIHPs, and PAHPs do not hold the enrollee liable for the following: • The MCO’s, PIHP’s or PAHP’s debts, in the event of the entity’s solvency. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(a)) • Covered services provided to the enrollee for which the State does not pay the MCO, PIHP or PAHP or for which the State, MCO, PIHP, or PAHP does not pay the individual or the health care provider that furnished the services under a contractual, referral or other arrangement. (42 CFR 457.1226, cross- referencing to 42 CFR 438.106(b)) • Payments for covered services furnished under a contract, referral or other arrangement that are in excess of the amount the enrollee would owe if the MCO, PIHP or PAHP covered the services directly. (42 CFR 457.1226, cross- referencing to 42 CFR 438.106(c)) 3.9 Grievances and Appeals Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete Section 3.9. States with PCCMs and/or PCCM entities should be adhering to the State’s review process for benefits. 3.9.1

The State assures that each MCO, PIHP, and PAHP has a grievance and appeal system in place that allows enrollees to file a grievance and request an appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)) 3.9.2

The State assures that each MCO, PIHP, and PAHP has only one level of appeal for enrollees. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(b)) 3.9.3

The State assures that an enrollee may request a State review after receiving notice that the adverse benefit determination is upheld, or after an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 438.402(c)) 3.9.4. Does the state offer and arrange for an external medical review?

33 Yes No

Guidance: Only states that answered yes to assurance 3.9.4 need to complete the next assurance (3.9.5). 3.9.5

The State assures that the external medical review is: • At the enrollee's option and not required before or used as a deterrent to proceeding to the State review; • Independent of both the State and MCO, PIHP, or PAHP; • Offered without any cost to the enrollee; and • Not extending any of the timeframes specified in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(1)(i)) 3.9.6

The State assures that an enrollee may file a grievance with the MCO, PIHP, or PAHP at any time. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(i)) 3.9.7

The State assures that an enrollee has 60 calendar days from the date on an adverse benefit determination notice to file a request for an appeal to the MCO, PIHP, or PAHP. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(ii)) 3.9.8

The State assures that an enrollee may file a grievance and request an appeal either orally or in writing. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(3)(i)) 3.9.9

The State assures that each MCO, PIHP, and PAHP gives enrollees timely and adequate notice of an adverse benefit determination in writing consistent with the requirements below in Section 3.9.10 and in 42 CFR 438.10. 3.9.10

The State assures that the notice of an adverse benefit determination explains: • The adverse benefit determination. • The reasons for the adverse benefit determination, including the right of the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee's adverse benefit determination. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits. • The enrollee's right to request an appeal of the MCO's, PIHP's, or PAHP's adverse benefit determination, including information on exhausting the MCO's, PIHP's, or PAHP's one level of appeal and the right to request a State review.

34 • The procedures for exercising the rights specified above under this assurance. • The circumstances under which an appeal process can be expedited and how to request it. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(b)) 3.9.11

The State assures that the notice of an adverse benefit determination is provided in a timely manner in accordance with 42 CFR 457.1260. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(c)) 3.9.12

The State assures that MCOs, PIHPs, and PAHPs give enrollees reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal. This includes, but is not limited to, auxiliary aids and services upon request, such as providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(a)) 3.9.13 The state makes the following assurances related to MCO, PIHP, and PAHP processes for handling enrollee grievances and appeals: Individuals who make decisions on grievances and appeals were neither involved in any previous level of review or decision-making nor a subordinate of any such individual. Individuals who make decisions on grievances and appeals, if deciding any of the following, are individuals who have the appropriate clinical expertise in treating the enrollee's condition or disease: • An appeal of a denial that is based on lack of medical necessity. • A grievance regarding denial of expedited resolution of an appeal. • A grievance or appeal that involves clinical issues. All comments, documents, records, and other information submitted by the enrollee or their representative will be taken into account, without regard to whether such information was submitted or considered in the initial adverse benefit determination. Enrollees have a reasonable opportunity, in person and in writing, to present evidence and testimony and make legal and factual arguments. Enrollees are provided the enrollee's case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the MCO, PIHP or PAHP (or at the direction of the MCO, PIHP or PAHP) in connection with the appeal of the adverse benefit determination. This information must be provided free of charge and sufficiently in advance of the resolution timeframe for appeals. The enrollee and his or her representative or the legal representative of a deceased enrollee's estate are included as parties to the appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(b))

35 3.9.14

The State assures that standard grievances are resolved (including notice to the affected parties) within 90 calendar days from the day the MCO, PIHP, or PAHP receives the grievance. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(b)) 3.9.15

The State assures that standard appeals are resolved (including notice to the affected parties) within 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal. The MCO, PIHP, or PAHP may extend the timeframe by up to 14 calendar days if the enrollee requests the extension or the MCO, PIHP, or PAHP shows that there is need for additional information and that the delay is in the enrollee's interest. (42 CFR 457.1260, cross-referencing to 42 CFR 42 CFR 438.408(b) and (c)) 3.9.16

The State assures that each MCO, PIHP, and PAHP establishes and maintains an expedited review process for appeals that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal. The expedited review process applies when the MCO, PIHP, or PAHP determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request) that taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(b) and (c), and 42 CFR 438.410(a)) 3.9.17

The State assures that if an MCO, PIHP, or PAHP denies a request for expedited resolution of an appeal, it transfers the appeal within the timeframe for standard resolution in accordance with 42 CFR 438.408(b)(2). (42 CFR 457.1260, cross- referencing to 42 CFR 438.410(c)(1)) 3.9.18

The State assures that if the MCO, PIHP, or PAHP extends the timeframes for an appeal not at the request of the enrollee or it denies a request for an expedited resolution of an appeal, it completes all of the following: • Make reasonable efforts to give the enrollee prompt oral notice of the delay. • Within 2 calendar days give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a grievance if he or she disagrees with that decision. • Resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(c) and 42 CFR 438.410(c)) 3.9.19

The State assures that if an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in this section, the enrollee is deemed to have exhausted the MCO's, PIHP's, or PAHP's appeals process and the enrollee may initiate a State review. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c)(3))

36 3.9.20

The State assures that has established a method that an MCO, PIHP, and PAHP will use to notify an enrollee of the resolution of a grievance and ensure that such methods meet, at a minimum, the standards described at 42 CFR 438.10. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(1)) 3.9.21

For all appeals, the State assures that each contracted MCO, PIHP, and PAHP provides written notice of resolution in a format and language that, at a minimum, meet the standards described at 42 CFR 438.10. The notice of resolution includes at least the following items: • The results of the resolution process and the date it was completed; and • For appeals not resolved wholly in favor of the enrollees: o The right to request a State review, and how to do so. o The right to request and receive benefits while the hearing is pending, and how to make the request. o That the enrollee may, consistent with State policy, be held liable for the cost of those benefits if the hearing decision upholds the MCO's, PIHP's, or PAHP's adverse benefit determination. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(i) and (e))

3.9.22

For notice of an expedited resolution, the State assures that each contracted MCO, PIHP, or PAHP makes reasonable efforts to provide oral notice, in addition to the written notice of resolution. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(ii)) 3.9.23

The State assures that if it offers an external medical review: • The review is at the enrollee's option and is not required before or used as a deterrent to proceeding to the State review; • The review is independent of both the State and MCO, PIHP, or PAHP; and • The review is offered without any cost to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(f)) 3.9.24

The State assures that MCOs, PIHPs, and PAHPs do not take punitive action against providers who request an expedited resolution or support an enrollee's appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(b)) 3.9.25

The State assures that MCOs, PIHPs, or PAHPs must provide information specified in 42 CFR 438.10(g)(2)(xi) about the grievance and appeal system to all providers and subcontractors at the time they enter into a contract. This includes: • The right to file grievances and appeals; • The requirements and timeframes for filing a grievance or appeal; • The availability of assistance in the filing process; • The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; and

37 • The fact that, when requested by the enrollee, benefits that the MCO, PIHP, or PAHP seeks to reduce or terminate will continue if the enrollee files an appeal or a request for State review within the timeframes specified for filing, and that the enrollee may, consistent with State policy, be required to pay the cost of services furnished while the appeal or State review is pending if the final decision is adverse to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.414) 3.9.26

The State assures that it requires MCOs, PIHPs, and PAHPs to maintain records of grievances and appeals and reviews the information as part of its ongoing monitoring procedures, as well as for updates and revisions to the State quality strategy. The record must be accurately maintained in a manner accessible to the state and available upon request to CMS. (42 CFR 457.1260, cross-referencing to 42 CFR 438.416) 3.9.27

The State assures that if the MCO, PIHP, or PAHP, or the State review officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the MCO, PIHP, or PAHP must authorize or provide the disputed services promptly and as expeditiously as the enrollee's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. (42 CFR 457.1260, cross-referencing to 42 CFR 438.424(a)) 3.10 Program Integrity Guidance: The State should complete Section 11 (Program Integrity) in addition to Section 3.10. Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the first seven assurances (3.10.1 through 3.10.7). 3.10.1 The State assures that any entity seeking to contract as an MCO, PIHP, or PAHP under a separate child health program has administrative and management arrangements or procedures designed to safeguard against fraud and abuse, including:

Enforcing MCO, PIHP, and PAHP compliance with all applicable Federal and State statutes, regulations, and standards;

Prohibiting MCOs, PIHPs, or PAHPs from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity; and

Including a mechanism for MCOs, PIHPs, and PAHPs to report to the State, to CMS, or to the Office of Inspector General (OIG) as appropriate, information on violations of law by subcontractors, providers, or enrollees of an MCO, PIHP, or PAHP and other individuals. (42 CFR 457.1280)

38

3.10.2

The State assures that it has in effect safeguards against conflict of interest on the part of State and local officers and employees and agents of the State who have responsibilities relating to the MCO, PIHP, or PAHP contracts or enrollment processes described in 42 CFR 457.1210(a). (42 CFR 457.1214, cross referencing 42 CFR 438.58) 3.10.3

The State assures that it periodically, but no less frequently than once every 3 years, conducts, or contracts for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP or PAHP. (42 CFR 457.1285, cross referencing 42 CFR 438.602(e)) 3.10.4

The State assures that it requires MCOs, PIHPs, PAHP, and or subcontractors (only to the extent that the subcontractor is delegated responsibility by the MCO, PIHP, or PAHP for coverage of services and payment of claims) implement and maintain arrangements or procedures that are designed to detect and prevent fraud, waste, and abuse. The arrangements or procedures must include the following: • A compliance program that include all of the elements described in 42 CFR 438.608(a)(1); • Provision for prompt reporting of all overpayments identified or recovered, specifying the overpayments due to potential fraud, to the State; • Provision for prompt notification to the State when it receives information about changes in an enrollee's circumstances that may affect the enrollee's eligibility; • Provision for notification to the State when it receives information about a change in a network provider's circumstances that may affect the network provider's eligibility to participate in the managed care program, including the termination of the provider agreement with the MCO, PIHP or PAHP; • Provision for a method to verify, by sampling or other methods, whether services that have been represented to have been delivered by network providers were received by enrollees and the application of such verification processes on a regular basis; • In the case of MCOs, PIHPs, or PAHPs that make or receive annual payments under the contract of at least $5,000,000, provision for written policies for all employees of the entity, and of any contractor or agent, that provide detailed information about the False Claims Act and other Federal and State laws described in section 1902(a)(68) of the Act, including information about rights of employees to be protected as whistleblowers; • Provision for the prompt referral of any potential fraud, waste, or abuse that the MCO, PIHP, or PAHP identifies to the State Medicaid/CHIP program integrity unit or any potential fraud directly to the State Medicaid Fraud

39 Control Unit; and • Provision for the MCO's, PIHP's, or PAHP's suspension of payments to a network provider for which the State determines there is a credible allegation of fraud in accordance with 42 CFR 455.23. (42 CFR 457.1285, cross referencing 42 CFR 438.608(a)) 3.10.5

The State assures that each MCO, PIHP, or PAHP requires and has a mechanism for a network provider to report to the MCO, PIHP or PAHP when it has received an overpayment, to return the overpayment to the MCO, PIHP or PAHP within 60 calendar days after the date on which the overpayment was identified, and to notify the MCO, PIHP or PAHP in writing of the reason for the overpayment. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(2)) 3.10.6

The State assures that each MCO, PIHP, or PAHP reports annually to the State on their recoveries of overpayments. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(3)) 3.10.7

The State assures that it screens and enrolls, and periodically revalidates, all network providers of MCOs, PIHPs, and PAHPs, in accordance with the requirements of part 455, subparts B and E. This requirement also extends to PCCMs and PCCM entities to the extent that the primary care case manager is not otherwise enrolled with the State to provide services to fee-for-service beneficiaries. (42 CFR 457.1285, cross referencing 42 CFR 438.602(b)(1) and 438.608(b)) 3.10.8

The State assures that it reviews the ownership and control disclosures submitted by the MCO, PIHP, PAHP, PCCM or PCCM entity, and any subcontractors. (42 CFR 457.1285, cross referencing 42 CFR 438.602(c)) 3.10.9

The State assures that it confirms the identity and determines the exclusion status of the MCO, PIHP, PAHP, PCCM or PCCM entity, any subcontractor, as well as any person with an ownership or control interest, or who is an agent or managing employee of the MCO, PIHP, PAHP, PCCM or PCCM entity through routine checks of Federal databases. If the State finds a party that is excluded, the State promptly notifies the MCO, PIHP, PAHP, PCCM, or PCCM entity and takes action consistent with 42 CFR 438.610(c). (42 CFR 457.1285, cross referencing 42 CFR 438.602(d)) 3.10.10

The State assures that it receives and investigates information from whistleblowers relating to the integrity of the MCO, PIHP, PAHP, PCCM, or PCCM entity, subcontractors, or network providers receiving Federal funds under this part. (42 CFR 457.1285, cross referencing 42 CFR 438.602(f))

40 3.10.11

The State assures that MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities with which the State contracts are not located outside of the United States and that no claims paid by an MCO, PIHP, or PAHP to a network provider, out-of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates. (42 CFR 457.1285, cross referencing to 42 CFR 438.602(i); Section 1902(a)(80) of the Social Security Act) 3.10.12 The State assures that MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities submit to the State the following data, documentation, and information:

Encounter data in the form and manner described in 42 CFR 438.818.

Data on the basis of which the State determines the compliance of the MCO, PIHP, or PAHP with the medical loss ratio requirement described in 42 CFR 438.8.

Data on the basis of which the State determines that the MCO, PIHP or PAHP has made adequate provision against the risk of insolvency as required under 42 CFR 438.116.

Documentation described in 42 CFR 438.207(b) on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services, including the adequacy of the provider network, as set forth in 42 CFR 438.206.

Information on ownership and control described in 42 CFR 455.104 of this chapter from MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors as governed by 42 CFR 438.230.

The annual report of overpayment recoveries as required in 42 CFR 438.608(d)(3). (42 CFR 457.1285, cross referencing 42 CFR 438.604(a))

3.10.13 The State assures that:

It requires that the data, documentation, or information submitted in accordance with 42 CFR 457.1285, cross referencing 42 CFR 438.604(a), is certified in a manner that the MCO's, PIHP's, PAHP's, PCCM's, or PCCM entity's Chief Executive Officer or Chief Financial Officer is ultimately responsible for the certification. (42 CFR 457.1285, cross referencing 42 CFR 438.606(a))

It requires that the certification includes an attestation that, based on best information, knowledge, and belief, the data, documentation, and information specified in 42 CFR 438.604 are accurate, complete, and truthful. (42 CFR 457.1285, cross referencing 42 CFR 438.606(b)); and

It requires the MCO, PIHP, PAHP, PCCM, or PCCM entity to submit the certification concurrently with the submission of the data, documentation, or information required in 42 CFR 438.604(a) and (b). (42 CFR 457.1285, cross referencing 42 CFR 438.604(c))

41 3.10.14

The State assures that each MCO, PIHP, PAHP, PCCM, PCCM entity, and any subcontractors provides: written disclosure of any prohibited affiliation under 42 CFR 438.610, written disclosure of and information on ownership and control required under 42 CFR 455.104, and reports to the State within 60 calendar days when it has identified the capitation payments or other payments in excess of amounts specified in the contract. (42 CFR 457.1285, cross referencing 42 CFR 438.608(c)) 3.10.15

The State assures that services are provided in an effective and efficient manner. (Section 2101(a)) 3.10.16

The State assures that it operates a Web site that provides: • The documentation on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services; • Information on ownership and control of MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors; and • The results of any audits conducted under 42 CFR 438.602(e). (42 CFR 457.1285, cross-referencing to 42 CFR 438.602(g)). 3.11 Sanctions Guidance: Only States with MCOs need to answer the next three assurances (3.11.1 through 3.11.3).

Intermediate sanctions are defined at 42 CFR 438.702(a)(4) as: (1) Civil money penalties; (2) Appointment of temporary management (for an MCO); (3) Granting enrollees the right to terminate enrollment without cause; (4) Suspension of all new enrollment; and (5) Suspension of payment for beneficiaries.

3.11.1

The State assures that it has established intermediate sanctions that it may impose if it makes the determination that an MCO has acted or failed to act in a manner specified in 438.700(b)-(d). (42 CFR 457.1270, cross referencing 42 CFR 438.700) 3.11.2

The State assures that it will impose temporary management if it finds that an MCO has repeatedly failed to meet substantive requirements of part 457 subpart L. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) 3.11.3

The State assures that if it imposes temporary management on an MCO, the State allows enrollees the right to terminate enrollment without cause and notifies the affected enrollees of their right to terminate enrollment. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b))

42 Guidance: Only states with PCCMs, or PCCM entities need to answer the next assurance (3.11.4). 3.11.4 Does the State establish intermediate sanctions for PCCMs or PCCM entities? Yes No

Guidance: Only states with MCOs and states that answered yes to assurance 3.11.4 need to complete the next three assurances (3.11.5 through 3.11.7). 3.11.5

The State assures that before it imposes intermediate sanctions, it gives the affected entity timely written notice. (42 CFR 457.1270, cross referencing 42 CFR 438.710(a)) 3.11.6

The State assures that if it intends to terminate an MCO, PCCM, or PCCM entity, it provides a pre-termination hearing and written notice of the decision as specified in 42 CFR 438.710(b). If the decision to terminate is affirmed, the State assures that it gives enrollees of the MCO, PCCM or PCCM entity notice of the termination and information, consistent with 42 CFR 438.10, on their options for receiving CHIP services following the effective date of termination. (42 CFR 457.1270, cross referencing 42 CFR 438.710(b)) 3.11.7

The State assures that it will give CMS written notice that complies with 42 CFR 438.724 whenever it imposes or lifts a sanction for one of the violations listed in 42 CFR 438.700. (42 CFR 457.1270, cross referencing 42 CFR 438.724) 3.12 Quality Measurement and Improvement; External Quality Review Guidance: The State should complete Sections 7 (Quality and Appropriateness of Care) and 9 (Strategic Objectives and Performance Goals and Plan Administration) in addition to Section 3.12. Guidance: States with MCO(s), PIHP(s), PAHP(s), or certain PCCM entity/ies (PCCM entities whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes - see 42 CFR 457.1240(f)) - should complete the applicable sub-sections for each entity type in this section, regarding 42 CFR 457.1240 and 1250. 3.12.1 Quality Strategy Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities need to complete section 3.12.1.

43 3.12.1.1

The State assures that it will draft and implement a written quality strategy for assessing and improving the quality of health care and services furnished CHIP enrollees as described in 42 CFR 438.340(a). The quality strategy must include the following items: • The State-defined network adequacy and availability of services standards for MCOs, PIHPs, and PAHPs required by 42 CFR 438.68 and 438.206 and examples of evidence-based clinical practice guidelines the State requires in accordance with 42 CFR 438.236; • A description of: o The quality metrics and performance targets to be used in measuring the performance and improvement of each MCO, PIHP, and PAHP with which the State contracts, including but not limited to, the performance measures reported in accordance with 42 CFR 438.330(c); and o The performance improvement projects to be implemented in accordance with 42 CFR 438.330(d), including a description of any interventions the State proposes to improve access, quality, or timeliness of care for beneficiaries enrolled in an MCO, PIHP, or PAHP; • Arrangements for annual, external independent reviews, in accordance with 42 CFR 438.350, of the quality outcomes and timeliness of, and access to, the services covered under each contract; • A description of the State's transition of care policy required under 42 CFR 438.62(b)(3); • The State's plan to identify, evaluate, and reduce, to the extent practicable, health disparities based on age, race, ethnicity, sex, and primary language; • For MCOs, appropriate use of intermediate sanctions that, at a minimum, meet the requirements of subpart I of 42 CFR Part 438; • A description of how the State will assess the performance and quality outcomes achieved by each PCCM entity; • The mechanisms implemented by the State to comply with 42 CFR 438.208(c)(1) (relating to the identification of persons with special health care needs); • Identification of the external quality review (EQR)-related activities for which the State has exercised the option under 42 CFR 438.360 (relating to nonduplication of EQR-related activities), and explain the rationale for the State's determination that the private accreditation activity is comparable to such EQR-related activities; • Identification of which quality measures and performance outcomes the State will publish at least annually on the Web site required under 42 CFR 438.10(c)(3); and

44 • The State's definition of a “significant change” for the purposes of updating the quality strategy under 42 CFR 438.340(c)(3)(ii). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)) 3.12.1.2

The State assures that the goals and objectives for continuous quality improvement in the quality strategy are measurable and take into consideration the health status of all populations in the State served by the MCO, PIHP, and PAHP. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(2)) 3.12.1.3

The State assures that for purposes of the quality strategy, the State provides the demographic information for each CHIP enrollee to the MCO, PIHP or PAHP at the time of enrollment. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(6)) 3.12.1.4

The State assures that it will review and update the quality strategy as needed, but no less than once every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)) 3.12.1.5

The State assures that its review and updates to the quality strategy will include an evaluation of the effectiveness of the quality strategy conducted within the previous 3 years and the recommendations provided pursuant to 42 CFR 438.364(a)(4). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(i) and (iii). 3.12.1.6

The State assures that it will submit to CMS: • A copy of the initial quality strategy for CMS comment and feedback prior to adopting it in final; and • A copy of the revised strategy whenever significant changes are made to the document, or whenever significant changes occur within the State's CHIP program, including after the review and update required every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(3)) 3.12.1.7

Before submitting the strategy to CMS for review, the State assures that when it drafts or revises the State’s quality strategy it will: • Make the strategy available for public comment; and • If the State enrolls Indians in the MCO, PIHP, or PAHP, consult with Tribes in accordance with the State's Tribal consultation policy. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(1)) 3.12.1.8

The State assures that it makes the results of the review of the quality strategy (including the effectiveness evaluation) and the final quality

45 strategy available on the Web site required under 42 CFR 438.10(c)(3). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(ii) and (d)) 3.12.2 Quality Assessment and Performance Improvement Program 3.12.2.1 Quality Assessment and Performance Improvement Program: Measures and Projects Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next two assurances (3.12.2.1.1 and 3.12.2.1.2). 3.12.2.1.1 The State assures that it requires that each MCO, PIHP, and PAHP establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The elements of the assessment and program include at least: • Standard performance measures specified by the State; • Any measures and programs required by CMS (42 CFR 438.330(a)(2); • Performance improvement projects that focus on clinical and non-clinical areas, as specified in 42 CFR 438.330(d); • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c); • Mechanisms to detect both underutilization and overutilization of services; and • Mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs, as defined by the State in the quality strategy under 42 CFR 457.1240(e) and Section 3.12.1 of this template). (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(b) and (c)(1))

Guidance: A State may request an exemption from including the performance measures or performance improvement programs established by CMS under 42 CFR 438.330(a)(2), by submitting a written request to CMS explaining the basis for such request. 3.12.2.1.2 The State assures that each MCO, PIHP, and PAHP’s performance improvement projects are designed to achieve significant improvement, sustained over time, in health outcomes and enrollee

46 satisfaction. The performance improvement projects include at least the following elements: • Measurement of performance using objective quality indicators; • Implementation of interventions to achieve improvement in the access to and quality of care; • Evaluation of the effectiveness of the interventions based on the performance measures specified in 42 CFR 438.330(d)(2)(i); and • Planning and initiation of activities for increasing or sustaining improvement. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(2)) Guidance: Only states with a PCCM entity whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes need to, complete the next assurance (3.12.2.1.3).

3.12.2.1.3 The State assures that it requires that each PCCM entity establishes and implements an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The assessment and program must include: • Standard performance measures specified by the State; • Mechanisms to detect both underutilization and overutilization of services; and • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c). (42 CFR 457.1240(a) and (b), cross referencing to 42 CFR 438.330(b)(3) and (c)) 3.12.2.2 Quality Assessment and Performance Improvement Program: Reporting and Effectiveness Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.2.2. 3.12.2.2.1 The State assures that each MCO, PIHP, and PAHP reports on the status and results of each performance improvement project conducted by the MCO, PIHP, and PAHP to the State as required by the State, but not less than once per year. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(3))

47 3.12.2.2.2 The State assures that it annually requires each MCO, PIHP, and PAHP to:

1) Measure and report to the State on its performance using the standard measures required by the State;

2) Submit to the State data specified by the State to calculate the MCO's, PIHP's, or PAHP's performance using the standard measures identified by the State; or

3) Perform a combination of options (1) and (2) of this assurance. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(c)(2))

3.12.2.2.3 The State assures that the State reviews, at least annually, the impact and effectiveness of the quality assessment and performance improvement program of each MCO, PIHP, PAHP and PCCM entity. The State’s review must include: • The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required to report; and • The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement projects. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(e)(1)) 3.12.3 Accreditation Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.3. 3.12.3.1

The State assures that it requires each MCO, PIHP, and PAHP to inform the state whether it has been accredited by a private independent accrediting entity, and, if the MCO, PIHP, or PAHP has received accreditation by a private independent accrediting agency, that the MCO, PIHP, and PAHP authorizes the private independent accrediting entity to provide the State a copy of its recent accreditation review that includes the MCO, PIHP, and PAHP’s accreditation status, survey type, and level (as applicable); accreditation results, including recommended actions or improvements, corrective action plans, and summaries of findings; and expiration date of the accreditation. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(a) and (b)). 3.12.3.2

The State assures that it will make the accreditation status for each contracted MCO, PIHP, and PAHP available on the Web site required under 42 CFR 438.10(c)(3), including whether each MCO, PIHP, and PAHP has been accredited and, if applicable, the name of the accrediting entity, accreditation program, and accreditation level; and update this information at least annually. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(c))

48 3.12.4 Quality Rating Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.4.

The State assures that it will implement and operate a quality rating system that issues an annual quality rating for each MCO, PIHP, and PAHP, which the State will prominently display on the Web site required under 42 CFR 438.10(c)(3), in accordance with the requirements set forth in 42 CFR 438.334. (42 CFR 457.1240(d)) Guidance: States will be required to comply with this assurance within 3 years after CMS, in consultation with States and other Stakeholders and after providing public notice and opportunity for comment, has identified performance measures and a methodology for a Medicaid and CHIP managed care quality rating system in the Federal Register. 3.12.5 Quality Review Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5 and 3.12.5.1.

The State assures that each contract with a MCO, PIHP, PAHP, or PCCM entity requires that a qualified EQRO performs an annual external quality review (EQR) for each contracting MCO, PIHP, PAHP or PCCM entity, except as provided in 42 CFR 438.362. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(a)) 3.12.5.1 External Quality Review Organization 3.12.5.1.1 The State assures that it contracts with at least one external quality review organization (EQRO) to conduct either EQR alone or EQR and other EQR-related activities. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(a)) 3.12.5.1.2 The State assures that any EQRO used by the State to comply with 42 CFR 457.1250 must meet the competence and independence requirements of 42 CFR 438.354 and, if the EQRO uses subcontractors, that the EQRO is accountable for and oversees all subcontractor functions. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.354 and 42 CFR 438.356(b) through (d)) 3.12.5.2 External Quality Review-Related Activities Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next three assurances (3.12.5.2.1 through 3.12.5.2.3). Under 42 CFR 457.1250(a), the State, or its agent or EQRO, must conduct the EQR-related activity

49 under 42 CFR 438.358(b)(1)(iv) regarding validation of the MCO, PIHP, or PAHP’s network adequacy during the preceding 12 months; however, the State may permit its contracted MCO, PIHP, and PAHPs to use information from a private accreditation review in lieu of any or all the EQR-related activities under 42 CFR 438.358(b)(1)(i) through (iii) (relating to the validation of performance improvement projects, validation of performance measures, and compliance review). 3.12.5.2.1 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(1)(i) through (iv) (relating to the validation of performance improvement projects, validation of performance measures, compliance review, and validation of network adequacy) will be conducted on all MCOs, PIHPs, or PAHPs. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(b)(1))

3.12.5.2.2 The State assures that if it elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will document the use of nonduplication in the State’s quality strategy. (42 CFR 457.1250(a), cross referencing 438.360, 438.358(b)(1)(i) through (b)(1)(iii), and 438.340) 3.12.5.2.3 The State assures that if the State elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will ensure that all information from a Medicare or private accreditation review for an MCO, PIHP, or PAHP will be furnished to the EQRO for analysis and inclusion in the EQR technical report described in 42 CFR 438.364. ((42 CFR 457.1250(a), cross referencing to 42 CFR 438.360(b)) Guidance: Only states with PCCM entities need to complete the next assurance (3.12.5.2.4). 3.12.5.2.4 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(2) (cross-referencing 42 CFR 438.358(b)(1)(ii) and (b)(1)(iii)) will be conducted on all PCCM entities, which include: • Validation of PCCM entity performance measures required in accordance with 42 CFR 438.330(b)(2) or PCCM entity performance measures calculated by the State during the preceding 12 months; and

50 • A review, conducted within the previous 3-year period, to determine the PCCM entity’s compliance with the standards set forth in subpart D of 42 CFR part 438 and the quality assessment and performance improvement requirements described in 42 CFR 438.330. (42 CFR 457.1250(a), cross referencing to 438.358(b)(2))

3.12.5.3 External Quality Review Report Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5.3. 3.12.5.3.1 The State assures that data obtained from the mandatory and optional, if applicable, EQR-related activities in 42 CFR 438.358 is used for the annual EQR to comply with 42 CFR 438.350 and must include, at a minimum, the elements in §438.364(a)(2)(i) through (iv). (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(a)(2))

3.12.5.3.2 The State assures that only a qualified EQRO will produce the EQR technical report (42 CFR 438.364(c)(1)).

3.12.5.3.3 The State assures that in order for the qualified EQRO to perform an annual EQR for each contracting MCO, PIHP, PAHP or PCCM entity under 42 CFR 438.350(a) that the following conditions are met: • The EQRO has sufficient information to use in performing the review; • The information used to carry out the review must be obtained from the EQR-related activities described in 42 CFR 438.358 and, if applicable, from a private accreditation review as described in 42 CFR 438.360; • For each EQR-related activity (mandatory or optional), the information gathered for use in the EQR must include the elements described in 42 CFR 438.364(a)(2)(i) through (iv); and • The information provided to the EQRO in accordance with 42 CFR 438.350(b) is obtained through methods consistent with the protocols established by the Secretary in accordance with 42 CFR 438.352. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(b) through (e))

51 3.12.5.3.4 The State assures that the results of the reviews performed by a qualified EQRO of each contracting MCO, PIHP, PAHP, and PCCM entity are made available as specified in 42 CFR 438.364 in an annual detailed technical report that summarizes findings on access and quality of care. The report includes at least the following items: • A description of the manner in which the data from all activities conducted in accordance with 42 CFR 438.358 were aggregated and analyzed, and conclusions were drawn as to the quality, timeliness, and access to the care furnished by the MCO, PIHP, PAHP, or PCCM entity (described in 42 CFR 438.310(c)(2)); • For each EQR-related activity (mandatory or optional) conducted in accordance with 42 CFR 438.358: o Objectives; o Technical methods of data collection and analysis; o Description of data obtained, including validated performance measurement data for each activity conducted in accordance with 42 CFR 438.358(b)(1)(i) and (ii); and o Conclusions drawn from the data; • An assessment of each MCO's, PIHP's, PAHP's, or PCCM entity's strengths and weaknesses for the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; • Recommendations for improving the quality of health care services furnished by each MCO, PIHP, PAHP, or PCCM entity, including how the State can target goals and objectives in the quality strategy, under 42 CFR 438.340, to better support improvement in the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; • Methodologically appropriate, comparative information about all MCOs, PIHPs, PAHPs, and PCCM entities, consistent with guidance included in the EQR protocols issued in accordance with 42 CFR 438.352(e); and • An assessment of the degree to which each MCO, PIHP, PAHP, or PCCM entity has addressed effectively the recommendations for quality improvement made by the EQRO during the previous year's EQR. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(f) and 438.364(a)) 3.12.5.3.5 The State assures that it does not substantively revise the content of the final EQR technical report without evidence of error or

52 omission. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(b)) 3.12.5.3.6 The State assures that it finalizes the annual EQR technical report by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(1)) 3.12.5.3.7 The State assures that it posts the most recent copy of the annual EQR technical report on the Web site required under 42 CFR 438.10(c)(3) by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(i)) 3.12.5.3.8 The State assures that it provides printed or electronic copies of the information specified in 42 CFR 438.364(a) for the annual EQR technical report, upon request, to interested parties such as participating health care providers, enrollees and potential enrollees of the MCO, PIHP, PAHP, or PCCM, beneficiary advocacy groups, and members of the general public. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(ii)) 3.12.5.3.9 The State assures that it makes the information specified in 42 CFR 438.364(a) for the annual EQR technical report available in alternative formats for persons with disabilities, when requested. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(3)) 3.12.5.3.10 The State assures that information released under 42 CFR 438.364 for the annual EQR technical report does not disclose the identity or other protected health information of any patient. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(d)) Section 4. Eligibility Standards and Methodology Guidance: States electing to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan or combination plan should check the appropriate box and provide the ages and income level for each eligibility group. If the State is electing to take up the option to expand Medicaid eligibility as allowed under section 214 of CHIPRA regarding lawfully residing, complete section 4.1-LR as well as update the budget to reflect the additional costs if the state will claim title XXI match for these children until and if the time comes that the children are eligible for Medicaid. 4.0. Medicaid Expansion

_____________________________________________________________________________ Table of Contents State/Territory Name: North Dakota State Plan Amendments (SPA) #: ND-20-0014 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

(CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

August 21, 2020

Jodi Hulm

North Dakota CHIP Program Administrator ND Department of Human Services

600 East Boulevard Avenue

Bismarck, ND 58505-0250

Dear Ms. Hulm:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA), ND- 20-0014, submitted on June 11, 2020, has been approved. Through this SPA, the state removes references to its separate CHIP program throughout the state plan. This population transitioned to North Dakota’s Medicaid state plan through Medicaid SPA ND-19-0022. SPA ND-20-0014

has an effective date of January 1, 2020.

Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Jordan’s contact information is

as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

Mail Stop: S2-01-16

7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-3413

E-mail: Joyce.Jordan@cms.hhs.gov

If you have additional questions, please contact Meg Barry, Acting Director, Division of State Coverage Programs at (410) 786-1536. We look forward to continuing to work with you and

your staff.

Sincerely,

/signed Amy Lutzky/

Amy Lutzky Acting Deputy Director

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MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available; we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Form CMS-R-211

OMB #: 0938-0707 Exp. Date:

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MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory: North Dakota As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b)) (Signature of Governor, or designee, of State/Territory, Date Signed) submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department. The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Caprice Knapp

Position/Title: Director, Medical Services Name: Jodi Hulm

Position/Title: Healthy Steps Program Administrator Name:

Position/Title: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

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Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1.

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR 1.1.2.

Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR 1.1.3.

A combination of both of the above. 1.2

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d)) 1.3

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130) 1.4 Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65): Original SCHIP State Plan Date Plan Submitted: July 24, 1998 Date Plan Approved: September 28, 1998 Effective Date: October 1, 1998

State Plan Amendment #1 –Establish Separate Child Health Program. Effective Date: October 1, 1999 Implementation Date: October 1, 1999

State Plan Amendment #2 – Expand Eligibility, Eliminate Assets Test. Effective date: January 1, 2002 Implementation date: January 1, 2002;

State Plan Amendment #3 –Compliance Plan. Approval Date: September 27, 2002

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State Plan Amendment #4 - Amended Section 4. Effective date: July 1, 2005 Implementation date: July 1, 2005

This change will result in moving some families from the current private coverage option to the Medicaid Program. It will be advantageous to these families because they will no longer be subject to any co-payments and will have access to the full array of Medicaid program benefits that are more generous than the current private insurance option.

These children will be required to participate in the North Dakota Access to Care program. Each will be required to select a primary care provider who can be a primary care physician, a rural health clinic, a Federally Qualified Health Center or the Indian Health Service. The primary care provider will provide direct primary care and make referrals for specialty care and other specified medical services. All services are paid using a fee for service process. In addition, children residing in Grand Forks County may also select the “capitated” health plan known as AltruCare. The Department makes a monthly per member per month payment to this managed care plan who provides all appropriate medical services contained in the contract. Services not covered in the contract are covered through the regular fee for service payment process.

State Plan Amendment #5 – Amended Section 4.

Effective date: September 1, 2007 Implementation date: September 1, 2007

This amendment made revisions to Section 4.1.3 on income deductions and disregards.

Effective date: October 1, 2008 Implementation date: October 1, 2008

Increase Poverty Level from 140% to 150%.

State Plan Amendment #6 – Amended Section 4.

Effective date: October 1, 2008 Implementation date: October 1, 2008

This amendment will make revisions to Section 4.1.3 page 19, regarding wages paid by the Census Bureau for decennial temporary employment.

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State Plan Amendment #7 – Amended Section 4.

Effective Date: July 1, 2009 Implementation Date: July 1, 2009

Increase Poverty Level from 150% to 160%.

State Plan Amendment #8 – Amended Section 4.

Effective Date: October 1, 2009 Implementation Date: October 1, 2009

Alternate Payment Methodology with FQHCs and RHCs.

State Plan Amendment #9 – Amended Section 6

Effective Date: July 1, 2011 Implementation Date: July 1, 2011

Add orthodontia services. Remove limits on mental health and substance abuse services. Update quality measures.

State Plan Amendment #10 – Amended Section 4

Effective Date: July 1, 2012 Implementation Date: July 1, 2012

This amendment implements provisions for temporary adjustments to redetermination policies for children in families living or working in Governor or federally declared disasters areas.

State Plan Amendment #11

Effective Date: July 1, 2014 Implementation Date: July 1, 2014

This amendment updates services based on a new contract.

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State Plan Amendment #12 Effective Date: October 1, 2017 Implementation Date: October 1, 2017

This amendment incorporates the Mental Health Parity and Addiction Equity Act (MHPAEA) section.

State Plan Amendment #13 Purpose of SPA: Compliance with Managed Care Regulations

Effective date: July 1, 2018 Implementation date: July 1, 2018

State Plan Amendment #14 Purpose of SPA: Transition program from a separate child health program (operated as managed care) to providing expanded benefits under the State’s Medicaid plan (operated as fee-for-service).

Proposed effective date: January 1, 2020 Proposed implementation date: January 1, 2020

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. TN No:

18-0012 Effective Date: October 1, 2017 Implementation Date: October 1, 2017

A letter was sent to all tribal leaders on June 8, 2018 describing the MHPAEA SPA that the state of North Dakota will be submitting to CMS. The tribal consultation letter was also posted on the Department of Human Services website on June 8, 2018.

TN No:

19-0013 Effective Date: July 1, 2018 Implementation Date: July 1, 2018

A letter was sent to all tribal leaders on May 8, 2019 describing the Managed Care Regulations SPA that the state of North Dakota will be submitting to CMS. The tribal consultation letter was also posted on the Department of Human Services website on May 8, 2019.

TN No:

20-0014 Effective Date: January 1, 2020

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Implementation Date: January 1, 2020 A letter was sent to all tribal leaders on July 1, 2019 describing the transition of children from a managed care organization to Medicaid fee for service. The tribal consultation letter was also posted on the Department of Human Services website on July 1, 2019.

Superseding Pages of MAGI CHIP State Plan Material State: North Dakota

Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) ND 20-0101 Effective/Implementation Date: January 1, 2020 XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion CS3 from ND TN 13-0101 ND- 19-0022 Effective/Implementation Date: January 1, 2020 Optional Targeted Low- Income Children MACPro RU Medicaid Optional Targeted Low- Income Children CS7 from ND TN 13-0100 ND-14-0100 Effective/Implementation Date: April 1, 2014 Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporate within a separate subsection under section 4.1 ND-13-0100 Effective/Implementation Date: January 1, 2014 MAGI Eligibility & Methods CS7

CS15 Eligibility – Targeted Low-Income Children

MAGI-Based Income Methodologies Supersedes sections Geographic Area 4.1.1; Age 4.1.2; and Income 4.1.3 Incorporate within a separate subsection under section 4.3

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Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B)) 2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a)) The Department has used a 1998 survey of the uninsured conducted in conjunction with the Robert Wood Johnson Foundation to estimate the number of insured and uninsured ND-13-0101 Effective/Implementation Date: January 1, 2014 XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program Supersedes Medicaid expansion section 4.0 ND-13-0103 Effective/Implementation Date: January 1, 2014 Eligibility Processing CS24 Eligibility Processing Supersedes sections 4.3 and 4.4 ND-13-0104 Effective/Implementation Date: January 1, 2014 Non-Financial Eligibility CS17

CS18

CS19

CS20

CS27 Non-Financial Eligibility – Residency

Non-Financial – Citizenship Non-Financial – Social Security Number Substitution of Coverage Continuous Eligibility Supersedes section 4.1.5

Supersedes sections 4.1.0; 4.1-LR; 4.1.1-LR Supersedes section 4.1.9.1

Supersedes section 4.4.4 Supersedes section 4.1.8

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children in North Dakota. While this data is now more than three years old, it remains the most reliable information for North Dakota at this time. We have considered the use of other national data sources but have found that due to sampling errors for small states much of the information is not accurate. For example, the U.S. Census Bureau Health Insurance Coverage Status indicates that the number of children under 18 years of age in 2000 was 127,000. The actual 2000 census data indicates that North Dakota has 160,849 children under 18 years of age. This is a significant difference of more than 26%. This also makes suspect the number of insured and uninsured children because the sampling error for total number of children will also affect the estimated number of children without health insurance. For the above reason we will continue to utilize the 1998 survey as an estimate of the number of uninsured children in North Dakota until a more accurate national survey tool becomes available for small population states. The following table provides information on the number of children 0 through 18 years of age residing in North Dakota in 1998, the number who were uninsured, the total number of insured, the number insured by Medicaid and the number of children insured by private plans. As noted above, the data was obtained through a 1998 survey that was conducted under the auspices of the Robert Wood Johnson Foundation Family Survey. 1998 Insured and Uninsured North Dakota Children by Poverty Level, Age, and Race/Ethnicity

Demographic Subgroups

Population Distribution

Number of Insured Children*

Number of Uninsured Children

Number of Children with Unknown Status

Number Insured by Medicaid

Number Insured by Private Plans

Number Covered by HIS, Military and Other 1998 North Dakota Population 175,822 160,448 14,633 710 14,833 134,791 24,131 Household Poverty Level Unknown <100 100% - 133% 134% - 200% Overall 200% Total Children <=18

16,004 17,689 16,011 32,868 93,250

13,951 14,448 12,920 29,309 89,820

1,754 2,975 3,091 2,558 3,285

299 266 0 0 145

1,186 7,694 3,122 1,881 950

11,435 5,253 7,250 25,534 85,319

2,031 4,664 4,701 5,014 7,721 Age Group Less than 1 Year 1 to 5 Years 6 to 12 years 13 to 18 Years Total Children <=18

7,265 38,992 66,971 62,594

6,905 35,673 59,976 57,894

231 3,203 6,818 4,411

129 115 177 289

1,029 4,791 6,271 2,742

5,467 28,501 50,189 50,634

818 5,408 8,567 9,338 Race/Ethnicity Unknown White Black Native American Asian/Pacific Islander Other Total Children <=18

838 158,462 1,742 11,832 832 2,116

607 144,641 1,684 11,157 832 1,527

199 13,200 58 675 0 531

32 620 0 0 0 58

30 9,995 475 3,904 90 339

295 128,532 856 3,751 599 758

314 13,545 759 8,831 190 492

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The survey indicates that 14,663 children where uninsured in 1998. Of that number, 2,975 children resided in families with income below 100% of the poverty level and 6,649 children resided in families with incomes between 100% and 200% of the federal poverty level. At the time Phase II of the State Children’s Health Insurance Program was implemented in North Dakota on October 1, 1999, a total of 20,516 nondisabled children were enrolled in the Medicaid Program. As of May 31, 2002, the number of enrolled non-disabled children had increased to 22,916, an increase of 11.7% or 2,400 children. In addition, a total of 2,452 children were eligible for Phase II, Healthy Steps, of the Title XXI program. Therefore, after 31 months an additional 4,852 children or an increase of 16.3% were covered through Medicaid or Healthy Steps. While the exact number of uninsured is unknown at this time because of the imprecise national data available to small states, the fact that 4,852 additional children have coverage when the number of children in North Dakota is declining indicates that the two programs have experienced success in reducing the number of uninsured children in North Dakota. PUBLIC HEALTH COVERAGE The Medicaid Program remains the primary public health insurance program available for families in North Dakota. It provides an array of services to individuals and families, who are eligible through the 1931 provision, individuals who are aged, blind or disabled and receive Supplemental Security Income if they meet 209b criteria established by the Department of Human Services. Coverage is also provided for children in foster care and subsidized adoption. In addition, aged, blind and disabled individuals and children and certain caretakers in families who have sufficient income to meet their basic maintenance needs, as defined by the State, (Medically Needy) may be eligible for Medicaid. North Dakota also provides poverty level coverage for pregnant women at 162%. Children through 18years of age in families with modified adjusted gross income at or below 133% of the federal poverty level. This group also includes 18-year-old children who are eligible for Medicaid by virtue of the initial CHIP Medicaid expansion that was approved in October 1998. Children, adult caretakers and pregnant women who are enrolled in Medicaid through the 1931 provision, poverty level, medically needy or CHIP expansion categories are required to choose a primary care provider who delivers primary care services and makes referrals for many of the other medical services available through the program. Primary Care Providers receive a monthly administrative fee for managing care and providers receive a fee for service payment for services provided to Medicaid recipients.

In Grand Forks County, children in the above-named categories are required to choose between the Primary Care Provider Program and a capitated Health Plan. As of July 1, 2001, a total of

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18,500 children were enrolled in the Primary Care Provider Program and 365 children were enrolled in the Health Plan. Beginning on January 1, 2002, the asset test for Medicaid was eliminated for the children and family coverage groups. Children in families with income within the Medicaid eligibility guidelines that were previously eligible for Healthy Steps because family assets exceeded the Medicaid limits are now eligible for the Medicaid Program. These children are included within the CHIP Medicaid Expansion Group that was approved by CMS. The second public program available to children is the Healthy Steps Program, Phase II of SCHIP in North Dakota. It provides private insurance coverage to about 2,450 children whose family net adjusted income is at or below 140% of the federal poverty level and who are not otherwise eligible for the Medicaid Program. The benchmark insurance coverage for this group is the coverage available for State Employees plus preventive dental and vision coverage. The insurance contractors make payments on a fee for service indemnity basis. PUBLIC PRIVATE HEALTH INSURANCE PARTNERSHIPS The Comprehensive Health Association of North Dakota (CHAND) was created by the North Dakota Legislative Assembly in 1981 and became operational in 1982. Its initial purpose was to provide comprehensive health insurance benefits to residents of the state who have been denied health insurance or have been given restricted coverage or excessive health premiums because of high-risk health problems.

CHAND offers health insurance to North Dakota residents who either are unable to find adequate health insurance coverage in the private market due to medical conditions or who have lost their employer-sponsored group health insurance.

Insurance carriers licensed to do business in North Dakota must inform individuals denied health insurance coverage by their company about CHAND.

CHAND covers major medical and prescription drug expenses, subject to benefit plan limitations and exclusions. An individual is eligible to receive $1,000,000 in benefits from CHAND during their lifetime. An individual who has received $1,000,000 in CHAND benefits from enrollment in any combination of benefit plans is not eligible to obtain new coverage through the association.

Premiums fund approximately one-half to two-thirds of the program, not to exceed 135 percent of premiums charged in the state of North Dakota for similar coverage. The balance is covered by assessments to companies that write $100,000 in annual premiums on behalf of residents of North Dakota. Additional dollars may also come through federal grants. Applicants are required to meet CHAND eligibility requirements to qualify.

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While not considered a true public/private partnership, the Department does cooperate with Blue Cross/Blue Shield of North Dakota who operates the Caring Program. This program provides limited health and dental coverage to children who are not eligible for Medicaid or Healthy Steps and have gross family income under 200% of the poverty level. Premiums for coverage come from corporate and private donations. If children are not eligible for Medicaid or Healthy Steps, the family is referred to the Caring Program for possible enrollment in that program. Conversely, the Caring Program will encourage families to apply for Medicaid or Healthy Steps if families who apply to that program appear eligible for the two government programs. 2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b)) 2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance): The following are the steps being taken to identify and enroll children who are eligible to participate in the North Dakota Medicaid Program and the Children’s Health Insurance Program.

The Department has established partnerships with numerous other state and local programs that serve children and families. In addition, the Department has reached out to other public health programs to find children who may be eligible for public health programs.

The North Dakota Medicaid and CHIP programs, Women, Infants and Children Program, (WIC), Community Healthcare Association, Maternal and Child Health (MCH), Immunization, , Optimal Pregnancy Outcome Project (OPOP) and the Special Health Services (SHS) have a statewide interagency agreement that allows exchange of information and coordination both on the state and local levels. This agreement allows the state to share common information that encourages easier access to services, such as eligibility information on behalf of children’s health.

Public Health Programs - All 53 counties in North Dakota have access to local public health units that are enrolled Medicaid Providers. This gives them a direct link to the Medicaid program as providers and connects them to the local county social service offices that determine eligibility. If a child is referred and determined ineligible for Medicaid, the public health clinic refers them to other appropriate programs.

WIC - All local WIC programs are required to refer all potentially eligible recipients to Medicaid. Current WIC guidelines also denote Medicaid income guidelines. Those not participating in Medicaid but appear potentially eligible are given program information along with the telephone numbers for referral to the nearest county social service agency Other state WIC program mandatory contacts include County Social Service Agencies, Homeless and

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Ministerial health providers, Substance Abuse Centers, Food Pantries, Public Health Units and Indian and Migrant Health Services. Special Health Services (SHS) - The SHS program conducts a variety of outreach and enrollment activities through a network of state and local staff. The SHS program serves individuals who may have a chronic or disabling condition. Medicaid and CHIP status is monitored on the 1,700 children served through all areas of the program. For the 500 to 600 children served through the diagnostic and treatment programs, Medicaid eligibility is automatically checked. For children who are not eligible for Medicaid or private insurance, SHS will link families to other resources such as SSI. Rural Health Clinics (RHC's) - North Dakota has approximately 52 Medicaid enrolled Rural Health Clinics that includes border state providers from Montana, South Dakota and Minnesota. The RHC's provide services on a sliding fee scale. Referrals are made to local county social service agencies if a family appears eligible for Medicaid and CHIP. Federally Qualified Health Center (FQHC) - North Dakota has 19 designated federally qualified health center Medical sites in North Dakota and six dental sites. The FQHCs conducts a financial screen to determine when to refer to other public health insurance programs such as Medicaid and CHIP. Family Planning Clinics – Family Planning Clinics refer clients to appropriate providers for necessary services that are outside the scope of their practice. Included are referrals for clients in need of primary and preventive services and those who may be eligible for Medicaid, CHIP, WIC and OPOP. Indian Health Services (IHS) - There are two IHS hospitals, one compact clinic, one contract clinic, one student wellness center and one Indian Service Area facility in North Dakota. Each site uses a benefits coordinator to identify and refer potentially eligible children and families to the Medicaid and CHIP. IHS staff receive training designed to identify families who may need referral to other health care programs including Medicaid and CHIP. This allows families to access health care information at different entry points within the IHS system at different times. Continued training occurs between the Department and Benefits Coordinators at Reservation sights. Optimal Pregnancy Outcome Program (OPOP) - OPOP is a primary prevention program designed to empower pregnant women to make informed health and lifestyle choices for healthy babies. There are 2 OPOP sites in North Dakota. All sites are Medicaid enrolled providers and deliver nursing, dietitian and other appropriate health services to pregnant women. Target populations include pregnant adolescents who may be considered high risk. As part of the OPOP intake process, insurance status is identified and referrals made to the Medicaid and CHIP. Healthy Start –The Healthy Start program is a Native American case management program located in seven Healthy Start communities in North and South Dakota.. The program is intended to prevent infant mortality in these areas and is funded by a federal grant. Part of the intake

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assessment for services of this program is to determine if there is Medicaid or CHIP eligibility. The Healthy Start programs are enrolled Medicaid providers who provide certain services through Medicaid. Healthy Start has established referral protocols for both Medicaid and CHIP as part of their case management activity to high-risk pregnant women. Migrant Health Centers are located along the North Dakota/Minnesota border and they provide health services to seasonal migrant families. The health centers refer families to the local county social service agencies if it appears they may meet Medicaid or CHIP eligibility guidelines. Head Start Programs - Local Head Start programs review income and insurance status of all children who apply for that program. They specifically ask if a child is Medicaid eligible. If the family is not currently enrolled, Head Start will refer the family to the local county social service office for an eligibility determination for Medicaid and CHIP. 2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public- private partnership: North Dakota currently refers clients that are ineligible for Medicaid and CHIP to the federal marketplace. 2.3. Describe the procedures the state uses to accomplish coordination of CHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c)) Strategies to coordinate Medicaid and CHIP include the following: 1. As of May 1, 2002, a joint application for Medicaid and CHIP has been developed and is available to applicants. The application is designed to be used for all Medicaid children and family coverage groups including adults . That office reviews the application and makes the final decision regarding Medicaid and CHIP eligibility. 2. Conducting statewide training forums for outreach partners including county staff who determine Medicaid and CHIP eligibility.

3. Through cooperative agreements, work closely with other agencies who have an interest in uninsured children such as the Title V Program to share information and coordinate outreach activities for all public insurance programs. (Additional details regarding these relationships are detailed in 2.1 above). 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

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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)) 3.1. Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L)

3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. No, the State does not use a managed care delivery system for any CHIP populations. Yes, the State uses a managed care delivery system for all CHIP populations. Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care delivery system and some of the CHIP population is included in a fee- for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2. Guidance: Utilization control systems are those administrative mechanisms that are 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. Examples of utilization control systems include: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b))

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If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of: • 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); 42 CFR 457.490(a)) • The utilization control 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); 42 CFR 457.490(b))

Guidance: Only States that use a managed care delivery system for all or some CHIP populations need to answer the remaining questions under Section 3 (starting with 3.1.1.2). If the State uses a managed care delivery system for only some of its CHIP population, the State’s responses to the following questions will only apply to those populations. Through fee-for-service. Examples of carved out services may include transportation and dental, among others. 3.1.2 Use of a Managed Care Delivery System for All or Some of the State’s CHIP Populations 3.1.2.1 Check each of the types of entities below that the State will contract with under its managed care delivery system, and select and/or explain the method(s) of payment that the State will use: Managed care organization (MCO) (42 CFR 457.10) Capitation payment Actuarial sound capitation rates developed by contracted actuary.

Describe population served: CHIP stand along population

Prepaid inpatient health plan (PIHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Guidance: If the State uses prepaid ambulatory health plan(s) (PAHP) to exclusively provide non-emergency medical transportation (a NEMT PAHP), the State should not check the following box for that plan. Instead, complete section 3.1.3 for the NEMT PAHP. Prepaid ambulatory health plan (PAHP) (42 CFR 457.10)

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Capitation payment Other (please explain)

Describe population served:

Primary care case manager (PCCM) (individual practitioners) (42 CFR 457.10) Case management fee Other (please explain) Primary care case management entity (PCCM Entity) (42 CFR 457.10) Case management fee Shared savings, incentive payments, and/or other financial rewards for improved quality outcomes (see 42 CFR 457.1240(f)) Other (please explain)

If PCCM entity is selected, please indicate which of the following function(s) the entity will provide (as described in 42 CFR 457.10), in addition to PCCM services: Provision of intensive telephonic case management Provision of face-to-face case management Operation of a nurse triage advice line Development of enrollee care plans Execution of contracts with fee-for-service (FFS) providers in the FFS program Oversight responsibilities for the activities of FFS providers in the FFS program Provision of payments to FFS providers on behalf of the State Provision of enrollee outreach and education activities Operation of a customer service call center Review of provider claims, utilization and/or practice patterns to conduct provider profiling and/or practice improvement Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers Coordination with behavioral health systems/providers Other (please describe)

3.1.2.2

The State assures that if its contract with an MCO, PAHP, or PIHP allows the entity to use a physician incentive plan, the contract stipulates that the entity must comply with the requirements set forth in 42 CFR 422.208 and 422.210. (42 CFR 457.1201(h), cross-referencing to 42 CFR 438.3(i))

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3.1.3 Nonemergency Medical Transportation PAHPs Guidance: Only complete Section 3.1.3 if the State uses a PAHP to exclusively provide non- emergency medical transportation (a NEMT PAHP). If a NEMT PAHP is the only managed care entity for CHIP in the State, please continue to Section 4 after checking the assurance below. If the State uses a PAHP that does not exclusively provide NEMT and/or uses other managed care entities beyond a NEMT PAHP, the State will need to complete the remaining sections within Section 3.

The State assures that it complies with all requirements applicable to NEMT PAHPs, and through its contracts with such entities, requires NEMT PAHPs to comply with all applicable requirements, including the following (from 42 CFR 457.1206(b)): All contract provisions in 42 CFR 457.1201 except those set forth in 42 CFR 457.1201(h) (related to physician incentive plans) and 42 CFR 457.1201(l) (related to mental health parity). The information requirements in 42 CFR 457.1207 (see Section 3.5 below for more details). The provision against provider discrimination in 42 CFR 457.1208. The State responsibility provisions in 42 CFR 457.1212 (about disenrollment), 42 CFR 457.1214 (about conflict of interest safeguards), and 42 CFR 438.62(a), as cross-referenced in 42 CFR 457.1216 (about continued services to enrollees). The provisions on enrollee rights and protections in 42 CFR 457.1220, 457.1222, 457.1224, and 457.1226. The PAHP standards in 42 CFR 438.206(b)(1), as cross-referenced by 42 CFR 457.1230(a) (about availability of services), 42 CFR 457.1230(d) (about coverage and authorization of services), and 42 CFR 457.1233(a), (b) and (d) (about structure and operation standards). An enrollee's right to a State review under subpart K of 42 CFR 457. Prohibitions against affiliations with individuals debarred or excluded by Federal agencies in 42 CFR 438.610, as cross referenced by 42 CFR 457.1285. Requirements relating to contracts involving Indians, Indian Health Care Providers, and Indian managed care entities in 42 CFR 457.1209.

3.2. General Managed Care Contract Provisions

3.2.1

The State assures that it provides for free and open competition, to the maximum extent practical, in the bidding of all procurement contracts for coverage or other services, including external quality review organizations, in accordance with the procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b); 42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e)) 3.2.2

The State assures that it will include provisions in all managed care contracts that define a sound and complete procurement contract, as required by 45 CFR part 75, as applicable. (42 CFR 457.940(c))

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3.2.3

The State assures that each MCO, PIHP, PAHP, PCCM, and PCCM entity complies with any applicable Federal and State laws that pertain to enrollee rights, and ensures that its employees and contract providers observe and protect those rights (42 CFR 457.1220, cross-referencing to 42 CFR 438.100). These Federal and State laws include: Title VI of the Civil Rights Act of 1964 (45 CFR part 80), Age Discrimination Act of 1975 (45 CFR part 91), Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, Titles II and III of the Americans with Disabilities Act, and section 1557 of the Patient Protection and Affordable Care Act. 3.2.4

The State assures that it operates a Web site that provides the MCO, PIHP, PAHP, and PCCM entity contracts. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(3)) 3.3 Rate Development Standards and Medical Loss Ratio 3.3.1 The State assures that its payment rates are: Based on public or private payment rates for comparable services for comparable populations; and Consistent with actuarially sound principles as defined in 42 CFR 457.10. (42 CFR 457.1203(a))

Guidance: States that checked both boxes under 3.3.1 above do not need to make the next assurance. If the state is unable to check both boxes under 3.1.1 above, the state must check the next assurance. If the State is unable to meet the requirements under 42 CFR 457.1203(a), the State attests that it must establish higher rates because such rates are necessary to ensure sufficient provider participation or provider access or to enroll providers who demonstrate exceptional efficiency or quality in the provision of services. (42 CFR 457.1203(b)) 3.3.2

The State assures that its rates are designed to reasonably achieve a medical loss ratio standard equal to at least 85 percent for the rate year and provide for reasonable administrative costs. (42 CFR 457.1203(c)) 3.3.3

The State assures that it will provide to CMS, if requested by CMS, a description of the manner in which rates were developed in accordance with the requirements of 42 CFR 457.1203(a) through (c). (42 CFR 457.1203(d)) 3.3.4

The State assures that it annually submits to CMS a summary description of the reports pertaining to the medical loss ratio received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(a)) 3.3.5 Does the State require an MCO, PIHP, or PAHP to pay remittances through the contract for not meeting the minimum MLR required by the State? (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b)(1))

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No, the State does not require any MCO, PIHP, or PAHP to pay remittances. Yes, the State requires all MCOs, PIHPs, and PAHPs to pay remittances. Yes, the State requires some, but not all, MCOs, PIHPs, and PAHPs to pay remittances.

If the State requests some, but not all, MCOs, PIHPs, and PAHPs to pay remittances through the contract for not meeting the minimum MLR required by the State, please describe which types of managed care entities are and are not required to pay remittances. For example, if a state requires a medical MCO to pay a remittances but not a dental PAHP, please include this information. If the answer to the assurance above is yes for any or all managed care entities, please answer the next assurance: The State assures that it if a remittance is owed by an MCO, PIHP, or PAHP to the State, the State: Reimburses CMS for an amount equal to the Federal share of the remittance, taking into account applicable differences in the Federal matching rate; and Submits a separate report describing the methodology used to determine the State and Federal share of the remittance with the annual report provided to CMS that summarizes the reports received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b))

3.3.6

The State assures that each MCO, PIHP, and PAHP calculates and reports the medical loss ratio in accordance with 42 CFR 438.8. (42 CFR 457.1203(f)) 3.4 Enrollment

The State assures that its contracts with MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities provide that the MCO, PIHP, PAHP, PCCM or PCCM entity:

Accepts individuals eligible for enrollment in the order in which they apply without restriction (unless authorized by CMS), up to the limits set under the contract (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(1));

Will not, on the basis of health status or need for health care services, discriminate against individuals eligible to enroll (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(3)); and

Will not discriminate against individuals eligible to enroll on the basis of race, color, national origin, sex, sexual orientation, gender identity, or disability and will not use any policy or practice that has the effect of discriminating on the basis of race, color, national origin, sex, sexual orientation, gender identity or disability. (42 CFR 457.1201(d), cross-referencing to 438.3(d)(4)).

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3.4.1 Enrollment Process 3.4.1.1

The State assures that it provides informational notices to potential enrollees in an MCO, PIHP, PAHP, PCCM, or PCCM entity that includes the available managed care entities, explains how to select an entity, explains the implications of making or not making an active choice of an entity, explains the length of the enrollment period as well as the disenrollment policies, and complies with the information requirements in 42 CFR 457.1207 and accessibility standards established under 42 CFR 457.340. (42 CFR 457.1210(c)) 3.4.1.2

The State assures that its enrollment system gives beneficiaries already enrolled in an MCO, PIHP, PAHP, PCCM, or PCCM entity priority to continue that enrollment if the MCO, PIHP, PAHP, PCCM, or PCCM entity does not have the capacity to accept all those seeking enrollment under the program. (42 CFR 457.1210(b)) 3.4.1.3 Does the State use a default enrollment process to assign beneficiaries to an MCO, PIHP, PAHP, PCCM, or PCCM entity? (42 CFR 457.1210(a)) Yes No

If the State uses a default enrollment process, please make the following assurances: The State assigns beneficiaries only to qualified MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities that are not subject to the intermediate sanction of having suspension of all new enrollment (including default enrollment) under 42 CFR 438.702 and have capacity to enroll beneficiaries. (42 CFR 457.1210(a)(1)(i)) The State maximizes continuation of existing provider-beneficiary relationships under 42 CFR 457.1210(a)(1)(ii) or if that is not possible, distributes the beneficiaries equitably and does not arbitrarily exclude any MCO, PIHP, PAHP, PCCM or PCCM entity from being considered. (42 CFR 457.1210(a)(1)(ii), 42 CFR 457.1210(a)(1)(iii))

3.4.2 Disenrollment 3.4.2.1

The State assures that the State will notify enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f)(2)) 3.4.2.2

The State assures that the effective date of an approved disenrollment, regardless of the procedure followed to request the disenrollment, will be no later than the first day of the second month following the month in which the enrollee requests disenrollment or the MCO, PIHP, PAHP,

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PCCM or PCCM entity refers the request to the State. (42 CFR 457.1212, cross-referencing to 438.56(e)(1)) 3.4.2.3

If a beneficiary disenrolls from an MCO, PIHP, PAHP, PCCM, or PCCM entity, the State assures that the beneficiary is provided the option to enroll in another plan or receive benefits from an alternative delivery system. (Section 2103(f)(3) of the Social Security Act, incorporating section 1932(a)(4); 42 CFR 457.1212, cross referencing to 42 CFR 438.56; State Health Official Letter #09-008) 3.4.2.4 MCO, PIHP, PAHP, PCCM and PCCM Entity Requests for Disenrollment. The State assures that contracts with MCOs, PIHPs, PAHPs, PCCMs and PCCM entities describe the reasons for which an MCO, PIHP, PAHP, PCCM and PCCM entity may request disenrollment of an enrollee, if any. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)) Guidance: Reasons for disenrollment by the MCO, PIHP, PAHP, PCCM, and PCCM entity must be specified in the contract with the State. Reasons for disenrollment may not include an adverse change in the enrollee's health status, or because of the enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the MCO, PIHP, PAHP, PCCM or PCCM entity seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)(2)) 3.4.2.5 Enrollee Requests for Disenrollment. Guidance: The State may also choose to limit disenrollment from the MCO, PIHP, PAHP, PCCM, or PCCM entity, except for either: 1) for cause, at any time; or 2) without cause during the latter of the 90 days after the beneficiary’s initial enrollment or the State sends the beneficiary notice of that enrollment, at least once every 12 months, upon reenrollment if the temporary loss of CHIP eligibility caused the beneficiary to miss the annual disenrollment opportunity, or when the State imposes the intermediate sanction specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Does the State limit disenrollment from an MCO, PIHP, PAHP, PCCM and PCCM entity by an enrollee? (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Yes

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No

If the State limits disenrollment by the enrollee from an MCO, PIHP, PAHP, PCCM and PCCM entity, please make the following assurances (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)): The State assures that enrollees and their representatives are given written notice of disenrollment rights at least 60 days before the start of each enrollment period. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(1)) The State assures that beneficiary requests to disenroll for cause will be permitted at any time by the MCO, PIHP, PAHP, PCCM or PCCM entity. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(1) and (d)(2)) The State assures that beneficiary requests for disenrollment without cause will be permitted by the MCO, PIHP, PAHP, PCCM or PCCM entity at the following times: • During the 90 days following the date of the beneficiary's initial enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later; • At least once every 12 months thereafter; • If the State plan provides for automatic reenrollment for an individual who loses CHIP eligibility for a period of 2 months or less and the temporary loss of CHIP eligibility has caused the beneficiary to miss the annual disenrollment opportunity; and • When the State imposes the intermediate sanction on the MCO, PIHP, PAHP, PCCM or PCCM entity specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(2)) 3.4.2.6

The State assures that the State ensures timely access to a State review for any enrollee dissatisfied with a State agency determination that there is not good cause for disenrollment. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(2)) 3.5 Information Requirements for Enrollees and Potential Enrollees 3.5.1

The State assures that it provides, or ensures its contracted MCOs, PAHPs, PIHPs, PCCMs and PCCM entities provide, all enrollment notices, informational materials, and instructional materials related to enrollees and potential enrollees in accordance with the terms of 42 CFR 457.1207, cross-referencing to 42 CFR 438.10. 3.5.2

The State assures that all required information provided to enrollees and potential enrollees are in a manner and format that may be easily understood and is readily accessible by such enrollees and potential enrollees. (42 CFR 457.1207, cross- referencing to 42 CFR 438.10(c)(1))

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3.5.3

The State assures that it operates a Web site that provides the content specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)-(i) either directly or by linking to individual MCO, PIHP, PAHP and PCCM entity Web sites. 3.5.4

The State assures that it has developed and requires each MCO, PIHP, PAHP and PCCM entity to use: Definitions for the terms specified under 42 CFR 438.10(c)(4)(i), and Model enrollee handbooks, and model enrollee notices. (42 CFR 457.1207, cross- referencing to 42 CFR 438.10(c)(4))

3.5.5

If the State, MCOs, PIHPs, PAHPs, PCCMs or PCCM entities provide the information required under 42 CFR 457.1207 electronically, check this box to confirm that the State assures that it meets the requirements under 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(6) for providing the material in an accessible manner. Including that: The format is readily accessible; The information is placed in a location on the State, MCO's, PIHP's, PAHP's, or PCCM's, or PCCM entity's Web site that is prominent and readily accessible; The information is provided in an electronic form which can be electronically retained and printed; The information is consistent with the content and language requirements in 42 CFR 438.10; and The enrollee is informed that the information is available in paper form without charge upon request and is provided the information upon request within 5 business days. 3.5.6

The State assures that it meets the language and format requirements set forth in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(d), including but not limited to: Establishing a methodology that identifies the prevalent non-English languages spoken by enrollees and potential enrollees throughout the State, and in each MCO, PIHP, PAHP, or PCCM entity service area; Making oral interpretation available in all languages and written translation available in each prevalent non-English language; Requiring each MCO, PIHP, PAHP, and PCCM entity to make its written materials that are critical to obtaining services available in the prevalent non- English languages in its particular service area; Making interpretation services available to each potential enrollee and requiring each MCO, PIHP, PAHP, and PCCM entity to make those services available free of charge to each enrollee; and Notifying potential enrollees, and requiring each MCO, PIHP, PAHP, and PCCM entity to notify its enrollees: That oral interpretation is available for any language and written translation is available in prevalent languages; That auxiliary aids and services are available upon request and at no cost for enrollees with disabilities; and

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How to access the services in 42 CFR 457.1207, cross-referencing 42 CFR 438.10(d)(5)(i) and (ii).

3.5.7

The State assures that the State or its contracted representative provides the information specified in 42 CFR 457.1207, cross-referencing to 438.10(e)(2), and includes the information either in paper or electronic format, to all potential enrollees at the time the potential enrollee becomes eligible to enroll in a voluntary managed care program or is first required to enroll in a mandatory managed care program and within a timeframe that enables the potential enrollee to use the information to choose among the available MCOs, PIHPs, PAHPs, PCCMs and PCCM entities: Information about the potential enrollee's right to disenroll consistent with the requirements of 42 CFR 438.56 and which explains clearly the process for exercising this disenrollment right, as well as the alternatives available to the potential enrollee based on their specific circumstance; The basic features of managed care; Which populations are excluded from enrollment in managed care, subject to mandatory enrollment, or free to enroll voluntarily in the program;

The service area covered by each MCO, PIHP, PAHP, PCCM, or PCCM entity; Covered benefits including: Which benefits are provided by the MCO, PIHP, or PAHP; and which, if any, benefits are provided directly by the State; and For a counseling or referral service that the MCO, PIHP, or PAHP does not cover because of moral or religious objections, where and how to obtain the service; The provider directory and formulary information required in 42 CFR 4

57.1207, cross-referencing to 42 CFR 438.10(h) and (i); Any cost-sharing for the enrollee that will be imposed by the MCO, PIHP, PAHP, PCCM, or PCCM entity consistent with those set forth in the State plan; The requirements for each MCO, PIHP or PAHP to provide adequate access to covered services, including the network adequacy standards established in 42 CFR 457.1218, cross-referencing 42 CFR 438.68; The MCO, PIHP, PAHP, PCCM and PCCM entity's responsibilities for coordination of enrollee care; and To the extent available, quality and performance indicators for each MCO, PIHP, PAHP and PCCM entity, including enrollee satisfaction. 3.5.8

The State assures that it will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that the State must notify all enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. 3.5.9

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that:

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The MCO, PIHP, PAHP and, when appropriate, the PCCM entity, must make a good faith effort to give written notice of termination of a contracted provider within the timeframe specified in 42 CFR 438.10(f), and The MCO, PIHP, PAHP and, when appropriate, the PCCM entity must make available, upon request, any physician incentive plans in place as set forth in 42 CFR 438.3(i).

3.5.10

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide enrollees of that MCO, PIHP, PAHP or PCCM entity an enrollee handbook that meets the requirements as applicable to the MCO, PIHP, PAHP and PCCM entity, specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(1)-(2), within a reasonable time after receiving notice of the beneficiary's enrollment, by a method consistent with 42 CFR 438.10(g)(3), and including the following items: Information that enables the enrollee to understand how to effectively use the managed care program, which, at a minimum, must include: Benefits provided by the MCO, PIHP, PAHP or PCCM entity; How and where to access any benefits provided by the State, including any cost sharing, and how transportation is provided; and In the case of a counseling or referral service that the MCO, PIHP, PAHP, or PCCM entity does not cover because of moral or religious objections, the MCO, PIHP, PAHP, or PCCM entity must inform enrollees that the service is not covered by the MCO, PIHP, PAHP, or PCCM entity and how they can obtain information from the State about how to access these services; The amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled; Procedures for obtaining benefits, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the enrollee's primary care provider; The extent to which, and how, after-hours and emergency coverage are provided, including: What constitutes an emergency medical condition and emergency services; The fact that prior authorization is not required for emergency services; and The fact that, subject to the provisions of this section, the enrollee has a right to use any hospital or other setting for emergency care; Any restrictions on the enrollee's freedom of choice among network providers; The extent to which, and how, enrollees may obtain benefits, including family planning services and supplies from out-of-network providers; Cost sharing, if any is imposed under the State plan; Enrollee rights and responsibilities, including the elements specified in 42 CFR §438.100; The process of selecting and changing the enrollee's primary care provider; Grievance, appeal, and review procedures and timeframes, consistent with 42 CFR 457.1260, in a State-developed or State-approved description, including: The right to file grievances and appeals;

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The requirements and timeframes for filing a grievance or appeal; The availability of assistance in the filing process; and The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; How to access auxiliary aids and services, including additional information in alternative formats or languages; The toll-free telephone number for member services, medical management, and any other unit providing services directly to enrollees; and Information on how to report suspected fraud or abuse. 3.5.11

The State assures that each MCO, PIHP, PAHP and PCCM entity will give each enrollee notice of any change that the State defines as significant in the information specified in the enrollee handbook at least 30 days before the intended effective date of the change. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(4)) 3.5.12

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available a provider directory for the MCO’s, PIHP’s, PAHP’s or PCCM entity’s network providers, including for physicians (including specialists), hospitals, pharmacies, and behavioral health providers, that includes information as specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(1)-(2) and (4). 3.5.13

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will update any information included in a paper provider directory at least monthly and in an electronic provider directories as specified in 42 CFR 438.10(h)(3). (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(3)) 3.5.14

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available the MCO’s, PIHP’s, PAHP’s, or PCCM entity’s formulary that meets the requirements specified in 42 CFR 457.1207, cross- referencing to 42 CFR 438.10(i), including: Which medications are covered (both generic and name brand); and What tier each medication is on. 3.5.15

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity follows the requirements for marketing activities under 42 CFR 457.1224, cross- referencing to 42 CFR 438.104 (except 42 CFR 438.104(c)). Guidance: Requirements for marketing activities include, but are not limited to, that the MCO, PIHP, PAHP, PCCM, or PCCM entity does not distribute any marketing materials without first obtaining State approval; distributes the materials to its entire service areas as indicated in the contract; does not seek to influence enrollment in conjunction with the sale or offering of any private insurance; and does not, directly or indirectly, engage in door-to-door, telephone, email, texting, or other cold-call marketing activities. (42 CFR 104(b))

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Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.5 (3.5.16 through 3.5.18). 3.5.16

The State assures that each MCO, PIHP and PAHP protects communications between providers and enrollees under 42 CFR 457.1222, cross-referencing to 42 CFR 438.102. 3.5.17

The State assures that MCOs, PIHPs, and PAHPs have arrangements and procedures that prohibit the MCO, PIHP, and PAHP from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity. (42 CFR 457.1280(b)(2)) Guidance: States should also complete Section 3.9, which includes additional provisions about the notice procedures for grievances and appeals. 3.5.18

The State assures that each contracted MCO, PIHP, and PAHP comply with the notice requirements specified for grievances and appeals in accordance with the terms of 42 CFR 438, Subpart F, except that the terms of 42 CFR 438.420 do not apply and that references to reviews should be read to refer to reviews as described in 42 CFR 457, Subpart K. (42 CFR 457.1260) 3.6 Benefits and Services Guidance: The State should also complete Section 3.10 (Program Integrity). 3.6.1

The State assures that MCO, PIHP, PAHP, PCCM entity, and PCCM contracts involving Indians, Indian health care providers, and Indian managed care entities comply with the requirements of 42 CFR 438.14. (42 CFR 457.1209) 3.6.2

The State assures that all services covered under the State plan are available and accessible to enrollees. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.3

The State assures that it: Publishes the State’s network adequacy standards developed in accordance with 42 CFR 457.1218, cross-referencing 42 CFR 438.68(b)(1) on the Web site required by 42 CFR 438.10; and Makes available, upon request, the State’s network adequacy standards at no cost to enrollees with disabilities in alternate formats or through the provision of auxiliary aids and services. (42 CFR 457.1218, cross-referencing 42 CFR 438.68(e)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete the remaining assurances in Section 3.6 (3.6.4 through 3.6.20.

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3.6.4

The State assures that each MCO, PAHP and PIHP meet the State’s network adequacy standards. (42 CFR 457.1218, cross-referencing 42 CFR 438.68; 42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.5

The State assures that each MCO, PIHP, and PAHP includes within its network of credentialed providers: A sufficient number of providers to provide adequate access to all services covered under the contract for all enrollees, including those with limited English proficiency or physical or mental disabilities; Women’s health specialists to provide direct access to covered care necessary to provide women’s routine and preventative health care services for female enrollees; and Family planning providers to ensure timely access to covered services. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b). 3.6.6

The State assures that each contract under 42 CFR 457.1201 permits an enrollee to choose his or her network provider. (42 CFR 457.1201(j), cross-referencing 42 CFR 438.3(l)) 3.6.7

The State assures that each MCO, PIHP, and PAHP provides for a second opinion from a network provider, or arranges for the enrollee to obtain one outside the network, at no cost. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(3)) 3.6.8

The State assures that each MCO, PIHP, and PAHP ensures that providers, in furnishing services to enrollees, provide timely access to care and services, including by: Requiring the contract to adequately and timely cover out-of-network services if the provider network is unable to provide necessary services covered under the contract to a particular enrollee and at a cost to the enrollee that is no greater than if the services were furnished within the network; Requiring the MCO, PIHP and PAHP meet and its network providers to meet State standards for timely access to care and services, taking into account the urgency of the need for services; Ensuring that the hours of operation for a network provider are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid or CHIP Fee-For-Service, if the provider serves only Medicaid or CHIP enrollees; Ensuring that the MCO, PIHP and PAHP makes available services include in the contract on a 24 hours a day, 7 days a week basis when medically necessary; Establishing mechanisms to ensure compliance by network providers; Monitoring network providers regularly to determine compliance; Taking corrective action if there is a failure to comply by a network provider. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(4) and (5) and (c))

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3.6.9

The State assures that each MCO, PIHP, and PAHP has the capacity to serve the expected enrollment in its service area in accordance with the State's standards for access to care. (42 CFR 457.1230(b), cross-referencing to 42 CFR 438.207) 3.6.10

The State assures that each MCO, PIHP, and PAHP will be required to submit documentation to the State, at the time of entering into a contract with the State, on an annual basis, and at any time there has been a significant change to the MCO, PIHP, or PAHP’s operations that would affect the adequacy of capacity and services, to demonstrate that each MCO, PIHP, and PAHP for the anticipated number of enrollees for the service area: Offers an appropriate range of preventative, primary care and specialty services; and Maintains a provider network that is sufficient in number, mix, and geographic distribution. (42 CFR 457.1230, cross-referencing to 42 CFR 438.207(b)).

3.6.11

Except that 42 CFR 438.210(a)(5) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the coverage of services requirements under 42 CFR 438.210, including: Identifying, defining, and specifying the amount, duration, and scope of each service that the MCO, PIHP, or PAHP is required to offer; and Permitting an MCO, PIHP, or PAHP to place appropriate limits on a service. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(a) except that 438.210(a)(5) does not apply to CHIP contracts).

3.6.12

Except that 438.210(b)(2)(iii) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the authorization of services requirements under 42 CFR 438.210, including that: The MCO, PIHP, or PAHP and its subcontractors have in place and follow written policies and procedures; The MCO, PIHP, or PAHP have in place mechanisms to ensure consistent application of review criteria and consult with the requesting provider when appropriate; and Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by an individual with appropriate expertise in addressing the enrollee’s medical, or behavioral health needs. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(b), except that 438.210(b)(2)(iii) does not apply to CHIP contracts).

3.6.13

The State assures that its contracts with each MCO, PIHP, or PAHP require each MCO, PIHP, or PAHP to notify the requesting provider and given written notice to the enrollee of any adverse benefit determination to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(c)).

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3.6.14

The State assures that its contracts with each MCO, PIHP, or PAHP provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(e)). 3.6.15

The State assures that it has a transition of care policy that meets the requirements of 438.62(b)(1) and requires that each contracted MCO, PIHP, and PAHP implements the policy. (42 CFR 457.1216, cross-referencing to 42 CFR 438.62). 3.6.16

The State assures that each MCO, PIHP, and PAHP has implemented procedures to deliver care to and coordinate services for all enrollees in accordance with 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208, including: Ensure that each enrollee has an ongoing source of care appropriate to his or her needs; Ensure that each enrollee has a person or entity formally designated as primarily responsible for coordinating the services accessed by the enrollee; Provide the enrollee with information on how to contract their designated person or entity responsible for the enrollee’s coordination of services; Coordinate the services the MCO, PIHP, or PAHP furnishes to the enrollee between settings of care; with services from any other MCO, PIHP, or PAHP; with fee-for-service services; and with the services the enrollee receives from community and social support providers; Make a best effort to conduct an initial screening of each enrollees needs within 90 days of the effective date of enrollment for all new enrollees; Share with the State or other MCOs, PIHPs, or PAHPs serving the enrollee the results of any identification and assessment of the enrollee’s needs; Ensure that each provider furnishing services to enrollees maintains and shares, as appropriate, an enrollee health record in accordance with professional standards; and Ensure that each enrollee’s privacy is protected in the process of coordinating care is protected with the requirements of 45 CFR parts 160 and 164 subparts A and E. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(b)). Guidance: For assurances 3.6.17 through 3.6.20, applicability to PIHPs and PAHPs is based a determination by the State in relation to the scope of the entity’s services and on the way the State has organized its delivery of managed care services, whether a particular PIHP or PAHP is required to implement the mechanisms for identifying, assessing, and producing a treatment plan for an individual with special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(a)(2)) 3.6.17

The State assures that it has implemented mechanisms for identifying to MCOs, PIHPs, and PAHPs enrollees with special health care needs who are eligible for assessment and treatment services under 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c) and included the mechanism in the State’s quality strategy.

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3.6.18

The State assures that each applicable MCO, PIHP, and PAHP implements the mechanisms to comprehensively assess each enrollee identified by the state as having special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(2)) 3.6.19

The State assures that each MCO, PIHP, and PAHP will produce a treatment or service plan that meets the following requirements for enrollees identified with special health care needs: • Is in accordance with applicable State quality assurance and utilization review standards; • Reviewed and revised upon reassessment of functional need, at least every 12 months, or when the enrollee’s circumstances or needs change significantly. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(3)) 3.6.20

The State assures that each MCO, PIHP, and PAHP must have a mechanism in place to allow enrollees to directly access a specialist as appropriate for the enrollee's condition and identified needs for enrollees identified with special health care needs who need a course of treatment or regular care monitoring. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(4)) 3.7 Operations 3.7.1

The State assures that it has established a uniform credentialing and recredentialing policy that addresses acute, primary, behavioral, and substance use disorders providers and requires each MCO, PIHP and PAHP to follow those policies. (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(b)(1)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.7 (3.7.2 through 3.7.9). 3.7.2 The State assures each contracted MCO, PIHP and PAHP will comply with the provider selection requirements in 42 CFR 457.1208 and 457.1233(a), cross- referencing 42 CFR 438.12 and 438.214, including that: Each MCO, PIHP, or PAHP implements written policies and procedures for selection and retention of network providers (42 CFR 457.1233(a), cross- referencing 42 CFR 438.214(a)); MCO, PIHP, and PAHP network provider selection policies and procedures do not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(c)); MCOs, PIHPs, and PAHPs do not discriminate in the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification, solely on the basis of that license or certification (42 CFR 457.1208, cross referencing 42 CFR 438.12(a));

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If an MCO, PIHP, or PAHP declines to include individual or groups of providers in the MCO, PIHP, or PAHP’s provider network, the MCO, PIHP, and PAHP gives the affected providers written notice of the reason for the decision (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); and MCOs, PIHPs, and PAHPs do not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. (42 CFR 457.1233(a), cross- referencing 42 CFR 438.214(d)).

3.7.3 The State assures that each contracted MCO, PIHP, and PAHP complies with the subcontractual relationships and delegation requirements in 42 CFR 457.1233(b), cross-referencing 42 CFR 438.230, including that: The MCO, PIHP, or PAHP maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its contract with the State; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor specify that all delegated activities or obligations, and related reporting responsibilities, are specified in the contract or written agreement, the subcontractor agrees to perform the delegated activities and reporting responsibilities specified in compliance with the MCO's, PIHP's, or PAHP's contract obligations, and the contract or written arrangement must either provide for revocation of the delegation of activities or obligations, or specify other remedies in instances where the State or the MCO, PIHP, or PAHP determine that the subcontractor has not performed satisfactorily; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor must specify that the subcontractor agrees to comply with all applicable CHIP laws, regulations, including applicable subregulatory guidance and contract provisions; and The subcontractor agrees to the audit provisions in 438.230(c)(3). 3.7.4

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP, adopts and disseminates practice guidelines that are based on valid and reliable clinical evidence or a consensus of providers in the particular field; consider the needs of the MCO's, PIHP's, or PAHP's enrollees; are adopted in consultation with network providers; and are reviewed and updated periodically as appropriate. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(b) and (c)) 3.7.5

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP makes decisions for utilization management, enrollee education, coverage of services, and other areas to which the guidelines apply are consistent with the practice guidelines. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(d))

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3.7.6

The State assures that each contracted MCO, PIHP, and PAHP maintains a health information system that collects, analyzes, integrates, and reports data consistent with 42 CFR 438.242. The systems must provide information on areas including, but not limited to, utilization, claims, grievances and appeals, and disenrollments for other than loss of CHIP eligibility. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.7

The State assures that it reviews and validates the encounter data collected, maintained, and submitted to the State by the MCO, PIHP, or PAHP to ensure it is a complete and accurate representation of the services provided to the enrollees under the contract between the State and the MCO, PIHP, or PAHP and meets the requirements 42 CFR 438.242 of this section. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.8

The State assures that it will submit to CMS all encounter data collected, maintained, submitted to the State by the MCO, PIHP, and PAHP once the State has reviewed and validated the data based on the requirements of 42 CFR 438.242. (CMS State Medicaid Director Letter #13-004) 3.7.9

The State assures that each contracted MCO, PIHP and PAHP complies with the privacy protections under 42 CFR 457.1110. (42 CFR 457.1233(e)) 3.8 Beneficiary Protections 3.8.1

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity has written policies regarding the enrollee rights specified in 42 CFR 438.100. (42 CFR 457.1220, cross-referencing to 42 CFR 438.100(a)(1)) 3.8.2

The State assures that its contracts with an MCO, PIHP, PAHP, PCCM, or PCCM entity include a guarantee that the MCO, PIHP, PAHP, PCCM, or PCCM entity will not avoid costs for services covered in its contract by referring enrollees to publicly supported health care resources. (42 CFR 457.1201(p)) 3.8.3

The State assures that MCOs, PIHPs, and PAHPs do not hold the enrollee liable for the following: The MCO’s, PIHP’s or PAHP’s debts, in the event of the entity’s solvency. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(a)) Covered services provided to the enrollee for which the State does not pay the MCO, PIHP or PAHP or for which the State, MCO, PIHP, or PAHP does not pay the individual or the health care provider that furnished the services under a contractual, referral or other arrangement. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(b)) Payments for covered services furnished under a contract, referral or other arrangement that are in excess of the amount the enrollee would owe if the MCO, PIHP or PAHP covered the services directly. (42 CFR 457.1226, cross- referencing to 42 CFR 438.106(c))

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3.9 Grievances and Appeals Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete Section 3.9. States with PCCMs and/or PCCM entities should be adhering to the State’s review process for benefits. 3.9.1

The State assures that each MCO, PIHP, and PAHP has a grievance and appeal system in place that allows enrollees to file a grievance and request an appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)) 3.9.2

The State assures that each MCO, PIHP, and PAHP has only one level of appeal for enrollees. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(b)) 3.9.3

The State assures that an enrollee may request a State review after receiving notice that the adverse benefit determination is upheld, or after an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 438.402(c)) 3.9.4. Does the state offer and arrange for an external medical review? Yes No

Guidance: Only states that answered yes to assurance 3.9.4 need to complete the next assurance (3.9.5). 3.9.5

The State assures that the external medical review is: At the enrollee's option and not required before or used as a deterrent to proceeding to the State review; Independent of both the State and MCO, PIHP, or PAHP; Offered without any cost to the enrollee; and Not extending any of the timeframes specified in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(1)(i))

3.9.6

The State assures that an enrollee may file a grievance with the MCO, PIHP, or PAHP at any time. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(i)) 3.9.7

The State assures that an enrollee has 60 calendar days from the date on an adverse benefit determination notice to file a request for an appeal to the MCO, PIHP, or PAHP. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(ii)) 3.9.8

The State assures that an enrollee may file a grievance and request an appeal either orally or in writing. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(3)(i))

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3.9.9

The State assures that each MCO, PIHP, and PAHP gives enrollees timely and adequate notice of an adverse benefit determination in writing consistent with the requirements below in Section 3.9.10 and in 42 CFR 438.10. 3.9.10

The State assures that the notice of an adverse benefit determination explains: The adverse benefit determination. The reasons for the adverse benefit determination, including the right of the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee's adverse benefit determination. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits. The enrollee's right to request an appeal of the MCO's, PIHP's, or PAHP's adverse benefit determination, including information on exhausting the MCO's, PIHP's, or PAHP's one level of appeal and the right to request a State review. The procedures for exercising the rights specified above under this assurance. The circumstances under which an appeal process can be expedited and how to request it. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(b))

3.9.11

The State assures that the notice of an adverse benefit determination is provided in a timely manner in accordance with 42 CFR 457.1260. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(c)) 3.9.12

The State assures that MCOs, PIHPs, and PAHPs give enrollees reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal. This includes, but is not limited to, auxiliary aids and services upon request, such as providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(a)) 3.9.13 The state makes the following assurances related to MCO, PIHP, and PAHP processes for handling enrollee grievances and appeals: Individuals who make decisions on grievances and appeals were neither involved in any previous level of review or decision-making nor a subordinate of any such individual. Individuals who make decisions on grievances and appeals, if deciding any of the following, are individuals who have the appropriate clinical expertise in treating the enrollee's condition or disease: An appeal of a denial that is based on lack of medical necessity. A grievance regarding denial of expedited resolution of an appeal. A grievance or appeal that involves clinical issues. All comments, documents, records, and other information submitted by the enrollee or their representative will be taken into account, without regard to whether such information was submitted or considered in the initial adverse benefit determination.

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Enrollees have a reasonable opportunity, in person and in writing, to present evidence and testimony and make legal and factual arguments. Enrollees are provided the enrollee's case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the MCO, PIHP or PAHP (or at the direction of the MCO, PIHP or PAHP) in connection with the appeal of the adverse benefit determination. This information must be provided free of charge and sufficiently in advance of the resolution timeframe for appeals. The enrollee and his or her representative or the legal representative of a deceased enrollee's estate are included as parties to the appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(b)) 3.9.14

The State assures that standard grievances are resolved (including notice to the affected parties) within 90 calendar days from the day the MCO, PIHP, or PAHP receives the grievance. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(b)) 3.9.15

The State assures that standard appeals are resolved (including notice to the affected parties) within 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal. The MCO, PIHP, or PAHP may extend the timeframe by up to 14 calendar days if the enrollee requests the extension or the MCO, PIHP, or PAHP shows that there is need for additional information and that the delay is in the enrollee's interest. (42 CFR 457.1260, cross-referencing to 42 CFR 42 CFR 438.408(b) and (c)) 3.9.16

The State assures that each MCO, PIHP, and PAHP establishes and maintains an expedited review process for appeals that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal. The expedited review process applies when the MCO, PIHP, or PAHP determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request) that taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(b) and (c), and 42 CFR 438.410(a)) 3.9.17

The State assures that if an MCO, PIHP, or PAHP denies a request for expedited resolution of an appeal, it transfers the appeal within the timeframe for standard resolution in accordance with 42 CFR 438.408(b)(2). (42 CFR 457.1260, cross- referencing to 42 CFR 438.410(c)(1)) 3.9.18

The State assures that if the MCO, PIHP, or PAHP extends the timeframes for an appeal not at the request of the enrollee or it denies a request for an expedited resolution of an appeal, it completes all of the following: Make reasonable efforts to give the enrollee prompt oral notice of the delay. Within 2 calendar days give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a

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grievance if he or she disagrees with that decision. Resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c) and 42 CFR 438.410(c))

3.9.19

The State assures that if an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in this section, the enrollee is deemed to have exhausted the MCO's, PIHP's, or PAHP's appeals process and the enrollee may initiate a State review. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c)(3)) 3.9.20

The State assures that has established a method that an MCO, PIHP, and PAHP will use to notify an enrollee of the resolution of a grievance and ensure that such methods meet, at a minimum, the standards described at 42 CFR 438.10. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(1)) 3.9.21

For all appeals, the State assures that each contracted MCO, PIHP, and PAHP provides written notice of resolution in a format and language that, at a minimum, meet the standards described at 42 CFR 438.10. The notice of resolution includes at least the following items: The results of the resolution process and the date it was completed; and For appeals not resolved wholly in favor of the enrollees: The right to request a State review, and how to do so. The right to request and receive benefits while the hearing is pending, and how to make the request. That the enrollee may, consistent with State policy, be held liable for the cost of those benefits if the hearing decision upholds the MCO's, PIHP's, or PAHP's adverse benefit determination. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(i) and (e))

3.9.22

For notice of an expedited resolution, the State assures that each contracted MCO, PIHP, or PAHP makes reasonable efforts to provide oral notice, in addition to the written notice of resolution. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(ii)) 3.9.23

The State assures that if it offers an external medical review: The review is at the enrollee's option and is not required before or used as a deterrent to proceeding to the State review; The review is independent of both the State and MCO, PIHP, or PAHP; and The review is offered without any cost to the enrollee. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(f))

3.9.24

The State assures that MCOs, PIHPs, and PAHPs do not take punitive action against providers who request an expedited resolution or support an enrollee's appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(b))

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3.9.25

The State assures that MCOs, PIHPs, or PAHPs must provide information specified in 42 CFR 438.10(g)(2)(xi) about the grievance and appeal system to all providers and subcontractors at the time they enter into a contract. This includes: The right to file grievances and appeals; The requirements and timeframes for filing a grievance or appeal; The availability of assistance in the filing process; The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; and The fact that, when requested by the enrollee, benefits that the MCO, PIHP, or PAHP seeks to reduce or terminate will continue if the enrollee files an appeal or a request for State review within the timeframes specified for filing, and that the enrollee may, consistent with State policy, be required to pay the cost of services furnished while the appeal or State review is pending if the final decision is adverse to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.414)

3.9.26

The State assures that it requires MCOs, PIHPs, and PAHPs to maintain records of grievances and appeals and reviews the information as part of its ongoing monitoring procedures, as well as for updates and revisions to the State quality strategy. The record must be accurately maintained in a manner accessible to the state and available upon request to CMS. (42 CFR 457.1260, cross-referencing to 42 CFR 438.416) 3.9.27

The State assures that if the MCO, PIHP, or PAHP, or the State review officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the MCO, PIHP, or PAHP must authorize or provide the disputed services promptly and as expeditiously as the enrollee's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. (42 CFR 457.1260, cross-referencing to 42 CFR 438.424(a)) 3.10 Program Integrity Guidance: The State should complete Section 11 (Program Integrity) in addition to Section 3.10. Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the first seven assurances (3.10.1 through 3.10.7). 3.10.1 The State assures that any entity seeking to contract as an MCO, PIHP, or PAHP under a separate child health program has administrative and management arrangements or procedures designed to safeguard against fraud and abuse, including:

Enforcing MCO, PIHP, and PAHP compliance with all applicable Federal and State statutes, regulations, and standards;

Prohibiting MCOs, PIHPs, or PAHPs from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity; and

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Including a mechanism for MCOs, PIHPs, and PAHPs to report to the State, to CMS, or to the Office of Inspector General (OIG) as appropriate, information on violations of law by subcontractors, providers, or enrollees of an MCO, PIHP, or PAHP and other individuals. (42 CFR 457.1280)

3.10.2

The State assures that it has in effect safeguards against conflict of interest on the part of State and local officers and employees and agents of the State who have responsibilities relating to the MCO, PIHP, or PAHP contracts or enrollment processes described in 42 CFR 457.1210(a). (42 CFR 457.1214, cross referencing 42 CFR 438.58) 3.10.3

The State assures that it periodically, but no less frequently than once every 3 years, conducts, or contracts for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP or PAHP. (42 CFR 457.1285, cross referencing 42 CFR 438.602(e)) 3.10.4

The State assures that it requires MCOs, PIHPs, PAHP, and or subcontractors (only to the extent that the subcontractor is delegated responsibility by the MCO, PIHP, or PAHP for coverage of services and payment of claims) implement and maintain arrangements or procedures that are designed to detect and prevent fraud, waste, and abuse. The arrangements or procedures must include the following: • A compliance program that include all of the elements described in 42 CFR 438.608(a)(1); • Provision for prompt reporting of all overpayments identified or recovered, specifying the overpayments due to potential fraud, to the State; • Provision for prompt notification to the State when it receives information about changes in an enrollee's circumstances that may affect the enrollee's eligibility; • Provision for notification to the State when it receives information about a change in a network provider's circumstances that may affect the network provider's eligibility to participate in the managed care program, including the termination of the provider agreement with the MCO, PIHP or PAHP; • Provision for a method to verify, by sampling or other methods, whether services that have been represented to have been delivered by network providers were received by enrollees and the application of such verification processes on a regular basis; • In the case of MCOs, PIHPs, or PAHPs that make or receive annual payments under the contract of at least $5,000,000, provision for written policies for all employees of the entity, and of any contractor or agent, that provide detailed information about the False Claims Act and other Federal and State laws described in section 1902(a)(68) of the Act, including information about rights of employees to be protected as whistleblowers; • Provision for the prompt referral of any potential fraud, waste, or abuse that

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the MCO, PIHP, or PAHP identifies to the State Medicaid/CHIP program integrity unit or any potential fraud directly to the State Medicaid Fraud Control Unit; and • Provision for the MCO's, PIHP's, or PAHP's suspension of payments to a network provider for which the State determines there is a credible allegation of fraud in accordance with 42 CFR 455.23. (42 CFR 457.1285, cross referencing 42 CFR 438.608(a)) 3.10.5

The State assures that each MCO, PIHP, or PAHP requires and has a mechanism for a network provider to report to the MCO, PIHP or PAHP when it has received an overpayment, to return the overpayment to the MCO, PIHP or PAHP within 60 calendar days after the date on which the overpayment was identified, and to notify the MCO, PIHP or PAHP in writing of the reason for the overpayment. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(2)) 3.10.6

The State assures that each MCO, PIHP, or PAHP reports annually to the State on their recoveries of overpayments. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(3)) 3.10.7

The State assures that it screens and enrolls, and periodically revalidates, all network providers of MCOs, PIHPs, and PAHPs, in accordance with the requirements of part 455, subparts B and E. This requirement also extends to PCCMs and PCCM entities to the extent that the primary care case manager is not otherwise enrolled with the State to provide services to fee-for-service beneficiaries. (42 CFR 457.1285, cross referencing 42 CFR 438.602(b)(1) and 438.608(b)) 3.10.8

The State assures that it reviews the ownership and control disclosures submitted by the MCO, PIHP, PAHP, PCCM or PCCM entity, and any subcontractors. (42 CFR 457.1285, cross referencing 42 CFR 438.602(c)) 3.10.9

The State assures that it confirms the identity and determines the exclusion status of the MCO, PIHP, PAHP, PCCM or PCCM entity, any subcontractor, as well as any person with an ownership or control interest, or who is an agent or managing employee of the MCO, PIHP, PAHP, PCCM or PCCM entity through routine checks of Federal databases. If the State finds a party that is excluded, the State promptly notifies the MCO, PIHP, PAHP, PCCM, or PCCM entity and takes action consistent with 42 CFR 438.610(c). (42 CFR 457.1285, cross referencing 42 CFR 438.602(d)) 3.10.10

The State assures that it receives and investigates information from whistleblowers relating to the integrity of the MCO, PIHP, PAHP, PCCM, or PCCM entity, subcontractors, or network providers receiving Federal funds under this part. (42 CFR 457.1285, cross referencing 42 CFR 438.602(f))

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3.10.11

The State assures that MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities with which the State contracts are not located outside of the United States and that no claims paid by an MCO, PIHP, or PAHP to a network provider, out-of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates. (42 CFR 457.1285, cross referencing to 42 CFR 438.602(i); Section 1902(a)(80) of the Social Security Act) 3.10.12 The State assures that MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities submit to the State the following data, documentation, and information:

Encounter data in the form and manner described in 42 CFR 438.818.

Data on the basis of which the State determines the compliance of the MCO, PIHP, or PAHP with the medical loss ratio requirement described in 42 CFR 438.8.

Data on the basis of which the State determines that the MCO, PIHP or PAHP has made adequate provision against the risk of insolvency as required under 42 CFR 438.116.

Documentation described in 42 CFR 438.207(b) on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services, including the adequacy of the provider network, as set forth in 42 CFR 438.206.

Information on ownership and control described in 42 CFR 455.104 of this chapter from MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors as governed by 42 CFR 438.230.

The annual report of overpayment recoveries as required in 42 CFR 438.608(d)(3). (42 CFR 457.1285, cross referencing 42 CFR 438.604(a))

3.10.13 The State assures that:

It requires that the data, documentation, or information submitted in accordance with 42 CFR 457.1285, cross referencing 42 CFR 438.604(a), is certified in a manner that the MCO's, PIHP's, PAHP's, PCCM's, or PCCM entity's Chief Executive Officer or Chief Financial Officer is ultimately responsible for the certification. (42 CFR 457.1285, cross referencing 42 CFR 438.606(a))

It requires that the certification includes an attestation that, based on best information, knowledge, and belief, the data, documentation, and information specified in 42 CFR 438.604 are accurate, complete, and truthful. (42 CFR 457.1285, cross referencing 42 CFR 438.606(b)); and

It requires the MCO, PIHP, PAHP, PCCM, or PCCM entity to submit the certification concurrently with the submission of the data, documentation, or information required in 42 CFR 438.604(a) and (b). (42 CFR 457.1285, cross referencing 42 CFR 438.604(c))

3.10.14

The State assures that each MCO, PIHP, PAHP, PCCM, PCCM entity, and any subcontractors provides: written disclosure of any prohibited affiliation under 42 CFR 438.610, written disclosure of and information on ownership and control

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required under 42 CFR 455.104, and reports to the State within 60 calendar days when it has identified the capitation payments or other payments in excess of amounts specified in the contract. (42 CFR 457.1285, cross referencing 42 CFR 438.608(c)) 3.10.15

The State assures that services are provided in an effective and efficient manner. (Section 2101(a)) 3.10.16

The State assures that it operates a Web site that provides: • The documentation on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services; • Information on ownership and control of MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors; and • The results of any audits conducted under 42 CFR 438.602(e). (42 CFR 457.1285, cross-referencing to 42 CFR 438.602(g)). 3.11 Sanctions Guidance: Only States with MCOs need to answer the next three assurances (3.11.1 through 3.11.3).

Intermediate sanctions are defined at 42 CFR 438.702(a)(4) as: (1) Civil money penalties; (2) Appointment of temporary management (for an MCO); (3) Granting enrollees the right to terminate enrollment without cause; (4) Suspension of all new enrollment; and (5) Suspension of payment for beneficiaries.

3.11.1

The State assures that it has established intermediate sanctions that it may impose if it makes the determination that an MCO has acted or failed to act in a manner specified in 438.700(b)-(d). (42 CFR 457.1270, cross referencing 42 CFR 438.700) 3.11.2

The State assures that it will impose temporary management if it finds that an MCO has repeatedly failed to meet substantive requirements of part 457 subpart L. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) 3.11.3

The State assures that if it imposes temporary management on an MCO, the State allows enrollees the right to terminate enrollment without cause and notifies the affected enrollees of their right to terminate enrollment. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) Guidance: Only states with PCCMs, or PCCM entities need to answer the next assurance (3.11.4). 3.11.4 Does the State establish intermediate sanctions for PCCMs or PCCM entities? Yes No

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Guidance: Only states with MCOs and states that answered yes to assurance 3.11.4 need to complete the next three assurances (3.11.5 through 3.11.7). 3.11.5

The State assures that before it imposes intermediate sanctions, it gives the affected entity timely written notice. (42 CFR 457.1270, cross referencing 42 CFR 438.710(a)) 3.11.6

The State assures that if it intends to terminate an MCO, PCCM, or PCCM entity, it provides a pre-termination hearing and written notice of the decision as specified in 42 CFR 438.710(b). If the decision to terminate is affirmed, the State assures that it gives enrollees of the MCO, PCCM or PCCM entity notice of the termination and information, consistent with 42 CFR 438.10, on their options for receiving CHIP services following the effective date of termination. (42 CFR 457.1270, cross referencing 42 CFR 438.710(b)) 3.11.7

The State assures that it will give CMS written notice that complies with 42 CFR 438.724 whenever it imposes or lifts a sanction for one of the violations listed in 42 CFR 438.700. (42 CFR 457.1270, cross referencing 42 CFR 438.724) 3.12 Quality Measurement and Improvement; External Quality Review Guidance: The State should complete Sections 7 (Quality and Appropriateness of Care) and 9 (Strategic Objectives and Performance Goals and Plan Administration) in addition to Section 3.12. Guidance: States with MCO(s), PIHP(s), PAHP(s), or certain PCCM entity/ies (PCCM entities whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes - see 42 CFR 457.1240(f)) - should complete the applicable sub-sections for each entity type in this section, regarding 42 CFR 457.1240 and 1250. 3.12.1 Quality Strategy Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities need to complete section 3.12.1. 3.12.1.1

The State assures that it will draft and implement a written quality strategy for assessing and improving the quality of health care and services furnished CHIP enrollees as described in 42 CFR 438.340(a). The quality strategy must include the following items: The State-defined network adequacy and availability of services standards for MCOs, PIHPs, and PAHPs required by 42 CFR 438.68 and 438.206 and examples of evidence-based clinical practice guidelines the State requires in accordance with 42 CFR 438.236; A description of: The quality metrics and performance targets to be used in measuring

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the performance and improvement of each MCO, PIHP, and PAHP with which the State contracts, including but not limited to, the performance measures reported in accordance with 42 CFR 438.330(c); and The performance improvement projects to be implemented in accordance with 42 CFR 438.330(d), including a description of any interventions the State proposes to improve access, quality, or timeliness of care for beneficiaries enrolled in an MCO, PIHP, or PAHP; Arrangements for annual, external independent reviews, in accordance with 42 CFR 438.350, of the quality outcomes and timeliness of, and access to, the services covered under each contract; A description of the State's transition of care policy required under 42 CFR 438.62(b)(3); The State's plan to identify, evaluate, and reduce, to the extent practicable, health disparities based on age, race, ethnicity, sex, and primary language; For MCOs, appropriate use of intermediate sanctions that, at a minimum, meet the requirements of subpart I of 42 CFR Part 438; A description of how the State will assess the performance and quality outcomes achieved by each PCCM entity; The mechanisms implemented by the State to comply with 42 CFR 438.208(c)(1) (relating to the identification of persons with special health care needs); Identification of the external quality review (EQR)-related activities for which the State has exercised the option under 42 CFR 438.360 (relating to nonduplication of EQR-related activities), and explain the rationale for the State's determination that the private accreditation activity is comparable to such EQR-related activities; Identification of which quality measures and performance outcomes the State will publish at least annually on the Web site required under 42 CFR 438.10(c)(3); and The State's definition of a “significant change” for the purposes of updating the quality strategy under 42 CFR 438.340(c)(3)(ii). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b))

3.12.1.2

The State assures that the goals and objectives for continuous quality improvement in the quality strategy are measurable and take into consideration the health status of all populations in the State served by the MCO, PIHP, and PAHP. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(2)) 3.12.1.3

The State assures that for purposes of the quality strategy, the State provides the demographic information for each CHIP enrollee to the MCO, PIHP or PAHP at the time of enrollment. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(6))

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3.12.1.4

The State assures that it will review and update the quality strategy as needed, but no less than once every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)) 3.12.1.5

The State assures that its review and updates to the quality strategy will include an evaluation of the effectiveness of the quality strategy conducted within the previous 3 years and the recommendations provided pursuant to 42 CFR 438.364(a)(4). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(i) and (iii). 3.12.1.6

The State assures that it will submit to CMS: A copy of the initial quality strategy for CMS comment and feedback prior to adopting it in final; and A copy of the revised strategy whenever significant changes are made to the document, or whenever significant changes occur within the State's CHIP program, including after the review and update required every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(3)).

3.12.1.7

Before submitting the strategy to CMS for review, the State assures that when it drafts or revises the State’s quality strategy it will: Make the strategy available for public comment; and If the State enrolls Indians in the MCO, PIHP, or PAHP, consult with Tribes in accordance with the State's Tribal consultation policy. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(1)).

3.12.1.8

The State assures that it makes the results of the review of the quality strategy (including the effectiveness evaluation) and the final quality strategy available on the Web site required under 42 CFR 438.10(c)(3). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(ii) and (d)). 3.12.2 Quality Assessment and Performance Improvement Program 3.12.2.1 Quality Assessment and Performance Improvement Program: Measures and Projects Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next two assurances (3.12.2.1.1 and 3.12.2.1.2). 3.12.2.1.1 The State assures that it requires that each MCO, PIHP, and PAHP establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The elements of the assessment and program include at least:

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• Standard performance measures specified by the State; • Any measures and programs required by CMS (42 CFR 438.330(a)(2); • Performance improvement projects that focus on clinical and non-clinical areas, as specified in 42 CFR 438.330(d); • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c); • Mechanisms to detect both underutilization and overutilization of services; and • Mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs, as defined by the State in the quality strategy under 42 CFR 457.1240(e) and Section 3.12.1 of this template). (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(b) and (c)(1)) Guidance: A State may request an exemption from including the performance measures or performance improvement programs established by CMS under 42 CFR 438.330(a)(2), by submitting a written request to CMS explaining the basis for such request. 3.12.2.1.2 The State assures that each MCO, PIHP, and PAHP’s performance improvement projects are designed to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction. The performance improvement projects include at least the following elements: • Measurement of performance using objective quality indicators; • Implementation of interventions to achieve improvement in the access to and quality of care; • Evaluation of the effectiveness of the interventions based on the performance measures specified in 42 CFR 438.330(d)(2)(i); and • Planning and initiation of activities for increasing or sustaining improvement. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(2)) Guidance: Only states with a PCCM entity whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes need to, complete the next assurance (3.12.2.1.3).

3.12.2.1.3 The State assures that it requires that each PCCM entity establishes and implements an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms

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of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The assessment and program must include: • Standard performance measures specified by the State; • Mechanisms to detect both underutilization and overutilization of services; and • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c). (42 CFR 457.1240(a) and (b), cross referencing to 42 CFR 438.330(b)(3) and (c)) 3.12.2.2 Quality Assessment and Performance Improvement Program: Reporting and Effectiveness Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.2.2. 3.12.2.2.1 The State assures that each MCO, PIHP, and PAHP reports on the status and results of each performance improvement project conducted by the MCO, PIHP, and PAHP to the State as required by the State, but not less than once per year. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(3)) 3.12.2.2.2 The State assures that it annually requires each MCO, PIHP, and PAHP to:

1) Measure and report to the State on its performance using the standard measures required by the State;

2) Submit to the State data specified by the State to calculate the MCO's, PIHP's, or PAHP's performance using the standard measures identified by the State; or

3) Perform a combination of options (1) and (2) of this assurance. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(c)(2))

3.12.2.2.3 The State assures that the State reviews, at least annually, the impact and effectiveness of the quality assessment and performance improvement program of each MCO, PIHP, PAHP and PCCM entity. The State’s review must include: • The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required to report; and • The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement projects. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(e)(1)) 3.12.3 Accreditation Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.3.

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3.12.3.1

The State assures that it requires each MCO, PIHP, and PAHP to inform the state whether it has been accredited by a private independent accrediting entity, and, if the MCO, PIHP, or PAHP has received accreditation by a private independent accrediting agency, that the MCO, PIHP, and PAHP authorizes the private independent accrediting entity to provide the State a copy of its recent accreditation review that includes the MCO, PIHP, and PAHP’s accreditation status, survey type, and level (as applicable); accreditation results, including recommended actions or improvements, corrective action plans, and summaries of findings; and expiration date of the accreditation. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(a) and (b)). 3.12.3.2

The State assures that it will make the accreditation status for each contracted MCO, PIHP, and PAHP available on the Web site required under 42 CFR 438.10(c)(3), including whether each MCO, PIHP, and PAHP has been accredited and, if applicable, the name of the accrediting entity, accreditation program, and accreditation level; and update this information at least annually. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(c))

3.12.4 Quality Rating Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.4.

The State assures that it will implement and operate a quality rating system that issues an annual quality rating for each MCO, PIHP, and PAHP, which the State will prominently display on the Web site required under 42 CFR 438.10(c)(3), in accordance with the requirements set forth in 42 CFR 438.334. (42 CFR 457.1240(d)) Guidance: States will be required to comply with this assurance within 3 years after CMS, in consultation with States and other Stakeholders and after providing public notice and opportunity for comment, has identified performance measures and a methodology for a Medicaid and CHIP managed care quality rating system in the Federal Register. 3.12.5 Quality Review Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5 and 3.12.5.1.

The State assures that each contract with a MCO, PIHP, PAHP, or PCCM entity requires that a qualified EQRO performs an annual external quality review (EQR) for each contracting MCO, PIHP, PAHP or PCCM entity, except as provided in 42 CFR 438.362. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(a))

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3.12.5.1 External Quality Review Organization 3.12.5.1.1 The State assures that it contracts with at least one external quality review organization (EQRO) to conduct either EQR alone or EQR and other EQR-related activities. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(a)) 3.12.5.1.2 The State assures that any EQRO used by the State to comply with 42 CFR 457.1250 must meet the competence and independence requirements of 42 CFR 438.354 and, if the EQRO uses subcontractors, that the EQRO is accountable for and oversees all subcontractor functions. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.354 and 42 CFR 438.356(b) through (d)) 3.12.5.2 External Quality Review-Related Activities Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next three assurances (3.12.5.2.1 through 3.12.5.2.3). Under 42 CFR 457.1250(a), the State, or its agent or EQRO, must conduct the EQR-related activity under 42 CFR 438.358(b)(1)(iv) regarding validation of the MCO, PIHP, or PAHP’s network adequacy during the preceding 12 months; however, the State may permit its contracted MCO, PIHP, and PAHPs to use information from a private accreditation review in lieu of any or all the EQR-related activities under 42 CFR 438.358(b)(1)(i) through (iii) (relating to the validation of performance improvement projects, validation of performance measures, and compliance review). 3.12.5.2.1 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(1)(i) through (iv) (relating to the validation of performance improvement projects, validation of performance measures, compliance review, and validation of network adequacy) will be conducted on all MCOs, PIHPs, or PAHPs. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(b)(1))

3.12.5.2.2 The State assures that if it elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will document the use of nonduplication in the State’s quality strategy. (42 CFR 457.1250(a), cross referencing 438.360, 438.358(b)(1)(i) through (b)(1)(iii), and 438.340) 3.12.5.2.3 The State assures that if the State elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will ensure that all information from a Medicare or private accreditation review for an

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MCO, PIHP, or PAHP will be furnished to the EQRO for analysis and inclusion in the EQR technical report described in 42 CFR 438.364. ((42 CFR 457.1250(a), cross referencing to 42 CFR 438.360(b)) Guidance: Only states with PCCM entities need to complete the next assurance (3.12.5.2.4). 3.12.5.2.4 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(2) (cross-referencing 42 CFR 438.358(b)(1)(ii) and (b)(1)(iii)) will be conducted on all PCCM entities, which include: • Validation of PCCM entity performance measures required in accordance with 42 CFR 438.330(b)(2) or PCCM entity performance measures calculated by the State during the preceding 12 months; and • A review, conducted within the previous 3-year period, to determine the PCCM entity’s compliance with the standards set forth in subpart D of 42 CFR part 438 and the quality assessment and performance improvement requirements described in 42 CFR 438.330. (42 CFR 457.1250(a), cross referencing to 438.358(b)(2))

3.12.5.3 External Quality Review Report Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5.3. 3.12.5.3.1 The State assures that data obtained from the mandatory and optional, if applicable, EQR-related activities in 42 CFR 438.358 is used for the annual EQR to comply with 42 CFR 438.350 and must include, at a minimum, the elements in §438.364(a)(2)(i) through (iv). (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(a)(2))

3.12.5.3.2 The State assures that only a qualified EQRO will produce the EQR technical report (42 CFR 438.364(c)(1)).

3.12.5.3.3 The State assures that in order for the qualified EQRO to perform an annual EQR for each contracting MCO, PIHP, PAHP or PCCM entity under 42 CFR 438.350(a) that the following conditions are met: • The EQRO has sufficient information to use in performing the review; • The information used to carry out the review must be obtained from the EQR-related activities described in 42 CFR 438.358

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and, if applicable, from a private accreditation review as described in 42 CFR 438.360; • For each EQR-related activity (mandatory or optional), the information gathered for use in the EQR must include the elements described in 42 CFR 438.364(a)(2)(i) through (iv); and • The information provided to the EQRO in accordance with 42 CFR 438.350(b) is obtained through methods consistent with the protocols established by the Secretary in accordance with 42 CFR 438.352. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(b) through (e)) 3.12.5.3.4 The State assures that the results of the reviews performed by a qualified EQRO of each contracting MCO, PIHP, PAHP, and PCCM entity are made available as specified in 42 CFR 438.364 in an annual detailed technical report that summarizes findings on access and quality of care. The report includes at least the following items: • A description of the manner in which the data from all activities conducted in accordance with 42 CFR 438.358 were aggregated and analyzed, and conclusions were drawn as to the quality, timeliness, and access to the care furnished by the MCO, PIHP, PAHP, or PCCM entity (described in 42 CFR 438.310(c)(2)); • For each EQR-related activity (mandatory or optional) conducted in accordance with 42 CFR 438.358: o Objectives; o Technical methods of data collection and analysis; o Description of data obtained, including validated performance measurement data for each activity conducted in accordance with 42 CFR 438.358(b)(1)(i) and (ii); and o Conclusions drawn from the data; • An assessment of each MCO's, PIHP's, PAHP's, or PCCM entity's strengths and weaknesses for the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; • Recommendations for improving the quality of health care services furnished by each MCO, PIHP, PAHP, or PCCM entity, including how the State can target goals and objectives in the quality strategy, under 42 CFR 438.340, to better support improvement in the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; • Methodologically appropriate, comparative information about all MCOs, PIHPs, PAHPs, and PCCM entities, consistent with guidance included in the EQR protocols issued in accordance with 42 CFR 438.352(e); and

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