New Hampshire State Children’s Health Insurance Program State Plan Final SPA #5 Submitted October 01, 2009

Approved December 18, 2009

Effective Date: May 1998

Approval Date: September 1998 1

OMB #: 0938-0707 Exp. 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.

New Hampshire State Children’s Health Insurance Program State Plan Final SPA #5 Submitted October 01, 2009

Approved December 18, 2009

Effective Date: May 1998

Approval Date: September 1998 2 Form CMS-R-211

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:______New Hampshire_____________ (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 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: Ann Walls Position/Title: SCHIP Manager, NH DHHS-Office of Medicaid Business and Policy Name: Kathleen Dunn Position/Title: Director, NH DHHS-Office of Medicaid Business and Policy Name: Marilee Nihan Position/Title: Financial Manager, NH DHHS-Office of Medicaid Business and Policy

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: May 1998

Approval Date: September 1998 3 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.

New Hampshire’s expansion of children’s health care coverage under Title XXI occurred in two phases, which involved providing expanded benefits under the State’s Medicaid plan and obtaining coverage that meets the requirements for a State Children’s Health Insurance Program.

In Phase 1, implemented May 1998, the state expanded Medicaid to include newborns and infants from birth to age 1 with family income greater than 185% and equal to or less than 300% of FPL. Income is calculated in the same manner currently used by the state for poverty level children (children with family income at or below 185% of FPL) with an additional disregard of 65% of the FPL for the family size involved as revised annually in the Federal Register. In no case will income be disregarded such that the resulting net income is less than or equal to 185% FPL. The federal eligibility standard is 235% FPL.

In Phase II, implemented in January 1999, the New Hampshire Department of Health and Human Services (DHHS) partnered with the New Hampshire Healthy Kids Corporation (NHHKC) to provide insurance coverage through the development of a State Children’s Health Insurance Program (SCHIP) for children ages 1 through 18 with family income greater than 185% and equal to or less than 300% of FPL. Income is calculated in the same manner currently used by the state for poverty level children (children with family income at or below 185% of FPL) with an additional disregard of 65% of the FPL for the family size involved as revised annually in the Federal Register. In no case will income be disregarded such that the resulting net income is less than or equal to 185% FPL.

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

Effective Date: May 1998

Approval Date: September 1998 4 The federal eligibility standard is 235% FPL.

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))

No expenditures were claimed prior to the time the state had the legislative authority to operate the State plan or plan amendment as approved by CMS.

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)

New Hampshire’s SCHIP complies with all applicable civil rights requirements, including the above-mentioned sites.

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):

State Plan (Phase 1 - Title XIX expansion): Effective/Implementation Date: May 1, 1999

Amendment #1 (Phase 2 - Title XXI): Effective/Implementation Date: January 1, 1999

Amendment #2 (adding “good-cause” exceptions): Effective/Implementation Date: April 1, 2002

Amendment #3 (increasing premiums): Effective/Implementation Date: January 1, 2003

Amendment #4 (adding a tiered drug formulary): Effective/Implementation Date: January 1, 2005

Amendment #5 (increasing premiums) Effective: October 1, 2009

(change in healthcare MCO) Implementation: July 1, 2009

(enrollment cap authority): Effective: July 1, 2009 (CHIPRA citizenship documentation): Implementation: January 1, 2010

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

Effective Date: May 1998

Approval Date: September 1998 5

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))

See electronically attached Health Resources and Services Administration New Hampshire State Planning Grant Interim Report, March 2002.

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):

Brochures outlining options for health care coverage, including Medicaid eligibility as well as Medicaid application forms (New Hampshire has a short application form commonly referred to as the 800-P for poverty level children's groups and pregnant women) are available at a variety of community agencies and provider sites such as hospitals, WIC sites, and public health clinics and community health centers funded through Title V and Title X grants. These same agencies are part of an on-going effort by the state to identify Medicaid eligible children and provide support to eligible families who up until now have not availed themselves of Medicaid benefits but would be eligible if they applied.

Formal Medicaid application and intake sites include the twelve local New Hampshire DHHS district offices strategically located around the state. In addition, the Medicaid 800-P short forms can be completed and

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

Effective Date: May 1998

Approval Date: September 1998 6 submitted via the Title V agencies, Title X clinics, WIC sites, disproportionate share hospitals, Early Intervention sites and Federally Qualified Health Centers (FQHC's).

The state also maintains a toll free phone number and client service units in both the Medicaid Administration Services and the Division of Family Assistance (DFA) to provide prompt answers to questions regarding eligibility and services. At this time there is no other public health or state only insurance program for children.

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:

The only health insurance program for children that involves a public private-partnership is New Hampshire Healthy Kids Corporation (NHHKC). In 1993, the New Hampshire Legislature passed the Healthy Kids Act (RSA 126: H) to address the growing problem of uninsured children. The Act created the New Hampshire Healthy Kids Corporation, a private non-profit, "deemed to be a public instrumentality and ... by the authority of the powers conferred by this chapter shall be deemed and held to be the performance of public and essential government functions of the state.”

The state does not subsidize premiums at this time, but it provides funds for administration, marketing and outreach. NHHKC is governed by a seventeen member Board of Directors that includes six appointees of state government including the Department of Health and Human Services. State oversight includes a requirement for an annual report to the Governor, various Commissioners, and members of the Legislature.

The state created NHHKC to provide affordable health coverage and access to health care services for uninsured children. The program design and operations are consistent with the goals of Title XXI. As a public-private partnership, the goal has been to conduct multifaceted outreach and marketing, simplify the enrollment process, and design and operate a program that would avoid the stigma often associated with Medicaid.

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

Effective Date: May 1998

Approval Date: September 1998 7

NHHKC’s plan provides comprehensive health and dental benefits, which emphasize the preventive and primary care that children need to stay healthy and go to school ready to learn. Currently coverage is underwritten by Harvard Pilgrim Healthcare for health benefits and mental health benefits, and Northeast Delta Dental for dental benefits. Selection of the insurance carrier was conducted through a formal RFP process and contracts are renegotiated biennially.

To be eligible for SCHIP component of Healthy Kids, a child must be a full time resident of the state, not eligible for Medicaid, not enrolled in employment-related group health insurance in the past six months, and their family income cannot exceed 300% of the federal poverty level.

Efforts to identify and enroll children in NHHKC have been extensive. The Corporation has developed outreach partnerships with schools, childcare agencies, health care providers, municipalities and community-based social service agencies. Award-winning printed materials include postcards, posters, annual reports, brochures and flyers, which are widely distributed and displayed throughout the state. The Corporation conducts an aggressive media campaign, which has resulted in frequent coverage in newspapers, on radio and television; speaking engagements on public affairs programs, and public service announcements. The Corporation teams with businesses for promotion activities such as fast food tray liners and promotion cards stuffed in bags at retail outlets such as grocery stores, pharmacies and discount department stores.

Schools provide the largest source of referral (about 40%) where twice each year the school age population is blanketed with promotion information and school nurses display information and make direct referrals. Twenty percent of inquiries cite media as their source of information about the program. As the program becomes more well known, provider and word-of-mouth referrals are becoming more frequent. The Corporation tracks response to its various marketing and outreach activities for informed decision making about the most effective methods and messages. At the present time NHHKC estimates that it has reached over 12,000 families in New Hampshire.

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

Effective Date: May 1998

Approval Date: September 1998 8

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 state coordinates SCHIP enrollment and outreach efforts with other public and private health insurance programs and child health agencies in order to increase the number of children with creditable health coverage. This coordination reduces duplication of efforts and provides quality health care coverage to New Hampshire’s uninsured children.

As demonstrated in section 4.4, the state closely coordinates SCHIP enrollment efforts with the state’s Medicaid program. The state’s Division of Family Assistance (DFA) utilizes a software program called New HEIGHTS in the district offices. The program utilizes a cascading logic that allows staff in the district offices to screen for eligibility for various Medicaid coverage groups as well as other public assistance programs. With the advent of Title XXI, efforts were taken to incorporate the logic required to automate the screening and eligibility referrals of Healthy Kids Silver to NHHKC. Referrals are also automated to NHHKC for families whose income exceeds 300% FPL and do not qualify for services funded by Title XIX or XXI, but may qualify for the unsubsidized Healthy Kids Silver Buy-In program.

As part of their contract with the state, Title V agencies must screen all children they see at their agencies for health insurance. If that child is uninsured, agency staff is required to assist families in applying for the program. As part of their health performance measurements, Title V agencies are also expected to document clients who are enrolled in the Healthy Kids program. The Department’s SCHIP coordinator also meets with Maternal and Child Health coordinators on a regular basis to discuss problems and coordinate efforts.

In addition, at the time of implementation of SCHIP, plans were made to provide for the screening, referral and tracking of children with special health needs. A question on the Healthy Kids application (800P) asks, “ Are there any children with special heath care needs who require ongoing supports to maintain their care at

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

Effective Date: May 1998

Approval Date: September 1998 9 home?”. If the applicant checks off yes, that person’s name and information is sent to Family Voices, a family to family health information and resource project, who will assist that family with the coordination of other private and state resources for children with special heath care needs such as the Special Medical Services Bureau, a Title V funded program.

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

Effective Date: May 1998

Approval Date: September 1998 10

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))

As noted in Section 1.1.3 and described in the state's Medicaid state plan amendment, Phase 1 of the NH’s State Children’s Health Insurance Program consists of the state using Title XXI funds to expand Medicaid coverage for newborns and infants from birth to age 1 with family income greater than 185% and equal to or less than 300% of FPL. To complement Phase 1, the state instituted a name change to all children's Medicaid programs to Healthy Kids Gold in an effort to reduce barriers due to stigma associated with Medicaid enrollment. The Medicaid expansion program is also called Healthy Kids Gold and infants on this program receive Medicaid benefits until they turn 1.

Utilizing the provisions of Title XXI the state offers retroactive coverage, for infants at greater than 185% FPL and equal to or less than 300% FPL. Consistent with the current Medicaid fee-for- service program, the state will provide 3 months of retroactive coverage for services received in the 3 months prior to application date for Healthy Kids as long as the services received are within the scope of benefits and as long as the infant met the eligibility requirements during those 3 months.

Through Phase 2 of NH’s SCHIP plan, the state provides insurance coverage to children between ages 1 and 19 whose family income is greater than 185% and equal to or less than 300% of FPL. The state purchases insurance for these children through NHHKC. To be consistent with Phase I, this program is called Healthy Kids Silver.

NHHKC subcontracts with Harvard Pilgrim Healthcare of New Hampshire and Northeast Delta Dental. The coverage offered is a managed care product with a focus on preventive and well-child

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

Effective Date: May 1998

Approval Date: September 1998 11 care. NHHKC selected Harvard Pilgrim Healthcare and Northeast Delta Dental via a competitive bid process. Contracts have been renegotiated biennially. The state will requires a competitive bid process until such time as their enrollment reaches a sufficient capacity to support a competitive bid process.

The Healthy Kids Silver benefits package includes an emphasis on perinatal care coverage for pregnant adolescent girls not previously served by NHHKC.

Mental health benefits are accessed through a phone call to Harvard Pilgrim Healthcare’s Behavioral Health Access Center.. Prior PCP authorization is not necessary to access the mental health or dental benefits.

At the time of enrollment for Healthy Kids Silver, a family chooses a primary care provider (PCP) from the Harvard Pilgrim network. If a PCP is not chosen, the family is assisted by either Harvard Pilgrim Healthcare’s customer service staff or NHHKC to select one.. The family also needs to submit the first month's premium, which is collected by NHHKC on behalf of the state.

Utilizing the provisions under Title XXI the state has implemented cost sharing provisions Healthy Kids Silver. Families whose income is greater than 185% and equal to or less than 250% of FPL pay a $32 per child per month premium, and there is a $128 cap on monthly premiums for these families with multiple children. Families whose income is greater than 250% and equal to or less than 300% of FPL pay a $54 per child per month premium, and there is a $162 cap on monthly premiums for these families with multiple children. NHHKC has made the premium payment process as user friendly as possible including mailing labels, change of address forms, use of coupon books. NHHKC implemented voluntary participation in electronic funds transfer (EFT) for premium payment in Fall 2002.

Defaulting on the payment of premiums result in the termination of eligibility after 60 days except for pregnant teens. NHHKC reports to the state children whose eligibility is terminated and the circumstances of the termination. NHHKC and the state can waive premium payment for hardship/good cause as described in section 8.7. NHHKC supports a premium rescue fund through which charitable dollars are used to help families overcome a temporary loss of income or unexpected financial crisis.

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

Effective Date: May 1998

Approval Date: September 1998 12

Pregnant teens do not have their eligibility terminated for failure to pay premiums until after the postpartum period. The default clock begins on the sixty-first (61st) day postpartum. Terminating health care coverage mid-pregnancy is counterproductive to the state's goal of healthy birth outcomes for mother and infant.

In addition to the monthly premium for Healthy Kids Silver, the following co-payments are also required: $10 for office visits (excluding well-child or preventative health visits and any covered dental services), $5 for covered formulary generic prescriptive drugs, $15 for covered formulary brand name drugs when no generic equivalent is available or the provider indicates that it is medically necessary, $25 for covered non-formulary brand name drugs when no generic equivalent is available or the provider indicates that it is medically necessary, and a $50 fee for emergency room visits, unless the patient is admitted to the hospital. Providers will be responsible for collecting the co-pays at the time of service.

In compliance with Section 2103 of the Social Security Act, as amended by Section 403 of the Children’s Health Insurance Reauthorization Act of 2009 (CHIPRA), families enrolled in SCHIP who are dissatisfied with the CHIP managed care plan may, at disenrollment, opt in to Fee for Service coverage.

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 state bears the responsibility for utilization control for the Healthy Kids Gold fee for service program.

The primary utilization control for Healthy Kids Silver is the responsibility of the managed care organization, Harvard Pilgrim Healthcare. The contract with Harvard Pilgrim includes a definition of medical necessity and utilization management requirements, including clinical staffing requirements. The plan is required to have written utilization management policies and procedures that include appropriateness criteria for authorization and denial of services and protocols for prior approval, hospital discharge planning, and

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

Effective Date: May 1998

Approval Date: September 1998 13 retrospective review.

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

Effective Date: May 1998

Approval Date: September 1998 14 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)) (42CFR 457.305(a) and 457.320(a))

4.1.1. Geographic area served by the Plan: Statewide 4.1.2.

Age: For Phase I, Healthy Kids Gold -Medicaid expansion: Infants up to age 1. For Phase II, Healthy Kids Silver: Children between age 1 through age 18. 4.1.3. Income: Family income must be greater than 185% and equal to or less than 300% of the FPL. (Income is calculated in the same manner as currently used by the state for poverty level children - children with family income at or below 185% of FPL-with an additional disregard of 65% of the federal poverty level for the family size involved as revised annually in the Federal Register. In no case will income be disregarded such that the resulting net income is less than or equal to 185% FPL. The federal eligibility standard is 235% FPL.) Methods for evaluating income include paycheck stubs, W-2s, income tax returns and letters from employers on company letterhead. 4.1.4. Resources (including any standards relating to spend downs and disposition of resources): There is no resource or assets test. 4.1.5.

Residency (so long as residency requirement is not based on length of time in state) : To be eligible a child must be a resident of the State of New Hampshire. There is no time requirement to be considered a resident. 4.1.6. Disability Status (so long as any standard relating to disability status does not restrict eligibility): 4.1.7.

Access to or coverage under other health coverage: Children who are covered under a group health plan or other health insurance coverage, or are children of a public employee eligible for coverage under a state health benefits plan are not eligible for the Healthy Kids Silver. An application for Healthy Kids Silver will be disapproved if it is determined that the child

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

Effective Date: May 1998

Approval Date: September 1998 15 was covered under a health insurance plan within the last six months. However, an application may be approved for good cause. Such reasons include: loss of employment, change of employment to an employer who does not provide dependent coverage, death of the employed parent, discontinuation of coverage to all employees (regardless of income) by the employer, insurer closes its operation in New Hampshire, an involuntary reduction in work hours that no longer allows the employee to enroll the employees dependent children under the employer’s health plan, voluntary loss of employment and the loss occurred for any of the good cause reasons specified in New Hampshire Code of Administrative Rules He-W 910.09( c) (2)a-g, cases of domestic violence, a temporary insurance policy is ending, COBRA coverage if good cause existed when employer coverage was lost, loss of coverage beyond the control of custodial parent when non-custodial parent drops insurance, and loss of coverage when parent leaves work to be the primary caretaker for his/her children ages 5 and under (effective April 1, 2002).

4.1.8.

Duration of eligibility: In general, a child who has been determined eligible for Healthy Kids Gold or Silver shall remain eligible unless the child attains the upper age limit, as appropriate, is no longer a resident of the state, or fails to pay premiums (for Healthy Kids Silver). Exceptions to this policy are previously noted.

The state may determine that an enrollee is not eligible if eligibility was a result of making a false statement, misrepresentation or concealment of or failure to disclose income or health insurance coverage. The state may recover payments made by the state on behalf of enrollees as a result of any false statement, misrepresentation, etc. regarding income or health insurance coverage. Eligibility is re-determined not more than 12 months after the effective date of eligibility and annually thereafter. 4.1.9.

Other standards (identify and describe): The state asks for verification of citizenship and identity.Applicants are asked for child’s social security number on the Healthy Kids application. The social security number is required for cross-match with Social Security Administration for citizenship verification.

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))

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

Effective Date: May 1998

Approval Date: September 1998 16 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 lower family income. (Exception to this is during enrollment cap periods. See Section 4.3.1 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)) (42CFR 457.350) With the implementation of SCHIP, the state created a single application, the 800P, for both Healthy Kids Silver and Healthy Kids Gold programs. Families can apply for the Healthy Kids program by visiting their local DHHS District Office, or by mailing the application directly to the mail- in enrollment center located at NHHKC.

By Federal regulation, only state employees are permitted to make eligibility determinations. DFA case technicians at the local district office and at NHHKC are responsible for screening all applications and verifying income, age, and other eligibility requirements. Information collected on the application form, include name, address, date of birth, social security number, residency, citizenship, family income, employment, and insurance (both current and in the previous six months).

If information is incomplete or questionable, the state will attempt to contact the applicant by phone to obtain missing information or to clarify questionable information within 10 business days of receipt of the application. If the family does not have access to a phone and/or if the state is not able to make contact by phone, the state will attempt to contact the family by mail. If no response is obtained within 10 days of sending a letter, the application will be denied.

The state will test for Medicaid eligibility first before determining eligibility for Healthy Kids Silver. If a child meets Medicaid eligibility, he/she will be enrolled in Healthy Kids Gold (Medicaid). If a child is not eligible for Medicaid but meets eligibility requirements for Healthy Kids Silver (including income, residence, and insurance requirements), he/she will be enrolled in Title XXI via NHHKC. The exception to this is during enrollment cap periods. See Section 4.3.1. If a child is not eligible for either program but may be eligible for the non-subsidized Healthy Kids Silver Buy-In program, a referral is made to NHHKC.

Eligibility information for children determined eligible for Healthy Kids Silver will be entered into New HEIGHTS and sent to NHHKC. NHHKC will complete

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

Effective Date: May 1998

Approval Date: September 1998 17 enrollment, including sending a letter notifying the family of the child’s eligibility (including the effective date), materials about NHHKC and the health plan and a coupon payment book for premiums. Eligibility will be effective the date a child is enrolled in a plan and payment received. This will generally be the first day of the month after the child was determined eligible but may be later if eligibility is determined within one week of the end of the month, if the premium is not received or if the family takes additional time to select a plan (if and when there is a choice of plans) or primary care provider. Exception to this is during enrollment cap periods. See Section 4.3.1.

Enrollees are required to notify NHHKC or DHHS of any change in household (i.e. changed address or number of individuals in household) or income within 10 days of change.

Not more than 12 months after the effective date of eligibility and annually thereafter, the state will re-determine eligibility for Healthy Kids Silver and Healthy Kids Gold. The state will mail a form to enrollees to obtain information necessary to review eligibility. Enrollees will be required to notify NHHKC or DHHS of any change in circumstance that could affect continued eligibility for coverage. If a child is no longer eligible for Healthy Kids Silver, he/she will be disenrolled. If he/she is eligible for Medicaid, he/she will be enrolled in Healthy Kids Gold. If a child is no longer eligible for Healthy Kids Gold, he/she will be disenrolled. If that child is eligible for Silver, NHHKC will receive an electronic referral and the above-mentioned process will occur to enroll the family in Healthy Kids Silver.

The state also facilitates the enrollment of uninsured children through its presumptive eligibility program for Healthy Kids Gold. Presumptive eligibility has been enhanced so that presumptive eligibility and community facilitated applications, processed by qualified entities that are authorized and trained by the DHHS, will be centralized at the mail-in enrollment center at NHHKC.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

Check here if this section does not apply to your state.

NH currently has no waiting list. Enrollment may be limited in the future if state general fund appropriation is insufficient. The need to implement an enrollment cap is assessed as follows: DHHS monitors current or “actual” CHIP monthly enrollment. If actual enrollment grows to within range of a predetermined member month number, (as representing enrollment that couldn't be supported financially by State funds if it were to continue to grow at that sustained annual growth rate), that member month number would be

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

Effective Date: May 1998

Approval Date: September 1998 18 considered a “trigger” for capping enrollment. Financial calculation of the predetermined trigger point is a product of the number currently enrolled and the state share cost of the per member per month premium fee. Should NH reach the trigger point the following procedures will be put in to place: The enrollment is “capped” meaning that no additional children may enroll. A wait list accepts children determined to be eligible and they queue up on the list, first come, first served. Since NH has a joint application for Medicaid and SCHIP, the application and eligibility determination process continue during the SCHIP enrollment cap and wait list period. Families determined to be eligible for Medicaid are enrolled and those determined to be eligible for SCHIP are informed of the enrollment cap and their children placed on the wait list. While on the SCHIP wait list, families must continue to report changes that effect eligibility such as income or household composition. If eligibility redetermination of a family on the SCHIP wait list results in eligibility for Medicaid, the children are enrolled in Medicaid and taken off the wait list. Enrollment is tracked monthly. Potential enrollment spaces become available at the end of each month when enrollment ends for currently enrolled children who disenrolled because they: 1. Have turned 19; 2. Become eligible for Medicaid coverage; 3. Move out of state; 4. Failed to pay monthly premium; 5. Failed to complete redetermination process; 6. Obtained other insurance; 7. Were determined ineligible during redetermination process; 8. Moved within the state with no forwarding address; 9. Voluntarily disenrolled with no stated reason; 10. Died.

When enrollment “slots” become available, a specified number of children (equal to number of slots available) at the top of the wait list are contacted, and their families informed that they may enroll. Children are removed from the wait list and families are provided 30 days to enroll.

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 redetermination, 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 assistance under the state child health plan. (Sections

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

Effective Date: May 1998

Approval Date: September 1998 19 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3))

As noted in section 4.3, the state determines eligibility for both Healthy Kids Silver and Healthy Kids Gold. As part of the determination for Healthy Kids Silver, the state verifies that an applicant is not a Medicaid beneficiary through New HEIGHTS, the states eligibility system. If the child is not a Medicaid beneficiary, the state will (based on the information collected as part of the application process) determine whether he/she may be eligible for Medicaid (e.g., because of income level). If the child is already enrolled in Medicaid, the application for Healthy Kids Silver will be denied. If the child appears likely to be eligible for Medicaid, the state will determine eligibility and assist in the enrollment of the child into Healthy Kids Gold (Medicaid).

The application includes questions about insurance coverage. If a child has insurance coverage, he/she will not be eligible to receive coverage under Healthy Kids Silver. Also, if a child has had insurance coverage in the past six months and does not meet one of the good cause exemptions (as noted in section 4.1.7), he/she will not be eligible to receive coverage via Healthy Kids Silver. Children who were enrolled in NHHKC prior to the state’s Title XXI program and who met the remaining eligibility guidelines were grandfathered into Healthy Kids Silver.

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)) (42CFR 457.350(a)(2))

The same state unit determines eligibility for both Healthy Kids Silver and Healthy Kids Gold (Medicaid), which maximizes the coordination of eligibility for both programs. The state will first determine whether or not a child is eligible for Healthy Kids Gold. If the child is eligible, he/she will be enrolled. Only if he/she is not eligible for Healthy Kids Gold will he/she be screened and enrolled in Healthy Kids Silver via NHHKC.

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)) (42CFR 431.636(b)(4))

The same state unit determines eligibility for both Healthy Kids Silver and Healthy Kids Gold (Medicaid), which maximizes the coordination of

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

Effective Date: May 1998

Approval Date: September 1998 20 eligibility for both programs. The state will first determine whether or not a child is eligible for Healthy Kids Gold. If the child is eligible, he/she will be enrolled. Only if he/she is not eligible for Healthy Kids Gold will he/she be screened and enrolled in Healthy Kids Silver via NHHKC. 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)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

The application process involves collecting information about current coverage and coverage in the past six months. Children currently covered will not be eligible for Healthy Kids Silver coverage. The state will review applications to determine whether applicants or employers of applicants have discontinued private or employer-sponsored dependent coverage in order to participate in the program. Children who had employer-sponsored coverage within the previous six months who lost coverage for reasons related to the availability of Healthy Kids Silver (e.g., no longer purchasing family coverage) will not be eligible. As noted in section 4.1.7, an application may be approved for good cause. Such reasons include: loss of employment, change of employment to an employer who does not provide dependent coverage, death of the employed parent, discontinuation of coverage to all employees (regardless of income) by the employer, insurer closes its operation in New Hampshire, an involuntary reduction in work hours that no longer allows the employee to enroll the employees dependent children under the employer’s health plan, voluntary quit of employment and the quit occurred for any of the good cause reasons specified in New Hampshire Code of Administrative Rules He-W 910.09( c) (2)a-g, cases of domestic violence, a temporary insurance policy is ending, COBRA coverage if good cause existed when employer coverage was lost, loss of coverage beyond the control of custodial parent when non-custodial parent drops insurance, and loss of coverage when parent leaves work to be the primary caretaker for his/her children ages 5 and under (effective April 1, 2002).

4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution. Children, ages 0-19, in families with income at 0- 185% FPL, or newborns and infants ages 0-1 with income at greater than 185% to 300% of FPL are covered under Healthy Kids Gold (Medicaid) and can have other insurance. Children ages 0-19, in families with income at 185%-300% FPL are on Healthy Kids Silver and can not

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

Effective Date: May 1998

Approval Date: September 1998 21 have other health insurance. Therefore, the methods of monitoring substitution stated in section 4.4.4 apply. 4.4.4.2. Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable. The methods of monitoring substitution stated in section 4.4.4 apply for these families. 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. The methods of monitoring substitution stated in section 4.4.4 apply for these families. 4.4.4.4. If the state provides coverage under a premium assistance program, describe:

N/A

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

N/A

The minimum employer contribution. N/A

The cost-effectiveness determination.

N/A 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))

Cost sharing protection is in place to ensure enrollment of American Indians and Alaska Natives, as defined in 457.10. The following documents will be revised to disclose that members of federally recognized Indian Tribes and Alaska Natives are eligible for free coverage under Title XXI although the children may qualify for premium-based coverage: 1. The Children’s Health Insurance Program Guide to Benefits – this is the primary information booklet that describes the programs and how to apply. 2. Silver Eligibility Letter – Families who have applied for coverage

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

Effective Date: May 1998

Approval Date: September 1998 22 through the DHHS District Office and are referred to NHHKC for enrollment. 3. Silver Enrollment Letter – Families who have applied through the mail-in unit at NHHKC and have been deemed eligible for the premium-based Healthy Kids (Title XXI) program.

In order to process the free coverage enrollment, members of tribes will be asked to inform NHHKC of their tribe status by phone or mail. The contract between NHHKC and the State of New Hampshire will be amended to provide full reimbursement of the premium and co- payments for members of tribes to NHHKC (effective August 24, 2001).

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

Effective Date: May 1998

Approval Date: September 1998 23 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)

Along with contracting with NHHKC to administer the Title XXI program, the state also contracts with NHHKC to market and perform outreach services for the state’s Medicaid and SCHIP programs. An initial outreach plan was developed in partnership with NHHKC and other community health partners, to ensure that New Hampshire families are aware of the child health insurance coverage options available under Title XXI as well as under Title XIX. This plan was designed using the successful practices of NHHKC and capitalizes on the collaborative relationships already developed with schools and child care centers as well as expanding the existing network of social service agencies and advocacy groups beyond those that had traditionally worked with the state and NHHKC.

Outreach materials include a variety of brochures, posters, flyers, and enrollment package materials. Information covers the benefits offered, eligibility requirements, and how and where to apply. NHHKC employs field coordinators in different areas of the state who maintain relationships with community partners and provide outreach support through training and promotional materials. The focus of this strategy is to work with organizations that directly serve families and children.

Outreach campaigns are conducted periodically to focus on boosting enrollment in specific target groups, such as developing materials to focus on infants. The outreach takes advantage of seasonal and geographic differences and events, such as the start of the school year. Historically, the most effective method of reaching families have been to distribute information through the schools.

Other elements of the outreach plan include: • Biannual blanket distribution of promotional postcards to all public and religious schools in the state; • Distributing information through, child care centers, Head Start centers, WIC sites, community agencies and health care providers; • Providing displays for these sites and appropriate commercial establishments;

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

Effective Date: May 1998

Approval Date: September 1998 24 • Use of retail bag stuffers; • Using public speaking engagements, talk shows, public affairs programs, news releases, press conferences, and radio and TV PSAs as appropriate; • Informing partners and consumers about the availability of “NH Easy” an online application system that DHHS has developed for a more convenient access to Healthy Kids and other family assistance programs. Conducting direct mail campaigns to demographically selected lists that match profiles of uninsured families, building on the current Healthy Kids mailing lists of previous inquiries as well as other providers lists; • Initial and refresher training of staff at all applications sites that provide one-on-one assistance on such topics as how to effectively deal with inquiries and potential members to maximize the contact as an enrollment opportunity; accuracy and completeness of the application; and referrals to other services; and, • Developing an evaluation methodology based upon the concepts of continuous quality improvement to ensure the efficient and effective use of outreach resources.

Effectiveness of outreach campaigns are tracked by referral sources on all families that inquire and apply. These statistics are compiled and analyzed through database queries. In addition, questions regarding outreach methods and messages are included in periodic surveys of enrollees, disenrollees and prospective enrollees. Over one-third of families indicate they learned about the program through their child’s school.

Central to the state’s goal of maximizing the enrollment of uninsured children are efforts to support speedy application and enrollment. Activities include: • Providing a toll-free telephone line to directly request brochures or other information packages and applications or to request assistance with completing an application; • Developing one application for both Healthy Kids Silver and Healthy Kids Gold; • Implementing a centralized mail-in enrollment center where applications can be mailed; • Increasing the availability of on-site application assistance at community based organizations utilizing staff trained in the eligibility requirements of the various public health and state benefit programs.

Special outreach efforts to minority and rural populations will be conducted

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

Effective Date: May 1998

Approval Date: September 1998 25 through the upcoming Robert Wood Johnson Covering Kids and Families Grant, which will allow the state to pilot outreach, simplification and coordination of children’s health care coverage programs in 2 local pilots locations, Manchester and the rural North.

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

Effective Date: May 1998

Approval Date: September 1998 26 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. 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 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. 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 existing

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

Effective Date: May 1998

Approval Date: September 1998 27 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)) In a short-term /general hospital, skilled nursing facility or physical rehabilitation facility. 6.2.2. Outpatient services (Section 2110(a)(2)) Facility charges and medical services, such as operating room, hospital, pharmacy and supplies, physician visits, laboratory and x-rays and surgery. 6.2.3.

Physician services (Section 2110(a)(3)) Including primary care providers such as Advanced Registered Nurse Practitioners and Physician Assistants. 6.2.4. Surgical services (Section 2110(a)(4)) 6.2.5. Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6. Prescription drugs (Section 2110(a)(6)) Including all FDA approved oral contraceptives and Depo- Provera. 6.2.7.

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

Laboratory and radiological services (Section 2110(a)(8)) 6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) 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)) Maximum of 15 days per year. 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)

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

Effective Date: May 1998

Approval Date: September 1998 28 Maximum of 20 visits per year. 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)) Eyeglasses, hearing aids, prosthetic devices and other DME as determined to be medically necessary and consistent with diagnosis. 6.2.13. Disposable medical supplies (Section 2110(a)(13)) Disposable medical supplies as medically necessary and consistent with diagnosis, are covered. 6.2.14. Home and community-based health care services (See instructions) (Section 2110(a)(14)) 20 home health visits a year. 6.2.15. Nursing care services (See instructions) (Section 2110(a)(15)) 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) 6.2.17. Dental services (Section 2110(a)(17)) Diagnostic and preventive services including sealants, fillings, and simple extractions are covered 100% up to a maximum $600 per child per year (effective January 1, 2001). No orthodontics are covered. 6.2.18. Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) Inpatient detoxification for medically necessary stays. No limit on the number of times a member may be admitted for inpatient detoxification. 6.2.19. Outpatient substance abuse treatment services (Section 2110(a)(19)) Outpatient substance abuse visits wrapped into the 20 outpatient mental health benefit. Therefore a member will have a total of 20 outpatient visits for mental health and substance abuse counseling. Not 20 visits for each. 6.2.20. Case management services (Section 2110(a)(20)) 6.2.21. Care coordination services (Section 2110(a)(21)) To be provided as part of the role of the Primary Care Provider. 6.2.22. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders. (Section 2110(a)(22)) 24 visits for speech therapy; 24 visits for occupational therapy or 24 visits for physical therapy or a combination of occupational

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

Effective Date: May 1998

Approval Date: September 1998 29 and physical therapies for each medical episode. 6.2.23. Hospice care (Section 2110(a)(23)) 6.2.24. Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) Chiropractic services, allergy testing and treatment, cardiac rehabilitation services, infusion therapy, vision and hearing services, preventive health services such as diabetes management program, routine hearing exams, laboratory and x- ray tests, medical exams and childhood immunization for well children, prenatal care and vision care and early intervention services up to age 3, ($3,200 annual, 9,600 lifetime maximum) are also covered (effective January 1, 2001). 6.2.25. Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26. Medical transportation (Section 2110(a)(26)) Emergency transportation by ambulance. 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 and rehabilitation facility services as deemed medically necessary and pre-authorized by the health 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) (2) and(3)) (42 CFR 457.1005 and 457.1010)

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

Effective Date: May 1998

Approval Date: September 1998 30

N/A

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))

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

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

Effective Date: May 1998

Approval Date: September 1998 31 457.1010)

N/A

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: May 1998

Approval Date: September 1998 32 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(a))

NHHKC and their insurance subcontractor are required to meet all standards for quality of care in the contract in order to contract with the state. The state reviewed and approved the subcontract agreement between NHHKC and the health plan prior to the enrollment of children into Healthy Kids Silver.

DHHS will continuously monitor quality through various mechanisms, including: health plan contracting standards, reporting requirements, enrollee input, external reviews, and on-site reviews. The state will strive to establish a continuum across the Title XIX and Title XXI programs for quality e.g. contracting with the same External Quality Review Organization (EQRO), establishing priority areas for review and utilizing consistent measurement methodologies. The state will bear final responsibility for the quality improvement activities outlined in this application however, the quality improvement plan will be based upon a partnership with NHHKC and their contracted insurerAs a monitoring tool for children’s healthcare, DHHS utilizes data from NH Comprehensive Health Care Information System (NH CHIS), which includes a commercial health care claims database, to compare Medicaid, SCHIP and commercially available insurance enrollment, access, service utilization, payments and other variables.

The Phase 1 Healthy Kids Gold (Medicaid) program will be monitored via the established quality improvement program in the Medicaid Administration Services. The established QIP includes the monitoring of quality and appropriateness of care and highlights well-baby and well childcare. It is based upon this pre-existing program that the Phase 2 quality improvement program will be designed.

For Phase 2, the contract with NHHKC will include specific standards for quality of care, including the provision of well-baby care, well-child care, and immunizations that will be carried out by the health plan as their subcontractor. The health plan will be required to arrange for immunizations, physical examinations, health education, dental examinations/treatments and comprehensive screens (and any needed interperiodic screens) in

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

Effective Date: May 1998

Approval Date: September 1998 33 accordance with the schedules recommended by the most current Recommended Childhood Immunization Schedule, United States and the American Academy of Pediatrics. The health plan will be required to have enrollees up to date on screening and immunizations within 3 months of being enrolled.

Reporting will include a report on the plan’s quality improvement plan (QIP), HEDIS reports on immunizations and well child care, and other pediatric preventive health measures as part of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program, utilization reports, and periodic provider network reports. The state will require the subcontracted health plan to submit encounter data. The state recognizes that this information is crucial to the on-going monitoring and evaluation of the Healthy Kids program and will strive to develop a system that will receive, process and permit for detailed analysis, the scope of services provided to Healthy Kids enrollees. The state will work with NHHKC and the plan to develop the data elements, medium, format and time frames for submissions.

Other utilization information that involve health plan interventions and enrollee participation in activities such as complaints/grievance resolution, case coordination services, health risk screenings, disease management and health promotion programs will be reported and tracked.

NHHKC will be responsible for conducting enrollee satisfaction surveys. NHHKC may delegate this function to the health plan. However, the state will review and approve the survey tool for specific questions from the CAHPS instrument, sampling methodology, research design and final results. The state is also developing a provider satisfaction survey.

The functions of the external quality review organization are described in section 7.1.1. In addition, the state will conduct periodic focus groups as part of its on-going community involvement process and maintains the option of conducting annual on-site evaluations at the health plan to assess compliance with contract requirements (such as utilization management decisions), and to establish, with the health plan, quality improvement projects and performance goals.

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)

7.1.1.

Quality standards The state will contract for an external quality review of the health plan. Such review shall include, but not be limited to, an

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

Effective Date: May 1998

Approval Date: September 1998 34 evaluation of access to care, quality of care studies, medical record standards, and individual case review and appropriateness of care. All activities carried out by the EQRO will be prior approved by the state in order to assure appropriate monitoring and to assure consistency in quality improvement activities across programs. 7.1.2.

Performance measurement DHHS annually reviews and reports on a variety of health care measures to compare children enrolled in New Hampshire Medicaid, in NH SCHIP and in commercial health insurance plans in NH. This allows ongoing monitoring of healthcare for children, aged 0-18, covered in these programs and to study enrollment and disenrollment, access to primary care providers, well-child visits, effectiveness of care management, and utilization and payments. State data is also compared to HEDIS quality and access to compare measures and reported accordingly.

7.1.3.

Information strategies

The state, NHHKC, and the health plan will be required to educate enrollees about their benefits under Healthy Kids Silver and Healthy Kids Gold as well as their rights and responsibilities. The plan will also educate enrollees about the importance of preventive services, health promotion activities, care coordination services, disease management programs, and visiting their primary care provider instead of an emergency room.

7.1.4. Quality improvement strategies

The contract with NHHKC will include specific standards for quality of care including access to care and appointment availability, and the health plan will have to meet those standards in order to contract with NHHKC and the state. These standards will be monitored by the state and NHHKC through reporting requirements, on-site reviews, external reviews and enrollee input through complaint data and satisfaction surveys.

In particular, the plan will be required to establish an internal quality improvement plan (QIP), which will be in writing and available to the public. The written description shall include detailed goals and annually developed objectives; address the quality of clinical care and non-clinical aspects of services for

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

Effective Date: May 1998

Approval Date: September 1998 35 the range of care provided by the plan; specify quality of care studies and related activities; provide for continuous performance of activities, including tracking of issues over time; and provide for review and feedback by physicians and other health professionals. By the end of the first contract year, the plan will be required to initiate two (2) clinical focused projects aimed at improving care for enrollees. Clinical focus areas applicable to this target population include topics related to: lead toxicity screening and treatment, • chronic pediatric asthma, • attention deficit disorder, • adolescent counseling on smoking and substance abuse, • well-child care, • behavioral health screening and treatment and • perinatal services.

The state, NHHKC and the health plan will work collaboratively to select the clinical areas to be studied and define the improvement strategy.

An annual report on the QIP will be required. This report will be made in the form of a presentation to the state and its community advisors. In addition, the report will be made available as a formal written report that will be made available to the public as hard copy and on the DHHS website.

For Healthy Kids Silver enrollees that become pregnant while eligible, comprehensive perinatal services shall be available and accessed through the contracted health plan. The plan’s purchasing specifications must describe and demonstrate a comprehensive, proactive perinatal program with adherence to care guidelines as recommended by the American College of Obstetrics and Gynecology. HEDIS perinatal and birth outcome indicators will be utilized to measure and assess performance. Depending upon the results and trends, the health plan’s QIP shall be expected to develop further interventions and strategies to increase participation and positive outcomes.

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))

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

Effective Date: May 1998

Approval Date: September 1998 36 (42CFR 457.495(a))

The state requires the Healthy Kids Silver health plan to provide access to preventive care such as, well-child care, well-adolescent care and childhood and adolescent immunizations. No office visit co- payments are required for routine childhood examinations and immunizations The state requires the health plan to include sufficient numbers of appropriately trained and certified staff to provide this access to care. The state and NHHKC monitor access requirements through reporting and member satisfaction surveys. Infants covered under Title XXI receive well-baby care under Healthy Kids Gold as part of the Medicaid expansion. The state monitors access issues for Healthy Kids Gold.

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 state requires the health plan to include sufficient numbers of appropriately trained and certified clinicians of pediatric care, including primary, medical subspecialty and surgical specialty physicians, as well as providers of necessary related services such as, dental and mental health services. The state monitors network capacity through quarterly provider network reports and will suspend enrollment if capacity is exceeded.

The health plan is required to ensure that their provider networks provide access to primary care providers (PCPs) within 20 miles/45 minutes and access to emergency services on a 24-hour, seven-day-a- week basis. Emergency care shall be provided immediately, urgent care within 24 hours, non-urgent, symptomatic PCP appointments shall be available within 48 hours from the enrollee’s request to be seen and non-symptomatic, routine/preventive care within 30 calendar days. An emergency medical condition will be defined as a condition such that a prudent lay person, acting reasonably, would have believed that emergency medical treatment is needed. The state and NHHKC monitor access requirements through reporting and member satisfaction surveys.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

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

Effective Date: May 1998

Approval Date: September 1998 37

The health plan is required to treat enrollees with chronic, or serious medical conditions, and provide access and adequate number of visits to specialists experienced in treating the specific medical condition. Enrollees will have access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. The state and NHHKC will monitor access requirements through reporting and member satisfaction surveys.

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))

Most health services do not require prior authorization unless a referral is made to an out of network provider. Decisions related to prior authorization of health services are in accordance with the New Hampshire Department of Insurance’s regulations.

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

Effective Date: May 1998

Approval Date: September 1998 38 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 to 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:

There are no premiums for Healthy Kids Gold. Under Healthy Kids Silver, families whose income are greater than 185% and equal to or less than 250% of FPL pay a $32 per child per month premium, and there is a $128 cap on monthly premiums for these families with multiple children. Families whose income is greater than 250% and equal to or less than 300% of FPL pay a $54 per child per month premium, and there is a $162 cap on monthly premiums for these families with multiple children.

8.2.2. Deductibles:

There are no deductibles for Healthy Kids Gold or Healthy Kids Silver.

8.2.3. Coinsurance or co-payments:

There is no coinsurance for Healthy Kids Gold or Silver. There are no co-payments for Healthy Kids Gold.

For Healthy Kids Silver, there is a $10 co-pay for provider office visits, and a prescription drug co-payment of $5 for covered generic prescription drugs, $15 for covered formulary brand name drugs when no generic equivalent is available or the provider indicates that it is medically necessary, and $25 for covered non-formulary brand name

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

Effective Date: May 1998

Approval Date: September 1998 39 drugs when no generic equivalent is available or the provider indicates that it is medically necessary. There is also a $50 co-payment for emergency care, unless the patient is admitted to the hospital. There are no co-payments for preventive health and/or well child visits, dental check-ups, dental x-rays, cleanings and fluoride treatments.

8.2.4 Other:

8.3. Describe how the public will be notified, including the public schedule, of this 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))

Both the state and NHHKC provide information on the cost sharing requirements to enrollees as well as to the provider community. Information about premiums and co-pays are included in all outreach/education material including brochures, flyers, posters, the Children’s Health Insurance Guide to Benefits and on the website. It is also included in the enrollment materials that the family receives. Families that have enrolled are sent enrollment forms that give them the amount of what that 5% cap out of pocket expense will be.

Changes in premiums are subject to Legislative approval of State rule changes. Such rule changes require public notification and a public hearing.

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)

The state plan follows this requirement. 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)

The state plan follows this requirement.

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))

The state plan follows this requirement.

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

Effective Date: May 1998

Approval Date: September 1998 40 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))

The State contracts with NHHK to provide for the administration of the cost- sharing provisions of the Title XXI plan. As part of its role, NHHK educates families about the cost sharing rules and requirements including premiums and co-payments. The education includes; how much money 5% of the family’s income, translated into terms of dollars and cents, what period of time the monitoring period covers, and that the responsibility for monitoring out of pocket expenses will be shared by the family and NHHK. The education will instruct families in tracking their out of pocket expenses on a monthly basis (the emphasis will be on tracking and documenting medical/dental office and pharmacy co-payments) and to contact NHHK immediately (via mail or the statewide toll free number) should their out of pocket expenses equal or exceed the previously determined amount of money or if the family income should suddenly decrease. NHHK also monitors medical and dental co- payments on a quarterly basis via a cost sharing report generated by health and dental plans. Premium cost-sharing is monitored directly by NHHK via their accounting system.

Families who exceed the 5% cap will be formally notified by NHHK in writing and all cost sharing will cease for the remainder of the current 12 month eligibility period. The letter will include the specific date that the cost-sharing exemption expires (it coincides with the eligibility re-determination date). The family utilizes the NHHK formal notification as proof of exemption from cost- sharing, to be presented to providers as needed. The State and NHHK will emphasize and re-emphasize cost-sharing rules and regulations in its provider education and communications. Out of pocket expenses that exceed the 5% cap will be reimbursed to the family after review of all cost sharing documentation for the family, NHHKC and medical/dental plans. At the end of the first 12 months of eligibility, eligibility will be re-determined; the 5% cap will be recalculated for the family and the monitoring cycle will begin anew.

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)

Cost sharing protection is in place to ensure enrollment of American Indians and Alaska Natives, as defined in 457.10. The following documents will be

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

Effective Date: May 1998

Approval Date: September 1998 41 revised to disclose that members of federally recognized Indian Tribes and Alaska Natives are eligible for free coverage under Title XXI although the children may qualify for premium-based coverage:

1. The Children’s Health Insurance Program Guide to Benefits – this is the primary information booklet that describes the programs and how to apply. 2. Silver Eligibility Letter – Families who have applied for coverage through the local DHHS District Office and are referred to NHHKC for enrollment. 3. Silver Enrollment Letter – Families who have applied through the mail-in unit at NHHKC and have been deemed eligible for the premium-based Healthy Kids Silver program.

In order to process the free coverage enrollment, members of tribes will be asked to inform NHHKC of their tribe status by phone or mail. The contract between NHHKC and the State of New Hampshire will be amended to provide full reimbursement of the premium and co-payments for members of tribes to NHHKC (effective August 24, 2001).

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))

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, co-payments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

There are no premiums, co-payments, coinsurance, or deductibles for Healthy Kids Gold.

There are no coinsurance or deductible fees for Healthy Kids Silver. However, there are co-payments and premiums. Providers are responsible for collecting the co-payments at the time of service. Premiums for Healthy Kids Silver are collected by NHHKC under contract with the Department of Health and Human Services as a third party administrator for Healthy Kids Silver.

In accordance with federal regulations, if payment has not been collected, eligibility may be terminated after sixty (60)

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

Effective Date: May 1998

Approval Date: September 1998 42 days due to the non-payment of premiums. (As noted in section 3.1, pregnant teens do not have their eligibility terminated for failure to pay premiums until after the postpartum period.)

Families have until the last day of the current month to pay the next month’s premium. The state has established a process that give enrollees 60 days notice from the beginning of a new coverage period before the coverage may be terminated for non-payment. During this grace period, they have an opportunity to pay past due premiums but child or children will still receive coverage. At a minimum, 3 points of contact are made to the family. The process is as follows:

• NHHKC will send a notice when a premium payment is 15 days past due. • When the account is then 25 to 30 past due, a call is made to the enrollee. • A ”two months due” (cancellation pending) letter is sent to the family not later than 7 days after the first day of the second month of missed payments, generally on the 2nd or 3rd of month. • The family will receive a final phone call on the 8th of the second month of missed payment when the account is 38 -40 days past due. They will have until the 45th day to pay premium. On the 46th day, if payment still has not been made they are sent notice of termination which will be effective the beginning of the next month. In the letter the family will be advised of their right to challenge the proposed termination pursuant to the applicable Federal regulations.

If the family has been terminated for non-payment of premiums, they are “locked out” of the program for 3 months by the state’s New HEIGHTS eligibility system.

NHHKC supports a premium rescue fund through which charitable dollars are used to help families overcome a temporary loss of income or unexpected financial crisis.

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

Effective Date: May 1998

Approval Date: September 1998 43

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

As noted in section 4.3, enrollees are required to notify NHHKC or DHHS of any change in circumstance that could affect continued eligibility for coverage. If enrollee notifies NHHKC prior to disenrollment for non-payment of premiums and the child is no longer eligible for Healthy Kids Silver, he/she will be disenrolled. If he/she is eligible for Medicaid, he/she will be enrolled in Healthy Kids Gold (Medicaid) .The family also has the opportunity to show that their income has declined enough to make them eligible for the lower premium category of Healthy Kids Silver, which will then facilitate the enrollment into that premium level.

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))

As noted in section 4.3, enrollees are required to notify NHHKC or DHHS of any change in circumstance that could affect continued eligibility for coverage. If enrollee notifies NHHKC prior to disenrollment for non-payment of premium, and the child is no longer eligible for Healthy Kids Silver, he/she will be disenrolled. If he/she is eligible for Medicaid, he/she will be enrolled in Healthy Kids Gold (Medicaid). There is no cost-sharing for Healthy Kids Gold. The family also has the opportunity to show that their income has declined enough to make them eligible for the lower premium category of Healthy Kids Silver, which will then facilitate the enrollment into that premium level.

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

Individuals have a right to request an Administrative Appeals Hearing if they are not satisfied with any decision made by the Department of Health and Human Services or NHHKC. Hearings can be requested verbally or in writing by contacting a DHHS district office, NHHKC or the Office of Administrative Appeals. This information is on the Healthy Kids application.

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

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

Effective Date: May 1998

Approval Date: September 1998 44 8.8.1. No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 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 the 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)

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

Effective Date: May 1998

Approval Date: September 1998 45 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))

Reduce the number of uninsured children in NH.Improve SCHIP and Medicaid enrollment efficiencies.Reduce inappropriate utilization of emergency room care.

Increase SCHIP enrolled children’s utilization of preventive care.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

1) Reduce the number of uninsured children. • Decrease the number of NH children who are uninsured. • Increase the number of SCHIP and Medicaid children ever enrolled in NH Healthy Kids programs. 2) Improve SCHIP and Medicaid Enrollment efficiencies . • Increase the percentage of Healthy Kids applications that are submitted as complete by the Community Application Assistors.

3) Reduce inappropriate utilization of emergency room care. • Decrease emergency department use by SCHIP children for selected conditions. 4) Increase utilization of preventive care.

Increase the percentage of adolescents (12-18 years) enrolled in SCHIP who have a well child visit.

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))

1) Reducing the number of uninsured children in NH will be addressed through two separate goals. Performance related to the first goal, to decrease the number of NH children who are uninsured, will be measurd through NH’s Behavioral Risk Factor Surveillance System. The biennial survey results will be analyzed every other year for an estimate of uninsured children.

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

Effective Date: May 1998

Approval Date: September 1998 46 Performance related to the second goal, to increase the number of SCHIP and Medicaid children ever enrolled in NH Healthy Kids Programs, will be measured through SCHIP and Medicaid enrollment data, as reported annually in Statistical Enrollment Data Report (SEDS).

2) Improving Medicaid enrollment efficiencies will be addressed by a goal to increase the percentage of Healthy Kids applications that are submitted as complete by the Community Application Assistors. Performance will be measured through an annual report of complete and incomplete applications, generated by the SCHIP administrator, NH Healthy Kids Corporation, who oversee the Application Assistor program.

3) Reducing inappropriate utilization of emergency department care will be addressed by a goal to decrease emergency department .use by SCHIP children for selected conditions. Goal performance will be measured by SCHIP claims data that is collected through the State’s Comprehensive Health Information System and analyzed within studies sponsored by DHHS.4) Increasing utlilization of preventive care will be addressed by the goal to increase the percentage of adolescents (12-18 years) enrolled in SCHIP who have had a well child visit. Goal performance will be measured by claims data that is collected through the State’s Comprehensive Health Information System and analyzed within studies sponsored by DHHS..

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

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

Effective Date: May 1998

Approval Date: September 1998 47 9.3.7.6. Dental care 9.3.7.7. Other, please list:

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) DHHS 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.

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) DHHS will perform the annual assessments and evaluations required under sections 10.1 and 10.2. The annual report will assess the operation of the Title XXI plan, including the progress made in reducing the number of uninsured children.

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) DHHS assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit.

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 457.710(e)) DHHS assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed.

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

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

Effective Date: May 1998

Approval Date: September 1998 48 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(a) and (b))

A multidisciplinary group comprised of Department staff and representatives from the Governor’s Office and NHHKC worked to develop and review the initial conceptual model. The Department met with the NHHKC Board of Directors on March 2, 1998, to review the proposed model and to solicit input into the plan. The Board membership includes representatives from the Department of Education, Department of Insurance, State Legislators, New Hampshire School Boards Association, New Hampshire Pediatric Society, New Hampshire School Nurses Association, New Hampshire Children’s Alliance, New Hampshire Child Care Association, and the New Hampshire Hospital Association. Follow up meetings were held with the Board of Directors. The Department also met with representatives from Blue Cross Blue Shield of New Hampshire.

A series of public meetings were also held throughout the state. Each session included an overview of the Title XXI legislation and application requirements; a review of proposed conceptual plan; and a review of the proposed benefits package. In addition to providing time for commentary on the plan, time was spent on developing a long-term plan to ensure on-going public involvement. From each session a list of questions and answers as well as comments was generated and documented. Department staff followed up unanswered questions.

The public meetings included:

March 12, 1998

The Commissioner’s Managed Care Advisory Group and NH

Child Action Team March 18, 1998

Community Mental Health Centers Executive Directors March 19, 1998

The Consumer Policy Advisory Board March 24, 1998

A formal Public Hearing was held on the NH SCHIP Plan March 27, 1998

The Welfare Reform Advisory Group April 1, 1998 The Medicaid Medical Care Advisory Committee April 10, 1998

Child Health Coordinators of the Title V-funded Well Child

Clinics and Primary Care agencies

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

Effective Date: May 1998

Approval Date: September 1998 49 April 14, 1998

Headstart Health and Nutrition Coordinators April 14, 1998

RWJF Outreach Grant Participants April 15, 1998

Health Planning District Council Meeting in Manchester April 16, 1998

Health Planning District Council Meeting in Plymouth April 20, 1998

A formal Public Hearing on rule changes for the NH SCHIP Plan May 11, 1998

NH DHHS Primary Care Steering Committee May 15, 1998

Commissioner’s Child Care Advisory Committee May 21,1 998

NH Welfare Directors/NH Municipal Association

In addition to the public meetings noted above, the state created a site on the DHHS web page. The web site included information on the proposed plan and as each section of this application was drafted, it was added to the web page. A copy of the final working draft of the application was made directly available to a variety of advocacy groups and community leaders.

DHHS continues to include the public in ongoing efforts involving SCHIP. These efforts include: • The SCHIP workgroup that originally met to assist the Department in working through a variety of operational issues such as eligibility, enrollment, benefits, cost-sharing and outreach continues to meet to provide input and public process to program changes.

• DHHS hosted a SCHIP Summit with DHHS and community partners in November 2000, to discuss the progress of the SCHIP program and to identify issues and barriers to enrollment and retention. From the summit, 6 workgroup were formed; presumptive eligibility, good cause waivers, application, documentation, continuous eligibility, and letters and notices. Workgroups generated recommendations for policy and practice that would enhance enrollment and retention of eligible children in the Healthy Kids programs.

• Four regional meetings were held in the fall of 2001 to review workgroup recommendation and further solicit input from both internal and external stakeholders in Healthy Kids programs. These stakeholders included providers (hospitals, CHCs and private offices), past and current families enrolled in Healthy Kids, human service agencies as well as outreach and advocacy groups.

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

Effective Date: May 1998

Approval Date: September 1998 50

• A public hearing was held on October 26th, 2001 by the Department on "Proposed Changes to State's Children's Health Insurance Program State Plan", in order to receive written and oral comments These changes included reduced verification, improving the presumptive eligibility process, a further simplified Healthy Kids application, and additional good cause waivers of prior insurance. The changes requiring a state plan amendment to CMS are included in this plan. DHHS amended its administrative rules to reflect these changes.

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))

There are no organized tribes or tribal organizations in New Hampshire, however public process for amendments relating to 42 CFR 457.125 included four regional meetings to solicit input from both internal and external stakeholders in the Healthy Kids program. These stakeholders included providers (hospitals, CHCs and private offices), past and current families enrolled in Healthy Kids, human service agencies as well as outreach and advocacy groups. A public hearing was held on October 26th, 2001 by the Department on "Proposed Changes to State's Children's Health Insurance Program State Plan" in order to receive written and oral comments. 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 as required in 42 CFR 457.65(b) through (d).

Public process for amendments made in 2002 relating to eligibility or benefits included four regional meetings to solicit input from both internal and external stakeholders in the Healthy Kids program. These stakeholders included providers (hospitals, CHCs and private offices), past and current families enrolled in Healthy Kids, human service agencies as well as outreach and advocacy groups.

In addition to the efforts noted above, all amendments that require changes to the New Hampshire Administrative Rules (He-W 910) were completed in accordance with the requirements of NH RSA 541-A. This process requires a public notification of any changes to the rules (typically by publishing a notice in the Rulemaking Register) and that a public hearing and a written comment period be provided. For changes

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

Effective Date: May 1998

Approval Date: September 1998 51 to the administrative rules, effective April 1, 2002 and as reflected in the 2002 State Plan Amendment, the Department held a public hearing on October 26th, 2001. Written comments were accepted until November 26, 2001. Changes to the administrative rules effective January 1, 2005 and as reflected in the 2005 State Plan Amendment, the Department held a public hearing on October 15, 2004 and written comments were accepted until October 25, 2004.

A public notice about premium increases, as reflected in the 2009 State Plan Amendment, was published in the statewide Manchester Union Leader on Thursday, July 9, 2009.

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.

The State’s contracted SCHIP administrator, New Hampshire Healthy Kids Corporation (NHHK), conducts a procurement process and contracts with the medical and dental providers for CHIP benefits. NHHK pays a per member per month fee directly to the contracted medical and dental managed care entities. NHHK negotiates these contracted fees with State input. The dental and medical monthly pmpm rate paid to providers by NHHK is the same for each member and is independent of family cost share.

As part of its contracted services for the State, NHHK also calculates and collects family pmpm premiums and manages the 5% cap requirement relative to family cost sharing. NHHK invoices the State monthly for a reimbursement of pmpm fee paid to medical and dental contractor. The invoice amount includes a monthly administrative fee plus the balance of insurance payments paid once NHHK has debited the family premiums paid directly to them. As such, the family premium payments are not included in the Budget presented below. During FFY 09, NHHK collected and retained $2,767,143.00 in family premiums (again, as an offset to the medical and dental fees they pay monthly to managed care entities.)

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

Effective Date: May 1998

Approval Date: September 1998 52

There are two levels of per child per month premiums paid by families depending on income level. The premium is capped for families who have multiple children enrolled.

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

Effective Date: May 1998

Approval Date: September 1998 53

CHIP Budget Template

New Hampshire

FFY Budget FFY Budget Variation between FFY 2009 and FFY 2010 Budget Federal Fiscal Year

FFY 2009 FFY 2010

State's enhanced FMAP rate

65.00% 65.00%

-

Benefit Costs

Insurance payments

$ 15,015,587 $19,327,000 $ 4,311,413 Managed care

$ - per member/per month rate

Fee for Service

$ 2,202.810 $ 3,096,000 $ 893,190 Total Benefit Costs

$ 17,218,397 $22,423,000 $ 5,204,603 (Offsetting beneficiary cost sharing payments) $ - $ - $ - Net Benefit Costs

$ 17,218,397 $22,423,000 $ 5,204,603

Administration Costs

Personnel

$ 295,320 $ 326,350 $ 31,030 General administration

$ 136,344 $ 150,670 $ 14,326 Contractors/Brokers

$ - $ - $ - Claims Processing

$ - $ - $ - Outreach/marketing costs

$ 120,336 $ 132,980 $ 12,644 Other

$ - $ - $ - Total Administration Costs

$ 552,000 $ 610,000 $ 58,000 10% Administrative Cap

$ 1,714,778 $ 2,491,444 $ 776,667

Federal Share

$ 11,550,758 $14,971,450 $ 3,420,692 State Share

$ 6,219,639 $ 8,061,550 $ 1,841,911 TOTAL COSTS OF APPROVED CHIP PLAN $ 17,770,397 $23,033,000 $ 5,262,603

Beneficiary cost-sharing payments have been accounted for and Net Benefit costs are net of the cost-sharing.

Fee for Service Increase in FFY 2010 represents CHIPRA allowable qualifying State claim for 100% of enhanced match for children in NH Expanded Medicaid group, 0-1 years at 133%-185% FPL

The Source of State Share Funds: State General Funds.

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

Effective Date: May 1998

Approval Date: September 1998 54 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: May 1998

Approval Date: September 1998 55 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) 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: Phase 1: May 1998, Phase 2: Jan. 1999 Approval Date: September 1998

56 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.

As noted in section 8.7.1, individuals have a right to request an Administrative Appeals Hearing if they are not satisfied with any decision made by the Department of Health and Human Services or NHHKC. Hearings can be requested verbally or in writing by contacting a local district office, NHHKC or the Office of Administrative Appeals. This information is on the Healthy Kids application, and complies in the same manner as the Medicaid program.

Health Services Matters 12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120.

If the child is enrolled in Healthy Kids Gold, the process to review health services matter is through the state’s Medicaid fair hearing process.

Individuals have the right to appeal any decision made that the health insurer makes about coverage, benefits, or failure to provide coverage or benefits through the managed care internal appeal process. In addition to the internal appeal procedure, individuals have the right to an external review process to appeal decisions regarding denial, delay, reduction, suspension or termination of health care services and the failure to provide payment for health services in a timely manner through an Administrative Appeals Hearing. If an individual is not satisfied with any decision made by the health insurer, hearings can be requested verbally or in writing by contacting the Department of Health and Human Services, a local district office, the health insurer, NHHKC, or the Office of Administrative Appeals. This information is on the Healthy Kids application, and complies in the same manner as the Medicaid program.

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

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

Effective Date: Phase 1: May 1998, Phase 2: Jan. 1999 Approval Date: September 1998

57 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. N/A

1

NEW HAMPSHIRE TITLE XXI STATE PLAN FACT SHEET

Name of Plan: Healthy Kids Gold (Title XIX expansion) Healthy Kids Silver (Title XXI separate child health program)

Date Plan Submitted:

May 21, 1998 Date Plan Approved:

September 15, 1998 Effective Date:

May 1, 1998 (Title XIX expansion)

January 1, 1999 (Title XXI)

Date Amendment #1 Submitted: December 28, 1998 Date Amendment #1 Approved: March 25, 1999 Date Amendment #1 Effective: January 1, 1999

Date Amendment #2 Submitted: November 26, 2002 Date Amendment #2 Approved: February 20, 2003

Date Amendment #3 Submitted: February 24, 2003 Date Amendment #3 Approved: May 15, 2003 Date Amendment #3 Effective: January 1, 2003

Date Amendment #4 Submitted: January 27, 2005 Date Amendment #4 Approved: April 21, 2005 Date Amendment #4 Effective: January 1, 2005

Date Amendment #5 Submitted: October 1, 2009 Date Amendment #5 Approved: December 18, 2009 Date Amendment #5 Effective: July 1, 2009 (MCO change) October 1, 2009 (premium increase & Enrollment Cap) January 1, 2010 (Citizenship Documentation)

Background

• New Hampshire submitted a title XXI State plan to: 1) Healthy Kids Gold - expand Medicaid to infants to age 1 with family income greater than 185 percent up to including 300 percent of the Federal poverty level (FPL); and 2) Healthy Kids Silver - implement a separate health insurance program to cover children ages 1 to 19 with family income greater than 185 percent up to including 300 percent of the FPL.

2

Amendments

• On December 28, 1998, New Hampshire submitted a State plan amendment to modify the benefit package. Effective January 1, 1999, New Hampshire modified the prescription drug benefit, mental health and substance abuse benefit, and the dental benefit.

• On November 26, 2002, New Hampshire submitted a State plan amendment to indicate the State’s compliance with the final Children’s health Insurance Program (CHIP) regulations and to update program descriptions. Additionally, this amendment assures that American Indian/Alaska Native children are exempt from cost-sharing requirements. This amendment also adds good-cause exceptions to the 6-month period of uninsurance prior to enrolling in Healthy Kids Silver and eliminates the 6-month period of uninsurance prior to enrollment in Healthy Kids Gold.

• On February 24, 2003, New Hampshire submitted a State plan amendment to increase cost sharing in Healthy Kids Silver. The State increased monthly premiums from $20 to $25 per child for families with incomes between 185 and 250 percent of the FPL. The State increased monthly premiums from $40 to $45 per child for families with incomes above 250 percent of the FPL. The family monthly premium cap increased from $100 to $135 for families with incomes above 250 percent of the FPL. Copayments increased from $5 to $10 per office visit, and from $25 to $50 per emergency room visit.

• On January 27, 2005, New Hampshire submitted a State Plan Amendment to increase copayments for formulary and non-formulary prescription drugs.

• On October 1, 2009, New Hampshire submitted a State Plan Amendment to increase premiums in Health Kids Silver. The State increased monthly premiums from $25 to $32 per child for families with incomes between 185 up to including 250 percent of the FPL and a monthly cap of $128 per family per month. The State increased monthly premiums from $ 45 to $54 per child for families with incomes above 250 up to including 300 percent of the FPL and a monthly cap of $162 per family per month. The State changed MCO provider from Anthem BCBS of New Hampshire to Harvard Pilgrim Healthcare; children may opt into a Medicaid fee-for- service benefits delivery when dissatisfied with the MCO. The State establishes an enrollment trigger for capping enrollment in Healthy Kids Silver; and compliance with citizenship documentation requirements of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA).

3

Children Covered Under the Program

• The State reported that 12,236 children were ever enrolled in CHIP in Federal Fiscal Year (FFY) 2008.

Administration

• New Hampshire’s Department of Health and Human Services administers the CHIP program.

Health Care Delivery System

• The State purchases a managed care product with a focus on preventative and well- child care through the New Hampshire Healthy Kids Corporation (NHHKC).

• Children may opt into a Medicaid fee-for-service benefits delivery when dissatisfied with the managed care product.

Benefit Package

• Benchmark-equivalent coverage is provided. An actuarial analysis comparing the benefit package to the Federal Employees Health Benefit Program was conducted.

• Effective January 1, 1999, a State plan amendment modified the prescription benefit, mental health and substance abuse benefit, and dental benefit. An actuarial analysis submitted to CMS demonstrated that health benefit coverage under the amended Title XXI plan remains benchmark-equivalent.

Cost Sharing

• There is no cost sharing in Healthy Kids Gold.

• Healthy Kids Silver cost sharing consists of both premiums and co-pays.

• Cost sharing has a 5 percent of family income cap. Families that have enrolled are sent enrollment forms that give them the amount of what that 5 percent cap for cost sharing will be.

Premiums • $32 monthly premium per child for families with incomes between 185 and 250 percent of the FPL. There is a monthly premium cap of $128 for families with

4

multiple children.

• $54 monthly premium per child for families with incomes above 250 percent of the FPL. There is a $162 monthly premium cap for families with multiple children.

Copayments • $10 copayment for office visits (does not apply to well-child or preventive health visits, and any covered dental service); • $5 copayment for covered generic prescription drugs; • $15 copayment for covered formulary brand name prescription drugs, when no generic equivalent is available or the provider indicates that it is medically necessary; • $25 copayment for covered non-formulary brand-name prescription drugs, when no generic equivalent is available or the provider indicates that it is medically necessary; and • $50 copayment for emergency-room care, unless the patient is admitted to the hospital.

Coordination between Separate Child Health Program and Medicaid

• The same unit determines eligibility for both Healthy Kids Silver and Healthy Kids Gold (Medicaid) that maximizes the coordination of eligibility for both programs. The State will first determine whether or not a child is eligible for Healthy Kids Gold. If the child is eligible, he or she will be enrolled. Only if the child is not eligible for Healthy Kids Gold will he or she be screened and enrolled in Healthy Kids Silver via NHHKC.

Crowd-Out Strategy

• The joint application requests information about current and prior insurance coverage for the most recent 6-month period. If applicants have lost coverage for reasons related to the availability of CHIP, eligibility for the separate child health program will be denied. The Department can determine that good cause exists for dropping the employer-based coverage.

Outreach Activities

• Outreach materials include a variety of brochures, posters, flyers, and enrollment package materials. The outreach effort takes advantage of seasonal and geographic differences and events, such as the start of the school year. The outreach plan includes distribution of postcards to schools; distribution of information through child care centers, Head Start centers, WIC sites, and other

5

health care providers; use of retail bag stuffers; use of public speaking engagements, news releases, and radio and television public service announcements; a special web site; and, direct mail campaigns.

Financial Information

Total FFY 2010 CHIP Allotment: $15,540,481 FFY 2010 Enhanced Federal Matching Rate: 65.00%

Updated: CMS, CMSO, FCHPG, DSCHI, December 18, 2009

_____________________________________________________________________________

Table of Contents

State/Territory Name: New Hampshire

State Plan Amendment (SPA) #: NH-13-9001

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for New Hampshire consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

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

7500 Security Boulevard, Mail Stop: $2-26-12 Baltimore, Maryland 21244-1850

(CMS

‘CENTERS FOR MEDICARE & MEDICAID SERVICES. CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group JUN 25 2014

Christine Shannon

New Hampshire Department of Health & Human Services Office of Medicaid and Business Policy

Medicaid Policy Unit

Brown Building, 4" Floor

129 Pleasant Street

Concord, NH 03301

Dear Ms. Shannon:

Iam pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number NH-13- 9001, submitted on December 31, 2013, and with additional information submitted on June 11, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number NH-13-9001 converts the state’s existing income eligibility standards to MAGIT-equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment and other CHIP-related issues. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

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

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. Richard McGreal, Associate Regional Administrator (ARA) in our Boston Regional Office. Mr. McGreal’s address is:

Page 2 — Ms. Christine Shannon

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations JFK Federal Building

15 Sudbury Street, Room 2325

Boston, Massachusetts 02203-0003

If you have additional questions, please contact Ms. Barbara K. Richards, Acting Director, Division of State Coverage Programs, at (410) 786-5920. We look forward to continuing to work with you and your staff.

Sincerely, Eliot Fishman _ Director

Enclosure

ce:

Richard McGreal, ARA, CMS Region I

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility NH.0709.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: New Hampshire State Funds: $ Federal Funds: $ Submitted By: Valerie King Last Revision Date: Dec 31, 2013 Submit Date: Dec 31, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NH-13-9001 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:73 out of 2000 Sets MAGI-based income standards for children in CHIP Medicaid Expansion. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_179.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_179.jsp

coms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

CS3

42 CFR 457.320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered.

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL)

+ lio 19 196 318 x

PRA Disclosure Statement 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 0938-1148. The time required to complete this information collection is estimated to average 50 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 comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

JUN 25 2014 SPA# NH-13-9001 Approval Date: Effective Date: January 1, 2014 Page | of 1

_____________________________________________________________________________

Table of Contents

State/Territory Name: New Hampshire

State Plan Amendment (SPA) #: NH-13-9002

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for New Hampshire consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 Cc M Ss

Baltimore, Maryland 21244-1850 CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAR 14 2014

Christine Shannon

New Hampshire Department of Health & Human Services Office of Medicaid and Business Policy

Medicaid Policy Unit

Brown Building, 4" Floor

129 Pleasant Street

Concord, NH 03301,

Dear Ms. Shannon:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number NH-13-9002, submitted on December 26, 2013, and related Modified Adjusted Gross Income (MAGI) Eligibility, with an effective date of January 1, 2014.

The SPA number NH-13-9002 describes the state’s plan to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) of the Affordable Care Act, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of New Hampshire’s approved CHIP state plan.

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

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

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. Richard McGreal, Associate Regional Administrator in our Boston Regional Office. Mr. McGreal’s address is:

Page 2 — Ms. Christine Shannon

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations JFK Federal Building

15 Sudbury Street, Room 2325

Boston, MA 02203

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely, Eliot Fishman Director Enclosure ce:

Richard McGreal, ARA, CMS Region I

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility NH.0673.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: New Hampshire State Funds: $ Federal Funds: $ Submitted By: Valerie King Last Revision Date: Dec 31, 2013 Submit Date: Dec 26, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NH-13-9002 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 2101(f) of the ACA and 42 CFR 457.310(d) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:139 out of 2000 Establishes the 2101(f) group, a new coverage group for children who lose Medicaid eligibilty as a result of discontinuation of disregards. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

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ccmMs CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

C814

Child Health Insurance. gram : : 8 [Eligibility - Children Ineligible for Medicaid asa Result of 1c

come Disregards

Section 2101(f) of the ACA and 42 CFR 457.310(d)

{M] Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards

The CHIP agency provides coverage for this group of children as follows:

The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016). -

PRA Disclosure Statement 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 0938-1148. The time required to complete this information collection is estimated to average 50 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 comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130917

SPA# NH-13-9002 Approval Date: MAR 1 A 2014

Effective Date: January 1, 2014

Page | of I

New Hampshire State Children’s Health Insurance Program State Plan Final SPA #4 Submitted January 27, 2005

Approved April 21, 2005

Effective Date: May 1998

Approval Date: September 1998 1

OMB #: 0938-0707 Exp. 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.

New Hampshire State Children’s Health Insurance Program State Plan Final SPA #4 Submitted January 27, 2005

Approved April 21, 2005

Effective Date: May 1998

Approval Date: September 1998 2 Form CMS-R-211

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:______New Hampshire_____________ (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 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: Ann Walls Position/Title: SCHIP Manager, NH DHHS-Office of Medicaid Business and Policy Name: Kathleen Dunn Position/Title: Director, NH DHHS-Office of Medicaid Business and Policy Name: Marilee Nihan Position/Title: Financial Manager, NH DHHS-Office of Medicaid Business and Policy

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. Deleted: Valerie King Deleted: Coordinator Deleted: Health Planning and Deleted: Stephen Norton Deleted: Health Planning and Deleted: Health Planning and

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

Effective Date: May 1998

Approval Date: September 1998 3 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.

New Hampshire’s expansion of children’s health care coverage under Title XXI occurred in two phases, which involved providing expanded benefits under the State’s Medicaid plan and obtaining coverage that meets the requirements for a State Children’s Health Insurance Program.

In Phase 1, implemented May 1998, the state expanded Medicaid to include newborns and infants from birth to age 1 with family income greater than 185% and equal to or less than 300% of FPL. Income is calculated in the same manner currently used by the state for poverty level children (children with family income at or below 185% of FPL) with an additional disregard of 65% of the FPL for the family size involved as revised annually in the Federal Register. In no case will income be disregarded such that the resulting net income is less than or equal to 185% FPL. The federal eligibility standard is 235% FPL.

In Phase II, implemented in January 1999, the New Hampshire Department of Health and Human Services (DHHS) partnered with the New Hampshire Healthy Kids Corporation (NHHKC) to provide insurance coverage through the development of a State Children’s Health Insurance Program (SCHIP) for children ages 1 through 18 with family income greater than 185% and equal to or less than 300% of FPL. Income is calculated in the same manner currently used by the state for poverty level children (children with family income at or below 185% of FPL) with an additional disregard of 65% of the FPL for the family size involved as revised annually in the Federal Register. In no case will income be disregarded such that the resulting net income is less than or equal to 185% FPL.

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

Effective Date: May 1998

Approval Date: September 1998 4 The federal eligibility standard is 235% FPL.

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))

No expenditures were claimed prior to the time the state had the legislative authority to operate the State plan or plan amendment as approved by CMS.

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)

New Hampshire’s SCHIP complies with all applicable civil rights requirements, including the above-mentioned sites.

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):

State Plan (Phase 1 - Title XIX expansion): Effective/Implementation Date: May 1, 1999

Amendment #1 (Phase 2 - Title XXI): Effective/Implementation Date: January 1, 1999

Amendment #2 (adding “good-cause” exceptions): Effective/Implementation Date: April 1, 2002

Amendment #3 (increasing premiums): Effective/Implementation Date: January 1, 2003

Amendment #4 (adding a tiered drug formulary): Effective/Implementation Date: January 1, 2005

Amendment #5 (increasing premiums) Effective: October 1, 2009

(change in healthcare MCO) Implementation: July 1, 2009

(enrollment cap authority): Effective: July 1, 2009 (CHIPRA citizenship documentation): Implementation: January 1, 2010

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

Effective Date: May 1998

Approval Date: September 1998 5

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))

See electronically attached Health Resources and Services Administration New Hampshire State Planning Grant Interim Report, March 2002.

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):

Brochures outlining options for health care coverage, including Medicaid eligibility as well as Medicaid application forms (New Hampshire has a short application form commonly referred to as the 800-P for poverty level children's groups and pregnant women) are available at a variety of community agencies and provider sites such as hospitals, WIC sites, and public health clinics and community health centers funded through Title V and Title X grants. These same agencies are part of an on-going effort by the state to identify Medicaid eligible children and provide support to eligible families who up until now have not availed themselves of Medicaid benefits but would be eligible if they applied.

Formal Medicaid application and intake sites include the twelve local New Hampshire DHHS district offices strategically located around the state. In addition, the Medicaid 800-P short forms can be completed and

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

Effective Date: May 1998

Approval Date: September 1998 6 submitted via the Title V agencies, Title X clinics, WIC sites, disproportionate share hospitals, Early Intervention sites and Federally Qualified Health Centers (FQHC's).

The state also maintains a toll free phone number and client service units in both the Medicaid Administration Services and the Division of Family Assistance (DFA) to provide prompt answers to questions regarding eligibility and services. At this time there is no other public health or state only insurance program for children.

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:

The only health insurance program for children that involves a public private-partnership is New Hampshire Healthy Kids Corporation (NHHKC). In 1993, the New Hampshire Legislature passed the Healthy Kids Act (RSA 126: H) to address the growing problem of uninsured children. The Act created the New Hampshire Healthy Kids Corporation, a private non-profit, "deemed to be a public instrumentality and ... by the authority of the powers conferred by this chapter shall be deemed and held to be the performance of public and essential government functions of the state.”

The state does not subsidize premiums at this time, but it provides funds for administration, marketing and outreach. NHHKC is governed by a seventeen member Board of Directors that includes six appointees of state government including the Department of Health and Human Services. State oversight includes a requirement for an annual report to the Governor, various Commissioners, and members of the Legislature.

The state created NHHKC to provide affordable health coverage and access to health care services for uninsured children. The program design and operations are consistent with the goals of Title XXI. As a public-private partnership, the goal has been to conduct multifaceted outreach and marketing, simplify the enrollment process, and design and operate a program that would avoid the stigma often

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

Effective Date: May 1998

Approval Date: September 1998 7 associated with Medicaid.

NHHKC’s plan provides comprehensive health and dental benefits, which emphasize the preventive and primary care that children need to stay healthy and go to school ready to learn. Currently coverage is underwritten by Harvard Pilgrim Healthcare for health benefits and mental health benefits, and Northeast Delta Dental for dental benefits. Selection of the insurance carrier was conducted through a formal RFP process and contracts are renegotiated biennially.

To be eligible for SCHIP component of Healthy Kids, a child must be a full time resident of the state, not eligible for Medicaid, not enrolled in employment-related group health insurance in the past six months, and their family income cannot exceed 300% of the federal poverty level.

Efforts to identify and enroll children in NHHKC have been extensive. The Corporation has developed outreach partnerships with schools, childcare agencies, health care providers, municipalities and community-based social service agencies. Award-winning printed materials include postcards, posters, annual reports, brochures and flyers, which are widely distributed and displayed throughout the state. The Corporation conducts an aggressive media campaign, which has resulted in frequent coverage in newspapers, on radio and television; speaking engagements on public affairs programs, and public service announcements. The Corporation teams with businesses for promotion activities such as fast food tray liners and promotion cards stuffed in bags at retail outlets such as grocery stores, pharmacies and discount department stores.

Schools provide the largest source of referral (about 40%) where twice each year the school age population is blanketed with promotion information and school nurses display information and make direct referrals. Twenty percent of inquiries cite media as their source of information about the program. As the program becomes more well known, provider and word-of-mouth referrals are becoming more frequent. The Corporation tracks response to its various marketing and outreach activities for informed decision making about the most effective methods and Deleted: Anthem Blue Cross Blue Shield of New Hampshire Deleted: annually Deleted: 400%

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

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Approval Date: September 1998 8 messages. At the present time NHHKC estimates that it has reached over 12,000 families in New Hampshire.

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 state coordinates SCHIP enrollment and outreach efforts with other public and private health insurance programs and child health agencies in order to increase the number of children with creditable health coverage. This coordination reduces duplication of efforts and provides quality health care coverage to New Hampshire’s uninsured children.

As demonstrated in section 4.4, the state closely coordinates SCHIP enrollment efforts with the state’s Medicaid program. The state’s Division of Family Assistance (DFA) utilizes a software program called New HEIGHTS in the district offices. The program utilizes a cascading logic that allows staff in the district offices to screen for eligibility for various Medicaid coverage groups as well as other public assistance programs. With the advent of Title XXI, efforts were taken to incorporate the logic required to automate the screening and eligibility referrals of Healthy Kids Silver to NHHKC. Referrals are also automated to NHHKC for families whose income exceeds 300% FPL and do not qualify for services funded by Title XIX or XXI, but may qualify for the unsubsidized Healthy Kids Silver Buy-In program.

As part of their contract with the state, Title V agencies must screen all children they see at their agencies for health insurance. If that child is uninsured, agency staff is required to assist families in applying for the program. As part of their health performance measurements, Title V agencies are also expected to document clients who are enrolled in the Healthy Kids program. The Department’s SCHIP coordinator also meets with Maternal and Child Health coordinators on a regular basis to discuss problems and coordinate efforts.

In addition, at the time of implementation of SCHIP, plans were made to provide for the screening, referral and tracking of children

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

Effective Date: May 1998

Approval Date: September 1998 9 with special health needs. A question on the Healthy Kids application (800P) asks, “ Are there any children with special heath care needs who require ongoing supports to maintain their care at home?”. If the applicant checks off yes, that person’s name and information is sent to Family Voices, a family to family health information and resource project, who will assist that family with the coordination of other private and state resources for children with special heath care needs such as the Special Medical Services Bureau, a Title V funded program.

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

Effective Date: May 1998

Approval Date: September 1998 10

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))

As noted in Section 1.1.3 and described in the state's Medicaid state plan amendment, Phase 1 of the NH’s State Children’s Health Insurance Program consists of the state using Title XXI funds to expand Medicaid coverage for newborns and infants from birth to age 1 with family income greater than 185% and equal to or less than 300% of FPL. To complement Phase 1, the state instituted a name change to all children's Medicaid programs to Healthy Kids Gold in an effort to reduce barriers due to stigma associated with Medicaid enrollment. The Medicaid expansion program is also called Healthy Kids Gold and infants on this program receive Medicaid benefits until they turn 1.

Utilizing the provisions of Title XXI the state offers retroactive coverage, for infants at greater than 185% FPL and equal to or less than 300% FPL. Consistent with the current Medicaid fee-for- service program, the state will provide 3 months of retroactive coverage for services received in the 3 months prior to application date for Healthy Kids as long as the services received are within the scope of benefits and as long as the infant met the eligibility requirements during those 3 months.

Through Phase 2 of NH’s SCHIP plan, the state provides insurance coverage to children between ages 1 and 19 whose family income is greater than 185% and equal to or less than 300% of FPL. The state purchases insurance for these children through NHHKC. To be consistent with Phase I, this program is called Healthy Kids Silver.

NHHKC subcontracts with Harvard Pilgrim Healthcare of New Hampshire and Northeast Delta Dental. The coverage offered is a Deleted: Anthem Blue Cross Blue Shield

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

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Approval Date: September 1998 11 managed care product with a focus on preventive and well-child care. NHHKC selected Harvard Pilgrim Healthcare and Northeast Delta Dental via a competitive bid process. Contracts have been renegotiated biennially. The state will requires a competitive bid process until such time as their enrollment reaches a sufficient capacity to support a competitive bid process.

The Healthy Kids Silver benefits package includes an emphasis on perinatal care coverage for pregnant adolescent girls not previously served by NHHKC.

Mental health benefits are accessed through a phone call to Harvard Pilgrim Healthcare’s Behavioral Health Access Center.. Prior PCP authorization is not necessary to access the mental health or dental benefits.

At the time of enrollment for Healthy Kids Silver, a family chooses a primary care provider (PCP) from the Harvard Pilgrim network. If a PCP is not chosen, the family is assisted by either Harvard Pilgrim Healthcare’s customer service staff or NHHKC to select one.. The family also needs to submit the first month's premium, which is collected by NHHKC on behalf of the state.

Utilizing the provisions under Title XXI the state has implemented cost sharing provisions Healthy Kids Silver. Families whose income is greater than 185% and equal to or less than 250% of FPL pay a $32 per child per month premium, and there is a $128 cap on monthly premiums for these families with multiple children. Families whose income is greater than 250% and equal to or less than 300% of FPL pay a $54 per child per month premium, and there is a $162 cap on monthly premiums for these families with multiple children. NHHKC has made the premium payment process as user friendly as possible including mailing labels, change of address forms, use of coupon books. NHHKC implemented voluntary participation in electronic funds transfer (EFT) for premium payment in Fall 2002.

Defaulting on the payment of premiums result in the termination of eligibility after 60 days except for pregnant teens. NHHKC reports to the state children whose eligibility is terminated and the circumstances of the termination. NHHKC and the state can waive premium payment for hardship/good cause as described in section 8.7. NHHKC supports a premium rescue fund through which Deleted: Anthem Blue Cross Blue Shield Deleted: annually until November 2001 when the contracts were negotiated for 18 months Deleted: not require another Deleted: The state bears full risk for the maternity benefit and carries out a cost settlement after the adolescent has reached sixty (60) days postpartum. Deleted: the Blue Cross Blue Shield Behavioral Health Network Deleted: Blue Cross Blue Shield provider Deleted: contacted by NHHKC Deleted: and assisted with the selection process. Deleted: 25 Deleted: 100 Deleted: 45 Deleted: 135

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

Effective Date: May 1998

Approval Date: September 1998 12 charitable dollars are used to help families overcome a temporary loss of income or unexpected financial crisis.

Pregnant teens do not have their eligibility terminated for failure to pay premiums until after the postpartum period. The default clock begins on the sixty-first (61st) day postpartum. Terminating health care coverage mid-pregnancy is counterproductive to the state's goal of healthy birth outcomes for mother and infant.

In addition to the monthly premium for Healthy Kids Silver, the following co-payments are also required: $10 for office visits (excluding well-child or preventative health visits and any covered dental services), $5 for covered formulary generic prescriptive drugs, $15 for covered formulary brand name drugs when no generic equivalent is available or the provider indicates that it is medically necessary, $25 for covered non-formulary brand name drugs when no generic equivalent is available or the provider indicates that it is medically necessary, and a $50 fee for emergency room visits, unless the patient is admitted to the hospital. Providers will be responsible for collecting the co-pays at the time of service.

In compliance with Section 2103 of the Social Security Act, as amended by Section 403 of the Children’s Health Insurance Reauthorization Act of 2009 (CHIPRA), families enrolled in SCHIP who are dissatisfied with the CHIP managed care plan may, at disenrollment, opt in to Fee for Service coverage.

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 state bears the responsibility for utilization control for the Healthy Kids Gold fee for service program.

The primary utilization control for Healthy Kids Silver is the responsibility of the managed care organization, Harvard Pilgrim Healthcare. The contract with Harvard Pilgrim includes a definition of medical necessity and utilization management requirements, including clinical staffing requirements. The plan Deleted: The state includes in its contract with NHHKC, provisions for quality assurance, and data and reporting requirements as outlined in the section 7.0 and 9.0 of this application.¶ Deleted: Anthem Blue Cross Blue Shield of New Hampshire Deleted: Anthem

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Approval Date: September 1998 13 is required to have written utilization management policies and procedures that include appropriateness criteria for authorization and denial of services and protocols for prior approval, hospital discharge planning, and retrospective review.

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Approval Date: September 1998 14 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)) (42CFR 457.305(a) and 457.320(a))

4.1.1. Geographic area served by the Plan: Statewide 4.1.2.

Age: For Phase I, Healthy Kids Gold -Medicaid expansion: Infants up to age 1. For Phase II, Healthy Kids Silver: Children between age 1 through age 18. 4.1.3. Income: Family income must be greater than 185% and equal to or less than 300% of the FPL. (Income is calculated in the same manner as currently used by the state for poverty level children - children with family income at or below 185% of FPL-with an additional disregard of 65% of the federal poverty level for the family size involved as revised annually in the Federal Register. In no case will income be disregarded such that the resulting net income is less than or equal to 185% FPL. The federal eligibility standard is 235% FPL.) Methods for evaluating income include paycheck stubs, W-2s, income tax returns and letters from employers on company letterhead. 4.1.4. Resources (including any standards relating to spend downs and disposition of resources): There is no resource or assets test. 4.1.5.

Residency (so long as residency requirement is not based on length of time in state) : To be eligible a child must be a resident of the State of New Hampshire. There is no time requirement to be considered a resident. 4.1.6. Disability Status (so long as any standard relating to disability status does not restrict eligibility): 4.1.7.

Access to or coverage under other health coverage: Children who are covered under a group health plan or other health insurance coverage, or are children of a public employee eligible for coverage under a state health benefits plan are not eligible for the Healthy Kids Silver. An application for Healthy

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

Effective Date: May 1998

Approval Date: September 1998 15 Kids Silver will be disapproved if it is determined that the child was covered under a health insurance plan within the last six months. However, an application may be approved for good cause. Such reasons include: loss of employment, change of employment to an employer who does not provide dependent coverage, death of the employed parent, discontinuation of coverage to all employees (regardless of income) by the employer, insurer closes its operation in New Hampshire, an involuntary reduction in work hours that no longer allows the employee to enroll the employees dependent children under the employer’s health plan, voluntary loss of employment and the loss occurred for any of the good cause reasons specified in New Hampshire Code of Administrative Rules He-W 910.09( c) (2)a-g, cases of domestic violence, a temporary insurance policy is ending, COBRA coverage if good cause existed when employer coverage was lost, loss of coverage beyond the control of custodial parent when non-custodial parent drops insurance, and loss of coverage when parent leaves work to be the primary caretaker for his/her children ages 5 and under (effective April 1, 2002).

4.1.8.

Duration of eligibility: In general, a child who has been determined eligible for Healthy Kids Gold or Silver shall remain eligible unless the child attains the upper age limit, as appropriate, is no longer a resident of the state, or fails to pay premiums (for Healthy Kids Silver). Exceptions to this policy are previously noted.

The state may determine that an enrollee is not eligible if eligibility was a result of making a false statement, misrepresentation or concealment of or failure to disclose income or health insurance coverage. The state may recover payments made by the state on behalf of enrollees as a result of any false statement, misrepresentation, etc. regarding income or health insurance coverage. Eligibility is re-determined not more than 12 months after the effective date of eligibility and annually thereafter. 4.1.9.

Other standards (identify and describe): The state asks for verification of citizenship and identity.Applicants are asked for child’s social security number on the Healthy Kids application. The social security number is required for cross-match with Social Security Administration for citizenship verification.

4.2. The state assures that it has made the following findings with respect to the Deleted: a Deleted: Healthy Kids Gold Deleted: .

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

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Approval Date: September 1998 16 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 lower family income. (Exception to this is during enrollment cap periods. See Section 4.3.1 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)) (42CFR 457.350) With the implementation of SCHIP, the state created a single application, the 800P, for both Healthy Kids Silver and Healthy Kids Gold programs. Families can apply for the Healthy Kids program by visiting their local DHHS District Office, or by mailing the application directly to the mail- in enrollment center located at NHHKC.

By Federal regulation, only state employees are permitted to make eligibility determinations. DFA case technicians at the local district office and at NHHKC are responsible for screening all applications and verifying income, age, and other eligibility requirements. Information collected on the application form, include name, address, date of birth, social security number, residency, citizenship, family income, employment, and insurance (both current and in the previous six months).

If information is incomplete or questionable, the state will attempt to contact the applicant by phone to obtain missing information or to clarify questionable information within 10 business days of receipt of the application. If the family does not have access to a phone and/or if the state is not able to make contact by phone, the state will attempt to contact the family by mail. If no response is obtained within 10 days of sending a letter, the application will be denied.

The state will test for Medicaid eligibility first before determining eligibility for Healthy Kids Silver. If a child meets Medicaid eligibility, he/she will be enrolled in Healthy Kids Gold (Medicaid). If a child is not eligible for Medicaid but meets eligibility requirements for Healthy Kids Silver (including income, residence, and insurance requirements), he/she will be enrolled in Title XXI via NHHKC. The exception to this is during enrollment cap periods. See Section 4.3.1. If a child is not eligible for either program but may be eligible for the non-subsidized Healthy Kids Silver Buy-In program, a referral is made to NHHKC.

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Eligibility information for children determined eligible for Healthy Kids Silver will be entered into New HEIGHTS and sent to NHHKC. NHHKC will complete enrollment, including sending a letter notifying the family of the child’s eligibility (including the effective date), materials about NHHKC and the health plan and a coupon payment book for premiums. Eligibility will be effective the date a child is enrolled in a plan and payment received. This will generally be the first day of the month after the child was determined eligible but may be later if eligibility is determined within one week of the end of the month, if the premium is not received or if the family takes additional time to select a plan (if and when there is a choice of plans) or primary care provider. Exception to this is during enrollment cap periods. See Section 4.3.1.

Enrollees are required to notify NHHKC or DHHS of any change in household (i.e. changed address or number of individuals in household) or income within 10 days of change.

Not more than 12 months after the effective date of eligibility and annually thereafter, the state will re-determine eligibility for Healthy Kids Silver and Healthy Kids Gold. The state will mail a form to enrollees to obtain information necessary to review eligibility. Enrollees will be required to notify NHHKC or DHHS of any change in circumstance that could affect continued eligibility for coverage. If a child is no longer eligible for Healthy Kids Silver, he/she will be disenrolled. If he/she is eligible for Medicaid, he/she will be enrolled in Healthy Kids Gold. If a child is no longer eligible for Healthy Kids Gold, he/she will be disenrolled. If that child is eligible for Silver, NHHKC will receive an electronic referral and the above-mentioned process will occur to enroll the family in Healthy Kids Silver.

The state also facilitates the enrollment of uninsured children through its presumptive eligibility program for Healthy Kids Gold. Presumptive eligibility has been enhanced so that presumptive eligibility and community facilitated applications, processed by qualified entities that are authorized and trained by the DHHS, will be centralized at the mail-in enrollment center at NHHKC.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

Check here if this section does not apply to your state.

NH currently has no waiting list. Enrollment may be limited in the future if state general fund appropriation is insufficient. The need to implement an enrollment cap is assessed as follows: DHHS monitors current or “actual” Deleted: Deleted: state.

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

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Approval Date: September 1998 18 CHIP monthly enrollment. If actual enrollment grows to within range of a predetermined member month number, (as representing enrollment that couldn't be supported financially by State funds if it were to continue to grow at that sustained annual growth rate), that member month number would be considered a “trigger” for capping enrollment. Financial calculation of the predetermined trigger point is a product of the number currently enrolled and the state share cost of the per member per month premium fee. Should NH reach the trigger point the following procedures will be put in to place: The enrollment is “capped” meaning that no additional children may enroll. A wait list accepts children determined to be eligible and they queue up on the list, first come, first served. Since NH has a joint application for Medicaid and SCHIP, the application and eligibility determination process continue during the SCHIP enrollment cap and wait list period. Families determined to be eligible for Medicaid are enrolled and those determined to be eligible for SCHIP are informed of the enrollment cap and their children placed on the wait list. While on the SCHIP wait list, families must continue to report changes that effect eligibility such as income or household composition. If eligibility redetermination of a family on the SCHIP wait list results in eligibility for Medicaid, the children are enrolled in Medicaid and taken off the wait list. Enrollment is tracked monthly. Potential enrollment spaces become available at the end of each month when enrollment ends for currently enrolled children who disenrolled because they: 1. Have turned 19; 2. Become eligible for Medicaid coverage; 3. Move out of state; 4. Failed to pay monthly premium; 5. Failed to complete redetermination process; 6. Obtained other insurance; 7. Were determined ineligible during redetermination process; 8. Moved within the state with no forwarding address; 9. Voluntarily disenrolled with no stated reason; 10. Died.

When enrollment “slots” become available, a specified number of children (equal to number of slots available) at the top of the wait list are contacted, and their families informed that they may enroll. Children are removed from the wait list and families are provided 30 days to enroll.

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 redetermination, that

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

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Approval Date: September 1998 19 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 assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3))

As noted in section 4.3, the state determines eligibility for both Healthy Kids Silver and Healthy Kids Gold. As part of the determination for Healthy Kids Silver, the state verifies that an applicant is not a Medicaid beneficiary through New HEIGHTS, the states eligibility system. If the child is not a Medicaid beneficiary, the state will (based on the information collected as part of the application process) determine whether he/she may be eligible for Medicaid (e.g., because of income level). If the child is already enrolled in Medicaid, the application for Healthy Kids Silver will be denied. If the child appears likely to be eligible for Medicaid, the state will determine eligibility and assist in the enrollment of the child into Healthy Kids Gold (Medicaid).

The application includes questions about insurance coverage. If a child has insurance coverage, he/she will not be eligible to receive coverage under Healthy Kids Silver. Also, if a child has had insurance coverage in the past six months and does not meet one of the good cause exemptions (as noted in section 4.1.7), he/she will not be eligible to receive coverage via Healthy Kids Silver. Children who were enrolled in NHHKC prior to the state’s Title XXI program and who met the remaining eligibility guidelines were grandfathered into Healthy Kids Silver.

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)) (42CFR 457.350(a)(2))

The same state unit determines eligibility for both Healthy Kids Silver and Healthy Kids Gold (Medicaid), which maximizes the coordination of eligibility for both programs. The state will first determine whether or not a child is eligible for Healthy Kids Gold. If the child is eligible, he/she will be enrolled. Only if he/she is not eligible for Healthy Kids Gold will he/she be screened and enrolled in Healthy Kids Silver via NHHKC.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of

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

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Approval Date: September 1998 20 children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

The same state unit determines eligibility for both Healthy Kids Silver and Healthy Kids Gold (Medicaid), which maximizes the coordination of eligibility for both programs. The state will first determine whether or not a child is eligible for Healthy Kids Gold. If the child is eligible, he/she will be enrolled. Only if he/she is not eligible for Healthy Kids Gold will he/she be screened and enrolled in Healthy Kids Silver via NHHKC. 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)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

The application process involves collecting information about current coverage and coverage in the past six months. Children currently covered will not be eligible for Healthy Kids Silver coverage. The state will review applications to determine whether applicants or employers of applicants have discontinued private or employer-sponsored dependent coverage in order to participate in the program. Children who had employer-sponsored coverage within the previous six months who lost coverage for reasons related to the availability of Healthy Kids Silver (e.g., no longer purchasing family coverage) will not be eligible. As noted in section 4.1.7, an application may be approved for good cause. Such reasons include: loss of employment, change of employment to an employer who does not provide dependent coverage, death of the employed parent, discontinuation of coverage to all employees (regardless of income) by the employer, insurer closes its operation in New Hampshire, an involuntary reduction in work hours that no longer allows the employee to enroll the employees dependent children under the employer’s health plan, voluntary quit of employment and the quit occurred for any of the good cause reasons specified in New Hampshire Code of Administrative Rules He-W 910.09( c) (2)a-g, cases of domestic violence, a temporary insurance policy is ending, COBRA coverage if good cause existed when employer coverage was lost, loss of coverage beyond the control of custodial parent when non- custodial parent drops insurance, and loss of coverage when parent leaves work to be the primary caretaker for his/her children ages 5 and under (effective April 1, 2002).

4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution. Deleted: ¶ Formatted

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

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Approval Date: September 1998 21 Children, ages 0-19, in families with income at 0- 185% FPL, or newborns and infants ages 0-1 with income at greater than 185% to 300% of FPL are covered under Healthy Kids Gold (Medicaid) and can have other insurance. Children ages 0-19, in families with income at 185%-300% FPL are on Healthy Kids Silver and can not have other health insurance. Therefore, the methods of monitoring substitution stated in section 4.4.4 apply. 4.4.4.2. Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable. The methods of monitoring substitution stated in section 4.4.4 apply for these families. 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. The methods of monitoring substitution stated in section 4.4.4 apply for these families. 4.4.4.4. If the state provides coverage under a premium assistance program, describe:

N/A

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

N/A

The minimum employer contribution. N/A

The cost-effectiveness determination.

N/A 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))

Cost sharing protection is in place to ensure enrollment of American Indians and Alaska Natives, as defined in 457.10. The following documents will be revised to disclose that members of federally

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

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Approval Date: September 1998 22 recognized Indian Tribes and Alaska Natives are eligible for free coverage under Title XXI although the children may qualify for premium-based coverage: 1. The Children’s Health Insurance Program Guide to Benefits – this is the primary information booklet that describes the programs and how to apply. 2. Silver Eligibility Letter – Families who have applied for coverage through the DHHS District Office and are referred to NHHKC for enrollment. 3. Silver Enrollment Letter – Families who have applied through the mail-in unit at NHHKC and have been deemed eligible for the premium-based Healthy Kids (Title XXI) program.

In order to process the free coverage enrollment, members of tribes will be asked to inform NHHKC of their tribe status by phone or mail. The contract between NHHKC and the State of New Hampshire will be amended to provide full reimbursement of the premium and co- payments for members of tribes to NHHKC (effective August 24, 2001).

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Effective Date: May 1998

Approval Date: September 1998 23 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)

Along with contracting with NHHKC to administer the Title XXI program, the state also contracts with NHHKC to market and perform outreach services for the state’s Medicaid and SCHIP programs. An initial outreach plan was developed in partnership with NHHKC and other community health partners, to ensure that New Hampshire families are aware of the child health insurance coverage options available under Title XXI as well as under Title XIX. This plan was designed using the successful practices of NHHKC and capitalizes on the collaborative relationships already developed with schools and child care centers as well as expanding the existing network of social service agencies and advocacy groups beyond those that had traditionally worked with the state and NHHKC.

Outreach materials include a variety of brochures, posters, flyers, and enrollment package materials. Information covers the benefits offered, eligibility requirements, and how and where to apply. NHHKC employs field coordinators in different areas of the state who maintain relationships with community partners and provide outreach support through training and promotional materials. The focus of this strategy is to work with organizations that directly serve families and children.

Outreach campaigns are conducted periodically to focus on boosting enrollment in specific target groups, such as developing materials to focus on infants. The outreach takes advantage of seasonal and geographic differences and events, such as the start of the school year. Historically, the most effective method of reaching families have been to distribute information through the schools.

Other elements of the outreach plan include: • Biannual blanket distribution of promotional postcards to all public and religious schools in the state; • Distributing information through, child care centers, Head Start centers, WIC sites, community agencies and health care providers; • Providing displays for these sites and appropriate commercial establishments;

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

Effective Date: May 1998

Approval Date: September 1998 24 • Use of retail bag stuffers; • Using public speaking engagements, talk shows, public affairs programs, news releases, press conferences, and radio and TV PSAs as appropriate; • Informing partners and consumers about the availability of “NH Easy” an online application system that DHHS has developed for a more convenient access to Healthy Kids and other family assistance programs. Conducting direct mail campaigns to demographically selected lists that match profiles of uninsured families, building on the current Healthy Kids mailing lists of previous inquiries as well as other providers lists; • Initial and refresher training of staff at all applications sites that provide one-on-one assistance on such topics as how to effectively deal with inquiries and potential members to maximize the contact as an enrollment opportunity; accuracy and completeness of the application; and referrals to other services; and, • Developing an evaluation methodology based upon the concepts of continuous quality improvement to ensure the efficient and effective use of outreach resources.

Effectiveness of outreach campaigns are tracked by referral sources on all families that inquire and apply. These statistics are compiled and analyzed through database queries. In addition, questions regarding outreach methods and messages are included in periodic surveys of enrollees, disenrollees and prospective enrollees. Over one-third of families indicate they learned about the program through their child’s school.

Central to the state’s goal of maximizing the enrollment of uninsured children are efforts to support speedy application and enrollment. Activities include: • Providing a toll-free telephone line to directly request brochures or other information packages and applications or to request assistance with completing an application; • Developing one application for both Healthy Kids Silver and Healthy Kids Gold; • Implementing a centralized mail-in enrollment center where applications can be mailed; • Increasing the availability of on-site application assistance at community based organizations utilizing staff trained in the eligibility requirements of the various public health and state benefit programs.

Special outreach efforts to minority and rural populations will be conducted Deleted: Creating a special web site, Wired Wizard, with links to both Healthy Kids Corporation’s website and the DHHS websites and where applications can be downloaded; Formatted: Bullets and Numbering Formatted: Bullets and Numbering

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

Effective Date: May 1998

Approval Date: September 1998 25 through the upcoming Robert Wood Johnson Covering Kids and Families Grant, which will allow the state to pilot outreach, simplification and coordination of children’s health care coverage programs in 2 local pilots locations, Manchester and the rural North.

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

Effective Date: May 1998

Approval Date: September 1998 26 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. 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 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. 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 existing Deleted: .

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

Effective Date: May 1998

Approval Date: September 1998 27 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)) In a short-term /general hospital, skilled nursing facility or physical rehabilitation facility. 6.2.2. Outpatient services (Section 2110(a)(2)) Facility charges and medical services, such as operating room, hospital, pharmacy and supplies, physician visits, laboratory and x-rays and surgery. 6.2.3.

Physician services (Section 2110(a)(3)) Including primary care providers such as Advanced Registered Nurse Practitioners and Physician Assistants. 6.2.4. Surgical services (Section 2110(a)(4)) 6.2.5. Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6. Prescription drugs (Section 2110(a)(6)) Including all FDA approved oral contraceptives and Depo- Provera. 6.2.7.

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

Laboratory and radiological services (Section 2110(a)(8)) 6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) 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)) Maximum of 15 days per year. 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)

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

Effective Date: May 1998

Approval Date: September 1998 28 Maximum of 20 visits per year. 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)) Eyeglasses, hearing aids, prosthetic devices and other DME as determined to be medically necessary and consistent with diagnosis. 6.2.13. Disposable medical supplies (Section 2110(a)(13)) Disposable medical supplies as medically necessary and consistent with diagnosis, are covered. 6.2.14. Home and community-based health care services (See instructions) (Section 2110(a)(14)) 20 home health visits a year. 6.2.15. Nursing care services (See instructions) (Section 2110(a)(15)) 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) 6.2.17. Dental services (Section 2110(a)(17)) Diagnostic and preventive services including sealants, fillings, and simple extractions are covered 100% up to a maximum $600 per child per year (effective January 1, 2001). No orthodontics are covered. 6.2.18. Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) Inpatient detoxification for medically necessary stays. No limit on the number of times a member may be admitted for inpatient detoxification. 6.2.19. Outpatient substance abuse treatment services (Section 2110(a)(19)) Outpatient substance abuse visits wrapped into the 20 outpatient mental health benefit. Therefore a member will have a total of 20 outpatient visits for mental health and substance abuse counseling. Not 20 visits for each. 6.2.20. Case management services (Section 2110(a)(20)) 6.2.21. Care coordination services (Section 2110(a)(21)) To be provided as part of the role of the Primary Care Provider. 6.2.22. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders. (Section 2110(a)(22)) 24 visits for speech therapy; 24 visits for occupational therapy or 24 visits for physical therapy or a combination of occupational

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

Effective Date: May 1998

Approval Date: September 1998 29 and physical therapies for each medical episode. 6.2.23. Hospice care (Section 2110(a)(23)) 6.2.24. Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) Chiropractic services, allergy testing and treatment, cardiac rehabilitation services, infusion therapy, vision and hearing services, preventive health services such as diabetes management program, routine hearing exams, laboratory and x- ray tests, medical exams and childhood immunization for well children, prenatal care and vision care and early intervention services up to age 3, ($3,200 annual, 9,600 lifetime maximum) are also covered (effective January 1, 2001). 6.2.25. Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26. Medical transportation (Section 2110(a)(26)) Emergency transportation by ambulance. 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 and rehabilitation facility services as deemed medically necessary and pre-authorized by the health 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) (2) and(3)) (42 CFR 457.1005 and 457.1010)

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

Effective Date: May 1998

Approval Date: September 1998 30

N/A

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))

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

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

Effective Date: May 1998

Approval Date: September 1998 31 457.1010)

N/A

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: May 1998

Approval Date: September 1998 32 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(a))

NHHKC and their insurance subcontractor are required to meet all standards for quality of care in the contract in order to contract with the state. The state reviewed and approved the subcontract agreement between NHHKC and the health plan prior to the enrollment of children into Healthy Kids Silver.

DHHS will continuously monitor quality through various mechanisms, including: health plan contracting standards, reporting requirements, enrollee input, external reviews, and on-site reviews. The state will strive to establish a continuum across the Title XIX and Title XXI programs for quality e.g. contracting with the same External Quality Review Organization (EQRO), establishing priority areas for review and utilizing consistent measurement methodologies. The state will bear final responsibility for the quality improvement activities outlined in this application however, the quality improvement plan will be based upon a partnership with NHHKC and their contracted insurerAs a monitoring tool for children’s healthcare, DHHS utilizes data from NH Comprehensive Health Care Information System (NH CHIS), which includes a commercial health care claims database, to compare Medicaid, SCHIP and commercially available insurance enrollment, access, service utilization, payments and other variables.

The Phase 1 Healthy Kids Gold (Medicaid) program will be monitored via the established quality improvement program in the Medicaid Administration Services. The established QIP includes the monitoring of quality and appropriateness of care and highlights well-baby and well childcare. It is based upon this pre-existing program that the Phase 2 quality improvement program will be designed.

For Phase 2, the contract with NHHKC will include specific standards for quality of care, including the provision of well-baby care, well-child care, and immunizations that will be carried out by the health plan as their subcontractor. The health plan will be required to arrange for immunizations, physical examinations, health education, dental examinations/treatments and Deleted: Once the state has signed a contract with NHHKC, it Deleted: .

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

Effective Date: May 1998

Approval Date: September 1998 33 comprehensive screens (and any needed interperiodic screens) in accordance with the schedules recommended by the most current Recommended Childhood Immunization Schedule, United States and the American Academy of Pediatrics. The health plan will be required to have enrollees up to date on screening and immunizations within 3 months of being enrolled.

Reporting will include a report on the plan’s quality improvement plan (QIP), HEDIS reports on immunizations and well child care, and other pediatric preventive health measures as part of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program, utilization reports, and periodic provider network reports. The state will require the subcontracted health plan to submit encounter data. The state recognizes that this information is crucial to the on-going monitoring and evaluation of the Healthy Kids program and will strive to develop a system that will receive, process and permit for detailed analysis, the scope of services provided to Healthy Kids enrollees. The state will work with NHHKC and the plan to develop the data elements, medium, format and time frames for submissions.

Other utilization information that involve health plan interventions and enrollee participation in activities such as complaints/grievance resolution, case coordination services, health risk screenings, disease management and health promotion programs will be reported and tracked.

NHHKC will be responsible for conducting enrollee satisfaction surveys. NHHKC may delegate this function to the health plan. However, the state will review and approve the survey tool for specific questions from the CAHPS instrument, sampling methodology, research design and final results. The state is also developing a provider satisfaction survey.

The functions of the external quality review organization are described in section 7.1.1. In addition, the state will conduct periodic focus groups as part of its on-going community involvement process and maintains the option of conducting annual on-site evaluations at the health plan to assess compliance with contract requirements (such as utilization management decisions), and to establish, with the health plan, quality improvement projects and performance goals.

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)

7.1.1.

Quality standards The state will contract for an external quality review of the health

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

Effective Date: May 1998

Approval Date: September 1998 34 plan. Such review shall include, but not be limited to, an evaluation of access to care, quality of care studies, medical record standards, and individual case review and appropriateness of care. All activities carried out by the EQRO will be prior approved by the state in order to assure appropriate monitoring and to assure consistency in quality improvement activities across programs. 7.1.2.

Performance measurement DHHS annually reviews and reports on a variety of health care measures to compare children enrolled in New Hampshire Medicaid, in NH SCHIP and in commercial health insurance plans in NH. This allows ongoing monitoring of healthcare for children, aged 0-18, covered in these programs and to study enrollment and disenrollment, access to primary care providers, well-child visits, effectiveness of care management, and utilization and payments. State data is also compared to HEDIS quality and access to compare measures and reported accordingly.

7.1.3.

Information strategies

The state, NHHKC, and the health plan will be required to educate enrollees about their benefits under Healthy Kids Silver and Healthy Kids Gold as well as their rights and responsibilities. The plan will also educate enrollees about the importance of preventive services, health promotion activities, care coordination services, disease management programs, and visiting their primary care provider instead of an emergency room.

7.1.4. Quality improvement strategies

The contract with NHHKC will include specific standards for quality of care including access to care and appointment availability, and the health plan will have to meet those standards in order to contract with NHHKC and the state. These standards will be monitored by the state and NHHKC through reporting requirements, on-site reviews, external reviews and enrollee input through complaint data and satisfaction surveys.

In particular, the plan will be required to establish an internal quality improvement plan (QIP), which will be in writing and available to the public. The written description shall include

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

Effective Date: May 1998

Approval Date: September 1998 35 detailed goals and annually developed objectives; address the quality of clinical care and non-clinical aspects of services for the range of care provided by the plan; specify quality of care studies and related activities; provide for continuous performance of activities, including tracking of issues over time; and provide for review and feedback by physicians and other health professionals. By the end of the first contract year, the plan will be required to initiate two (2) clinical focused projects aimed at improving care for enrollees. Clinical focus areas applicable to this target population include topics related to: lead toxicity screening and treatment, • chronic pediatric asthma, • attention deficit disorder, • adolescent counseling on smoking and substance abuse, • well-child care, • behavioral health screening and treatment and • perinatal services.

The state, NHHKC and the health plan will work collaboratively to select the clinical areas to be studied and define the improvement strategy.

An annual report on the QIP will be required. This report will be made in the form of a presentation to the state and its community advisors. In addition, the report will be made available as a formal written report that will be made available to the public as hard copy and on the DHHS website.

For Healthy Kids Silver enrollees that become pregnant while eligible, comprehensive perinatal services shall be available and accessed through the contracted health plan. The plan’s purchasing specifications must describe and demonstrate a comprehensive, proactive perinatal program with adherence to care guidelines as recommended by the American College of Obstetrics and Gynecology. HEDIS perinatal and birth outcome indicators will be utilized to measure and assess performance. Depending upon the results and trends, the health plan’s QIP shall be expected to develop further interventions and strategies to increase participation and positive outcomes.

7.2 Describe the methods used, including monitoring, to assure: (2102(a) (7) (B)) (42CFR 457.495)

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

Effective Date: May 1998

Approval Date: September 1998 36 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 state requires the Healthy Kids Silver health plan to provide access to preventive care such as, well-child care, well-adolescent care and childhood and adolescent immunizations. No office visit co-payments are required for routine childhood examinations and immunizations The state requires the health plan to include sufficient numbers of appropriately trained and certified staff to provide this access to care. The state and NHHKC monitor access requirements through reporting and member satisfaction surveys. Infants covered under Title XXI receive well-baby care under Healthy Kids Gold as part of the Medicaid expansion. The state monitors access issues for Healthy Kids Gold.

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 state requires the health plan to include sufficient numbers of appropriately trained and certified clinicians of pediatric care, including primary, medical subspecialty and surgical specialty physicians, as well as providers of necessary related services such as, dental and mental health services. The state monitors network capacity through quarterly provider network reports and will suspend enrollment if capacity is exceeded.

The health plan is required to ensure that their provider networks provide access to primary care providers (PCPs) within 20 miles/45 minutes and access to emergency services on a 24-hour, seven-day-a- week basis. Emergency care shall be provided immediately, urgent care within 24 hours, non-urgent, symptomatic PCP appointments shall be available within 48 hours from the enrollee’s request to be seen and non-symptomatic, routine/preventive care within 30 calendar days. An emergency medical condition will be defined as a condition such that a prudent lay person, acting reasonably, would have believed that emergency medical treatment is needed. The state and NHHKC monitor access requirements through reporting and member satisfaction surveys.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the

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

Effective Date: May 1998

Approval Date: September 1998 37 network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

The health plan is required to treat enrollees with chronic, or serious medical conditions, and provide access and adequate number of visits to specialists experienced in treating the specific medical condition. Enrollees will have access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. The state and NHHKC will monitor access requirements through reporting and member satisfaction surveys.

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))

Most health services do not require prior authorization unless a referral is made to an out of network provider. Decisions related to prior authorization of health services are in accordance with the New Hampshire Department of Insurance’s regulations.

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

Effective Date: May 1998

Approval Date: September 1998 38 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 to 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:

There are no premiums for Healthy Kids Gold. Under Healthy Kids Silver, families whose income are greater than 185% and equal to or less than 250% of FPL pay a $32 per child per month premium, and there is a $128 cap on monthly premiums for these families with multiple children. Families whose income is greater than 250% and equal to or less than 300% of FPL pay a $54 per child per month premium, and there is a $162 cap on monthly premiums for these families with multiple children.

8.2.2. Deductibles:

There are no deductibles for Healthy Kids Gold or Healthy Kids Silver.

8.2.3. Coinsurance or co-payments:

There is no coinsurance for Healthy Kids Gold or Silver. There are no co-payments for Healthy Kids Gold.

For Healthy Kids Silver, there is a $10 co-pay for provider office visits, and a prescription drug co-payment of $5 for covered generic prescription drugs, $15 for covered formulary brand name drugs when no generic equivalent is available or the provider indicates that it is medically necessary, and $25 for covered non-formulary brand name Deleted: 25 Deleted: 100 Deleted: 45 Deleted: 135

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

Effective Date: May 1998

Approval Date: September 1998 39 drugs when no generic equivalent is available or the provider indicates that it is medically necessary. There is also a $50 co-payment for emergency care, unless the patient is admitted to the hospital. There are no co-payments for preventive health and/or well child visits, dental check-ups, dental x-rays, cleanings and fluoride treatments.

8.2.4 Other:

8.3. Describe how the public will be notified, including the public schedule, of this 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))

Both the state and NHHKC provide information on the cost sharing requirements to enrollees as well as to the provider community. Information about premiums and co-pays are included in all outreach/education material including brochures, flyers, posters, the Children’s Health Insurance Guide to Benefits and on the website. It is also included in the enrollment materials that the family receives. Families that have enrolled are sent enrollment forms that give them the amount of what that 5% cap out of pocket expense will be.

Changes in premiums are subject to Legislative approval of State rule changes. Such rule changes require public notification and a public hearing.

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)

The state plan follows this requirement. 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)

The state plan follows this requirement.

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))

The state plan follows this requirement.

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

Effective Date: May 1998

Approval Date: September 1998 40 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))

The State contracts with NHHK to provide for the administration of the cost- sharing provisions of the Title XXI plan. As part of its role, NHHK educates families about the cost sharing rules and requirements including premiums and co-payments. The education includes; how much money 5% of the family’s income, translated into terms of dollars and cents, what period of time the monitoring period covers, and that the responsibility for monitoring out of pocket expenses will be shared by the family and NHHK. The education will instruct families in tracking their out of pocket expenses on a monthly basis (the emphasis will be on tracking and documenting medical/dental office and pharmacy co-payments) and to contact NHHK immediately (via mail or the statewide toll free number) should their out of pocket expenses equal or exceed the previously determined amount of money or if the family income should suddenly decrease. NHHK also monitors medical and dental co- payments on a quarterly basis via a cost sharing report generated by health and dental plans. Premium cost-sharing is monitored directly by NHHK via their accounting system.

Families who exceed the 5% cap will be formally notified by NHHK in writing and all cost sharing will cease for the remainder of the current 12 month eligibility period. The letter will include the specific date that the cost-sharing exemption expires (it coincides with the eligibility re-determination date). The family utilizes the NHHK formal notification as proof of exemption from cost- sharing, to be presented to providers as needed. The State and NHHK will emphasize and re-emphasize cost-sharing rules and regulations in its provider education and communications. Out of pocket expenses that exceed the 5% cap will be reimbursed to the family after review of all cost sharing documentation for the family, NHHKC and medical/dental plans. At the end of the first 12 months of eligibility, eligibility will be re-determined; the 5% cap will be recalculated for the family and the monitoring cycle will begin anew.

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)

Cost sharing protection is in place to ensure enrollment of American Indians

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

Effective Date: May 1998

Approval Date: September 1998 41 and Alaska Natives, as defined in 457.10. The following documents will be revised to disclose that members of federally recognized Indian Tribes and Alaska Natives are eligible for free coverage under Title XXI although the children may qualify for premium-based coverage:

1. The Children’s Health Insurance Program Guide to Benefits – this is the primary information booklet that describes the programs and how to apply. 2. Silver Eligibility Letter – Families who have applied for coverage through the local DHHS District Office and are referred to NHHKC for enrollment. 3. Silver Enrollment Letter – Families who have applied through the mail-in unit at NHHKC and have been deemed eligible for the premium-based Healthy Kids Silver program.

In order to process the free coverage enrollment, members of tribes will be asked to inform NHHKC of their tribe status by phone or mail. The contract between NHHKC and the State of New Hampshire will be amended to provide full reimbursement of the premium and co-payments for members of tribes to NHHKC (effective August 24, 2001).

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))

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, co-payments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

There are no premiums, co-payments, coinsurance, or deductibles for Healthy Kids Gold.

There are no coinsurance or deductible fees for Healthy Kids Silver. However, there are co-payments and premiums. Providers are responsible for collecting the co-payments at the time of service. Premiums for Healthy Kids Silver are collected by NHHKC under contract with the Department of Health and Human Services as a third party administrator for Healthy Kids Silver.

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

Effective Date: May 1998

Approval Date: September 1998 42 In accordance with federal regulations, if payment has not been collected, eligibility may be terminated after sixty (60) days due to the non-payment of premiums. (As noted in section 3.1, pregnant teens do not have their eligibility terminated for failure to pay premiums until after the postpartum period.)

Families have until the last day of the current month to pay the next month’s premium. The state has established a process that give enrollees 60 days notice from the beginning of a new coverage period before the coverage may be terminated for non-payment. During this grace period, they have an opportunity to pay past due premiums but child or children will still receive coverage. At a minimum, 3 points of contact are made to the family. The process is as follows:

• NHHKC will send a notice when a premium payment is 15 days past due. • When the account is then 25 to 30 past due, a call is made to the enrollee. • A ”two months due” (cancellation pending) letter is sent to the family not later than 7 days after the first day of the second month of missed payments, generally on the 2nd or 3rd of month. • The family will receive a final phone call on the 8th of the second month of missed payment when the account is 38 -40 days past due. They will have until the 45th day to pay premium. On the 46th day, if payment still has not been made they are sent notice of termination which will be effective the beginning of the next month. In the letter the family will be advised of their right to challenge the proposed termination pursuant to the applicable Federal regulations.

If the family has been terminated for non-payment of premiums, they are “locked out” of the program for 3 months by the state’s New HEIGHTS eligibility system.

NHHKC supports a premium rescue fund through which Deleted: reasonable Deleted: if Deleted: After a second payment has been missed, a Deleted: letter of “ intent to terminate” Formatted Formatted Deleted: . Formatted Deleted: termination Deleted: Termination for non-payment is effective the beginning of the next month. The child or children will still receive health insurance coverage during the 2 months that payment is past due. ¶

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

Effective Date: May 1998

Approval Date: September 1998 43 charitable dollars are used to help families overcome a temporary loss of income or unexpected financial crisis.

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

As noted in section 4.3, enrollees are required to notify NHHKC or DHHS of any change in circumstance that could affect continued eligibility for coverage. If enrollee notifies NHHKC prior to disenrollment for non-payment of premiums and the child is no longer eligible for Healthy Kids Silver, he/she will be disenrolled. If he/she is eligible for Medicaid, he/she will be enrolled in Healthy Kids Gold (Medicaid) .The family also has the opportunity to show that their income has declined enough to make them eligible for the lower premium category of Healthy Kids Silver, which will then facilitate the enrollment into that premium level.

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))

As noted in section 4.3, enrollees are required to notify NHHKC or DHHS of any change in circumstance that could affect continued eligibility for coverage. If enrollee notifies NHHKC prior to disenrollment for non-payment of premium, and the child is no longer eligible for Healthy Kids Silver, he/she will be disenrolled. If he/she is eligible for Medicaid, he/she will be enrolled in Healthy Kids Gold (Medicaid). There is no cost-sharing for Healthy Kids Gold. The family also has the opportunity to show that their income has declined enough to make them eligible for the lower premium category of Healthy Kids Silver, which will then facilitate the enrollment into that premium level.

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

Individuals have a right to request an Administrative Appeals Hearing if they are not satisfied with any decision made by the Department of Health and Human Services or NHHKC. Hearings can be requested verbally or in writing by contacting a DHHS district office, NHHKC or the Office of Administrative Appeals. This information is on the Healthy Kids application.

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

Effective Date: May 1998

Approval Date: September 1998 44 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)) (42CFR 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 the 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)

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

Effective Date: May 1998

Approval Date: September 1998 45 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))

Reduce the number of uninsured children in NH.Improve SCHIP and Medicaid enrollment efficiencies.Reduce inappropriate utilization of emergency room care.

Increase SCHIP enrolled children’s utilization of preventive care.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

1) Reduce the number of uninsured children. • Decrease the number of NH children who are uninsured. • Increase the number of SCHIP and Medicaid children ever enrolled in NH Healthy Kids programs. 2) Improve SCHIP and Medicaid Enrollment efficiencies . • Increase the percentage of Healthy Kids applications that are submitted as complete by the Community Application Assistors.

3) Reduce inappropriate utilization of emergency room care. • Decrease emergency department use by SCHIP children for selected conditions. 4) Increase utilization of preventive care.

Increase the percentage of adolescents (12-18 years) enrolled in SCHIP who have a well child visit.

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))

1) Reducing the number of uninsured children in NH will be addressed through two separate goals. Performance related to the first goal, to decrease the number of NH children who are uninsured, will be measurd through NH’s Behavioral Risk Factor Surveillance System. The biennial survey results will be analyzed every other year for an estimate of uninsured children.

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

Effective Date: May 1998

Approval Date: September 1998 46 Performance related to the second goal, to increase the number of SCHIP and Medicaid children ever enrolled in NH Healthy Kids Programs, will be measured through SCHIP and Medicaid enrollment data, as reported annually in Statistical Enrollment Data Report (SEDS).

2) Improving Medicaid enrollment efficiencies will be addressed by a goal to increase the percentage of Healthy Kids applications that are submitted as complete by the Community Application Assistors. Performance will be measured through an annual report of complete and incomplete applications, generated by the SCHIP administrator, NH Healthy Kids Corporation, who oversee the Application Assistor program.

3) Reducing inappropriate utilization of emergency department care will be addressed by a goal to decrease emergency department .use by SCHIP children for selected conditions. Goal performance will be measured by SCHIP claims data that is collected through the State’s Comprehensive Health Information System and analyzed within studies sponsored by DHHS.4) Increasing utlilization of preventive care will be addressed by the goal to increase the percentage of adolescents (12-18 years) enrolled in SCHIP who have had a well child visit. Goal performance will be measured by claims data that is collected through the State’s Comprehensive Health Information System and analyzed within studies sponsored by DHHS..

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

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

Effective Date: May 1998

Approval Date: September 1998 47 9.3.7.6. Dental care 9.3.7.7. Other, please list:

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) DHHS 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.

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) DHHS will perform the annual assessments and evaluations required under sections 10.1 and 10.2. The annual report will assess the operation of the Title XXI plan, including the progress made in reducing the number of uninsured children.

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) DHHS assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit.

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 457.710(e)) DHHS assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed.

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

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

Effective Date: May 1998

Approval Date: September 1998 48 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(a) and (b))

A multidisciplinary group comprised of Department staff and representatives from the Governor’s Office and NHHKC worked to develop and review the initial conceptual model. The Department met with the NHHKC Board of Directors on March 2, 1998, to review the proposed model and to solicit input into the plan. The Board membership includes representatives from the Department of Education, Department of Insurance, State Legislators, New Hampshire School Boards Association, New Hampshire Pediatric Society, New Hampshire School Nurses Association, New Hampshire Children’s Alliance, New Hampshire Child Care Association, and the New Hampshire Hospital Association. Follow up meetings were held with the Board of Directors. The Department also met with representatives from Blue Cross Blue Shield of New Hampshire.

A series of public meetings were also held throughout the state. Each session included an overview of the Title XXI legislation and application requirements; a review of proposed conceptual plan; and a review of the proposed benefits package. In addition to providing time for commentary on the plan, time was spent on developing a long-term plan to ensure on-going public involvement. From each session a list of questions and answers as well as comments was generated and documented. Department staff followed up unanswered questions.

The public meetings included:

March 12, 1998

The Commissioner’s Managed Care Advisory Group and NH

Child Action Team March 18, 1998

Community Mental Health Centers Executive Directors March 19, 1998

The Consumer Policy Advisory Board March 24, 1998

A formal Public Hearing was held on the NH SCHIP Plan March 27, 1998

The Welfare Reform Advisory Group April 1, 1998 The Medicaid Medical Care Advisory Committee April 10, 1998

Child Health Coordinators of the Title V-funded

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

Effective Date: May 1998

Approval Date: September 1998 49 Well Child

Clinics and Primary Care agencies April 14, 1998

Headstart Health and Nutrition Coordinators April 14, 1998

RWJF Outreach Grant Participants April 15, 1998

Health Planning District Council Meeting in Manchester April 16, 1998

Health Planning District Council Meeting in Plymouth April 20, 1998

A formal Public Hearing on rule changes for the NH SCHIP Plan May 11, 1998

NH DHHS Primary Care Steering Committee May 15, 1998

Commissioner’s Child Care Advisory Committee May 21,1 998

NH Welfare Directors/NH Municipal Association

In addition to the public meetings noted above, the state created a site on the DHHS web page. The web site included information on the proposed plan and as each section of this application was drafted, it was added to the web page. A copy of the final working draft of the application was made directly available to a variety of advocacy groups and community leaders.

DHHS continues to include the public in ongoing efforts involving SCHIP. These efforts include: • The SCHIP workgroup that originally met to assist the Department in working through a variety of operational issues such as eligibility, enrollment, benefits, cost-sharing and outreach continues to meet to provide input and public process to program changes.

• DHHS hosted a SCHIP Summit with DHHS and community partners in November 2000, to discuss the progress of the SCHIP program and to identify issues and barriers to enrollment and retention. From the summit, 6 workgroup were formed; presumptive eligibility, good cause waivers, application, documentation, continuous eligibility, and letters and notices. Workgroups generated recommendations for policy and practice that would enhance enrollment and retention of eligible children in the Healthy Kids programs.

• Four regional meetings were held in the fall of 2001 to review workgroup recommendation and further solicit input from both internal and external stakeholders in Healthy Kids programs. These stakeholders included providers (hospitals, CHCs and private offices), past and current families enrolled in Healthy Kids, human service agencies as well as outreach and advocacy

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

Effective Date: May 1998

Approval Date: September 1998 50 groups.

• A public hearing was held on October 26th, 2001 by the Department on "Proposed Changes to State's Children's Health Insurance Program State Plan", in order to receive written and oral comments These changes included reduced verification, improving the presumptive eligibility process, a further simplified Healthy Kids application, and additional good cause waivers of prior insurance. The changes requiring a state plan amendment to CMS are included in this plan. DHHS amended its administrative rules to reflect these changes.

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))

There are no organized tribes or tribal organizations in New Hampshire, however public process for amendments relating to 42 CFR 457.125 included four regional meetings to solicit input from both internal and external stakeholders in the Healthy Kids program. These stakeholders included providers (hospitals, CHCs and private offices), past and current families enrolled in Healthy Kids, human service agencies as well as outreach and advocacy groups. A public hearing was held on October 26th, 2001 by the Department on "Proposed Changes to State's Children's Health Insurance Program State Plan" in order to receive written and oral comments. 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 as required in 42 CFR 457.65(b) through (d).

Public process for amendments made in 2002 relating to eligibility or benefits included four regional meetings to solicit input from both internal and external stakeholders in the Healthy Kids program. These stakeholders included providers (hospitals, CHCs and private offices), past and current families enrolled in Healthy Kids, human service agencies as well as outreach and advocacy groups.

In addition to the efforts noted above, all amendments that require changes to the New Hampshire Administrative Rules (He-W 910) were completed in accordance with the requirements of NH RSA 541-A. This process requires a public notification of any changes to the rules

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

Effective Date: May 1998

Approval Date: September 1998 51 (typically by publishing a notice in the Rulemaking Register) and that a public hearing and a written comment period be provided. For changes to the administrative rules, effective April 1, 2002 and as reflected in the 2002 State Plan Amendment, the Department held a public hearing on October 26th, 2001. Written comments were accepted until November 26, 2001. Changes to the administrative rules effective January 1, 2005 and as reflected in the 2005 State Plan Amendment, the Department held a public hearing on October 15, 2004 and written comments were accepted until October 25, 2004.

A public notice about premium increases, as reflected in the 2009 State Plan Amendment, was published in the statewide Manchester Union Leader on Thursday, July 9, 2009.

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.

The State’s contracted SCHIP administrator, New Hampshire Healthy Kids Corporation (NHHK), conducts a procurement process and contracts with the medical and dental providers for CHIP benefits. NHHK pays a per member per month fee directly to the contracted medical and dental managed care entities. NHHK negotiates these contracted fees with State input. The dental and medical monthly pmpm rate paid to providers by NHHK is the same for each member and is independent of family cost share.

As part of its contracted services for the State, NHHK also calculates and collects family pmpm premiums and manages the 5% cap requirement relative to family cost sharing. NHHK invoices the State monthly for a reimbursement of pmpm fee paid to medical and dental contractor. The invoice amount includes a monthly administrative fee plus the balance of insurance payments paid once NHHK has debited the family premiums paid directly to them. As such, the family premium payments are not included in the Budget presented below. During FFY 09, NHHK collected and retained Formatted Formatted Formatted Formatted

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

Effective Date: May 1998

Approval Date: September 1998 52 $2,767,143.00 in family premiums (again, as an offset to the medical and dental fees they pay monthly to managed care entities.)

There are two levels of per child per month premiums paid by families depending on income level. The premium is capped for families who have multiple children enrolled.

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

Effective Date: May 1998

Approval Date: September 1998 53

CHIP Budget Template

New Hampshire

FFY Budget FFY Budget Variation between FFY 2009 and FFY 2010 Budget Federal Fiscal Year

FFY 2009 FFY 2010

State's enhanced FMAP rate

65.00% 65.00%

-

Benefit Costs

Insurance payments

$ 15,015,587 $19,327,000 $ 4,311,413 Managed care

$ - per member/per month rate

Fee for Service

$ 2,202.810 $ 3,096,000 $ 893,190 Total Benefit Costs

$ 17,218,397 $22,423,000 $ 5,204,603 (Offsetting beneficiary cost sharing payments) $ - $ - $ - Net Benefit Costs

$ 17,218,397 $22,423,000 $ 5,204,603

Administration Costs

Personnel

$ 295,320 $ 326,350 $ 31,030 General administration

$ 136,344 $ 150,670 $ 14,326 Contractors/Brokers

$ - $ - $ - Claims Processing

$ - $ - $ - Outreach/marketing costs

$ 120,336 $ 132,980 $ 12,644 Other

$ - $ - $ - Total Administration Costs

$ 552,000 $ 610,000 $ 58,000 10% Administrative Cap

$ 1,714,778 $ 2,491,444 $ 776,667

Federal Share

$ 11,550,758 $14,971,450 $ 3,420,692 State Share

$ 6,219,639 $ 8,061,550 $ 1,841,911 TOTAL COSTS OF APPROVED CHIP PLAN $ 17,770,397 $23,033,000 $ 5,262,603

Beneficiary cost-sharing payments have been accounted for and Net Benefit costs are net of the cost-sharing.

Fee for Service Increase in FFY 2010 represents CHIPRA allowable qualifying State claim for 100% of enhanced match for children in NH Expanded Medicaid group, 0-1 years at 133%-185% FPL

The Source of State Share Funds: State General Funds.

Deleted: ¶ Page Break New Hampshire ...

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

Effective Date: May 1998

Approval Date: September 1998 54 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: May 1998

Approval Date: September 1998 55 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) 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: Phase 1: May 1998, Phase 2: Jan. 1999 Approval Date: September 1998

56 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.

As noted in section 8.7.1, individuals have a right to request an Administrative Appeals Hearing if they are not satisfied with any decision made by the Department of Health and Human Services or NHHKC. Hearings can be requested verbally or in writing by contacting a local district office, NHHKC or the Office of Administrative Appeals. This information is on the Healthy Kids application, and complies in the same manner as the Medicaid program.

Health Services Matters 12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120.

If the child is enrolled in Healthy Kids Gold, the process to review health services matter is through the state’s Medicaid fair hearing process.

Individuals have the right to appeal any decision made that the health insurer makes about coverage, benefits, or failure to provide coverage or benefits through the managed care internal appeal process. In addition to the internal appeal procedure, individuals have the right to an external review process to appeal decisions regarding denial, delay, reduction, suspension or termination of health care services and the failure to provide payment for health services in a timely manner through an Administrative Appeals Hearing. If an individual is not satisfied with any decision made by the health insurer, hearings can be requested verbally or in writing by contacting the Department of Health and Human Services, a local district office, the health insurer, NHHKC, or the Office of Administrative Appeals. This information is on the Healthy Kids application, and complies in the same manner as the Medicaid program.

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

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

Effective Date: Phase 1: May 1998, Phase 2: Jan. 1999 Approval Date: September 1998

57 coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility. N/A

New Hampshire State Children’s Health Insurance Program State Plan Final SPA #4 Submitted January 27, 2005

Approved April 21, 2005

Effective Date: May 1998

Approval Date: September 1998 1

OMB #: 0938-0707 Exp. 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.

New Hampshire State Children’s Health Insurance Program State Plan Final SPA #4 Submitted January 27, 2005

Approved April 21, 2005

Effective Date: May 1998

Approval Date: September 1998 2 Form CMS-R-211

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:______New Hampshire_____________ (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 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: Ann Walls Position/Title: SCHIP Manager, NH DHHS-Office of Medicaid Business and Policy Name: Kathleen Dunn Position/Title: Director, NH DHHS-Office of Medicaid Business and Policy Name: Marilee Nihan Position/Title: Financial Manager, NH DHHS-Office of Medicaid Business and Policy

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. Deleted: Valerie King Deleted: Coordinator Deleted: Health Planning and Deleted: Stephen Norton Deleted: Health Planning and Deleted: Health Planning and

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

Effective Date: May 1998

Approval Date: September 1998 3 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.

New Hampshire’s expansion of children’s health care coverage under Title XXI occurred in two phases, which involved providing expanded benefits under the State’s Medicaid plan and obtaining coverage that meets the requirements for a State Children’s Health Insurance Program.

In Phase 1, implemented May 1998, the state expanded Medicaid to include newborns and infants from birth to age 1 with family income greater than 185% and equal to or less than 300% of FPL. Income is calculated in the same manner currently used by the state for poverty level children (children with family income at or below 185% of FPL) with an additional disregard of 65% of the FPL for the family size involved as revised annually in the Federal Register. In no case will income be disregarded such that the resulting net income is less than or equal to 185% FPL. The federal eligibility standard is 235% FPL.

In Phase II, implemented in January 1999, the New Hampshire Department of Health and Human Services (DHHS) partnered with the New Hampshire Healthy Kids Corporation (NHHKC) to provide insurance coverage through the development of a State Children’s Health Insurance Program (SCHIP) for children ages 1 through 18 with family income greater than 185% and equal to or less than 300% of FPL. Income is calculated in the same manner currently used by the state for poverty level children (children with family income at or below 185% of FPL) with an additional disregard of 65% of the FPL for the family size involved as revised annually in the Federal Register. In no case will income be disregarded such that the resulting net income is less than or equal to 185% FPL.

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

Effective Date: May 1998

Approval Date: September 1998 4 The federal eligibility standard is 235% FPL.

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))

No expenditures were claimed prior to the time the state had the legislative authority to operate the State plan or plan amendment as approved by CMS.

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)

New Hampshire’s SCHIP complies with all applicable civil rights requirements, including the above-mentioned sites.

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):

State Plan (Phase 1 - Title XIX expansion): Effective/Implementation Date: May 1, 1999

Amendment #1 (Phase 2 - Title XXI): Effective/Implementation Date: January 1, 1999

Amendment #2 (adding “good-cause” exceptions): Effective/Implementation Date: April 1, 2002

Amendment #3 (increasing premiums): Effective/Implementation Date: January 1, 2003

Amendment #4 (adding a tiered drug formulary): Effective/Implementation Date: January 1, 2005

Amendment #5 (increasing premiums) Effective: October 1, 2009

(change in healthcare MCO) Implementation: July 1, 2009

(enrollment cap authority): Effective: July 1, 2009 (CHIPRA citizenship documentation): Implementation: January 1, 2010

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

Effective Date: May 1998

Approval Date: September 1998 5

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))

See electronically attached Health Resources and Services Administration New Hampshire State Planning Grant Interim Report, March 2002.

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):

Brochures outlining options for health care coverage, including Medicaid eligibility as well as Medicaid application forms (New Hampshire has a short application form commonly referred to as the 800-P for poverty level children's groups and pregnant women) are available at a variety of community agencies and provider sites such as hospitals, WIC sites, and public health clinics and community health centers funded through Title V and Title X grants. These same agencies are part of an on-going effort by the state to identify Medicaid eligible children and provide support to eligible families who up until now have not availed themselves of Medicaid benefits but would be eligible if they applied.

Formal Medicaid application and intake sites include the twelve local New Hampshire DHHS district offices strategically located around the state. In addition, the Medicaid 800-P short forms can be completed and

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

Effective Date: May 1998

Approval Date: September 1998 6 submitted via the Title V agencies, Title X clinics, WIC sites, disproportionate share hospitals, Early Intervention sites and Federally Qualified Health Centers (FQHC's).

The state also maintains a toll free phone number and client service units in both the Medicaid Administration Services and the Division of Family Assistance (DFA) to provide prompt answers to questions regarding eligibility and services. At this time there is no other public health or state only insurance program for children.

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:

The only health insurance program for children that involves a public private-partnership is New Hampshire Healthy Kids Corporation (NHHKC). In 1993, the New Hampshire Legislature passed the Healthy Kids Act (RSA 126: H) to address the growing problem of uninsured children. The Act created the New Hampshire Healthy Kids Corporation, a private non-profit, "deemed to be a public instrumentality and ... by the authority of the powers conferred by this chapter shall be deemed and held to be the performance of public and essential government functions of the state.”

The state does not subsidize premiums at this time, but it provides funds for administration, marketing and outreach. NHHKC is governed by a seventeen member Board of Directors that includes six appointees of state government including the Department of Health and Human Services. State oversight includes a requirement for an annual report to the Governor, various Commissioners, and members of the Legislature.

The state created NHHKC to provide affordable health coverage and access to health care services for uninsured children. The program design and operations are consistent with the goals of Title XXI. As a public-private partnership, the goal has been to conduct multifaceted outreach and marketing, simplify the enrollment process, and design and operate a program that would avoid the stigma often

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

Effective Date: May 1998

Approval Date: September 1998 7 associated with Medicaid.

NHHKC’s plan provides comprehensive health and dental benefits, which emphasize the preventive and primary care that children need to stay healthy and go to school ready to learn. Currently coverage is underwritten by Harvard Pilgrim Healthcare for health benefits and mental health benefits, and Northeast Delta Dental for dental benefits. Selection of the insurance carrier was conducted through a formal RFP process and contracts are renegotiated biennially.

To be eligible for SCHIP component of Healthy Kids, a child must be a full time resident of the state, not eligible for Medicaid, not enrolled in employment-related group health insurance in the past six months, and their family income cannot exceed 300% of the federal poverty level.

Efforts to identify and enroll children in NHHKC have been extensive. The Corporation has developed outreach partnerships with schools, childcare agencies, health care providers, municipalities and community-based social service agencies. Award-winning printed materials include postcards, posters, annual reports, brochures and flyers, which are widely distributed and displayed throughout the state. The Corporation conducts an aggressive media campaign, which has resulted in frequent coverage in newspapers, on radio and television; speaking engagements on public affairs programs, and public service announcements. The Corporation teams with businesses for promotion activities such as fast food tray liners and promotion cards stuffed in bags at retail outlets such as grocery stores, pharmacies and discount department stores.

Schools provide the largest source of referral (about 40%) where twice each year the school age population is blanketed with promotion information and school nurses display information and make direct referrals. Twenty percent of inquiries cite media as their source of information about the program. As the program becomes more well known, provider and word-of-mouth referrals are becoming more frequent. The Corporation tracks response to its various marketing and outreach activities for informed decision making about the most effective methods and Deleted: Anthem Blue Cross Blue Shield of New Hampshire Deleted: annually Deleted: 400%

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

Effective Date: May 1998

Approval Date: September 1998 8 messages. At the present time NHHKC estimates that it has reached over 12,000 families in New Hampshire.

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 state coordinates SCHIP enrollment and outreach efforts with other public and private health insurance programs and child health agencies in order to increase the number of children with creditable health coverage. This coordination reduces duplication of efforts and provides quality health care coverage to New Hampshire’s uninsured children.

As demonstrated in section 4.4, the state closely coordinates SCHIP enrollment efforts with the state’s Medicaid program. The state’s Division of Family Assistance (DFA) utilizes a software program called New HEIGHTS in the district offices. The program utilizes a cascading logic that allows staff in the district offices to screen for eligibility for various Medicaid coverage groups as well as other public assistance programs. With the advent of Title XXI, efforts were taken to incorporate the logic required to automate the screening and eligibility referrals of Healthy Kids Silver to NHHKC. Referrals are also automated to NHHKC for families whose income exceeds 300% FPL and do not qualify for services funded by Title XIX or XXI, but may qualify for the unsubsidized Healthy Kids Silver Buy-In program.

As part of their contract with the state, Title V agencies must screen all children they see at their agencies for health insurance. If that child is uninsured, agency staff is required to assist families in applying for the program. As part of their health performance measurements, Title V agencies are also expected to document clients who are enrolled in the Healthy Kids program. The Department’s SCHIP coordinator also meets with Maternal and Child Health coordinators on a regular basis to discuss problems and coordinate efforts.

In addition, at the time of implementation of SCHIP, plans were made to provide for the screening, referral and tracking of children

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

Effective Date: May 1998

Approval Date: September 1998 9 with special health needs. A question on the Healthy Kids application (800P) asks, “ Are there any children with special heath care needs who require ongoing supports to maintain their care at home?”. If the applicant checks off yes, that person’s name and information is sent to Family Voices, a family to family health information and resource project, who will assist that family with the coordination of other private and state resources for children with special heath care needs such as the Special Medical Services Bureau, a Title V funded program.

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

Effective Date: May 1998

Approval Date: September 1998 10

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))

As noted in Section 1.1.3 and described in the state's Medicaid state plan amendment, Phase 1 of the NH’s State Children’s Health Insurance Program consists of the state using Title XXI funds to expand Medicaid coverage for newborns and infants from birth to age 1 with family income greater than 185% and equal to or less than 300% of FPL. To complement Phase 1, the state instituted a name change to all children's Medicaid programs to Healthy Kids Gold in an effort to reduce barriers due to stigma associated with Medicaid enrollment. The Medicaid expansion program is also called Healthy Kids Gold and infants on this program receive Medicaid benefits until they turn 1.

Utilizing the provisions of Title XXI the state offers retroactive coverage, for infants at greater than 185% FPL and equal to or less than 300% FPL. Consistent with the current Medicaid fee-for- service program, the state will provide 3 months of retroactive coverage for services received in the 3 months prior to application date for Healthy Kids as long as the services received are within the scope of benefits and as long as the infant met the eligibility requirements during those 3 months.

Through Phase 2 of NH’s SCHIP plan, the state provides insurance coverage to children between ages 1 and 19 whose family income is greater than 185% and equal to or less than 300% of FPL. The state purchases insurance for these children through NHHKC. To be consistent with Phase I, this program is called Healthy Kids Silver.

NHHKC subcontracts with Harvard Pilgrim Healthcare of New Hampshire and Northeast Delta Dental. The coverage offered is a Deleted: Anthem Blue Cross Blue Shield

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

Effective Date: May 1998

Approval Date: September 1998 11 managed care product with a focus on preventive and well-child care. NHHKC selected Harvard Pilgrim Healthcare and Northeast Delta Dental via a competitive bid process. Contracts have been renegotiated biennially. The state will requires a competitive bid process until such time as their enrollment reaches a sufficient capacity to support a competitive bid process.

The Healthy Kids Silver benefits package includes an emphasis on perinatal care coverage for pregnant adolescent girls not previously served by NHHKC.

Mental health benefits are accessed through a phone call to Harvard Pilgrim Healthcare’s Behavioral Health Access Center.. Prior PCP authorization is not necessary to access the mental health or dental benefits.

At the time of enrollment for Healthy Kids Silver, a family chooses a primary care provider (PCP) from the Harvard Pilgrim network. If a PCP is not chosen, the family is assisted by either Harvard Pilgrim Healthcare’s customer service staff or NHHKC to select one.. The family also needs to submit the first month's premium, which is collected by NHHKC on behalf of the state.

Utilizing the provisions under Title XXI the state has implemented cost sharing provisions Healthy Kids Silver. Families whose income is greater than 185% and equal to or less than 250% of FPL pay a $32 per child per month premium, and there is a $128 cap on monthly premiums for these families with multiple children. Families whose income is greater than 250% and equal to or less than 300% of FPL pay a $54 per child per month premium, and there is a $162 cap on monthly premiums for these families with multiple children. NHHKC has made the premium payment process as user friendly as possible including mailing labels, change of address forms, use of coupon books. NHHKC implemented voluntary participation in electronic funds transfer (EFT) for premium payment in Fall 2002.

Defaulting on the payment of premiums result in the termination of eligibility after 60 days except for pregnant teens. NHHKC reports to the state children whose eligibility is terminated and the circumstances of the termination. NHHKC and the state can waive premium payment for hardship/good cause as described in section 8.7. NHHKC supports a premium rescue fund through which Deleted: Anthem Blue Cross Blue Shield Deleted: annually until November 2001 when the contracts were negotiated for 18 months Deleted: not require another Deleted: The state bears full risk for the maternity benefit and carries out a cost settlement after the adolescent has reached sixty (60) days postpartum. Deleted: the Blue Cross Blue Shield Behavioral Health Network Deleted: Blue Cross Blue Shield provider Deleted: contacted by NHHKC Deleted: and assisted with the selection process. Deleted: 25 Deleted: 100 Deleted: 45 Deleted: 135

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

Effective Date: May 1998

Approval Date: September 1998 12 charitable dollars are used to help families overcome a temporary loss of income or unexpected financial crisis.

Pregnant teens do not have their eligibility terminated for failure to pay premiums until after the postpartum period. The default clock begins on the sixty-first (61st) day postpartum. Terminating health care coverage mid-pregnancy is counterproductive to the state's goal of healthy birth outcomes for mother and infant.

In addition to the monthly premium for Healthy Kids Silver, the following co-payments are also required: $10 for office visits (excluding well-child or preventative health visits and any covered dental services), $5 for covered formulary generic prescriptive drugs, $15 for covered formulary brand name drugs when no generic equivalent is available or the provider indicates that it is medically necessary, $25 for covered non-formulary brand name drugs when no generic equivalent is available or the provider indicates that it is medically necessary, and a $50 fee for emergency room visits, unless the patient is admitted to the hospital. Providers will be responsible for collecting the co-pays at the time of service.

In compliance with Section 2103 of the Social Security Act, as amended by Section 403 of the Children’s Health Insurance Reauthorization Act of 2009 (CHIPRA), families enrolled in SCHIP who are dissatisfied with the CHIP managed care plan may, at disenrollment, opt in to Fee for Service coverage.

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 state bears the responsibility for utilization control for the Healthy Kids Gold fee for service program.

The primary utilization control for Healthy Kids Silver is the responsibility of the managed care organization, Harvard Pilgrim Healthcare. The contract with Harvard Pilgrim includes a definition of medical necessity and utilization management requirements, including clinical staffing requirements. The plan Deleted: The state includes in its contract with NHHKC, provisions for quality assurance, and data and reporting requirements as outlined in the section 7.0 and 9.0 of this application.¶ Deleted: Anthem Blue Cross Blue Shield of New Hampshire Deleted: Anthem

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

Effective Date: May 1998

Approval Date: September 1998 13 is required to have written utilization management policies and procedures that include appropriateness criteria for authorization and denial of services and protocols for prior approval, hospital discharge planning, and retrospective review.

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

Effective Date: May 1998

Approval Date: September 1998 14 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)) (42CFR 457.305(a) and 457.320(a))

4.1.1. Geographic area served by the Plan: Statewide 4.1.2.

Age: For Phase I, Healthy Kids Gold -Medicaid expansion: Infants up to age 1. For Phase II, Healthy Kids Silver: Children between age 1 through age 18. 4.1.3. Income: Family income must be greater than 185% and equal to or less than 300% of the FPL. (Income is calculated in the same manner as currently used by the state for poverty level children - children with family income at or below 185% of FPL-with an additional disregard of 65% of the federal poverty level for the family size involved as revised annually in the Federal Register. In no case will income be disregarded such that the resulting net income is less than or equal to 185% FPL. The federal eligibility standard is 235% FPL.) Methods for evaluating income include paycheck stubs, W-2s, income tax returns and letters from employers on company letterhead. 4.1.4. Resources (including any standards relating to spend downs and disposition of resources): There is no resource or assets test. 4.1.5.

Residency (so long as residency requirement is not based on length of time in state) : To be eligible a child must be a resident of the State of New Hampshire. There is no time requirement to be considered a resident. 4.1.6. Disability Status (so long as any standard relating to disability status does not restrict eligibility): 4.1.7.

Access to or coverage under other health coverage: Children who are covered under a group health plan or other health insurance coverage, or are children of a public employee eligible for coverage under a state health benefits plan are not eligible for the Healthy Kids Silver. An application for Healthy

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

Effective Date: May 1998

Approval Date: September 1998 15 Kids Silver will be disapproved if it is determined that the child was covered under a health insurance plan within the last six months. However, an application may be approved for good cause. Such reasons include: loss of employment, change of employment to an employer who does not provide dependent coverage, death of the employed parent, discontinuation of coverage to all employees (regardless of income) by the employer, insurer closes its operation in New Hampshire, an involuntary reduction in work hours that no longer allows the employee to enroll the employees dependent children under the employer’s health plan, voluntary loss of employment and the loss occurred for any of the good cause reasons specified in New Hampshire Code of Administrative Rules He-W 910.09( c) (2)a-g, cases of domestic violence, a temporary insurance policy is ending, COBRA coverage if good cause existed when employer coverage was lost, loss of coverage beyond the control of custodial parent when non-custodial parent drops insurance, and loss of coverage when parent leaves work to be the primary caretaker for his/her children ages 5 and under (effective April 1, 2002).

4.1.8.

Duration of eligibility: In general, a child who has been determined eligible for Healthy Kids Gold or Silver shall remain eligible unless the child attains the upper age limit, as appropriate, is no longer a resident of the state, or fails to pay premiums (for Healthy Kids Silver). Exceptions to this policy are previously noted.

The state may determine that an enrollee is not eligible if eligibility was a result of making a false statement, misrepresentation or concealment of or failure to disclose income or health insurance coverage. The state may recover payments made by the state on behalf of enrollees as a result of any false statement, misrepresentation, etc. regarding income or health insurance coverage. Eligibility is re-determined not more than 12 months after the effective date of eligibility and annually thereafter. 4.1.9.

Other standards (identify and describe): The state asks for verification of citizenship and identity.Applicants are asked for child’s social security number on the Healthy Kids application. The social security number is required for cross-match with Social Security Administration for citizenship verification.

4.2. The state assures that it has made the following findings with respect to the Deleted: a Deleted: Healthy Kids Gold Deleted: .

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

Effective Date: May 1998

Approval Date: September 1998 16 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 lower family income. (Exception to this is during enrollment cap periods. See Section 4.3.1 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)) (42CFR 457.350) With the implementation of SCHIP, the state created a single application, the 800P, for both Healthy Kids Silver and Healthy Kids Gold programs. Families can apply for the Healthy Kids program by visiting their local DHHS District Office, or by mailing the application directly to the mail- in enrollment center located at NHHKC.

By Federal regulation, only state employees are permitted to make eligibility determinations. DFA case technicians at the local district office and at NHHKC are responsible for screening all applications and verifying income, age, and other eligibility requirements. Information collected on the application form, include name, address, date of birth, social security number, residency, citizenship, family income, employment, and insurance (both current and in the previous six months).

If information is incomplete or questionable, the state will attempt to contact the applicant by phone to obtain missing information or to clarify questionable information within 10 business days of receipt of the application. If the family does not have access to a phone and/or if the state is not able to make contact by phone, the state will attempt to contact the family by mail. If no response is obtained within 10 days of sending a letter, the application will be denied.

The state will test for Medicaid eligibility first before determining eligibility for Healthy Kids Silver. If a child meets Medicaid eligibility, he/she will be enrolled in Healthy Kids Gold (Medicaid). If a child is not eligible for Medicaid but meets eligibility requirements for Healthy Kids Silver (including income, residence, and insurance requirements), he/she will be enrolled in Title XXI via NHHKC. The exception to this is during enrollment cap periods. See Section 4.3.1. If a child is not eligible for either program but may be eligible for the non-subsidized Healthy Kids Silver Buy-In program, a referral is made to NHHKC.

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

Effective Date: May 1998

Approval Date: September 1998 17

Eligibility information for children determined eligible for Healthy Kids Silver will be entered into New HEIGHTS and sent to NHHKC. NHHKC will complete enrollment, including sending a letter notifying the family of the child’s eligibility (including the effective date), materials about NHHKC and the health plan and a coupon payment book for premiums. Eligibility will be effective the date a child is enrolled in a plan and payment received. This will generally be the first day of the month after the child was determined eligible but may be later if eligibility is determined within one week of the end of the month, if the premium is not received or if the family takes additional time to select a plan (if and when there is a choice of plans) or primary care provider. Exception to this is during enrollment cap periods. See Section 4.3.1.

Enrollees are required to notify NHHKC or DHHS of any change in household (i.e. changed address or number of individuals in household) or income within 10 days of change.

Not more than 12 months after the effective date of eligibility and annually thereafter, the state will re-determine eligibility for Healthy Kids Silver and Healthy Kids Gold. The state will mail a form to enrollees to obtain information necessary to review eligibility. Enrollees will be required to notify NHHKC or DHHS of any change in circumstance that could affect continued eligibility for coverage. If a child is no longer eligible for Healthy Kids Silver, he/she will be disenrolled. If he/she is eligible for Medicaid, he/she will be enrolled in Healthy Kids Gold. If a child is no longer eligible for Healthy Kids Gold, he/she will be disenrolled. If that child is eligible for Silver, NHHKC will receive an electronic referral and the above-mentioned process will occur to enroll the family in Healthy Kids Silver.

The state also facilitates the enrollment of uninsured children through its presumptive eligibility program for Healthy Kids Gold. Presumptive eligibility has been enhanced so that presumptive eligibility and community facilitated applications, processed by qualified entities that are authorized and trained by the DHHS, will be centralized at the mail-in enrollment center at NHHKC.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

Check here if this section does not apply to your state.

NH currently has no waiting list. Enrollment may be limited in the future if state general fund appropriation is insufficient. The need to implement an enrollment cap is assessed as follows: DHHS monitors current or “actual” Deleted: Deleted: state.

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

Effective Date: May 1998

Approval Date: September 1998 18 CHIP monthly enrollment. If actual enrollment grows to within range of a predetermined member month number, (as representing enrollment that couldn't be supported financially by State funds if it were to continue to grow at that sustained annual growth rate), that member month number would be considered a “trigger” for capping enrollment. Financial calculation of the predetermined trigger point is a product of the number currently enrolled and the state share cost of the per member per month premium fee. Should NH reach the trigger point the following procedures will be put in to place: The enrollment is “capped” meaning that no additional children may enroll. A wait list accepts children determined to be eligible and they queue up on the list, first come, first served. Since NH has a joint application for Medicaid and SCHIP, the application and eligibility determination process continue during the SCHIP enrollment cap and wait list period. Families determined to be eligible for Medicaid are enrolled and those determined to be eligible for SCHIP are informed of the enrollment cap and their children placed on the wait list. While on the SCHIP wait list, families must continue to report changes that effect eligibility such as income or household composition. If eligibility redetermination of a family on the SCHIP wait list results in eligibility for Medicaid, the children are enrolled in Medicaid and taken off the wait list. Enrollment is tracked monthly. Potential enrollment spaces become available at the end of each month when enrollment ends for currently enrolled children who disenrolled because they: 1. Have turned 19; 2. Become eligible for Medicaid coverage; 3. Move out of state; 4. Failed to pay monthly premium; 5. Failed to complete redetermination process; 6. Obtained other insurance; 7. Were determined ineligible during redetermination process; 8. Moved within the state with no forwarding address; 9. Voluntarily disenrolled with no stated reason; 10. Died.

When enrollment “slots” become available, a specified number of children (equal to number of slots available) at the top of the wait list are contacted, and their families informed that they may enroll. Children are removed from the wait list and families are provided 30 days to enroll.

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 redetermination, that

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

Effective Date: May 1998

Approval Date: September 1998 19 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 assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3))

As noted in section 4.3, the state determines eligibility for both Healthy Kids Silver and Healthy Kids Gold. As part of the determination for Healthy Kids Silver, the state verifies that an applicant is not a Medicaid beneficiary through New HEIGHTS, the states eligibility system. If the child is not a Medicaid beneficiary, the state will (based on the information collected as part of the application process) determine whether he/she may be eligible for Medicaid (e.g., because of income level). If the child is already enrolled in Medicaid, the application for Healthy Kids Silver will be denied. If the child appears likely to be eligible for Medicaid, the state will determine eligibility and assist in the enrollment of the child into Healthy Kids Gold (Medicaid).

The application includes questions about insurance coverage. If a child has insurance coverage, he/she will not be eligible to receive coverage under Healthy Kids Silver. Also, if a child has had insurance coverage in the past six months and does not meet one of the good cause exemptions (as noted in section 4.1.7), he/she will not be eligible to receive coverage via Healthy Kids Silver. Children who were enrolled in NHHKC prior to the state’s Title XXI program and who met the remaining eligibility guidelines were grandfathered into Healthy Kids Silver.

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)) (42CFR 457.350(a)(2))

The same state unit determines eligibility for both Healthy Kids Silver and Healthy Kids Gold (Medicaid), which maximizes the coordination of eligibility for both programs. The state will first determine whether or not a child is eligible for Healthy Kids Gold. If the child is eligible, he/she will be enrolled. Only if he/she is not eligible for Healthy Kids Gold will he/she be screened and enrolled in Healthy Kids Silver via NHHKC.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of

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

Effective Date: May 1998

Approval Date: September 1998 20 children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

The same state unit determines eligibility for both Healthy Kids Silver and Healthy Kids Gold (Medicaid), which maximizes the coordination of eligibility for both programs. The state will first determine whether or not a child is eligible for Healthy Kids Gold. If the child is eligible, he/she will be enrolled. Only if he/she is not eligible for Healthy Kids Gold will he/she be screened and enrolled in Healthy Kids Silver via NHHKC. 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)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

The application process involves collecting information about current coverage and coverage in the past six months. Children currently covered will not be eligible for Healthy Kids Silver coverage. The state will review applications to determine whether applicants or employers of applicants have discontinued private or employer-sponsored dependent coverage in order to participate in the program. Children who had employer-sponsored coverage within the previous six months who lost coverage for reasons related to the availability of Healthy Kids Silver (e.g., no longer purchasing family coverage) will not be eligible. As noted in section 4.1.7, an application may be approved for good cause. Such reasons include: loss of employment, change of employment to an employer who does not provide dependent coverage, death of the employed parent, discontinuation of coverage to all employees (regardless of income) by the employer, insurer closes its operation in New Hampshire, an involuntary reduction in work hours that no longer allows the employee to enroll the employees dependent children under the employer’s health plan, voluntary quit of employment and the quit occurred for any of the good cause reasons specified in New Hampshire Code of Administrative Rules He-W 910.09( c) (2)a-g, cases of domestic violence, a temporary insurance policy is ending, COBRA coverage if good cause existed when employer coverage was lost, loss of coverage beyond the control of custodial parent when non- custodial parent drops insurance, and loss of coverage when parent leaves work to be the primary caretaker for his/her children ages 5 and under (effective April 1, 2002).

4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution. Deleted: ¶ Formatted

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

Effective Date: May 1998

Approval Date: September 1998 21 Children, ages 0-19, in families with income at 0- 185% FPL, or newborns and infants ages 0-1 with income at greater than 185% to 300% of FPL are covered under Healthy Kids Gold (Medicaid) and can have other insurance. Children ages 0-19, in families with income at 185%-300% FPL are on Healthy Kids Silver and can not have other health insurance. Therefore, the methods of monitoring substitution stated in section 4.4.4 apply. 4.4.4.2. Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable. The methods of monitoring substitution stated in section 4.4.4 apply for these families. 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. The methods of monitoring substitution stated in section 4.4.4 apply for these families. 4.4.4.4. If the state provides coverage under a premium assistance program, describe:

N/A

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

N/A

The minimum employer contribution. N/A

The cost-effectiveness determination.

N/A 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))

Cost sharing protection is in place to ensure enrollment of American Indians and Alaska Natives, as defined in 457.10. The following documents will be revised to disclose that members of federally

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

Effective Date: May 1998

Approval Date: September 1998 22 recognized Indian Tribes and Alaska Natives are eligible for free coverage under Title XXI although the children may qualify for premium-based coverage: 1. The Children’s Health Insurance Program Guide to Benefits – this is the primary information booklet that describes the programs and how to apply. 2. Silver Eligibility Letter – Families who have applied for coverage through the DHHS District Office and are referred to NHHKC for enrollment. 3. Silver Enrollment Letter – Families who have applied through the mail-in unit at NHHKC and have been deemed eligible for the premium-based Healthy Kids (Title XXI) program.

In order to process the free coverage enrollment, members of tribes will be asked to inform NHHKC of their tribe status by phone or mail. The contract between NHHKC and the State of New Hampshire will be amended to provide full reimbursement of the premium and co- payments for members of tribes to NHHKC (effective August 24, 2001).

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

Effective Date: May 1998

Approval Date: September 1998 23 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)

Along with contracting with NHHKC to administer the Title XXI program, the state also contracts with NHHKC to market and perform outreach services for the state’s Medicaid and SCHIP programs. An initial outreach plan was developed in partnership with NHHKC and other community health partners, to ensure that New Hampshire families are aware of the child health insurance coverage options available under Title XXI as well as under Title XIX. This plan was designed using the successful practices of NHHKC and capitalizes on the collaborative relationships already developed with schools and child care centers as well as expanding the existing network of social service agencies and advocacy groups beyond those that had traditionally worked with the state and NHHKC.

Outreach materials include a variety of brochures, posters, flyers, and enrollment package materials. Information covers the benefits offered, eligibility requirements, and how and where to apply. NHHKC employs field coordinators in different areas of the state who maintain relationships with community partners and provide outreach support through training and promotional materials. The focus of this strategy is to work with organizations that directly serve families and children.

Outreach campaigns are conducted periodically to focus on boosting enrollment in specific target groups, such as developing materials to focus on infants. The outreach takes advantage of seasonal and geographic differences and events, such as the start of the school year. Historically, the most effective method of reaching families have been to distribute information through the schools.

Other elements of the outreach plan include: • Biannual blanket distribution of promotional postcards to all public and religious schools in the state; • Distributing information through, child care centers, Head Start centers, WIC sites, community agencies and health care providers; • Providing displays for these sites and appropriate commercial establishments;

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

Effective Date: May 1998

Approval Date: September 1998 24 • Use of retail bag stuffers; • Using public speaking engagements, talk shows, public affairs programs, news releases, press conferences, and radio and TV PSAs as appropriate; • Informing partners and consumers about the availability of “NH Easy” an online application system that DHHS has developed for a more convenient access to Healthy Kids and other family assistance programs. Conducting direct mail campaigns to demographically selected lists that match profiles of uninsured families, building on the current Healthy Kids mailing lists of previous inquiries as well as other providers lists; • Initial and refresher training of staff at all applications sites that provide one-on-one assistance on such topics as how to effectively deal with inquiries and potential members to maximize the contact as an enrollment opportunity; accuracy and completeness of the application; and referrals to other services; and, • Developing an evaluation methodology based upon the concepts of continuous quality improvement to ensure the efficient and effective use of outreach resources.

Effectiveness of outreach campaigns are tracked by referral sources on all families that inquire and apply. These statistics are compiled and analyzed through database queries. In addition, questions regarding outreach methods and messages are included in periodic surveys of enrollees, disenrollees and prospective enrollees. Over one-third of families indicate they learned about the program through their child’s school.

Central to the state’s goal of maximizing the enrollment of uninsured children are efforts to support speedy application and enrollment. Activities include: • Providing a toll-free telephone line to directly request brochures or other information packages and applications or to request assistance with completing an application; • Developing one application for both Healthy Kids Silver and Healthy Kids Gold; • Implementing a centralized mail-in enrollment center where applications can be mailed; • Increasing the availability of on-site application assistance at community based organizations utilizing staff trained in the eligibility requirements of the various public health and state benefit programs.

Special outreach efforts to minority and rural populations will be conducted Deleted: Creating a special web site, Wired Wizard, with links to both Healthy Kids Corporation’s website and the DHHS websites and where applications can be downloaded; Formatted: Bullets and Numbering Formatted: Bullets and Numbering

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

Effective Date: May 1998

Approval Date: September 1998 25 through the upcoming Robert Wood Johnson Covering Kids and Families Grant, which will allow the state to pilot outreach, simplification and coordination of children’s health care coverage programs in 2 local pilots locations, Manchester and the rural North.

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

Effective Date: May 1998

Approval Date: September 1998 26 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. 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 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. 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 existing Deleted: .

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

Effective Date: May 1998

Approval Date: September 1998 27 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)) In a short-term /general hospital, skilled nursing facility or physical rehabilitation facility. 6.2.2. Outpatient services (Section 2110(a)(2)) Facility charges and medical services, such as operating room, hospital, pharmacy and supplies, physician visits, laboratory and x-rays and surgery. 6.2.3.

Physician services (Section 2110(a)(3)) Including primary care providers such as Advanced Registered Nurse Practitioners and Physician Assistants. 6.2.4. Surgical services (Section 2110(a)(4)) 6.2.5. Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6. Prescription drugs (Section 2110(a)(6)) Including all FDA approved oral contraceptives and Depo- Provera. 6.2.7.

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

Laboratory and radiological services (Section 2110(a)(8)) 6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) 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)) Maximum of 15 days per year. 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)

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

Effective Date: May 1998

Approval Date: September 1998 28 Maximum of 20 visits per year. 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)) Eyeglasses, hearing aids, prosthetic devices and other DME as determined to be medically necessary and consistent with diagnosis. 6.2.13. Disposable medical supplies (Section 2110(a)(13)) Disposable medical supplies as medically necessary and consistent with diagnosis, are covered. 6.2.14. Home and community-based health care services (See instructions) (Section 2110(a)(14)) 20 home health visits a year. 6.2.15. Nursing care services (See instructions) (Section 2110(a)(15)) 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) 6.2.17. Dental services (Section 2110(a)(17)) Diagnostic and preventive services including sealants, fillings, and simple extractions are covered 100% up to a maximum $600 per child per year (effective January 1, 2001). No orthodontics are covered. 6.2.18. Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) Inpatient detoxification for medically necessary stays. No limit on the number of times a member may be admitted for inpatient detoxification. 6.2.19. Outpatient substance abuse treatment services (Section 2110(a)(19)) Outpatient substance abuse visits wrapped into the 20 outpatient mental health benefit. Therefore a member will have a total of 20 outpatient visits for mental health and substance abuse counseling. Not 20 visits for each. 6.2.20. Case management services (Section 2110(a)(20)) 6.2.21. Care coordination services (Section 2110(a)(21)) To be provided as part of the role of the Primary Care Provider. 6.2.22. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders. (Section 2110(a)(22)) 24 visits for speech therapy; 24 visits for occupational therapy or 24 visits for physical therapy or a combination of occupational

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

Effective Date: May 1998

Approval Date: September 1998 29 and physical therapies for each medical episode. 6.2.23. Hospice care (Section 2110(a)(23)) 6.2.24. Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) Chiropractic services, allergy testing and treatment, cardiac rehabilitation services, infusion therapy, vision and hearing services, preventive health services such as diabetes management program, routine hearing exams, laboratory and x- ray tests, medical exams and childhood immunization for well children, prenatal care and vision care and early intervention services up to age 3, ($3,200 annual, 9,600 lifetime maximum) are also covered (effective January 1, 2001). 6.2.25. Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26. Medical transportation (Section 2110(a)(26)) Emergency transportation by ambulance. 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 and rehabilitation facility services as deemed medically necessary and pre-authorized by the health 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) (2) and(3)) (42 CFR 457.1005 and 457.1010)

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

Effective Date: May 1998

Approval Date: September 1998 30

N/A

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))

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

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

Effective Date: May 1998

Approval Date: September 1998 31 457.1010)

N/A

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: May 1998

Approval Date: September 1998 32 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(a))

NHHKC and their insurance subcontractor are required to meet all standards for quality of care in the contract in order to contract with the state. The state reviewed and approved the subcontract agreement between NHHKC and the health plan prior to the enrollment of children into Healthy Kids Silver.

DHHS will continuously monitor quality through various mechanisms, including: health plan contracting standards, reporting requirements, enrollee input, external reviews, and on-site reviews. The state will strive to establish a continuum across the Title XIX and Title XXI programs for quality e.g. contracting with the same External Quality Review Organization (EQRO), establishing priority areas for review and utilizing consistent measurement methodologies. The state will bear final responsibility for the quality improvement activities outlined in this application however, the quality improvement plan will be based upon a partnership with NHHKC and their contracted insurerAs a monitoring tool for children’s healthcare, DHHS utilizes data from NH Comprehensive Health Care Information System (NH CHIS), which includes a commercial health care claims database, to compare Medicaid, SCHIP and commercially available insurance enrollment, access, service utilization, payments and other variables.

The Phase 1 Healthy Kids Gold (Medicaid) program will be monitored via the established quality improvement program in the Medicaid Administration Services. The established QIP includes the monitoring of quality and appropriateness of care and highlights well-baby and well childcare. It is based upon this pre-existing program that the Phase 2 quality improvement program will be designed.

For Phase 2, the contract with NHHKC will include specific standards for quality of care, including the provision of well-baby care, well-child care, and immunizations that will be carried out by the health plan as their subcontractor. The health plan will be required to arrange for immunizations, physical examinations, health education, dental examinations/treatments and Deleted: Once the state has signed a contract with NHHKC, it Deleted: .

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

Effective Date: May 1998

Approval Date: September 1998 33 comprehensive screens (and any needed interperiodic screens) in accordance with the schedules recommended by the most current Recommended Childhood Immunization Schedule, United States and the American Academy of Pediatrics. The health plan will be required to have enrollees up to date on screening and immunizations within 3 months of being enrolled.

Reporting will include a report on the plan’s quality improvement plan (QIP), HEDIS reports on immunizations and well child care, and other pediatric preventive health measures as part of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program, utilization reports, and periodic provider network reports. The state will require the subcontracted health plan to submit encounter data. The state recognizes that this information is crucial to the on-going monitoring and evaluation of the Healthy Kids program and will strive to develop a system that will receive, process and permit for detailed analysis, the scope of services provided to Healthy Kids enrollees. The state will work with NHHKC and the plan to develop the data elements, medium, format and time frames for submissions.

Other utilization information that involve health plan interventions and enrollee participation in activities such as complaints/grievance resolution, case coordination services, health risk screenings, disease management and health promotion programs will be reported and tracked.

NHHKC will be responsible for conducting enrollee satisfaction surveys. NHHKC may delegate this function to the health plan. However, the state will review and approve the survey tool for specific questions from the CAHPS instrument, sampling methodology, research design and final results. The state is also developing a provider satisfaction survey.

The functions of the external quality review organization are described in section 7.1.1. In addition, the state will conduct periodic focus groups as part of its on-going community involvement process and maintains the option of conducting annual on-site evaluations at the health plan to assess compliance with contract requirements (such as utilization management decisions), and to establish, with the health plan, quality improvement projects and performance goals.

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)

7.1.1.

Quality standards The state will contract for an external quality review of the health

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

Effective Date: May 1998

Approval Date: September 1998 34 plan. Such review shall include, but not be limited to, an evaluation of access to care, quality of care studies, medical record standards, and individual case review and appropriateness of care. All activities carried out by the EQRO will be prior approved by the state in order to assure appropriate monitoring and to assure consistency in quality improvement activities across programs. 7.1.2.

Performance measurement DHHS annually reviews and reports on a variety of health care measures to compare children enrolled in New Hampshire Medicaid, in NH SCHIP and in commercial health insurance plans in NH. This allows ongoing monitoring of healthcare for children, aged 0-18, covered in these programs and to study enrollment and disenrollment, access to primary care providers, well-child visits, effectiveness of care management, and utilization and payments. State data is also compared to HEDIS quality and access to compare measures and reported accordingly.

7.1.3.

Information strategies

The state, NHHKC, and the health plan will be required to educate enrollees about their benefits under Healthy Kids Silver and Healthy Kids Gold as well as their rights and responsibilities. The plan will also educate enrollees about the importance of preventive services, health promotion activities, care coordination services, disease management programs, and visiting their primary care provider instead of an emergency room.

7.1.4. Quality improvement strategies

The contract with NHHKC will include specific standards for quality of care including access to care and appointment availability, and the health plan will have to meet those standards in order to contract with NHHKC and the state. These standards will be monitored by the state and NHHKC through reporting requirements, on-site reviews, external reviews and enrollee input through complaint data and satisfaction surveys.

In particular, the plan will be required to establish an internal quality improvement plan (QIP), which will be in writing and available to the public. The written description shall include

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

Effective Date: May 1998

Approval Date: September 1998 35 detailed goals and annually developed objectives; address the quality of clinical care and non-clinical aspects of services for the range of care provided by the plan; specify quality of care studies and related activities; provide for continuous performance of activities, including tracking of issues over time; and provide for review and feedback by physicians and other health professionals. By the end of the first contract year, the plan will be required to initiate two (2) clinical focused projects aimed at improving care for enrollees. Clinical focus areas applicable to this target population include topics related to: lead toxicity screening and treatment, • chronic pediatric asthma, • attention deficit disorder, • adolescent counseling on smoking and substance abuse, • well-child care, • behavioral health screening and treatment and • perinatal services.

The state, NHHKC and the health plan will work collaboratively to select the clinical areas to be studied and define the improvement strategy.

An annual report on the QIP will be required. This report will be made in the form of a presentation to the state and its community advisors. In addition, the report will be made available as a formal written report that will be made available to the public as hard copy and on the DHHS website.

For Healthy Kids Silver enrollees that become pregnant while eligible, comprehensive perinatal services shall be available and accessed through the contracted health plan. The plan’s purchasing specifications must describe and demonstrate a comprehensive, proactive perinatal program with adherence to care guidelines as recommended by the American College of Obstetrics and Gynecology. HEDIS perinatal and birth outcome indicators will be utilized to measure and assess performance. Depending upon the results and trends, the health plan’s QIP shall be expected to develop further interventions and strategies to increase participation and positive outcomes.

7.2 Describe the methods used, including monitoring, to assure: (2102(a) (7) (B)) (42CFR 457.495)

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

Effective Date: May 1998

Approval Date: September 1998 36 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 state requires the Healthy Kids Silver health plan to provide access to preventive care such as, well-child care, well-adolescent care and childhood and adolescent immunizations. No office visit co-payments are required for routine childhood examinations and immunizations The state requires the health plan to include sufficient numbers of appropriately trained and certified staff to provide this access to care. The state and NHHKC monitor access requirements through reporting and member satisfaction surveys. Infants covered under Title XXI receive well-baby care under Healthy Kids Gold as part of the Medicaid expansion. The state monitors access issues for Healthy Kids Gold.

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 state requires the health plan to include sufficient numbers of appropriately trained and certified clinicians of pediatric care, including primary, medical subspecialty and surgical specialty physicians, as well as providers of necessary related services such as, dental and mental health services. The state monitors network capacity through quarterly provider network reports and will suspend enrollment if capacity is exceeded.

The health plan is required to ensure that their provider networks provide access to primary care providers (PCPs) within 20 miles/45 minutes and access to emergency services on a 24-hour, seven-day-a- week basis. Emergency care shall be provided immediately, urgent care within 24 hours, non-urgent, symptomatic PCP appointments shall be available within 48 hours from the enrollee’s request to be seen and non-symptomatic, routine/preventive care within 30 calendar days. An emergency medical condition will be defined as a condition such that a prudent lay person, acting reasonably, would have believed that emergency medical treatment is needed. The state and NHHKC monitor access requirements through reporting and member satisfaction surveys.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the

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

Effective Date: May 1998

Approval Date: September 1998 37 network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

The health plan is required to treat enrollees with chronic, or serious medical conditions, and provide access and adequate number of visits to specialists experienced in treating the specific medical condition. Enrollees will have access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. The state and NHHKC will monitor access requirements through reporting and member satisfaction surveys.

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))

Most health services do not require prior authorization unless a referral is made to an out of network provider. Decisions related to prior authorization of health services are in accordance with the New Hampshire Department of Insurance’s regulations.

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

Effective Date: May 1998

Approval Date: September 1998 38 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 to 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:

There are no premiums for Healthy Kids Gold. Under Healthy Kids Silver, families whose income are greater than 185% and equal to or less than 250% of FPL pay a $32 per child per month premium, and there is a $128 cap on monthly premiums for these families with multiple children. Families whose income is greater than 250% and equal to or less than 300% of FPL pay a $54 per child per month premium, and there is a $162 cap on monthly premiums for these families with multiple children.

8.2.2. Deductibles:

There are no deductibles for Healthy Kids Gold or Healthy Kids Silver.

8.2.3. Coinsurance or co-payments:

There is no coinsurance for Healthy Kids Gold or Silver. There are no co-payments for Healthy Kids Gold.

For Healthy Kids Silver, there is a $10 co-pay for provider office visits, and a prescription drug co-payment of $5 for covered generic prescription drugs, $15 for covered formulary brand name drugs when no generic equivalent is available or the provider indicates that it is medically necessary, and $25 for covered non-formulary brand name Deleted: 25 Deleted: 100 Deleted: 45 Deleted: 135

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

Effective Date: May 1998

Approval Date: September 1998 39 drugs when no generic equivalent is available or the provider indicates that it is medically necessary. There is also a $50 co-payment for emergency care, unless the patient is admitted to the hospital. There are no co-payments for preventive health and/or well child visits, dental check-ups, dental x-rays, cleanings and fluoride treatments.

8.2.4 Other:

8.3. Describe how the public will be notified, including the public schedule, of this 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))

Both the state and NHHKC provide information on the cost sharing requirements to enrollees as well as to the provider community. Information about premiums and co-pays are included in all outreach/education material including brochures, flyers, posters, the Children’s Health Insurance Guide to Benefits and on the website. It is also included in the enrollment materials that the family receives. Families that have enrolled are sent enrollment forms that give them the amount of what that 5% cap out of pocket expense will be.

Changes in premiums are subject to Legislative approval of State rule changes. Such rule changes require public notification and a public hearing.

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)

The state plan follows this requirement. 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)

The state plan follows this requirement.

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))

The state plan follows this requirement.

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

Effective Date: May 1998

Approval Date: September 1998 40 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))

The State contracts with NHHK to provide for the administration of the cost- sharing provisions of the Title XXI plan. As part of its role, NHHK educates families about the cost sharing rules and requirements including premiums and co-payments. The education includes; how much money 5% of the family’s income, translated into terms of dollars and cents, what period of time the monitoring period covers, and that the responsibility for monitoring out of pocket expenses will be shared by the family and NHHK. The education will instruct families in tracking their out of pocket expenses on a monthly basis (the emphasis will be on tracking and documenting medical/dental office and pharmacy co-payments) and to contact NHHK immediately (via mail or the statewide toll free number) should their out of pocket expenses equal or exceed the previously determined amount of money or if the family income should suddenly decrease. NHHK also monitors medical and dental co- payments on a quarterly basis via a cost sharing report generated by health and dental plans. Premium cost-sharing is monitored directly by NHHK via their accounting system.

Families who exceed the 5% cap will be formally notified by NHHK in writing and all cost sharing will cease for the remainder of the current 12 month eligibility period. The letter will include the specific date that the cost-sharing exemption expires (it coincides with the eligibility re-determination date). The family utilizes the NHHK formal notification as proof of exemption from cost- sharing, to be presented to providers as needed. The State and NHHK will emphasize and re-emphasize cost-sharing rules and regulations in its provider education and communications. Out of pocket expenses that exceed the 5% cap will be reimbursed to the family after review of all cost sharing documentation for the family, NHHKC and medical/dental plans. At the end of the first 12 months of eligibility, eligibility will be re-determined; the 5% cap will be recalculated for the family and the monitoring cycle will begin anew.

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)

Cost sharing protection is in place to ensure enrollment of American Indians

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

Effective Date: May 1998

Approval Date: September 1998 41 and Alaska Natives, as defined in 457.10. The following documents will be revised to disclose that members of federally recognized Indian Tribes and Alaska Natives are eligible for free coverage under Title XXI although the children may qualify for premium-based coverage:

1. The Children’s Health Insurance Program Guide to Benefits – this is the primary information booklet that describes the programs and how to apply. 2. Silver Eligibility Letter – Families who have applied for coverage through the local DHHS District Office and are referred to NHHKC for enrollment. 3. Silver Enrollment Letter – Families who have applied through the mail-in unit at NHHKC and have been deemed eligible for the premium-based Healthy Kids Silver program.

In order to process the free coverage enrollment, members of tribes will be asked to inform NHHKC of their tribe status by phone or mail. The contract between NHHKC and the State of New Hampshire will be amended to provide full reimbursement of the premium and co-payments for members of tribes to NHHKC (effective August 24, 2001).

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))

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, co-payments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

There are no premiums, co-payments, coinsurance, or deductibles for Healthy Kids Gold.

There are no coinsurance or deductible fees for Healthy Kids Silver. However, there are co-payments and premiums. Providers are responsible for collecting the co-payments at the time of service. Premiums for Healthy Kids Silver are collected by NHHKC under contract with the Department of Health and Human Services as a third party administrator for Healthy Kids Silver.

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

Effective Date: May 1998

Approval Date: September 1998 42 In accordance with federal regulations, if payment has not been collected, eligibility may be terminated after sixty (60) days due to the non-payment of premiums. (As noted in section 3.1, pregnant teens do not have their eligibility terminated for failure to pay premiums until after the postpartum period.)

Families have until the last day of the current month to pay the next month’s premium. The state has established a process that give enrollees 60 days notice from the beginning of a new coverage period before the coverage may be terminated for non-payment. During this grace period, they have an opportunity to pay past due premiums but child or children will still receive coverage. At a minimum, 3 points of contact are made to the family. The process is as follows:

• NHHKC will send a notice when a premium payment is 15 days past due. • When the account is then 25 to 30 past due, a call is made to the enrollee. • A ”two months due” (cancellation pending) letter is sent to the family not later than 7 days after the first day of the second month of missed payments, generally on the 2nd or 3rd of month. • The family will receive a final phone call on the 8th of the second month of missed payment when the account is 38 -40 days past due. They will have until the 45th day to pay premium. On the 46th day, if payment still has not been made they are sent notice of termination which will be effective the beginning of the next month. In the letter the family will be advised of their right to challenge the proposed termination pursuant to the applicable Federal regulations.

If the family has been terminated for non-payment of premiums, they are “locked out” of the program for 3 months by the state’s New HEIGHTS eligibility system.

NHHKC supports a premium rescue fund through which Deleted: reasonable Deleted: if Deleted: After a second payment has been missed, a Deleted: letter of “ intent to terminate” Formatted Formatted Deleted: . Formatted Deleted: termination Deleted: Termination for non-payment is effective the beginning of the next month. The child or children will still receive health insurance coverage during the 2 months that payment is past due. ¶

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

Effective Date: May 1998

Approval Date: September 1998 43 charitable dollars are used to help families overcome a temporary loss of income or unexpected financial crisis.

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

As noted in section 4.3, enrollees are required to notify NHHKC or DHHS of any change in circumstance that could affect continued eligibility for coverage. If enrollee notifies NHHKC prior to disenrollment for non-payment of premiums and the child is no longer eligible for Healthy Kids Silver, he/she will be disenrolled. If he/she is eligible for Medicaid, he/she will be enrolled in Healthy Kids Gold (Medicaid) .The family also has the opportunity to show that their income has declined enough to make them eligible for the lower premium category of Healthy Kids Silver, which will then facilitate the enrollment into that premium level.

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))

As noted in section 4.3, enrollees are required to notify NHHKC or DHHS of any change in circumstance that could affect continued eligibility for coverage. If enrollee notifies NHHKC prior to disenrollment for non-payment of premium, and the child is no longer eligible for Healthy Kids Silver, he/she will be disenrolled. If he/she is eligible for Medicaid, he/she will be enrolled in Healthy Kids Gold (Medicaid). There is no cost-sharing for Healthy Kids Gold. The family also has the opportunity to show that their income has declined enough to make them eligible for the lower premium category of Healthy Kids Silver, which will then facilitate the enrollment into that premium level.

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

Individuals have a right to request an Administrative Appeals Hearing if they are not satisfied with any decision made by the Department of Health and Human Services or NHHKC. Hearings can be requested verbally or in writing by contacting a DHHS district office, NHHKC or the Office of Administrative Appeals. This information is on the Healthy Kids application.

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

Effective Date: May 1998

Approval Date: September 1998 44 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)) (42CFR 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 the 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)

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

Effective Date: May 1998

Approval Date: September 1998 45 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))

Reduce the number of uninsured children in NH.Improve SCHIP and Medicaid enrollment efficiencies.Reduce inappropriate utilization of emergency room care.

Increase SCHIP enrolled children’s utilization of preventive care.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

1) Reduce the number of uninsured children. • Decrease the number of NH children who are uninsured. • Increase the number of SCHIP and Medicaid children ever enrolled in NH Healthy Kids programs. 2) Improve SCHIP and Medicaid Enrollment efficiencies . • Increase the percentage of Healthy Kids applications that are submitted as complete by the Community Application Assistors.

3) Reduce inappropriate utilization of emergency room care. • Decrease emergency department use by SCHIP children for selected conditions. 4) Increase utilization of preventive care.

Increase the percentage of adolescents (12-18 years) enrolled in SCHIP who have a well child visit.

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))

1) Reducing the number of uninsured children in NH will be addressed through two separate goals. Performance related to the first goal, to decrease the number of NH children who are uninsured, will be measurd through NH’s Behavioral Risk Factor Surveillance System. The biennial survey results will be analyzed every other year for an estimate of uninsured children.

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

Effective Date: May 1998

Approval Date: September 1998 46 Performance related to the second goal, to increase the number of SCHIP and Medicaid children ever enrolled in NH Healthy Kids Programs, will be measured through SCHIP and Medicaid enrollment data, as reported annually in Statistical Enrollment Data Report (SEDS).

2) Improving Medicaid enrollment efficiencies will be addressed by a goal to increase the percentage of Healthy Kids applications that are submitted as complete by the Community Application Assistors. Performance will be measured through an annual report of complete and incomplete applications, generated by the SCHIP administrator, NH Healthy Kids Corporation, who oversee the Application Assistor program.

3) Reducing inappropriate utilization of emergency department care will be addressed by a goal to decrease emergency department .use by SCHIP children for selected conditions. Goal performance will be measured by SCHIP claims data that is collected through the State’s Comprehensive Health Information System and analyzed within studies sponsored by DHHS.4) Increasing utlilization of preventive care will be addressed by the goal to increase the percentage of adolescents (12-18 years) enrolled in SCHIP who have had a well child visit. Goal performance will be measured by claims data that is collected through the State’s Comprehensive Health Information System and analyzed within studies sponsored by DHHS..

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

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

Effective Date: May 1998

Approval Date: September 1998 47 9.3.7.6. Dental care 9.3.7.7. Other, please list:

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) DHHS 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.

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) DHHS will perform the annual assessments and evaluations required under sections 10.1 and 10.2. The annual report will assess the operation of the Title XXI plan, including the progress made in reducing the number of uninsured children.

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) DHHS assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit.

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 457.710(e)) DHHS assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed.

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

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

Effective Date: May 1998

Approval Date: September 1998 48 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(a) and (b))

A multidisciplinary group comprised of Department staff and representatives from the Governor’s Office and NHHKC worked to develop and review the initial conceptual model. The Department met with the NHHKC Board of Directors on March 2, 1998, to review the proposed model and to solicit input into the plan. The Board membership includes representatives from the Department of Education, Department of Insurance, State Legislators, New Hampshire School Boards Association, New Hampshire Pediatric Society, New Hampshire School Nurses Association, New Hampshire Children’s Alliance, New Hampshire Child Care Association, and the New Hampshire Hospital Association. Follow up meetings were held with the Board of Directors. The Department also met with representatives from Blue Cross Blue Shield of New Hampshire.

A series of public meetings were also held throughout the state. Each session included an overview of the Title XXI legislation and application requirements; a review of proposed conceptual plan; and a review of the proposed benefits package. In addition to providing time for commentary on the plan, time was spent on developing a long-term plan to ensure on-going public involvement. From each session a list of questions and answers as well as comments was generated and documented. Department staff followed up unanswered questions.

The public meetings included:

March 12, 1998

The Commissioner’s Managed Care Advisory Group and NH

Child Action Team March 18, 1998

Community Mental Health Centers Executive Directors March 19, 1998

The Consumer Policy Advisory Board March 24, 1998

A formal Public Hearing was held on the NH SCHIP Plan March 27, 1998

The Welfare Reform Advisory Group April 1, 1998 The Medicaid Medical Care Advisory Committee April 10, 1998

Child Health Coordinators of the Title V-funded

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

Effective Date: May 1998

Approval Date: September 1998 49 Well Child

Clinics and Primary Care agencies April 14, 1998

Headstart Health and Nutrition Coordinators April 14, 1998

RWJF Outreach Grant Participants April 15, 1998

Health Planning District Council Meeting in Manchester April 16, 1998

Health Planning District Council Meeting in Plymouth April 20, 1998

A formal Public Hearing on rule changes for the NH SCHIP Plan May 11, 1998

NH DHHS Primary Care Steering Committee May 15, 1998

Commissioner’s Child Care Advisory Committee May 21,1 998

NH Welfare Directors/NH Municipal Association

In addition to the public meetings noted above, the state created a site on the DHHS web page. The web site included information on the proposed plan and as each section of this application was drafted, it was added to the web page. A copy of the final working draft of the application was made directly available to a variety of advocacy groups and community leaders.

DHHS continues to include the public in ongoing efforts involving SCHIP. These efforts include: • The SCHIP workgroup that originally met to assist the Department in working through a variety of operational issues such as eligibility, enrollment, benefits, cost-sharing and outreach continues to meet to provide input and public process to program changes.

• DHHS hosted a SCHIP Summit with DHHS and community partners in November 2000, to discuss the progress of the SCHIP program and to identify issues and barriers to enrollment and retention. From the summit, 6 workgroup were formed; presumptive eligibility, good cause waivers, application, documentation, continuous eligibility, and letters and notices. Workgroups generated recommendations for policy and practice that would enhance enrollment and retention of eligible children in the Healthy Kids programs.

• Four regional meetings were held in the fall of 2001 to review workgroup recommendation and further solicit input from both internal and external stakeholders in Healthy Kids programs. These stakeholders included providers (hospitals, CHCs and private offices), past and current families enrolled in Healthy Kids, human service agencies as well as outreach and advocacy

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

Effective Date: May 1998

Approval Date: September 1998 50 groups.

• A public hearing was held on October 26th, 2001 by the Department on "Proposed Changes to State's Children's Health Insurance Program State Plan", in order to receive written and oral comments These changes included reduced verification, improving the presumptive eligibility process, a further simplified Healthy Kids application, and additional good cause waivers of prior insurance. The changes requiring a state plan amendment to CMS are included in this plan. DHHS amended its administrative rules to reflect these changes.

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))

There are no organized tribes or tribal organizations in New Hampshire, however public process for amendments relating to 42 CFR 457.125 included four regional meetings to solicit input from both internal and external stakeholders in the Healthy Kids program. These stakeholders included providers (hospitals, CHCs and private offices), past and current families enrolled in Healthy Kids, human service agencies as well as outreach and advocacy groups. A public hearing was held on October 26th, 2001 by the Department on "Proposed Changes to State's Children's Health Insurance Program State Plan" in order to receive written and oral comments. 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 as required in 42 CFR 457.65(b) through (d).

Public process for amendments made in 2002 relating to eligibility or benefits included four regional meetings to solicit input from both internal and external stakeholders in the Healthy Kids program. These stakeholders included providers (hospitals, CHCs and private offices), past and current families enrolled in Healthy Kids, human service agencies as well as outreach and advocacy groups.

In addition to the efforts noted above, all amendments that require changes to the New Hampshire Administrative Rules (He-W 910) were completed in accordance with the requirements of NH RSA 541-A. This process requires a public notification of any changes to the rules

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

Effective Date: May 1998

Approval Date: September 1998 51 (typically by publishing a notice in the Rulemaking Register) and that a public hearing and a written comment period be provided. For changes to the administrative rules, effective April 1, 2002 and as reflected in the 2002 State Plan Amendment, the Department held a public hearing on October 26th, 2001. Written comments were accepted until November 26, 2001. Changes to the administrative rules effective January 1, 2005 and as reflected in the 2005 State Plan Amendment, the Department held a public hearing on October 15, 2004 and written comments were accepted until October 25, 2004.

A public notice about premium increases, as reflected in the 2009 State Plan Amendment, was published in the statewide Manchester Union Leader on Thursday, July 9, 2009.

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.

The State’s contracted SCHIP administrator, New Hampshire Healthy Kids Corporation (NHHK), conducts a procurement process and contracts with the medical and dental providers for CHIP benefits. NHHK pays a per member per month fee directly to the contracted medical and dental managed care entities. NHHK negotiates these contracted fees with State input. The dental and medical monthly pmpm rate paid to providers by NHHK is the same for each member and is independent of family cost share.

As part of its contracted services for the State, NHHK also calculates and collects family pmpm premiums and manages the 5% cap requirement relative to family cost sharing. NHHK invoices the State monthly for a reimbursement of pmpm fee paid to medical and dental contractor. The invoice amount includes a monthly administrative fee plus the balance of insurance payments paid once NHHK has debited the family premiums paid directly to them. As such, the family premium payments are not included in the Budget presented below. During FFY 09, NHHK collected and retained Formatted Formatted Formatted Formatted

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

Effective Date: May 1998

Approval Date: September 1998 52 $2,767,143.00 in family premiums (again, as an offset to the medical and dental fees they pay monthly to managed care entities.)

There are two levels of per child per month premiums paid by families depending on income level. The premium is capped for families who have multiple children enrolled.

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

Effective Date: May 1998

Approval Date: September 1998 53

CHIP Budget Template

New Hampshire

FFY Budget FFY Budget Variation between FFY 2009 and FFY 2010 Budget Federal Fiscal Year

FFY 2009 FFY 2010

State's enhanced FMAP rate

65.00% 65.00%

-

Benefit Costs

Insurance payments

$ 15,015,587 $19,327,000 $ 4,311,413 Managed care

$ - per member/per month rate

Fee for Service

$ 2,202.810 $ 3,096,000 $ 893,190 Total Benefit Costs

$ 17,218,397 $22,423,000 $ 5,204,603 (Offsetting beneficiary cost sharing payments) $ - $ - $ - Net Benefit Costs

$ 17,218,397 $22,423,000 $ 5,204,603

Administration Costs

Personnel

$ 295,320 $ 326,350 $ 31,030 General administration

$ 136,344 $ 150,670 $ 14,326 Contractors/Brokers

$ - $ - $ - Claims Processing

$ - $ - $ - Outreach/marketing costs

$ 120,336 $ 132,980 $ 12,644 Other

$ - $ - $ - Total Administration Costs

$ 552,000 $ 610,000 $ 58,000 10% Administrative Cap

$ 1,714,778 $ 2,491,444 $ 776,667

Federal Share

$ 11,550,758 $14,971,450 $ 3,420,692 State Share

$ 6,219,639 $ 8,061,550 $ 1,841,911 TOTAL COSTS OF APPROVED CHIP PLAN $ 17,770,397 $23,033,000 $ 5,262,603

Beneficiary cost-sharing payments have been accounted for and Net Benefit costs are net of the cost-sharing.

Fee for Service Increase in FFY 2010 represents CHIPRA allowable qualifying State claim for 100% of enhanced match for children in NH Expanded Medicaid group, 0-1 years at 133%-185% FPL

The Source of State Share Funds: State General Funds.

Deleted: ¶ Page Break New Hampshire ...

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

Effective Date: May 1998

Approval Date: September 1998 54 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: May 1998

Approval Date: September 1998 55 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) 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: Phase 1: May 1998, Phase 2: Jan. 1999 Approval Date: September 1998

56 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.

As noted in section 8.7.1, individuals have a right to request an Administrative Appeals Hearing if they are not satisfied with any decision made by the Department of Health and Human Services or NHHKC. Hearings can be requested verbally or in writing by contacting a local district office, NHHKC or the Office of Administrative Appeals. This information is on the Healthy Kids application, and complies in the same manner as the Medicaid program.

Health Services Matters 12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120.

If the child is enrolled in Healthy Kids Gold, the process to review health services matter is through the state’s Medicaid fair hearing process.

Individuals have the right to appeal any decision made that the health insurer makes about coverage, benefits, or failure to provide coverage or benefits through the managed care internal appeal process. In addition to the internal appeal procedure, individuals have the right to an external review process to appeal decisions regarding denial, delay, reduction, suspension or termination of health care services and the failure to provide payment for health services in a timely manner through an Administrative Appeals Hearing. If an individual is not satisfied with any decision made by the health insurer, hearings can be requested verbally or in writing by contacting the Department of Health and Human Services, a local district office, the health insurer, NHHKC, or the Office of Administrative Appeals. This information is on the Healthy Kids application, and complies in the same manner as the Medicaid program.

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

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

Effective Date: Phase 1: May 1998, Phase 2: Jan. 1999 Approval Date: September 1998

57 coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility. N/A

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

Center for Medicaid and CHIP Services

December 21, 2011

Melanie Currier, MPH CHIP Manager State of New Hampshire Department of Health and Human Services Office of Medicaid Business and Policy 129 Pleasant Street Concord, NH 03301-3857

Dear Ms. Currier:

Your title XXI Children’s Health Insurance Program (CHIP) State plan amendment (SPA) number 6, submitted March 4, 2011, has been approved.

This amendment will allow New Hampshire to increase co-payment amounts and impose new co-payments for the tiered prescription drug formulary and other services, detailed below.

The State has requested to change the following co-payments effective January 3, 2011:

• Increase from $5 to $10 for covered formulary generic prescription drugs • Increase from $15 to $20 for covered formulary brand name prescription drugs when no generic equivalent is available or the provider indicates that it is medically necessary • Increase from $25 to $30 for covered non-formulary brand name prescription drugs when no generic equivalent is available or the provider indicates that it is medically necessary • Increase from $50 to $100 from emergency room visits, unless the patient is admitted to the hospital.

The State has requested to add the following co-payments effective January 3, 2011:

• $20 fro Tier 2 visits (Specialty care) • $10 for allergy injections • $10 for annual eye exams • $10 for occupational therapy visits • $10 for physical therapy visits • $10 for speech therapy visits • $50 for urgent care services

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

Page 2 - Melanie Currier, MPH

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) 786-8685

Facsimile: (410) 786-5943

E-mail: Erica.sontag@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Sontag and to Mr. Richard McGreal, Associate Regional Administrator in our Boston Regional Office. Mr. McGreal’s address is:

Centers for Medicare & Medicaid Services Division of Medicaid and Children’s Health Operations JFK Federal Building Boston, MA 02203-0003

If you have additional questions, please contact Ms. Victoria Wachino, Director, Children and Adults Health Programs Group at (410) 786-5647.

We look forward to work with you and your staff as you continue to improve health coverage for the children of New Hampshire.

Sincerely,

/s/

Cindy Mann

Director

cc: ARA, CMS Region I Office

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:____________New Hampshire__________________________________ (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: Valerie King Position/Title: Administrator I, NH DHHS-OMBP Name: Kathleen Dunn Position/Title: Director, NH DHHS-OMBP Name: Marilee Nihan Position/Title: Financial Manager, NH DHHS-OMBP

*Disclosure. 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 09380707. 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, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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):

2

1.1.1 Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR

1.1.2.

Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Descriptions of the requirements specified in Sections 3, 4, 6, 7, 8, 11 and 12 of this State Plan are incorporated by references through the State Medicaid plan.

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)

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.

State Plan Phase 1 - Title XIX expansion: Effective/Implementation Date: May 1, 1999 SPA #1 Phase 2 - Title XXI Effective/Implementation Date: January 1, 1999 SPA #2 Adding “good-cause” exceptions Effective/Implementation Date: April 1, 2002 SPA #3 Increasing premiums Effective/Implementation Date: January 1, 2003 SPA #4 Adding a tiered drug formulary Effective/Implementation Date: January 1, 2005

3 SPA #5 Increasing premiums Effective/Implementation Date: October 1, 2009 Change in healthcare MCO Effective/Implementation Date: July 1, 2009 Enrollment cap authority Effective/Implementation Date: October 1, 2009 Citizenship documentation Effective/Implementation Date: January 1, 2010 SPA #6 Increasing co-payments Effective/Implementation Date: January 3, 2011 SPA #7 FQHC wrap around Effective/Implementation Date: October 1, 2009 (see narrative) Orthodontic wrap around Effective/Implementation Date: July 1, 2011 SPA #8 Convert from a Combination to a Medicaid Expansion Effective/Implementation Date: July 1, 2012

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.

Not Applicable - New Hampshire does not have any recognized tribes.

Section 2. General Background and Description of Approach to Children’s Health Insurance Coverage and Coordination

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))

See the American Community Survey data as analyzed by the University of Minnesota's State Health Access Data Assistance Center (SHADAC), found at http://www.shadac.org/datacenter. Please note the sample size for race/ethnicity is too small to ensure reliable interpretations of the data.

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

4 457.10)

New Hampshire does not intend to use the health services initiative option.

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 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.

Not Applicable - New Hampshire does not have any recognized tribes.

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.

3.1. Delivery Standards 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))

Check here if the State child health program delivers services using a managed care delivery model. The State provides an assurance that its managed care contract(s) complies with the relevant provisions of section 1932 of the Act, including section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. The State also assures that it will submit the contract(s) to the CMS’ Regional Office for review and approval.

5 (Section 2103(f)(3))

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))

Section 4. Eligibility Standards and Methodology

4.0.

Medicaid Expansion

4.0.1. Ages of each eligibility group and the income standard for that group:

Prior to transitioning to a full Medicaid Expansion program, New Hampshire’s CHIP was administered as a combination program. The program consisted: • Medicaid Expansion for children under the age of 1 whose family income is greater than 185 and at or below 300% FPL. These children were enrolled in Medicaid (Healthy Kids Gold) • Separate CHIP which offered coverage to children who are between age 1 and under the age of 19 whose family income is from 186% to 300% FPL. This program was called Healthy Kids Silver Effective July 1, 2012, New Hampshire converted its “combined” program into a complete Medicaid Expansion program covering children 0 to 18 years of age in families with income up to 300% FPL. At this time there is no other public health or state only insurance program for children in New Hampshire.

4.1.

Separate Program Check all standards that will apply to the State plan. (42CFR 457.305(a) and 457.320(a)) 4.1.0 Describe how the State meets the citizenship verification requirements. Include whether or not State has opted to use SSA verification option. 4.1.1 Geographic area served by the Plan if less than Statewide: 4.1.2 Ages of each eligibility group, including unborn children and pregnant

women (if applicable) and the income standard for that group:

4.1.2.1-PC Age: _______________ through birth (SHO #02-004,

issued November 12, 2002) 4.1.3 Income of each separate eligibility group (if applicable):

4.1.3.1-PC 0% of the FPL (and not eligible for Medicaid) through

________% of the FPL (SHO #02-004, issued November 12, 2002) 4.1.4 Resources of each separate eligibility group (including any standards

relating to spend downs and disposition of resources): 4.1.5 Residency (so long as residency requirement is not based on length of

time in state): 4.1.6 Disability Status (so long as any standard relating to disability status

does not restrict eligibility):

6 4.1.7 Access to or coverage under other health coverage: 4.1.8 Duration of eligibility, not to exceed 12 months: 4.1.9 Other Standards- Identify and describe other standards for or affecting eligibility, including those standards in 457.310 and 457.320 that are not addressed above. For instance:

4.1.9.1 States should specify whether Social Security Numbers (SSN) are required.

4.1.9.2 Continuous eligibility

4.1-PW

Pregnant Women Option (section 2112)- The State includes eligibility for one or more populations of targeted low-income pregnant women under the plan. Describe the population of pregnant women that the State proposes to cover in this section. Include all eligibility criteria, such as those described in the above categories (for instance, income and resources) that will be applied to this population. Use the same reference number system for those criteria (for example, 4.1.1-P for a geographic restriction). Please remember to update sections 8.1.1- PW, 8.1.2-PW, and 9.10 when electing this option.

4.1- LR

Lawfully Residing Option (Sections 2107(e)(1)(J) and 1993(v)(4)(A); (CHIPRA # 17, SHO # 10-006 issued July 1, 2010) Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) regarding lawfully residing to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following: A child or pregnant woman shall be considered lawfully present if he or she is: (1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641); (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission; (3) An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; (4) An alien who belongs to one of the following classes: (i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending

7 applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101-649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status; (5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least180 days; (6) An alien who has been granted withholding of removal under the Convention Against Torture; (7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. § 1101(a)(27)(J)); (8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

Elected for pregnant women. Elected for children under age _____.

4.1.1-LR The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA Lawfully Residing option, it has verified, at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination, that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act.

4.1-DS Supplemental Dental (Section 2103(c)(5) - A child who is eligible to enroll in dental-only

8 supplemental coverage, effective January 1, 2009. Eligibility is limited to only targeted low- income children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer. The State’s CHIP plan income eligibility level is at least the highest income eligibility standard under its approved State child health plan (or under a waiver) as of January 1, 2009. All who meet the eligibility standards and apply for dental-only supplemental coverage shall be provided benefits. States choosing this option must report these children separately in SEDS. Please update sections 1.1-DS, 4.2-DS, and 9.10 when electing this option.

4.2. Assurances The State assures by checking the box below that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 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 lower family income. This applies to pregnant women included in the State plan as well as targeted low-income children.

4.2.3. These standards do not deny eligibility based on a child having a pre-existing medical condition. This applies to pregnant women as well as targeted low- income children.

4.2-DS Supplemental Dental Please update sections 1.1-DS, 4.1-DS, and 9.10 when electing this option. For dental-only supplemental coverage, the State assures that it has made the following findings with standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

4.2.1-DS These standards do not discriminate on the basis of diagnosis.

4.2.2-DS 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 lower family income.

4.2.3-DS These standards do not deny eligibility based on a child having a pre-

existing medical condition.

4.3 Methodology. Describe the methods of establishing and continuing eligibility and enrollment. The description should address the procedures for applying the eligibility standards, the organization and infrastructure responsible for making and reviewing eligibility determinations, and the process for enrollment of individuals receiving covered services, and whether the State uses the same application form for Medicaid and/or other public benefit programs. (Section 2102)(b)(2)) (42CFR, 457.350)

4.3.1 Limitation on Enrollment Describe the processes, if any, that a State will use for instituting enrollment caps, establishing waiting lists, and deciding which children will be given priority for enrollment. If this section does not apply to your state, check the box below. (Section 2102(b)(4)) (42CFR, 457.305(b))

9 Check here if this section does not apply to your State. NH currently has no waiting list. Enrollment may be limited in the future if state general fund appropriation is insufficient. The need to implement an enrollment cap is assessed as follows: the Department monitors current or “actual” CHIP monthly enrollment. If actual enrollment grows to within range of a predetermined member month number, (as representing enrollment that couldn't be supported financially by State funds if it were to continue to grow at that sustained annual growth rate), that member month number would be considered a “trigger” for capping enrollment (meaning that no additional children will be enrolled). A wait list will be established to accept children determined to be eligible. The list will be queued on as first come, first served. Since NH has a joint application for Medicaid and CHIP, the application and eligibility determination process continue during the CHIP enrollment cap and wait list period. Families determined to be eligible for Medicaid are enrolled and those determined to be eligible for CHIP are informed of the enrollment cap and their children placed on the wait list. While on the CHIP wait list, families must continue to report changes that effect eligibility such as income or household composition. If eligibility redetermination of a family on the CHIP wait-list results in eligibility for Medicaid, the children are enrolled in Medicaid and taken off the wait list. Enrollment is tracked monthly. Potential enrollment spaces become available at the end of each month when enrollment ends for currently enrolled children who disenroll because they 1. Have turned 19; 2. Become eligible for Medicaid coverage; 3. Move out of state; 4. Failed to complete redetermination process; 5. Were determined ineligible during redetermination process; 6. Moved within the state with no forwarding address; 7. Voluntarily disenrolled with no stated reason; 8. Died. When enrollment “slots” become available, a specified number of children (equal to number of slots available) at the top of the wait list are contacted, and their families informed that they may enroll. Children are removed from the wait list and families are provided 30 days to enroll.

4.3.2. Check if the State elects to provide presumptive eligibility for children that meets the requirements of section 1920A of the Act. (Section 2107(e)(1)(L)); (42 CFR 457.355)

4.3.3-EL Express Lane Eligibility Check here if the state elects the option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of CHIP eligibility. The state agrees to comply with the requirements of sections 2107(e)(1)(E) and 1902(e)(13) of the Act for this option. Please update

10 sections 4.4-EL, 5.2-EL, 9.10, and 12.1 when electing this option. This authority may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013. (Section 2107(e)(1)(E))

4.3.3.1-EL Also indicate whether the Express Lane option is

applied to (1) initial eligibility determination, (2) redetermination, or (3) both.

4.3.3.2-EL List the public agencies approved by the State as

Express Lane agencies.

4.3.3.3-EL List the components/components of CHIP eligibility

that are determined under the Express Lane. In this section, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between CHIP eligibility determinations for such children and the determination under the Express Lane option.

4.3.3.3-EL List the component/components of CHIP eligibility that

are determined under the Express Lane.

4.3.3.4-EL Describe the option used to satisfy the screen and

enrollment requirements before a child may be enrolled under

title XXI.

4.4 Eligibility screening and coordination with other health coverage programs States must describe how they will assure that:

4.4.1. only targeted low-income children who are ineligible for Medicaid or not

covered under a group health plan or health insurance (including access to a

State health benefits plan) are furnished child health assistance under the plan.

(Sections 2102)(b)(3)(A), 2110(b)(2)(B)) (42 CFR 457.310(b), 42 CFR

457.350(a)(1) and 42 CFR 457.80(c)(3)) Confirm that the State does not apply

a waiting period for pregnant women.

4.4.2. children found through the screening process to be potentially eligible for

medical assistance under the State Medicaid plan are enrolled for assistance

under such plan; (Section 2102)(b)(3)(B)) (42CFR, 457.350(a)(2))

4.4.3. children found through the screening process to be ineligible for Medicaid are

enrolled in CHIP; (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR,

431.636(b)(4))

4.4.4. the insurance provided under the State child health plan does not substitute for

11

coverage under group health plans; states should check the appropriate box.

(Section 2102)(b)(3)(C)) (42CFR, 457.805) (42CFR 457.810(a)-(c)) 4.4.4.1. (formerly 4.4.4.4) If the State provides coverage under a premium

assistance program, describe: 1) the minimum period without coverage

under a group health plan. This should include any allowable exceptions

to the waiting period; 2) the expected minimum level of contribution

employers will make; and 3) how cost-effectiveness is determined.

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))

Under Medicaid Expansion, the CHIP enrollees will join their “traditional” Medicaid counterparts in NH Medicaid. New Hampshire will continue to utilize a single application, regardless of whether the individual qualifies through Title XIX or Title XXI. The appropriate FMAP will be applied, but there will be no other visible differentiation between children who qualify under Title XXI and those who qualify under Title XIX.

The same unit (within the Department) determines eligibility for both CHIP and Medicaid. This maximizes the coordination of eligibility for both programs. As part of the determination process, Department staff verifies an applicant’s current enrollment status through New HEIGHTS, New Hampshire’s eligibility system. Staff then determine, based on the information collected as part of the application process, which program, if any, the child is eligible for, and assist the family in the enrollment of the child into the applicable program. Staff checks for eligibility with Medicaid first. If the child is eligible, he/she is enrolled. If the child is not found eligible for Medicaid, he/she will be screened.

There are no recognized tribes in New Hampshire; therefore, the state does not have any specific policies in place targeting American Indians for Alaskan Natives, as defined by 42 CFR 457.10. Tribal members receive the same outreach as other sectors of the population. There is currently no cost-sharing requirement for this program. If after January 1, 2014, New Hampshire chooses to assess a premium or other cost sharing measures on its Title XXI population, protections will be in place for American Indians and Alaskan Natives.

4.4-EL The State should designate the option it will be using to carry out screen and enroll

requirements:

The State will continue to use the screen and enroll procedures required under section

2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 42 CFR 457.80(c). Describe this process.

The State is establishing a screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by the Express Lane agency and those used by the State Formatted Formatted Formatted

12 for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated. The State is temporarily enrolling children in CHIP, based on the income finding from the Express Lane agency, pending the completion of the screen and enroll process.

Section 5. Outreach and Coordination

5.1. (formerly 2.2) Describe the current State efforts to provide or obtain creditable health coverage for uninsured children by addressing sections 5.1.1 and 5.1.2. (Section 2102)(a)(2) (42CFR 457.80(b))

5.1.1. (formerly 2.2.1.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance):

Applications are available at a variety of community agencies and provider sites such as hospitals, WIC sites, and public health clinics and community health centers funded through Title V and Title X grants. These same agencies are part of an on-going effort by the state to identify Medicaid eligible children and provide support to eligible families who up until now have not availed themselves of Medicaid benefits but would be eligible if they applied. Community Application Assistors are located in various hospitals and community health centers around the state. These assistors have been trained in the eligibility requirements for various public health and state benefit programs, and along with other community partners (e.g. school nurses), educate consumers and support them as they navigate the application process. The Department will also be utilizing it’s internal assets as “ambassadors” to help promote the program and identify eligible participants. These assets include the following organizations: the Bureau of Child Care Licensing, the Women Infants and Children program, the Child Development Bureau, Minority Health, the NH Employment Security’s Rapid Response program (which educates the recently unemployed about their options for health coverage following a lay off), the State Library, and community TV and school nurses located across the state. The Department will also be making information available to community organizations, including materials in Spanish (some materials also available in Bosnian) Formal Medicaid application and intake sites include the eleven local New Hampshire district offices strategically located around the state. In addition, the Medicaid 800-P short forms can be completed and submitted via the Title

13 V agencies, Title X clinics, WIC sites, disproportionate share hospitals, Early Intervention sites and Federally Qualified Health Centers (FQHC's). An application can also be completed and submitted on-line through NH Easy at https://nheasy.nh.gov. Since January of 2011, The New Hampshire Electronic Application System (NH EASY) has offered NH residents a fast and easy way to apply online for cash, medical, Child Care, Medicare Savings Program, and/or Food Stamp benefits. The Department also maintains a toll free phone number and client service units in both the Office of Medicaid Business and Policy and the Division of Family Assistance (DFA) to provide prompt answers to questions regarding eligibility and services.

5.1.2. (formerly 2.2.2.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in health insurance programs that involve a public-private partnership: New Hampshire’s CHIP had previously been administered as a combination program. The “separate” portion of the program (Healthy Kids Silver) was administered through a public private partnership with New Hampshire Healthy Kids Corporation. This partnership was dissolved effective June 30, 2012, when the State converted to a full Medicaid Expansion Program.

5.2. (formerly 2.3) Describe how CHIP coordinates with other public and private health insurance programs, other sources of health benefits coverage for children, other 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. Section 2102(a)(3) and 2102(c)(2) and 2102(b)(3)(E))(42CFR 457.80(c)). This item requires a brief overview of how Title XXI efforts - - particularly new enrollment outreach efforts will be coordinated with and improve upon existing State efforts described in Section 5.2.

The state coordinates enrollment and outreach efforts with other public programs and private health insurance programs and child health agencies in order to increase the number of children with creditable health coverage. As part of their contract with the state, Title V agencies must screen all children they see at their agencies for health insurance. If that child is uninsured, agency staff is required to assist families in applying for the program. When an applicant indicates on the form that a child in the family has special heath care needs that require ongoing supports to remain at home, that person’s name and information is sent to Family Voices, a family to family health information and resource project, who will assist that family with the coordination of other private and state resources for children with special heath care needs such as the Special Medical Services Bureau, a Title V funded program. Also, the New HEIGHTS software program, which utilizes a cascading logic, allows Department staff to screen eligibility for various Medicaid coverage groups as well as other public assistance

14 programs.

5.2-EL The State should include a description of its election of the Express Lane eligibility option to

provide a simplified eligibility determination process and expedited enrollment of eligible

children into Medicaid or CHIP.

5.3 Strategies

Section 6. Coverage Requirements for Children’s Health Insurance

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 proceed to Section 7 since children covered under a Medicaid expansion program will receive all Medicaid covered services including EPSDT.

6.1. The State elects to provide the following forms of coverage to children: (Check all that apply.) (Section 2103(c)); (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) (42 CFR 457.420(a)) (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. Attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431.

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) This option is only applicable to New York, Florida, and Pennsylvania. Attach a description of the benefits package, administration, and date of enactment. If existing comprehensive State-based coverage is modified, 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.

15 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 waiver 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 existing comprehensive state-based coverage applicable only New York, Pennsylvania, or Florida (under 457.440)

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)) 6.2.2.

Outpatient services (Section 2110(a)(2)) 6.2.3.

Physician services (Section 2110(a)(3)) 6.2.4.

Surgical services (Section 2110(a)(4)) 6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6.

Prescription drugs (Section 2110(a)(6)) 6.2.7.

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

Laboratory and radiological services (Section 2110(a)(8)) 6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) 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)) 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)

16 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)) 6.2.13.

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

6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14))

6.2.15.

Nursing care services (Section 2110(a)(15)) 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) 6.2.17.

Dental services (Section 2110(a)(17)) States updating their dental benefits must complete 6.2-DC (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) 6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.20.

Case management services (Section 2110(a)(20)) 6.2.21.

Care coordination services (Section 2110(a)(21)) 6.2.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23.

Hospice care (Section 2110(a)(23))

6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26.

Medical transportation (Section 2110(a)(26))

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))

6.2-DC Dental Coverage (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) The State will provide dental coverage to children through one of the following. Please update Sections 9.10 and 10.3- DC when electing this option. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5)):

6.2.1-DC State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT1) codes are included in the dental benefits:

Current Dental Terminology, © 2010 American Dental Association. All rights reserved.

17 1. Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must follow periodicity schedule) 2. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes: D1000-D1999) (must follow periodicity schedule) 3. Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999) 4. Endodontic (i.e., root canals) (CDT codes: D3000-D3999) 5. Periodontic (treatment of gum disease) (CDT codes: D4000-D4999) 6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200-D6999) 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999) 9. Emergency Dental Services

6.2.1.1-DC Periodicity Schedule. The State has adopted the following periodicity schedule: State-developed Medicaid-specific American Academy of Pediatric Dentistry Other Nationally recognized periodicity schedule Other (description attached)

6.2.2-DC Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR 457.420)

6.2.2.1-DC FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked, attach copy of the dental supplemental plan benefits description and the applicable CDT2 codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2.2.2-DC 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 the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)Page - 11 – State Health Official

6.2.2.3-DC 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 the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2-DS

Supplemental Dental Coverage- The State will provide dental coverage to

children eligible for dental-only supplemental services. Children eligible for

this option must receive the same dental services as provided to otherwise

eligible CHIP children (Section 2103(a)(5). Please update Sections 1.1-DS, 4.1- DS, 4.2-DS, and 9.10 when electing this option.

18

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 6.6.2. (formerly 6.4.2) of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). 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)(2) 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))

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

19 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. The State's cost of purchasing family coverage, including administrative expenditures, that includes coverage for the targeted low-income children involved or the family involved (as applicable) under premium assistance programs must not be greater than the cost of obtaining coverage under the State plan for all eligible targeted low-income children or families involved; and (2) The State may base its demonstration of cost effectiveness on an assessment of the cost of coverage, including administrative costs, for children or families under premium assistance programs to the cost of other CHIP coverage for these children or families, done on a case-by-case basis, or on the cost of premium assisted coverage in the aggregate.

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))

6.4.3-PA: Additional State Options for Providing Premium Assistance (CHIPRA # 13, SHO # 10-002 issued February, 2, 2010) A State may elect to offer a premium assistance subsidy for qualified employer-sponsored coverage, as defined in Section 2105(c)(10)(B), to all targeted low-income children who are eligible for child health assistance under the plan and have access to such coverage. No subsidy shall be provided to a targeted low-income child (or the child’s parent) unless the child voluntarily elects to receive such a subsidy. (Section 2105(c)(10)(A)). Please remember to update section 9.10 when electing this option. Does the State provide this option to targeted low-income children?

Yes

No

As of July 1, 2012, all children enrolled in NH Medicaid under Title XXI eligibility may apply for the Health Insurance Premium Payment (HIPP) program, NH §1906 enrollment assistance for group health plans. This program was unavailable to the State’s CHIP population prior to Medicaid Expansion, however, after July 1, 2012, all CHIP eligible children have access to this premium subsidy offering

20

The HIPP program defers medical costs from the NH Medicaid program by reimbursing certain Medicaid recipients’ private or employer-related group health insurance premiums when it is cost effective. An individual who is eligible for any of the various Medicaid programs and is enrolled in an employer provided health insurance plan may be eligible to participate in the HIPP Program. The HIPP Program will assist in paying the employees share of the employer provided health insurance premium or employer provided cobra insurance for the Medicaid eligible individuals if the insurance premium is less than paying the medical expenses under Medicaid. If the premium is more then the Medicaid average cost for services provided to the Medicaid member, then the member will not be eligible for HIPP.

6.4.3.1-PA Qualified Employer-Sponsored Coverage and Premium Assistance Subsidy 6.4.3.1.1-PA Provide an assurance that the qualified employer-sponsored insurance meets the definition of qualified employer-sponsored coverage as defined in Section 2105(c)(10)(B), and that the premium assistance subsidy meets the definition of premium assistance subsidy as defined in 2105(c)(10)(C). 6.4.3.1.2-PA Describe whether the State is providing the premium assistance subsidy as reimbursement to an employee or for out-of-pocket expenditures or directly to the employee’s employer.

6.4.3.2-PA: Supplemental Coverage for Benefits and Cost Sharing Protections Provided under the Child Health Plan. 6.4.3.2.1-PA If the State is providing premium assistance for qualified employer- sponsored coverage, as defined in Section 2105(c)(10)(E)(i), provide an assurance that the State is providing for each targeted low-income child enrolled in such coverage, supplemental coverage consisting of all items or services that are not covered or are only partially covered, under the qualified employer-sponsored coverage consistent with 2103(a) and cost sharing protections consistent with Section 2103(e). 6.4.3.2.2-PA Describe whether these benefits are being provided through the employer or by the State providing wraparound benefits. 6.4.3.2.3-PA If the State is providing premium assistance for benchmark or benchmark-equivalent coverage, the State ensures that such group health plans or health insurance coverage offered through an employer will be certified by an actuary as coverage that is equivalent to a benchmark benefit package described in Section 2103(b) or benchmark equivalent coverage that meets the requirements of Section 2103(a)(2).

6.4.3.3-PA: Application of Waiting Period Imposed Under State Plan: States are required to apply the same waiting period to premium assistance as is applied to direct coverage for children under their CHIP State plan, as specified in Section 2105(c)(10)(F). Formatted Formatted Formatted

21 6.4.3.3.1-PA Provide an assurance that the waiting period for children in premium assistance is the same as for those children in direct coverage (if State has a waiting period in place for children in direct CHIP coverage).

6.4.3.4-PA: Opt-Out and Outreach, Education, and Enrollment Assistance 6.4.3.4.1-PA Describe the State’s process for ensuring parents are permitted to disenroll their child from qualified employer-sponsored coverage and to enroll in CHIP effective on the first day of any month for which the child is eligible for such assistance and in a manner that ensures continuity of coverage for the child (Section 2105(c)(10)(G)). 6.4.3.4.2-PA Describe the State’s outreach, education, and enrollment efforts related to premium assistance programs, as required under Section 2102(c)(3). How does the State inform families of the availability of premium assistance, and assist them in obtaining such subsidies? What are the specific significant resources the State intends to apply to educate employers about the availability of premium assistance subsidies under the State child health plan? (Section 2102(c))

6.4.3.5-PA: Purchasing Pool- A State may establish an employer-family premium assistance purchasing pool and may provide a premium assistance subsidy for enrollment in coverage made available through this pool (Section 2105(c)(10)(I)). Does the State provide this option?

Yes

No

6.6.3.5.1-PA Describe the plan to establish an employer-family premium assistance purchasing pool. 6.6.3.5.2-PA Provide an assurance that employers who are eligible to participate: 1) have less than 250 employees; 2) have at least one employee who is a pregnant woman eligible for CHIP or a member of a family that has at least one child eligible under the State’s CHIP plan. 6.6.3.5.3-PA Provide an assurance that the State will not claim for any administrative expenditures attributable to the establishment or operation of such a pool except to the extent such payment would otherwise be permitted under this title.

6.4.3.6-PA Notice of Availability of Premium Assistance- Describe the procedures that assure that if a State provides premium assistance subsidies under this Section, it must: 1) provide as part of the application and enrollment process, information describing the availability of premium assistance and how to elect to obtain a subsidy; and 2) establish other procedures to ensure that parents are fully informed of the choices for child health assistance or through the receipt of premium assistance subsidies (Section 2105(c)(10)(K)). 6.4.3.6.1-PA Provide an assurance that the State includes information about premium assistance on the CHIP application or enrollment form.

22

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. (Section 2102(a)(7)(A)) (42CFR 457.495(a)) Will the State utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)

7.1.1.

Quality standards 7.1.2.

Performance measurement

7.1.2 (a)  CHIPRA Quality Core Set

7.1.2 (b)  Other

7.1.3.

Information strategies 7.1.4.

Quality improvement strategies

7.2. Describe the methods used, including monitoring, to assure: (Section 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))

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))

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of- network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

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)) Exigent medical circumstances may require more rapid response according to the medical needs of the patient.

Section 8. Cost-Sharing and Payment

23

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 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505) Indicate if this also applies for pregnant women. (CHIPRA #2, SHO # 09-006, issued May 11, 2009)

8.1.1.

Yes 8.1.2. No, skip to question 8.8. 8.1.1-PW

Yes 8.1.2-PW 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 by age and income (if applicable) 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:

8.2.2. Deductibles: 8.2.3. Coinsurance or copayments: 8.2.4. Other:

8.2-DS

Supplemental Dental (CHIPRA # 7, SHO # #09-012 issued October 7, 2009)For children enrolled in the dental-only supplemental coverage, describe the amount of cost- sharing, specifying any sliding scale based on income. Also describe how the State will track that the cost sharing does not exceed 5 percent of gross family income. The 5 percent of income calculation shall include all cost-sharing for health insurance and dental insurance (Section 2103(e)(1)(A)) (42 CFR 457.505(a), 457.510(b), and (c), 457.515(a) and (c), and 457.560(a)) Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, 6.2- DS, and 9.10 when electing this option. 8.2.1-DS Premiums: 8.2.2-DS Deductibles: 8.2.3-DS Coinsurance or copayments: 8.2.4-DS Other:

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

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

24 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))

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)

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

8.7.1 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.

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)) (42CFR 457.220) 8.8.2.

No cost-sharing (including premiums, deductibles, copayments, coinsurance and all other types) will be used toward State matching requirements. (Section

25 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 the 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

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)) New Hampshire already has an impressively low rate (4.7%) of un-insured children. Although the Department has made great strides to remove barriers, many children who are eligible for Medicaid coverage remain uninsured. In an effort to capture these remaining children, New Hampshire has concentrated it efforts toward specific populations, such as teenagers, a group with higher rates of un-insurance. The Department also continues to work toward improving appropriate utilization as well as retention of those children who are enrolled in CHIP and Medicaid. By converting to a Medicaid Expansion program, New Hampshire expects to increase enrollment and retention of its CHIP eligible population. Cost sharing (in the form of premiums and co-pays) and participation in “other” insurance are believed to have been significant factors that chilled participation in CHIP under the “combination” program model. Both of these barriers will be eliminated under the “expansion” model, which in turn is expected to result in increased enrollment, longer periods of continuous enrollment, appropriate utilization and the elimination of coverage gaps for those children who move between the CHIP and Medicaid programs. In addition to these improvements, New Hampshire has also focused outreach activities toward increasing enrollment, and appropriate use of benefits among the state’s adolescent population. In New Hampshire, 5.8% of 13-18 year olds are uninsured, as opposed to 4.8% of children ages 6-12 years and 4.3 of children 0-5 years old. Teens living on their own are uninsured at an even higher rate of 13%. NH expects this number to drop once outreach activities are underway.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

26 Performance Goal #1: Increase the average length of continuous enrollment by 3-months. Performance Measure#1: Compare the average length of continuous enrollment before and after the expansion Data Source: New Heights/MMIS Performance Goal #2: Increase the number of adolescents (ages 13-19 years) enrolled by 1%. Performance Measure #2: Compare the number and percent of adolescents enrolled as of June 30, 2012 to those enrolled as of December 31, 2012. Data Source: New Heights/MMIS

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))

Data sources for determining New Hampshire’s performance include: Census data, the Department’s New Heights (eligibility) and MMIS (claims) systems, as well as the NH CHIS commercial database. The Department will use a mix of HEDIS and non-HEDIS measures, and limits its measures to those that can be calculated use claims data. The Department does not have the capability to calculate performance for those measures that require medical chart review. Performance measures that the Department routinely assesses include: - Access to primary care practioners - Well child visits - Adolescent well-care visits - Annual dental visit - Appropriate testing for children with pharyngitis - Appropriate treatment for children with upper respiratory infection - Emergency Department use - Total - Emergency Department use - Conditions potentially treatable in primary care

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 childcare Formatted Formatted

27 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, list: see above 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)

Reporting will be complicated by the fact that NH Medicaid will be converting to a Managed Care system beginning in 2013. As a result, the New Hampshire may not have a full 12 months of data collection on FFS. This could result in data that is not compatible or comparable to data obtained for these measures under the combined” CHIP program.

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 Office of Medicaid Business and Policy (OMBP) is responsible for completing the Annual CHIP report (a.k.a. CARTS). The data needed to complete the report is gathered from several entities throughout the Department. A staff member will gather, analyze and draft a report of the data. The draft is reviewed and approved by upper managed within OMBP prior to uploading the information to CMS via the on-line reporting system.

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 457.710(e))

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)