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Effective Date: April 1, 2009

Approval Date: ____________ 42

State and contractor staff. These contract standards will also apply under Title XXI. Other monitoring activities of State and PRO staff are listed above. The State also uses focus groups and community and advocacy committees for continuous input into the managed care program.

7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495) HMO networks are reviewed by the Department of Health and Senior Services as part of the process for granting a required Certificate of Authority. The Medicaid contracts which will also be used for Title XXI coverage include additional, specific standards for network adequacy. HMO networks must be reviewed and approved by both DMAHS and HCFA prior to participation in the Medicaid program.

As part of the approval process, HMOs are granted approval to enroll beneficiaries up to a specified level of enrollment based on provider network capacity. Based upon a review of the enrollment caps and further analysis of the pediatric networks, it has been determined that the existing contract HMOs should have adequate network capabilities to serve the anticipated increased membership in 18 counties. In the three remaining counties, at least two plans have been approved in each county with sufficient capacity to serve both the Title XIX and the Title XXI beneficiaries. Ongoing access is monitored through regular reviews of any changes in the HMO network, ongoing contact with listed providers, review of grievance and complaint information, and, when appropriate, undercover operations.

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 employs methods, including monitoring, to assure access to well-baby care, well-adolescent care and childhood and adolescent immunizations.

Specifically with respect to well-baby care and immunizations provided under the plan, HMOs are contractually required to provide EPSDT screenings and preventive services under Plans A, B and C. Under NJ FamilyCare Plan D, certain preventive services are also covered, including well-baby care, immunizations and preventive dentistry for children under the age of 12. State medical staff conduct routine reviews of HMO compliance with these requirements and its operating systems to support the outreach, case management and follow-up requirements of the program. HMOs are required to submit formal studies on immunization rates. PRO staff conduct focused studies of preventive services.

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))