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

Effective Date:

Approval Date: 3-1 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))

Under the CHPlus program, the Department contracts with health plans for the purchase of a managed care insurance product. Health plans are paid a per member per month (PMPM) fee for a uniform benefit package that is comparable to the Medicaid managed care package. Costs for vaccines are excluded from the PMPM fee and are purchased and distributed, for CHPlus enrollees, by the NY State Department of Health through its Vaccine for Children program. Children, through the managed care arrangement, have primary care providers who coordinate their health care, including referrals to specialists, when appropriate. Insurers participate in the program as a result of a competitive RFP process. However, those health plans that are approved New York State Medicaid Managed Care insurers are allowed to participate in the CHPlus program without a competitive bid or request for proposal process. These insurers are authorized to contract with the State to provide a CHPlus managed care product. Health plans are in every geographic region of the State, assuring statewide coverage. Health plans are monitored for the provision of health care services through the semi and annual reporting of the services provided and through the reporting of data through the quality assurance and reporting system.

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 benefit package under the CHPlus program is a uniform benefit package that must be provided by all health plans. Plans cannot provide additional services outside of this benefit package. Since CHPlus is a managed care product and each child has a primary care physician, children receive health care that is appropriate, medically necessary, and/or approved by the State or the participating health plan.

Health plans participating in the CHPlus program, must have in place utilization review policies and procedures that include protocols for prior approval and denial of services, hospital discharge planning, physician profiling, and retrospective review of both inpatient and ambulatory claims meeting pre-defined criteria. Plans also must develop and implement procedures for identifying and correcting patterns of over and under utilization on the part of their enrollees.

More information can be found on utilization control in Section 7 - Quality and Appropriateness of Care.