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

Effective Date:

Approval Date: 7-4 7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

In order to assure access to primary and preventive health care, including well-child care, well-adolescent care and childhood and adolescent immunizations, health plans must establish and maintain provider networks with sufficient numbers of providers in geographically accessible locations for the populations they serve. Health plan networks must contain all of the provider types necessary to furnish the prepaid benefit package, including: well child care in accordance with visitation schedule established by American Academy of Pediatrics, immunizations according to the Immunization Schedule of the United States, hospitals, physicians (primary care and specialist), mental health and substance abuse providers, allied health professionals, pharmacies, and DME providers. Health plans shall not include in their networks, for purposes of serving CHPlus enrollees, any medical provider who has been sanctioned by Medicare or Medicaid if the provider has, as a result of the sanctions, been prohibited from serving Medicaid clients or receiving medical assistance payments.

Additionally, health plans must offer every member the opportunity to select from at least 3 primary care physicians with in the following distance/travel time standards:

● Non-metropolitan areas – 30 miles/30 minutes ● Metropolitan areas – 30 minutes by public transportation

Transport time and distance in rural areas to primary care sites and hospitals may be greater than 30 minutes/30 miles only if based on the community standard for accessing care or if by beneficiary choice.

Quality of care delivered by health plans is monitored by the use of both external and internal monitoring methods. Health plans participating in the Child Health Plus program are required to submit specific quality performance data to the Department of Health which is consistent with the New York State Department of Health Quality Assurance Reporting Requirements (QARR) data specifications, on an annual basis for the CHPlus population. These data provide information on health plan performance with respect to primary and preventive health visits, access to health care, and medical management of select chronic diseases.

Specific child health measures are included annually in the data collection. These data include Use of Appropriate Medications for People with Asthma (Ages 5-17); and the percentage of children age 3 months to 18 years with a diagnosed upper respiratory infection and who were not given a prescription for an antibiotic, the percentage of children age 2–18 years with a diagnosis of Pharyngitis who were prescribed an antibiotic and were given a group A streptococcus test, and Annual Dental Visit.

Health plans must have internal quality assurance programs and written quality improvement or assurance plans (Quality Improvement Programs/Quality Assurance Programs (QAP)) for monitoring and improving the quality of care furnished to members. Such plans must address all of the following: