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

Effective Date:

Approval Date: 7-6 the Department determines that deficiencies exist in the provider network that could impact member access to care, health plans are required to submit a plan of corrective action to the Department.

Health plans are required to submit semi-annual and annual operation reports to the Department which are used to monitor the availability of and use of services by health plans and their members. Health plans are required to report utilization statistics, ancillary service utilization, cost of and expense of services. Utilization statistics include emergency room visits, primary care visits by age group, immunizations, inpatient and outpatient utilization, dental visits, laboratory and ancillary therapies.

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))

Service Accessibility: The State considers service accessibility to be one of the key determinants of quality of care and overall member satisfaction. Accordingly, health plans will be expected to take all necessary measures to ensure compliance with the access standards. Health plans must allow access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. The State will actively monitor health plan performance in this area and will take prompt corrective action if problems are identified.

One way the State monitors health plan performance for treatment of children with chronic health conditions is through the Quality Assurance Reporting Requirements (QARR). Several childhood-specific measures are collected which are used to monitor the health plans effectiveness in providing care to these children including the use of appropriate medications for people with asthma and the lead testing measure. Individual health plan performance is then compared to the statewide average of all other health plans’ performance.

Also, Child Health Plus members contact the Department for assistance if they are unable to resolve problems associated with access to health care services. The Department works with individual families and health plans, as necessary, to insure that appropriate services are made available. The frequency of the type and nature of complaints is maintained and monitored by the Department on a monthly basis.

Specific standards are in place to ensure reasonable and timely access to providers. These standards include but are not limited to the following:

Days to Appointment: Health plans must abide by the following appointment standards:

● Urgent medical or behavioral problems within 24 hours; ● Non-urgent "sick visits" within 48 to 72 hours, as clinically indicated; ● Routine, non-urgent or preventive care visits within four weeks; and ● In-plan, non-urgent mental health or substance abuse visits within two weeks.