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

Effective Date:

Approval Date: 12-1 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.

12.1. Eligibility and Enrollment Matters Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

Review of eligibility and enrollment matters is conducted by both the health plans who determined the original enrollment and the Department. This combined approach complies with the federal requirement of affording an individual both an internal and external review. Enrollees are given sufficient notice that their eligibility may be terminated if they do not take action with specific instructions on what they must do. All requests for review are first addressed by the health plan. If the enrollee is still not satisfied with the determination, the enrollee can request an external review be completed by the state. A child will not be disenrolled during this review period.

The State assures that in the review process, enrollees have the opportunity to fully participate in the review process; decisions are made in writing; and impartial reviews are conducted in a reasonable amount of time and consideration is given for the need for expedited review when there is an immediate need for health services.

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

The health plans issue a subscriber contract, to every enrollee, which delineates the enrollee’s rights and responsibilities. This contract explains the review process for health services matters. This process allows for an internal review conducted by the health plan and an external review conducted by an appeal agent certified by the state. All reviews are conducted within the time frames stipulated in federal regulation and all decisions will be made in writing.

The State assures that enrollees receive timely written notice of any determinations that include the reasons for the determination, an explanation of applicable rights to review, the standard and expedited time frames for review, the manner in which a review can be requested, and the circumstances under which enrollment may continue pending review.

The State assures that enrollees have the opportunity for an independent, external review of a delay, denial, reduction, suspension, termination of health services or failure to approve health services in a timely manner. The independent review is available at the external appeals level.

The State assures that enrollees have the opportunity to represent themselves or have representatives in the process at the external appeals level.

The State assures that enrollees have the opportunity to timely review of their files and other applicable information relevant to the review of the decision. While this is assured at each level of review, members will be notified of the timeframes for the appeals process once an external appeal is filed.