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

Effective Date:

Approval Date: 16 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)) CHIP OHP Plus coverage: Health care services for CHIP clients are primarily provided through the managed care delivery system already established for the OHP Medicaid Demonstration. The managed care delivery system consists of prepaid health plans (PHPs) and primary care case managers (PCCMs) that manage the care of CHIP enrollees for a monthly capitated payment. The Division of Medical Assistance Programs (DMAP), within Oregon’s Department of Human Services (DHS), manages the Medicaid Demonstration Project, and has primary responsibility for operation of S-CHIP. The State of Oregon contracts with fourteen Fully Capitated Health Plans (FCHPs), one Physician Care Organization (PCO), nine Dental Care Organizations (DCOs), and nine Mental Health Organizations (MHOs). Oregon also contracts with one Chemical Dependency Organization (CDO) in Deschutes County (in all other counties, chemical dependency services are provided through the Fully Capitated Health Plans or on a fee-for-service basis). As part of OHP Medicaid and CHIP policy all plans are encouraged to incorporate safety net providers in their delivery system and most FQHCs, rural health clinics and local health departments that provide primary care are incorporated into plan networks.

CHIP enrollees have the same choice of managed care plans as OHP Medicaid enrollees in their area. CHIP clients are required to enroll in a FCHP or a PCO, and a DCO, a MHO, and, in Deschutes County only, a CDO, as a condition of eligibility. If no managed care plan is available, the CHIP client may select a PCCM from a list of available PCCMs in their service area and will receive health services on a managed fee-for- service (FFS) basis. DMAP monitors plan provider capacity quarterly and we track enrollment monthly. If it is determined that there is insufficient capacity in a geographic area, CHIP clients are not required to enroll in a managed care plan and may receive services on a fee for service basis. In service areas where DCO capacity is limited, CHIP clients are not