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

Effective Date:

Approval Date: 47 ♦ Emergency services ♦ Sufficient quantity of providers to ensure adequate capacity ♦ 24-hour-a-day, 7-day-a-week emergency and urgent care services ♦ Language and transportation services ♦ Medical Case Management services ♦ ADA compliant physical access to facilities and providers ♦ Community Standards governing scheduling, rescheduling and waiting time for scheduled appointments ♦ Client Referral system

Reporting Area Quality Assurance Requirement Quality of Care ♦ Documented policies and procedures for member care ♦ External review of policies and procedures relating to member care and medical record review for quality of care ♦ Internal Quality Assurance and Quality Improvement programs based on written policies, standards and procedures ♦ Quality assurance committee structure and membership guidelines

Member Rights ♦ Due process rights; including a formal complaints and hearings process ♦ Rights to informed consent ♦ Rights to treatment with dignity and respect ♦ Other processes establishing and maintaining rights to adequate medical care

Clinical Measures and Utilization The Health Plan Employers Data Information Set (HEDIS) and statewide goals described in Oregon Shines II, the state’s 20-year strategic plan, serves as the basis on which CHIP OHP Plus health care is assessed for quality and appropriateness of care. DMAP collects the following health measures specific to the population of OHP clients under 19 years of age:

♦ Access to Primary Care Provider ♦ Childhood Immunizations ♦ Well-Baby, Child and Adolescent Visits ♦ Annual dental visit

Over 85 percent of CHIP OHP Plus children are enrolled in managed care. DMAP evaluates and monitors the measures listed above for each