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

Effective Date:

Approval Date: 51 Elements described above for DMAP’s contracts with prepaid health plans. These include but are not limited to, benefit design, reporting quality assurance, enrollee rights, screening and prevention health care activities and the accessibility of services.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b)) CHIP OHP Plus: PHPs that contract with DMAP are required to follow established rules concerning access and availability of covered services outlined in the Oregon Health Plan Administrative Rules under rule OAR 410-141-0220: Oregon Health Plan Prepaid Health Plan Accessibility. Requirements of this rule include:

♦ Written policies and procedures that establish standards for access, capacity, risk assessment, interpreter services, and ADA compliant accommodation to ensure access to health care services to all OHP members ♦ Geographic proximity of facilities and appointment wait times as determined by the prevailing Community Standard ♦ Sufficient provider panels and networks to ensure adequate service capacity to provide availability of, and timely access to, medically appropriate services ♦ Professional expertise among providers to treat or otherwise accommodate the full range of medical, dental or mental health conditions experienced by OHP members ♦ Monitoring systems to assure access to services according to time standards as indicated by the nature of the appointment including: ♦ Emergency care – Immediately for physical. Within 24 hours for dental, mental, or chemical dependency. ♦ Urgent care – Within 48 hours for physical, mental or chemical dependency, as indicated. Within one to two weeks for dental. ♦ Well Care, Routine, Preventive or Non-urgent – Within four weeks or the Community Standard for physical. Intake assessment for mental or chemical dependency within two weeks of patient request. Within twelve weeks for dental. ♦ Maintenance of 24-hour telephone coverage with a live operator (not a recording) guided by established standards pertaining to Primary Care Provider (PCP) call-back and back-up in the areas of: • Emergency, urgent, and routine issues • Internal Medicine, Family Practice, OB/Gyn, and Pediatrics • Interpretive services after office hours