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

Effective Date:

Approval Date: 52 DMAP and the PHPs monitor all access issues from both the planning and implementation perspective. Regular reports, site inspections, internal and external audits, and consumer satisfaction surveys serve to validate the effectiveness and timeliness of access to covered medical services.

Healthy KidsConnect: Plans are licensed and regulated by the Department of Consumer and Business Services (DCBS), Oregon’s Insurance division. The Insurance division’s administrative rule contain many of the elements described for DMAPs contracts managed care plans above, such as benefit design, reporting quality assurance, enrollee rights, screening and prevention health care activities and the accessibility of services. Health insurers in Oregon are required to provide the enrollee with information relating to covered services, access, scheduling as well as how emergency medical conditions are covered and accessed including a statement of prudent layperson standards for emergency treatment.

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)) CHIP OHP Plus: PHPs are required to assure access to the services they provide including: specialists, pharmacy, hospital, vision and ancillary services, as accessible to DMAP Members in terms of timeliness, amount, duration and scope as those services are to non-DMAP persons within the same service area. If the PHP is unable to provide those services locally, it must so demonstrate to DMAP and provide reasonable alternatives for Members to access care that must be approved by DMAP. PHPs have a monitoring system that demonstrates to DHS, as applicable, that the plan has surveyed and monitored for equal access of DMAP Members to referral providers pharmacy, hospital, vision and ancillary services. Healthy KidsConnect: Plans are private insurers and regulated by the Oregon Insurance Division. The Insurance Division requires that commercial group health insurers submit their benefit plan designs and premium rates through an approval process. The HKC plans are considered Discretionary group plans and will be reviewed by the Insurance Division. This review by the Division helps assure that the Healthy KidsConnect benefit plans meets all Division requirements. The ultimate focus of the Insurance Division approval process is to protect