Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

1

OMB #: 0938-0707 Exp. Date:

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available, we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Form CMS-R-211

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

2

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory: Commonwealth of Pennsylvania ________________ (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: M. Diane Koken

Position/Title: Insurance Commissioner, PA Insurance Department Name: George L. Hoover

Position/Title: Deputy Commissioner, Children’s Health Insurance Program and adultBasic Coverage Program

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

3

Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1.

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2.

Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR

1.1.3.

A combination of both of the above.

1.2

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

1.4

Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Effective date:

May 28, 1998

Implementation date:

June 1, 1998

FIRST AMENDMENT

This amendment extended eligibility to children through the age of 18 with incomes at or below 200% of the FPL, eliminated cost sharing, and moved administration of the program to the Pennsylvania Insurance Department.

Effective Date: June 17, 1998

Implementation Date: June 17, 1998

Approval for this amendment was received on October 29, 1998

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

4

SECOND AMENDMENT

This amendment expanded income eligibility by allowing a work expense deduction and day-care expenses to be subtracted from gross earnings.

Effective Date: September 1, 1999

Implementation Date: September 1, 1999

Approval for this amendment was received on March 7, 2000

THIRD AMENDMENT

This amendment expanded the benefit package to include outpatient mental health services, disposable medical supplies, inpatient and outpatient substance abuse services, and rehabilitation services.

Effective Date: September 1, 1999

Implementation Date: September 1, 1999

Approval for this amendment was received on March 7, 2000

FOURTH AMENDMENT

This amendment expanded the benefit package to include maternity care.

Effective Date: September 1, 2000

Implementation Date: September 1, 2000

Approval for this amendment was received on December 18, 2000

FIFTH AMENDMENT

This amendment describes the review process for eligibility and enrollment matters in conformance with 42 CFR 457.1120.

Effective Date: August 24, 2001

Implementation Date: August 24, 2001

Approval for this amendment was received on September 19, 2002

SIXTH AMENDMENT

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

5

This amendment included an increase in the work deduction $90 per month to $120 per month for each employed family member whose income must be counted in determining eligibility ($120 monthly/$1440 annually).

Effective Date: November 1, 2003

Implementation Date: November 1, 2003

Approval for this amendment was received on March 29, 2004

SEVENTH AMENDMENT

This amendment increases the income eligibility for CHIP from 200% of the FPL to 300% of the FPL. It adds federal reimbursement for coverage for children whose families have income greater than 200% FPL, but no greater than 300% FPL and allows for premiums and co-payments for the expanded population. This amendment also includes a period of uninsurance of six months for children over the age of two in households with income greater than 200% FPL.

Effective Date: January 1, 2007

Implementation Date: March 1, 2007

Approval for this amendment was received on: February 20, 2007

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

6

Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B))

2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

A. Public-Private Health Insurance Program

Children’s Health Insurance Program (CHIP)

The Children’s Health Insurance Act, 62 P.S. §§ 5001.101 et seq., as amended by Act 68 of 1998, 40 P.S. §§ 991.2301 et seq. (the Children’s Health Care Act), and Act 136 of 2006, was originally enacted in December 1992 and implemented in May of 1993 (see Appendix A for a copy of the Children’s Health Care Act as amended [the “Act”]). The Program provides Free or Subsidized insurance for children in low-income families who are not eligible for Medicaid or not otherwise insured through private or employer- based insurance. The program also allows those that do not meet the income guidelines to purchase the coverage at the state’s negotiated rate. (See Appendix B, Children’s Health Coverage in Pennsylvania). CHIP is administered by the Pennsylvania Insurance Department through individual contracts with eight health insurance companies (hereinafter referred to as Contractors). Under terms of the contract, Pennsylvania requires the Contractors to:

• Conduct outreach • Utilize CAPS to determine eligibility • Enroll and renew enrollment for eligible children • Provide required in-plan services • Contract with qualified providers to provide primary and preventative health care • Provide parent health education • Perform quality assurance tasks (including but not limited to monitoring of quality of care and health outcomes)

CHIP provides free coverage to children from birth through age 18 whose family income is no greater than 200% of the Federal Poverty Level (FPL). Subsidized coverage is provided to children from birth through age 18 in families whose income is greater than 200% but no greater than 300% of the

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

7

FPL. The free and subsidized programs are funded by State and Federal funds. Families whose income is greater than 300% FPL may purchase the CHIP benefit package at the rate negotiated by the Commonwealth. The buy- in program is not supported through State or Federal funds. Additionally, utilization experience of the buy-in program is not included in rate setting for the free and subsidized programs.

The Program is administered by the Pennsylvania Insurance Department (see Appendix A, the Act , Section 2311(G)(1)). In addition, the Act provides for a Children’s Health Advisory Council. The Council consists of fourteen voting members, seven (7) of whom appointed by the Insurance Commissioner. The Council also includes the Secretary of Health, the Insurance Commissioner, the Secretary of Public Welfare, or their respective designees (see Appendix A, the Act , Section 2311 (I)). Its primary functions are to review outreach activities; and to review and evaluate the accessibility and availability of services to children enrolled in the program.

B. Public Insurance Program

Pennsylvania has operated a categorically and medically needy Medicaid program for many years. However, major program expansions have occurred.

In 1988, the State implemented Federally-mandated coverage for pregnant women and qualified children. This coverage was designated as Healthy Beginnings. Healthy Beginnings provides medical coverage to pregnant women and infants up to age one (Income Standard: 185% FPL); children ages one to six (Income Standard: 133% FPL); and children ages six and born after September 30, 1983 (Income Standard: 100% FPL). Early periodic screening, diagnosis and treatment provide comprehensive health services to all persons under age 21 who are receiving Medicaid. These services include check-ups and follow-up care. Pennsylvania has also elected to provide presumptive eligibility to pregnant women thereby encouraging early prenatal care and providing payment for outpatient primary care expenses incurred during pregnancy.

See Appendix C for the number of children currently enrolled in CHIP and Medicaid

C. Private Health Insurance Programs for Low Income Families

Special Care Program

Description: Special Care is a low cost insurance plan offered statewide to low-income residents by Pennsylvania Blue

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

8

Cross plans and Pennsylvania Blue Shield. Special Care provides basic preventive care services to children and adults ineligible for CHIP and Medicaid who cannot afford private health insurance. Special Care provides protection for families by covering the high cost of hospitalization, surgery, emergency medical care in addition to routine primary care.

2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance):

The Commonwealth is committed to providing access to quality health care coverage and to improving the health status of its children. Of particular concern are children of low-income families; families with limited access to care; and families having children with special needs due to chronic or disabling conditions. (Special needs programs include spina bifida, diabetes, asthma, hepatitis B, etc.)

To achieve the goal of providing access to health care, the Commonwealth has brought together a unique interagency consortium dedicated to increasing awareness and enrollment in both CHIP and Medicaid. Senior and management staff of the Departments of Insurance, Public Welfare, Health and Education meet to do strategic planning, to monitor progress, and to problem solve. In addition to time and effort, three of these agencies (Insurance, Public Welfare and Health) have also jointly committed funding to a multi-media and multi- faceted public awareness campaign for CHIP, Medicaid and Maternal and Child Health services.

The interagency agenda for increasing awareness and enrollment includes but is not limited to:

• Establishing a single statewide toll-free number (1-800- 986-KIDS) to provide access to helpline staff who inform, refer, and assist in applying for CHIP and Medicaid. • Jointly funding a multi-year contract with a media consultant. • Developing complementary media messages about the availability of healthcare coverage and the importance of preventative care.

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

9

• Improving access to enrollment by streamlining eligibility and application practices. • Conducting studies regarding hard-to-reach populations to increase knowledge on how to achieve better results in outreaching to them. • Measuring the effectiveness of our joint efforts by gathering and analyzing available data.

The Department’s particular efforts to identify and enroll all uncovered children who may be eligible for CHIP include but are not limited to the following:

• Conducting a statewide media campaign for CHIP. The campaign includes but is not limited to: paid television, Internet and radio advertisements, , posters, brochures, banners and the like. • Monitoring, measuring and evaluating the effectiveness of the statewide media campaign as well as other outreach strategies initiated and implemented by the Department. • Engaging in collaborative interagency outreach for the purpose of developing and implementing strategies to enroll children in both CHIP and Medicaid. Agencies include but are not limited to: the Department of Education (school- and library-based enrollment), the Department of Health, the Department of Public Welfare, and the Department of Labor and Industry. • Developing a strategic plan to maximize awareness of CHIP with organizations and associations with existing statewide networks. • Implementing school-based outreach and/or enrollment. • Approving and monitoring the outreach and enrollment strategies of CHIP insurance company contractors. • Participating in and providing technical assistance for outreach activities initiated by local community organizations. • Conducting studies which improve the Department’s understanding of issues relating to hard to reach populations and developing outreach strategies recommended by such studies.

As stated above, the Commonwealth is committed to assuring that children receive the healthcare coverage for which they are eligible (either CHIP or Medicaid). If a parent or guardian applies for CHIP

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

10

coverage on behalf of a child and it is determined that the child is ineligible (e.g. because the level of family income is within the Medicaid range), the application and documentation submitted by the parent or guardian is automatically forwarded to the local County Assistance Office (CAO) for the determination of Medicaid eligibility. Conversely, if an application for Medicaid is filed and the child is found ineligible, the application and documentation are forwarded to a CHIP contractor. This practice negates the need for the parent or guardian to file separate applications for the two programs and facilitates enrollment of the child.

The Department has worked closely with the Department of Public Welfare to expand access and simplify the application and renewal process for the CHIP and Medicaid programs through the development of an online application and renewal system called COMPASS (Commonwealth of Pennsylvania Access to Social Services). This web portal allows citizens to screen and apply for CHIP as well as many other social service programs across four Commonwealth agencies with one application. Both departments provide administrative funding for a toll-free helpline that can answer citizens questions about CHIP, Medicaid and various other social service programs, as well as assist callers with completing applications over the phone, utilizing COMPASS.

In 2003, shortly after being sworn into office, Governor Edward G. Rendell created the Governor’s Office of Health Care Reform (GOHCR) aimed at improving access, affordability and quality by rejuvenating the state government’s approach to health care. In January 2004, Pennsylvania launched a statewide data collection effort to more accurately define the characteristics of the state’s uninsured. In July 2004, the GOHCR was given the lead responsibility to apply for a State Planning Grant through the Health Resources and Services Administration (HRSA). The purpose of the grant was to develop a comprehensive plan to provide access to affordable, quality health care coverage for every Pennsylvanian.

In keeping with that goal, in early 2006, the Governor introduced the Cover All Kids expansion that makes CHIP benefits available to all children in the Commonwealth.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

CHIP insurance company contractors are mandated by contract to

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

11

conduct outreach activities.

Each CHIP contractor is required to provide the following outreach information:

• Identification of outreach objectives and activities for the contract period; • Description of activities to locate potentially eligible children; • Requirement that outreach materials be linguistically and culturally appropriate, and that outreach services include specific provisions for reaching special populations; • Indication of whether the contractor will employ a dedicated marketing staff, and if not, submission of a program to assure special efforts are coordinated within overall outreach activities.

Operationally, outreach activities include canvassing local businesses, daycare centers, school districts, CAO’s, hospitals/providers, legislative offices, religious organizations and churches, social service agencies, unions and civic groups, and numerous other organizations and groups.

All contractors employ bilingual representatives who are capable of responding to CHIP inquiries in either English or Spanish. TDD lines allow for communication with the hearing impaired and access to multiple language translating services are also available.

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

See Section 2.2.1

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

12

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 benefits are provided on a statewide basis using a managed care model through eight insurers. The eight insurers are Health Plan Corporations, subsidiaries or affiliates of Health Plan Corporations, Health Maintenance Organizations (HMO), or risk-assuming Preferred Provider Organizations (PPO). One contractor in Central Pennsylvania utilizes a PPO in 21 counties; one contractor has PPOs in two of the same counties in Central Pennsylvania. Those enrollees are provided the same Act 68 protections as the individuals covered by the HMOs.

As a condition of licensure, Managed Care Organizations (MCO’s) in Pennsylvania are required by the Department of Health (DOH) to undergo review by the National Committee for Quality Assurance (NCQA). DOH not only receives and monitors NCQA findings, but also attend the on-site reviews. Because CHIP enrollees utilize the same provider networks as commercial subscribers, the CHIP program relies upon NCQA evaluation and accreditation status as evidence of compliance with program goals, service delivery and objectives concerning quality management and improvement.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

CHIP services are provided primarily through a managed care model, in which enrollees select a primary care physician who is responsible for providing basic primary care services and referrals to other specialty care. For those enrollees in counties with a PPO, a medical home is assigned in lieu of a primary care physician.

As a means of determining the level of utilization, managed care plans systematically track the utilization of health services to identify patterns of over

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

13

and under utilization of health services. In addition, each CHIP Contractor is required to submit specific utilization data to the Department on a quarterly and annual basis. The data includes:

• the number of enrollee visits to primary care physicians, medical specialists, as well as visits for vision, hearing, dental, and mental health services. • the number of prescriptions and the ten most utilized drugs; and • the number of hospital admissions for medical, surgical, maternity, mental health and substance abuse and average length of stay, by age group.

The data collected is analyzed by the Department to identify outliers and potential utilization issues. The Department then works with the plans to further evaluate the outliers and correct problems as necessary during its ongoing utilization review and quality improvement programs.

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

14

Section 4. Eligibility Standards and Methodology. (Section 2102(b))

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 5.

4.1. The following standards may be used to determine eligibility of targeted low- income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1.

Geographic area served by the Plan: 4.1.2.

Age: CHIP provides free coverage to children from birth though 18. (see Appendix A, the Act , section 2311 (D)) 4.1.3.

Income: CHIP provides free coverage to children in families with net income at or under 200% of FPL. Subsidized CHIP will be provided to children in families with net income of greater than 200% of FPL, but not greater than 300% of FPL. “Net” income is determined by subtracting from gross earnings:

• a work deduction for each employed family member whose income must be counted in determining eligibility ($120 monthly/$1440 annually).

• day care expense incurred up to $200 monthly/$2400 annually for a child under age two; up to $175 monthly/$2100 annually for a child over the age of two or for a disabled adult.

After income disregards above are applied and net income is determined for eligibility and cost sharing purposes, all income above 200% up to 300% FPL is disregarded

4.1.4.

Resources (including any standards relating to spend downs and disposition of resources): 4.1.5.

Residency (so long as residency requirement is not based on length of time in state): 4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility): 4.1.7.

Access to or coverage under other health coverage: Pennsylvania requires that children be totally uninsured or ineligible for Medicaid to be eligible for CHIP. Contractors have the capacity to compare enrollee families to their own company subscribers to verify whether the family has private or employer

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

15

sponsored coverage. We currently match new applications against a Medicaid data base to ensure the applicants are not already enrolled in Medicaid. Effective with the implementation of state plan amendment, the Commonwealth will also run a match through a Third Party Liability contract to assist in the determination that the applicants do not currently have private insurance and that the required period of uninsurance has been met.

4.1.8.

Duration of eligibility: Children are guaranteed a minimum of 12 months coverage and are recertified on their anniversary date.

4.1.9.

Other standards (identify and describe):

• A child must be a citizen of the United States, a U.S. national, or a qualified alien, consistent with SCHIP regulations defined at 42 CFR 457.320(b)(6).

• Children over the age of 2 whose family’s net income is greater than 200% of FPL will be subject to a period of uninsurance. The period of uninsurance is defined as six months prior to enrollment, except as specified in 4.4.4.2.

• To facilitate cross matches between information technology systems, Social Security numbers will be requested on applications. If an applicant does not yet have a social security number, the insurance contractor will conduct outreach to the applicant to obtain the number. An application will not be delayed nor denied due to the absence of the Social Security number.

4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

4.2.1.

These standards do not discriminate on the basis of diagnosis. 4.2.2.

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3.

These standards do not deny eligibility based on a child having a pre-existing medical condition.

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

CHIP Contractors enter application data into the Commonwealth’s CHIP and adultBasic Processing System (CAPS). CAPS is the automated system

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

16

developed by the Department for the purpose of determining eligibility for CHIP and adultBasic. Applications for enrollment and re-enrollment are received via: the internet through the Commonwealth of Pennsylvania’s Access to Social Services (COMPASS); telephone through calls to the Health and Human Services Helpline; through referrals from the Medicaid agency; or, a mail-in process. Data matches with other agencies, health insurance carriers and employers are conducted after an application is entered into CAPS and prior to a final determination of eligibility. Contractors enroll children on a prospective basis on the first of each month. Contractors are provided with the CHIP Procedures Manual and other forms of instruction (i.e. CHIP Transmittals) which prescribe the method and procedures to be used in the determination of eligibility. Parts I and II of the manual prescribe:

• Basic eligibility requirements relating to income, age, residency, citizenship, and the lawful status of non-citizens • Verification requirements (required for income only unless, in the judgment of the contractor, other verification is needed to clarify incomplete or inconsistent information provided on the application) • Application processing standards (a decision on eligibility or ineligibility must be made within fifteen calendar days from the receipt of a complete application) • Notification requirements for notices of eligibility, ineligibility, renewal and termination

4.3.1. Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

Check here if this section does not apply to your state.

The Commonwealth would closely monitor expenditures of SCHIP funds. If necessary and feasible, we would cap the number of new enrollees in the expanded population (those above 200% of the FPL) and create a waiting list for that population to ensure we do not exceed our SCHIP allotment for the year. Prior to implementing a cap and waiting list, the state will provide CMS with appropriate notifications. Other actions at time of decision include: • Publication in the Pennsylvania Bulletin 60 days prior as public notification • Include waiting list information on CHIP and COMPASS web sites

New applications would still be accepted through the normal processes. Screen and enroll procedures for Medicaid would remain unchanged. Eligibility would be run on all applications. The applications of individuals that appear to be eligible for Medicaid would be forwarded to the Department of Public Welfare for eligibility determination. Those applicants not eligible for Medicaid

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

17

would be put on the waitlist with an effective date of the date when the contractor received a complete enough application to enter into CAPS for an eligibility determination. On a monthly basis, the Commonwealth would make an assessment of the number of enrollees against the appropriated funds for the program. As additional funds would become available (either through attrition of enrollees or more funding is identified) applicants on the waitlist would be notified of the availability of coverage through CHIP. A determination would be made as to the number of new enrollees that could be accommodated with the identified funds. Notifications would go out first to those applicants with the earliest completion date; thus a first come, first served process. To update eligibility, applicants would need to attest that there have not been any changes to their family circumstances (e.g. number in household, income, insurance status, and the like). If changes have occurred, the new information would be added into CAPS and eligibility is re-determined. The signing of the attestation or the submission of additional information would be the basis for a new eligibility date and the 12 months of eligibility would begin with the enrollment. It is not expected that enrollees would be affected by any caps or waiting lists that may be implemented.

4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3))

Families declare on the application form whether their children are receiving Medicaid or some other form of health insurance coverage. Only those children without another source of creditable coverage are enrolled in CHIP. CHIP contractors compare applicants’ names against their commercial subscribers to determine if they have health insurance coverage through their companies. Matches are also conducted against Medicaid Client Information (CIS) files to determine if a child is already enrolled in Medicaid. With the CHIP expansion, we will include a match of all new applications against the Department of Public Welfare’s Third Party Liability database to assist in the determination that applicants do not have creditable private insurance and meet the state’s required period of uninsurance. We will also run a full enrollment match on a minimum of a quarterly basis to verify that enrollees have not picked up private insurance during the enrollment period. The combination of these efforts gives a high degree of assurance that coverage is received only by those without another source of coverage.

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

18

Screening procedures at initial application and at times of renewal ensure that a child will not be enrolled in CHIP if a child is found eligible for Medicaid.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

A process known as “Any Form is a Good Form” was adopted in February 1999 which facilitates enrollment in both CHIP and Medicaid. Application documents with a common set of data elements are being utilized to accommodate both the CHIP and Medicaid Program. Application materials for children determined ineligible for Medicaid because family income is within the CHIP range are sent to a CHIP Contractor for a determination of eligibility for CHIP. Application materials for children determined ineligible for CHIP because family income is within the Medicaid range are sent to the appropriate County Assistance Office for a determination of eligibility for Medicaid.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

See Section 4.4.2

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

Pennsylvania has taken a number of steps to guard against and monitor for crowd-out. Questions regarding insurance coverage are contained on the application and renewal forms and cross matches against Medicaid and private insurance files are completed to help determine that only uninsured children are enrolled. Data regarding private insurance coverage is collected and reported in the required annual SCHIP report.

Pennsylvania enjoys one of the nation’s highest rates of

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

19

the persons insured by employer based coverage. The continued stability of the rate of employer based coverage supports the hypothesis that no serious degree of “crowd out” has or is occurring as the result of expansion of publicly funded health care programs.

4.4.4.2. Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

Monitoring: Pennsylvania will continue to monitor the rate of employer based coverage for changes. In addition to using information obtained from the applications, Pennsylvania is implementing a cross match through a Third Party Liability contract to determine current and recent health insurance status. This match will assist in the determination that the applicant is currently uninsured and has met the required period of uninsurance. This match will also provide us a source of data, other than applicant provided information, on the number of individuals who applied for CHIP and had private insurance within the previous six months prior to application. With the addition of this data, we will be able to more accurately determine the possibility of substitution among these individuals.

Strategy to limit substitution – children over the age of two: Pennsylvania is implementing an uninsured period of six months. Children, over the age of two with a net income of over 200% of FPL, who were covered by a health insurance plan, a self-insurance plan or a self funded plan, are not eligible to enroll in CHIP for a period of six months following the end date of the private insurance except if the child’s parent is eligible to receive unemployment compensation or is no longer employed and is ineligible for unemployment compensation, or the child is transferring from one government subsidized health care program to another.

Another disincentive for dropping private coverage is the addition of cost sharing (premiums and copayments) in the CHIP benefit package for families with net incomes greater than 200% of FPL.

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

20

Strategy to limit substitution - children under the age of two: In addition to monitoring for overall level of substitution, we will compare the data for the 0 - 2 year olds with data for 2 – 5 year olds to determine if the no period of uninsurance for the 0 – 2 year olds is significantly increasing the rate of substitution in Pennsylvania. If the rate of substitution in the under-2 year olds approaches one and a half times that for 2 – 5 year olds, Pennsylvania will consider implementing a one or two month period of uninsurance. If the rate of substitution continues to grow in the under-2 year olds to a point of twice that of the 2 – 5 year olds, Pennsylvania will consider increasing the period of uninsurance incrementally up to six months.

Cost sharing requirements (premiums and copayments) also apply to the under age two group.

4.4.4.3. Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution.

Please see 4.4.4.2.

If Pennsylvania finds a significant level of substitution (10% of enrollees dropping or being dropped from private coverage), it will reevaluate the exceptions to the waiting period to determine if they are contributing to substitution and modify them as necessary. We would also consider incrementally increasing the uninsured period up to an additional 6 months to reverse the substitution trend.

Another strategic option that is available is to increase the cost sharing requirements for this target population to deter substitution.

Pennsylvania’s Office of Health Care Reform is nearing the end of its study to develop a strategic, time-phased plan to provide affordable, accessible quality health care coverage for all Pennsylvanians. It is expected that this strategic plan will include viable suggestions on how to best reform Pennsylvania’s overall health care system, negating any incentives for employers or employees to drop employer-based health insurance coverage.

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

21

4.4.4.4. If the state provides coverage under a premium assistance program, describe:

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

The minimum employer contribution.

The cost-effectiveness determination.

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

Pennsylvania does not have any American Indian tribes recognized by the Federal or State government. However, outreach and enrollment strategies outlined in Section 5 include all children, including American Indians and Alaska Natives.

The application form requests information regarding the applicant’s racial and ethnic identity, including whether the child is an American Indian or Alaska Native. This information is collected and reported as required.

See Appendix C

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

22

Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90)

The Commonwealth is committed to providing access to quality health care coverage and to improving access to coverage. The achieve this goal, the Commonwealth brought together a unique interagency consortium dedicated to increasing public awareness of and enrollment in both CHIP and Medicaid. Senior Management staff and others in the Departments of Insurance, Public Welfare, Health and Education meet regularly to do strategic planning, to monitor progress, and to problem solve. In addition to time and effort, three of these agencies have also jointly committed funding to a multi-media and multi- faceted public awareness campaign for CHIP, Medicaid and Maternal and Child Health services. This unique consortium has been cited by the Health Care Financing Administration as a best practice to be emulated by other states.

The agenda for increasing awareness and enrollment includes but is not limited to:

• Broad based marketing strategies using television, Internet and radio advertising to increase public awareness of the program and to encourage families to enroll their children. • Targeted marketing to special populations to address cultural diversity and barriers to participation. • Strong relationships with other public and private agencies to promote outreach and enrollment activities. • Utilizing (e.g. on-line application) technology to create optional methodologies for enrollment in CHIP. • Establishing a single statewide toll-free number (1-800-986-KIDS) to provide access to helpline staff who inform, refer and assist in applying for CHIP and Medicaid, the Special Kids Network and other public programs (e.g. WIC). • Increasing access to coverage by improving eligibility and enrollment practices. • Conducting market research to improve targeted marketing and outreach. • Measuring the effectiveness of all efforts by gathering and analyzing available data.

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

23

Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

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 7.

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a))

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1. FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions.

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

A. Benefits Package: (See Appendix D, Benefits

Chart, submitted with previous State Plan Amendment). Also, note Section 6.2. which denotes benefits provided by Contractors beyond the minimums required by the Act).

B. Administration: CHIP is administered by the Insurance Department (see Appendix A, Section 2311 (G)(1)). The Insurance Department is required by statute to:

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

24

(1) Review all bids and approve and execute all contracts for the purpose of expanding access to health care services for eligible children (See Appendix A, Section 2311 (G)(2)):

(2) Conduct monitoring and oversight of contracts entered into (See Appendix A, Section 2311 (G)(3)):

(3) Issue an annual report to the Governor, the General Assembly, and the Public for each fiscal year outlining primary health services funded for the year, detailing the outreach and enrollment efforts, and reporting by county the number of children receiving health care services from the fund, and the projected number of eligible children (see Appendix A, Section 2311 (G)(4)):

(4) In consultation with other Commonwealth agencies (e.g. the Departments of Health, Welfare and Education), monitor, review and evaluate the adequacy, accessibility and availability of services delivered to enrolled children (see Appendix A, Section 2311 (G)(6)):

(5) Promulgate regulations necessary for the administration of the program (see Appendix A, Section 2311 (H)):

(6) Establish the Children’s Health Insurance Advisory Council (see Appendix A, Section 2311 (I)):

(7) Solicit bids and award contracts through a competitive procurement process (see Appendix A, Section 2311 (J)):

(8) In consultation with appropriate Commonwealth agencies, review enrollment patterns for the program (see Appendix A, Section 2311 (N)): and

(9) In consultation with appropriate Commonwealth agencies, coordinate the development of an outreach plan to inform potential contractors, providers and enrollees regarding eligibility and available benefits (see Appendix A, Section 2312).

C. Program Enactment and Effective Date: The Children’s Health Insurance Act, 62 P.S. §§ 5001.101, et seq., was enacted in December 1992 and implemented in May of 1993. The Act was amended on June 17, 1998 by Act 68 of 1998, 40 P.S. §§ 991.2301 et seq., and on November 2, 2006 by Act 136 of 2006

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

25

(see Appendix A).

D. Fiscal year 1996 state expenditures for CHIP are as follows: CHIP expenditures in fiscal year 1996 totaled $31,611,373, including an expenditure of $30,685,814 for its Free Program, and $915,559 for its Subsidized Program.

6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

6.1.4.1. Coverage the same as Medicaid State plan

6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration project

6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population

6.1.4.4. Coverage that includes benchmark coverage plus additional coverage

6.1.4.5. Coverage that is the same as defined by existing comprehensive state-based coverage

6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done)

6.1.4.7. Other (Describe)

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

26

6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

Pennsylvania assures that the benefit package described below is identical to the coverage offered as of August 5, 1997 except for the addition of benefits which have been approved in subsequent state plan amendments

6.2.1.

Inpatient services (Section 2110(a)(1)) CHIP enrollees are entitled to 90 days of hospitalization per year (combined physical and mental health).

6.2.2.

Outpatient services (Section 2110(a)(2))

6.2.3.

Physician services (Section 2110(a)(3))

6.2.4.

Surgical services (Section 2110(a)(4))

Cosmetic surgery not included

6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

6.2.6.

Prescription drugs (Section 2110(a)(6))

6.2.7.

Over-the-counter medications (Section 2110(a)(7))

6.2.8.

Laboratory and radiological services (Section 2110(a)(8))

6.2.9.

Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9))

Includes counseling, education and related services to prevent and address the consequences of at-risk behaviors related to sexually transmitted diseases (STDs) and pregnancy.

6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10))

Inpatient mental health services are subject to the same 90-day limitation as physical health services

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

27

6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

Outpatient mental health services are limited to 50 visits per year and include case management designed to promote coordination, monitoring, and access to any medically necessary service or resource to provide support, training and assistance designed to enable CHIP enrollees to function in family, school and community; individual, group or family therapy which is office or community based (family, home, school, daycare, etc.); appropriate and medically necessary intervention in the home, school or other community setting with an emphasis on family involvement in enrollee treatment; and prescription medication.

6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

6.2.13.

Disposable medical supplies (Section 2110(a)(13))

6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14))

6.2.15.

Nursing care services (See instructions) (Section 2110(a)(15))

6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16)

6.2.17.

Dental services (Section 2110(a)(17))

6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) • Inpatient Treatment – Detoxification limited to seven (7) days per year, with a lifetime maximum of four (4) inpatient admissions • Non-hospital Residential treatment – Ninety (90) days per year; lifetime maximum of three hundred sixty days (360)

6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19)) • Outpatient treatment – Ninety (90) full-session visits per year;

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

28

lifetime maximum of three hundred sixty days (360)

6.2.20.

Case management services (Section 2110(a)(20))

6.2.21.

Care coordination services (Section 2110(a)(21))

6.2.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) • Speech, occupational, and physical therapy (sixty (60) visits per therapy, per year) • Chemotherapy, dialysis, respiratory, and radiation therapy are unlimited

6.2.23.

Hospice care (Section 2110(a)(23))

6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24))

6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.26.

Medical transportation (Section 2110(a)(26))

Ambulance services are provided when medically necessary.

6.2.27.

Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27))

6.2.28.

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480) 6.3.1.

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR

6.3.2.

The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

29

6.4 Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

6.4.1. Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above.; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

30

6.4.2. Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low- income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a))

6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b))

6.4.2.3. The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

31

Section 7. Quality and Appropriateness of Care

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 8.

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495(a))

CHIP provides services to enrolled children primarily through a managed care model. By state law and regulation, all of the CHIP Contractor delivery systems are state licensed managed care organizations (predominantly HMOs, though two of them use PPO delivery systems in limited counties) which, as a condition of licensure, must undergo periodic external reviews of their quality assurance systems and the quality of care provided to their members. These reviews are required within one year of licensure and again at three-year intervals or for cause. The reviews are performed by the National Committee for Quality Assurance (“NCQA”) with Health Department participation. The scope of review includes a detailed examination of the plan’s quality assurance/improvement program including access, availability, continuity of care, and preventive and health maintenance services to members, including CHIP-enrolled children. With the assistance of the Department of Health, the Department identified opportunities for improvement are the responsibility of Health Department staff. These staff also independently assess managed care compliance with current state regulations on a periodic basis.

CHIP enrollees also have access to a complaint and grievance resolution process through their managed care plans. This process is mandated by state laws (Act 1998- 68) for all managed care organizations and requires members to go through a two-step process at the HMO level, with the second level including one-third member representation in the decision-making process. If the member is still dissatisfied, he or she has the right to appeal the plan’s decision to the Department of Health. The Contractor is required to have a data system in place capable of tracking and trending all complaints and grievances. In addition to assuring that appropriate care is accessible to members, this process also enables the Department to track and identify patterns of inappropriate care or service.

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

32

7.1.1.

Quality standards

The Department has established Quality Management and Utilization Management requirements to which the insurer is contractually bound. See Appendix E (Provided in the original State Plan) which contains requirements as specified in the Departments Request for Procurement.

7.1.2.

Performance measurement

In addition to evaluating contractors based on their overall NCQA accreditation ratings, the program also conducts Health Employer Data Information Set (HEDIS) reviews which compare the CHIP population with the commercial subscribers of the insurer. In addition, the program has started doing direct comparisons of its HEDIS data with medical assistance programs regionally and nationally.

During FY 2000 the Department, for the first time, began collecting HEDIS data and will continue to do so annually thereafter.

The Department is utilizing the technical assistance (TA) services funded through the Maternal and Child Health Bureau and sponsored in collaboration with the Center for Medicare and Medical Services. Under this initiative, referred to as CompCare, Pennsylvania has requested assistance from Health Systems Research, Inc. (HSR) in developing a system to monitor and measure the quality of care provided under the program. The specific goals of the project include:

• Assessing the capacity of contracting plans to collect and submit data; • Presenting and facilitating the selection of a set of appropriate, feasible indicators of the quality of care provided to children under CHIP; • Identifying data sources for each of the selected indicators; and • Pilot-testing the data collection plan to analyze and interpret the selected indicators.

To assist in the initial step of the TA project effort, HSR contracted with NCQA’s Quality Solution Group to conduct a readiness assessment of the Department’s contracted health

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

33

plans. This assessment is intended to evaluate the plans’ collection of accurate HEDIS data, to submit high quality encounter data, and to administer timely consumer surveys. HRS concluded that the contracted insurers are equipped to accurately collect the required performance data.

7.1.3.

Information strategies

All CHIP enrollees receive membership handbooks (see Appendix F (provided with the original State Plan submission), sample handbook which describes the benefits provided to enrollees under the Program). These materials also describe members’ rights and responsibilities and the specific steps to appeal any medical or service issue to the plan and to the Department of Health. All service denials or reduction in benefits must also contain information about how to appeal the decision through the member grievance process. Managed care plan providers have developed a multitude of member educational materials and informational items that encourage CHIP enrollees to obtain age-appropriate health services and preventive care. These are distributed widely by the plans.

CHIP collects information from the eight CHIP Contractors on a quarterly and annual basis. This reporting provides information on CHIP enrollment, demographic and ethnic characteristics, outreach efforts, use of medical and dental services, member grievance information, and data on financial expenditures. Information is used by Program managers to document performance and promote adequate Program accountability. The data elements are updated on specific needs as identified.

7.1.4.

Quality improvement strategies

Several key initiatives mentioned herein are the basis for individual and collective quality improvement activities.

• Based on the clinical standards adopted and the data obtained from external reviews, each of the eight contractors have been required to identify appropriate mechanisms for improving the provision of preventative and health maintenance services for children enrolled in CHIP.

• The Department and the contractors work together

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

34

to implement interventions that will raise the rates of preventative services to conform with established CHIP goals. Such intervention includes:

o patient information on the availability and necessity of services; o parent education o a system of patient reminders; o member satisfaction surveys to detect barriers to accessing care; o community-based education; o physician education; o immunization registries which follow children across providers and insurance programs.

7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

State-licensed HMOs are the principal Contractor health service provider entity for CHIP enrollees. Under Pennsylvania statute, these entities are subject to oversight and regulation by the Department of Health and the Insurance Department, which also have joint licensing authority of these entities (see 40 P.S. 1551, et seq. and 31 Pa. Code, Chapters 301-303) The Insurance Department is primarily responsible for monitoring initial capitalization and financial solvency. The Department of Health is charged with monitoring quality of care and assuring the availability of and accessibility to health

services.

To obtain licensure, certain requirements regarding availability and access

must be satisfied by an HMO. These requirements are:

• coverage for basic health services, including emergency services; • provisions for access to a primary care physician for each subscriber; • evidence of arrangements for the ten most commonly used specialties; • policies on obtaining referrals for specialty care; • professional staff standards (for example, there must be at least one full-time primary care physician per 1600 members); • physician and provider network capacities.

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

35

Many of these requirements are evaluated initially upon licensure; upon request for service area expansion; and periodically through complaint and grievance monitoring,

on-site visits by Department of Health staff, external reviews by NCQA, and various quarterly and annual reports addressing the provider delivery systems of the CHIP Contractors.

As part of the annual re-contracting process, Contractor health service delivery system information is assessed to assure an adequate number and distribution of providers and facilities of all types.

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

Primary care, including well-child care is provided in accordance with the schedule established by the American Academy of Pediatrics. Services related to those visits, include, but are not limited to, immunizations, health education, tuberculosis testing and developmental screening in accordance with routine schedule of well- child visits. Care must also include a comprehensive physical examination, including X-rays if necessary, for any child exhibiting symptoms of possible child abuse.

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))

Contractors must establish and maintain adequate provider networks as determined by the Department of Health to serve all eligible children who are or may be enrolled, to include, but not be limited to: hospitals, children’s tertiary care hospitals, specialty clinics, trauma centers, pediatricians, specialists, physicians, pharmacies, dentists, substance abuse treatment facilities, emergency transportation services, rehab facilities, home health agencies and DME suppliers in sufficient numbers and geographic dispersions to make available all services in a timely manner. Covered services must be provided out-of-network if such services are not available in a timely and accessible manner through in-network providers. In accordance with Article XXI Section 2111, of Act 1998-68, and 28 Pa. Code Sections 9.679(D) and 9.679(E), the contractor must have adequate health care available in a timely and accessible manner through its network providers. Contractors not utilizing provider networks shall implement procedures to ensure these standards are met by providers providing coverage to their enrollees.

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

36

Contractors cannot discriminate against CHIP enrollees by offering them access to physician services which differ from the access offered commercial enrollees. For example, a plan may not specifically close a practice to CHIP enrollees if the practice is open to commercial enrollees.

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))

See response to 7.2.2

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

Decisions related to the prior authorization of health services are made in accordance with State law (Act 1998-68). Contractors must establish and maintain written policies and procedures relating to prior authorization of health services that must be submitted for review and comment by the Department. Contractors must individually identify service(s), medical item(s), and/or therapeutic categories of drugs to be prior authorized. In addition, the list and scope of services to be prior authorized must be approved by the Department.

The policies and procedures must include an expedited review process to address situations when an item or service must be provided in an urgent basis.

Contractors must demonstrate how written policies and procedures for requests for prior authorization comply and are integrated with the enrollee notification requirements and enrollee grievance and appeal procedures. Section 8. Cost Sharing and Payment (Section 2103(e))

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 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

37

8.1.1.

YES 8.1.2.

NO, skip to question 8.8.

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c))

Children with a family net income of 200% of FPL or less will not be subject to any cost sharing requirements.

8.2.1. Premiums: If the family net income is determined to be above 200% FPL, the family will be required to share in the cost of the coverage. The negotiated rate for calendar year 2007 is expected to average approximately $149 statewide. The per child monthly premiums are:

Percent FPL Per Child >200 – 250 25 percent of the state negotiated rate (approx $37.25for 2007) >250 – 275 35 percent of the state negotiated rate (approx $52.15 for 2007) >275 – 300 40 percent of the state negotiated rate (approx $59.60 for 2007) >300 Full cost of coverage as negotiated by the Commonwealth with each of the contractors. This (>300% coverage) is a full payment program and is not included in any Title XXI funding.

Premiums will be due to the contractors on an established date prior to the first of the month for which premiums are paid.

8.2.2. Deductibles: Not applicable

8.2.3. Coinsurance or copayments: Coinsurance is not applicable

Copayments: For children in families with net income greater than 200% FPL, but less than 300% FPL, the Commonwealth has established reasonable copayments for services other than the following: well-baby; well-child; immunizations; or emergency care that results in admissions.

Copayments are as follows:

Primary Care visits $5 Specialists

$10

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

38

Emergency Care $25 (waived if admitted) Prescriptions $6 for generic and $9 for brand names

Copayments are limited to physical health and do not include routine preventive and diagnostic dental services or vision services. Copayments will be due at the point of service.

8.2.4. Other: Not applicable

8.3. Describe how the public will be notified, including the public schedule, of this cost-sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b))

Notice of the initial premiums and the cost sharing requirements will be published in the Pennsylvania Bulletin prior to the requested effective date of the state plan amendment. Premiums, copayments, and the benefit plan were all included in statewide public hearings regarding the Cover All Kids initiative to expand Pennsylvania’s CHIP. Adequate time has been allotted for anyone to provide comment on any aspect of the expansion. This information was also shared at the following meetings in October 2006:

• Medical Assistance Advisory Committee (MAAC) Presentation – The Commonwealth presented the plan and program design at a MAAC meeting, which is a monthly meeting conducted by DPW for the purpose of presenting and gaining input from stakeholders on issues of policy development and program administration. MAAC is open to the public and is composed of Commonwealth citizens who have experience, knowledge, and interest in the delivery of health care services to low-income citizens and medically vulnerable groups. Members include physicians and other providers, representatives of managed care organizations under contract with the Department, representatives of consumer and provider organizations, current Medicaid recipients and parents of minor child recipients. The Commonwealth will provide copies of the SPA it submits to CMS to committee members upon request. • Consumer Subcommittee of MAAC – The Commonwealth presented the plan and program design at a Consumer Subcommittee meeting, which is a monthly subcommittee meeting conducted by DPW for the purpose of reviewing and advising the MAAC on policy development and program administration of publicly funded medical assistance (MA) programs. The Consumer Subcommittee’s mission is to be a resource to the MAAC, enabling the committee to advise the Department of Public Welfare on issues regarding access to service and quality of service. A majority of the members of the Consumer Subcommittee are current MA recipients and may also include representatives of: low-income groups whose

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

39

membership is primarily medical assistance recipients; advisory groups advocating on health care issues for low-income Pennsylvanians; aging or elderly consumer groups advocating on health care issues for low-income Pennsylvanians; disease or health care condition specific groups; Hispanic or other ethnic groups advocating on health care issues for low-income Pennsylvanians; former recipients (within past year); parents of minor child recipients; families of recipients; and others knowledgeable and interested in matters that come before the Subcommittee. At least one, but no more than two, members of the Consumer Subcommittee may serve on other subcommittees. • Income Maintenance Advisory Committee (IMAC) - The Commonwealth presented the proposed waiver and program design at an IMAC meeting, which is a bi-monthly meeting conducted by DPW for the purpose of advising the Department on the development and implementation of policies and procedures relating to cash assistance, food stamps, the Low- Income Energy Assistance Program (LIHEAP) and eligibility for Medicaid. The IMAC is composed of 17 members: 12 Medicaid recipients, four advocates and an Executive Director of a County Assistance Office. The Committee Members meet every other month with Department staff in Harrisburg, Pennsylvania. The Commonwealth will provide copies of the SPA to Committee Members upon request. • CHIP Advisory Committee Presentation – The Commonwealth presented the plan and general program design at the CHIP Advisory Council meeting. The purpose of the CHIP Advisory Council is to advise the Commonwealth on CHIP outreach activities and to review and evaluate the accessibility and availability of services delivered to children enrolled in CHIP. This meeting is open to the public.

All of Pennsylvania’s CHIP outreach and enrollment materials will display the eligibility requirements, coverage types and cost sharing requirements. The CHIP contractors will include cost sharing requirements in the member handbooks and in letters sent to the applicant that provide notification of eligibility for CHIP. Eligibility letters will also clearly indicate the cumulative maximum cost sharing (5% of gross income) expected of the family. Information about cost sharing will also be available through the Health and Human Services Help Line at 1-800-986-KIDS. Any changes to costs will be included in correspondence to enrollees a minimum of 30 days in advance of the changes.

8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1.

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530)

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

40

8.4.2. No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520)

8.4.3

No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

The cost sharing requirement was designed to only include modest premiums and copayments. Only rare circumstances of low income families combined with very high utilization of non-preventive services by multiple family members would result in families potentially exceeding the 5 percent of family income ceiling. The cost-sharing limit will be calculated annually starting with the date of initial enrollment of any children in the family or the annual re- enrollment date. Premium payments will be required monthly, but the need to continue premium payment for the entire 12-month eligibility period will be taken into account in determining if/when the cost-sharing cap has been exceeded.

The initial letter announcing enrollment in a subsidized program will include notification of the requirements for the cost sharing, the family limitation on cost sharing based upon the reported gross income, the requirement for the family to keep track of the cost sharing amounts paid and instructions on what to do when the family’s cost sharing limits have been exceeded. Families will be instructed to contact the state when the cap is met and then to submit copies of the receipts for calculation. Pennsylvania’s claims processing is decentralized to each of the eight insurance contractors. Therefore, there is no simple way for the state to track the copayments made. Additionally, all children are enrolled in our eligibility and enrollment system as separate cases and it would be difficult to provide a linkage to get to family output.

Once the limits have been exceeded, a family can apply to the state for a rebate of any cost sharing already paid in excess of the limit. Upon verification that the family exceeded the 5% cost sharing limit, the state will issue a letter to each child in the family to present to the provider that explains that cost sharing is exempt until a specified date (redetermination date) that will be included on the letter. The appropriate contractors will also receive the letter and will then know that premiums will not be required from the enrollees until the next eligibility period begins.

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

41

8.6 Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

Pennsylvania ensures that American Indian and Alaska Native children will be excluded from cost sharing by collecting information on the application and at the time of redetermination of eligibility regarding a child’s status as an American Indian or Alaska Native. The applicant/enrollee will be asked to indicate their tribal membership by stating this on the application. If they are found to be in the American Indian or Alaska Native category, the family will be notified of the exemption and an identification card will be issued with an appropriate group number that excludes cost sharing. All providers are required to verify eligibility by checking the enrollment card which contains a notation regarding copayments, as is the telephone eligibility verification system used by providers.

8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c)) Failure to pay the premium for the subsidized program may result in termination. Contractors provide for a 10-day grace period for the receipt of premiums. A notice of proposed termination must be sent to the parent or guardian at least 30 calendar days in advance of the effective date of termination. The notice will include the effective date of termination, the reason for termination (non-payment of premium), what corrective measures may be taken to prevent termination from occurring (appeal the decision to the eligibility review officer or provide proof of a decrease in income since the determination was made), and the contact number for any questions or to resolve the situation.

Upon receipt of the termination notice, the enrollee may provide income information that would lead to a reassessment of their eligibility. During a reassessment, eligibility is redetermined. If income appears to have decreased enough that the enrollee appears they may be eligible for Medicaid, the termination is stayed for 60 days and the application and supporting documentation are forwarded to Medicaid for an eligibility determination. If Medicaid denies for income too high, the enrollee will be evaluated for continued coverage in CHIP. For example, if reassessment found the enrollee possibly eligible for Medicaid, they would most likely qualify for free CHIP and would be re-enrolled in the program with no lapse in coverage. Along the same lines, if reassessment results in an income in a lower premium bracket, the individual will be offered the opportunity to pay the lower premium and be re-enrolled in the program.

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

42

If the enrollee disagrees with the reassessment results, the enrollee may request an impartial review through the existing Eligibility Review Process (ERP) (please see section 12.1). An enrollee remains enrolled in the current program as long as premiums are paid while the (impartial) ERP officer reviews the case.

Copayments will be required at the time of service. Service can be denied if copayments are not paid.

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non payment of cost-sharing charges. (42CFR 457.570(b))

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

8.8 The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.

No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220) 8.8.2.

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1)) 8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

43

those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5)) 8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475) 8.8.6.

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

44

Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

1. Increase public awareness of CHIP and other state programs aimed at providing health care assistance.

2. Increase overall access to coverage relative to estimated number of uninsured children in Pennsylvania.

3. Increase access to coverage for racial, ethnic, minority and special needs children eligible for CHIP.

4. Increase access to coverage for children in rural areas, specifically central and northeast Pennsylvania.

5. Increase the percentage of children receiving age appropriate well child care, immunizations and preventive health services.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

1. Increase state government participation in and administration of outreach efforts to include public service announcements, interagency mutual referrals and revision, and distribution of CHIP information. With the implementation of the Cover All Kids initiative to expand CHIP, families will not have to guess whether they meet the income guidelines. All children will be eligible – the only determination will be the amount of cost sharing required.

2. Require Contractors to increase outreach focus on community-based agencies in predominantly minority, non-English speaking areas. Implement the Cover All Kids initiative in FY 2007.

3. Seek to establish a working relationship with the Center for Rural Pennsylvania, a not-for-profit organization dedicated to identifying, studying and offering solutions to public policy issues of concern to rural areas of the Commonwealth, to identify barriers to access in central and northeastern Pennsylvania.

4. Ensure by explicit reference in contract that Contractors provide to CHIP quality improvement plans which will include the process by which

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

45

Contractors will monitor and quantify quality improvement.

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state’s performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d))

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4))

9.3.1.

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid will be maintained at or below 90 percent.

9.3.2.

The reduction in the percentage of uninsured children below 200% of the Federal Poverty Income Guidelines.

9.3.3.

The increase in the percentage of children with a usual source of care.

9.3.4.

The extent to which outcome measures show progress on one or more of the health problems identified by the state.

9.3.5.

HEDIS Measurement Set relevant to children and adolescents younger than 19.

9.3.6.

Other child appropriate measurement set. List or describe the set used.

9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1. Immunizations 9.3.7.2. Well child care 9.3.7.3. Adolescent well visits 9.3.7.4. Satisfaction with care 9.3.7.5. Mental health 9.3.7.6. Dental care 9.3.7.7. Other, please list:

9.3.8.

Performance measures for special targeted populations.

9.4.

The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

46

the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720)

9.5.

The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

CHIP requires the submission of annual reports containing information on enrollments, demographics, utilization of services, etc.

CHIP requires monitoring and evaluation of quality and access to health care services. The Department of Health contracts with an external review organization to conduct this evaluation.

9.6.

The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720)

9.7.

The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e))

Pennsylvania assumes the promulgation of such measures by the Secretary of the Department of Health and Human Services.

9.8. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards)

9.8.2.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment)

9.8.3.

Section 1903(w) (relating to limitations on provider donations and taxes)

9.8.4.

Section 1132 (relating to periods within which claims must be filed)

9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

The Commonwealth of Pennsylvania, in December of 1997, conducted public forum hearings across the state to provide a platform for advocacy and community-based groups, private citizens and

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

47

representatives of the insurance industry, to express concerns and recommendations on the design and implementation of the state plan.

The Insurance Department in May of 1998, again conducted a public workshop for the purpose of soliciting recommendations on the development of outreach strategies to facilitate maximum enrollment of children in both the CHIP program and Medicaid. As a result of these meetings and workshops, the Insurance Department has developed a business plan which will be implemented in phases. The first phase will be to “get the word out” about the program expansion. The Departments of Public Welfare and Health will also be helping us to improve the information and referral mechanisms between CHIP and the Medicaid. Additionally, various organizations outside of state government have, or are about to, initiate a variety of awareness campaigns which have been endorsed by the Insurance Department. For example, the “Kids First” initiative sponsored by the Hospital Association of Pennsylvania and a grant application submitted to the Robert Wood Johnson Foundation by the Pennsylvania Partnerships for Children entitled “Covering Kids”. Plans for this initial emphasis will begin during the months of July, August, and September. We will then move on to more long-term enrollment strategies. In addition, tentative plans call for a reconvening of the individuals who participated in the May workshop in early fall for general discussions of community connections, and update and assessment of the impact of our efforts.

Another primary mechanism for public input and involvement is the Children’s Health Advisory Council which was created by state statute. The Children’s Advisory Council is now under jurisdiction of the Insurance Department as a result of amendments to the CHIP law (see Appendix A, Act 68, section 2311(I)). The Children’s Advisory Council is chaired by the Insurance Commissioner and consists of three ex- officio members from the Insurance Department, the Department of Health, and the Department of Public Welfare, respectively. It also consists of 14 voting members ranging from legislators to a parent with a child enrolled in CHIP.

For the expansion program, the Commonwealth is using a multi-step process to solicit input from various stakeholders including providers, CHIP and Medicaid recipients and their families, and advocacy groups. Events that have already occurred or are scheduled include the Governor’s budget address, Secretary level presentations to the state legislature, program summaries to interested parties as part of the budget clarifications, governor’s press announcements at various locations around the state, and Cabinet level presentations to various interest groups. The advocacy community is already involved as well as

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

48

each of the Commonwealth’s eight insurance contractors.

The legislature has been hosting Healthcare Excellence and Accountability Response Team (HEART) hearings across the state, focused on the CHIP expansion through the Cover All Kids initiative. Testimony is received from invited guests. Testimony is followed by open discussions in which all attendees are invited to participate. Each of these hearings has been open to the general public.

The Commonwealth will continue to accept comments on its implementation of the SPA. In addition we are utilizing the following notification processes.

• Pennsylvania Bulletin Notice – The Pennsylvania Bulletin is the Commonwealth’s official method of communicating information and rulemaking. The Commonwealth will post a notice about the proposed plan and program design prior to the requested effective date of the SPA, and indicate how interested persons can obtain copies of the plan the Commonwealth is submitting to CMS. • Medical Assistance Advisory Committee (MAAC) Presentation – The Commonwealth presented the proposed plan and program design at a MAAC meeting, which is a monthly meeting conducted by DPW for the purpose of presenting and gaining input from stakeholders on issues of policy development and program administration. MAAC is open to the public and is composed of Commonwealth citizens who have experience, knowledge, and interest in the delivery of health care services to low-income citizens and medically vulnerable groups. Members include physicians and other providers, representatives of managed care organizations under contract with the Department, representatives of consumer and provider organizations, current Medicaid recipients and parents of minor child recipients. The Commonwealth will provide copies of the plan it submits to CMS to committee members upon request. • Consumer Subcommittee of MAAC – The Commonwealth presented the proposed plan and program design at a Consumer Subcommittee meeting, which is a monthly subcommittee meeting conducted by DPW for the purpose of reviewing and advising the MAAC on policy development and program administration of publicly funded medical assistance (MA) programs. The Consumer Subcommittee’s mission is to be a resource to the MAAC, enabling the committee to advise the Department of Public Welfare on issues regarding access to service and quality of service. A majority of the members of the Consumer Subcommittee are current MA recipients and may also include representatives of: low-income groups whose

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

49

membership is primarily medical assistance recipients; advisory groups advocating on health care issues for low-income Pennsylvanians; aging or elderly consumer groups advocating on health care issues for low- income Pennsylvanians; disease or health care condition specific groups; Hispanic or other ethnic groups advocating on health care issues for low-income Pennsylvanians; former recipients (within past year); parents of minor child recipients; families of recipients; and others knowledgeable and interested in matters that come before the Subcommittee. At least one, but no more than two, members of the Consumer Subcommittee may serve on other subcommittees. • Income Maintenance Advisory Committee (IMAC) - The Commonwealth presented the proposed waiver and program design at an IMAC meeting, which is a bi-monthly meeting conducted by the Department for the purpose of advising the Department on the development and implementation of policies and procedures relating to cash assistance, food stamps, the Low-Income Energy Assistance Program (LIHEAP) and eligibility for Medicaid. The IMAC is composed of 17 members: 12 Medicaid recipients, four advocates and an Executive Director of a County Assistance Office. The Committee Members meet every other month with Department staff in Harrisburg, Pennsylvania. The Commonwealth will provide copies of the waiver to Committee Members upon request. • CHIP Advisory Committee Presentation – The Commonwealth presented the proposed plan and general program design at the October CHIP Advisory Council meeting. The purpose of the CHIP Advisory Council is to advise the Commonwealth on CHIP outreach activities and to review and evaluate the accessibility and availability of services delivered to children enrolled in CHIP.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c))

Pennsylvania does not have any American Indian Tribes recognized by the Federal or State government. Any Pennsylvania resident, including those who are American Indians or Alaska Natives, may participate, through the process described in Section 9.9, in the design and implementation of the program, including those policies that would ensure the provisions of child health assistance to American Indian and Alaska Native children.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in 457.65(b) through (d).

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

50

• Pennsylvania Bulletin Notice – The Pennsylvania Bulletin is the Commonwealth’s official method of communicating information and rulemaking. The Commonwealth will post a notice about the proposed plan and program design prior to the requested effective date of the SPA, and indicate how interested persons can obtain copies of the plan the Commonwealth submits to CMS.

9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment.

Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

See Appendix G

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

51

Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750)

10.1.1.

The progress made in reducing the number of uncovered low-income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

10.2.

The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

10.3.

The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

52

Section 11. Program Integrity (Section 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, and continue to Section 12.

11.1 The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on public and private rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9)

11.2.1.

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2.

Section 1124 (relating to disclosure of ownership and related information) 11.2.3.

Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4.

Section 1128A (relating to civil monetary penalties) 11.2.5.

Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6.

Section 1128E (relating to the National health care fraud and abuse data collection program)

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

53

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.

Eligibility and Enrollment Matters

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

Pennsylvania implemented an Eligibility Review Process on July 1, 2001. An eligibility review may be requested when:

• an applicant is denied coverage • an enrollee’s coverage is to be terminated

• an enrollee’s coverage is to change from Free Health Care Insurance to Subsidized Health Care Insurance • an enrollee’s coverage is to move from a lower premium rate to a higher premium rate within the subsidized program or coverage is moved to the at cost program • an enrollee’s coverage is to move from a higher premium rate to a lower premium rate, but the enrollee disagrees with the determination (mistake in calculating income or family size) or states that they should be in the free program or Medicaid • there is a failure to make a timely determination of eligibility

The parent or guardian of an applicant or an enrollee may request a review within 30 days of the date of the notice of ineligibility, termination or change in coverage. A request for a review is sent to the Pennsylvania Insurance Department.

Notices to the parent or guardian must include information concerning the impartial eligibility review process. Whenever possible, disputes related to eligibility are resolved prior to the conduct of the review by the Department.

When a request for an impartial review is received, the Department:

• Logs in the request for a review • Determines the need for expedited review (i.e. the parent or guardian has indicated that the child has an immediate need for medical attention) • Informs the Contractor that a request for review has been received • Informs the Contractor that coverage should continue or be reinstated until the review process has been concluded • Requests that the contractor forward to the Review Officer a copy of

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

54

the application or renewal form completed by the parent or guardian and the accompanying documentation • Schedules a review interview (to be held by telephone unless a face- to-face review is requested by the parent or guardian) • When the need for an expedited review is identified, an interview is scheduled consistent with 42 CFR 457.1160(a)

• Informs the parent or guardian in writing of the: o Date, time and location of the interview o Right to review records maintained by the contractor regarding the eligibility determination o Right to receive a copy of the relevant portions of the CHIP Procedures Manual and State or Federal law upon which the decision of ineligibility was based o Right to have a representative during the interview o Right to have appropriate interpretative service available during the interview if needed o Opportunity for continuation of coverage for an enrolled child • Provides the parent or guardian with a copy of the application and verification received from the Contractor • Informs the Contractor that the interview has been scheduled • Conducts the review interview • Issues a written decision within a reasonable time consistent with 42 CFR 457. 1180 • Sends confirmation that a request for a review has been withdrawn, if appropriate. (Withdrawal of a request may occur if the contractor, applicant or enrollee informs the Department that the request for review has been withdrawn for any reason. Example: contractor has resolved the matter at issue prior to the date of the scheduled review interview.)

When a Contractor is informed by the Department that a request for a review has been received, the contractor conducts a management review of the decision of ineligibility within two working days of the date of notification by the Department. The purpose of the management review is to assure that the decision made regarding ineligibility was appropriate. A written record of the management review is prepared. The Contractor informs the Review Officer of the results of the management review.

If the management review results in a determination that the eligibility decision was not appropriate, the Contractor:

• Informs the parent or guardian and review officer in writing that an error occurred and the child is eligible

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

55

• Enrolls the applicant child retroactively to the date that the child should have been enrolled • Re-enrolls an enrollee who has been terminated retroactively to the date the child was terminated

If the management review results in a determination that the decision was appropriate, the Contractor prepares to present facts at the review interview. The Department designates a Review Officer to conduct the eligibility review. The review is an informal process and is not an administrative hearing. The primary objectives of the review are to, where possible, facilitate resolution of the matter at issue and to enroll the child, when appropriate. The Review Officer reviews the application document and verification and the letter of request prior to the conference call in order to become familiar with the case circumstances. Additional documents that may have an impact on the outcome may be submitted by the parent or guardian or their representative. The Reviewer Officer may ask either or both parties for additional documentation, as needed.

A written decision in the form of letter is prepared and sent to the parent or guardian, the representative (if appropriate) and to the Contractor. The Contractor implements the decision of the review officer upon receipt of the letter.

A parent or guardian or representative may request reconsideration of the decision of the review officer if they are dissatisfied with the outcome of the review. A parent or guardian must file a written request for reconsideration with the Insurance Commissioner within 15 calendar days from the date of the Review Officer’s decision. The request for reconsideration must describe the reason(s) upon which the request is made. Requests for reconsideration will stay the action proposed in the decision of the Review Officer (e.g. that coverage should be terminated).

The Commissioner may affirm, amend, or reverse the decision of the review officer. After reviewing the factors considered by the review officer and the request for reconsideration, the Insurance Commissioner will respond in writing to the request. A copy of the reconsideration decision will be sent to the parent or guardian, the representative (if appropriate) and to the Contractor.

A parent or guardian or representative may appeal the decision of the Pennsylvania Insurance Department to Commonwealth Court within 30 days from the date that the Insurance Commissioner responds to the request for reconsideration.

12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120.

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

56

The review process for health services matters comports with Section 2161 of Act 1998-68 (relating to Grievances) and associated regulations promulgated by the Department of Health. Pennsylvania assures that the health services matters subject to review as described are consistent with the intent of 42 CFR 457.1130(b). See Appendix A.

Premium Assistance Programs

12.3 If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

N/A

PENNSYLVANIA TITLE XXI PROGRAM & TITLE XXI AMENDMENT FACT SHEET

Name of Plan:

Pennsylvania CHIP

Date Plan Submitted:

November 13, 1997 Date Plan Approved:

May 28, 1998 Effective Date:

June 1, 1998

Date Amendment #1 Submitted:

August 14, 1998 Date Amendment #1 Approved:

October 29, 1998 Date Amendment #1 Effective:

June 17, 1998

Date Amendment #2 Submitted:

December 9, 1999 Date Amendment #2 Approved:

March 7, 2000 Date Amendment #2 Effective:

September 1, 1999

Date Amendment #3 Submitted:

December 9, 1999 Date Amendment #3 Approved:

March 7, 2000 Date Amendment #3 Effective:

September 1, 1999

Date Amendment #4 Submitted:

September 22, 2000 Date Amendment #4 Approved:

December 18, 2000 Date Amendment #4 Effective:

September 1, 2000

Date Amendment #5 Submitted:

June 28, 2002 Date Amendment #5 Approved:

September 19, 2002 Date Amendment #5 Effective:

August 24, 2001

Date Amendment #6 Submitted:

December 19, 2003 Date Amendment #6 Approved:

March 18, 2004 Date Amendment #6 Effective:

November 1, 2003

Date Amendment #7 Submitted:

November 20, 2006 Date Amendment #7 Approved:

February 20, 2007 Date Amendment #7 Effective:

January 1, 2007

Background

• Pennsylvania is one of three states whose comprehensive benefit package was cited by Title XXI, section 2103(a)(3) as having sufficient coverage to meet the requirements for a State Children's Health Insurance Plan.

Amendments

• The State's first amendment, approved on October 29, 1998, expanded eligibility to children with family incomes at or below 200 percent of the FPL, eliminated cost

sharing, and moved administration of the program to the Pennsylvania Insurance Department.

• The second amendment, approved on March 7, 2000, expanded the income eligibility by allowing a work expense deduction and day-care expenses to be subtracted from gross earnings.

• The third amendment, also approved on March 7, 2000, expanded the benefit package by including outpatient mental health services, disposable medical supplies, inpatient and outpatient substance abuse services, and rehabilitation services.

• The fourth amendment, submitted on September 22, 2000, expanded the benefit package to include prenatal care and pre-pregnancy family services and supplies.

• Pennsylvania submitted its fifth amendment on June 28, 2002. This amendment updated and amended the CHIP state plan to indicate the State's compliance with the final CHIP regulations.

• The sixth amendment was submitted on December 19, 2003. This amendment increased the work income disregard from $90 per month to $120 per month to be consistent with the State’s Medicaid Program.

• The seventh amendment was submitted on November 20, 2006. This amendment made the following changes to the State plan:

• Expanded health insurance coverage to children from 200 percent of the Federal poverty level (FPL) to 300 percent of the FPL.

• Added monthly premiums to children above 200 percent and at or below 300 percent of the FPL.

• Added co-payments for physician visits (other than preventive and diagnostic dental services, vision services, well-baby-well-child, immunizations, or emergency care that results in admissions) for children above 200 percent of the FPL as follows:

o $5 for non-well primary care visits, o $10 for specialists, o $25 for emergency care, o $6 for generic prescriptions, and o $9 for brand name prescriptions.

SPA #7 made the following modifications to benefits:

• Added counseling, education and related services to prevent and address the consequences of at-risk behavior related to sexually transmitted diseases and pregnancy; • Clarified that inpatient services limits of 90 days per year includes both physical and mental health; • Clarified that inpatient substance abuse detoxification is limited to seven days per incident and 4 incidents per lifetime;

• Increased outpatient substance abuse treatment from 30 days to 90 full-session visits per year, and from 120 to 360 days in a lifetime; • Increased the non-hospital residential care limit from 30 to 90 days per year and from 90 to 360 in a lifetime; • Increased the number of therapy visits for speech, occupational and physical therapy from 60 combined to 60 for each type of service annually; and • Established no maximums for chemotherapy, dialysis, respiratory and radiation therapy.

• This SPA also added two crowd-out strategies for children above 200 percent of the FPL.

Children Covered Under the Program

• The State reported that 256,627 children were ever enrolled in its program during Federal Fiscal Year 2008.

Administration

• PA CHIP is administered by the Pennsylvania Insurance Department.

Health Care Delivery System

• Managed care contracts cover most areas of the State. Less than 5 percent of enrollees in rural areas do not have access to managed care and are served through fee for service.

Benefit Package

• The benefit package is the PA CHIP benefit package that was implement prior to SCHIP. Pennsylvania is one of three states whose comprehensive benefit package was cited by Title XXI as having sufficient coverage to meet the requirements for a State Children's Health Insurance Plan. Services include: inpatient hospitalization; outpatient services; physician services; surgical services; clinic services; prescription drugs; laboratory and radiological services; inpatient and outpatient mental health services; inpatient and outpatient substance abuse services; durable medical equipment; home and community-based health care services; nursing care services; dental services; case management; physical, occupational, and speech therapy; hospice care; and ambulance services when medically necessary. Did you update in relationship to this amendment? Please make sure it’s accurate.

Cost Sharing

• There is no cost sharing for families at or below 200 of the FPL.

• There are monthly premiums to children above 200 percent and at or below 300 percent of the FPL.

• For children above 200 percent of the FPL, there are co-payments for physician visits (other than preventive and diagnostic dental services, vision services, well-baby-well-child, immunizations, or emergency care that results in admissions as follows:

• $5 for non-well primary care visits, • $10 for specialists, • $25 for emergency care, • $6 for generic prescriptions, and • $9 for brand name prescriptions.

Coordination between CHIP and Medicaid

• PA CHIP managed care contractors and local Medicaid offices accept applications for the CHIP program. If the application is sent to a managed care contractor, the contractor first screens applicants for Medicaid. If the applicant appears to be Medicaid eligible, the managed care contractor forwards the application to the appropriate Medicaid eligibility office and notifies the family that the application has been forwarded. If the application is sent to a local Medicaid office, the office first determines Medicaid eligibility. If the application is denied for Medicaid, it is sent to a PA CHIP managed care contractor for CHIP determination. Families are also notified in this instance that they have been denied for Medicaid but that their application has been forwarded to PA CHIP.

• Eligibility criteria for Medicaid and PA CHIP are comparable in order to simplify the screening process. There are also several official versions of an application for health care benefits that can be used for determination of eligibility for either PA CHIP or Medicaid, including a common application form for both programs.

State Action to Avoid Crowd Out

• For families below 200 percent of the FPL, the State monitors crowd-out by asking about private insurance coverage on the application and renewal form, and data matches are made against private insurance files. This data is used to monitor the amount of substitution over time.

• There are two crowd-out strategies for children above 200 percent of the FPL.

o Children who are two years of age and older will be subject to a six-month period of uninsurance. o Children under age two will be monitored for substitution of coverage with a trigger rate, at which point a period of uninsurance will be imposed. The State is implementing this monitoring strategy to ensure that children in this younger age group receive the 11 developmental assessments and the 21 immunizations recommended during this time period by the American Academy of Pediatrics and the Centers for Disease Control and Prevention.

Outreach Activities

• Each of the health insurance companies under contract provides a range of outreach activities. Outreach activities include canvassing local businesses, day care centers, school districts, hospitals, providers, legislative offices, religious organizations and churches, social service agencies, unions, and civic groups.

• The Department of Insurance coordinates with the Department of Public Welfare and Department of Health on various outreach activities, including a toll-free telephone Help Line and community-based outreach grants.

Financial Information

Total FFY '09 Allotment -- $310,308,900 FFY '09 Enhanced Federal Matching Rate -- 68.16%

Last update: September 1, 2009

Table of Contents

State/Territory Name: Pennsylvania State Plan Amendment (SPA) #: PA-14-0001-MC This file contains the following documents in the order listed: 1) Approval Letter 2) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

JAN 2 9 2015

Franca M. D'Agostino

Executive Director

Pennsylvania Insurance Department

Bureau of Children's Health Insurance Program (CHIP) 1142 Strawberry Square

Harrisburg, PA 17120

Dear Ms. D’ Agostino:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number PA-14-0001 submitted on June 20, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

In SPA number PA-14-0001, page CS15 provides assurance that the state will apply methodologies based on MAGI for all separate CHIP covered groups. Page CS7 indicates that, using the approved MAGI conversion plan income thresholds, the state will cover targeted low- income children. Page CS10 allows the state to cover children who have access to public employee coverage and updates the supporting documentation. Page CS13 indicates that the state elects to cover children born to mothers enrolled as targeted low-income children in CHIP as deemed newborns. These pages are attached to this letter and should be incorporated into the current CHIP state plan according to the table below. Where the current CHIP state plan contains relevant information, the new pages should replace and supersede the corresponding information throughout the current state plan.

New State Plan Page Impact on Current State Plan Section

CS15: MAGI-Based Income Methodologies Section 4.3: Add new subsection; supersede information in Section 4.1.3 on income counting

CS7: Targeted Low-Income Children Sections 4.1.1, 4.1.2, 4.1.3: Supersede all

CS10: Children Who Have Access to Public Section 4.4.1: Supersede information on

Employee Coverage dependents of employees of a public agency

CS10: Hardship Exception Appendix: Supersede current documentation

CS13: Deemed Newborns Section 4.3: Add new subsection; supersede information in Section 4.1.9 on CHIP deeming

Your title XXI project officer, Ms. Ticia Jones, is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Jones’ contact information is as follows:

Centers for Medicare & Medicaid Services

/s/

Cems. CHIP Eligibility

OMB Control Number: 0938-1148

Expiration date: 10/31/2014

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.315

The CHIP Agency will apply Modified Adjusted Gross Income methodologies for all separate CHIP covered groups, as described below, and consistent with 42 CFR 457.315 and 435.603(b) through (i).

In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31, 2013, MAGI- based income methodologies will not be applied until March 31, 2014 or the next regularly-scheduled renewal of eligibility, whichever is later.

If the state covers pregnant women, in determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver.

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: @ The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself, plus one. C The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @ Current monthly household income and family size. C Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: Include a prorated portion of the reasonably predictable increase in future income and/or family size. Account for a reasonably predictable decrease in future income and/or family size.

Except as provided at 42 CFR 457.315 and 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household.

Household income includes actually available cash support, exceeding nominal amounts, provided

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. Ne

The CHIP Agency certifies that it has submitted and received approval for the conversion for all separate CHIP covered group income standards to MAGI-equivalent standards.

An attachment is submitted.

PRA Disclosure Statement

JAN 29 205

SPA# PA-14-0001 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

Cems CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

JAN 2.9 2015

SPA# PA-14-0001 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

CccmMs CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320

ri Targeted Low-Income Children - Uninsured children under age 19 whose household income is within standards established by the state.

The CHIP Agency operates this covered group in accordance with the following provisions: Age

Must be under age 19. Income Standards

Income standards are applied statewide.

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income standard or a county income standard?

No

Statewide Income Standards

[Begin with lowest age range first.

Please note that the lower bound for CHIP eligibility should be the highest standard used for Medicaid poverty- level children for the same age group or groups entered here.

From Age To Age Above (% FPL) Up to & including (% FPL) + {lo 1 215 314 4 + oli 6 157 314 x + IIe 19 133 314 ».4

Age ranges may overlap. If there is an overlap, provide an explanation. Include the age ranges for each income standard that has overlapping ages and the reason for having different income standards.

The lower bound income standard for the 6 - 19 age group is equal to 133% FPL instead of the MAGI conversion rate of 119% based on the rules in the final regulation that we should use 133% if it is greater than the converted rate (119%). Children with incomes over the age of 1 with incomes equal to or less than 208% of FPL will be in Free CHIP.

Special Program for Children with Disabilities

Does the state have a special program for children with disabilities?

JAN 2.9 2015

SPA# PA-14-0001 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

ccmMs CHIP Eligibility

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

JAN 2.9 2015

SPA# PA-14-0001 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

ccms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Sec. 2110(b)(2)(B) and (b)(6) of the SSA

iw Children Who Have Access to Public Employee Coverage - Otherwise eligible targeted low-income children who have access to public employee coverage on the basis of a family member's employment.

The CHIP Agency operates this covered group in accordance with the following provisions: Select one of the following conditions as described in Section 2110(b)(6) of the Social Security Act: C:. Maintenance of agency contribution as provided in 2110(b)(6)(B) of the SSA. @ Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act. Coverage under this option is extended to children whose household income is: Select one of the options for the income standard when compared to Targeted Low Income Children (@. The same as the standards for Targeted Low-Income Children C Lower than the income standards for Targeted Low-Income Children

Indicate whether coverage under this option is extended to all children who have access to public employee coverage, or only certain children:

C: All children who have access to public employee coverage @ Certain children who have access to public employee coverage: [7] Employees of certain public agencies.

Certain types of public employees.

Describe type of public employees

This will affect public employees that are part time or seasonal who work enough hours to become eligible for health care benefits, but not enough hours to be eligible for full-time benefits. Such

+ employees contribute an amount determined by the Fund’s Trustees toward the cost of the x coverage with no state subsidy for their dependent children. Children of those employees whose

contributions exceed five percent of their household’s annual gross income will meet the hardship exemption.

[BH] Attach methodology the state has used to calculate financial hardship.

An attachment is submitted.

The state provides assurance that the state will, on an annual basis, recalculate the financial status to determine if the hardship condition continues to be met.

Children who are eligible for public employee health benefits coverage who are not described above are excluded from eligibility under the plan.

SPA# PA-14-0001 Approval Date: JAN 2 9 2015

Effective Date: January 1, 2014 Page 1 of 2

Cems CHIP Eligibility

Children considered to have access to public employee coverage, and therefore not excluded from CHIP through this option, otherwise meet the definition of targeted low-income child provided at 42 CFR 457.310.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130917

JAN 2 9 2015

SPA# PA-14-0001 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

PA CHIP SPA CS10 Attachment 1

Hardship Exception for Children of Pennsylvania Public Employees

Pennsylvania CHIP continues to choose to provide coverage to children of employees of a public agency in the state who meet the hardship exception as defined in P.L. 111-148 Section 10203(d)(2)(D). This will only impact those employees that are part time or seasonal who work enough hours to become eligible for health care benefits, but not enough hours to qualify for full-time benefits. Such employees contribute an amount determined by the Fund’s Trustees toward the cost of the coverage. Children of those employees whose contributions exceed five (5%) percent of their gross income will meet the hardship exemption.

PEBTF's 2013 Open Enrollment documentation (that's the current enrollment for 2014 calendar year) shows:

Part time employees: HMO Family Option is $309.72 biweekly (x 26 biweekly pays = $8,052.72 annually).

For a family to NOT meet the hardship exception, they would need to have a gross annual household income of $160,054 and higher. Incomes below this amount would qualify to meet the hardship exception regardless of additional copays.

PEBTF's HMO option is cheaper than the PPO option which is $347.26 biweekly if hired before 8/1/03 and $384.80 biweekly if hired on or after 8/1/03.

We compare against the HMO option.

For the past 12 months (June 2013 through May 2014), 32 children were found to meet the requirements of the exception.

JAN 29 2015

SPA# PA-14-0001 Approval Date: Effective Date: January 1, 2014

Cems CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Section 2112(e) of the SSA and 42 CFR 457.360

im Deemed Newborns - Children born to targeted low-income pregnant women are deemed to have applied for and be eligible for CHIP or Medicaid until the child turns one.

The state operates this covered group in accordance with the following provisions: [ii] The child was born to an eligible targeted low-income pregnant woman under section 2112 of the SSA.

wl The child is deemed to have applied for and been found eligible for CHIP or Medicaid, as appropriate, as of the date of the child's birth, and remains eligible without regard to changes in circumstances until the child's first birthday.

The state elects the following option(s):

The state elects to cover as a deemed newborn a child born to a mother who is covered as a targeted low-income child under the state's separate CHIP on the date of the newborn's birth.

Oo The state elects to recognize a child's deemed newborn status from another state and provides benefits in accordance with the requirements of section 2112(e) of the SSA.

a The state elects to cover as a deemed newborn a child born to a mother who is covered under Medicaid or CHIP through the authority of the state’s section 1115 demonstration on the date of the newborn’s birth.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130917

JAN 29 2015

SPA# PA-14-0001 Approval Date: Effective Date: January 1, 2014 Page 1 of 1

_____________________________________________________________________________ Table of Contents State/Territory Name: Pennsylvania State Plan Amendments (SPA) #: PA-14-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Pennsylvania consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services (CMS 7500 Security Boulevard, Mail Stop: S2-26-12

[ o FOR MEDICARE & MEDICAID SERVICES.

Baltimore, Maryland 21244-1850

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

SEP 1 1 2014

Franca M. D'Agostino

Executive Director of CHIP and Strategic Initiatives Office of Insurance Commissioner

Pennsylvania Insurance Department

1326 Strawberry Square

Harrisburg, PA 17120

Dear Ms. D’ Agostino:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number PA-14-0003 submitted on June 20, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number PA-14-0003 describes the state’s plan to provide coverage in its separate CHIP, for children subject to Section 2101(f) of the Affordable Care Act, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved CS14 is attached, and should be incorporated within a separate subsection under Section 4.1 of Pennsylvania’s approved CHIP state plan.

Your title XXI project officer is Ms. Ticia Jones. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Jones’ contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S$2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-8145

Facsimile: (410) 786-5882

E-mail: Ticia.Jones@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Jones and to Mr. Francis McCullough, Associate Regional Administrator (ARA) in our Philadelphia Regional Office. Mr. McCullough’s address is:

Page 2 - Ms. Franca M. D' Agostino Centers for Medicare & Medicaid Services The Public Ledger Building, Suite 216 150 South Independence Mall West Philadelphia, PA 19106 Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SP As. If you have additional questions, please contact Ms. Kelly Whitener, Director, Division of State Coverage Programs at (410) 786- 0719. Enclosure cc: Sincerely, Eliot Fishman Director Mr. Francis McCullough, ARA, CMS Region III, Philadelphia

Control Panel

General Information

File Management

Tribal Input

Summary

Children's Health Insurance Program Eligibility

Children’s Health Insurance Program Eligibility: Summary Page

State/Territory Pennsylvania

name: Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number

with leading zeros. The dashes must also be entered. |PA-14-0003

Type of SPA: MAGI Eligibility & Methods | XXI Medicaid Expansion ¥ Establish 2101(f) Group | Eligibility Processing Non-Financial Eligibility Proposed Effective Date

(nm da/yyyy)

Federal Statute/ Regulation Citation

[Section 2104(f) of the ACa and 42 CFR 457.310(d)

Federal Budget Impact This SPA has a budget impact. Total budget impact: State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes. Character Count:103 out of 2000

Provides coverage for all children ineligible for Medicaid due to the elimination of income disregards.

Signature of State Agency Official

Submitted By: William Shaffer

Last Revision Jun 20, 2014 Date:

Submit Date: Jun 20, 2014

ccmMs CHIP Eligibility

OMB Control Number: 0938-1148 [xpiration d 10/31/2014

Section 2101(f) of the ACA and 42 CFR 457.310(d)

[i] Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards , The CHIP agency provides coverage for this group of children as follows:

The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected

* from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ).

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f) of the Affordable Care Act:

The state has demonstrated and CMS has agreed that all children qualifying for section 2101(1) protection will qualify for the state’s existing separate CHIP.

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their first renewal applying MAGI methods. The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who

* would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

215 (Yo FPL.

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAG] methodology.

Cc

C Other.

Describe the benefits provided to this population:

C This population will be provided the same benefits as are provided to children in the state’s Medicaid program. @ This population will be provided the same benefits as are provided to children in the state's separate CHIP.

C Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

C Cost sharing is the same as for children in the Medicaid program.

4 9A42 SEP TT Cuts

SPA# PA-14-0003 Approval Date: Effective Date: January 1, 2014

Page | of 2

ccms CHIP Eligibility

PACERS SR AOC Set ONE SAIC

@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. C No premiums. copayments, deductibles, coinsurance or other cost sharing is required.

C Other premiums and/or cost-sharing requirements (consistent with Section"2 103(e) of the SSA and 42 CFR 457 Subpart E).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. ‘The valid OMB control number for this information collection is 0938-1148, The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form. please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# PA-14-0003 Approval Date: SEP j { 2014 Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Pennsylvania State Plan Amendments (SPA) #: PA-14-0004 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are Part of the State Plan The complete title XXI state plan for Pennsylvania consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

(CENTERS FOR MEDICARE & MEDICAID SERVICES ‘CENTER FOR MEDICAID & CHIP SERVICES

SEP 1 1 2014

Ms. Franca M. D'Agostino Executive Director Pennsylvania Insurance Department

Bureau of Children's Health Insurance Program (CHIP)

1142 Strawberry Square Harrisburg, PA 17120

Dear Ms. D’ Agostino:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number PA-14-0005 submitted on June 20, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number PA-14-0005 is approved to clarify the state’s non-financial eligibility policies on residency; citizenship; social security numbers; substitution of coverage, non-payment of premiums; and, continuous eligibility. Copies of the approved state plan pages are attached and these approved pages supersede sections of Pennsylvania’s current state plan as laid out below:

New State Plan Page

Impact on Current State Plan Section

CS17: Non-Financial Eligibility — Residency

Section 4.1.5

C818: Non-Financial Eligibility — Citizenship

Section 4.1.0; 4.1-LR; 4.1.1-LR

CS19: Non-Financial Eligibility — Social Security Number

Section 4.1.9.1

C820: Non-Financial Eligibility — Substitution of | Section 4.4.4 Coverage CS21: Non-Payment of Premiums Section 8.7

C827: General Eligibility — Continuous Eligibility

Section 4.1.8

Your title XXI project officer, Ms. Ticia Jones, is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Jones’ contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-8145

Facsimile: (410) 786-5882

E-mail: Ticia. Jones@cms.hhs.gov

Page 2 — Ms. Franca M. D’ Agostino

Official communications regarding program matters should be sent simultaneously to Ms. Jones and to Ms. Francis McCullough, Associate Regional Administrator (ARA) in our Philadelphia Regional Office. Ms. McCullough’s address is:

Centers for Medicare & Medicaid Services The Public Ledger Building, Suite 216 150 South Independence Mall West Philadelphia, PA 19106

If you have additional questions, please contact Ms. Kelly Whitener; Director, Division of State Coverage Programs, at (410) 786-0719. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely,

Eliot Fishman Director

Enclosure

ce: Ms. Francis McCullough, ARA, CMS Region III, Philadelphia

Children's Health Insurance Program Eligibility

Control Panel

General Information

File Management

Tribal Input

Summary

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Pennsylvania

name: Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number

with leading zeros. The dashes must also be entered. |Pa-14-0005 |

Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion |) Establish 2101(f) Group | Eligibility Processing “| Non-Financial Eligibility Proposed Effective Date

(nm/de/yyyy)

Federal Statute/ Regulation Citation

[42 CFR 457.320, 42 CFR 457.570, 2105(a)(4\(A) of the SSA and 42 CFR 457.342 and 438

Federal Budget Impact

This SPA has a budget impact. Total budget impact:

State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes.

Character Count: 734 out of 2000 spands the definition of residency; provides coverage to otherwise eligible citizens and nationals of the United Staes “~ land ce@rain non-citizens, including the time period during which they are provided with reasonable opportunity to submit v erification of their citizenship, national status or

Signature of State Agency Official

Submitted By: William Shaffer

Last Revision Oct 23, 2014 Date: Submit Date: Jun 20, 2014

BACK , CONTINUE — )

ccmMs. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

42 CFR 457.320

Residency ‘

rn

The CHIP Agency provides CHIP to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions.

A child is considered to be a resident of the state under the following conditions:

wl A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

1. Intends to reside in the state, including without a fixed address, or

2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. [W A non-institutionalized child not described above and a child who is not a ward of the state:

1. Residing in the state, with or without a fixed address, or

2. The state of residency of the parent or caretaker, in accordance with 42 CFR.435.403(h)(1), with whom the individual resides.

cl An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

[lm A child who is a ward of the state regardless of where the child lives, or

im A child physically located in the state when there is a dispute with one or more states as to the child's actual state of residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [i A non-institutionalized pregnant woman who is living in the state and: 1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

im An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or

iw An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

ry] A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

The state has in place related to the residency of children and pregnant women (if covered by the state):

SPA# PA-14-0005 Approval Date: SEP 1 | 2014 Effective Date: January 1, 2014 Page | of 2

ccmMs CHIP Eligibility

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SEP 1 1 2014

SPA# PA-14-0005 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

CccMs. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens,

including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[Mi] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation

Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort

to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the No verification process.

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date . +e . geo No earlier than the date the notice is received by the individual.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing ry in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). &s

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status.

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state

also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- No Income Pregnant Women.

ry An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

[i] An individual is considered to be lawfully present in the United States if he or she is:

SPA# PA-14-0005 Approval Date: SEP i I 2014 Effcetive Date: January 1, 2014

Page 1 of 2

CccmMs. CHIP Eligibility

1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. A non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

By

3. A non-citizen who has been paroled into the United States in accordance with 8 U.S.C.1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

4. A non-citizen who belongs to one of the following classes: (i) Granted temporary resident status in accordance with 8 U.S.C.1160 or 1255a, respectively;

(ii) Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

(iii) Granted employment authorization under 8 CFR 274a.12(c);

(iv) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

(v) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; (vi) Granted Deferred Action status;

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231,or under the Convention Against Torture, who:

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C.1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)).

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. SEP , i ont

SPA# PA-14-0005 Approval Date: Effcetive Date: January 1, 2014 Page 2 of 2

cemMs CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

42 CFR 457.340(b)

Social Security Number

As a condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or Individuals who are issued an SSN only for a valid non-work purpose.

rl The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

{] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the

Fa individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their

SSN. Yes

When requesting an SSN for non-applicant household members, the state assures that:

mw At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

rl The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

SEP 1 { 2014 Page 1 of 2

Cems. CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information colléction. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SEP 1 1 2014

Page 2 of 2

coms. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Section 2102(b)(3)(C) of the SSA and 42 CFR 457.340(d)(3), 457.350(i), and 457.805

Substitution of Coverage

The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include:

[Mi] Substitution of coverage prevention strategy:

Name of policy Description

Application Questions are included on the application and renewal + forms regarding insurance coverage to help ensure that] XX only uninsured children are enrolled in CHIP.

Monitoring Pennsylvania enjoys one of the nation's highest rates of persons insured by employer based coverage. The continued stability of the rate of employer based coverage supports the hypothesis that no serious degree of crowd out has or is occurring as the result of + expansion of publicly funded health care programs. x

Pennsylvania will continue to monitor the rate of employer based coverage for changes. If Pennsylvania finds a significant level of substitution (10% of enrollees dropping or being dropped from private coverage), it will collaborate with CMS to identify potential strategies to reduce substitution.

Data Matching In addition to using information obtained from the applications, Pennsylvania implemented a cross match through a Third Party Liability contract to determine current and recent health insurance status. This match provides us a source of data, other than applicant + provided information, on the number of individuals x who applied for CHIP and had private insurance within the previous six months prior to application. With the addition of this data, we are able to more accurately determine the possibility of substitution among these individuals. This match is only applicable to individuals not eligible for free CHIP.

Cost Sharing Another disincentive for dropping private coverage is the addition of cost sharing (premiums and point-of- + service copayments) in the CHIP benefit package for xX families with household incomes in excess of 200% of FPL.

A waiting period during which an individual is ineligible due to having dropped group health coverage. No

If the state elects to offer dental only supplemental coverage, the following assurances apply:

SPA#PA-14-0005 Approval Date: SEP i 1 2014 Effective Date: January 1, 2014 Page 1 of 2

cCcMs. CHIP Eligibility

0 The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as provided in section 2110(b)(5) of the SSA.

[([] The waiting period does not apply to children eligible for dental only supplemental coverage.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20131122

SEP 1 1 2014

SPA#PA-14-0005 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

Cems CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes Does the state have a premium lock out period? Yes

Please describe the lock-out period:

Failure to pay the premium for the Low-Cost or Full-Cost program will result in termination. Within 7 days of the start of the 30-day grace period, a notice of proposed termination must be sent to the parent in advance of the effective date of termination. For example, a family’s premium is due September 30 for the new coverage period beginning October 1. If the premium is not received by September 30, the contractor must send a notice to the family no later than October 8 (no later than seven days after the first day of the coverage period) stating that payment must be received by October 30 or coverage will be terminated effective September 30.

The notice must include at least the following information:

+ The effective date of termination;

* The reason for termination (i.e., non-payment);

« What corrective measures the parent may take to prevent termination from occurring;

* The contractor’s customer service telephone number a parent may call if they have questions or wish to resolve the situation;

* That the 90-day premium lock out requirement will be imposed if they reapply.

In order for a child to be reinstated without implementing the 90-day premium lock out period, all unpaid monthly premiums must be paid prior to reinstatement.

There is no limit to the number of reinstatements that may be granted as long as the family is willing to pay all unpaid monthly premiums.

If the family is unwilling to pay all unpaid premiums, then the 90-day premium lock out period will be imposed.

This policy does not apply to families that fail to make their initial premium payments.

What is the length of the time premium lock-out period? Select a length of time:

C One month

C Two months

@ 90 days

SPA# PA-14-0005 Approval Date SEP 1 { 2014 Effective Date: January 1, 2014 Page | of 2

Cems CHIP Eligibility

C Other (not to exceed 90 days)

Are there exceptions to the required lock-out period? Yes

Individual's income decreased to a level where no premium is fequired or within Medicaid standards

(1) Other financial hardship [7] Other :

The state assures that:

It does not require the collection of past due premiums or enrollment fees as a condition of eligibility for enrollment once the lock-out period has expired; and

It provides enrollees with an opportunity for an impartial review to address disenrollment from the program in accordance with section 457.1130(a)(3); and

The child will be reenrolled in CHIP during the lock-out period upon payment of past due premiums or enrollment fees.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB contro! number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

SPA# PA-14-0005 Approval Date SEP 1 { 2014 Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

OMB Control Number: 0938-1148

Expiration date: 10/31/2014 $27

2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926

and ends:

Other

The CHIP Agency elects to provide continuous eligibility to children under this provision. Yes

C For children up to age

The continuous eligibility period b

[iM] At the end of the

[im] The child dies.

(@ For children up to age 19

12 months continuous eligibility period.

Exceptions to the continuous eligibility period: {il] The child attains the age specified by the state Agency or age 19. [mM] The child or child's representative requests voluntary disenrollment.

[Mi] The child is no longer a resident of the state.

The CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, during a continuous eligibility period up to 12 months, or until the time the child reaches an age specified by the state (not to exceed age 19), whichever is earlier.

egins on the effective date of the child's most recent determination or redetermination of eligibility,

iw The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative.

[Mi] There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan.

Describe

The child becomes an inmate of a public institution or a patient in a public institution for mental diseases

The child is eligible for coverage through a state health benefit plan based on a parent's employment with a state/public agency

The child becomes enrolled in Medicaid

Special needs child is referred to MA but the family does not provide required information for an eligibility determination.

+) +) +) +] +

Private health insurance is obtained for the child

mM 1K | | OK

SPA# PA-14-0005

§ Approval Date: SEf i i eot

Effective Date: January 1, 2014 Page 1 of 2

coms. CHIP Eligibility

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, includihg the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130717

SPA# PA-14-0005 Approval Date: SEP i ! 2014 Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Pennsylvania State Plan Amendments (SPA) #: PA-14-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Pennsylvania consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

(CENTERS FOR MEDICARE & MEDICAID SERVICES ‘CENTER FOR MEDICAID & CHIP SERVICES

SEP 1 1 2014

Ms. Franca M. D'Agostino Executive Director Pennsylvania Insurance Department

Bureau of Children's Health Insurance Program (CHIP)

1142 Strawberry Square Harrisburg, PA 17120

Dear Ms. D’ Agostino:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number PA-14-0005 submitted on June 20, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number PA-14-0005 is approved to clarify the state’s non-financial eligibility policies on residency; citizenship; social security numbers; substitution of coverage, non-payment of premiums; and, continuous eligibility. Copies of the approved state plan pages are attached and these approved pages supersede sections of Pennsylvania’s current state plan as laid out below:

New State Plan Page

Impact on Current State Plan Section

CS17: Non-Financial Eligibility — Residency

Section 4.1.5

C818: Non-Financial Eligibility — Citizenship

Section 4.1.0; 4.1-LR; 4.1.1-LR

CS19: Non-Financial Eligibility — Social Security Number

Section 4.1.9.1

C820: Non-Financial Eligibility — Substitution of | Section 4.4.4 Coverage CS21: Non-Payment of Premiums Section 8.7

C827: General Eligibility — Continuous Eligibility

Section 4.1.8

Your title XXI project officer, Ms. Ticia Jones, is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Jones’ contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-8145

Facsimile: (410) 786-5882

E-mail: Ticia. Jones@cms.hhs.gov

Page 2 — Ms. Franca M. D’ Agostino

Official communications regarding program matters should be sent simultaneously to Ms. Jones and to Ms. Francis McCullough, Associate Regional Administrator (ARA) in our Philadelphia Regional Office. Ms. McCullough’s address is:

Centers for Medicare & Medicaid Services The Public Ledger Building, Suite 216 150 South Independence Mall West Philadelphia, PA 19106

If you have additional questions, please contact Ms. Kelly Whitener; Director, Division of State Coverage Programs, at (410) 786-0719. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely,

Eliot Fishman Director

Enclosure

ce: Ms. Francis McCullough, ARA, CMS Region III, Philadelphia

Children's Health Insurance Program Eligibility

Control Panel

General Information

File Management

Tribal Input

Summary

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Pennsylvania

name: Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number

with leading zeros. The dashes must also be entered. |Pa-14-0005 |

Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion |) Establish 2101(f) Group | Eligibility Processing “| Non-Financial Eligibility Proposed Effective Date

(nm/de/yyyy)

Federal Statute/ Regulation Citation

[42 CFR 457.320, 42 CFR 457.570, 2105(a)(4\(A) of the SSA and 42 CFR 457.342 and 438

Federal Budget Impact

This SPA has a budget impact. Total budget impact:

State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes.

Character Count: 734 out of 2000 spands the definition of residency; provides coverage to otherwise eligible citizens and nationals of the United Staes “~ land ce@rain non-citizens, including the time period during which they are provided with reasonable opportunity to submit v erification of their citizenship, national status or

Signature of State Agency Official

Submitted By: William Shaffer

Last Revision Oct 23, 2014 Date: Submit Date: Jun 20, 2014

BACK , CONTINUE — )

ccmMs. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

42 CFR 457.320

Residency ‘

rn

The CHIP Agency provides CHIP to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions.

A child is considered to be a resident of the state under the following conditions:

wl A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

1. Intends to reside in the state, including without a fixed address, or

2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. [W A non-institutionalized child not described above and a child who is not a ward of the state:

1. Residing in the state, with or without a fixed address, or

2. The state of residency of the parent or caretaker, in accordance with 42 CFR.435.403(h)(1), with whom the individual resides.

cl An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

[lm A child who is a ward of the state regardless of where the child lives, or

im A child physically located in the state when there is a dispute with one or more states as to the child's actual state of residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [i A non-institutionalized pregnant woman who is living in the state and: 1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

im An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or

iw An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

ry] A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

The state has in place related to the residency of children and pregnant women (if covered by the state):

SPA# PA-14-0005 Approval Date: SEP 1 | 2014 Effective Date: January 1, 2014 Page | of 2

ccmMs CHIP Eligibility

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SEP 1 1 2014

SPA# PA-14-0005 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

CccMs. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens,

including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[Mi] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation

Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort

to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the No verification process.

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date . +e . geo No earlier than the date the notice is received by the individual.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing ry in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). &s

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status.

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state

also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- No Income Pregnant Women.

ry An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

[i] An individual is considered to be lawfully present in the United States if he or she is:

SPA# PA-14-0005 Approval Date: SEP i I 2014 Effcetive Date: January 1, 2014

Page 1 of 2

CccmMs. CHIP Eligibility

1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. A non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

By

3. A non-citizen who has been paroled into the United States in accordance with 8 U.S.C.1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

4. A non-citizen who belongs to one of the following classes: (i) Granted temporary resident status in accordance with 8 U.S.C.1160 or 1255a, respectively;

(ii) Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

(iii) Granted employment authorization under 8 CFR 274a.12(c);

(iv) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

(v) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; (vi) Granted Deferred Action status;

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231,or under the Convention Against Torture, who:

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C.1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)).

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. SEP , i ont

SPA# PA-14-0005 Approval Date: Effcetive Date: January 1, 2014 Page 2 of 2

cemMs CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

42 CFR 457.340(b)

Social Security Number

As a condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or Individuals who are issued an SSN only for a valid non-work purpose.

rl The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

{] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the

Fa individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their

SSN. Yes

When requesting an SSN for non-applicant household members, the state assures that:

mw At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

rl The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

SEP 1 { 2014 Page 1 of 2

Cems. CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information colléction. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SEP 1 1 2014

Page 2 of 2

coms. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Section 2102(b)(3)(C) of the SSA and 42 CFR 457.340(d)(3), 457.350(i), and 457.805

Substitution of Coverage

The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include:

[Mi] Substitution of coverage prevention strategy:

Name of policy Description

Application Questions are included on the application and renewal + forms regarding insurance coverage to help ensure that] XX only uninsured children are enrolled in CHIP.

Monitoring Pennsylvania enjoys one of the nation's highest rates of persons insured by employer based coverage. The continued stability of the rate of employer based coverage supports the hypothesis that no serious degree of crowd out has or is occurring as the result of + expansion of publicly funded health care programs. x

Pennsylvania will continue to monitor the rate of employer based coverage for changes. If Pennsylvania finds a significant level of substitution (10% of enrollees dropping or being dropped from private coverage), it will collaborate with CMS to identify potential strategies to reduce substitution.

Data Matching In addition to using information obtained from the applications, Pennsylvania implemented a cross match through a Third Party Liability contract to determine current and recent health insurance status. This match provides us a source of data, other than applicant + provided information, on the number of individuals x who applied for CHIP and had private insurance within the previous six months prior to application. With the addition of this data, we are able to more accurately determine the possibility of substitution among these individuals. This match is only applicable to individuals not eligible for free CHIP.

Cost Sharing Another disincentive for dropping private coverage is the addition of cost sharing (premiums and point-of- + service copayments) in the CHIP benefit package for xX families with household incomes in excess of 200% of FPL.

A waiting period during which an individual is ineligible due to having dropped group health coverage. No

If the state elects to offer dental only supplemental coverage, the following assurances apply:

SPA#PA-14-0005 Approval Date: SEP i 1 2014 Effective Date: January 1, 2014 Page 1 of 2

cCcMs. CHIP Eligibility

0 The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as provided in section 2110(b)(5) of the SSA.

[([] The waiting period does not apply to children eligible for dental only supplemental coverage.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20131122

SEP 1 1 2014

SPA#PA-14-0005 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

Cems CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes Does the state have a premium lock out period? Yes

Please describe the lock-out period:

Failure to pay the premium for the Low-Cost or Full-Cost program will result in termination. Within 7 days of the start of the 30-day grace period, a notice of proposed termination must be sent to the parent in advance of the effective date of termination. For example, a family’s premium is due September 30 for the new coverage period beginning October 1. If the premium is not received by September 30, the contractor must send a notice to the family no later than October 8 (no later than seven days after the first day of the coverage period) stating that payment must be received by October 30 or coverage will be terminated effective September 30.

The notice must include at least the following information:

+ The effective date of termination;

* The reason for termination (i.e., non-payment);

« What corrective measures the parent may take to prevent termination from occurring;

* The contractor’s customer service telephone number a parent may call if they have questions or wish to resolve the situation;

* That the 90-day premium lock out requirement will be imposed if they reapply.

In order for a child to be reinstated without implementing the 90-day premium lock out period, all unpaid monthly premiums must be paid prior to reinstatement.

There is no limit to the number of reinstatements that may be granted as long as the family is willing to pay all unpaid monthly premiums.

If the family is unwilling to pay all unpaid premiums, then the 90-day premium lock out period will be imposed.

This policy does not apply to families that fail to make their initial premium payments.

What is the length of the time premium lock-out period? Select a length of time:

C One month

C Two months

@ 90 days

SPA# PA-14-0005 Approval Date SEP 1 { 2014 Effective Date: January 1, 2014 Page | of 2

Cems CHIP Eligibility

C Other (not to exceed 90 days)

Are there exceptions to the required lock-out period? Yes

Individual's income decreased to a level where no premium is fequired or within Medicaid standards

(1) Other financial hardship [7] Other :

The state assures that:

It does not require the collection of past due premiums or enrollment fees as a condition of eligibility for enrollment once the lock-out period has expired; and

It provides enrollees with an opportunity for an impartial review to address disenrollment from the program in accordance with section 457.1130(a)(3); and

The child will be reenrolled in CHIP during the lock-out period upon payment of past due premiums or enrollment fees.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB contro! number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

SPA# PA-14-0005 Approval Date SEP 1 { 2014 Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

OMB Control Number: 0938-1148

Expiration date: 10/31/2014 $27

2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926

and ends:

Other

The CHIP Agency elects to provide continuous eligibility to children under this provision. Yes

C For children up to age

The continuous eligibility period b

[iM] At the end of the

[im] The child dies.

(@ For children up to age 19

12 months continuous eligibility period.

Exceptions to the continuous eligibility period: {il] The child attains the age specified by the state Agency or age 19. [mM] The child or child's representative requests voluntary disenrollment.

[Mi] The child is no longer a resident of the state.

The CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, during a continuous eligibility period up to 12 months, or until the time the child reaches an age specified by the state (not to exceed age 19), whichever is earlier.

egins on the effective date of the child's most recent determination or redetermination of eligibility,

iw The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative.

[Mi] There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan.

Describe

The child becomes an inmate of a public institution or a patient in a public institution for mental diseases

The child is eligible for coverage through a state health benefit plan based on a parent's employment with a state/public agency

The child becomes enrolled in Medicaid

Special needs child is referred to MA but the family does not provide required information for an eligibility determination.

+) +) +) +] +

Private health insurance is obtained for the child

mM 1K | | OK

SPA# PA-14-0005

§ Approval Date: SEf i i eot

Effective Date: January 1, 2014 Page 1 of 2

coms. CHIP Eligibility

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, includihg the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130717

SPA# PA-14-0005 Approval Date: SEP i ! 2014 Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Pennsylvania State Plan Amendments (SPA) #: PA-18-0001-CHIP This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

May 3, 2019

Ms. Patricia Allan Executive Director Office of Children's Health Insurance Program Pennsylvania Department of Human Services 1142 Strawberry Square Tower P.O. Box 2675 Harrisburg, PA 17105-2675

Dear Ms. Allan:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) PA- 18-0001-CHIP submitted on June 29, 2018, with additional information submitted on April 25, 2019, has been approved. This SPA has an effective date of October 2, 2017.

Through this SPA, Pennsylvania implements mental health parity requirements to ensure that treatment limitations and financial requirements applied to mental health (MH) and substance use disorder (SUD) benefits are no more restrictive than those applied to medical/surgical (M/S) benefits. Section 2103(c)(7)(A) of the Social Security Act (the Act), as implemented through regulations at 42 CFR 457.496(d)(3)-(5), requires states that provide both M/S and MH/SUD benefits to ensure that financial requirements and treatment limitations applied to MH/SUD benefits covered under the state child health plan are consistent with the mental health parity requirements of section 2705(a) of the Public Health Service Act, in the same manner that such requirements apply to a group health plan. Pennsylvania demonstrated compliance by providing the necessary assurances and supporting documentation that the state’s application of financial requirements and non-quantitative treatment limitations to MH/SUD benefits are consistent with section 2103(c)(7)(A) of the Act.

This approval relates only to benefits provided under the CHIP state plan; Medicaid benefits will be analyzed separately.

The state also removes authority for express lane eligibility and amends section 4.4 of the CHIP State Plan. This amendment clarifies that the state’s existing policy of accepting a determination of CHIP eligibility made by the Medicaid agency is permissible under 42 CFR 457.348, which describes the requirements relating to determinations of CHIP eligibility by another insurance affordability program.

Page 2 — Ms. Patricia Allan

Your title XXI project officer is Ms. Ticia Jones. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Jones’ contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-8145

E-mail: Ticia.Jones@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Jones and to Mr. Francis McCullough, Director, Division of Medicaid Field Operations - East. Mr. McCullough’s address is:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Division of Medicaid Field Operations - East 801 Market Street

Suite 9400

Philadelphia, PA 19107-3134

If you have additional questions or concerns, please contact Ms. Amy Lutzky, Director, Division of State Coverage Programs, at (410) 786-0721. We look forward to continuing to work with you and your staff.

Sincerely,

/signed Anne Marie Costello/

Anne Marie Costello Director

ec: Mr. Francis McCullough, Director, Division of Medicaid Field Operations - East

1 TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory: Pennsylvania

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR 457.40(b))

(Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Teresa Miller

Position/Title: Secretary, Human Services Name: Leesa Allen

Position/Title: Executive Deputy Secretary, Human Services

Name: Patricia Allan

Position/Title: Executive Director, CHIP

*Disclosure. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

2 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)(1)); (42 CFR 457.70):

1.1.1. Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR

1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

1.1.3. A combination of both of the above. (Section 2101(a)(2))

1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5))

1.2.

Check to provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3.

Check to provide an assurance that the State complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42 CFR 457.130)

1.4. Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Original Plan Effective Date: May 28, 1998

Implementation Date: June 1, 1998

SPA #19-0001 Purpose of SPA: This amendment includes Section 3, assurances to meet the managed care rules published in 2016.

3 Proposed effective date: July 1, 2018

Proposed implementation date: June 30, 2018

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

TN No: Approval Date Effective Date

Transmittal Number SPA Group PDF Description Superseded Plan Section(s) PA-14-0001

Effective/Implementation Date: July 1, 2014 MAGI Eligibility & Methods CS7

CS10

CS10

CS13

CS15 Eligibility – Targeted Low Income Children

Children Who Have Access to Public Employee Coverage

Hardship Exemption

Deemed Newborns

MAGI-Based Income Methodologies Sections 4.1.1, 4.1.2, 4.1.3: Supersede all

Section 4.4.1: Supersede information on dependents of employees of a public agency

Appendix: Supersede current documentation

Section 4.3: Add new subsection; supersedes information in section 4.1.9 on CHIP deeming

Section 4.3: Add new subsection; supersedes information in section 4.1.3 on income counting

4 PA-14-0002

Effective/Implementation Date: July 1, 2014 XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program Supersedes the current Medicaid expansion section 4.0 PA-14-0003

Effective/Implementation Date: July 1, 2014 Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporate within a separate subsection under section 4.1 PA-14-0005

Effective/Implementation Date: July 1, 2014 Non- Financial Eligibility CS17

CS18

CS19

CS20

CS21

CS27 Non-Financial Eligibility – Residency

Non-Financial – Citizenship

Non-Financial – Social Security Number

Substitution of Coverage

Non-Payment of Premiums

Continuous Eligibility Supersedes the current section 4.1.5

Supersedes the current sections 4.1.0; 4.1.1-LR; 4.1.1-LR

Supersedes the current section 4.1.9.1

Supersedes the current section 4.4.4

Supersedes the current section 8.7

Supersedes the current section 4.1.8

5 Section 2. General Background and Description of Approach to Children’s Health Insurance Coverage and Coordination

2.1. Describe the extent to which, and manner in which, children in the State (including targeted low-income children and other groups of children specified) identified, by income level and other relevant factors, such as race, ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, distinguish between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (Section 2102(a)(1)); (42 CFR 457.80(a))

Children’s Health Insurance Program (CHIP)

The Children’s Health Insurance Act, 62 P.S. §§ 5001.101 et seq., as amended by Act 68 of 1998, 40 P.S. §§ 991.2301 et seq. (the Children’s Health Care Act), Act 136 of 2006, and Act 84 of 2015, was originally enacted in December 1992 and implemented in May of 1993 (see Appendix A for a copy of the Children’s Health Care Act as amended [the “Act”]). The program provides free or subsidized insurance for children in low-income families who are not eligible for Medicaid or not otherwise insured through private or employer-based insurance. The program also allows those that do not meet the income guidelines to purchase the coverage at the state’s negotiated rate. CHIP is administered by the Pennsylvania Department of Human Services through individual contracts with eight health insurance companies (hereinafter referred to as Contractors). Under terms of the contract, Pennsylvania requires the Contractors to:

• Conduct outreach • Utilize CAPS to determine eligibility • Enroll and renew enrollment for eligible children • Provide required in-plan services • Contract with qualified providers to provide primary and preventative health care • Provide parent health education • Perform quality assurance tasks (including but not limited to monitoring of quality of care and health outcomes)

CHIP provides free coverage to children from birth through age 18 whose family income exceeds the Medicaid limit, but is no greater than 208% of the Federal Poverty Level (FPL). Subsidized coverage is provided to children from birth through age 18 in families whose income is greater than 208% but no greater than 314% of the FPL. The free and subsidized programs are funded by state and federal funds. Families whose income is greater than 314% FPL may purchase the CHIP benefit package at the rate negotiated by

6 the commonwealth. The buy-in program is not supported through state or federal funds. Additionally, utilization experience of the buy-in program is not included in rate setting for the free and subsidized programs.

The program is administered by the Pennsylvania Department of Human Services (see Appendix A). In addition, the Act provides for a Children’s Health Advisory Council. The Council consists of sixteen voting members, nine (9) of whom are appointed by the Human Services Secretary. The Council also includes the Secretary of Health, the Insurance Commissioner, the Human Services Secretary, or their respective designees (see Appendix A, the Act, Section 2311 (I)). Its primary functions are to review outreach activities; and to review and evaluate the accessibility and availability of services to children enrolled in the program.

Public Insurance Program

Pennsylvania has operated a categorically and medically needy Medicaid program for many years. However, major program expansions have occurred, including the expansion of Medicaid for individuals age 19 – 64 with income below 138% of FPL provisions.

In 1988, the state implemented federally-mandated coverage for pregnant women and qualified children. This coverage was designated as Healthy Beginnings. Healthy Beginnings provides medical coverage to pregnant women and infants up to age one (Income Standard: 215% FPL); children ages one to five (Income Standard: 157% FPL); and children ages six to under the age of 19. (Income Standard: 133% FPL). Early periodic screening, diagnosis and treatment provide comprehensive health services to all persons under age 19 who are receiving Medicaid. These services include check-ups and follow-up care. Pennsylvania has also elected to provide presumptive eligibility to pregnant women thereby encouraging early prenatal care and providing payment for outpatient primary care expenses incurred during pregnancy.

Private Health Insurance Programs for Low-Income Families

Special Care Program

Description: Special Care is a low-cost insurance plan offered statewide to low-income residents by Pennsylvania Blue Cross plans and Pennsylvania Blue Shield. Special Care provides basic preventive care services to children and adults ineligible for CHIP and Medicaid who cannot afford private health insurance. Special Care provides protection for families by covering the high cost of hospitalization, surgery, emergency medical care in addition to routine primary care.

7

2.2. Health Services Initiatives- Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10)

The commonwealth is committed to providing access to quality health care coverage and to improving the health status of its children. Of particular concern are children of low-income families; families with limited access to care; and families having children with special needs due to chronic or disabling conditions. (Special needs programs include spina bifida, diabetes, asthma, hepatitis B, etc.)

To achieve the goal of providing access to health care the office of CHIP meets regularly with the statewide advocacy community dedicated to increasing awareness and enrollment in both CHIP and Medicaid. Senior and management staffs of the Department of Human Services, Health and Education are consulted to complete strategic planning, to monitor progress, collaborate, share resources and to problem solve. The efforts of these meetings and relationships has increased awareness and enrollment with the following efforts which include but are not limited to:

• Establishing a single statewide toll-free number (1-800-986-KIDS) to provide access to helpline staff who inform, refer, and assist in applying for CHIP and Medicaid. • Jointly funding a multi-year contract with a media consultant. • Developing complementary media messages about the availability of healthcare coverage and the importance of preventative care. • Improving access to enrollment by streamlining eligibility and application practices. • Conducting studies regarding hard-to-reach populations to increase knowledge on how to achieve better results in- outreach to them. • Measuring the effectiveness of our efforts by gathering and analyzing available data.

The Department’s particular efforts to identify and enroll all uncovered children who may be eligible for CHIP include but are not limited to the following:

• Conducting a statewide outreach campaign for CHIP. The campaign includes but is not limited to: paid television, Internet and radio advertisements, posters, brochures, banners and the like. • Monitoring, measuring and evaluating the effectiveness of the statewide outreach campaign as well as other outreach strategies initiated and

8 implemented by the Department. • Engaging in collaborative interagency outreach for the purpose of developing and implementing strategies to enroll children in both CHIP and Medicaid. Agencies include but are not limited to: the Department of Education (school- and library-based enrollment) and, the Department of Health • Developing a strategic plan to maximize awareness of CHIP with organizations and associations with existing statewide networks. • Implementing school-based outreach and/or enrollment. • Approving and monitoring the outreach and enrollment strategies of CHIP insurance company contractors. • Participating in outreach activities initiated by local community organizations. • Conducting studies which improve the Department’s understanding of issues relating to hard to reach populations and developing outreach strategies recommended by such studies.

As stated above, the commonwealth is committed to assuring that children receive the health care coverage for which they are eligible (either CHIP or Medicaid). If a parent or guardian applies for CHIP coverage on behalf of a child and it is determined that the child is ineligible (e.g. because the level of family income is within the Medicaid range), the application submitted by the parent or guardian is automatically forwarded to the local County Assistance Office (CAO) for the determination of Medicaid eligibility. Conversely, if an application for Medicaid is filed and the child is found ineligible, the application is forwarded to a CHIP contractor. This practice negates the need for the parent or guardian to file separate applications for the two programs and facilitates enrollment of the child. In 2008, this process was automated through the implementation of the “Health care Handshake”. The health care handshake improves efficiencies by removing the need to print applications, to mail or fax applications between agencies, and to reenter data, and significantly reduces the time required for an eligibility decision by the receiving agency.

Additionally, the Department is making a concerted effort to have the CHIP contractors identify children who are potentially eligible for Medicaid due to a serious illness or disabling condition.

The Department has worked to expand access and simplify the application and renewal process for the CHIP and Medicaid programs through the development of an online application and renewal system called COMPASS (Commonwealth of Pennsylvania Access to Social Services). This web portal allows citizens to screen and apply for CHIP or Medicaid as well as many other social service programs across several Commonwealth agencies with one application. The Department provides administrative funding for toll-free helplines that can

9 answer citizens’ questions about CHIP, Medicaid, and various other social service programs, as well as assist callers with completing applications over the phone, utilizing COMPASS.

In 2003, shortly after being sworn into office, Governor Edward G. Rendell created the Governor’s Office of Health Care Reform (GOHCR) aimed at improving access, affordability and quality by rejuvenating the state government’s approach to health care. In January 2004, Pennsylvania launched a statewide data collection effort to more accurately define the characteristics of the state’s uninsured. This effort was repeated in 2008. In July 2004, the GOHCR was given the lead responsibility to apply for a State Planning Grant through the Health Resources and Services Administration (HRSA). The purpose of the grant was to develop a comprehensive plan to provide access to affordable, quality health care coverage for every Pennsylvanian.

In keeping with that goal, in early 2006, the Governor introduced the Cover All Kids expansion that makes CHIP benefits available to all eligible children in the commonwealth. Later that year, eligibility was expanded to cover all children in Pennsylvania through either Medicaid or CHIP. Following federal approval in February 2007, enrollment began in the expanded program in March 2007.

Pennsylvania has added a post application screening process to COMPASS. If a family applies for any of the social services accessed by COMPASS other than Medicaid or CHIP, at the end of the application, the family is made aware of the fact that it appears they are eligible for Medicaid or CHIP and asks if they wish to apply. The information is then pulled from the current application into the application for access to health care. COMPASS then requests any additional information from the family, screens for eligibility and routes the application to the appropriate agency for an eligibility determination.

2.3-TC Tribal Consultation Requirements- (Sections 1902(a)(73) and 2107(e)(1)(C)); (ARRA #2, CHIPRA #3, issued May 28, 2009) Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(1)(C) of the Act was also amended to apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

10 Describe the process the State uses to seek advice on a regular, ongoing basis from federally-recognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to Medicaid and CHIP programs and for consultation on State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prior to submission to CMS. Include information about the frequency, inclusiveness and process for seeking such advice. Currently there are no recognized tribes, Indian Health Programs or Urban Indian Organizations in Pennsylvania.

11 Section 3. Methods of Delivery and Utilization Controls

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 (Eligibility Standards and Methodology).

Guidance: In Section 3.1, describe all delivery methods the State will use to provide services to enrollees, including: (1) contracts with managed care organizations (MCO), prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), primary care case management entities (PCCM entities), and primary care case managers (PCCM); (2) contracts with indemnity health insurance plans; (3) fee-for-service (FFS) paid by the State to health care providers; and (4) any other arrangements for health care delivery. The State should describe any variations based upon geography and by population (including the conception to birth population). States must submit the managed care contract(s) to CMS’ Regional Office for review.

CHIP benefits are provided on a statewide basis using a managed care model with covered benefits delivered through insurers. The insurers are Blue Cross and/or Blue Shield entities, subsidiaries or affiliates of Blue Cross and/or Blue Shield entities, Health Maintenance Organizations (HMO), or risk-assuming gatekeeper Preferred Provider Organizations (PPO). All enrollees are provided the same Act 68 consumer protections. (Act 68 of 1998 is the state law that outlines requirements for managed care plans in Pennsylvania, many of those mirroring the requirements of Section 403 of CHIPRA.) Enrollees do have the option to terminate enrollment or voluntarily transfer from one contractor to another as required by Section 2103(f)(3) (incorporating section 1932(a)(4) (42 U.S.C. §1396u-2(a)(4)).

Effective with dates of service on or after October 1, 2009, Pennsylvania will ensure the Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) will receive a reimbursement equivalent in aggregate by federal fiscal year to the amounts of reimbursement each FQHC/RHC would have received under the Medicaid Prospective Payment System (PPS). This is the result of Section 503 of the CHIP Reauthorization Act of 2009 (CHIPRA) which amended section 2107(e)(1) of the Social Security Act to make section 1902(bb) of the Social Security Act applicable to CHIP in the same manner as it applies to Medicaid.

Under this provision of CHIPRA, PA CHIP will ensure that payments to each FQHC and RHC for services provided on and after October 1, 2009 to PA CHIP covered children are at least equal in aggregate by federal fiscal year by date of service to the amount that would have been paid to that FQHC/RHC if PA CHIP reimbursement had been consistent with Medicaid prospective payment principles. Beginning December 1, 2013 CHIP Contractors assumed the responsibility of reimbursing FQHCs and RHCs at the Medicaid prospective payment rate. All internal claims systems have the ability to

12 process reimbursements.

On an annual basis, PPS rates are developed by PA DHS, and PA CHIP disseminates these rates to all PA CHIP contractors. Changes in rates during the year, are sent by DHS to the FQHCs via hard copy letter and the CHIP contractors are notified via email on the change in rates. For other policy changes, FQHCs are notified via MA Bulletin or the Public Notice process. PA CHIP has taken several steps to ensure that the FQHC/RHC’s receive at least the full Medicaid PPS reimbursement rate. The first of which is a CHIP PPS Quarterly Report. Within this report, contractors must list a total count of all paid encounters within the reporting quarter. These encounters are broken down by category- medical, dental, and vaccine. Within this report providers are required to summarize reportable FQHC/RHC encounters. CHIP Contractors provide reimbursement for the difference between the established Prospective Payment System (PPS) Rate and the amounts paid to FQHC/RHC’s for encounters provided to CHIP recipients. In order to receive reimbursement, this Report of Managed Care encounters and receipts must be completed by the Provider for the end of each quarter and submitted to DHS. Data from the Quarterly CHIP Report, from our CHIP contractors, is used in comparison with the Quarterly DHS Report, from the FQHC’s, to ensure correct payment is made to participating FQHC/RHC’s. FQHC/RHC’s have been instructed to contact the appropriate CHIP contractor to resolve any discrepancies. FQHC’s and or PACHC (Pennsylvania Association of Community Health Centers) will notify PA CHIP of any discrepancies between PA CHIP contractors and FQHC’s. PA CHIP will facilitate communications concerning discrepancies between PA CHIP contractors and FQHC’s. Dialogue between CHIP contractor and FQHC/RHC is monitored to ensure amicable and timely resolution of discrepancies.

3.1. Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L)

3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. No, the State does not use a managed care delivery system for any CHIP populations. Yes, the State uses a managed care delivery system for all CHIP populations. Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care

13 delivery system and some of the CHIP population is included in a fee- for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2. Guidance: Utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package. Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b)) If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of: • 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); 42 CFR 457.490(a)) • The utilization control systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102(a)(4); 42 CFR 457.490(b))

Guidance: Only States that use a managed care delivery system for all or some CHIP populations need to answer the remaining questions under Section 3 (starting with 3.1.1.2). If the State uses a managed care delivery system for only some of its CHIP population, the State’s responses to the following questions will only apply to those populations.

14 3.1.1.2 Do any of your CHIP populations that receive services through a managed care delivery system receive any services outside of a managed care delivery system? No Yes

If yes, please describe which services are carved out of your managed care delivery system and how the State provides these services to an enrollee, such as through fee-for-service. Examples of carved out services may include transportation and dental, among others. 3.1.2 Use of a Managed Care Delivery System for All or Some of the State’s CHIP Populations 3.1.2.1 Check each of the types of entities below that the State will contract with under its managed care delivery system, and select and/or explain the method(s) of payment that the State will use: Managed care organization (MCO) (42 CFR 457.10) Capitation payment

Describe population served: Entire CHIP population.

Prepaid inpatient health plan (PIHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Guidance: If the State uses prepaid ambulatory health plan(s) (PAHP) to exclusively provide non-emergency medical transportation (a NEMT PAHP), the State should not check the following box for that plan. Instead, complete section 3.1.3 for the NEMT PAHP. Prepaid ambulatory health plan (PAHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Primary care case manager (PCCM) (individual practitioners) (42 CFR 457.10) Case management fee Other (please explain)

15 Primary care case management entity (PCCM Entity) (42 CFR 457.10) Case management fee Shared savings, incentive payments, and/or other financial rewards for improved quality outcomes (see 42 CFR 457.1240(f)) Other (please explain)

If PCCM entity is selected, please indicate which of the following function(s) the entity will provide (as described in 42 CFR 457.10), in addition to PCCM services: Provision of intensive telephonic case management Provision of face-to-face case management Operation of a nurse triage advice line Development of enrollee care plans Execution of contracts with fee-for-service (FFS) providers in the FFS program Oversight responsibilities for the activities of FFS providers in the FFS program Provision of payments to FFS providers on behalf of the State Provision of enrollee outreach and education activities Operation of a customer service call center Review of provider claims, utilization and/or practice patterns to conduct provider profiling and/or practice improvement Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers Coordination with behavioral health systems/providers Other (please describe)

3.1.2.2

The State assures that if its contract with an MCO, PAHP, or PIHP allows the entity to use a physician incentive plan, the contract stipulates that the entity must comply with the requirements set forth in 42 CFR 422.208 and 422.210. (42 CFR 457.1201(h), cross-referencing to 42 CFR 438.3(i)).

The current CHIP contract stipulates CHIP MCOs must comply with the Physician Incentive requirements under 42 CFR 438.3(i) incorporating 42 CFR 422.208 and 422.210. 3.1.3 Nonemergency Medical Transportation PAHPs Guidance: Only complete Section 3.1.3 if the State uses a PAHP to exclusively provide non- emergency medical transportation (a NEMT PAHP). If a NEMT PAHP is the

16 only managed care entity for CHIP in the State, please continue to Section 4 after checking the assurance below. If the State uses a PAHP that does not exclusively provide NEMT and/or uses other managed care entities beyond a NEMT PAHP, the State will need to complete the remaining sections within Section 3.

The State assures that it complies with all requirements applicable to NEMT PAHPs, and through its contracts with such entities, requires NEMT PAHPs to comply with all applicable requirements, including the following (from 42 CFR 457.1206(b)): • All contract provisions in 42 CFR 457.1201 except those set forth in 42 CFR 457.1201(h) (related to physician incentive plans) and 42 CFR 457.1201(l) (related to mental health parity). • The information requirements in 42 CFR 457.1207 (see Section 3.5 below for more details). • The provision against provider discrimination in 42 CFR 457.1208. • The State responsibility provisions in 42 CFR 457.1212 (about disenrollment), 42 CFR 457.1214 (about conflict of interest safeguards), and 42 CFR 438.62(a), as cross-referenced in 42 CFR 457.1216 (about continued services to enrollees). • The provisions on enrollee rights and protections in 42 CFR 457.1220, 457.1222, 457.1224, and 457.1226. • The PAHP standards in 42 CFR 438.206(b)(1), as cross-referenced by 42 CFR 457.1230(a) (about availability of services), 42 CFR 457.1230(d) (about coverage and authorization of services), and 42 CFR 457.1233(a), (b) and (d) (about structure and operation standards). • An enrollee's right to a State review under subpart K of 42 CFR 457. • Prohibitions against affiliations with individuals debarred or excluded by Federal agencies in 42 CFR 438.610, as cross referenced by 42 CFR 457.1285. • Requirements relating to contracts involving Indians, Indian Health Care Providers, and Indian managed care entities in 42 CFR 457.1209.

3.2. General Managed Care Contract Provisions

3.2.1

The State assures that it provides for free and open competition, to the maximum extent practical, in the bidding of all procurement contracts for coverage or other services, including external quality review organizations, in accordance with the procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b); 42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e)).

17 3.2.2

The State assures that it will include provisions in all managed care contracts that define a sound and complete procurement contract, as required by 45 CFR part 75, as applicable. (42 CFR 457.940(c)). 3.2.3

The State assures that each MCO, PIHP, PAHP, PCCM, and PCCM entity complies with any applicable Federal and State laws that pertain to enrollee rights, and ensures that its employees and contract providers observe and protect those rights (42 CFR 457.1220, cross-referencing to 42 CFR 438.100). These Federal and State laws include: Title VI of the Civil Rights Act of 1964 (45 CFR part 80), Age Discrimination Act of 1975 (45 CFR part 91), Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, Titles II and III of the Americans with Disabilities Act, and section 1557 of the Patient Protection and Affordable Care Act. 3.2.4

The State assures that it operates a Web site that provides the MCO, PIHP, PAHP, and PCCM entity contracts. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(3)). 3.3 Rate Development Standards and Medical Loss Ratio 3.3.1 The State assures that its payment rates are: Based on public or private payment rates for comparable services for comparable populations; and Consistent with actuarially sound principles as defined in 42 CFR 457.10. (42 CFR 457.1203(a)).

Guidance: States that checked both boxes under 3.3.1 above do not need to make the next assurance. If the state is unable to check both boxes under 3.1.1 above, the state must check the next assurance. If the State is unable to meet the requirements under 42 CFR 457.1203(a), the State attests that it must establish higher rates because such rates are necessary to ensure sufficient provider participation or provider access or to enroll providers who demonstrate exceptional efficiency or quality in the provision of services. (42 CFR 457.1203(b)) 3.3.2

The State assures that its rates are designed to reasonably achieve a medical loss ratio standard equal to at least 85 percent for the rate year and provide for reasonable administrative costs. (42 CFR 457.1203(c)). 3.3.3

The State assures that it will provide to CMS, if requested by CMS, a description of the manner in which rates were developed in accordance with the requirements of 42 CFR 457.1203(a) through (c). (42 CFR 457.1203(d)).

18 3.3.4

The State assures that it annually submits to CMS a summary description of the reports pertaining to the medical loss ratio received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(a)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1203. The CHIP Procedures Handbook, incorporated by reference in the current contract, provides specific reporting requirements, timeframes and templates pertaining to medical loss ratio. 3.3.5 Does the State require an MCO, PIHP, or PAHP to pay remittances through the contract for not meeting the minimum MLR required by the State? (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b)(1)) No, the State does not require any MCO, PIHP, or PAHP to pay remittances. Yes, the State requires all MCOs, PIHPs, and PAHPs to pay remittances. Yes, the State requires some, but not all, MCOs, PIHPs, and PAHPs to pay remittances.

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1203. The CHIP Procedures Handbook, incorporated by reference in the current contract, states that the MCO will owe a remittance to the Department if an MLR of at least 85 percent is not achieved for the MLR Reporting Year. The Department uses the MLR reporting template, published with the CHIP Procedures Handbook, to track MLR for each MCO.

If the State requests some, but not all, MCOs, PIHPs, and PAHPs to pay remittances through the contract for not meeting the minimum MLR required by the State, please describe which types of managed care entities are and are not required to pay remittances. For example, if a state requires a medical MCO to pay a remittances but not a dental PAHP, please include this information. If the answer to the assurance above is yes for any or all managed care entities, please answer the next assurance: The State assures that it if a remittance is owed by an MCO, PIHP, or PAHP to the State, the State: • Reimburses CMS for an amount equal to the Federal share of the remittance, taking into account applicable differences in the Federal matching rate; and • Submits a separate report describing the methodology used to determine the State and Federal share of the remittance with the annual report provided to CMS that summarizes the reports received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR

19 438.74(b))

3.3.6

The State assures that each MCO, PIHP, and PAHP calculates and reports the medical loss ratio in accordance with 42 CFR 438.8. (42 CFR 457.1203(f)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1203. The CHIP Procedures Handbook, incorporated by reference in the current contract, provides specific reporting requirements, timeframes and templates pertaining to medical loss ratio. 3.4 Enrollment

The State assures that its contracts with MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities provide that the MCO, PIHP, PAHP, PCCM or PCCM entity: • Accepts individuals eligible for enrollment in the order in which they apply without restriction (unless authorized by CMS), up to the limits set under the contract (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(1)); • Will not, on the basis of health status or need for health care services, discriminate against individuals eligible to enroll (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(3)); and • Will not discriminate against individuals eligible to enroll on the basis of race, color, national origin, sex, sexual orientation, gender identity, or disability and will not use any policy or practice that has the effect of discriminating on the basis of race, color, national origin, sex, sexual orientation, gender identity or disability. (42 CFR 457.1201(d), cross-referencing to 438.3(d)(4)). 3.4.1 Enrollment Process 3.4.1.1

The State assures that it provides informational notices to potential enrollees in an MCO, PIHP, PAHP, PCCM, or PCCM entity that includes the available managed care entities, explains how to select an entity, explains the implications of making or not making an active choice of an entity, explains the length of the enrollment period as well as the disenrollment policies, and complies with the information requirements in 42 CFR 457.1207 and accessibility standards established under 42 CFR 457.340. (42 CFR 457.1210(c)). The Department publishes informational notices on its website that includes the available managed care entities, explains how to select and entity, the implications of making or not making an active choice of an entity, the length of the enrollment period as well as the disenrollment policies on its website at which complies with the

20 information requirements in 42 CFR 457.1207. The website is at www.chipcoverspakids.com. Furthermore, the CHIP standardized paper application includes the available managed care entities, explains how to select an entity, and explains the implications of making or not making an active choice of an entity. Both the website and paper application meet the accessibility standards established under 42 CFR 457.430. 3.4.1.2

The State assures that its enrollment system gives beneficiaries already enrolled in an MCO, PIHP, PAHP, PCCM, or PCCM entity priority to continue that enrollment if the MCO, PIHP, PAHP, PCCM, or PCCM entity does not have the capacity to accept all those seeking enrollment under the program. (42 CFR 457.1210(b)). 3.4.1.3 Does the State use a default enrollment process to assign beneficiaries to an MCO, PIHP, PAHP, PCCM, or PCCM entity? (42 CFR 457.1210(a)). Yes No

If the State uses a default enrollment process, please make the following assurances: The State assigns beneficiaries only to qualified MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities that are not subject to the intermediate sanction of having suspension of all new enrollment (including default enrollment) under 42 CFR 438.702 and have capacity to enroll beneficiaries. (42 CFR 457.1210(a)(1)(i)). The State maximizes continuation of existing provider-beneficiary relationships under 42 CFR 457.1210(a)(1)(ii) or if that is not possible, distributes the beneficiaries equitably and does not arbitrarily exclude any MCO, PIHP, PAHP, PCCM or PCCM entity from being considered. (42 CFR 457.1210(a)(1)(ii), 42 CFR 457.1210(a)(1)(iii)).

The Department has a default enrollment process if an applicant does not choose a CHIP MCO at application, or an application is submitted by referral from a County Assistance Office. The Department’s electronic application processing system, COMPASS, automatically assigns an application without a designated provider using a “round robin” assignment system to ensure equitable distribution of applications to all eligible MCOs within a county. If a household is adding a new member, and already has existing coverage with CHIP, system rules are

21 designed so that the application will be routed to the CHIP MCO with the existing provider-beneficiary relationship.

3.4.2 Disenrollment 3.4.2.1

The State assures that the State will notify enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f)(2)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f)(2)) regarding and enrollee’s right to disenroll. The Department does not restrict an enrollee’s right to disenroll at any time. This right to disenroll is included in the CHIP Procedures Handbook. To ensure enrollees are receiving annual notice of this established policy, CHIP is updating its application and renewal notices to include the information. CHIP anticipates release of the revised application in July 2019 and revised renewal notices in September 2019. 3.4.2.2

The State assures that the effective date of an approved disenrollment, regardless of the procedure followed to request the disenrollment, will be no later than the first day of the second month following the month in which the enrollee requests disenrollment or the MCO, PIHP, PAHP, PCCM or PCCM entity refers the request to the State. (42 CFR 457.1212, cross-referencing to 438.56(e)(1)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1212. Furthermore, CHIP provides templated notices which MCOs use to systematically populate the disenrollment date in accordance with 42 CFR 457.1212. 3.4.2.3

If a beneficiary disenrolls from an MCO, PIHP, PAHP, PCCM, or PCCM entity, the State assures that the beneficiary is provided the option to enroll in another plan or receive benefits from an alternative delivery system. (Section 2103(f)(3) of the Social Security Act, incorporating section 1932(a)(4); 42 CFR 457.1212, cross referencing to 42 CFR 438.56; State Health Official Letter #09-008).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1212. Furthermore, CHIP provides templated notices which MCOs utilize to inform disenrolled individuals of the option to receive

22 benefits in another plan or alternate delivery system such as Medical Assistance. CHIP enrollees are offered Medical Assistance enrollment if they are disenrolled due to income. The Healthcare Handshake sends the enrollee’s information and income directly to Medical Assistance for consideration. Income and citizenship are considered verified. 3.4.2.4 MCO, PIHP, PAHP, PCCM and PCCM Entity Requests for Disenrollment. The State assures that contracts with MCOs, PIHPs, PAHPs, PCCMs and PCCM entities describe the reasons for which an MCO, PIHP, PAHP, PCCM and PCCM entity may request disenrollment of an enrollee, if any. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1212. Furthermore, the CHIP Procedures Handbook lists the reasons for disenrollment. The reasons are provided to the CHIP MCOs to include in the CHIP templated letters via an automated reason code. The CHIP Procedures Handbook is incorporated in the CHIP MCOs current contract by reference. Disenrollment reasons include the following: 1. The child moves out of state; 2. The child becomes 19 years of age (At age 19, the child is screened for potential MA eligibility and if potential MA eligibility exists, then the child is electronically referred to the appropriate CAO for final eligibility determination); 3. Private health insurance is obtained, or the child becomes eligible for or is enrolled in MA; 4. The child becomes an inmate of a juvenile delinquency facility or related public facility; 5. The child is a resident in a public hospital or similar facility for treating behavioral or mental health issues; 6. Notification is received that the child is deceased; 7. A voluntary request for termination is received; 8. Information was omitted, or misinformation was provided at the time of the application or renewal that would have resulted in a different eligibility determination had the correct information been provided;

23 9. A special needs child is referred to MA, but the family or physician does not provide required information for an eligibility determination; 10. The child is eligible for coverage through a state health benefit plan based on a family member’s employment with a state/public agency; or 11. Nonpayment of the required monthly premium payment for Low-Cost and Full-Cost CHIP.

Guidance: Reasons for disenrollment by the MCO, PIHP, PAHP, PCCM, and PCCM entity must be specified in the contract with the State. Reasons for disenrollment may not include an adverse change in the enrollee's health status, or because of the enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the MCO, PIHP, PAHP, PCCM or PCCM entity seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)(2)) 3.4.2.5 Enrollee Requests for Disenrollment. Guidance: The State may also choose to limit disenrollment from the MCO, PIHP, PAHP, PCCM, or PCCM entity, except for either: 1) for cause, at any time; or 2) without cause during the latter of the 90 days after the beneficiary’s initial enrollment or the State sends the beneficiary notice of that enrollment, at least once every 12 months, upon reenrollment if the temporary loss of CHIP eligibility caused the beneficiary to miss the annual disenrollment opportunity, or when the State imposes the intermediate sanction specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)). Does the State limit disenrollment from an MCO, PIHP, PAHP, PCCM and PCCM entity by an enrollee? (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Yes No

If the State limits disenrollment by the enrollee from an MCO, PIHP, PAHP, PCCM and PCCM entity, please make the following assurances (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)):

24 The State assures that enrollees and their representatives are given written notice of disenrollment rights at least 60 days before the start of each enrollment period. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(1)) The State assures that beneficiary requests to disenroll for cause will be permitted at any time by the MCO, PIHP, PAHP, PCCM or PCCM entity. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(1) and (d)(2)) The State assures that beneficiary requests for disenrollment without cause will be permitted by the MCO, PIHP, PAHP, PCCM or PCCM entity at the following times: • During the 90 days following the date of the beneficiary's initial enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later; • At least once every 12 months thereafter; • If the State plan provides for automatic reenrollment for an individual who loses CHIP eligibility for a period of 2 months or less and the temporary loss of CHIP eligibility has caused the beneficiary to miss the annual disenrollment opportunity; and • When the State imposes the intermediate sanction on the MCO, PIHP, PAHP, PCCM or PCCM entity specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(2)) 3.4.2.6

The State assures that the State ensures timely access to a State review for any enrollee dissatisfied with a State agency determination that there is not good cause for disenrollment. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(2)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1212. 3.5 Information Requirements for Enrollees and Potential Enrollees 3.5.1

The State assures that it provides, or ensures its contracted MCOs, PAHPs, PIHPs, PCCMs and PCCM entities provide, all enrollment notices, informational materials, and instructional materials related to enrollees and potential enrollees in accordance with the terms of 42 CFR 457.1207, cross-referencing to 42 CFR 438.10.

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1207. The CHIP Procedures Handbook includes templated letters which comply with 42 CFR

25 457.1207. The CHIP Procedures Handbook is incorporated into the MCO contract by reference. 3.5.2

The State assures that all required information provided to enrollees and potential enrollees are in a manner and format that may be easily understood and is readily accessible by such enrollees and potential enrollees. (42 CFR 457.1207, cross- referencing to 42 CFR 438.10(c)(1)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1207. Furthermore, The Department reviews information sent to enrollees and potential enrollees through its programmatic change process and by providing templated notices. Both the programmatic change process and templated notices are part of the CHIP Procedures Handbook. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. 3.5.3

The State assures that it operates a Web site that provides the content specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)-(i) either directly or by linking to individual MCO, PIHP, PAHP and PCCM entity Web sites.

The CHIP Procedures Handbook and the CHIP Eligibility and Benefits Handbook are on-line at www.chipcoverspakids.com/Pages/default.aspx. Each CHIP MCO posts its provider directories and enrollee handbooks on their individual websites. 3.5.4

The State assures that it has developed and requires each MCO, PIHP, PAHP and PCCM entity to use: • Definitions for the terms specified under 42 CFR 438.10(c)(4)(i), and • Model enrollee handbooks, and model enrollee notices. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(4)).

Pennsylvania is working towards a Department-wide model enrollee handbook and uniform definitions for all MCOs to utilize which meets 42 CFR 438.10(c)(4)(i), and 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(4)). The intent is to provide all MCOs with a single product that allows for a one-time, seamless transition rather than each program issuing separate model enrollee handbooks or definitions at separate times. The MCO CHIP enrollee handbooks currently utilized by the CHIP MCOs are reviewed and approved by PA CHIP through its programmatic change process to ensure information is accurate and consistent throughout the program. Any changes to an enrollee handbook including its definitions must be approved by the Department through PA CHIP prior to the CHIP MCO implementing the change. The programmatic change process is

26 incorporated by reference to the Procedures Handbook in the CHIP MCOs current contract. The Department intends to release its model enrollee handbook and uniform definitions in January 2020.

3.5.5

If the State, MCOs, PIHPs, PAHPs, PCCMs or PCCM entities provide the information required under 42 CFR 457.1207 electronically, check this box to confirm that the State assures that it meets the requirements under 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(6) for providing the material in an accessible manner. Including that: • The format is readily accessible; • The information is placed in a location on the State, MCO's, PIHP's, PAHP's, or PCCM's, or PCCM entity's Web site that is prominent and readily accessible; • The information is provided in an electronic form which can be electronically retained and printed; • The information is consistent with the content and language requirements in 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without charge upon request and is provided the information upon request within 5 business days. The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1207. Furthermore, any changes to MCO communications to enrollees must be approved by the Department through PA CHIP prior to the CHIP MCO implementing the change. The changes are reviewed through the programmatic change process. The programmatic change process is part of the CHIP Procedures Handbook. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. 3.5.6

The State assures that it meets the language and format requirements set forth in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(d), including but not limited to: • Establishing a methodology that identifies the prevalent non-English languages spoken by enrollees and potential enrollees throughout the State, and in each MCO, PIHP, PAHP, or PCCM entity service area; • Making oral interpretation available in all languages and written translation available in each prevalent non-English language; • Requiring each MCO, PIHP, PAHP, and PCCM entity to make its written materials that are critical to obtaining services available in the prevalent non- English languages in its particular service area; • Making interpretation services available to each potential enrollee and requiring each MCO, PIHP, PAHP, and PCCM entity to make those services

27 available free of charge to each enrollee; and • Notifying potential enrollees, and requiring each MCO, PIHP, PAHP, and PCCM entity to notify its enrollees: o That oral interpretation is available for any language and written translation is available in prevalent languages; o That auxiliary aids and services are available upon request and at no cost for enrollees with disabilities; and o How to access the services in 42 CFR 457.1207, cross-referencing 42 CFR 438.10(d)(5)(i) and (ii).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1207. The Department’s online COMPASS application has a choice of 67 languages, or an “other” option. If the applicant chooses a language which the CHIP Application Processing System (CAPS) automatically captures, the language populates into the applicant’s record. If CAPS does not automatically capture the language, then CAPS lists the language as “other” and a case comment is noted as to the preferred language of the applicant. For a paper application, there is a question asking for the applicant’s primary language. When an applicant chooses a language other than English, the language is entered into the applicant’s record in CAPS when the paper application information is data entered. Additionally, the Department contracts with Propio Language Services. When an applicant is in need of materials in a language other than English, or calls into PA CHIP’s toll-free consumer helpline, and requires an interpreter, the Department utilizes Propio for interpretation and translation services. These translation and interpretation services are free of charge to applicants and enrollees. Furthermore, the Department reviews and approves MCO materials to ensure compliance through its programmatic change request process. When a material is translated into a foreign language, the Department requires the MCO to provide a certification of accurate translation for the material. The programmatic change process is outlined in the CHIP Procedures Handbook. The CHIP Procedures Handbook is incorporated into the MCO contract by reference. Also, as stated previously, the current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1207, therefore, CHIP MCOs are required to provide interpretation and translation services as required by federal regulation. 3.5.7

The State assures that the State or its contracted representative provides the information specified in 42 CFR 457.1207, cross-referencing to 438.10(e)(2), and includes the information either in paper or electronic format, to all potential

28 enrollees at the time the potential enrollee becomes eligible to enroll in a voluntary managed care program or is first required to enroll in a mandatory managed care program and within a timeframe that enables the potential enrollee to use the information to choose among the available MCOs, PIHPs, PAHPs, PCCMs and PCCM entities: • Information about the potential enrollee's right to disenroll consistent with the requirements of 42 CFR 438.56 and which explains clearly the process for exercising this disenrollment right, as well as the alternatives available to the potential enrollee based on their specific circumstance; • The basic features of managed care; • Which populations are excluded from enrollment in managed care, subject to mandatory enrollment, or free to enroll voluntarily in the program; • The service area covered by each MCO, PIHP, PAHP, PCCM, or PCCM entity; • Covered benefits including: o Which benefits are provided by the MCO, PIHP, or PAHP; and which, if any, benefits are provided directly by the State; and o For a counseling or referral service that the MCO, PIHP, or PAHP does not cover because of moral or religious objections, where and how to obtain the service; • The provider directory and formulary information required in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h) and (i); • Any cost-sharing for the enrollee that will be imposed by the MCO, PIHP, PAHP, PCCM, or PCCM entity consistent with those set forth in the State plan; • The requirements for each MCO, PIHP or PAHP to provide adequate access to covered services, including the network adequacy standards established in 42 CFR 457.1218, cross-referencing 42 CFR 438.68; • The MCO, PIHP, PAHP, PCCM and PCCM entity's responsibilities for coordination of enrollee care; and • To the extent available, quality and performance indicators for each MCO, PIHP, PAHP and PCCM entity, including enrollee satisfaction. Enrollment and disenrollment information, network adequacy standards, cost-sharing information, coordination of care standards and benefit information are found in both the CHIP Eligibility and Benefits Handbook as well as the CHIP Procedures Handbook located on-line at https://www.chipcoverspakids.com/Pages/default.aspx. 3.5.8

The State assures that it will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that the State must notify all

29 enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually.

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1207, cross- referencing to 42 CFR 438.10(f) regarding an enrollee’s right to disenroll and appropriate timeframes. The Department does not restrict an enrollee’s right to disenroll at any time. Current disenrollment templates do specify and comply with the notice timeframes within the regulation. This right to disenroll is included in the CHIP Procedures Handbook. The CHIP Procedures Handbook is incorporated in the CHIP MCOs current contract by reference. Furthermore, to ensure enrollees are receiving annual notice of this established policy, CHIP is updating its application and renewal notices to include the information. 3.5.9

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that: • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity, must make a good faith effort to give written notice of termination of a contracted provider within the timeframe specified in 42 CFR 438.10(f), and • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity must make available, upon request, any physician incentive plans in place as set forth in 42 CFR 438.3(i).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 1207. Furthermore, PA CHIP provides templated notices for provider termination. The CHIP Procedures Handbook includes templated letters in compliance with 42 CFR 1207. The CHIP Procedures Handbook is incorporated into the MCO contract by reference.

3.5.10

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide enrollees of that MCO, PIHP, PAHP or PCCM entity an enrollee handbook that meets the requirements as applicable to the MCO, PIHP, PAHP and PCCM entity, specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(1)-(2), within a reasonable time after receiving notice of the beneficiary's enrollment, by a method consistent with 42 CFR 438.10(g)(3), and including the following items: • Information that enables the enrollee to understand how to effectively use the managed care program, which, at a minimum, must include: o Benefits provided by the MCO, PIHP, PAHP or PCCM entity;

30 o How and where to access any benefits provided by the State, including any cost sharing, and how transportation is provided; and o In the case of a counseling or referral service that the MCO, PIHP, PAHP, or PCCM entity does not cover because of moral or religious objections, the MCO, PIHP, PAHP, or PCCM entity must inform enrollees that the service is not covered by the MCO, PIHP, PAHP, or PCCM entity and how they can obtain information from the State about how to access these services; • The amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled; • Procedures for obtaining benefits, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the enrollee's primary care provider; • The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition and emergency services; o The fact that prior authorization is not required for emergency services; and o The fact that, subject to the provisions of this section, the enrollee has a right to use any hospital or other setting for emergency care; • Any restrictions on the enrollee's freedom of choice among network providers; • The extent to which, and how, enrollees may obtain benefits, including family planning services and supplies from out-of-network providers; • Cost sharing, if any is imposed under the State plan; • Enrollee rights and responsibilities, including the elements specified in 42 CFR §438.100; • The process of selecting and changing the enrollee's primary care provider; • Grievance, appeal, and review procedures and timeframes, consistent with 42 CFR 457.1260, in a State-developed or State-approved description, including: o The right to file grievances and appeals; o The requirements and timeframes for filing a grievance or appeal; o The availability of assistance in the filing process; and o The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; • How to access auxiliary aids and services, including additional information in alternative formats or languages;

31 • The toll-free telephone number for member services, medical management, and any other unit providing services directly to enrollees; and • Information on how to report suspected fraud or abuse. Each CHIP MCO provides an enrollment packet and access to the CHIP MCO’s enrollee handbook to all new enrollees as required by 42 CFR 457.1207 cross-referencing 438.10(g). Each CHIP MCO enrollee handbook is reviewed and approved by CHIP Quality Assurance staff to ensure all required information as outlined in the bulleted list above is included. CHIP MCOs provide paper copies of the enrollee handbook upon request to an enrollee. Any changes to the enrollee handbook are sent to the Department for review and approval through the programmatic change request process. Furthermore, the current contract between CHIP MCOs and the Department stipulates that CHIP MCOs must meet the requirements of 42 CFR 1207. All requirements listed under this assurance are also outlined within the CHIP Procedures Handbook as well as the programmatic change process. The CHIP Procedures Handbook is incorporated into the CHIP MCO contract by reference. 3.5.11

The State assures that each MCO, PIHP, PAHP and PCCM entity will give each enrollee notice of any change that the State defines as significant in the information specified in the enrollee handbook at least 30 days before the intended effective date of the change. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(4)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1207. Furthermore, any significant changes to an enrollee handbook must be approved by PA CHIP prior to the CHIP MCO implementing the change. The programmatic review process ensures that CHIP MCOs provide at least 30 days-notice to enrollees regarding significant changes to the enrollee handbook. The programmatic change process is incorporated by reference to the CHIP Procedures Handbook in the CHIP MCOs current contract. 3.5.12

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available a provider directory for the MCO’s, PIHP’s, PAHP’s or PCCM entity’s network providers, including for physicians (including specialists), hospitals, pharmacies, and behavioral health providers, that includes information as specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(1)-(2) and (4).

32

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1207. This includes the provision of a provider directory. 3.5.13

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will update any information included in a paper provider directory at least monthly and in an electronic provider directories as specified in 42 CFR 438.10(h)(3). (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(3)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1207. This includes timely updates of paper and electronic provider directories. 3.5.14

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available the MCO’s, PIHP’s, PAHP’s, or PCCM entity’s formulary that meets the requirements specified in 42 CFR 457.1207, cross- referencing to 42 CFR 438.10(i), including: • Which medications are covered (both generic and name brand); and • What tier each medication is on. The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1207. This includes making the formulary available, and that the formulary meets the requirements of 42 CFR 438.10(i). 3.5.15

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity follows the requirements for marketing activities under 42 CFR 457.1224, cross- referencing to 42 CFR 438.104 (except 42 CFR 438.104(c)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1224. Furthermore, marketing activities must be approved by the Department prior to the CHIP MCO implementing the activity. The CHIP Procedures Handbook outlines acceptable marketing activities which comply with 42 CFR 457.1224 and provides reporting templates that CHIP MCOs must use. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. Guidance: Requirements for marketing activities include, but are not limited to, that the MCO, PIHP, PAHP, PCCM, or PCCM entity does not distribute any marketing materials without first obtaining State approval; distributes the materials to its entire service areas as indicated in the contract; does not seek to influence enrollment in conjunction with the sale or offering of any private insurance; and

33 does not, directly or indirectly, engage in door-to-door, telephone, email, texting, or other cold-call marketing activities. (42 CFR 104(b)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.5 (3.5.16 through 3.5.18). 3.5.16

The State assures that each MCO, PIHP and PAHP protects communications between providers and enrollees under 42 CFR 457.1222, cross-referencing to 42 CFR 438.102.

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1222. 3.5.17

The State assures that MCOs, PIHPs, and PAHPs have arrangements and procedures that prohibit the MCO, PIHP, and PAHP from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity. (42 CFR 457.1280(b)(2)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1280. Furthermore, the Department reviews and approves potential and existing enrollee communications through its programmatic change process to ensure no prohibited unsolicited contact occurs. The programmatic change process is incorporated by reference to the Procedures Handbook in the CHIP MCOs current contract. Guidance: States should also complete Section 3.9, which includes additional provisions about the notice procedures for grievances and appeals. 3.5.18

The State assures that each contracted MCO, PIHP, and PAHP comply with the notice requirements specified for grievances and appeals in accordance with the terms of 42 CFR 438, Subpart F, except that the terms of 42 CFR 438.420 do not apply and that references to reviews should be read to refer to reviews as described in 42 CFR 457, Subpart K. (42 CFR 457.1260). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides specific instructions managing grievances and appeals as well as letter templates. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. 3.6 Benefits and Services

34 Guidance: The State should also complete Section 3.10 (Program Integrity). 3.6.1

The State assures that MCO, PIHP, PAHP, PCCM entity, and PCCM contracts involving Indians, Indian health care providers, and Indian managed care entities comply with the requirements of 42 CFR 438.14. (42 CFR 457.1209).

Currently there are no recognized tribes, Indian health providers, or Indian managed care entities in Programs in Pennsylvania. However, the current contract between CHIP MCOs and the Department does stipulate that CHIP MCOs meet the requirements of 42 CFR 457.1209. 3.6.2

The State assures that all services covered under the State plan are available and accessible to enrollees. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1230. Furthermore, The Department provides a standardized PA CHIP enrollee eligibility and benefits handbook that outlines all services available and accessible to enrollees. 3.6.3

The State assures that it: • Publishes the State’s network adequacy standards developed in accordance with 42 CFR 457.1218, cross-referencing 42 CFR 438.68(b)(1) on the Web site required by 42 CFR 438.10; • Makes available, upon request, the State’s network adequacy standards at no cost to enrollees with disabilities in alternate formats or through the provision of auxiliary aids and services. (42 CFR 457.1218, cross- referencing 42 CFR 438.68(e)). Pennsylvania has codified its network adequacy standards in 28 Pa. Code § 9.679 regarding access requirements in service areas. The network adequacy standards are available on-line at www.pacode.com/secure/data/028/chapter9/s9.679.html. The Department provides copies to enrollees upon request at no cost and in alternate formats or through auxiliary aids and services. Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete the remaining assurances in Section 3.6 (3.6.4 through 3.6.20. 3.6.4

The State assures that each MCO, PAHP and PIHP meet the State’s network adequacy standards. (42 CFR 457.1218, cross-referencing 42 CFR 438.68; 42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206).

35 Pennsylvania has codified its network adequacy standards in 28 Pa. Code § 9.679 regarding access requirements in service areas. Before the Department contracts with a CHIP MCO, the CHIP MCO must provide certification from the Pennsylvania Department of Health (PA DOH) that it meets network adequacy standards. The PA DOH is responsible for certifying that Pennsylvania MCOs comply with Title 28 of the Pa Code. Furthermore, PA CHIP requires that each CHIP MCO has National Committee for Quality Assurance (NCQA) accreditation. NCQA accreditation provides for further certification of network adequacy standards. CHIP MCOs are required to provide the Department with verification of NCQA certification at initial contract and every three years after (recredential). 3.6.5

The State assures that each MCO, PIHP, and PAHP includes within its network of credentialed providers: • A sufficient number of providers to provide adequate access to all services covered under the contract for all enrollees, including those with limited English proficiency or physical or mental disabilities; • Women’s health specialists to provide direct access to covered care necessary to provide women’s routine and preventative health care services for female enrollees; and • Family planning providers to ensure timely access to covered services. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b). Pennsylvania has codified its network adequacy standards in 28 Pa. Code § 9.679 regarding access requirements in service areas. The standards include the composition requirements of a network. Before the Department contracts with a CHIP MCO, the CHIP MCO must provide certification from the Pennsylvania Department of Health (PA DOH) that it meets network adequacy standards. The PA DOH is responsible for certifying that Pennsylvania MCOs comply with Title 28 of the Pa Code. Furthermore, the Department requires that each CHIP MCO has National Committee for Quality Assurance (NCQA) accreditation. NCQA accreditation provides for further certification of network adequacy standards including network composition. CHIP MCOs are required to provide the Department with verification of NCQA certification at initial contract and every three years after (recredential).

3.6.6

The State assures that each contract under 42 CFR 457.1201 permits an enrollee to choose his or her network provider. (42 CFR 457.1201(j), cross-referencing 42 CFR 438.3(l)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1201(j).

36 3.6.7

The State assures that each MCO, PIHP, and PAHP provides for a second opinion from a network provider, or arranges for the enrollee to obtain one outside the network, at no cost. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(3)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1230. Furthermore, the PA CHIP Eligibility and Benefits handbook specifically states that each CHIP MCO must provide for a second opinion from a network provider or arrange for the enrollee to obtain a second opinion from outside the network, at no cost. During the MCO on-site review, PA CHIP Quality Assurance staff verify that MCOs meet the requirements of both federal regulations and the PA CHIP Eligibility and Benefits handbook. 3.6.8

The State assures that each MCO, PIHP, and PAHP ensures that providers, in furnishing services to enrollees, provide timely access to care and services, including by: • Requiring the contract to adequately and timely cover out-of-network services if the provider network is unable to provide necessary services covered under the contract to a particular enrollee and at a cost to the enrollee that is no greater than if the services were furnished within the network; • Requiring the MCO, PIHP and PAHP meet and its network providers to meet State standards for timely access to care and services, taking into account the urgency of the need for services; • Ensuring that the hours of operation for a network provider are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid or CHIP Fee-For-Service, if the provider serves only Medicaid or CHIP enrollees; • Ensuring that the MCO, PIHP and PAHP makes available services include in the contract on a 24-hours a day, 7 days a week basis when medically necessary; • Establishing mechanisms to ensure compliance by network providers; • Monitoring network providers regularly to determine compliance; • Taking corrective action if there is a failure to comply by a network provider. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(4) and (5) and (c)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1230. Furthermore, the CHIP Procedures Handbook stipulates CHIP MCOS must provide timely access to care and services which includes all of the bulleted items in this assurance. PA CHIP also reviews provider agreements between the

37 CHIP MCO and network providers to ensure network providers meet their obligations as stipulated in this assurance. The requirement for CHIP MCOs to provide provider agreements to PA CHIP is a process within the CHIP Procedures Handbook. The CHIP Procedures handbook is incorporated into the current CHIP MCO contract by reference. Additionally, PA CHIP Quality Assurance staff review network provider and service provision during its annual on-site review with CHIP MCOs starting in 2019.

3.6.9

The State assures that each MCO, PIHP, and PAHP has the capacity to serve the expected enrollment in its service area in accordance with the State's standards for access to care. (42 CFR 457.1230(b), cross-referencing to 42 CFR 438.207). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1230. Also, Pennsylvania has codified its network adequacy standards in 28 Pa. Code § 9.679 regarding access requirements in service areas. Before the Department contracts with a CHIP MCO, the CHIP MCO must provide certification from the Pennsylvania Department of Health (PA DOH) that it meets network adequacy standards which includes the state’s standards for access to care. The PA DOH is responsible for certifying that Pennsylvania MCOs comply with Title 28 of the Pa Code. Furthermore, the Department requires that each CHIP MCO has National Committee for Quality Assurance (NCQA) accreditation. NCQA accreditation provides for further certification of network adequacy standards which includes access to care standards. CHIP MCOs are required to provide the Department with verification of NCQA certification at initial contract and every three years after (recredential). 3.6.10

The State assures that each MCO, PIHP, and PAHP will be required to submit documentation to the State, at the time of entering into a contract with the State, on an annual basis, and at any time there has been a significant change to the MCO, PIHP, or PAHP’s operations that would affect the adequacy of capacity and services, to demonstrate that each MCO, PIHP, and PAHP for the anticipated number of enrollees for the service area: • Offers an appropriate range of preventative, primary care and specialty services; and • Maintains a provider network that is sufficient in number, mix, and geographic distribution. (42 CFR 457.1230, cross-referencing to 42 CFR 438.207(b)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1230.

38

3.6.11

Except that 42 CFR 438.210(a)(5) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the coverage of services requirements under 42 CFR 438.210, including: • Identifying, defining, and specifying the amount, duration, and scope of each service that the MCO, PIHP, or PAHP is required to offer; and • Permitting an MCO, PIHP, or PAHP to place appropriate limits on a service. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(a) except that 438.210(a)(5) does not apply to CHIP contracts). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1230.

3.6.12

Except that 438.210(b)(2)(iii) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the authorization of services requirements under 42 CFR 438.210, including that: • The MCO, PIHP, or PAHP and its subcontractors have in place and follow written policies and procedures; • The MCO, PIHP, or PAHP have in place mechanisms to ensure consistent application of review criteria and consult with the requesting provider when appropriate; and • Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by an individual with appropriate expertise in addressing the enrollee’s medical, or behavioral health needs. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(b), except that 438.210(b)(2)(iii) does not apply to CHIP contracts). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1230.

3.6.13

The State assures that its contracts with each MCO, PIHP, or PAHP require each MCO, PIHP, or PAHP to notify the requesting provider and given written notice to the enrollee of any adverse benefit determination to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(c)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1230.

3.6.14

The State assures that its contracts with each MCO, PIHP, or PAHP provide that compensation to individuals or entities that conduct utilization management

39 activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(e)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1230.

3.6.15

The State assures that it has a transition of care policy that meets the requirements of 438.62(b)(1) and requires that each contracted MCO, PIHP, and PAHP implements the policy. (42 CFR 457.1216, cross-referencing to 42 CFR 438.62). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1216. The CHIP Procedures Handbook outlines a transition of care policy that meets the requirements of 42 CFR 438.62(b). CHIP MCOs are required to implement the CHIP Procedures Handbook because the CHIP Procedures Handbook is incorporated by reference into the CHIP MCO contract with the Department.

3.6.16

The State assures that each MCO, PIHP, and PAHP has implemented procedures to deliver care to and coordinate services for all enrollees in accordance with 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208, including: • Ensure that each enrollee has an ongoing source of care appropriate to his or her needs; • Ensure that each enrollee has a person or entity formally designated as primarily responsible for coordinating the services accessed by the enrollee; • Provide the enrollee with information on how to contract their designated person or entity responsible for the enrollee’s coordination of services; • Coordinate the services the MCO, PIHP, or PAHP furnishes to the enrollee between settings of care; with services from any other MCO, PIHP, or PAHP; with fee-for-service services; and with the services the enrollee receives from community and social support providers; • Make a best effort to conduct an initial screening of each enrollees needs within 90 days of the effective date of enrollment for all new enrollees; • Share with the State or other MCOs, PIHPs, or PAHPs serving the enrollee the results of any identification and assessment of the enrollee’s needs; • Ensure that each provider furnishing services to enrollees maintains and shares, as appropriate, an enrollee health record in accordance with professional standards; and

40 • Ensure that each enrollee’s privacy is protected in the process of coordinating care is protected with the requirements of 45 CFR parts 160 and 164 subparts A and E. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(b)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1230(c). PA CHIP also reviews information on coordination of care, screening requirements, service delivery, privacy protections, and designation of a primary care coordinator during quality on-site reviews. During the Quarterly Quality Review Meetings with each CHIP MCO, the Department discusses issues of coordination of care, service delivery, and privacy protections. Furthermore, PA CHIP reviews the CHIP MCO enrollee handbooks to ensure compliance with regulatory requirements and policies such as those required in the PA CHIP Procedures Handbook. Any changes to an enrollee handbook must be approved by PA CHIP prior to the CHIP MCO implementing the change. The CHIP Procedures Handbook outlines the above bulleted requirements and the CHIP MCO’s obligation to meet those requirements. The CHIP Procedures handbook is incorporated into the current CHIP MCO contract by reference. Guidance: For assurances 3.6.17 through 3.6.20, applicability to PIHPs and PAHPs is based a determination by the State in relation to the scope of the entity’s services and on the way the State has organized its delivery of managed care services, whether a particular PIHP or PAHP is required to implement the mechanisms for identifying, assessing, and producing a treatment plan for an individual with special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(a)(2)) 3.6.17

The State assures that it has implemented mechanisms for identifying to MCOs, PIHPs, and PAHPs enrollees with special health care needs who are eligible for assessment and treatment services under 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c) and included the mechanism in the State’s quality strategy. The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1230(c). Furthermore, The Department has a special needs process in place to ensure enrollees are getting appropriate care. CHIP MCOs identify special needs enrollee by conducting a claims review. A packet regarding special needs information is sent to the Department’s Office of Income Maintenance for review and determination of eligibility for Medical Assistance. The special needs process is outlined in the CHIP Procedures Handbook. The CHIP Procedures handbook is incorporated into the current CHIP MCO contract

41 by reference.

3.6.18

The State assures that each applicable MCO, PIHP, and PAHP implements the mechanisms to comprehensively assess each enrollee identified by the state as having special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(2)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1230(c). Furthermore, The Department has a special needs process in place to ensure enrollees are getting appropriate care. CHIP MCOs are required to review history from medical claims management information to identify children enrolled in CHIP who may potentially be eligible for MA based on the child’s disability. The Department has a program for children under the age of 18 with special needs who meet the SSA definition of a disability. The SSA’s definition of a disability for a child is:

1. A physical or mental condition or a combination of conditions, that results in “marked and severe functional limitations”. This means that the condition(s) must very seriously limit the child’s activities; and 2. The child’s condition(s) must be permanent or have lasted or be expected to last at least 12 months; or must be expected to result in death. A packet regarding special needs information is sent to the Department’s Office of Income Maintenance for review and determination of eligibility for Medical Assistance. Quarterly Quality Review Meetings are held by the Department with each CHIP MCO to ensure that treatment and service plans are in place for enrollees identified as having special heath care needs. These assessments and service plans are also reviewed during on-site visits. The special needs process is outlined in the CHIP Procedures Handbook. The CHIP Procedures handbook is incorporated into the current CHIP MCO contract by reference.

3.6.19

The State assures that each MCO, PIHP, and PAHP will produce a treatment or service plan that meets the following requirements for enrollees identified with special health care needs: • Is in accordance with applicable State quality assurance and utilization review standards; • Reviewed and revised upon reassessment of functional need, at least every 12 months, or when the enrollee’s circumstances or needs change significantly. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(3)).

42 The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1230(c). Furthermore, The Department conducts Quarterly Quality Review Meetings with each CHIP MCO to ensure that treatment and service plans are in place for enrollees identified as having special heath care needs. These assessments and service plans are also reviewed during annual on-site visits. The special needs process is outlined in the CHIP Procedures Handbook. The CHIP Procedures handbook outlines the states quality assurance and utilization review standards and is incorporated into the current CHIP MCO contract by reference. Additionally, the CHIP MCOs are required to have NCQA accreditation every three years. NCQA accreditation includes quality assurances and utilization review standards. Once the CHIP MCOs obtain the accreditation certificate they are required to send a copy to the Department.

3.6.20

The State assures that each MCO, PIHP, and PAHP must have a mechanism in place to allow enrollees to directly access a specialist as appropriate for the enrollee's condition and identified needs for enrollees identified with special health care needs who need a course of treatment or regular care monitoring. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(4)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1230(c). Furthermore, the CHIP Procedures Handbook and the CHIP Eligibility and Benefits Handbook require CHIP MCOs to ensure that an enrollee has direct access to a specialist appropriate for the condition, so the enrollee receives appropriate course of treatment. The CHIP Procedures handbook is incorporated into the current CHIP MCO contract by reference. The CHIP Eligibility and Benefits Handbook outlines all services and benefits available to enrollees through CHIP regardless of their chosen MCO. 3.7 Operations 3.7.1

The State assures that it has established a uniform credentialing and recredentialing policy that addresses acute, primary, behavioral, and substance use disorders providers and requires each MCO, PIHP and PAHP to follow those policies. (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(b)(1)).

The Department requires that each MCO has National Committee for Quality Assurance (NCQA) accreditation. NCQA accreditation provides for a uniform credentialing and recredentialing policy that addresses acute and primary providers. The NCQA credentialing/ recredentialling assures that

43 CHIP MCOs are following prescribed policies. Recredentialling occurs every three years. CHIP MCOs are required to provide a copy of their NCQA credentialing to the Department per the CHIP MCO contract. The CHIP MCOs are responsible for ensuring the credentialing for behavioral health and substance use disorder providers. The Department reviews the CHIP MCOs credentialing procedures during its on-site reviews to ensure CHIP MCOs are providing appropriate credentialing and recredentialing. Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.7 (3.7.2 through 3.7.9). 3.7.2 The State assures each contracted MCO, PIHP and PAHP will comply with the provider selection requirements in 42 CFR 457.1208 and 457.1233(a), cross- referencing 42 CFR 438.12 and 438.214, including that: Each MCO, PIHP, or PAHP implements written policies and procedures for selection and retention of network providers (42 CFR 457.1233(a), cross- referencing 42 CFR 438.214(a)); MCO, PIHP, and PAHP network provider selection policies and procedures do not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(c)); MCOs, PIHPs, and PAHPs do not discriminate in the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification, solely on the basis of that license or certification (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); If an MCO, PIHP, or PAHP declines to include individual or groups of providers in the MCO, PIHP, or PAHP’s provider network, the MCO, PIHP, and PAHP gives the affected providers written notice of the reason for the decision (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); and MCOs, PIHPs, and PAHPs do not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. (42 CFR 457.1233(a), cross- referencing 42 CFR 438.214(d)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1208 and 457.1233. Furthermore, the Department through PA CHIP conducts on-site monitoring with each MCO. During the monitoring, PA CHIP assures that an MCO’s documents, policies and procedures comply with provisions listed above including network adequacy, MCO certification and provider credentialing, provider enrollment validation, and provider communications.

44

3.7.3 The State assures that each contracted MCO, PIHP, and PAHP complies with the subcontractual relationships and delegation requirements in 42 CFR 457.1233(b), cross-referencing 42 CFR 438.230, including that: The MCO, PIHP, or PAHP maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its contract with the State; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor specify that all delegated activities or obligations, and related reporting responsibilities, are specified in the contract or written agreement, the subcontractor agrees to perform the delegated activities and reporting responsibilities specified in compliance with the MCO's, PIHP's, or PAHP's contract obligations, and the contract or written arrangement must either provide for revocation of the delegation of activities or obligations, or specify other remedies in instances where the State or the MCO, PIHP, or PAHP determine that the subcontractor has not performed satisfactorily; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor must specify that the subcontractor agrees to comply with all applicable CHIP laws, regulations, including applicable subregulatory guidance and contract provisions; and The subcontractor agrees to the audit provisions in 438.230(c)(3). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1233. Furthermore, PA CHIP may review contracts between CHIP MCOs and their subcontractors to ensure the subcontractor meets the provisions of 42 CFR 457.1233. This review requirement is outlined in the CHIP Procedures Handbook. The review is at PA CHIP’s discretion. In 2019, all contracts are reviewed. The Procedures Handbook is incorporated by reference in the MCOs current contract.

3.7.4

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP, adopts and disseminates practice guidelines that are based on valid and reliable clinical evidence or a consensus of providers in the particular field; consider the needs of the MCO's, PIHP's, or PAHP's enrollees; are adopted in consultation with network providers; and are reviewed and updated periodically as appropriate. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(b) and (c)). Each CHIP MCO has provider agreements that are reviewed during on-site visits by PA CHIP Quality Assurance (QA) staff. The review includes ensuring that covered services adhere to Bright Futures guidelines and case

45 management are a based on valid and reliable clinical evidence. Bright Futures is a national health promotion and prevention initiative, led by the American Academy of Pediatrics and supported, in part, by the US Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). The Bright Futures Guidelines provide theory-based and evidence driven guidance for all preventative care screenings and well-child visits. The Department through PA CHIP ensures these guidelines are adopted in consultation with network providers. PA CHIP QA staff also ensure MCOs update and review their guidelines periodically as appropriate. Furthermore, all CHIP MCOs have National Committee for Quality Assurance (NCQA) accreditation. NCQA accreditation also monitors provider quality every three years.

3.7.5

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP makes decisions for utilization management, enrollee education, coverage of services, and other areas to which the guidelines apply are consistent with the practice guidelines. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(d)).

The Department holds Quarterly Quality Review Meetings with each CHIP MCO. During each meeting, the CHIP MCO provides the Department information regarding utilization management, enrollee education, and coverage of services. The Department through PA CHIP also reviews information on utilization management, enrollee education and coverage of services contained within the CHIP MCO enrollee handbook. Any changes to an enrollee handbook must be approved by the Deparment through PA CHIP prior to the CHIP MCO implementing the change. The programmatic change process is incorporated by reference to the Procedures Handbook in the CHIP MCOs current contract.

3.7.6

The State assures that each contracted MCO, PIHP, and PAHP maintains a health information system that collects, analyzes, integrates, and reports data consistent with 42 CFR 438.242. The systems must provide information on areas including, but not limited to, utilization, claims, grievances and appeals, and disenrollments for other than loss of CHIP eligibility. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1233. Each CHIP MCO maintains a health information system that collects, analyzes, integrates and reports data on utilization, claims, grievances and appeals as well as disenrollment. CHIP MCOs provide regular and ad hoc reports

46 related to utilization, claims, grievances and appeals and disenrollment as directed by the Department. 3.7.7

The State assures that it reviews and validates the encounter data collected, maintained, and submitted to the State by the MCO, PIHP, or PAHP to ensure it is a complete and accurate representation of the services provided to the enrollees under the contract between the State and the MCO, PIHP, or PAHP and meets the requirements 42 CFR 438.242 of this section. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242). 3.7.8

The State assures that it will submit to CMS all encounter data collected, maintained, submitted to the State by the MCO, PIHP, and PAHP once the State has reviewed and validated the data based on the requirements of 42 CFR 438.242. (CMS State Medicaid Director Letter #13-004). 3.7.9

The State assures that each contracted MCO, PIHP and PAHP complies with the privacy protections under 42 CFR 457.1110. (42 CFR 457.1233(e)).

The CHIP MCO contract has multiple provisions establishing privacy protections of enrollee health information which comply with 42 CFR 457.1110. Furthermore, the current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1233(e). The Department through PA CHIP issued a transmittal to MCOs that outlines how and when a provider must report a privacy breach to the HIPPA Privacy Coordinator. The transmittal was issued January 28, 2018. The Quality Assurance director receives non-compliance notifications and follows-up with the MCO to ensure remediation occurs. 3.8 Beneficiary Protections 3.8.1

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity has written policies regarding the enrollee rights specified in 42 CFR 438.100. (42 CFR 457.1220, cross-referencing to 42 CFR 438.100(a)(1)).

The CHIP MCOs enrollee handbooks contain the enrollees’ rights. All CHIP MCO enrollee handbooks are vetted by PA CHIP through its programmatic change process to ensure information is accurate and consistent throughout the program. Any changes to an enrollee handbook including its enrollee rights must be approved by PA CHIP prior to the CHIP MCO implementing the change. The programmatic change process is incorporated by reference to the Procedures Handbook in the CHIP MCOs current contract. 3.8.2

The State assures that its contracts with an MCO, PIHP, PAHP, PCCM, or PCCM entity include a guarantee that the MCO, PIHP, PAHP, PCCM, or PCCM entity

47 will not avoid costs for services covered in its contract by referring enrollees to publicly supported health care resources. (42 CFR 457.1201(p)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1201(p). 3.8.3

The State assures that MCOs, PIHPs, and PAHPs do not hold the enrollee liable for the following: • The MCO’s, PIHP’s or PAHP’s debts, in the event of the entity’s solvency. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(a)) • Covered services provided to the enrollee for which the State does not pay the MCO, PIHP or PAHP or for which the State, MCO, PIHP, or PAHP does not pay the individual or the health care provider that furnished the services under a contractual, referral or other arrangement. (42 CFR 457.1226, cross- referencing to 42 CFR 438.106(b)) • Payments for covered services furnished under a contract, referral or other arrangement that are in excess of the amount the enrollee would owe if the MCO, PIHP or PAHP covered the services directly. (42 CFR 457.1226, cross- referencing to 42 CFR 438.106(c)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1226. 3.9 Grievances and Appeals Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete Section 3.9. States with PCCMs and/or PCCM entities should be adhering to the State’s review process for benefits. 3.9.1

The State assures that each MCO, PIHP, and PAHP has a grievance and appeal system in place that allows enrollees to file a grievance and request an appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides specific instructions managing grievances and appeals as well as letter templates. The CHIP Procedures Handbook is incorporated by reference in the MCOs current contract. 3.9.2

The State assures that each MCO, PIHP, and PAHP has only one level of appeal for enrollees. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(b)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore,

48 the CHIP Procedures Handbook provides specific instructions managing grievances and appeals including the MCO level of appeal. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. 3.9.3

The State assures that an enrollee may request a State review after receiving notice that the adverse benefit determination is upheld, or after an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 438.402(c)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides specific instructions regarding the state review. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. 3.9.4. Does the state offer and arrange for an external medical review? Yes No

Guidance: Only states that answered yes to assurance 3.9.4 need to complete the next assurance (3.9.5). 3.9.5

The State assures that the external medical review is: • At the enrollee's option and not required before or used as a deterrent to proceeding to the State review; • Independent of both the State and MCO, PIHP, or PAHP; • Offered without any cost to the enrollee; and • Not extending any of the timeframes specified in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(1)(i)). CHIP Procedures Handbook outlines the external medical review process that is conducted by the Department of Health. The process is at the enrollee’s option and does not impede upon an enrollee’s right for further review. There is no cost to the enrollee for the review. The MCOs are required to follow the external medical review process requirement as the CHIP Procedures Handbook is incorporated by reference into the CHIP MCOs current contract. Furthermore, state statute (40 P.S. §§ 991.2301- A – 991.2309-A) requires CHIP to offer an external medical review and that review meets the requirements as outlined in 42 CFR 1260, cross referencing 438.408(f).

49 3.9.6

The State assures that an enrollee may file a grievance with the MCO, PIHP, or PAHP at any time. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(i)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides specific instructions on how and when and enrollee may file a grievance. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. 3.9.7

The State assures that an enrollee has 60 calendar days from the date on an adverse benefit determination notice to file a request for an appeal to the MCO, PIHP, or PAHP. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(ii)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides specific instructions including timeframes regarding appeals. The Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. 3.9.8

The State assures that an enrollee may file a grievance and request an appeal either orally or in writing. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(3)(i)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides specific instructions including how an enrollee may request an appeal. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. 3.9.9

The State assures that each MCO, PIHP, and PAHP gives enrollees timely and adequate notice of an adverse benefit determination in writing consistent with the requirements below in Section 3.9.10 and in 42 CFR 438.10. The current contract between CHIP MCOs and the Department stipulates that MCOs meet the requirements of 42 CFR 457.1260 (referenced in Section 3.9.10 (below)). Furthermore, the CHIP Procedures Handbook provides specific instructions including timely and adequate notice. Templated notices are also provided through the CHIP Procedures Handbook. The CHIP Procedures Handbook outlines the external medical review process that is conducted by the Department of Health. There is no cost to the enrollee for the review. The CHIP MCOs are required to follow the external medical review process requirement as the CHIP Procedures Handbook is

50 incorporated by reference into the CHIP MCOs current contract. 3.9.10

The State assures that the notice of an adverse benefit determination explains: • The adverse benefit determination. • The reasons for the adverse benefit determination, including the right of the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee's adverse benefit determination. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits. • The enrollee's right to request an appeal of the MCO's, PIHP's, or PAHP's adverse benefit determination, including information on exhausting the MCO's, PIHP's, or PAHP's one level of appeal and the right to request a State review. • The procedures for exercising the rights specified above under this assurance. • The circumstances under which an appeal process can be expedited and how to request it. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(b)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides specific instructions including adverse benefit explanations. Templated notices are also provided through the CHIP Procedures Handbook. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract.

3.9.11

The State assures that the notice of an adverse benefit determination is provided in a timely manner in accordance with 42 CFR 457.1260. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(c)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides specific instructions including adverse benefit explanation timeframes. Templated notices are also provided through the CHIP Procedures Handbook. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract.

3.9.12

The State assures that MCOs, PIHPs, and PAHPs give enrollees reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal. This includes, but is not limited to, auxiliary aids and services upon request, such as providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(a)).

51 The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides specific instructions including providing assistance to enrollees in completing forms and procedural steps related to grievances and appeals. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract.

3.9.13 The state makes the following assurances related to MCO, PIHP, and PAHP processes for handling enrollee grievances and appeals: Individuals who make decisions on grievances and appeals were neither involved in any previous level of review or decision-making nor a subordinate of any such individual. Individuals who make decisions on grievances and appeals, if deciding any of the following, are individuals who have the appropriate clinical expertise in treating the enrollee's condition or disease: • An appeal of a denial that is based on lack of medical necessity. • A grievance regarding denial of expedited resolution of an appeal. • A grievance or appeal that involves clinical issues. All comments, documents, records, and other information submitted by the enrollee or their representative will be taken into account, without regard to whether such information was submitted or considered in the initial adverse benefit determination. Enrollees have a reasonable opportunity, in person and in writing, to present evidence and testimony and make legal and factual arguments. Enrollees are provided the enrollee's case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the MCO, PIHP or PAHP (or at the direction of the MCO, PIHP or PAHP) in connection with the appeal of the adverse benefit determination. This information must be provided free of charge and sufficiently in advance of the resolution timeframe for appeals. The enrollee and his or her representative or the legal representative of a deceased enrollee's estate are included as parties to the appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(b)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides MCOs with specific information regarding the handling of grievances and appeals, and includes each element listed in this assurance. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. Furthermore, PA CHIP Quality Assurance staff

52 review MCOs’ appeals and grievance procedures and files as part of on- site reviews, and through ad hoc reporting requests. The review and reports provide the state assurances that the MCOs meet the requirements of 42 CFR 457.1260. 3.9.14

The State assures that standard grievances are resolved (including notice to the affected parties) within 90 calendar days from the day the MCO, PIHP, or PAHP receives the grievance. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(b)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides MCOs with specific information regarding the handling of grievances and appeals including the requirement standard grievances are resolved within 90 calendar days. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. Furthermore, PA CHIP Quality Assurance staff review MCOs’ appeals and grievance procedures and files as part of on-site reviews, and through ad hoc reporting requests. The review and reports provide the state assurances that the MCOs meet the requirements of 42 CFR 457.1260. 3.9.15

The State assures that standard appeals are resolved (including notice to the affected parties) within 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal. The MCO, PIHP, or PAHP may extend the timeframe by up to 14 calendar days if the enrollee requests the extension or the MCO, PIHP, or PAHP shows that there is need for additional information and that the delay is in the enrollee's interest. (42 CFR 457.1260, cross-referencing to 42 CFR 42 CFR 438.408(b) and (c)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides CHIP MCOs with specific information regarding the handling of grievances and appeals including the requirement standard appeals are resolved within 30 calendar days. The process outlined in the CHIP Procedures Handbook also allows for the 14- calendar day extension. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. Furthermore, PA CHIP Quality Assurance staff review CHIP MCOs’ appeals and grievance procedures and files as part of on-site reviews, and through ad hoc reporting requests. The review and reports provide the state assurances that the CHIP MCOs meet the requirements of 42 CFR 457.1260.

53 3.9.16

The State assures that each MCO, PIHP, and PAHP establishes and maintains an expedited review process for appeals that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal. The expedited review process applies when the MCO, PIHP, or PAHP determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request) that taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(b) and (c), and 42 CFR 438.410(a)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides CHIP MCOs with specific information regarding the handling of grievances and appeals including expedited review process for appeals is no longer than 72 hours and when to apply the expedited review process as described in 42 CFR 457.1260. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. Furthermore, PA CHIP Quality Assurance staff review CHIP MCOs’ appeals and grievance procedures and files as part of on-site reviews, and through ad hoc reporting requests. The review and reports provide the state assurances that the MCOs meet the requirements of 42 CFR 457.1260. 3.9.17

The State assures that if an MCO, PIHP, or PAHP denies a request for expedited resolution of an appeal, it transfers the appeal within the timeframe for standard resolution in accordance with 42 CFR 438.408(b)(2). (42 CFR 457.1260, cross- referencing to 42 CFR 438.410(c)(1)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides CHIP MCOs with specific information regarding the handling of grievances and appeals which is in accordance with timeframes established. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. Furthermore, PA CHIP Quality Assurance staff review CHIP MCOs’ appeals and grievance procedures and files as part of on-site reviews, and through ad hoc reporting requests. The review and reports provide the state assurances that the MCOs meet the requirements of 42 CFR 457.1260. 3.9.18

The State assures that if the MCO, PIHP, or PAHP extends the timeframes for an appeal not at the request of the enrollee or it denies a request for an expedited resolution of an appeal, it completes all of the following:

54 • Make reasonable efforts to give the enrollee prompt oral notice of the delay. • Within 2 calendar days give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a grievance if he or she disagrees with that decision. • Resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(c) and 42 CFR 438.410(c)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides CHIP MCOs with specific information regarding the handling of grievances and appeals including the bullet items listed in this assurance. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. Furthermore, PA CHIP Quality Assurance staff reviews CHIP MCOs’ appeals and grievance procedures and files as part of on-site reviews, and through ad hoc reporting requests. The review and reports provide the state assurances that the CHIP MCOs meet the requirements of 42 CFR 457.1260.

3.9.19

The State assures that if an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in this section, the enrollee is deemed to have exhausted the MCO's, PIHP's, or PAHP's appeals process and the enrollee may initiate a State review. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c)(3)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. The stipulation includes that if a CHIP MCO fails to adhere to the notice and timing requirements of 42 CFR 1260, that the enrollee is deemed to have exhausted the CHIP MCO’s appeals process and the enrollee may initiate a state review.

3.9.20

The State assures that has established a method that an MCO, PIHP, and PAHP will use to notify an enrollee of the resolution of a grievance and ensure that such methods meet, at a minimum, the standards described at 42 CFR 438.10. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(1)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides templated notices for notification of an enrollee of the resolution of a grievance. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract.

55 3.9.21

For all appeals, the State assures that each contracted MCO, PIHP, and PAHP provides written notice of resolution in a format and language that, at a minimum, meet the standards described at 42 CFR 438.10. The notice of resolution includes at least the following items: • The results of the resolution process and the date it was completed; and • For appeals not resolved wholly in favor of the enrollees: o The right to request a State review, and how to do so. o The right to request and receive benefits while the hearing is pending, and how to make the request. o That the enrollee may, consistent with State policy, be held liable for the cost of those benefits if the hearing decision upholds the MCO's, PIHP's, or PAHP's adverse benefit determination. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(i) and (e)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides templated notices for notification of an enrollee of the resolution of a grievance including all bulleted elements listed in this assurance. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. Additionally, PA CHIP Quality Assurance reviews MCOs’ appeals and grievance procedures and files as part of on-site reviews, and through ad hoc reporting requests. The review and reports provide the state assurances that the MCOs meet the requirements of 42 CFR 457.1260.

3.9.22

For notice of an expedited resolution, the State assures that each contracted MCO, PIHP, or PAHP makes reasonable efforts to provide oral notice, in addition to the written notice of resolution. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(ii)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides MCOs with specific information regarding the handling of grievances and appeals including the requirement to provide oral notice. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. Furthermore, PA CHIP Quality Assurance reviews CHIP MCOs’ appeals and grievance procedures and files as part of on-site reviews, and through ad hoc reporting requests. The review and reports provide the state assurances that the CHIP MCOs meet the requirements of 42 CFR 457.1260.

3.9.23

The State assures that if it offers an external medical review: • The review is at the enrollee's option and is not required before or used as a

56 deterrent to proceeding to the State review; • The review is independent of both the State and MCO, PIHP, or PAHP; and • The review is offered without any cost to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(f)). CHIP Procedures Handbook outlines the external medical review process that is conducted by the Department of Health. The process is at the enrollee’s option and does not impede upon an enrollee’s right for further review. There is no cost to the enrollee for the review. The CHIP MCOs are required to follow the external medical review process requirement as the CHIP Procedures Handbook is incorporated by reference into the CHIP MCOs current contract. Furthermore, state statute (40 P.S. §§ 991.2301-A – 991.2309-A) requires CHIP to offer an external medical review and that review meets the requirements as outlined in 42 CFR 1260, cross referencing 438.408(f).

3.9.24

The State assures that MCOs, PIHPs, and PAHPs do not take punitive action against providers who request an expedited resolution or support an enrollee's appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(b)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides MCOs with specific information regarding the handling of grievances and appeals including the requirement not to take punitive action against a provider who requests an expedited resolution or supports an enrollee’s appeal. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. Furthermore, PA CHIP Quality Assurance staff review MCOs’ appeals and grievance procedures and files as part of on-site reviews, and through ad hoc reporting requests. The review and reports provide the state assurances that the MCOs meet the requirements of 42 CFR 457.1260.

3.9.25

The State assures that MCOs, PIHPs, or PAHPs must provide information specified in 42 CFR 438.10(g)(2)(xi) about the grievance and appeal system to all providers and subcontractors at the time they enter into a contract. This includes: • The right to file grievances and appeals; • The requirements and timeframes for filing a grievance or appeal; • The availability of assistance in the filing process; • The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; and • The fact that, when requested by the enrollee, benefits that the MCO, PIHP, or PAHP seeks to reduce or terminate will continue if the enrollee files an appeal

57 or a request for State review within the timeframes specified for filing, and that the enrollee may, consistent with State policy, be required to pay the cost of services furnished while the appeal or State review is pending if the final decision is adverse to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.414). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides CHIP MCOs with specific information regarding the handling of grievances and appeals including each element listed in this assurance. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. Each CHIP MCO is required to provide grievance and appeals information to enrollees through the CHIP MCOs enrollee handbook, and to provide information on filing an appeal when adverse decisions are made. The Department provides templated notices regarding benefit decisions to CHIP MCOs to use which includes appeal and grievance information. Those notices are also part of the CHIP Procedures Handbook. The CHIP Procedures Handbook is also available on-line at https://www.chipcoverspakids.com. Furthermore, PA CHIP Quality Assurance staff review CHIP MCOs’ appeals and grievance procedures and files as part of on-site reviews, and through ad hoc reporting requests. The review and reports provide the state assurances that the CHIP MCOs meet the requirements of 42 CFR 457.1260.

3.9.26

The State assures that it requires MCOs, PIHPs, and PAHPs to maintain records of grievances and appeals and reviews the information as part of its ongoing monitoring procedures, as well as for updates and revisions to the State quality strategy. The record must be accurately maintained in a manner accessible to the state and available upon request to CMS. (42 CFR 457.1260, cross-referencing to 42 CFR 438.416). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, the CHIP Procedures Handbook provides requirements for maintain grievance and appeal records. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract.

3.9.27

The State assures that if the MCO, PIHP, or PAHP, or the State review officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the MCO, PIHP, or PAHP must authorize or provide the disputed services promptly and as expeditiously as the enrollee's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. (42 CFR 457.1260, cross-referencing to 42 CFR 438.424(a)).

58 The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1260. Furthermore, PA CHIP conducts on-site reviews at MCOs. During the on-site reviews, the Department through PA CHIP Quality Assurance staff reviews MCO decisions and follow-up actions to ensure that services were provided appropriately after an appeal decision and within prescribed timeframes. Additionally, the requirement the MCOs provide disputed services promptly and expeditiously but no later than 72 hours from the date of notice of the decision reversal is included in the CHIP Procedures Handbook. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract.

3.10 Program Integrity Guidance: The State should complete Section 11 (Program Integrity) in addition to Section 3.10. Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the first seven assurances (3.10.1 through 3.10.7). 3.10.1 The State assures that any entity seeking to contract as an MCO, PIHP, or PAHP under a separate child health program has administrative and management arrangements or procedures designed to safeguard against fraud and abuse, including:

Enforcing MCO, PIHP, and PAHP compliance with all applicable Federal and State statutes, regulations, and standards;

Prohibiting MCOs, PIHPs, or PAHPs from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity; and

Including a mechanism for MCOs, PIHPs, and PAHPs to report to the State, to CMS, or to the Office of Inspector General (OIG) as appropriate, information on violations of law by subcontractors, providers, or enrollees of an MCO, PIHP, or PAHP and other individuals. (42 CFR 457.1280)

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1280. Furthermore, the CHIP Procedures Handbook provides requirements and procedures designed to safeguard against fraud and abuse as stated in this assurance. PA CHIP also reviews and approves all enrollee communications are through the programmatic change process. The programmatic change process is part of the CHIP Procedures Handbook. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract.

59 Additionally, PA CHIP conducts on-site reviews to ensure compliance with the requirements of 42 CFR 457.1280. 3.10.2

The State assures that it has in effect safeguards against conflict of interest on the part of State and local officers and employees and agents of the State who have responsibilities relating to the MCO, PIHP, or PAHP contracts or enrollment processes described in 42 CFR 457.1210(a). (42 CFR 457.1214, cross referencing 42 CFR 438.58). 3.10.3

The State assures that it periodically, but no less frequently than once every 3 years, conducts, or contracts for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP or PAHP. (42 CFR 457.1285, cross referencing 42 CFR 438.602(e)). 3.10.4

The State assures that it requires MCOs, PIHPs, PAHP, and or subcontractors (only to the extent that the subcontractor is delegated responsibility by the MCO, PIHP, or PAHP for coverage of services and payment of claims) implement and maintain arrangements or procedures that are designed to detect and prevent fraud, waste, and abuse. The arrangements or procedures must include the following: • A compliance program that include all of the elements described in 42 CFR 438.608(a)(1); • Provision for prompt reporting of all overpayments identified or recovered, specifying the overpayments due to potential fraud, to the State; • Provision for prompt notification to the State when it receives information about changes in an enrollee's circumstances that may affect the enrollee's eligibility; • Provision for notification to the State when it receives information about a change in a network provider's circumstances that may affect the network provider's eligibility to participate in the managed care program, including the termination of the provider agreement with the MCO, PIHP or PAHP; • Provision for a method to verify, by sampling or other methods, whether services that have been represented to have been delivered by network providers were received by enrollees and the application of such verification processes on a regular basis; • In the case of MCOs, PIHPs, or PAHPs that make or receive annual payments under the contract of at least $5,000,000, provision for written policies for all employees of the entity, and of any contractor or agent, that provide detailed information about the False Claims Act and other Federal and State laws described in section 1902(a)(68) of the Act, including information about rights of employees to be protected as whistleblowers; • Provision for the prompt referral of any potential fraud, waste, or abuse that

60 the MCO, PIHP, or PAHP identifies to the State Medicaid/CHIP program integrity unit or any potential fraud directly to the State Medicaid Fraud Control Unit; and • Provision for the MCO's, PIHP's, or PAHP's suspension of payments to a network provider for which the State determines there is a credible allegation of fraud in accordance with 42 CFR 455.23. (42 CFR 457.1285, cross referencing 42 CFR 438.608(a)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1285. Furthermore, the CHIP Procedures Handbook provides requirements for compliance programs, reporting overpayments, providing notifications and referrals, and ability for the CHIP MCO to suspend payments to providers as outlined in the above section. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. 3.10.5

The State assures that each MCO, PIHP, or PAHP requires and has a mechanism for a network provider to report to the MCO, PIHP or PAHP when it has received an overpayment, to return the overpayment to the MCO, PIHP or PAHP within 60 calendar days after the date on which the overpayment was identified, and to notify the MCO, PIHP or PAHP in writing of the reason for the overpayment. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(2)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1285. Furthermore, the CHIP Procedures Handbook requires MCOs have a mechanism to receive and return and overpayment within 60 calendar days of identification of the overpayment. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract.

3.10.6

The State assures that each MCO, PIHP, or PAHP reports annually to the State on their recoveries of overpayments. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(3)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1285. Furthermore, the CHIP Procedures Handbook requires CHIP MCOs to have “prompt reporting” rather than annually so reporting may occur more frequently. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. 3.10.7

The State assures that it screens and enrolls, and periodically revalidates, all network providers of MCOs, PIHPs, and PAHPs, in accordance with the

61 requirements of part 455, subparts B and E. This requirement also extends to PCCMs and PCCM entities to the extent that the primary care case manager is not otherwise enrolled with the State to provide services to fee-for-service beneficiaries. (42 CFR 457.1285, cross referencing 42 CFR 438.602(b)(1) and 438.608(b)).

The Department screens and enrolls CHIP providers as part of the Department’s provider enrollment process. Revalidation of providers occurs every 5 years. 3.10.8

The State assures that it reviews the ownership and control disclosures submitted by the MCO, PIHP, PAHP, PCCM or PCCM entity, and any subcontractors. (42 CFR 457.1285, cross referencing 42 CFR 438.602(c)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1285. Furthermore, the Department through PA CHIP reviews the ownership and control disclosures submitted by the CHIP MCO and subcontractors. These disclosures are submitted to the Department using the programmatic change process. The programmatic change process is part of the CHIP Procedures Handbook. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract.

3.10.9

The State assures that it confirms the identity and determines the exclusion status of the MCO, PIHP, PAHP, PCCM or PCCM entity, any subcontractor, as well as any person with an ownership or control interest, or who is an agent or managing employee of the MCO, PIHP, PAHP, PCCM or PCCM entity through routine checks of Federal databases. If the State finds a party that is excluded, the State promptly notifies the MCO, PIHP, PAHP, PCCM, or PCCM entity and takes action consistent with 42 CFR 438.610(c). (42 CFR 457.1285, cross referencing 42 CFR 438.602(d)). The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1285. Furthermore, the Department through PA CHIP reviews changes regarding key staff positions within the MCO and subcontractors. These changes are submitted to the Department using the programmatic change process. Organization charts must be included to further document owner and control. The Department through PA CHIP reviews specific website for provider exclusions. The programmatic change process is part of the CHIP Procedures Handbook. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract.

62 3.10.10

The State assures that it receives and investigates information from whistleblowers relating to the integrity of the MCO, PIHP, PAHP, PCCM, or PCCM entity, subcontractors, or network providers receiving Federal funds under this part. (42 CFR 457.1285, cross referencing 42 CFR 438.602(f)).

When PA CHIP receives information from a whistleblower relating to the integrity of an MCO or network provider, the CHIP Quality Assurance staff conduct an investigation based on established fraud, waste and abuse policies and procedures set forth in the CHIP Procedures Handbook. 3.10.11

The State assures that MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities with which the State contracts are not located outside of the United States and that no claims paid by an MCO, PIHP, or PAHP to a network provider, out-of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates. (42 CFR 457.1285, cross referencing to 42 CFR 438.602(i); Section 1902(a)(80) of the Social Security Act).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1285. Specifically, the contract prohibits CHIP MCOs from making payments for claims to providers, sucontractors or financial institutions located outside of the United States. This requirement will be reviewed at the next annual MCO on-site monitoring. conducted by the Department. Furthermore, the eight MCOs contracting with the Department are all incorporated within the United States. Additionally, the Department is currently working with CHIP MCOs to provide certification that future claims data provided will not include claims paid from outside the United States. 3.10.12 The State assures that MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities submit to the State the following data, documentation, and information:

Encounter data in the form and manner described in 42 CFR 438.818.

Data on the basis of which the State determines the compliance of the MCO, PIHP, or PAHP with the medical loss ratio requirement described in 42 CFR 438.8.

Data on the basis of which the State determines that the MCO, PIHP or PAHP has made adequate provision against the risk of insolvency as required under 42 CFR 438.116.

Documentation described in 42 CFR 438.207(b) on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services, including the adequacy of the provider network, as set forth in 42 CFR 438.206.

63

Information on ownership and control described in 42 CFR 455.104 of this chapter from MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors as governed by 42 CFR 438.230.

The annual report of overpayment recoveries as required in 42 CFR 438.608(d)(3). (42 CFR 457.1285, cross referencing 42 CFR 438.604(a)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1285. Furthermore, the CHIP Procedures Handbooks provides additional information regarding submission of data, documentation and information as stated above. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract.

3.10.13 The State assures that:

It requires that the data, documentation, or information submitted in accordance with 42 CFR 457.1285, cross referencing 42 CFR 438.604(a), is certified in a manner that the MCO's, PIHP's, PAHP's, PCCM's, or PCCM entity's Chief Executive Officer or Chief Financial Officer is ultimately responsible for the certification. (42 CFR 457.1285, cross referencing 42 CFR 438.606(a));

It requires that the certification includes an attestation that, based on best information, knowledge, and belief, the data, documentation, and information specified in 42 CFR 438.604 are accurate, complete, and truthful. (42 CFR 457.1285, cross referencing 42 CFR 438.606(b)); and

It requires the MCO, PIHP, PAHP, PCCM, or PCCM entity to submit the certification concurrently with the submission of the data, documentation, or information required in 42 CFR 438.604(a) and (b). (42 CFR 457.1285, cross referencing 42 CFR 438.604(c)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1285. Furthermore, the CHIP Procedures Handbooks outlines the certification requirements when submitting information. Each MCO submits certifications to the Department for review in accordance with the Procedures Handbook. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. 3.10.14

The State assures that each MCO, PIHP, PAHP, PCCM, PCCM entity, and any subcontractors provides: written disclosure of any prohibited affiliation under 42 CFR 438.610, written disclosure of and information on ownership and control required under 42 CFR 455.104, and reports to the State within 60 calendar days when it has identified the capitation payments or other payments in excess of

64 amounts specified in the contract. (42 CFR 457.1285, cross referencing 42 CFR 438.608(c)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1285. 3.10.15

The State assures that services are provided in an effective and efficient manner. (Section 2101(a)). 3.10.16

The State assures that it operates a Web site that provides: • The documentation on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services; • Information on ownership and control of MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors; and • The results of any audits conducted under 42 CFR 438.602(e). (42 CFR 457.1285, cross-referencing to 42 CFR 438.602(g)). Each CHIP MCOs must have National Committee for Quality Assurance (NCQA) accreditation which verifies it complies with standards for availability and accessibility of services. NCQA certifications are found on- line at https://www.chipcoverspakids.com/chip- resources/Pages/AccreditationStatus.aspx. Ownership and control information is part of each contract. CHIP MCO contracts are found on-line at http://contracts.patreasury.gov/ and http://www.emarketplace.state.pa.us/. MCO audit information is posted by the Department at http://www.dhs.pa.gov/learnaboutdhs/dhsorganization/officeofadministratio n/bureauoffinancialoperations/index.htm and http://www.dhs.pa.gov/publications/finalperformanceauditreports/ .

3.11 Sanctions Guidance: Only States with MCOs need to answer the next three assurances (3.11.1 through 3.11.3).

Intermediate sanctions are defined at 42 CFR 438.702(a)(4) as: (1) Civil money penalties; (2) Appointment of temporary management (for an MCO); (3) Granting enrollees the right to terminate enrollment without cause; (4) Suspension of all new enrollment; and (5) Suspension of payment for beneficiaries.

3.11.1

The State assures that it has established intermediate sanctions that it may impose if it makes the determination that an MCO has acted or failed to act in a manner

65 specified in 438.700(b)-(d). (42 CFR 457.1270, cross referencing 42 CFR 438.700).

The current contract between CHIP MCOs and the Department stipulates intermediate sanctions including liquidated damages and corrective action plans as requirements of 42 CFR 457.1270. 3.11.2

The State assures that it will impose temporary management if it finds that an MCO has repeatedly failed to meet substantive requirements of part 457 subpart L. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)).

3.11.3

The State assures that if it imposes temporary management on an MCO, the State allows enrollees the right to terminate enrollment without cause and notifies the affected enrollees of their right to terminate enrollment. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)). Guidance: Only states with PCCMs, or PCCM entities need to answer the next assurance (3.11.4). 3.11.4 Does the State establish intermediate sanctions for PCCMs or PCCM entities? Yes No

Guidance: Only states with MCOs and states that answered yes to assurance 3.11.4 need to complete the next three assurances (3.11.5 through 3.11.7). 3.11.5

The State assures that before it imposes intermediate sanctions, it gives the affected entity timely written notice. (42 CFR 457.1270, cross referencing 42 CFR 438.710(a)). 3.11.6

The State assures that if it intends to terminate an MCO, PCCM, or PCCM entity, it provides a pre-termination hearing and written notice of the decision as specified in 42 CFR 438.710(b). If the decision to terminate is affirmed, the State assures that it gives enrollees of the MCO, PCCM or PCCM entity notice of the termination and information, consistent with 42 CFR 438.10, on their options for receiving CHIP services following the effective date of termination. (42 CFR 457.1270, cross referencing 42 CFR 438.710(b)).

This requirement will be included in the next CHIP contract amendment on 3/1/2020. 3.11.7

The State assures that it will give CMS written notice that complies with 42 CFR 438.724 whenever it imposes or lifts a sanction for one of the violations listed in 42 CFR 438.700. (42 CFR 457.1270, cross referencing 42 CFR 438.724).

66 3.12 Quality Measurement and Improvement; External Quality Review Guidance: The State should complete Sections 7 (Quality and Appropriateness of Care) and 9 (Strategic Objectives and Performance Goals and Plan Administration) in addition to Section 3.12. Guidance: States with MCO(s), PIHP(s), PAHP(s), or certain PCCM entity/ies (PCCM entities whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes - see 42 CFR 457.1240(f)) - should complete the applicable sub-sections for each entity type in this section, regarding 42 CFR 457.1240 and 1250.

67 3.12.1 Quality Strategy Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities need to complete section 3.12.1. 3.12.1.1

The State assures that it will draft and implement a written quality strategy for assessing and improving the quality of health care and services furnished CHIP enrollees as described in 42 CFR 438.340(a). The quality strategy must include the following items: • The State-defined network adequacy and availability of services standards for MCOs, PIHPs, and PAHPs required by 42 CFR 438.68 and 438.206 and examples of evidence-based clinical practice guidelines the State requires in accordance with 42 CFR 438.236; • A description of: o The quality metrics and performance targets to be used in measuring the performance and improvement of each MCO, PIHP, and PAHP with which the State contracts, including but not limited to, the performance measures reported in accordance with 42 CFR 438.330(c); and o The performance improvement projects to be implemented in accordance with 42 CFR 438.330(d), including a description of any interventions the State proposes to improve access, quality, or timeliness of care for beneficiaries enrolled in an MCO, PIHP, or PAHP; • Arrangements for annual, external independent reviews, in accordance with 42 CFR 438.350, of the quality outcomes and timeliness of, and access to, the services covered under each contract; • A description of the State's transition of care policy required under 42 CFR 438.62(b)(3); • The State's plan to identify, evaluate, and reduce, to the extent practicable, health disparities based on age, race, ethnicity, sex, and primary language; • For MCOs, appropriate use of intermediate sanctions that, at a minimum, meet the requirements of subpart I of 42 CFR Part 438; • A description of how the State will assess the performance and quality outcomes achieved by each PCCM entity; • The mechanisms implemented by the State to comply with 42 CFR 438.208(c)(1) (relating to the identification of persons with special health care needs); • Identification of the external quality review (EQR)-related activities for which the State has exercised the option under 42 CFR 438.360 (relating to nonduplication of EQR-related activities), and explain the rationale for the State's determination that the private accreditation

68 activity is comparable to such EQR-related activities; • Identification of which quality measures and performance outcomes the State will publish at least annually on the Web site required under 42 CFR 438.10(c)(3); and • The State's definition of a “significant change” for the purposes of updating the quality strategy under 42 CFR 438.340(c)(3)(ii). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)). 3.12.1.2

The State assures that the goals and objectives for continuous quality improvement in the quality strategy are measurable and take into consideration the health status of all populations in the State served by the MCO, PIHP, and PAHP. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(2)). 3.12.1.3

The State assures that for purposes of the quality strategy, the State provides the demographic information for each CHIP enrollee to the MCO, PIHP or PAHP at the time of enrollment. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(6)). 3.12.1.4

The State assures that it will review and update the quality strategy as needed, but no less than once every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)). 3.12.1.5

The State assures that its review and updates to the quality strategy will include an evaluation of the effectiveness of the quality strategy conducted within the previous 3 years and the recommendations provided pursuant to 42 CFR 438.364(a)(4). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(i) and (iii). 3.12.1.6

The State assures that it will submit to CMS: • A copy of the initial quality strategy for CMS comment and feedback prior to adopting it in final; and • A copy of the revised strategy whenever significant changes are made to the document, or whenever significant changes occur within the State's CHIP program, including after the review and update required every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(3)). 3.12.1.7

Before submitting the strategy to CMS for review, the State assures that when it drafts or revises the State’s quality strategy it will: • Make the strategy available for public comment; and • If the State enrolls Indians in the MCO, PIHP, or PAHP, consult with Tribes in accordance with the State's Tribal consultation policy. (42

69 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(1)). 3.12.1.8

The State assures that it makes the results of the review of the quality strategy (including the effectiveness evaluation) and the final quality strategy available on the Web site required under 42 CFR 438.10(c)(3). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(ii) and (d)).

3.12.2 Quality Assessment and Performance Improvement Program 3.12.2.1 Quality Assessment and Performance Improvement Program: Measures and Projects Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next two assurances (3.12.2.1.1 and 3.12.2.1.2). 3.12.2.1.1 The State assures that it requires that each MCO, PIHP, and PAHP establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The elements of the assessment and program include at least: • Standard performance measures specified by the State; • Any measures and programs required by CMS (42 CFR 438.330(a)(2); • Performance improvement projects that focus on clinical and non-clinical areas, as specified in 42 CFR 438.330(d); • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c); • Mechanisms to detect both underutilization and overutilization of services; and • Mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs, as defined by the State in the quality strategy under 42 CFR 457.1240(e) and Section 3.12.1 of this template). (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(b) and (c)(1)). The CHIP Procedures Handbook requires MCOs to develop and implement a comprehensive quality improvement assessment and performance improvement program through its Quality Management/ Utilization Management (QM/UM) requirements. The MCOs must adhere to Pennsylvania Performance Measures and CMS performance measures as

70 required. PA CHIP currently has Performance Improvement Projects (PIPs) that run from 2017-2021. IPRO provides performance measurement data annually to CHIP Quality Assurance staff for review. Further data is provided through the QM/UM reports including data on underutilization and overutilization. Furthermore. Quality Assurance staff reviews reports to assess the quality and appropriateness of care furnished to enrollees with special health care needs.

Guidance: A State may request an exemption from including the performance measures or performance improvement programs established by CMS under 42 CFR 438.330(a)(2), by submitting a written request to CMS explaining the basis for such request. 3.12.2.1.2 The State assures that each MCO, PIHP, and PAHP’s performance improvement projects are designed to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction. The performance improvement projects include at least the following elements: • Measurement of performance using objective quality indicators; • Implementation of interventions to achieve improvement in the access to and quality of care; • Evaluation of the effectiveness of the interventions based on the performance measures specified in 42 CFR 438.330(d)(2)(i); and • Planning and initiation of activities for increasing or sustaining improvement. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(2)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1240(b). Furthermore, the CHIP Procedures Handbook provides specific requirements regarding performance improvement projects. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. A member of the CHIP Quality Assurance Staff reviews performance improvement projects to ensure compliance with the requirements outlined in the Procedures Handbook. The performance improvement projects are reviewed at each Quarterly Quality Review Meeting (QQRMs). Quarterly Quality Review Meetings are

71 held by the Department with each CHIP MCO on a quarterly calendar schedule. Guidance: Only states with a PCCM entity whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes need to, complete the next assurance (3.12.2.1.3).

3.12.2.1.3 The State assures that it requires that each PCCM entity establishes and implements an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The assessment and program must include: • Standard performance measures specified by the State; • Mechanisms to detect both underutilization and overutilization of services; and • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c). (42 CFR 457.1240(a) and (b), cross referencing to 42 CFR 438.330(b)(3) and (c)) 3.12.2.2 Quality Assessment and Performance Improvement Program: Reporting and Effectiveness Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.2.2. 3.12.2.2.1 The State assures that each MCO, PIHP, and PAHP reports on the status and results of each performance improvement project conducted by the MCO, PIHP, and PAHP to the State as required by the State, but not less than once per year. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(3)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1240(b). Furthermore, the CHIP Procedures Handbook provides reporting requirements and timeframes regarding performance improvement projects. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract. The performance improvement projects are reviewed at each Quarterly Quality Review Meeting (QQRMs). Quarterly Quality Review Meetings are held by the Department with each CHIP MCO on a quarterly calendar schedule.

72

3.12.2.2.2 The State assures that it annually requires each MCO, PIHP, and PAHP to:

1) Measure and report to the State on its performance using the standard measures required by the State;

2) Submit to the State data specified by the State to calculate the MCO's, PIHP's, or PAHP's performance using the standard measures identified by the State; or

3) Perform a combination of options (1) and (2) of this assurance. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(c)(2)).

The current contract between CHIP MCOs and the Department stipulates that CHIP MCOs meet the requirements of 42 CFR 457.1240(b). Furthermore, the CHIP Procedures Handbook provides specific requirements to measure, report and submit data specified by the state. The CHIP Procedures Handbook is incorporated by reference in the CHIP MCOs current contract.

3.12.2.2.3 The State assures that the State reviews, at least annually, the impact and effectiveness of the quality assessment and performance improvement program of each MCO, PIHP, PAHP and PCCM entity. The State’s review must include: • The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required to report; and • The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement projects. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(e)(1)).

The CHIP Quality Assurance staff receive reports from IPRO, the EQR vendor, which analyze the impact and effectiveness of the quality assessment. The reports also document trends and outcomes. The CHIP Quality Assurance staff receive, review and analyze this information on an annual basis. 3.12.3 Accreditation Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.3. 3.12.3.1

The State assures that it requires each MCO, PIHP, and PAHP to inform the state whether it has been accredited by a private independent

73 accrediting entity, and, if the MCO, PIHP, or PAHP has received accreditation by a private independent accrediting agency, that the MCO, PIHP, and PAHP authorizes the private independent accrediting entity to provide the State a copy of its recent accreditation review that includes the MCO, PIHP, and PAHP’s accreditation status, survey type, and level (as applicable); accreditation results, including recommended actions or improvements, corrective action plans, and summaries of findings; and expiration date of the accreditation. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(a) and (b)).

PA CHIP receives a copy of each CHIP MCO’s National Committee for Quality Assurance (NCQA) certification. 3.12.3.2

The State assures that it will make the accreditation status for each contracted MCO, PIHP, and PAHP available on the Web site required under 42 CFR 438.10(c)(3), including whether each MCO, PIHP, and PAHP has been accredited and, if applicable, the name of the accrediting entity, accreditation program, and accreditation level; and update this information at least annually. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(c)). 3.12.4 Quality Rating Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.4.

The State assures that it will implement and operate a quality rating system that issues an annual quality rating for each MCO, PIHP, and PAHP, which the State will prominently display on the Web site required under 42 CFR 438.10(c)(3), in accordance with the requirements set forth in 42 CFR 438.334. (42 CFR 457.1240(d)). Guidance: States will be required to comply with this assurance within 3 years after CMS, in consultation with States and other Stakeholders and after providing public notice and opportunity for comment, has identified performance measures and a methodology for a Medicaid and CHIP managed care quality rating system in the Federal Register. 3.12.5 Quality Review Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5 and 3.12.5.1.

The State assures that each contract with a MCO, PIHP, PAHP, or PCCM entity requires that a qualified EQRO performs an annual external quality review (EQR) for each

74 contracting MCO, PIHP, PAHP or PCCM entity, except as provided in 42 CFR 438.362. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(a)).

PA CHIP and PA CHIP MCOs contract with Island Peer Review Organization (IPRO) which is a qualified EQR vendor. The CHIP Procedures Handbook requires a qualified EQRO perform an annual EQR with each contracting MCO. 3.12.5.1 External Quality Review Organization 3.12.5.1.1 The State assures that it contracts with at least one external quality review organization (EQRO) to conduct either EQR alone or EQR and other EQR-related activities. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(a)). 3.12.5.1.2 The State assures that any EQRO used by the State to comply with 42 CFR 457.1250 must meet the competence and independence requirements of 42 CFR 438.354 and, if the EQRO uses subcontractors, that the EQRO is accountable for and oversees all subcontractor functions. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.354 and 42 CFR 438.356(b) through (d)).

PA CHIP contracts with Island Peer Review Organization (IPRO) which is a qualified EQR vendor. 3.12.5.2 External Quality Review-Related Activities Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next three assurances (3.12.5.2.1 through 3.12.5.2.3). Under 42 CFR 457.1250(a), the State, or its agent or EQRO, must conduct the EQR-related activity under 42 CFR 438.358(b)(1)(iv) regarding validation of the MCO, PIHP, or PAHP’s network adequacy during the preceding 12 months; however, the State may permit its contracted MCO, PIHP, and PAHPs to use information from a private accreditation review in lieu of any or all the EQR-related activities under 42 CFR 438.358(b)(1)(i) through (iii) (relating to the validation of performance improvement projects, validation of performance measures, and compliance review). 3.12.5.2.1 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(1)(i) through (iv) (relating to the validation of performance improvement projects, validation of performance measures, compliance review, and validation of network adequacy) will be conducted on all MCOs, PIHPs, or PAHPs. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(b)(1)).

75

3.12.5.2.2 The State assures that if it elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will document the use of nonduplication in the State’s quality strategy. (42 CFR 457.1250(a), cross referencing 438.360, 438.358(b)(1)(i) through (b)(1)(iii), and 438.340). 3.12.5.2.3 The State assures that if the State elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will ensure that all information from a Medicare or private accreditation review for an MCO, PIHP, or PAHP will be furnished to the EQRO for analysis and inclusion in the EQR technical report described in 42 CFR 438.364. ((42 CFR 457.1250(a), cross referencing to 42 CFR 438.360(b)). Guidance: Only states with PCCM entities need to complete the next assurance (3.12.5.2.4). 3.12.5.2.4 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(2) (cross-referencing 42 CFR 438.358(b)(1)(ii) and (b)(1)(iii)) will be conducted on all PCCM entities, which include: • Validation of PCCM entity performance measures required in accordance with 42 CFR 438.330(b)(2) or PCCM entity performance measures calculated by the State during the preceding 12 months; and • A review, conducted within the previous 3-year period, to determine the PCCM entity’s compliance with the standards set forth in subpart D of 42 CFR part 438 and the quality assessment and performance improvement requirements described in 42 CFR 438.330. (42 CFR 457.1250(a), cross referencing to 438.358(b)(2))

3.12.5.3 External Quality Review Report Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5.3. 3.12.5.3.1 The State assures that data obtained from the mandatory and optional, if applicable, EQR-related activities in 42 CFR 438.358 is used for the annual EQR to comply with 42 CFR 438.350 and must

76 include, at a minimum, the elements in §438.364(a)(2)(i) through (iv). (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(a)(2)).

3.12.5.3.2 The State assures that only a qualified EQRO will produce the EQR technical report (42 CFR 438.364(c)(1)).

3.12.5.3.3 The State assures that in order for the qualified EQRO to perform an annual EQR for each contracting MCO, PIHP, PAHP or PCCM entity under 42 CFR 438.350(a) that the following conditions are met: • The EQRO has sufficient information to use in performing the review; • The information used to carry out the review must be obtained from the EQR-related activities described in 42 CFR 438.358 and, if applicable, from a private accreditation review as described in 42 CFR 438.360; • For each EQR-related activity (mandatory or optional), the information gathered for use in the EQR must include the elements described in 42 CFR 438.364(a)(2)(i) through (iv); and • The information provided to the EQRO in accordance with 42 CFR 438.350(b) is obtained through methods consistent with the protocols established by the Secretary in accordance with 42 CFR 438.352. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(b) through (e)). The Department has a competitive procurement process in place to ensure the EQRO is qualified and meets the above stated conditions. 3.12.5.3.4 The State assures that the results of the reviews performed by a qualified EQRO of each contracting MCO, PIHP, PAHP, and PCCM entity are made available as specified in 42 CFR 438.364 in an annual detailed technical report that summarizes findings on access and quality of care. The report includes at least the following items: • A description of the manner in which the data from all activities conducted in accordance with 42 CFR 438.358 were aggregated and analyzed, and conclusions were drawn as to the quality, timeliness, and access to the care furnished by the MCO, PIHP, PAHP, or PCCM entity (described in 42 CFR 438.310(c)(2)); • For each EQR-related activity (mandatory or optional)

77 conducted in accordance with 42 CFR 438.358: o Objectives; o Technical methods of data collection and analysis; o Description of data obtained, including validated performance measurement data for each activity conducted in accordance with 42 CFR 438.358(b)(1)(i) and (ii); and o Conclusions drawn from the data; • An assessment of each MCO's, PIHP's, PAHP's, or PCCM entity's strengths and weaknesses for the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; • Recommendations for improving the quality of health care services furnished by each MCO, PIHP, PAHP, or PCCM entity, including how the State can target goals and objectives in the quality strategy, under 42 CFR 438.340, to better support improvement in the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; • Methodologically appropriate, comparative information about all MCOs, PIHPs, PAHPs, and PCCM entities, consistent with guidance included in the EQR protocols issued in accordance with 42 CFR 438.352(e); and • An assessment of the degree to which each MCO, PIHP, PAHP, or PCCM entity has addressed effectively the recommendations for quality improvement made by the EQRO during the previous year's EQR. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(f) and 438.364(a)).

The Department assures that the results of the reviews performed by a qualified EQRO of each contracting MCO entity are made available in an annual detailed technical report that summarizes findings on access and quality of care. The report includes all of the above listed item.

3.12.5.3.5 The State assures that it does not substantively revise the content of the final EQR technical report without evidence of error or omission. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(b)).

The Department does not substantively revise the content of the final EQR technical report. PA CHIP only reviews for errors.

78 3.12.5.3.6 The State assures that it finalizes the annual EQR technical report by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(1)). 3.12.5.3.7 The State assures that it posts the most recent copy of the annual EQR technical report on the Web site required under 42 CFR 438.10(c)(3) by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(i)).

The annual EQR technical report is posted at https://www.chipcoverspakids.com. 3.12.5.3.8 The State assures that it provides printed or electronic copies of the information specified in 42 CFR 438.364(a) for the annual EQR technical report, upon request, to interested parties such as participating health care providers, enrollees and potential enrollees of the MCO, PIHP, PAHP, or PCCM, beneficiary advocacy groups, and members of the general public. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(ii)). 3.12.5.3.9 The State assures that it makes the information specified in 42 CFR 438.364(a) for the annual EQR technical report available in alternative formats for persons with disabilities, when requested. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(3)). 3.12.5.3.10 The State assures that information released under 42 CFR 438.364 for the annual EQR technical report does not disclose the identity or other protected health information of any patient. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(d)).

The annual EQR technical report does not include protected health information.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102)(a)(4) (42 CFR 457.490(b))

CHIP services are provided through a managed care model, in which enrollees select a primary care physician who is responsible for providing basic primary care services and referrals to other specialty care. For those enrollees in counties with a Gatekeeper PPO, a

79 medical home is assigned in lieu of a primary care physician.

As a means of determining the level of utilization, managed care plans systematically track the utilization of health services to identify patterns of over and under utilization of health services. In addition, each CHIP Contractor is required to submit specific utilization data to the Department on a quarterly and annual basis. The data includes:

• The number of enrollee visits to primary care physicians, medical specialists, as well as visits for vision, hearing, dental, and mental health services. • The number of prescriptions and the ten most utilized drugs; and • The number of hospital admissions for medical, surgical, maternity, mental health and substance use disorder and average length of stay, by age group.

The data collected is analyzed by the Department to identify outliers and potential utilization issues. The Department then works with the plans to further evaluate the outliers and correct problems as necessary during its ongoing utilization review and quality improvement programs.

Section 4. Eligibility Standards and Methodology

4.0.

Medicaid Expansion

4.0.1. Ages of each eligibility group and the income standard for that group:

4.1.

Separate Program Check all standards that will apply to the State plan. (42 CFR 457.305(a) and 457.320(a))

4.1.0 Describe how the State meets the citizenship verification requirements. Include whether or not State has opted to use SSA verification option.

The verification of citizenship requirement includes verifying the identity of the applicant child claiming to be a U.S. citizen or lawfully residing. Citizenship and identity must only be verified once. An electronic match with the SSA will take place to match the child’s name, date of birth, gender, and Social Security Number (SSN) in the CHIP Application Processing System to the SSA database. If there is a match, citizenship and identity will be considered verified.

4.1.1 Geographic area served by the Plan if less than Statewide:

4.1.2 Ages of each eligibility group, including unborn children and pregnant women (if applicable) and the income standard for that group:

80

CHIP provides coverage to children from birth through 18. CHIP provides free coverage to children in families with incomes too high for Medicaid and adjusted gross income at or under 208% of FPL. Subsidized CHIP is provided to children in families with adjusted gross income of greater than 208% of FPL, but not greater than 314% of FPL (i.e., up to and including 314% FPL).

4.1.2.1-PC Age: through birth (SHO #02-004, issued November 12, 2002)

4.1.3 Income of each separate eligibility group (if applicable):

4.1.3.1-PC 0% of the FPL (and not eligible for Medicaid) through % of the FPL (SHO #02-004, issued November 12, 2002) 4.1.4 Resources of each separate eligibility group (including any standards relating to spend downs and disposition of resources):

4.1.5 Residency (so long as residency requirement is not based on length of time in state):

Must be a resident of the state. 4.1.6 Disability Status (so long as any standard relating to disability status does not restrict eligibility):

4.1.7 Access to or coverage under other health coverage:

Pennsylvania requires that children be totally uninsured or ineligible for Medicaid to be eligible for CHIP. Contractors have the capacity to compare enrollee families to their own company subscribers to verify whether the family has private or employer sponsored coverage. We currently match new applications against a Medicaid data base to ensure the applicants are not already enrolled in Medicaid. The Commonwealth also runs a match through a Third Party Liability contract to assist in the determination that the applicants qualifying for low cost CHIP do not currently have private insurance.

4.1.8 Duration of eligibility, not to exceed 12 months:

Enrollment normally begins the first of the month following determination of eligibility and receipt of premium payments, when required. Children are enrolled for a period of 12-months with the following exceptions.

81 Exceptions to the 12-months of continuous coverage include: • A child becomes 19 years of age • A child is found to have other insurance or is eligible for or receiving Medicaid • A child moves out of the household • A child moves out of the state • A child is deceased • Non-payment of required premiums • A voluntary termination of coverage is requested by the parent or guardian • The child was conditionally enrolled pending resolution of inconsistencies with information provided to the SSA for verification of citizenship status. The child will be enrolled for a maximum of 120 days while we attempt to work through the inconsistencies. • The child was enrolled in CHIP temporarily pending a Medicaid eligibility determination and Medicaid eligibility is confirmed • Misinformation was provided at application or renewal that would have resulted in a determination of ineligibility had the correct information been provided. In this case a child will be retro- terminated to the date of original enrollment. The rationale for this is the child was not eligible for the program and should not have been enrolled based on inaccurate information on the application (e.g. private insurance, not in the household, unreported income, and the like.)

4.1.9 Other Standards- Identify and describe other standards for or affecting eligibility, including those standards in 42 CFR 457.310 and 457.320 that are not addressed above. For instance: • A child must be a citizen of the United States, a U.S. national, or a qualified alien, consistent with SCHIP regulations defined at 42 CFR 457.320(b)(6). Citizenship of children declaring U.S. citizenship will be verified through a match with the Social Security Administration (SSA). Enrollment of otherwise eligible children will not be delayed pending verification of U.S. citizenship. Children will be conditionally enrolled in CHIP pending final verifications. If citizenship cannot be verified by the SSA, the state will work closely with the family to reconcile any

82 differences for up to 90 days. If the issue cannot be reconciled in the 90- day period, a termination notice will be issued and termination will be effective the first of the next month.

• Citizenship of other applicants may be verified through the Verification Information System – Systematic Alien Verification for Entitlements Program. The commonwealth elects to provide coverage to children who are lawfully residing in the United States and are otherwise eligible for CHIP including optional targeted low-income children described in section 1905(u)(2)(B) without a five-year delay.

• Pennsylvania CHIP simplified the application process by the elimination of the requirement for proof of income in those instances where verification may be obtained through various data exchanges (e.g., Income and Eligibility Verification System – IEVS). If the self-declared income on the application and the information available through IEVS is within tolerance, the income is considered verified. Within tolerance is defined as resulting in no change to the category of CHIP a child is to receive (Free, Subsidized level, or Full Cost). In this case, no further verification is required. If the income cannot be verified through IEVS or if the information in IEVS is out of tolerance, the application will be treated as incomplete and the appropriate notifications will be generated to request the information from the applicant. As with all eligibility determinations, the family retains the right to appeal any determination and provide additional information to show that the correct determination was not made.

• Pennsylvania state law requires the mother’s insurance to cover the newborn from the time of birth through 30 or 31 days. If a child is born to a CHIP enrollee, because the mother is covered by CHIP, full CHIP coverage is extended to the child from the time of birth and CHIP would pay for any claims during this period. Based upon the new mother’s eligibility status, we would naturally assume the newborn will be eligible for either Medicaid or CHIP.

• Children who are born to individuals eligible under the approved State Plan are considered by Pennsylvania to be targeted low-income children on the date of the child’s birth, to have applied and been determined otherwise eligible for Medicaid or CHIP, as appropriate, on the date of birth, and to remain eligible until attaining the age of 1 unless, after a reasonable opportunity period, the agency fails to obtain evidence to satisfy satisfactory documentation of citizenship under 42 CFR 435.407(c)(1) and (2) and identity under 42 CFR 435.407(e) and (f).

83

• To ensure no gap in access to health care between the coverage of the child by CHIP under the mother and the coverage of the child by either Medicaid or CHIP under the child’s identification number, upon notification of the birth, the insurance contractor will temporarily enroll the newborn in CHIP with an effective date of the first of the month following birth. The child will be assigned its own identification number at that time. Simultaneously, the centralized eligibility system will screen the newborn for potential Medicaid eligibility using the appropriate information on income and family size contained on the mother’s existing application.

o The appropriate information would be directly related to the newborn and the newborn’s parent(s) and siblings and their associated income only. The new grandparents and the new mother’s siblings and their incomes are not to be counted for the newborn’s eligibility determination. o In the vast majority of cases, the outcome will be that the newborn is potentially eligible for Medicaid. If potentially eligible for Medicaid, the newborn must be referred to the local county assistance office (CAO) for an eligibility determination. o The newborn will remain enrolled in CHIP until an Medicaid eligibility determination is completed. If eligible for Medicaid, the newborn will be terminated from CHIP effective the first day of the following month in which Medicaid determined the newborn eligible. This will ensure no gap in access to health care. o If not eligible for Medicaid, the newborn will be screened to determine in which category of CHIP the newborn is placed (Free, Low-cost, or Full-cost). o The newborn is guaranteed 1 year of eligibility in CHIP or MA, with the exceptions listed in Section 4.1.8 of the State Plan. The normal renewal process will remain in effect for the new mother. After 1 year, the newborn’s renewal due date will be synchronized with the new mother’s renewal due date. At the next renewal due date, the normal renewal process will be followed.

• Children born to mothers who are not covered by Medicaid or CHIP and are otherwise eligible for CHIP may be enrolled in CHIP with an effective date of the first of the month following the month of birth, if an application is received during the month of birth or the month following.

84 This allows for a newborn to have continuous access to the health care system with no gap in coverage. If the retroactive enrollment causes duplication of coverage with the mother’s insurance during the first 30 days of life, CHIP will be the payer of last resort.

• Pennsylvania CHIP chooses to provide coverage to children of employees of a public agency in the state who meet the hardship exception as defined in P.L. 111-148 Section 10203(d)(2)(D)

4.1.9.1

States should specify whether Social Security Numbers (SSN) are required.

All applicants for CHIP are required to provide Social Security Numbers.

4.1.9.2 Continuous eligibility

Coverage is provided for 12 consecutive months from the date of enrollment/renewal. Coverage is terminated on the last day of the calendar month in which the child becomes 19 years old.

4.1-PW

Pregnant Women Option (section 2112)- The State includes eligibility for one or more populations of targeted low-income pregnant women under the plan. Describe the population of pregnant women that the State proposes to cover in this section. Include all eligibility criteria, such as those described in the above categories (for instance, income and resources) that will be applied to this population. Use the same reference number system for those criteria (for example, 4.1.1-P for a geographic restriction). Please remember to update sections 8.1.1-PW, 8.1.2-PW, and 9.10 when electing this option.

4.1- LR

Lawfully Residing Option (Sections 2107(e)(1)(J) and 1903(v)(4)(A); (CHIPRA # 17, SHO # 10-006 issued July 1, 2010) Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) regarding lawfully residing to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following: A child or pregnant woman shall be considered lawfully present if he or she is: (1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641); (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission; (3) An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C.

85 §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; (4) An alien who belongs to one of the following classes: (i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101- 649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status; (5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least180 days; (6) An alien who has been granted withholding of removal under the Convention Against Torture; (7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. §1101(a)(27)(J)); (8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

Elected for pregnant women. Elected for children under age

4.1.1-LR The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA Lawfully Residing option, it has verified, at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination, that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or

86 further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act.

4.1-DS

Supplemental Dental (Section 2103(c)(5) - A child who is eligible to enroll in dental- only supplemental coverage, effective January 1, 2009. Eligibility is limited to only targeted low-income children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer. The State’s CHIP plan income eligibility level is at least the highest income eligibility standard under its approved State child health plan (or under a waiver) as of January 1, 2009. All who meet the eligibility standards and apply for dental-only supplemental coverage shall be provided benefits. States choosing this option must report these children separately in SEDS. Please update sections 1.1-DS, 4.2-DS, and 9.10 when electing this option.

4.2. Assurances The State assures by checking the box below that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

4.2.1. These standards do not discriminate on the basis of diagnosis.

4.2.2. Within a defined group of covered targeted low-income children, these

standards do not cover children of higher income families without covering

children with a lower family income. This applies to pregnant women included

in the State plan as well as targeted low-income children.

4.2.3. These standards do not deny eligibility based on a child having a pre-existing

medical condition. This applies to pregnant women as well as targeted low-

income children.

4.2-DS Supplemental Dental - Please update sections 1.1-DS, 4.1-DS, and 9.10 when electing this option. For dental-only supplemental coverage, the State assures that it has made the following findings with standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

4.2.1-DS These standards do not discriminate on the basis of diagnosis.

4.2.2-DS Within a defined group of covered targeted low-income children, these

standards do not cover children of higher income families without covering

children with a lower family income.

4.2.3-DS These standards do not deny eligibility based on a child having a pre-

existing medical condition.

4.3. Methodology. Describe the methods of establishing and continuing eligibility and enrollment. The description should address the procedures for applying the eligibility standards, the organization and infrastructure responsible for making and reviewing eligibility determinations, and the process for enrollment of individuals receiving covered services, and whether the State uses the same application form for Medicaid and/or other

87 public benefit programs. (Section 2102)(b)(2)) (42 CFR 457.350)

CHIP Contractors enter application data into the commonwealth’s CHIP Processing System (CAPS). CAPS is the automated system developed by the Department for the purpose of determining eligibility for CHIP. Applications for enrollment and re- enrollment are received via: the internet through the Commonwealth of Pennsylvania’s Access to Social Services (COMPASS); telephone through calls to the statewide customer service center; through electronic referrals from the Medicaid agency; or, a mail-in process. Data matches with other agencies, health insurance carriers, and employers are conducted after an application is entered into CAPS and prior to a final determination of eligibility.

Through our past SPA, the commonwealth initiated the verification of citizenship through a match with the Social Security Administration. Pennsylvania assures that it will follow the process outlined in Section 211 of CHIPRA.

To facilitate cross matches between information technology systems, Social Security numbers will be required on applications. If an applicant does not yet have a Social Security number or fails to include a Social Security number, the insurance contractor will conduct outreach to the applicant to obtain the number. An application will not be delayed nor denied due to the absence of the Social Security number. The demographic information from the application will be forwarded to the Social Security Administration to try to obtain any number that is not provided by using the enumeration process.

Contractors enroll children on a prospective basis on the first of each month. Contractors are provided with the CHIP Procedures Manual and other forms of instruction (i.e. CHIP Transmittals) which prescribe the method and procedures to be used in the determination of eligibility. Parts I and II of the manual prescribe:

Basic eligibility requirements relating to income, age, residency, citizenship, and the lawful status of non-citizens Verification requirements (required for income if not verifiable through data exchange matches, U.S. citizenship and proof of qualified alien status only unless, in the judgment of the contractor, other verification is needed to clarify incomplete or inconsistent information provided on the application) Application processing standards (a decision on eligibility or ineligibility must be made within fifteen calendar days from the receipt of a complete application) Notification requirements for notices of eligibility, ineligibility, renewal and termination

4.3.1. Limitation on Enrollment Describe the processes, if any, that a State will use for instituting enrollment caps, establishing waiting lists, and deciding which children will be given priority for enrollment. If this section does not apply to your state, check the box below. (Section 2102(b)(2)) (42 CFR 457.305(b))

88

The commonwealth would closely monitor expenditures of CHIP funds. If necessary and feasible, we would cap the number of new enrollees in the expanded population (those above 208% of the FPL) and create a waiting list for that population to ensure we do not exceed our CHIP allotment for the year. Prior to implementing a cap and waiting list, the state will provide CMS with appropriate notifications. Other actions at time of decision include: • Publication in the Pennsylvania Bulletin 60 days prior as public notification • Inclusion of waiting list information on CHIP and COMPASS web sites New applications would still be accepted through the normal processes. Screen and enroll procedures for Medicaid would remain unchanged. Eligibility would be run on all applications. The applications of individuals that appear to be eligible for Medicaid would be forwarded for eligibility determination. Those applicants not eligible for Medicaid would be put on the waiting list with an effective date of the date when the Contractor received an complete enough application to enter into CAPS for an eligibility determination. On at least a monthly basis, the commonwealth would make an assessment of the number of enrollees against the appropriated funds for the program. As additional funds would become available (either through attrition of enrollees or more funding is identified) applicants on the waiting list would be notified of the availability of coverage through CHIP. A determination would be made as to the number of new enrollees that could be accommodated with the identified funds. Notifications would go out first to those applicants with the earliest completion date; thus a first come, first served process. To update eligibility, applicants would need to attest that there have not been any changes to their family circumstances (e.g. number in household, income, insurance status, and the like). If changes have occurred, the new information would be added into CAPS and eligibility would be re-determined. The signing of the attestation or the submission of additional information would be the basis for a new eligibility date and the 12 months of eligibility would begin with the enrollment. It is not expected that enrollees would be affected by any caps or waiting lists that may be implemented.

Check here if this section does not apply to your State.

4.3.2. Check if the State elects to provide presumptive eligibility for children that meets the requirements of section 1920A of the Act. (Section 2107(e)(1)(L)); (42 CFR 457.355)

4.3.3-EL Express Lane Eligibility

Check here if the state elects the option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of CHIP eligibility. The state agrees to comply with the requirements of sections 2107(e)(1)(E) and 1902(e)(13) of the Act for this option. Please update sections 4.4-EL, 5.2-EL, 9.10, and

89 12.1 when electing this option. This authority may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013. (Section 2107(e)(1)(E))

4.3.3.1-EL Also indicate whether the Express Lane option is applied to (1) initial eligibility determination, (2) redetermination, or (3) both.

4.3.3.2-EL List the public agencies approved by the State as Express Lane agencies.

4.3.3.3-EL List the components/components of CHIP eligibility that are determined under the Express Lane. In this section, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between CHIP eligibility determinations for such children and the determination under the Express Lane option.

4.3.3.3-EL List the component/components of CHIP eligibility that are determined under the Express Lane.

4.3.3.4-EL Describe the option used to satisfy the screen and enrollment requirements before a child may be enrolled under title XXI.

4.4. Eligibility screening and coordination with other health coverage programs States must describe how they will assure that:

4.4.1. only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance (including access to a State health benefits plan) are furnished child health assistance under the plan. (Sections 2102(b)(3)(A), 2110(b)(2)(B)) (42 CFR 457.310(b), 42 CFR 457.350(a)(1) and 42 CFR 457.80(c)(3)) Confirm that the State does not apply a waiting period for pregnant women.

During the application process, if a child is found to have or be eligible for state employee health benefits, or other private insurance that meets Minimal Essential Coverage (MEC) requirements, the child is not enrolled in CHIP. CHIP does not enroll pregnant women over age 19 into its program.

There are no waiting periods in CHIP for any applicant.

4.4.2. children found through the screening process to be potentially eligible for medical assistance under the State Medicaid plan are enrolled for assistance under such plan; (Section 2102(b)(3)(B)) (42 CFR 457.350(a)(2)).

90

When a child is evaluated in the CHIP eligibility system, if they are below the 133% FPL, the application and all verified information is electronically transmitted to the Medicaid agency.

4.4.3. children found through the screening process to be ineligible for Medicaid are enrolled in CHIP. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

If a child applies to the Medicaid agency and the child’s household income is found to be over the Medicaid limit, the application is electronically transferred to CHIP. CHIP will import the information sent from Medicaid into the CHIP eligibility system and will determine the correct program of CHIP (Free, Sub, At Cost) for the child based on the verified eligibility factors from the Medicaid agency. CHIP will not reverify information already verified by the Medicaid agency. CHIP does not temporally enroll children pending verification of eligibility factors.

When a child is screened for eligibility, the eligibility system looks at the tax household composition, countable income and allowable tax deductions. The system will calculate the net income and compare to the applicable FPL for age and family size. If a child is over the 133% FPL for CHIP, they are placed in the correct program in CHIP – Free, a low-cost premium program or the Full Cost program. If a child is found to be under the 133% FPL, the completed application is electronically transferred to the Medicaid agency. The Medicaid agency accepts verified application data to enroll the child in Medicaid. In the same respect, the Medicaid eligibility system looks at the same factors (tax household composition, countable income and allowable tax deductions). If the child is found ineligible for Medicaid, the MA system makes an electronic referral to the CHIP system.

During the application process, if a child is found to have or be eligible for state employee health benefits, or other private insurance that meets Minimal Essential Coverage (MEC) requirements, the child is not enrolled in CHIP.

4.4.4. the insurance provided under the State child health plan does not substitute for coverage under group health plans. (Section 2102(b)(3)(C)) (42 CFR, 457.805)

The state does not provide coverage under a premium assistance program.

4.4.4.1. (formerly 4.4.4.4) If the State provides coverage under a premium assistance program, describe: 1) the minimum period without coverage

91 under a group health plan. This should include any allowable exceptions to the waiting period; 2) the expected minimum level of contribution employers will make; and 3) how cost-effectiveness is determined. (42 CFR 457.810(a)-(c))

4.4.5. Child health assistance is provided to targeted low-income children in the State who are American Indian and Alaska Native. (Section 2102(b)(3)(D)) (42 CFR 457.125(a))

Pennsylvania provides coverage equally to all low-income children regardless of their status as American Indian or Alaska Native. Pennsylvania does not have any registered American Indian tribes within its borders.

4.4-EL The State should designate the option it will be using to carry out screen and enroll

requirements:

The State will continue to use the screen and enroll procedures required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 42 CFR 457.80(c). Describe this process.

The State is establishing a screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by the Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated.

The State is temporarily enrolling children in CHIP, based on the income finding from the Express Lane agency, pending the completion of the screen and enroll process.

92 Section 5. Outreach and Coordination

5.1. (formerly 2.2) Describe the current State efforts to provide or obtain creditable health coverage for uninsured children by addressing sections 5.1.1 and 5.1.2. (Section 2102)(a)(2) (42 CFR 457.80(b))

5.1.1. (formerly 2.2.1.) The steps the State is currently takin4g to identify and enroll all uninsured children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance):

The commonwealth is committed to providing access to quality health care coverage and to improving the health status of its children. Of particular concern are children of low-income families; families with limited access to care; and families having children with special needs due to chronic or disabling conditions. (Special needs programs include spina bifida, diabetes, asthma, hepatitis B, etc.)

To achieve the goal of providing access to health care the office of CHIP meets regularly with the statewide advocacy community dedicated to increasing awareness and enrollment in both CHIP and Medicaid. Senior and management staffs of the Department of Human Services, Health and Education are consulted to complete strategic planning, to monitor progress, collaborate, share resources and to problem solve. The efforts of these meetings and relationships has increased awareness and enrollment with the following efforts which include but are not limited to:

Establishing a single statewide toll-free number (1-800-986-KIDS) to provide access to helpline staff who inform, refer, and assist in applying for CHIP and Medicaid. Jointly funding a multi-year contract with a media consultant. Developing complementary media messages about the availability of healthcare coverage and the importance of preventative care. Improving access to enrollment by streamlining eligibility and application practices. Conducting studies regarding hard-to-reach populations to increase knowledge on how to achieve better results in- outreach to them. Measuring the effectiveness of our efforts by gathering and analyzing available data.

The Department’s particular efforts to identify and enroll all uncovered children who may be eligible for CHIP include but are not limited to the following:

Conducting a statewide outreach campaign for CHIP. The campaign includes but is not limited to: paid television, Internet and radio advertisements, posters, brochures, banners and the like.

Monitoring, measuring and evaluating the effectiveness of the statewide outreach

93 campaign as well as other outreach strategies initiated and implemented by the Department.

Engaging in collaborative interagency outreach for the purpose of developing and implementing strategies to enroll children in both CHIP and Medicaid. Agencies include but are not limited to: the Department of Education (school- and library-based enrollment) and, the Department of Health Developing a strategic plan to maximize awareness of CHIP with organizations and associations with existing statewide networks. Implementing school-based outreach and/or enrollment. Approving and monitoring the outreach and enrollment strategies of CHIP insurance company contractors. Participating in outreach activities initiated by local community organizations. Conducting studies which improve the Department’s understanding of issues relating to hard to reach populations and developing outreach strategies recommended by such studies.

As stated above, the commonwealth is committed to assuring that children receive the health care coverage for which they are eligible (either CHIP or Medicaid). If a parent or guardian applies for CHIP coverage on behalf of a child and it is determined that the child is ineligible (e.g. because the level of family income is within the Medicaid range), the application submitted by the parent or guardian is automatically forwarded to the local County Assistance Office (CAO) for the determination of Medicaid eligibility. Conversely, if an application for Medicaid is filed and the child is found ineligible, the application is forwarded to a CHIP contractor. This practice negates the need for the parent or guardian to file separate applications for the two programs and facilitates enrollment of the child. In 2008, this process was automated through the implementation of the “Health care Handshake”. The health care handshake improves efficiencies by removing the need to print applications, to mail or fax applications between agencies, and to reenter data, and significantly reduces the time required for an eligibility decision by the receiving agency.

Additionally, the Department is making a concerted effort to have the CHIP contractors identify children who are potentially eligible for Medicaid due to a serious illness or disabling condition.

The Department has worked to expand access and simplify the application and renewal process for the CHIP and Medicaid programs through the development of an online application and renewal system called COMPASS (Commonwealth of Pennsylvania Access to Social Services). This web portal allows citizens to screen and apply for CHIP or Medicaid as well as many other social service programs across several Commonwealth agencies with one application. The Department provides administrative funding for toll-free helplines that can answer citizens’ questions about CHIP, Medicaid, and various other social service programs, as well as assist callers with completing applications over the

94 phone, utilizing COMPASS.