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Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

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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