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Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

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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.