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

Effective Date: August 24, 2001

Approval Date: 14 and M-SCHIP programs, including EPSDT benefits. Health care services are delivered using the existing delivery and payment systems including primary care case management and access to specialty health service providers, as approved under the State’s 1915(b) waiver under Medicaid. South Dakota will request the managed care waiver be incorporated into it’s Medicaid and SCHIP state plans. The State can assure that children receiving services under SCHIP will receive the same beneficiary protections as children receiving Medicaid coverage including grievances and appeals, privacy and confidentiality, respect and non-discrimination, access to emergency services, and an opportunity to participate in health care treatment decision and choice of providers. The State can also assure that it is providing SCHIP services in an effective and efficient manner by using Medicaid policies and procedures.

Children are considered uninsured if they do not qualify for Medicaid and have not had group health plan coverage in the three months immediately prior to application for the SCHIP program.

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))

Services provided under SCHIP will share the utilization controls used by the Medicaid program to ensure that only health care services that are appropriate, medically necessary, and approved by the State are used. Children covered under SCHIP will be enrolled into a primary care case management system to ensure access to primary care and to provide monitoring and authorization for required specialty medical services. The primary care case management system used will be the PRIME program operated for Medicaid and SCHIP children in South Dakota, authorized by CMS under a 1915(b)(1) waiver. South Dakota will request the managed care waiver be incorporated into it’s Medicaid and SCHIP state plan.

The SCHIP program will also share the Medicaid SURS resources for post payment review of services provided to SCHIP children. Appropriateness and necessity for care are also monitored by the Department through a contract with the Professional Review Organization (PRO), also used by the Medicaid and Medicare programs in South Dakota. Pharmacy services for SCHIP will be dispensed via a Medicaid point of service computer system that provides prospective drug utilization review on each prescription filled. Additionally, specialized medical services requiring prior authorization under the Medicaid program will also require prior authorization under the SCHIP program.