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

Effective Date: August 24, 2001

Approval Date: 42 a non-IHS PCP. Tribal clinics are also eligible to be PCP providers as federally qualified health centers (FQHC’s). Rural areas outside of American Indian reservation are served by rural health clinics and federally qualified health centers that are also enrolled as PCP entities to enhance service availability. Favorable reimbursement mechanisms are in place for all of these provider types to ensure the availability of services.

Under the PCCM program the Department of Social Services carefully monitors the capacity of each participating PCP and presently averages about 85 enrollees per PCP entity, with very few PCP’s closed to new enrollees. PCP’s are limited to a maximum of 750 enrollees. County and sub-state areas are also monitored for PCP availability. Most PCCM participants select their own PCP’s and have free choice of providers for non-PCCM services. Time and distance standards ensure that PCCM enrollees do not have to travel more than 75 miles to their PCP. Routine monitoring of PCP performance also includes an analysis of PCP provided services versus referred services with the dual purpose of ensuring PCP’s are accessible and providing services to enrolled clients, and also not withholding appropriate referrals for specialty care.

The Department also carefully monitors the PCP changes and disenrollment reasons to assure that access to care issues are resolved. In addition, the Department randomly monitors PCP compliance with 24 hour per day, seven day per week requirement for PCP availability.

The SCHIP program uses the definition and procedure for accessing emergency services that applies to Medicaid that are consistent with Federal law.

Access and availability to services are presently monitored under Medicaid. This monitoring will also include SCHIP enrollees. Surveys of participants to measure access to services, waiting times, and satisfaction with service availability will continue to be completed with all Medicaid and SCHIP children.

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))

Individuals with special healthcare needs are exempt from managed care requirements. As such, these individuals are not restricted under the SCHIP