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

Effective Date: August 24, 2001

Approval Date: 49 9.3.7.3. X Adolescent well visits – CPT codes 99384 through 99394 9.3.7.4. X Satisfaction with care 9.3.7.5. X Mental health – CPT codes 90804 through 90899 9.3.7.6. X Dental care – Codes covering exams, x-rays, and certain treatments 9.3.7.7. X Other, please list: Optometric and Substance Abuse – Range of SD codes W7500 through W7507m W8500, W8600, W8601 and W8620 through W8624 9.3.8. X Performance measures for special targeted populations.

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

9.5. X 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)

The South Dakota Department of Social Services will evaluate the operation and effectiveness of its State Children’s Health Insurance Program (SCHIP) on an ongoing basis and report the findings to CMS by January 1 of each year. A variety of data sources will be utilized to evaluate South Dakota’s program. These data sources will include, but will not be limited to, US Bureau of Census, South Dakota Department of Health, South Dakota Medical Assistance, and Indian Health Services. Annual reports will follow the format as specified by CMS.

9.6. X 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. X 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))

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. X Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2. X Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment)