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7.2 Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

CoverKids member handbooks will explain the importance of, and recommended timing for well-child care visits and immunizations. Access is monitored through a number of methods including periodic review of the number and types of providers by county, review of claims data, review of enrollee survey data, feedback from families via telephone, e-mail, and postal service mail, and feedback from providers.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR §457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

The health plan is required to maintain an adequate provider network that includes emergency room services. In addition, PCPs who participate in the health plan are required to have identified after hour patient access to address medical questions and concerns. Access to emergency services will be monitored through periodic review of the number and types of providers by county, review of claims data, review of enrollee survey data, feedback from families and feedback from providers.

The geographic access standard for children’s primary care practitioners (pediatricians, general medicine and family practice physicians), at a minimum, will be 2 physicians within 20 miles. The standard for acute care hospitals will be at least 1 facility within 30 miles. The standard for pediatric specialists is 5 physicians within 100 miles. The standard for specialists assures that enrollees will, at a minimum, have access to a children’s hospital where they may access specialty care.

One aspect of the initial measure of network adequacy in the procurement of a plan administrator and network is the distribution and absence of plan participants. The state will employ a proxy, the distribution of children in households with incomes below the federal poverty level, in executing the geoaccess analysis.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions,

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