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Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

3.1 Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

The State of Tennessee will provide health insurance benefits through a health plan managed by the Division of Insurance Administration. The Division will contract with a commercially licensed insurance plan to provide health benefit coverage to CoverKids enrollees on a statewide basis. The health plan will receive a monthly premium payment from the state for each enrollee and will assume full risk. Each enrollee will be provided with a list of participating providers in their area and will receive all services from providers within the network, with exceptions permitted if the network lacks a particular specialist. The health plan selected for CoverKids will be a separately contracted, commercial network. Providers within the CoverKids network do not necessarily have to be TennCare providers.

The responsibilities of the selected health plan will include, but are not limited to:

1. Providing insurance coverage; 2. Processing and distribution of benefit payments to providers; 3. Establishing a network of physicians, pharmacies, and other providers capable of meeting the demands of the CoverKids Program, including Centers of Excellence (Centers of Excellence are locations, usually children’s hospitals, where highly specialized procedures are performed.), and operate a credentialing process; 4. Maintaining an effective utilization/medical management program and incorporate an internal quality assurance program; 5. Furnishing coverage information and ID cards; 6. Responding to inquiries from plan members and providers; 7. Claims certification, investigation, adjudication, and internal appeals process; 8. Maintaining and updating enrollment data; 9. Production of management information that captures claim and utilization experience and trends; 10. Assisting with fraud detection through periodic audits;

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