Page 9

11. Meeting specific performance guidelines and guarantees; 12. Encouraging the use of a medical home for each enrollee; 13. Appropriate and accurate fee administration; 14. Strict financial accounting and reconciliation; 15. Production of claims, contract, and other legal forms as required; 16. Establishment and maintenance of appropriate banking arrangements; 17. Continuous and accurate electronic transmission of all data; 18. Other special services as may be requested from time to time.

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))

The same utilization controls used in the State Employees Health Plan will also be used in the Title XXI program. Selection of a health plan for the CoverKids program will be based on evidence of the plan’s provider credentialing policies, provider accessibility, cost-effectiveness, and efficiency. Before being approved for participation in CoverKids, the selected health plan will be required to develop and have in place utilization review policies and procedures to ensure that children use only health care that is appropriate and medically necessary. Utilization management guidelines may include guidelines on prior authorizations, use of drug formularies, and the vendor’s medical necessity definition. The health plan may not deny coverage due to the existence of a pre- existing medical condition. The health plan will be required to regularly report key contract indicators to the Division on a quarterly and annual basis.

9