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

Effective Date:

Approval Date: 14 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))

Child health benefits are delivered through managed care models, including an HMO model and an exclusive provider organization (EPO) model primarily in rural areas of the state. In the HMO & EPO models, the state contracts to deliver health care services, relying on managed care principles that will include a “manager of care” or “medical home” and utilization controls on inpatient hospital and certain other services in the case of the HMOs model and the latter only in the case of the EPO. The same requirements are applied to both HMOs and the EPO.

The SCHIP procurement of health plan services is aligned as closely as possible with other plans, such as Medicaid and the Title V CSHCN program to improve continuity of care. Enrollees are given a choice of at least two plans whenever possible and Medicaid plans are given extra consideration in the procurement of SCHIP health plans.

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))

Under the HMO/EPO model, plans are required to provide the range of children’s health services for a contracted per member/per month cost determined through actuarial analysis. The state monitors utilization of HMO/EPO services as part of its overall monitoring program. Please see section 7 for more information on the state’s monitoring efforts.

The HMO model includes a number of utilization management controls. Inpatient hospital stays and other services determined by the Medical Director are subject to prospective review for medical necessity and appropriateness of proposed care before services can be rendered. Clients are required to obtain authorized referrals from their primary care providers to other professional providers. The state or its designee also conduct retrospective utilization review activities to examine services to clients