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

Effective Date:

Approval Date: 47 Section 7. Quality and Appropriateness of Care

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 8.

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495(a))

The state has used numerous methods to assure that SCHIP beneficiaries receive quality services that are appropriate to their needs. These methods include the following:

• Requirement that health plans submit patient-level encounter data to the SCHIP External Quality Review Organization (EQRO). The data is analyzed using HEDIS and other benchmarks to assess the provision of well-baby, well-child and immunization services.

• Assess health plan delivery of child health services through comprehensive surveys of the enrolled SCHIP population.

• Requirement that HMOs and EPOs develop and maintain quality assurance and quality improvement programs.

• Verification that the HMOs and EPO have sufficient network providers and procedures to ensure that children have access to routine, urgent, and emergency services; telephone appointments; and advice and member service lines.

• Restrictions on physician incentive plans.

• Requirement that HMOs and EPOs provide training to providers on a number of topics including the special needs of SCHIP Phase II clients.

• Requirement that HMOs and EPOs have health education and wellness promotion programs.

• Requirement that HMOs and EPOs maintain a toll-free member hotline 24 hours a day, seven days a week for obtaining assistance in accessing services.

• Requirement that HMOs and EPOs develop, implement and maintain a member complaint system.

• Requirement that HMOs and EPOs send notice to SCHIP beneficiaries