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STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-10

Effective Date: 07/01/05

10 Approval Date: _____________/06 provide a comprehensive health benefits plan to FAMIS enrollees on a regional basis. . The plans have the discretion in reimbursing and contracting with providers and must ensure services are provided and a sufficient network exists.

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))

A. FFS/PCCM Utilization Controls.

Utilization controls for providers offering Secretary-approved coverage through the fee-for- service and the PCCM Program component are administrative mechanisms that are designed to ensure that children use only health care that is appropriate, medically necessary, and approved by DMAS. DMAS relies on the utilization controls already established and operational in the Title XIX program for eligibles under Title XXI. Administrative mechanisms to be employed include the following: prepayment reviews, prior authorizations and internal reviews, post payment and SURS reviews.

Managed Care Organization Utilization Controls

Managed care organizations providing the Secretary-approved coverage modeled after the State employee plan in effect in June 2000 are required by contract to manage service utilization and have in place a process of evaluating the necessity, appropriateness and efficiency of health care services against established guidelines and criteria. The utilization program may include drug formulary decisions and criteria. The UM program must demonstrate that enrollees have equitable access to care across the network and that UM decisions are made in a fair, impartial, and consistent manner that serves the best interest of the enrollees. The MCO’s UM program reflects standards for utilization management from the most current nationally accepted standards. The program must have mechanisms to detect over-utilization and/or under-utilization of care, including, but not limited to, provider profiling and disease management programs. MCOs must ensure that the preauthorization requirements do not apply to emergency care, family planning services, preventative services, and basic prenatal care.

For more information on utilization controls, please refer to the current Title XXI State Plan § 7 - Quality and Appropriateness of Care.