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

STATE: Virginia Page 7-51

Effective Date: 07/01/05

51 Approval Date: _____________/06 covered services to enrollees and ensuring that the delivery system provides available, accessible and adequate numbers of facilities, locations and personnel for the provision of covered services. The MCO and PCCM provider provides or otherwise arranges care by providers specializing in early childhood youth services. MCOs and PCCM providers provide services as established by recognized clinically approved guidelines for standards of care. MCOs and PCCM providers ensure that immunizations are rendered in accordance with the most current Advisory Committee on Immunization Practices (ACIP) or the American Academy of Pediatrics Advisory Committee recommendations.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

Health insurers are required to demonstrate their ability to monitor network capacity throughout their service area for routine, urgent, and emergency care. The Commonwealth establishes standards and reporting requirements for access to routine, urgent, and emergency care. The health plans are solely responsible for arranging for and administering covered services to enrollees and ensuring that its delivery system provides available, accessible and adequate numbers of facilities, locations and personnel for the provision of covered services. The health plan must include in its network or otherwise arrange care by providers specializing in early childhood, youth services.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

The State’s Disease Management program monitors and promotes appropriate and timely treatment for enrollees with chronic, complex or serious medical conditions.

The State monitors complaints pertaining to access to care received by DMAS, the Central Processing Unit, the MCOs or the PCCM providers with regard to access to care.

Children with special health care needs are not considered a separate population or as a special population under the FAMIS State Plan. MCOs and PCCM providers provide access to all covered services, including specialty service to any child regardless of the medical condition

Each provider must arrange to provide care according to established appointment standards and meet requirements determined by the contract for the monitoring and reporting access to services, timeliness of services, appropriateness of services for all enrollees including those with chronic, complex or serious medical conditions. The