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

STATE: Virginia Page 4-8

Effective Date: 07/01/05

8 Approval Date: _____________/06 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))

The Commonwealth of Virginia’s Title XXI State Plan utilizes two Secretary-approved benefit packages within FAMIS. One Secretary-approved coverage is a modified Medicaid look-alike component offered through a fee-for-service program and a Primary Care Case Management (PCCM) Program previously approved and continually provided under the State’s original Title XXI program, Virginia Children’s Medical Security Insurance Plan (VCMSIP). The group of children receiving services through a PCCM program are comprised of children who transitioned into FAMIS from either VCMSIP or Medicaid with a prior primary care case management (PCCM) history. Such children are initially assigned to the PCP with whom they had a previous relationship. The other Secretary-approved coverage is modeled after the state employee plan in effect in June 2000, provided under the current Title XXI State Plan, approved by the Centers for Medicare and Medicaid Services (CMS) December 22, 2000 and delivered by contracted (Managed Care Organizations) MCOs.

The Commonwealth is providing two benefit packages since no responding MCO was awarded specific geographic areas during the procurement process. The Commonwealth offers Secretary- approved coverage through the fee-for-service component or the PCCM program in areas that do not have contracted MCOs to offer Secretary-approved coverage modeled after the state employee plan in effect in June 2000. In areas without contracted MCOs, those recipients who transitioned from the VCMSIP or Medicaid programs to FAMIS and who were assigned to a primary care provider continue to receive services through the Primary Care Case Management program. All other newly eligible and enrolled FAMIS recipients in these areas are assigned to the fee-for- service program. Financing

Coverage under the fee-for-service/PCCM components (modified Medicaid look-alike component) will be reimbursed on a fee-for-service basis by the Department.

The managed care organizations (MCOs) are at risk for all services provided. The plans have the discretion in reimbursing and contracting with providers and must ensure services are provided and a sufficient network exists. FAMIS rates are actuarially sound rates, and are established in a