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

STATE: Virginia Page 4-9

Effective Date: 07/01/05

9 Approval Date: _____________/06 manner consistent with CMS regulations promulgated pursuant to the Balanced Budget Act of 1997. A managed care savings factor shall be applied to determine the final rates. The savings factor shall be determined annually.

PRIMARY CARE CASE MANAGEMENT

Secretary-approved coverage through the PCCM Program is provided through a Primary Care Case Management (PCCM) delivery system. The PCCM delivery system manages and delivers health care for enrollees and is reimbursed on a fee-for-service basis. This program is administered in conjunction with the State’s MEDALLION Primary Care Case Management program.

A. For areas that do not have contracted MCOs, children transitioning to FAMIS from VCMSIP and Medicaid PCCM programs are enrolled in the PCCM Program. The PCCM Program enrolls members with a primary care provider who acts as a health care manager, provides primary and preventive care, and authorizes most specialty services. . Members can access any program provider for specialty services if they obtain the necessary authorization from the PCP. Referrals are not required for the following services: mental health, family planning, dental, emergency services, obstetrical, vision, psychiatric and psychological services, substance abuse treatment for pregnant women, pharmacy services, transportation services, EPSDT services, school-based services, targeted case management, treatment of sexually transmitted diseases, and immunizations provided by local health departments.

B. Currently, there are approximately 3,031 active PCPs in the program’s network that includes practitioners, health departments, and community health clinics. The PCPs are reimbursed on a fee-for-service basis plus a $3.00 per member per month case manager's fee. Existing PCCM program capacities meet or exceed projected enrollment for Secretary-approved coverage in all service areas. The PCP capacity is monitored quarterly and enrollment is tracked monthly.

FEE-FOR-SERVICE

Coverage under the modified Medicaid look-alike component is based on the fee-for-service program and providers are reimbursed by the Department.

COVERAGE PROVIDED UNDER MCOs

The second benefit package is Secretary-approved coverage modeled after the state employee plan in effect in June 2000, provided under the current Title XXI State Plan through contracted MCOs.

Secretary-approved coverage modeled after the state employee health plan provides a comprehensive array of health care benefits for eligible enrollees. DMAS has contracted with various managed care health insurers that meet certain requirements and standards in order to