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68 subspecialty services with the primary care provider to which the child is assigned. This program will reimburse providers for these specialized services. Children receiving such services will continue to have their primary health needs serviced through the insurance program. Allowing those specialized services to be provided as a complement to, but outside of, the managed care setting is consistent with recent actions in the Federal Budget Reconciliation Act (BBA 1997) which prohibit mandatory enrollment of children with special medical needs in managed care.

On an annual basis the State will review the number of active CHIP cases in the CCS program. The State will also require participating plans to report the number of referrals they have made to the CCS program each quarter. The State will also use the HEDIS CAHPS survey to monitor access and quality of these services. This survey has a special module to address the satisfaction and experiences of families which children who have chronic conditions.

The state will include in its CCHIP contracts a requirement to report the number of active CCHIP/CCS cases and the number of children referred to the CCS program. Of those children enrolled in CCHIP, some will qualify for CCS services based on CCS eligibility requirements whereby services for the qualifying CCS eligible condition will be provided by CCS. In those cases where a family does not qualify based on CCS eligibility requirements, the medically necessary services will be provided by the CCHIP health plan.

California’s State Department of Managed Healthcare licensure requirements includes adequacy of network including specialists covered services not available in network must be covered out of network.

7.2.4. Decisions related to the prior authorization of health services are completed in accordance with State law or, in accordance with the medical needs of the patient,

within 14 days after the receipt of a request for services. (Section 2102(a)(7))

(42CFR 457.495(d)) Exigent medical circumstances may require more rapid response according to the medical needs of the patient.

California state law contains specific requirements for health plan utilization review, including prospective, retrospective, and concurrent review. State law also requires independent medical review of health plans decisions concerning medical necessity. These requirements, found at Health and Safety Code Section 1367.01 and 1374.30 et seq., are designed to ensure that the prior authorization process does not present an undue barrier for continuity and access to care.

The State assures that this method is implemented under the CCHIP program.