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Delaware Children's Health Insurance Plans (DCHIP)


General Signatures and Introduction

  • State officials administering program
  • Introduction
  • Federal Requirements for Submission and Review of a Proposed SPA
  • Section description
  • Program Options
  • Medicaid Expansion- Medicaid SPA Requirements
  • Combination of Options

 

Section 1 - General Description and Purpose of the Children's Health Insurance Plans and the Requirements

This section describes the program.

  • Program options
  • Assurances
  • Civil rights requirements
  • SPA effective and implementation dates

 

Section 2 - General Background and Description of State's Approach to Child Health Coverage and Coordination

Provides general information related to the program including the extent and manner to which children in the state currently have creditable health coverage, current state efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives.

  • 2.1       Creditable coverage
  • 2.2       Health Services Initiatives
  • 2.3TC  Tribal Consultation Requirements

 

Section 3 - Methods of Delivery and Utilization Controls

Describes the method of delivery including contracting standards; enrollee enrollment processes; enrollee notification and grievance processes; and plans for enrolling providers, among others.

  • 3.1       Delivery Standards
  • 3.1.1    Choice of Delivery System
  • 3.1.2    Use of a Managed Care Delivery System for All or Some of the State's CHIP Populations
  • 3.1.3    Nonemergency Medical Transportation PAHPs
  • 3.2       General Managed Care Contract Provisions
  • 3.3       Rate Development Standards and Medical Loss Ratio
  • 3.4       Enrollment
  • 3.5       Information Requirements for Enrollees and Potential Enrollees
  • 3.6       Benefits and Services
  • 3.7       Operations
  • 3.8       Beneficiary Protections
  • 3.9       Grievances and Appeals
  • 3.10     Program Integrity
  • 3.11     Sanctions
  • 3.12     Quality Measurement and Improvement; External Quality Review

 

Section 4 - Eligibility Standards and Methodology

Describes the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan.

  • 4.0         Medicaid Expansion
  • 4.1         Separate Program
  • 4.1PW   Pregnant Women Option
  • 4.1LR    Lawfully Residing Option
  • 4.1DS    Supplemental Dental
  • 4.2         Assurances
  • 4.3         Methodology
  • 4.4         Eligibility screening and coordination with other health coverage programs 

 

Section 5 - Outreach

Describes outreach activities.

  • 5.1          Efforts to provide or obtain creditable health coverage
  • 5.2EL      Express Lane eligibility option   
  • 5.3          Strategies

 

Section 6 - Coverage Requirements for Children's Health Insurance

Describes the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered.

  • 6.1           Coverage options
  • 6.2           Services covered
  • 6.2DC      Dental Coverage
  • 6.2DS      Supplemental Dental Coverage
  • 6.2           MHPAEA
  • 6.3           Assurances with respect to pre-existing medical conditions
  • 6.4           Additional Purchase Options

 

Section 7 - Quality and Appropriateness of Care

Describes the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services.

  • 7.1           Quality and appropriateness of care
  • 7.2           Methods used assure asses to care

 

Section 8 - Cost Sharing and Payment

Addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees.

  • 8.1           Statement of cost-sharing imposed
  • 8.2           Amount of cost-sharing
  • 8.3           How the public will be notified of cost-sharing
  • 8.4           Assurances with respect to cost-sharing
  • 8.5           Description of procedures related to cost-sharing annual maximum
  • 8.6           Description of procedures to ensure AI/AN children are excluded from cost sharing
  • 8.7           Disenrollment protections
  • 8.8           Expenditure limitations  

 

Section 9 - Strategic Objectives and Performance Goals and Plan Administration

Addresses strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state.

  • 9.1           Strategic objectives
  • 9.2           Performance goals
  • 9.3           Performance measures
  • 9.4           Annual Reports
  • 9.5           Annual assessment and evaluation
  • 9.6           Access to any records or information
  • 9.7           Modify measures to meet national requirements
  • 9.8           Comply with other provisions
  • 9.9           Ensuring ongoing public involvement in program development
  • 9.10         Provide a 1-year projected budget

 

Section 10 - Annual Reports and Evaluations

State assures compliance annual review and evaluation with requirements.

  • 10.1         Annual Reports    
  • 10.2         Future reporting requirements
  • 10.3         Comply with all applicable Federal laws and regulations
  • 10.3DC    Submit yearly the approved dental benefit package

 

Section 11 - Program Integrity

State assures services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound.

  • 11.1         Procurement standards
  • 11.2         Sanctions and penalties

 

Section 12 - Applicant and Enrollee Protections

Describes review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan.

  • 12.1         Eligibility and Enrollment Matters
  • 12.2         Health Services Matters
  • 12.3         Premium Assistance Programs

 

Appendix

  • Key for Newly Incorporated Templates
  • CMS Regional Offices
  • GLOSSARY

 

MAGI Pages

 

Attachments

  • Attachment 1 - 6.2.6.1- List of NQTLS Highmark Health Options
  • Attachment 2 - 6.2.6.1- List of NQTLS UnitedHealth Care Community Plan
  • Attachment 3 - 6.2.6.1 - NQTL Analysis UnitedHealth care Community Plan
  • Attachment 4 - 6.2.6.1 - NQTL Analysis Highmark Health Options

 



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