Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.14-023 - Transition of ARKids First-B Program

200.110 ARKids First-A and ARKids First-B

Medicaid-eligible children in the SOBRA eligibility category for pregnant women, infants and children (category 61 PW-PL) and newborn children born to Medicaid-eligible mothers (categories 52 and 63), are known as ARKids First-A beneficiaries. Un-insured, non Medicaid-eligible children that meet additional established eligibility requirements will have health coverage under ARKids First-B, a CHIP separate child health program. All ARKids First beneficiaries will receive a program identification card without indication of level of coverage (either ARKids First-A or ARKids First-B).

A Provider Electronic Solutions (PES) eligibility verification transaction response will indicate that the individual is either an ARKids First-A beneficiary or an ARKids First-B beneficiary. The response will also indicate that cost sharing may be required for ARKids First-B beneficiaries.

When a child presents as an ARKids First-A eligible beneficiary, the provider must refer to the regular Medicaid provider policy manuals. When an ARKids First-B eligible beneficiary is identified, the provider must refer to the ARKids First-B Provider Manual for determination of levels of coverage, as well as the associated Medicaid provider policy manuals for the services provided.

221.100 ARKids First-B Medical Care Benefits

Listed below are the covered services for the ARKids First-B program. This chart also includes benefits, whether Prior Authorization or a Primary Care Physician (PCP) referral is required, and specifies the cost-sharing requirements.

"Refer to your Arkansas Medicaid specialty provider manual for prior authorization and PCP referral procedures.

"ARKids First-B beneficiary cost-sharing is capped at 5% of the family's gross annual income.

***ARKids First-B beneficiaries will pay a maximum of $5.00 per prescription. The beneficiary will pay the provider the amount of co-payment that the provider charges non-Medicaid purchasers up to $5.00 per prescription.

221.200 Exclusions

222.300 Dental Services Benefit

Dental services benefits for ARKids First-B beneficiaries are one periodic dental exam, bite-wing x-rays, and prophylaxis/fluoride treatments every six (6) months plus one (1) day. Scalings are covered once per State Fiscal Year (SFY). Orthodontia services are also covered for ARKids First-B beneficiaries.

The procedure codes listed in Section 262.150 may be billed for the periodic dental exams, interperiodic dental exams and prophylaxis/fluoride, and orthodontia services for ARKids First-B beneficiaries.

Refer to Section II of the Medicaid Dental Provider Manual for a complete listing of covered dental and orthodontia services. Procedures for dental treatment services that are not listed as a payable service in the Medicaid Dental Provider Manual may be requested on individual treatment plans for prior authorization review. These individually requested procedures and dental and orthodontia treatment services are subject to determination of medical necessity, review and approval by the Division of Medical Services dental consultants.

222.600 Occupational, Physical and Speech Therapy Benefits

Occupational, physical and speech therapy services are available to beneficiaries in the ARKids First-B program and must be performed by a qualified, Medicaid participating Occupational, Physical or Speech Therapist. A referral for an occupational, physical or speech therapy evaluation and prescribed treatment must be made by the beneficiary's PCP or attending physician if exempt from the PCP program. All therapy services for ARKids First-B beneficiaries require referrals and prescriptions be made utilizing the "Occupational, Physical and Speech Therapy for Medicaid Eligible Recipients Under Age 21" form DMS-640. View or print form DMS-640

Occupational, physical and speech therapy referrals and covered services are further defined in the Physicians and in the Occupational, Physical and Speech Therapy Provider Manuals. Physicians and therapists must refer to those manuals for additional rules and regulations that apply to occupational, physical or speech therapy services for ARKids First-B beneficiaries.

Arkansas Medicaid applies the following daily therapy benefits to occupational, physical and speech therapy services in this program:

223.200 Occupational, Physical and Speech Therapy Extended Benefits

If the referring PCP or attending physician, in conjunction with the treating occupational, physical or speech therapy provider, determines the beneficiary requires additional daily speech therapy services other than those allowed through regular benefits indicated in Section 222.600, a request for extended therapy services may be made. The therapist must refer to the guidelines in the Occupational, Physical and Speech Therapy Provider Manual to properly apply for extended benefits.

224.000 Cost Sharing

Co-payment or coinsurance applies to all ARKids First-B services, with the exception of immunizations, preventive health screenings, family planning, prenatal care, eyeglasses, medical supplies, and audiological services (only Tympanometry, CPT procedure code 92567, when the diagnosis is within the ICD range (View ICD codes.)). Co-payments or coinsurances range from up to $5.00 per prescription to 10% of the first day's hospital Medicaid per diem.

ARKids First-B families have an annual cumulative cost sharing maximum of 5% of their annual gross family income. The annual period is July 1 through June 30 SFY (state fiscal year). The ARKids First-B beneficiary's annual cumulative cost sharing maximum will be recalculated and the cumulative cost sharing counter reset to zero on July 1 each year.

The cost sharing provision will require providers to check and be alert to certain details about the ARKids First-B beneficiary's cost sharing obligation for this process to work smoothly. The following is a list of guidelines for providers:

224.220 Inpatient Hospital Co-Insurance

The co-insurance charge per inpatient hospital admission (including services in an inpatient psychiatric hospital and a psychiatric residential treatment facility) for ARKids First-B beneficiaries is10% of the hospital's Medicaid per diem, applied on the first covered day. For example:

An ARKids First-B beneficiary is an inpatient for four (4) days in a hospital with an Arkansas Medicaid per diem of $500.00. When the hospital files a claim for four (4) days, ARKids First-B will pay $1950.00; the beneficiary will pay $50.00.

Four (4 days) times $500.00 (the hospital per diem) = $2000.00 (hospital allowed amount).

Ten percent (10% ARKids First-B co-insurance rate) of $500.00 = $50.00 co-insurance.

Two thousand dollars ($2000.00 hospital allowed amount) minus $50.00 (co-insurance) = $1950.00 (ARKids First-B payment).

The ARKids First-B beneficiary is responsible for paying a co-insurance amount equal to 10% of the per diem for one (1) day, which is $50.00 in the above example.

240.300 Prior Authorization (PA) for Outpatient and Inpatient Mental Health

262.130 Preventive Health Screening Procedure Codes

There are two (2) types of full medical preventive health screening procedure codes to be used when billing for this service for ARKids First-B beneficiaries; Newborn and Child Preventive Health Screening:

For routine newborn care following a vaginal delivery or C-section, procedure code 99460, 99461 or 99463, with the required modifier UA and a primary detail diagnosis (View ICD codes.) must be used one time to cover all newborn care visits by the attending provider. Payment of these codes is considered a global rate and subsequent visits may not be billed in addition to code 99460, 99461 or 99463. These codes include the physical exam of the baby and the conference(s) with the newborn's parent(s), and are considered to be the Initial Health Screening.

For newborn illness care, e.g., neonatal jaundice, following a vaginal delivery or C-section, use procedure codes range 99221 through 99223. Do not bill codes 99460, 99461 or 99463 (routine newborn care) in addition to the newborn illness care codes.

262.140 Speech-Language Pathology, Occupational and Physical Therapy Procedure Codes

262.141 Speech-Language Pathology Procedure Codes

262.142 Occupational Therapy Procedure Codes

262.143 Physical Therapy Procedure Codes

262.150 Billing Procedure Codes for Periodic Dental Screens and Services

and Orthodontia Services

262.430 Vaccines for ARKids First-B Beneficiaries

ARKids First-B beneficiaries are not eligible for the Vaccines for Children (VFC) Program| however, vaccines can be obtained to administer to ARKids First-B beneficiaries who are under the age of 19 by contacting the Arkansas Department of Health and indicating the need to order ARKids-B SCHIP vaccines. View or print the Department of Health contact information.

Only a vaccine injection administration fee is reimbursed. When filing claims for administering vaccines for ARKids First-B beneficiaries, providers must use the CPT procedure code for the vaccine administered and the required modifier SL only for either electronic or paper claims. Providers must bill claims for ARKids First-B beneficiaries using the CMS-1500 claim format.

The following list contains the SCHIP vaccines available to ARKids-First-B beneficiaries through the Arkansas Department of Health.

TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN'S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:_________________ARKANSAS______________________________

(Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

___________Dawn Stehle. Director. DMS_________________

(Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following Child Health Plan for the Children's Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)) :

Name: John Selig Position/Title: Director, Department of Human Services (DHS)

Name: Dawn Stehle Position/Title: Director, DHS Division of Medical Services

(DMS) Name: Position/Title:

*Disclosure. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C 4-26-05, Baltimore, Maryland 21244-1850.

Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 105-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children's Health Insurance Program (CHIP). In February 2009, the Children's Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the program.

This template outlines the information that must be included in the state plans and the state plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: o Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance, o Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including:

* Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002)

* Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009)

* Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009)

* Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009)

* Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010)

* Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010)

* Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010)

o Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. o Removed crowd-out language that had been added by the August 17 letter that later was repealed.

The Centers for Medicare & Medicaid Services (CMS) is developing regulations to implement the CHIPRA requirements. When final regulations are published in the Federal Register, this template will be modified to reflect those rules and States will be required to submit SPAs illustrating compliance with the new regulations. States are not required to resubmit their state plans based on the updated template. However, States must use the updated template when submitting a state plan amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

When submitting a state plan amendment, states should redline the changes that are being made to the existing state plan and provide a "clean" copy including changes that are being made to the existing state plan.

The template includes the following sections:

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: o Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid, o Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements

In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections:

They will also be required to complete the appropriate program sections, including:

Medicaid Expansion- Medicaid SPA Requirements

States expanding through Medicaid-only will also be required to submit a Medicaid state plan Amendment to modify their Title XIX state plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections:

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

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its state plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the state plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

Section 2. General Background and Description of Approach to Children's Health Insurance Coverage and Coordination

Guidance: The demographic information requested in 2.1. can be used for State planning and will be used strictly for informational purposes. THESE NUMBERS WILL NOT BE USED AS A BASIS FOR THE ALLOTMENT.

Factors that the State may consider in the provision of this information are age breakouts, income brackets, definitions of insurability, and geographic location, as well as race and ethnicity. The State should describe its information sources and the assumptions it uses for the development of its description.

* Population

* Number of uninsured

* Race demographics

* Age Demographics

* Info per region/Geographic information

Guidance: Section 2.2 allows states to request to use the funds available under the 10 percent limit on administrative expenditures in order to fund services not otherwise allowable. The health services initiatives must meet the requirements of 42 CFR 457.10.

Section 3. Methods of Delivery and Utilization Controls

I I 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.

Guidance: In Section 3.1., discussion may include, but is not limited to: contracts with managed

health care plans (including fully and partially capitated plans); contracts with indemnity

health insurance plans; and other arrangements for health care delivery. The State should describe any variations based upon geography, as well as the State methods for establishing and defining the delivery systems.

Should the State choose to cover unborn children under the Title XXI state plan, the State must describe how services are paid. For example, some states make a global payment for all unborn children while other states pay for services on fee-for-services basis. The State's payment mechanism and delivery mechanism should be briefly described here. Section 2103 (f)(3) of the Act, as amended by section 403 of CHTPRA, requires separate or combination CHIP programs that operate a managed care delivery system to apply several provisions of section 1932 of the Act in the same manner as these provisions apply under title XIX of the Act. Specific provisions include: section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. If the State CHIP program operates a managed care delivery system, provide an assurance that the State CHIP managed care contract(s) complies with the relevant sections of section 1932 of the Act. States must submit the managed care contract(s) to the CMS Regional Office servicing them for review and approval.

In addition, states may use up to 10 percent of actual or estimated Federal expenditures for targeted low-income children to fund other forms of child health assistance, including contracts with providers for a limited range of direct services; other health services initiatives to improve children's health; outreach expenditures; and administrative costs (See 2105(c)(2)(A)). Describe which, if any, of these methods will be used.

Examples of the above may include, but are not limited to: direct contracting with school-based health services; direct contracting to provide enabling services; contracts with health centers receiving funds under section 330 of the Public Health Service Act; contracts with hospitals such as those that receive disproportionate share payment adjustments under section 1886(d)(5)(F) or 1923 of the Act; contracts with other hospitals; and contracts with public health clinics receiving Title V funding. If applicable, address how the new arrangements under Title XXI will work with existing service delivery methods, such as regional networks for chronic illness and disability; neonatal care units, or early-intervention programs for at-risk infants, in the delivery and utilization of services. (42CFR 457.490(a))

I I Check here if the State child health program delivers services using a managed care delivery model. The State provides an assurance that its managed care contract(s) complies with the relevant provisions of section 1932 of the Act, including section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. The State also assures that it will submit the contract(s) to the CMS Regional Office for review and approval. (Section 2103(f)(3))

Guidance: In Section 3.2., note that utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package.

Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42CFR, 457.490(b))

Section 4. Eligibility Standards and Methodology

Guidance: States electing to use funds provided under Title XXI only to provide expanded eligibility under the State's Medicaid plan or combination plan should check the appropriate box and provide the ages and income level for each eligibility group. If the State is electing to take up the option to expand Medicaid eligibility as allowed under section 214 of CHIPRA regarding lawfully residing, complete section 4.1-LR as well as update the budget to reflect the additional costs if the state will claim title XXI match for these children until and if the time comes that the children are eligible for Medicaid.

Section 5. Outreach and Coordination

Guidance: The State should describe below how its Title XXI program will closely coordinate the enrollment with Medicaid because under Title XXI, children identified as Medicaid-eligible are required to be enrolled in Medicaid. Specific information related to Medicaid screen and enroll procedures is requested in Section 4.4. (42CFR 457.80(c))

Section 6. Coverage Requirements for Children's Health Insurance - ARKids-B Program

I I 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 proceed to Section 7 since children covered under a Medicaid expansion program will receive all Medicaid covered services including EPSDT.

Guidance: Under Title XXI, pre-existing condition exclusions are not allowed, with the only exception being in relation to another law in existence (HIPAA/ERISA). Indicate that the plan adheres to this requirement by checking the applicable description.

In the event that the State provides benefits through a group health plan or group health coverage, or provides family coverage through a group health plan under a waiver (see Section 6.4.2.), pre-existing condition limits are allowed to the extent permitted by HIPAA/ERISA. If the State is contracting with a group health plan or provides benefits through group health coverage, describe briefly any limitations on pre-existing conditions. (Formerly 8.6.)

Section 6. Coverage Requirements for Children's Health Insurance - Title XXI CHIP Unborn Child Program

[] 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 proceed to Section 7 since children covered under a Medicaid expansion program will receive all Medicaid covered services including EPSDT.

Guidance: States may request two additional purchase options in Title XXI: cost effective coverage through a community-based health delivery system and for the purchase of family coverage. (Section 2105(c)(2) and (3)) (457.1005 and 457.1010)

Section 7. Quality and Appropriateness of Care

Guidance: Methods for Evaluating and Monitoring Quality- Methods to assure quality include the application of performance measures, quality standards consumer information strategies, and other quality improvement strategies.

Performance measurement strategies could include using measurements for external reporting either to the State or to consumers and for internal quality improvement purposes. They could be based on existing measurement sets that have undergone rigorous evaluation for their appropriateness (e.g., HEDIS). They may include the use of standardized member satisfaction surveys (e.g., CAHPS) to assess members' experience of care along key dimensions such as access, satisfaction, and system performance.

Quality standards are often used to assure the presence of structural and process measures that promote quality and could include such approaches as: the use of external and periodic review of health plans by groups such as the National Committee for Quality Assurance; the establishment of standards related to consumer protection and quality such as those developed by the National Association of Insurance Commissioners; and the formation of an advisory group to the State or plan to facilitate consumer and community participation in the plan.

Information strategies could include: the disclosure of information to beneficiaries about their benefits under the plan and their rights and responsibilities; the provision of comparative information to consumers on the performance of available health plans and providers; and consumer education strategies on how to access and effectively use health insurance coverage to maximize quality of care.

Quality improvement strategies should include the establishment of quantified quality improvement goals for the plan or the State and provider education. Other strategies include specific purchasing specifications, ongoing contract monitoring mechanisms, focus groups, etc.

Where States use managed care organizations to deliver CHIP care, recent legal changes require the State to use managed care quality standards and quality strategies similar to those used in Medicaid managed care.

Tools for Evaluating and Monitoring Quality- Tools and types of information available include, HEDIS (Health Employer Data Information Set) measures, CAHPS (Consumer Assessments of Health Plans Study) measures, vital statistics data, and State health registries (e.g., immunization registries).

Quality monitoring may be done by external quality review organizations, or, if the State wishes, internally by a State board or agency independent of the State CHIP Agency. Establishing grievance measures is also an important aspect of monitoring.

[] 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 8.

Guidance: The State must specify the qualifications of entities that will provide coverage and the conditions of participation. States should also define the quality standard they are using, for example, NCQA Standards or other professional standards. Any description of the information strategies used should be linked to Section 9. (Section 2102(a)(7)(A)) (42CFR, 457.495)

Access to Services - Arkansas Foundation for Medical Care (AFMC), DHS DMS contract agent for provider relations, encourages provider participation and compliance in the primary care case management program and other programs through site visits and regular correspondence to primary care physicians, select specialty physicians, and hospitals. Additionally, AFMC provider relations provides submissions to professional journals, participates in professional and specialty organizations, and sponsors conferences. Each quarter more than 750 primary care physicians are visited and pertinent information is shared related to program performance, policy, and updates on planned activities and initiatives.

AFMC regularly distributes articles of interest directly to the provider community via newsletter, blast faxes, conference calls and virtual meetings as well as publications in established journals. Furthermore, provider representatives are actively engaged in trade associations, such as the Arkansas Medical Society, the Arkansas Academy of Family Practice, and the Arkansas Hospital Association. These relationships afford additional opportunities for strengthening the provider network via collaboration, presentations, and exhibits at conferences and other healthcare related events throughout the state annually to offer a more dedicated venue for detailed discussion, collaboration and relationship advancement with the provider community and related stakeholders.

Information to Beneficiaries Regarding Covered Services, Preventive Health, and Facilitate Access to Primary Care Physicians and Specialists - Arkansas Foundation for Medical Care (AFMC), DHS DMS contract agent for beneficiary relations improves the quality and effectiveness of medical care by establishing and maintaining positive relationships with beneficiaries in Medicaid and CHIP related matters. This is accomplished through direct contact with beneficiaries and the creation, printing, and distribution of promotional, interventional, and informational materials. AFMC also operates a toll free complaint line that is available to the Medicaid or CHIP beneficiaries Monday - Friday.

There are a minimum of four beneficiary communications per year. Materials are available in Spanish and English and other languages upon request, e.g., beneficiaries are mailed a postcard with the number of the Beneficiary Grievance Line.

AFMC beneficiary relations also maintains a website that contains tools for beneficiaries as well as professionals. Educational materials can be downloaded and printed or ordered at the website by either beneficiaries or health care professionals. Currently the website has approximately 10 pages of educational brochures available, e.g. Acute Ml Indictors, Adolescent Immunization (Spanish and English), Adolescent Immunization Poster (Spanish and English), All Terrain Vehicle Safety (Spanish and English), Antibiotic Resistance Activity Sheet. Informational blogs are also available at the AFMC website. New B/P Guideline and Eat Like a Diabetic are the newest blogs posted. Other current informational blogs are: Adult Immunization, Adverse Drug Events, Breast Cancer Prevention, Cardiac Disparities, Colorectal Cancer.

Additionally, DHS DMS partners with the Arkansas Department of Health (ADH) to provide beneficiary outreach in the form of a newsletter with pertinent Medicaid or CHIP related messages. ADH provides a call center to facilitate the selection of a primary care physician and assistance in locating a dental provider.

Quality Improvement Strategies - DHS DMS contracts with a Quality Improvement Organization (QIO) to serve as a quality improvement contract agent. The QIO identifies potential projects through research of current challenges, national initiatives and HEDIS measures that will improve the quality of care for Arkansas beneficiaries. Data analysis is performed to determine the target population, clinical measures, and strategies for success. Project topics and research are presented to DHS DMS for approval.

Upon approval by DHS DMS, development of the project is begun including more intensive research utilizing evidence-based guidelines and criteria, journal research, and data analysis.

Strategies for success, resources, educational tools, and materials are developed for academic detailing. Materials are reviewed by the QIO contract agent's communication department to ensure that the literacy level is appropriate for the target audience. The project plan including all resources, educational tools and materials, and strategies for success is submitted to DHS for approval prior to dissemination of the project to the provider community. Academic detailing is provided to the relevant provider population to increase the quality of service provided to Medicaid and CHIP beneficiaries.

Performance Metrics - Arkansas Foundation for Medical Care (AFMC) beneficiary relations also assesses beneficiaries' needs and satisfaction through standardized surveys or focus groups. AFMC develops and conducts surveys and provides data analysis and reports. AFMC statisticians and analysts conduct consumer satisfaction surveys for beneficiaries participating in Primary Care Case Management (PCCM), Children's Health Insurance Program, Tax Equity and Fiscal Responsibility Act (TEFRA). These populations are surveyed using Consumer Assessment of Healthcare Providers and Systems (CAHPS®) modified CAHPS®, Experience of Care and Health Outcomes (ECHO®), Pregnancy Risk Assessment Monitoring System (PRAMS)-Like, SF-36. And custom designed surveys.

AFMC manages all aspects of sample design, population sampling, survey design, data collection, and analysis. AFMC also sends survey results to the National CAHPS® Benchmarking Database (NCBD). This process provided a means for comparison to other participating states' health care programs and set appropriate benchmarks CAHPS® surveys are designed to assess consumer satisfaction with various aspects of the healthcare delivery system including, but not limited to, the plan structure, providers, customer service, and overall healthcare and wellness.

In addition to CAHPS®, DHS DMS monitors performance of both the Medicaid and CHIP state plans through use of the HEDIS data set. Each year, DHS DMS data analytics contract agents publish a HEDIS report with many of the available metrics. Additionally, AFMC data analytics contract agent assists DHS DMS in compiling the date required for the submission through CARTS and CHIPRA core metrics such as annual well-child visits, annual dental visits, and immunization data.

Guidance: Provide a brief description of methods to be used to assure access to covered services,

including a description of how the State will assure the quality and appropriateness of the care provided. The State should consider whether there are sufficient providers of care for the newly enrolled populations and whether there is reasonable access to care. (Section 2102(a)(7)(B))

Section 8. Cost-Sharing and Payment

[] 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 9.

Guidance: The State should be able to demonstrate upon request its rationale and justification regarding these assurances. This section also addresses limitations on payments for certain expenditures and requirements for maintenance of effort.

Section 9. Strategic Objectives and Performance Goals and Plan Administration

Guidance: States should consider aligning its strategic objectives with those discussed in Section II of the CHIP Annual Report.

Guidance: Goals should be measurable, quantifiable and convey a target the State is working towards.

Performance Goal for Objective I:

The total number of children enrolled in CHIP will increase each year by one half percent or be adjusted up or down based on historical data. Performance Goal for Objective II:

The total number of children receiving preventive dental services, including orthodontia, will increase each year by one half percent or be adjusted up or down based on historical data.

Performance Goal for Objective III:

The total number of children under 15 months of life; children ages 3 through 6 years; and adolescents ages 12 through 18 years receiving well-child visits will increase each year by one half percent or be adjusted up or down based on historical data.

Guidance: The State should include data sources to be used to assess each performance goal. In

addition, check all appropriate measures from 9.3.1 to 9.3.8 that the State will be utilizing to measure performance, even if doing so duplicates what the State has already discussed in Section 9.

It is acceptable for the State to include performance measures for population subgroups chosen by the State for special emphasis, such as racial or ethnic minorities, particular high-risk or hard to reach populations, children with special needs, etc.

HEDIS (Health Employer Data and Information Set) 2008 contains performance measures relevant to children and adolescents younger than 19. In addition, HEDIS 3.0 contains measures for the general population, for which breakouts by children's age bands (e.g., ages [LESS THAN] 1, 1-9, 10-19) are required. Full definitions, explanations of data sources, and other important guidance on the use of HEDIS measures can be found in the HEDIS 2008 manual published by the National Committee on Quality Assurance. So that State HEDIS results are consistent and comparable with national and regional data, states should check the HEDIS 2008 manual for detailed definitions of each measure, including definitions of the numerator and denominator to be used. For states that do not plan to offer managed care plans, HEDIS measures may also be able to be adapted to organizations of care other than managed care.

Guidance: The State should verify that they will participate in the collection and evaluation of data as new measures are developed or existing measures are revised as deemed necessary by CMS, the states, advocates, and other interested parties.

Guidance: Section 9.9 can include discussion of community-based providers and consumer

representatives in the design and implementation of the plan and the method for ensuring ongoing public involvement. Issues to address include a listing of public meetings or announcements made to the public concerning the development of the children's health insurance program or public forums used to discuss changes to the state plan.

Section 10. Annual Reports and Evaluations

Guidance: The National Academy for State Health Policy (NASHP), CMS and the states developed framework for the annual report that states have the option to use to complete the required evaluation report. The framework recognizes the diversity in State approaches to implementing CHIP and provides consistency across states in the structure, content, and format of the evaluation report. Use of the framework and submission of this information will allow comparisons to be made between states and on a nationwide basis. The framework for the annual report can be obtained from NASHP's website at http://www.nashp.org. Per the title XXI statute at Section 2108(a), states must submit reports by January 1st to be compliant with requirements.

Section 11. Program Integrity (Section 2101(a))

[] 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 to Section 12.

Section 12. Applicant and Enrollee Protections (Sections 2101(a))

[] Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State's Medicaid plan.

Guidance: "Health services matters" refers to grievances relating to the provision of health care.

Key for Newly Incorporated Templates

The newly incorporated templates are indicated with the following letters after the numerical section throughout the template.

* PC- Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002)

* PW- Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009)

* TC- Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009)

* DC- Dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009)

* DS- Supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009)

* PA- Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010)

* EL- Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010)

* LR- Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010)

GLOSSARY

Adapted directly from Sec. 2110. DEFINITIONS.

CHILD HEALTH ASSISTANCE- For purposes of this title, the term 'child health assistance' means payment for part or all of the cost of health benefits coverage for targeted low-income children that includes any of the following (and includes, in the case described in Section 2105(a)(2)(A), payment for part or all of the cost of providing any of the following), as specified under the state plan:

1. Inpatient hospital services.

2. Outpatient hospital services.

3. Physician services.

4. Surgical services.

5. Clinic services (including health center services) and other ambulatory health care services.

6. Prescription drugs and biologicals and the administration of such drugs and biologicals, only if such drugs and biologicals are not furnished for the purpose of causing, or assisting in causing, the death, suicide, euthanasia, or mercy killing of a person.

7. Over-the-counter medications.

8. Laboratory and radiological services.

9. Prenatal care and pregnancy family planning services and supplies.

10. Inpatient mental health services, other than services described in paragraph (18) but including services furnished in a State-operated mental hospital and including residential or other 24-hour therapeutically planned structured services.

11. Outpatient mental health services, other than services described in paragraph (19) but including services furnished in a State-operated mental hospital and including community-based services.

12. Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices).

13. Disposable medical supplies.

14. Home and community-based health care services and related supportive services (such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home).

15. Nursing care services (such as nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services) in a home, school, or other setting.

16. Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest.

17. Dental services.

18. Inpatient substance abuse treatment services and residential substance abuse treatment services.

19. Outpatient substance abuse treatment services.

20. Case management services.

21. Care coordination services.

22. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders.

23. Hospice care.

24. Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services (whether in a facility, home, school, or other setting) if recognized by State law and only if the service is-

25. Premiums for private health care insurance coverage.

26. Medical transportation.

27. Enabling services (such as transportation, translation, and outreach services) only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.

28. Any other health care services or items specified by the Secretary and not excluded under this section.

TARGETED LOW-INCOME CHILD DEFINED - For purposes of this title-

1. IN GENERAL- Subject to paragraph (2), the term 'targeted low-income child' means a child-

2. CHILDREN EXCLUDED - Such term does not include-

3. SPECIAL RULE - A child shall not be considered to be described in paragraph (1)(C) notwithstanding that the child is covered under a health insurance coverage program that has been in operation since before July 1, 1997, and that is offered by a State which receives no Federal funds for the program's operation.

4. MEDICAID APPLICABLE INCOME LEVEL - The term 'Medicaid applicable income level' means, with respect to a child, the effective income level (expressed as a percent of the poverty line) that has been specified under the state plan under title XIX (including under a waiver authorized by the Secretary or under Section 1902(r)(2)), as of June 1, 1997, for the child to be eligible for medical assistance under Section 1902(1)(2) for the age of such child.

5. TARGETED LOW-INCOME PREGNANT WOMAN - The term 'targeted low-income pregnant woman' means an individual-

ADDITIONAL DEFINITIONS - For purposes of this title:

1. CHILD - The term 'child' means an individual under 19 years of age.

2. CREDITABLE HEALTH COVERAGE - The term 'creditable health coverage' has the meaning given the term 'creditable coverage' under Section 2701(c) of the Public Health Service Act (42 U.S.C. 300gg(c)) and includes coverage that meets the requirements of section 2103 provided to a targeted low-income child under this title or under a waiver approved under section 2105(c)(2)(B) (relating to a direct service waiver).

3. GROUP HEALTH PLAN; HEALTH INSURANCE COVERAGE; ETC - The terms 'group health plan', 'group health insurance coverage', and 'health insurance coverage' have the meanings given such terms in Section 2191 of the Public Health Service Act.

4. LOW-INCOME CHILD - The term 'low-income child' means a child whose family income is at or below 200 percent of the poverty line for a family of the size involved.

5. POVERTY LINE DEFINED - The term 'poverty line' has the meaning given such term in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section.

6. PREEXISTING CONDITION EXCLUSION - The term 'preexisting condition exclusion' has the meaning given such term in section 2701(b)(1)(A) of the Public Health Service Act (42 U.S.C. 300gg(b)(l)(A)).

7. STATE CHILD HEALTH PLAN; PLAN - Unless the context otherwise requires, the terms 'State child health plan' and 'plan' mean a State child health plan approved under Section 2106.

8. UNINSURED CHILD - The term 'uninsured child' means a child that does not have creditable health coverage.

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Methodology Calculations Used to Calculate Financial Hardship State's Health Benefits Plan Causes State Employees for Health Coverage for Their Children

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Methodology Used to Calculate Financial Hardship State's Health Benefits Plan Causes State Employees for Health Coverage for Their Children

The State has researched the State employee costs for the State-funded health benefits program and determined that the annual costs do exceed 5% of a State employee's gross family income. The State looked at the annual costs for the "Employee and Children" and "Employee and Family" categories of coverage. The average associated out-of-pocket expenses, including deductibles and co-pays, within each of these categories were also included in the calculation.

Example: A family of four with an annual household income at 211% of the FPL, $50,324, will pay approximately $4,317 in premiums for an employee and family policy and out-of-pocket expenditures per year which, in fact, exceeds 5% of their annual income. This example is based upon annual premiums for an Employee and Family which are $2,446 and annual out-of-pocket expenses which are estimated to be $1,871.

Other scenarios with various family sizes, etc. yielded the same result in which the annual expenditures for the State-funded health benefits exceed 5% of their household income. (Please see attached.)

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