CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) PROCEDURES HANDBOOK December 2018 Introduction Title XXI of the Social Security Act, enacted in 1997 by the Balanced Budget Act, allowed for the creation of the Children’s Health Insurance Program (CHIP). Pennsylvania’s CHIP was started as a one of a kind program established to provide health coverage to uninsured children that reside in households with income exceeding the current levels for Medical Assistance. Pennsylvania’s CHIP program was later used as a model for the federal government’s State Children’s Health Insurance Program (SCHIP). The CHIP Procedures Handbook serves to provide Managed Care Organizations (MCOs) with a comprehensive guide that ensures proper implementation of statutory requirements, including Title XXI of the Social Security Act, the Children’s Health Care Act, Pub. L. No. 106-113, § 113. Stat. 1501. (1999), and the Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 et seq. (2010). The CHIP Procedures Handbook is divided into four parts: Part 1: Application Processing Procedures Part 2: Quality Management Part 3: Marketing and Outreach Part 4: Administrative Requirements 2 TABLE OF CONTENTS Introduction ................................................................................................................... 2 Definitions ...................................................................................................................... 5 Part 1: Application Processing Procedures ............................................................. 22 Chapter 1: Application Submission ............................................................................... 22 Chapter 2: Central Eligibility Unit Verification Processes .............................................. 35 Chapter 3: Income and Tax Deduction Verification ....................................................... 41 Chapter 4: Determining Financial Eligibility ................................................................... 71 Chapter 5: Enrollment Procedure .................................................................................. 77 Chapter 6: Enrollee Services ......................................................................................... 79 Chapter 7: Complaint, Grievance and External Review ................................................ 84 Chapter 8: Notices....................................................................................................... 103 Chapter 9: Changes Affecting Eligibility During Intake or Renewal ............................. 106 Chapter 10: Eligibility Review Process ........................................................................ 108 Chapter 11: Changes during the Enrollment Period ................................................... 114 Chapter 12: Reassessment ........................................................................................ 129 Chapter 13: Renewal Procedures ............................................................................... 132 Chapter 14: Termination Procedures for Ineligible Child ............................................. 140 Part 2: Quality Management ..................................................................................... 144 Chapter 15: Division of Quality Assurance .................................................................. 144 Chapter 16: Quality Management Routine Reports ..................................................... 149 Chapter 17: Quality Management Intermittent Reports ............................................... 155 Chapter 18: Internal and External Audits ..................................................................... 158 Chapter 19: Data Warehouse ..................................................................................... 176 Chapter 20: Fraud, Waste, and Abuse ........................................................................ 185 Chapter 21: Managed Care Organizations Quality Requirements .............................. 194 3 Part 3: Marketing and Outreach .............................................................................. 253 Chapter 22: Marketing and Outreach .......................................................................... 253 Chapter 23: MCO Report on Company or Programmatic Changes ............................ 258 Part 4: Administration Requirements ..................................................................... 263 Chapter 24: Administrative Requirements ................................................................... 263 Acronyms ................................................................................................................... 272 4 DEFINITIONS For the purpose of this CHIP Procedure Handbook, the following definitions shall apply: Abuse- Any practice that is inconsistent with sound fiscal, business or medical practices, and results in unnecessary costs to the CHIP Program, or any reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or agreement obligations. Agreement obligations include those found in the Request for Proposal, Agreement, or the requirements of state or federal regulations for health care in a managed care setting. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider or entity has not knowingly or intentionally misrepresented facts to obtain payment. The abuse can be committed by the MCO, subcontractor to the MCO including providers, state employee, or an enrollee, among others. Abuse also includes enrollee practices that result in unnecessary costs to any of the following: 1. CHIP; 2. the MCO; 3. MCO’s subcontractor; or 4. the MCO’s provider. Actuarially Sound Principles- generally accepted actuarial principles and practices that are 1. applied to determine aggregate utilization pattern; 2. are appropriate for the population and services to be covered; and 3. have been certified by actuaries who meet the qualification standards established by the Actuarial Standards Board. Adult- custodial parent or legal guardian of a child. Adjudicated Claim- A claim that has been processed to payment or denial. Affiliate- Any entity that controls, is controlled by or under common control of the MCO or its parent(s), whether such control be direct or indirect, all persons, holding five (5) percent or more of the outstanding ownership interests of the MCO or its parent(s), directors or subsidiaries of MCO are Affiliates. For purposes of this definition, "control" means the possession of the power to direct or cause the direction of the management or policies. Amended Claim- A provider request to adjust the payment of a previously adjudicated claim. A provider appeal is not an amended claim. Appeal- To file a complaint, grievance, or request an external review. Applicant- a child who has filed an application or who has an application filed on their behalf. 5 Authorization- Approval for a service. Business Days- Monday through Friday except for those days recognized as federal holidays or Pennsylvania state holidays. Calendar Year- A one-year period that begins on January 1 and ends on December 31. Capitation- A fee the Department pays monthly to an MCO for each enrollee enrolled in its managed care plan to provide coverage of medical services, whether or not the enrollee receives the services during the period covered by the fee. Case Management Services- Services that assist individuals with chronic and complex conditions in gaining access to necessary medical, behavioral health, educational and other services. Certificate of Authority- A document issued jointly by the Pennsylvania Department of Health (PADOH) and Pennsylvania Insurance Department (PID) authorizing a corporation to establish, maintain and operate a Managed Care Organization (MCO) in Pennsylvania. Certified Nurse Midwife- An individual licensed under the laws within the scope of Chapter 6 of Professions & Occupations, 63 P.S. §§171-176. Certified Registered Nurse Practitioner- An individual licensed under the laws within the scope of Chapter 6 of Professions & Occupations, 63 P.S. §§218.2. Central Eligibility Unit (CEU)- The name of the unit within CHIP that verifies citizenship and identity, reviews data exchanges and verifies CHIP eligibility. Child- A person under nineteen (19) years of age. Children’s Health Insurance Program (CHIP)- The Pennsylvania program that provides free, low-Cost or full-cost health care services to children in accordance with 40 P.S. §§ 991.2301-A – 991.2309-A. CHIP Application Processing System (CAPS)- Automated system used by CHIP to capture application information and process eligibility determinations. Claim- A bill from a provider of a medical service or product that is assigned a claim reference number. A Claim does not include an encounter for which no payment is made or only a nominal payment is made. 6 Claim reference number- a unique identifier assigned to a provider of a medical service or product by the CHIP program. Client Information System (CIS)- The Department’s mainframe database that contains historical information for the Temporary Assistance for Needy Families (TANF), Medicaid and Supplemental Nutrition Assistance Program (SNAP) programs. Citizen- An applicant or enrollee who is a citizen of United States. Commonwealth of Pennsylvania Application for Social Services (COMPASS)- Pennsylvania’s online portal for applying for and renewing health and human services benefits. Community Provider- A private or public